Part II

Federal Register: April 30, 2008 (Volume 73, Number 84)

Proposed Rules

Page 23527-23938

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

DOCID:fr30ap08-26

Page 23527

Part II

Department of Health and Human Services

Centers for Medicare & Medicaid

42 CFR Parts 411, 412, 413 et al.

Medicare Program; Proposed Changes to the Hospital Inpatient

Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed

Changes to Disclosure of Physician Ownership in Hospitals and Physician

Self-Referral Rules; Proposed Collection of Information Regarding

Financial Relationships Between Hospitals and Physicians; Proposed Rule

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services 42 CFR Parts 411, 412, 413, 422, and 489

CMS-1390-P

RIN 0938-AP15

Medicare Program; Proposed Changes to the Hospital Inpatient

Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed

Changes to Disclosure of Physician Ownership in Hospitals and Physician

Self-Referral Rules; Proposed Collection of Information Regarding

Financial Relationships Between Hospitals and Physicians

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, the Medicare Improvements and Extension Act,

Division B, Title I of the Tax Relief and Health Care Act of 2006, and the TMA, Abstinence Education, and QI Programs Extension Act of 2007.

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. These proposed changes would be applicable to discharges occurring on or after October 1, 2008. We also are setting forth the proposed update to the rate-of-increase limits for certain hospitals and hospital units excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The proposed updated rate-of-increase limits would be effective for cost reporting periods beginning on or after October 1, 2008.

Among the other policy decisions and changes that we are proposing to make are changes related to: Limited proposed revisions of the classification of cases to Medicare severity diagnosis-related groups

(MS-DRGs), proposals to address charge compression issues in the calculation of MS-DRG relative weights, the proposed revisions to the classifications and relative weights for the Medicare severity long- term care diagnosis-related groups (MS-LTC-DRGs); applications for new medical services and technologies add-on payments; wage index reform changes and the wage data, including the occupational mix data, used to compute the proposed FY 2009 wage indices; submission of hospital quality data; proposed changes to the postacute care transfer policy relating to transfers to home for the furnishing of home health services; and proposed policy changes relating to the requirements for furnishing hospital emergency services under the Emergency Medical

Treatment and Labor Act of 1986 (EMTALA).

In addition, we are proposing policy changes relating to disclosure to patients of physician ownership or investment interests in hospitals and soliciting public comments on a proposed collection of information regarding financial relationships between hospitals and physicians. We are also proposing changes or soliciting comments on issues relating to policies on physician self-referrals.

DATES: To be assured consideration, comments must be received at one of the addresses provide below, no later than 5 p.m. E.S.T. on June 13, 2008.

ADDRESSES: When commenting on issues presented in this proposed rule, please refer to filecode CMS-1390-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of four ways (please choose only one of the ways listed): 1. Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions for

``Comment or Submission'' and enter the file code CMS-1390-P to submit comments on this proposed rule. 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-1390-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-1390-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 either of the following addresses: a. Room 445-G, Hubert H. Humphrey Building, 200 Independence

Avenue, SW., Washington, DC 20201.

(Because access to the interior of the HHH 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 a proof of filing by stamping in and retaining an extra copy of the comments being filed.) b. 7500 Security Boulevard, Baltimore, MD 21244-1850.

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.

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 following the instructions 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:

Michele Hudson, (410) 786-4487, Operating Prospective Payment, MS-

DRGs, Wage Index, New Medical Service and Technology Add-On Payments,

Hospital Geographic Reclassifications, and Postacute Care Transfer

Issues.

Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded

Hospitals, Direct and Indirect Graduate Medical Education, MS-LTC-DRGs,

EMTALA, Hospital Emergency Services, and Hospital-within-Hospital

Issues.

Siddhartha Mazumdar, (410) 786-6673, Rural Community Hospital

Demonstration Program Issues.

Sheila Blackstock, (410) 786-3502, Quality Data for Annual Payment

Update Issues.

Thomas Valuck, (410) 786-7479, Hospital Value-Based Purchasing and

Readmissions to Hospital Issues.

Anne Hornsby, (410) 786-1181, Collection of Managed Care Encounter

Data Issues.

Jacqueline Proctor, (410) 786-8852, Disclosure of Physician

Ownership in

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Hospitals and Financial Relationships between Hospitals and Physicians

Issues.

Lisa Ohrin, (410) 786-4565, and Don Romano, (410) 786-1404,

Physician Self-Referral Issues.

SUPPLEMENTARY INFORMATION:

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.regulations.gov. Follow the search instructions on that Web site to view public comments.

Comments received timely will also be available for public inspection, 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

AARP American Association of Retired Persons

AAHKS American Association of Hip and Knee Surgeons

AAMC Association of American Medical Colleges

ACGME Accreditation Council for Graduate Medical Education

AF Artrial fibrillation

AHA American Hospital Association

AICD Automatic implantable cardioverter defibrillator

AHIMA American Health Information Management Association

AHIC American Health Information Community

AHRQ Agency for Healthcare Research and Quality

AMA American Medical Association

AMGA American Medical Group Association

AMI Acute myocardial infarction

AOA American Osteopathic Association

APR DRG All Patient Refined Diagnosis Related Group System

ASC Ambulatory surgical center

ASITN American Society of Interventional and Therapeutic

Neuroradiology

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

CARE [Medicare] Continuity Assessment Record & Evaluation

Instrument

CART CMS Abstraction & Reporting Tool

CBSAs Core-based statistical areas

CC Complication or comorbidity

CCR Cost-to-charge ratio

CDAC [Medicare] Clinical Data Abstraction Center

CDAD Clostridium difficile-associated disease

CIPI Capital input 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

CoP [Hospital] condition of participation

CPI Consumer price index

CY Calendar year

DFRR Disclosure of financial relationship report

DRA Deficit Reduction Act of 2005, Pub. L. 109-171

DRG Diagnosis-related group

DSH Disproportionate share hospital

DVT Deep vein thrombosis

ECI Employment cost index

EMR Electronic medical record

EMTALA Emergency Medical Treatment and Labor Act of 1986, Pub. L. 99-272

FAH Federation of Hospitals

FDA Food and Drug Administration

FHA Federal Health Architecture

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

HACs Hospital-acquired conditions

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

HPMP Hospital Payment Monitoring Program

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

HWH Hospital-within-a hospital

ICD-9-CM International Classification of Diseases, Ninth Revision,

Clinical Modification

ICD-10-PCS International Classification of Diseases, Tenth Edition,

Procedure Coding System

ICR Information collection requirement

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

LAMCs Large area metropolitan counties

LTC-DRG Long-term care diagnosis-related group

LTCH Long-term care hospital

MA Medicare Advantage

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

MRSA Methicillin-resistant Staphylococcus aureus

MSA Metropolitan Statistical Area

MS-DRG Medicare severity diagnosis-related group

MS-LTC-DRG Medicare severity long-term care diagnosis-related group

NAICS North American Industrial Classification System

NCD National coverage determination

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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]

PE Pulmonary embolism

PMSAs Primary metropolitan statistical areas

POA Present on admission

PPI Producer price index

PPS Prospective payment system

PRM Provider Reimbursement Manual

ProPAC Prospective Payment Assessment Commission

PRRB Provider Reimbursement Review Board

PSF Provider-Specific File

PS&R Provider Statistical and Reimbursement (System)

QIG Quality Improvement Group, CMS

QIO Quality Improvement Organization

RCE Reasonable compensation equivalent

RHC Rural health clinic

RHQDAPU Reporting hospital quality data for annual payment update

RNHCI Religious nonmedical health care institution

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

TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97- 248

TMA TMA [Transitional Medical Assistance], Abstinence Education, and

QI [Qualifying Individuals] Programs Extension Act of 2007, Pub. L. 110-09

TJA Total joint arthroplasty

UHDDS Uniform hospital discharge data set

VAP Ventilator-associated pneumonia

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, Title I of the Tax Relief and Health Care Act of 2006 (MIEA-TRHCA)

D. Provision of the TMA, Abstinence Education, and QI Programs

Extension Act of 2007

E. Major Contents of this Proposed Rule 1. Proposed Changes to MS-DRG Classifications 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 Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages 6. Proposed Changes Relating to Disclosure of Physician

Ownership in Hospitals 7. Proposed Changes and Solicitation of Comments on Physician

Self-Referral Provisions 8. Proposed Collection of Information Regarding Financial

Relationships between Hospitals and Physicians 9. Determining Proposed Prospective Payment Operating and

Capital Rates and Rate-of-Increase Limits 10. Impact Analysis 11. Recommendation of Update Factors for Operating Cost Rates of

Payment for Inpatient Hospital Services 12. Disclosure of Financial Relationships Report (DFRR) Form 13. Discussion of Medicare Payment Advisory Commission

Recommendations

F. Public Comments Received on Issues in Related Rules 1. Comments on Phase-Out of the Capital Teaching Adjustment under the IPPS Included in the FY 2008 IPPS Final Rule with Comment

Period 2. Policy Revisions Related to Medicare GME Group Affiliations for Hospitals in Certain Declared Emergency Areas

II. Proposed Changes to Medicare Severity DRG (MS-DRG)

Classifications and Relative Weights

A. Background

B. MS-DRG Reclassifications 1. General 2. Yearly Review for Making MS-DRG Changes

C. Adoption of the MS-DRGs in FY 2008

D. MS-DRG Documentation and Coding Adjustment, Including the

Applicability to the Hospital-Specific Rates and the Puerto Rico-

Specific Standardized Amount 1. MS-DRG Documentation and Coding Adjustment 2. Application of the Documentation and Coding Adjustment to the

Hospital-Specific Rates 3. Application of the Documentation and Coding Adjustment to

Puerto Rico-Specific Standardized Amount 4. Potential Additional Payment Adjustments in FYs 2010 through 2012

E. Refinement of the MS-DRG Relative Weight Calculation 1. Background 2. Refining the Medicare Cost Report 3. Timeline for Revising the Medicare Cost Report 4. Revenue Codes used in the MedPAR File

F. Preventable Hospital-Acquired Conditions (HACs), Including

Infections 1. General 2. Statutory Authority 3. Public Input 4. Collaborative Process 5. Selection Criteria for HACs 6. HACs Selected in FY 2008 and Proposed Changes to Certain

Codes a. Foreign Object Retained After Surgery: Proposed Inclusion of

ICD-9-CM Code 998.7 (CC) b. Pressure Ulcers: Proposed Changes in Code Assignments 7. HACs Under Consideration as Additional Candidates a. Surgical Site Infections Following Elective Surgeries b. Legionnaires' Disease c. Glycemic Control d. Iatrogenic Pneumothorax e. Delirium f. Ventilator-Associated Pneumonia (VAP) g. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) h. Staphylococcus aureus Septicemia i. Clostridium Difficile-Associated Disease (CDAD) j. Methicillin-Resistant Staphylococcus aureus (MRSA) 8. Present on Admission (POA) Indicator Reporting 9. Enhancement and Future Issues a. Risk Adjustment b. Rates of HACs c. Use of POA Information d. Transition to ICD-10-PCS e. Application of Nonpayment for HACs to Other Settings f. Relationship to NQF's Serious Reportable Adverse Events

G. Proposed Changes to Specific MS-DRG Classifications 1. Pre-MDCs: Artificial Heart Devices 2. MDC 1 (Diseases and Disorders of the Nervous System) a. Transferred Stroke Patients Receiving Tissue Plasminogen

Activator (tPA) b. Intractable Epilepsy with Video Electroencephalogram (EEG) 3. MDC 5 (Diseases and Disorders of the Circulatory System) a. Automatic Implantable Cardioverter-Defibrillators (AICD) Lead and Generator Procedures b. Left Atrial Appendage Device 4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue): Hip and Knee Replacements and Revisions a. Brief History of Development of Hip and Knee Replacement

Codes b. Prior Recommendations of the AAHKS c. Adoption of MS-DRGs for Hip and Knee Replacements for FY 2008 and AAHKS' Recommendations d. AAHKS' Recommendations for FY 2009 e. CMS' Response to AAHKS' Recommendations f. Conclusion 5. MDC 18 (Infections and Parasitic Diseases Systemic or

Unspecified Sites): Severe Sepsis

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6. MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs):

Traumatic Compartment Syndrome 7. Medicare Code Editor (MCE) Changes a. List of Unacceptable Principal Diagnoses in MCE b. Diagnoses Allowed for Male Only Edit c. Limited Coverage Edit 8. Surgical Hierarchies 9. CC Exclusions List a. Background b. CC Exclusions List for FY 2009 10. Review of Procedure Codes in MS-DRGs 981, 982, and 983; 984, 985, and 986; and 987, 988, and 989 a. Moving Procedure Codes from MS-DRG 981 through 983 or MS-DRG 987 through 989 to MDCs b. Reassignment of Procedures among MS-DRGs 981 through 983, 984 through 986, and 987 through 989 c. Adding Diagnosis or Procedure Codes to MDCs 11. Changes to the ICD-9-CM Coding System

H. Recalibration of MS-DRG Weights

I. Proposed Medicare Severity Long-Term Care Diagnosis-Related

Group (MS-LTC-DRG) Reclassifications and Relative Weights for LTCHs for FY 2009 1. Background 2. Proposed Changes in the MS-LTC-DRG Classifications a. Background b. Patient Classifications into MS-LTC-DRGs 3. Development of the Proposed FY 2009 MS-LTC-DRG Relative

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

Weights b. Data c. Hospital-Specific Relative Value (HSRV) Methodology d. Treatment of Severity Levels in Developing Proposed Relative

Weights e. Proposed Low-Volume MS-LTC-DRGs 4. Steps for Determining the Proposed FY 2009 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 2009 Status of Technologies Approved for FY 2008 Add-On

Payments 4. FY 2009 Applications for New Technology Add-On Payments a. CardioWestTMTemporary Total Artificial Heart

System (CardioWestTMTAH-t) b. Emphasys Medical Zephyr[supreg] Endobronchial Valve

(Zephyr[supreg] EBV) c. Oxiplex[supreg] d. TherOx Downstream[supreg] System 5. Proposed Regulatory Change

III. Proposed Changes to the Hospital Wage Index

A. Background

B. Requirements of Section 106 of the MIEA-TRHCA 1. Wage Index Study Required Under the MIEA-TRHCA 2. CMS Proposals in Response to Requirements Under Section 106(b) of the MIEA-TRHCA a. Proposed Revision of the Reclassification Average Hourly Wage

Comparison Criteria b. Within-State Budget Neutrality Adjustment for the Rural and

Imputed Floors c. Within-State Budget Neutrality Adjustment for Geographic

Reclassification

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

D. Proposed Occupational Mix Adjustment to the Proposed FY 2009

Wage Index 1. Development of Data for the Proposed FY 2009 Occupational Mix

Adjustment 2. Calculation of the Proposed Occupational Mix Adjustment for

FY 2009 3. 2007-2008 Occupational Mix Survey for the FY 2010 Wage Index

E. Worksheet S-3 Wage Data for the Proposed FY 2009 Wage Index 1. Included Categories of Costs 2. Excluded Categories of Costs 3. Use of Wage Index Data by Providers Other Than Acute Care

Hospitals Under the IPPS

F. Verification of Worksheet S-3 Wage Data 1. Wage Data for Multicampus Hospitals 2. New Orleans' Post-Katrina Wage Index

G. Method for Computing the Proposed FY 2009 Unadjusted Wage

Index

H. Analysis and Implementation of the Proposed Occupational Mix

Adjustment and the Proposed FY 2009 Occupational Mix Adjustment Wage

Index

I. Proposed Revisions to the Wage Index Based on Hospital

Redesignations 1. General 2. Effects of Reclassification/Redesignation 3. FY 2009 MGCRB Reclassifications 4. FY 2008 Policy Clarifications and Revisions 5. Redesignations of Hospitals under Section 1886(d)(8)(B) of the Act 6. Reclassifications under Section 1886(d)(8)(B) of the Act

J. Proposed FY 2009 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 2009

IV. Other Decisions and Proposed Changes to the IPPS for Operating

Costs and GME Costs

A. Proposed Changes to the Postacute Care Transfer Policy 1. Background 2. Proposed Policy Change Relating to Transfers to Home with a

Written Plan for the Provision of Home Health Services 3. Evaluation of MS-DRGs under Postacute Care Transfer Policy for FY 2009

B. Reporting of Hospital Quality Data for Annual Hospital

Payment Update 1. Background a. Overview b. Voluntary Hospital Quality Data Reporting c. Hospital Quality Data Reporting under Section 501(b) of Pub.

L. 108-173 d. Hospital Quality Data Reporting under Section 5001(a) of Pub.

L. 109-171 2. Proposed Quality Measures for FY 2010 and Subsequent Years a. Proposed Quality Measures for FY 2010 b. Possible New Quality Measures, Measure Sets, and Program

Requirements for FY 2011 and Subsequent Years c. Considerations in Expanding and Updating Quality Measures

Under the RHQDAPU Program 3. Form and Manner and Timing of Quality Data Submission 4. Current and Proposed RHQDAPU Program Procedures a. RHQDAPU Program Procedures for FY 2009 b. Proposed RHQDAPU Program Procedures for FY 2010 5. Current and Proposed HCAHPS Requirements a. FY 2009 HCAHPS Requirements b. Proposed FY 2010 HCAHPS Requirements 6. Current and Proposed Chart Validation Requirements a. Chart Validation Requirements for FY 2009 b. Proposed Chart Validation Requirements for FY 2010 c. Chart Validation Methods and Requirements Under Consideration for FY 2011 and Subsequent Years 7. Data Attestation Requirements a. Proposed Change to Requirements for FY 2009 b. Proposed Requirements for FY 2010 8. Public Display Requirements 9. Proposed Reconsideration and Appeal Procedures 10. Proposed RHQDAPU Program Withdrawal Deadline for FYs 2009 and 2010 11. Requirements for New Hospitals 12. Electronic Medical Records

C. Medicare Hospital Value-Based Purchasing (VBP) 1. Medicare Hospital VBP Plan Report to Congress 2. Testing and Further Development of the Medicare Hospital VBP

Plan

D. Sole Community Hospitals (SCHs) and Medicare-Dependent, Small

Rural Hospitals (MDHs): Volume Decrease Adjustment 1. Background 2. Volume Decrease Adjustment for SCHs and MDHs: Data Sources for Determining Core Staff Values a. Occupational Mix Survey b. AHA Annual Survey

E. Rural Referral Centers (RRCs) 1. Case-Mix Index 2. Discharges

F. Indirect Medical Education (IME) Adjustment 1. Background 2. IME Adjustment Factor for FY 2009

G. Medicare GME Affiliation Provisions for Teaching Hospitals in

Certain Emergency Situations; Technical Correction 1. Background 2. Technical Correction

H. Payments to Medicare Advantage Organizations: Collection of

Risk Adjustment Data

I. Hospital Emergency Services under EMTALA

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1. Background 2. EMTALA Technical Advisory Group (TAG): Recommendations 3. Proposed Changes Relating to Applicability of EMTALA

Requirements to Hospital Inpatients 4. Proposed Changes to the EMTALA Physician On-Call Requirements a. Relocation of Regulatory Provisions b. Shared/Community Call 5. Proposed Technical Change to Regulations

J. Application of Incentives To Reduce Avoidable Readmissions to

Hospitals 1. Introduction 2. Measurement 3. Accountability 4. Interventions 5. Financial Incentive: Direct Payment Adjustment 6. Financial Incentive: Performance-Based Payment Adjustment 7. Nonfinancial Incentive: Public Reporting 8. Conclusion

K. Rural Community Hospital Demonstration Program

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

A. Background 1. Exception Payments 2. New Hospitals 3. Hospitals Located in Puerto Rico

B. Revisions to the Capital IPPS Based on Data on Hospitals

Medicare Capital Margins 1. Elimination of the Large Add-On Payment Adjustment 2. Changes to the Capital IME Adjustment a. Background and Changes Made for FY 2008 b. Public Comments Received on Phase Out of Capital IPPS

Teaching Adjustment Provisions Included in the FY 2008 Final Rule

With Comment Period and Further Solicitation of Public Comments

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

A. Proposed Payments to Excluded Hospitals and Hospital Units

B. IRF PPS

C. LTCH PPS

D. IPF PPS

E. Determining Proposed LTCH Cost-to-Charge Ratios (CCRs) under the LTCH PPS

F. Proposed Change to the Regulations Governing Hospitals-

Within-Hospitals

VII. Disclosure Required of Certain Hospitals and Critical Access

Hospitals Regarding Physician Ownership

VIII. Physician Self-Referrals Provisions

A. Stand in the Shoes Provisions 1. Physician ``Stand in the Shoes'' Provisions a. Background b. Proposals 2. DHS Entity ``Stand in the Shoes'' Provisions 3. Application of the Physician ``Stand in the Shoes'' and the

Entity ``Stand in the Shoes'' Provisions 4. Definitions: ``Physician'' and ``Physician Organization''

B. Period of Disallowance

C. Gainsharing Arrangements 1. Background 2. Statutory Impediments to Gainsharing Arrangements 3. Office of Inspector General (OIG) Approach Towards

Gainsharing Arrangements 4. MedPAC Recommendation 5. Demonstration Programs 6. Solicitation of Comments

D. Physician-Owned Implant and Other Medical Device Companies 1. Background 2. Solicitation of Comments

IX. Financial Relationships between Hospitals and Physicians

A. Background

B. Section 5006 of the Deficit Reduction Act (DRA) of 2005

C. Disclosure of Financial Relationships Report (DFRR)

D. Civil Monetary Penalties

E. Uses of Information Captured by the DFRR

F. Solicitation of Comments

X. MedPAC Recommendations

XI. Other Required Information

A. Requests for Data from the Public

B. Collection of Information Requirements 1. Legislative Requirement for Solicitation of Comments 2. Solicitation of Comments on Proposed Requirements in

Regulatory Text a. ICRs Regarding Physician Reporting Requirements b. ICRs Regarding Risk Adjustment Data c. ICRs Regarding Basic Commitments of Providers 3. Associated Information Collections Not Specified in

Regulatory Text a. Present on Admission (POA) Indicator Reporting b. Proposed Add-On Payments for New Services and Technologies c. Reporting of Hospital Quality Data for Annual Hospital

Payment Update d. Occupational Mix Adjustment to the FY 2009 Index (Hospital

Wage Index Occupational Mix Survey) 4. Addresses for Submittal of Comments on Information Collection

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, 2008

I. Summary and Background

II. Proposed Changes to the Prospective Payment Rates for Hospital

Inpatient Operating Costs for FY 2009

A. Calculation of the Adjusted Standardized Amount

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

C. Proposed MS-DRG Relative Weights

D. Calculation of the Proposed Prospective Payment Rates

III. Proposed Changes of Payment Rates for Acute Care Hospital

Inpatient Capital-Related Costs for FY 2009

A. Determination of Proposed Federal Hospital Inpatient Capital-

Related Prospective Payment Rate Update

B. Calculation of the Proposed Inpatient Capital-Related

Prospective Payments for FY 2009

C. Capital Input Price Index

IV. Proposed Changes to Payment Rates for Excluded Hospitals and

Hospital Units: Rate-of-Increase Percentages

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 2007; Hospital Wage Indexes for Federal Fiscal

Year 2009; Hospital Average Hourly Wages for Federal Fiscal Years 2007 (2003 Wage Data), 2008 (2004 Wage Data), and 2009 (2005 Wage

Data); and 3-Year Average of Hospital Average Hourly Wages

Table 3A.--FY 2009 and 3-Year Average Hourly Wage for Urban

Areas by CBSA

Table 3B.--FY 2009 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 and by State--FY 2009

Table 4B.--Wage Index and Capital Geographic Adjustment Factor

(GAF) for Rural Areas by CBSA and by State--FY 2009

Table 4C.--Wage Index and Capital Geographic Adjustment Factor

(GAF) for Hospitals That Are Reclassified by CBSA and by State--FY 2009

Table 4D-1.--Rural Floor Budget Neutrality Factors--FY 2009

Table 4D-2.--Urban Areas with Hospitals Receiving the Statewide

Rural Floor or Imputed Floor Wage Index--FY 2009

Table 4E.--Urban CBSAs and Constituent Counties--FY 2009

Table 4F.--Puerto Rico Wage Index and Capital Geographic

Adjustment Factor (GAF) by CBSA--FY 2009

Table 4J.--Out-Migration Wage Adjustment--FY 2009

Table 5.--List of 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 Exclusions List (Available through the Internet on the CMS Web site at: http://www.cms.hhs.gov/

AcuteInpatientPPS/)

Table 6H.--Deletions From the CC Exclusions List (Available

Through the

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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

(Available Through the Internet on the CMS Web Site at: http:// www.cms.hhs.gov/AcuteInpatientPPS/)

Table 6K.--Complication and Comorbidity (CC) List (Available

Through the Internet on the CMS Web site at: http://www.cms.hhs.gov/

AcuteInpatientPPS/)

Table 7A.--Medicare Prospective Payment System Selected

Percentile Lengths of Stay: FY 2007 MedPAR Update--December 2007

GROUPER V25.0 MS-DRGs

Table 7B.--Medicare Prospective Payment System Selected

Percentile Lengths of Stay: FY 2007 MedPAR Update--December 2007

GROUPER V26.0 MS-DRGs

Table 8A.--Proposed Statewide Average Operating Cost-to-Charge

Ratios--March 2008

Table 8B.--Proposed Statewide Average Capital Cost-to-Charge

Ratios--March 2008

Table 8C.--Proposed Statewide Average Total Cost-to-Charge

Ratios for LTCHs--March 2008

Table 9A.--Hospital Reclassifications and Redesignations--FY 2009

Table 9B.--Hospitals Redesignated as Rural under Section 1886(d)(8)(E) of the Act--FY 2009

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 Medicare Severity Diagnosis-Related

Groups (MS-DRGs)--March 2008

Table 11.--Proposed FY 2009 MS-LTC-DRGs, Proposed Relative

Weights, Proposed Geometric Average Length of Stay, and Proposed

Short-Stay Outlier Threshold

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 MS-DRG

Reclassifications and Relative Cost-Based Weights (Column 2)

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

E. Combined Effects of Proposed MS-DRG and Wage Index Changes

(Column 4)

F. Effects of MGCRB Reclassifications (Column 5)

G. Effects of the Proposed Rural Floor and Imputed Rural Floor,

Including the Proposed Application of Budget Neutrality at the State

Level (Column 6)

H. Effects of the Proposed Wage Index Adjustment for Out-

Migration (Column 7)

I. Effects of All Proposed Changes with CMI Adjustment Prior to

Estimated Growth (Column 8)

J. Effects of All Proposed Changes with CMI Adjustment and

Estimated Growth (Column 9)

K. Effects of Policy on Payment Adjustment for Low-Volume

Hospitals

L. Impact Analysis of Table II

VII. Effects of Other Proposed Policy Changes

A. Effects of Proposed Policy on HACs, Including Infections

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

Weights for LTCHs

C. Effects of Proposed Policy Change Relating to New Medical

Service and Technology Add-On Payments

D. Effects of Proposed Policy Change Regarding Postacute Care

Transfers to Home Health Services

E. Effects of Proposed Requirements for Hospital Reporting of

Quality Data for Annual Hospital Payment Update

F. Effects of Proposed Policy Change to Methodology for

Computing Core Staffing Factors for Volume Decrease Adjustment for

SCHs and MDHs

G. Effects of Proposed Clarification of Policy for Collection of

Risk Adjustment Data From MA Organizations

H. Effects of Proposed Policy Changes Relating to Hospital

Emergency Services under EMTALA

I. Effects of Implementation of Rural Community Hospital

Demonstration Program

J. Effects of Proposed Policy Changes Relating to Payments to

Hospitals-Within-Hospitals

K. Effects of Proposed Policy Changes Relating to Requirements for Disclosure of Physician Ownership in Hospitals

L. Effects of Proposed Changes Relating to Physician Self-

Referral Provisions

M. Effects of Proposed Changes Relating to Reporting of

Financial Relationships Between Hospitals and Physicians

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 2009

III. Secretary's Recommendation

IV. MedPAC Recommendation for Assessing Payment Adequacy and

Updating Payments in Traditional Medicare

Appendix C--Disclosure of Financial Relationships Report (DFRR) Form

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 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. 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

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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 in whole or in part based on their hospital-specific rate based on their costs in a base year. For example, sole community hospitals

(SCHs) receive the higher of a hospital-specific rate based on their costs in a base year (the higher of FY 1982, FY 1987, or FY 1996) or the IPPS rate based on the standardized amount. Until FY 2007, a

Medicare-dependent, small rural hospital (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 based on their costs in a base year (the higher of FY 1982, FY 1987, or FY 2002) is higher than the IPPS 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. SCHs are the sole source of care in their areas, and 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.

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. However, as discussed in section V.B.2. of this preamble, we are phasing out the IME adjustment beginning with FY 2008.

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'' under Sec. 412.23(e)(4) 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 psychiatric facilities (IPFs) (formerly psychiatric hospitals and psychiatric units of acute care hospitals) are paid under the IPF

PPS. For cost reporting periods beginning on or after January 1, 2008, all IPFs are paid 100 percent of the Federal per diem payment amount established under the IPF PPS. (For cost reporting periods beginning on or after January 1, 2005, and ending on or before December 31, 2007, some IPFs received transitioned payments for inpatient hospital services based on a blend of reasonable cost-based payment and a

Federal per diem payment rate.) The existing regulations governing payment under the IPF PPS are located in 42 CFR part 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 are 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

Page 23535

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)

Section 5001(b) of the Deficit Reduction Act of 2005 (DRA), Pub. L. 109-171, requires the Secretary to develop a plan to implement, beginning with FY 2009, a value-based purchasing plan for section 1886(d) hospitals defined in the Act. In section IV.C. of the preamble of this proposed rule, we discuss the report to Congress on the

Medicare value-based purchasing plan and the current testing of the plan.

C. Provisions of the Medicare Improvements and Extension Act Under

Division B, Title I of the Tax Relief and Health Care Act of 2006

(MIEA-TRHCA)

Section 106(b)(2) of the MIEA-TRHCA instructs the Secretary of

Health and Human Services 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

Secretary was also instructed to consider MedPAC's recommendations on the Medicare wage index classification system in developing these proposals. In section III. of the preamble of this proposed rule, we discuss MedPAC's recommendations in a report to Congress and present our proposed changes to the FY 2009 wage index in response to those recommendations.

D. Provision of the TMA, Abstinence Education, and QI Programs

Extension Act of 2007

Section 7 of the TMA [Transitional Medical Assistance], Abstinence

Education, and QI [Qualifying Individuals] Programs Extension Act of 2007 (Pub. L. 110-90) provides for a 0.9 percent prospective documentation and coding adjustment in the determination of standardized amounts under the IPPS (except for MDHs and SCHs) for discharges occurring during FY 2009. The prospective documentation and coding adjustment was established in FY 2008 in response to the implementation of an MS-DRG system under the IPPS that resulted in changes in coding and classification that did not reflect real changes in case-mix under section 1886(d) of the Act. We discuss our proposed implementation of this provision in section II.D. of the preamble of this proposed rule and in the Addendum and in Appendix A to this proposed rule.

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 2009. 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. In addition, we are presenting proposed changes relating to disclosure to patients of physician ownership and investment interests in hospitals, proposed changes to our physician self-referral regulations, and a solicitation of public comments on a proposed collection of information regarding financial relationships between hospitals and physicians.

The following is a summary of the major changes that we are proposing to make: 1. Proposed Changes to MS-DRG Classifications and Recalibrations of

Relative Weights

In section II. of the preamble to this proposed rule, we are including--

Proposed changes to MS-DRG reclassifications based on our yearly review.

Proposed application of the documentation and coding adjustment to hospital-specific rates resulting from implementation of the MS-DRG system.

Proposed changes to address the RTI reporting recommendations on charge compression.

Proposed recalibrations of the MS-DRG relative weights.

We also are proposing to refine the hospital cost reports so that charges for relatively inexpensive medical supplies are reported separately from the costs and charges for more expensive medical devices. This proposal would be applied to the determination of both the IPPS and the OPPS relative weights as well as the calculation of the ambulatory surgical center payment rates.

We are presenting a listing and discussion of additional hospital- acquired conditions (HACs), including infections, that are being proposed to be subject to the statutorily required quality adjustment in MS-DRG payments for FY 2009.

We are presenting our evaluation and analysis of the FY 2009 applicants for add-on payments for high-cost new medical services and technologies (including public input, as directed by Pub. L. 108-173, obtained in a town hall meeting).

We are proposing the annual update of the MS-LTC-DRG classifications and relative weights for use under the LTCH PPS for FY 2009. 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:

Proposed wage index reform changes in response to recommendations made to Congress as a result of the wage index study required under Pub. L. 109-432. We discuss changes related to reclassifications criteria, application of budget neutrality in reclassifications, and the rural floor and imputed floor budget neutrality at the State level.

Changes to the CBSA designations.

The methodology for computing the proposed FY 2009 wage index.

The proposed FY 2009 wage index update, using wage data from cost reporting periods that began during FY 2006.

Analysis and implementation of the proposed FY 2009 occupational mix adjustment to the wage index.

Proposed revisions to the wage index based on hospital redesignations and reclassifications.

The proposed adjustment to the wage index for FY 2009 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 used to compute the proposed FY 2009 wage index.

The proposed labor-related share for the FY 2009 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 the provisions of the regulations in 42 CFR Parts 412, 413, and 489, including the following:

Proposed changes to the postacute care transfer policy as it relates to transfers to home with the provision of home health services.

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

Proposed changes in the collection of Medicare Advantage

(MA) encounter data that are used for computing the risk payment adjustment made to MA organizations.

Discussion of the report to Congress on the Medicare value-based purchasing

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plan and current testing and further development of the plan.

Proposed changes to the methodology for determining core staff values for the volume decrease payment adjustment for SCHs and

MDHs.

The proposed updated national and regional case-mix values and discharges for purposes of determining RRC status.

The statutorily-required IME adjustment factor for FY 2009 and technical changes to the GME payment policies.

Proposed changes to policies on hospital emergency services under EMTALA to address EMTALA Technical Advisory Group (TAG) recommendations.

Solicitation of public comments on Medicare policies relating to incentives for avoidable readmissions to hospitals.

Discussion of the fifth 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. We acknowledge the public comments that we received on the phase-out of the capital teaching adjustment included in the FY 2008 IPPS final rule with comment period, and again are soliciting public comments on this phase-out in this proposed rule. 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 proposed changes to payments to excluded hospitals and hospital units, proposed changes for determining LTCH CCRs under the LTCH PPS, including a discussion regarding changing the annual payment rate update schedule for the LTCH PPS, and proposed changes to the regulations on hospitals-within-hospitals. 6. Proposed Changes Relating to Disclosure of Physician Ownership in

Hospitals

In section VII. of the preamble of this proposed rule, we present proposed changes to the regulations relating to the disclosure to patients of physician ownership or investment interests in hospitals. 7. Proposed Changes and Solicitation of Comments on Physician Self-

Referrals Provisions

In section VIII. of the preamble of this proposed rule, we present proposed changes to the policies on physician self-referrals relating to the ``Stand in Shoes'' provision, In addition, we solicit public comments regarding physician-owned implant companies and gainsharing arrangements. 8. Proposed Collection of Information Regarding Financial Relationships

Between Hospitals and Physicians

In section IX. of the preamble of this proposed rule, we solicit public comments on our proposed collection of information regarding financial relationships between hospitals and physicians. 9. 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 2009 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 2009 for hospitals and hospital units excluded from the

PPS. 10. 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. 11. 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 2009 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. 12. Disclosure of Financial Relationships Report (DFRR) Form

In Appendix C of this proposed rule, we present the reporting form that we are proposing to use for the proposed collection of information on financial relationships between hospitals and physicians discussed in section IX, of the preamble of this proposed rule. 13. 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 2008 recommendations concerning hospital inpatient payment policies address 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. We address these recommendations in Appendix B of this proposed rule. For further information relating specifically to the MedPAC March 2008 reports or to obtain a copy of the reports, contact MedPAC at (202) 220-3700 or visit MedPAC's Web site at: www.medpac.gov.

F. Public Comments Received on Issues in Related Rules 1. Comments on Phase-Out of the Capital Teaching Adjustment Under the

IPPS Included in the FY 2008 IPPS Final Rule With Comment Period

In the FY 2008 IPPS final rule with comment period, we solicited public comments on our policy changes related to phase-out of the capital teaching adjustment to the capital payment update under the

IPPS (72 FR 47401). We received approximately 90 timely pieces of correspondence in response to our solicitation. (These public comments may be viewed on the following Web site: http://www.cms.hhs.gov/ eRulemaking/ECCMSR/list.asp under file code CMS-1533-FC.) In section V. of the preamble of this proposed rule, we acknowledge receipt of these public comments and again solicit public comments on the phase-out in this proposed rule. We will respond to the public comments received in response to both the FY 2008 IPPS final rule with comment period and this proposed rule in the FY 2009 IPPS final rule, which is scheduled to be published in August 2008. 2. Policy Revisions Related to Medicare GME Group Affiliations for

Hospitals in Certain Declared Emergency Areas

We have issued two interim final rules with comment periods in the

Federal Register that modified the GME

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regulations as they apply to Medicare GME affiliated groups to provide for greater flexibility in training residents in approved residency programs during times of disasters: on April 12, 2006 (71 FR 18654) and on November 27, 2007 (72 FR 66892). We received a number of timely pieces of correspondence in response to these interim final rules with comment period. (The public comments that we received may be viewed on the Web site at: http://www.cms.hhs.gov/eRulemaking/ECCMSR/list.asp under the file codes CMS-1531-IFC1 and CMS-1531-IFC2, respectively.) We will summarize and address these public comments in the FY 2009 IPPS final rule, which is scheduled to be published in August 2008.

II. Proposed Changes to Medicare Severity DRG (MS-DRG) Classifications and Relative Weights

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 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. MS-DRG Reclassifications 1. General

As discussed in the preamble to the FY 2008 IPPS final rule with comment period (72 FR 47138), we focused 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 were intermediate steps towards comprehensive reform of both the relative weights and the DRG system that is occurring as we undertook further study. For FY 2008, we adopted 745 new Medicare

Severity DRGs (MS-DRGs) to replace the CMS DRGs. We refer readers to section II.D. of the FY 2008 IPPS final rule with comment period for a full detailed discussion of how the MS-DRG system was established based on severity levels of illness (72 FR 47141).

\1\ Medicare Payment Advisory Commission: Report to the

Congress, Physician-Owned Specialty Hospitals, March 25, page viii.

Currently, cases are classified into MS-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 MS-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 MS-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 to ensure 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 MS-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 2008, cases are assigned to one of 745 MS-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 an MS-DRG. However, under the most recent version of the Medicare GROUPER (Version 26.0), there are 9

MS-DRGs to

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which cases are directly assigned on the basis of ICD-9-CM procedure codes. These MS-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 for tracheostomies. Cases are assigned to these MS-DRGs before they are classified to an MDC. The table below lists the nine current pre-MDCs.

Pre-Major Diagnostic Categories (Pre-MDCs)

MS-DRG 103............................. Heart Transplant or Implant of

Heart Assist System.

MS-DRG 480............................. Liver Transplant and/or

Intestinal Transplant.

MS-DRG 481............................. Bone Marrow Transplant.

MS-DRG 482............................. Tracheostomy for Face, Mouth, and Neck Diagnoses.

MS-DRG 495............................. Lung Transplant.

MS-DRG 512............................. Simultaneous Pancreas/Kidney

Transplant.

MS-DRG 513............................. Pancreas Transplant.

MS-DRG 541............................. ECMO or Tracheostomy with

Mechanical Ventilation 96+

Hours or Principal Diagnosis

Except for Face, Mouth, and

Neck Diagnosis with Major O.R.

MS-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) or a major complication or comorbidity (MCC).

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 MS-DRG assignment for certain principal diagnoses. An example is extracorporeal shock wave lithotripsy for patients with a principal diagnosis of urinary stones. Lithotripsy procedures are not routinely performed in an operating room. Therefore, lithotripsy codes are not classified as O.R. procedures. However, our clinical advisors believe that patients with urinary stones who undergo extracorporeal shock wave lithotripsy should be considered similar to other patients who undergo

O.R. procedures. Therefore, we treat this group of patients similar to patients undergoing O.R. procedures.

Once the medical and surgical classes for an MDC were formed, each diagnosis class was evaluated to determine if complications or comorbidities would consistently affect the consumption of hospital resources. Each diagnosis was categorized into one of three severity levels. These three levels include a major complication or comorbidity

(MCC), a complication or comorbidity (CC), or a non-CC. Physician panels classified each diagnosis code based on a highly iterative process involving a combination of statistical results from test data as well as clinical judgment. As stated earlier, we refer readers to section II.D. of the FY 2008 IPPS final rule with comment period for a full detailed discussion of how the MS-DRG system was established based on severity levels of illness (72 FR 47141).

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 an MS-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 MS-DRG by the Medicare GROUPER software program.

The GROUPER program was developed as a means of classifying each case into an MS-DRG on the basis of the diagnosis and procedure codes and, for a limited number of MS-DRGs, demographic information (that is, sex, age, and discharge status).

After cases are screened through the MCE and assigned to an MS-DRG by the GROUPER, the PRICER software calculates a base MS-DRG payment.

The PRICER calculates the payment for each case covered by the IPPS based on the MS-DRG relative weight and additional factors associated with each hospital, such as IME and DSH payment adjustments. These additional factors increase the payment amount to hospitals above the base MS-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 MS-DRG classification changes and to recalibrate the MS-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.

As we indicated above, for FY 2008, we made significant improvement in the DRG system to recognize severity of illness and resource usage by adopting MS-DRGs. The changes we adopted were reflected in the FY 2008 GROUPER, Version 25.0, and were effective for discharges occurring on or after October 1, 2007. Our DRG analysis for the FY 2008 final rule with comment period was based on data from the March 2007 update of the FY 2006 MedPAR file, which contained hospital bills received through March 31, 2007, for discharges occurring through September 30, 2006. For this proposed rule, for FY 2009, our DRG analysis is based on data from the September 2007 update of the FY 2007 MedPAR file, which contains hospital bills received through September 30, 2007, for discharges through September 30, 2007. 2. Yearly Review for Making MS-DRG Changes

Many of the changes to the MS-DRG classifications we make annually are the result of specific issues brought to our attention by interested parties. We encourage individuals with concerns about MS-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

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timetable for interested parties to submit non-MedPAR data for consideration in the MS-DRG recalibration process, concerns about MS-

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 MS-DRGs was, and will likely continue to be, highly iterative, involving a combination of statistical results from test data combined with clinical judgment. In the FY 2008 IPPS final rule (72 FR 47140 through 47189), we described in detail the process we used to develop the MS-DRGs that we adopted for FY 2008. In addition, in deciding whether to make further modification to the MS-DRGs for particular circumstances brought to our attention, we considered 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 MS-DRG. We evaluated patient care costs using average charges and lengths of stay as proxies for costs and relied on the judgment of our medical advisors to decide whether patients are clinically distinct or similar to other patients in the MS-DRG. In evaluating resource costs, we considered both the absolute and percentage differences in average charges between the cases we selected for review and the remainder of cases in the MS-

DRG. We also considered 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 considered the number of patients who will have a given set of characteristics and generally preferred not to create a new MS-DRG unless it would include a substantial number of cases.

C. Adoption of the MS-DRGs in FY 2008

In the FY 2006, FY 2007, and FY 2008 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; 71 FR 47881 through 47939; and 72 FR 47140 through 47189). 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 contained 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 CMS 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 in connection with adopting severity DRGs. We describe below the progress we have made on these two initiatives, our actions for FY 2008, and our proposals for FY 2009 based on our continued analysis of reform of the DRG system. We note that the adoption of the MS-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 DSH payment adjustments. We discuss these implications for FY 2009 in other sections of this preamble and in the Addendum to this proposed rule.

In the FY 2007 IPPS proposed rule, we discussed MedPAC's recommendations to move to a cost-based HSRV weighting methodology using HSRVs beginning with the FY 2007 IPPS proposed rule for determining the DRG relative weights. Although we proposed to adopt the

HSRV weighting methodology for FY 2007, we decided not to adopt the proposed methodology in the final rule after considering the public comments we received on the proposal. Instead, in the FY 2007 IPPS final rule, we adopted a cost-based weighting methodology without the

HSRV portion of the proposed methodology. The cost-based 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 HSRV-based methodology as well as other issues brought to our attention related to the cost-based weighting methodology adopted in the FY 2007 final rule.

There was significant concern in the public comments that our cost- based weighting methodology does not adequately account for charge compression--the practice of applying a higher percentage charge markup over costs to lower cost items and services and a lower percentage charge markup over costs to higher cost items and services. 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) which we then applied to charges on the Medicare claims to determine the cost-based weights. The commenters were concerned about potential distortions to the cost-based 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 (RTI) 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 reports and how hospitals report charges on individual claims. Further, as part of its study of alternative DRG systems, the RAND Corporation analyzed the

HSRV cost-weighting methodology. We refer readers to section II.E. of the preamble of this proposed rule for our proposals for addressing the issue of charge compression and the HSRV cost-weighting methodology for

FY 2009.

We believe that revisions to the DRG system to better recognize severity of

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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 prospective payment system based on grouping cases will always present some opportunities for providers to specialize in cases they believe have higher margins, we believe that the changes we have adopted and the continuing reforms we are proposing in this proposed rule for FY 2009 will improve payment accuracy and reduce financial incentives to create specialty hospitals.

We refer readers to section II.D. of the FY 2008 IPPS final rule with comment period for a full discussion of how the MS-DRG system was established based on severity levels of illness (72 FR 47141).

D. MS-DRG Documentation and Coding Adjustment, Including the

Applicability to the Hospital-Specific Rates and the Puerto Rico-

Specific Standardized Amount 1. MS-DRG Documentation and Coding Adjustment

As stated above, we adopted the new MS-DRG patient classification system for the IPPS, effective October 1, 2007, to better recognize severity of illness in Medicare payment rates. Adoption of the MS-DRGs resulted in the expansion of the number of DRGs from 538 in FY 2007 to 745 in FY 2008. By increasing the number of DRGs and more fully taking into account severity of illness in Medicare payment rates, the MS-DRGs encourage hospitals to improve their documentation and coding of patient diagnoses. In the FY 2008 IPPS final rule with comment period

(72 FR 47175 through 47186), which appeared in the Federal Register on

August 22, 2007, we indicated that we believe the adoption of the MS-

DRGs had the potential to lead to increases in aggregate payments without a corresponding increase in actual patient severity of illness due to the incentives for improved documentation and coding. In that final rule with comment period, using the Secretary's authority under section 1886(d)(3)(A)(vi) of the Act to maintain budget neutrality by adjusting the standardized amount to eliminate the effect of changes in coding or classification that do not reflect real change in case-mix, we established prospective documentation and coding adjustments of -1.2 percent for FY 2008, -1.8 percent for FY 2009, and -1.8 percent for FY 2010.

On September 29, 2007, the TMA, Abstinence Education, and QI

Programs Extension Act of 2007, Pub. L. 110-90, was enacted. Section 7 of Pub. L. 110-90 included a provision that reduces the documentation and coding adjustment for the MS-DRG system that we adopted in the FY 2008 IPPS final rule with comment period to -0.6 percent for FY 2008 and -0.9 percent for FY 2009. To comply with the provision of section 7 of Pub. L. 110-90, in a final rule that appeared in the Federal

Register on November 27, 2007 (72 FR 66886), we changed the IPPS documentation and coding adjustment for FY 2008 to -0.6 percent, and revised the FY 2008 payment rates, factors, and thresholds accordingly, with these revisions effective October 1, 2007.

For FY 2009, Pub. L. 110-90 requires a documentation and coding adjustment of -0.9 percent instead of the -1.8 percent adjustment specified in the FY 2008 IPPS final rule with comment period. As required by statute, we are applying a documentation and coding adjustment of -0.9 percent to the FY 2009 IPPS national standardized amounts. The documentation and coding adjustments established in the FY 2008 IPPS final rule with comment period are cumulative. As a result, the -0.9 percent documentation and coding adjustment in FY 2009 is in addition to the -0.6 percent adjustment in FY 2008, yielding a combined effect of -1.5 percent. 2. Application of the Documentation and Coding Adjustment to the

Hospital-Specific Rates

Under section 1886(d)(5)(D)(i) of the Act, 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 are 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 based on the greater of either the FY 1982, 1987, or 2002 costs per discharge. In the FY 2008 IPPS final rule with comment period, we established a policy of applying the documentation and coding adjustment to the hospital-specific rates. In that rule, we indicated that because SCHs and MDHs use the same DRG system as all other hospitals, we believe they should be equally subject to the budget neutrality adjustment that we are applying for adoption of the MS-DRGs to all other hospitals. In establishing this policy, we cited our authority under section 1886(d)(3)(A)(vi) of the Act, which provides the authority to adjust ``the standardized amount'' to eliminate the effect of changes in coding or classification that do not reflect real change in case-mix. However, in a final rule that appeared in the

Federal Register on November 27, 2007 (72 FR 66886), we rescinded the application of the documentation and coding adjustment to the hospital- specific rates retroactive to October 1, 2007. In that final rule, we indicated that, while we still believe it would be appropriate to apply the documentation and coding adjustment to the hospital-specific rates, upon further review we decided that application of the documentation and coding adjustment to the hospital-specific rates is not consistent with the plain meaning of section 1886(d)(3)(A)(vi) of the Act, which only mentions adjusting ``the standardized amount'' and does not mention adjusting the hospital-specific rates.

We continue to have concerns about this issue. Because hospitals paid based on the hospital-specific rate use the same MS-DRG system as other hospitals, we believe they have the potential to realize increased payments from coding improvements that do not reflect real increases in patients' severity of illness. In section 1886(d)(3)(A)(vi) of the Act, Congress stipulated that hospitals paid based on the standardized amount should not receive additional payments based on the effect of documentation and coding changes that do not reflect real changes in case-mix. Similarly, we believe that hospitals paid based on the hospital-specific rate should not have the potential to realize increased payments due to documentation and coding improvements that do not reflect real increases in patients' severity of illness. While we continue to believe that section 1886(d)(3)(A)(vi) of the Act does not provide explicit authority for application of the documentation and coding adjustment to the hospital-specific rates, we believe that we have the authority to apply the documentation and coding adjustment to the hospital-specific rates using our special exceptions and adjustment authority under section 1886(d)(5)(I)(i) of the Act. 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.'' In light of this authority, for the FY 2010 rulemaking, we plan to

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examine our FY 2008 claims data for hospitals paid based on the hospital-specific rate. If we find evidence of significant increases in case-mix for patients treated in these hospitals, we would consider proposing application of the documentation and coding adjustments to the FY 2010 hospital-specific rates under our authority in section 1886(d)(5)(I)(i) of the Act. As noted previously, the documentation and coding adjustments established in the FY 2008 IPPS final rule with comment period are cumulative. For example, the -0.9 percent documentation and coding adjustment to the national standardized amount in FY 2009 is in addition to the -0.6 percent adjustment made in FY 2008, yielding a combined effect of -1.5 percent in FY 2009. Given the cumulative nature of the documentation and coding adjustments, if we were to propose to apply the documentation and coding adjustment to the

FY 2010 hospital-specific rates, it may involve applying the FY 2008 and FY 2009 documentation and coding adjustments (-1.5 percent combined) plus the FY 2010 documentation and coding adjustment, discussed in the FY 2008 IPPS final rule with comment period, to the FY 2010 hospital-specific rates. 3. Application of the Documentation and Coding Adjustment to the Puerto

Rico-Specific Standardized Amount

Puerto Rico hospitals are paid based on 75 percent of the national standardized amount and 25 percent of the Puerto Rico-specific standardized amount. As noted previously, the documentation and coding adjustment we adopted in the FY 2008 IPPS final rule with comment period relied upon our authority under section 1886(d)(3)(A)(vi) of the

Act, which provides the authority to adjust ``the standardized amounts computed under this paragraph'' to eliminate the effect of changes in coding or classification that do not reflect real change in case-mix.

Section 1886(d)(3)(A)(vi) of the Act applies to the national standardized amounts computed under section 1886(d)(3) of the Act, but does not apply to the Puerto Rico-specific standardized amount computed under section 1886(d)(9)(C) of the Act. In calculating the FY 2008 payment rates, we made an inadvertent error and applied the FY 2008 - 0.6 percent documentation and coding adjustment to the Puerto Rico- specific standardized amount, relying on our authority under section 1886(d)(3)(A)(vi) of the Act. We are currently in the process of developing a Federal Register notice to correct that error in the

Puerto Rico-specific standardized amount for FY 2008 retroactive to

October 1, 2007.

While section 1886(d)(3)(A)(vi) of the Act is not applicable to the

Puerto Rico-specific standardized amount, we believe that we have the authority to apply the documentation and coding adjustment to the

Puerto Rico-specific standardized amount using our special exceptions and adjustment authority under section 1886(d)(5)(I)(i) of the Act.

Similar to SCHs and MDHs that are paid based on the hospital-specific rate, discussed in section II.D.2. of this preamble, we believe that

Puerto Rico hospitals that are paid based on the Puerto Rico-specific standardized amount should not have the potential to realize increased payments due to documentation and coding improvements that do not reflect real increases in patients' severity of illness. Consistent with the approach described for SCHs and MDHs in section II.D.2. of the preamble of this proposed rule, for the FY 2010 rulemaking, we plan to examine our FY 2008 claims data for hospitals in Puerto Rico. If we find evidence of significant increases in case-mix for patients treated in these hospitals, we would consider proposing application of the documentation and coding adjustments to the FY 2010 Puerto Rico- specific standardized amount under our authority in section 1886(d)(5)(I)(i) of the Act. As noted previously, the documentation and coding adjustments established in the FY 2008 IPPS final rule with comment period are cumulative. Given the cumulative nature of the documentation and coding adjustments, if we were to propose to apply the documentation and coding adjustment to the FY 2010 Puerto Rico- specific standardized amount, it may involve applying the FY 2008 and

FY 2009 documentation and coding adjustments (-1.5 percent combined) plus the FY 2010 documentation and coding adjustment, discussed in the

FY 2008 IPPS final rule with comment period, to the FY 2010 Puerto

Rico-specific standardized amount. 4. Potential Additional Payment Adjustments in FYs 2010 Through 2012

Section 7 of Pub. L.110-90 also provides for payment adjustments in

FYs 2010 through 2012 based upon a retrospective evaluation of claims data from the implementation of the MS-DRG system. If, based on this retrospective evaluation, the Secretary finds that in FY 2008 and FY 2009, the actual amount of change in case-mix that does not reflect real change in underlying patient severity differs from the statutorily mandated documentation and coding adjustments implemented in those years, the law requires the Secretary to adjust payments for discharges occurring in FYs 2010 through 2012 to offset the estimated amount of increase or decrease in aggregate payments that occurred in FY 2008 and

FY 2009 as a result of that difference, in addition to making an appropriate adjustment to the standardized amount under section 1886(d)(3)(A)(vi) of the Act.

In order to implement these requirements of section 7 of Pub. L. 110-90, we are planning a thorough retrospective evaluation of our claims data. Results of this evaluation would be used by our actuaries to determine any necessary payment adjustments in FYs 2010 through 2012 to ensure the budget neutrality of the MS-DRG implementation for FY 2008 and FY 2009, as required by law. We are currently developing our analysis plans for this effort.

We intend to measure and corroborate the extent of the overall national average changes in case-mix for FY 2008 and FY 2009. We expect part of this overall national average change would be attributable to underlying changes in actual patient severity and part would be attributable to documentation and coding improvements under the MS-DRG system. In order to separate the two effects, we plan to isolate the effect of shifts in cases among base DRGs from the effect of shifts in the types of cases within base DRGs. The shifts among base DRGs are the result of changes in principal diagnoses while the shifts within base

DRGs are the result of changes in secondary diagnoses. Because we expect most of the documentation and coding improvements under the MS-

DRG system will occur in the secondary diagnoses, the shifts among base

DRGs are less likely to be the result of the MS-DRG system and the shifts within base DRGs are more likely to be the result of the MS-DRG system. We also anticipate evaluating data to identify the specific MS-

DRGs and diagnoses that contributed significantly to the improved documentation and coding payment effect and to quantify their impact.

This step would entail analysis of the secondary diagnoses driving the shifts in severity within specific base DRGs.

While we believe that the data analysis plan described previously will produce an appropriate estimate of the extent of case-mix changes resulting from documentation and coding improvements, we may also decide, if feasible, to use historical data from our Hospital Payment

Monitoring Program

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(HPMP) to corroborate the within base DRG shift analysis. The HPMP is supported by the Medicare Clinical Data Abstraction Center (CDAC). From 1999 to 2007, the CDAC obtained medical records for a sample of discharges as part of our hospital monitoring activities. These data were collected on a random sample of between 30,000 to 50,000 hospital discharges per year. The historical CDAC data could be used to develop an upper bound estimate of the trend in real case-mix growth (that is, real change in underlying patient severity) prior to implementation of the MS-DRGs.

We welcome public comments on our analysis plans, as well as suggestions on other possible approaches for conducting a retrospective analysis to identify the amount of case-mix changes that occurred in FY 2008 and FY 2009 that did not reflect real increases in patients' severity of illness. Our analysis, findings, and any resulting proposals to adjust payments for discharges occurring in FYs 2010 through 2012 to offset the estimated amount of increase or decrease in aggregate payments that occurred in FY 2008 and FY 2009 will be discussed in future years' rulemakings.

E. Refinement of the MS-DRG Relative Weight Calculation 1. Background

In the FY 2008 IPPS final rule with comment period (72 FR 47188), we continued to implement significant revisions to Medicare's inpatient hospital rates by basing relative weights on hospitals' estimated costs rather than on charges. We continued our 3-year transition from charge- based relative weights to cost-based relative weights. Beginning in FY 2007, we implemented relative weights based on cost report data instead of based on charge information. We had initially proposed to develop cost-based relative weights using the hospital-specific relative value cost center (HSRVcc) methodology as recommended by MedPAC. However, after considering concerns raised in the public comments, we modified

MedPAC's methodology to exclude the hospital-specific relative weight feature. Instead, we developed national CCRs based on distinct hospital departments and engaged a contractor to evaluate the HSRVcc methodology for future consideration. To mitigate payment instability due to the adoption of cost-based relative weights, we decided to transition cost- based weights over 3 years by blending them with charge-based weights beginning in FY 2007. In FY 2008, we continued our transition by blending the relative weights with one-third charge-based weights and two-thirds cost-based weights.

Also, in FY 2008, we adopted severity-based MS-DRGs, which increased the number of DRGs from 538 to 745. Many commenters raised concerns as to how the transition from charge-based weights to cost- based weights would continue with the introduction of new MS-DRGs. We decided to implement a 2-year transition for the MS-DRGs to coincide with the remainder of the transition to cost-based relative weights. In

FY 2008, 50 percent of the relative weight for each DRG was based on the CMS DRG relative weight and 50 percent was based on the MS-DRG relative weight. We refer readers to the FY 2007 IPPS final rule (71 FR 47882) for more detail on our final policy for calculating the cost- based DRG relative weights and to the FY 2008 IPPS final rule with comment period (72 FR 47199) for information on how we blended relative weights based on the CMS DRGs and MS-DRGs.

As we transitioned to cost-based relative weights, some commenters raised concerns about potential bias in the weights due to ``charge compression,'' which is the practice of applying a higher percentage charge markup over costs to lower cost items and services, and a lower percentage charge markup over costs to higher cost items and services.

As a result, the cost-based weights would 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. To address this concern, in August 2006, we awarded a contract to RTI to study the effects of charge compression in calculating the relative weights and to consider methods to reduce the variation in the CCRs across services within cost centers. RTI issued an interim draft report in March 2007 which was posted on the CMS Web site with its findings on charge compression. In that report, RTI found that a number of factors contribute to charge compression and affect the accuracy of the relative weights. RTI found inconsistent matching of charges in the Medicare cost report and their corresponding charges in the MedPAR claims for certain cost centers. In addition, there was inconsistent reporting of costs and charges among hospitals. For example, some hospitals would report costs and charges for devices and medical supplies in the Medical Supplies Charged to

Patients cost center, while other hospitals would report those costs and charges in their related ancillary departments such as Operating

Room or Radiology. RTI also found evidence that certain revenue codes within the same cost center had significantly different markup rates.

For example, within the Medicare Supplies Charged to Patients cost center, revenue codes for devices, implantables, and prosthetics had different markup rates than the other medical supplies in that cost center. RTI's findings demonstrated that charge compression exists in several CCRs, most notably in the Medical Supplies and Equipment CCR.

RTI offered short-term, medium-term, and long-term recommendations to mitigate the effects of charge compression. RTI's short-term recommendations included expanding the distinct hospital CCRs to 19 by disaggregating the ``Emergency Room'' and ``Blood and Blood Products'' from the Other Services cost center and by estimating regression-based

CCRs to disaggregate Medical Supplies, Drugs, and Radiology cost centers. RTI recommended, for the medium-term, to expand the MedPAR file to include separate fields that disaggregate several existing charge departments. In addition, RTI recommended improving hospital cost reporting instructions so that hospitals can properly report costs in the appropriate cost centers. RTI's long-term recommendations included adding new cost centers to the Medicare cost report, such as adding a ``Devices, Implants and Prosthetics'' line under ``Medical

Supplies Charged to Patients'' and a ``CT Scanning and MRI'' subscripted line under ``Radiology-Diagnostics''.

Among RTI's short-term recommendations, for FY 2008, we expanded the number of distinct hospital department CCRs from 13 to 15 by disaggregating ``Emergency Room'' and ``Blood and Blood Products'' from the Other Services cost center as these lines already exist on the hospital cost report. Furthermore, in an effort to improve consistency between costs and their corresponding charges in the MedPAR file, we moved the costs for cases involving electroencephalography (EEG) from the Cardiology cost center to the Laboratory cost center group which corresponds with the EEG MedPAR claims categorized under the Laboratory charges. We also agreed with RTI's recommendations to revise the

Medicare cost report and the MedPAR file as a long-term solution for charge compression. We stated that, in the upcoming year, we would consider additional lines to the cost report and additional revenue codes for the MedPAR file.

We did not adopt RTI's short-term recommendation to create four

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additional regression-based CCRs for several reasons, even though we had received comments in support of the regression-based CCRs as a means to immediately resolve the problem of charge compression, particularly within the Medical Supplies and Equipment CCR. We were concerned that RTI's analysis was limited to charges on hospital inpatient claims while typically hospital cost report CCRs combine both inpatient and outpatient services. Further, because both the IPPS and

OPPS rely on cost-based weights, we preferred to introduce any methodological adjustments to both payment systems at the same time. We have since expanded RTI's analysis of charge compression to incorporate outpatient services. RTI has been evaluating the cost estimation process for the OPPS cost-based weights, including a reassessment of the regression-based CCR models using both outpatient and inpatient charge data. The RTI report was finalized at the conclusion of our proposed rule development process and is expected to be posted on the

CMS Web site in the near future. We welcome comments on this report.

A second reason that we did not implement regression-based CCRs at the time of the FY 2008 IPPS final rule with comment period was our inability to investigate how regression-based CCRs would interact with the implementation of MS-DRGs. We stated that we would consider the results of the second phase of the RAND study as we prepared for the FY 2009 IPPS rulemaking process. The purpose of the RAND study was to analyze how the relative weights would change if we were to adopt regression-based CCRs to address charge compression while simultaneously adopting an HSRV methodology using fully phased-in MS-

DRGs. We had intended to include a detailed discussion of RAND's study in this FY 2009 IPPS proposed rule. However, due to some delays in releasing identifiable data to the contractor under revised data security rules, the report on this second stage of RAND's analysis was not completed in time for the development of this proposed rule.

Therefore, we continue to have the same concerns with respect to uncertainty about how regression-based CCRs would interact with the MS-

DRGs or an HSRV methodology. Therefore, we are not proposing to adopt the regression-based CCRs or an HSRV methodology in this FY 2009 IPPS proposed rule. Nevertheless, we welcome public comments on our proposals not to adopt regression-based CCRs or an HSRV methodology at this time or in the future. The RAND report on regression-based CCRs and the HSRV methodology was finalized at the conclusion of our proposed rule development process and is expected to be posted on the

CMS Web site in the near future. Although we are unable to include a discussion of the results of the RAND study in this proposed rule, we welcome public comment on the report.

Finally, we received public comments on the FY 2008 IPPS proposed rule raising concerns on the accuracy of using regression-based CCR estimates to determine the relative weights rather than the Medicare cost report. Commenters noted that regression-based CCRs would not fix the underlying mismatch of hospital reporting of costs and charges.

Instead, the commenters suggested that the impact of charge compression might be mitigated through an educational initiative that would encourage hospitals to improve their cost reporting. Commenters recommended that hospitals be educated to report costs and charges in a way that is consistent with how charges are grouped in the MedPAR file.

In an effort to achieve this goal, hospital associations have launched an educational campaign to encourage consistent reporting, which would result in consistent groupings of the cost centers used to establish the cost-based relative weights. The commenters requested that CMS communicate to the fiscal intermediaries/MACs that such action is appropriate. In the FY 2008 IPPS final rule with comment period, we stated that we were supportive of the educational initiative of the industry, and we encouraged hospitals to report costs and charges consistently with how the data are used to determine relative weights

(72 FR 47196). We would also like to affirm that the longstanding

Medicare principles of cost apportionment at 42 CFR 413.53 convey that, under the departmental method of apportionment, the cost of each ancillary department is to be apportioned separately rather than being combined with another ancillary department (for example, combining the cost of Medical Supplies Charged to Patients with the costs of

Operating Room or any other ancillary cost center. (We note that, effective for cost reporting periods starting on or after January 1, 1979, the departmental method of apportionment replaced the combination method of apportionment where all the ancillary departments were apportioned in the aggregate (Section 2200.3 of the Provider

Reimbursement Manual (PRM), Part I).)

Furthermore, longstanding Medicare cost reporting policy has been that hospitals must include the cost and charges of separately

``chargeable medical supplies'' in the Medical Supplies Charged to

Patients cost center (line 55 of Worksheet A), rather than in the

Operating Room, Emergency Room, or other ancillary cost centers.

Routine services, which can include ``minor medical and surgical supplies'' (Section 2202.6 of the PRM, Part 1), and items for which a separate charge is not customarily made, may be directly assigned through the hospital's accounting system to the department in which they were used, or they may be included in the Central Services and

Supply cost center (line 15 of Worksheet A). Conversely, the separately chargeable medical supplies should be assigned to the Medical Supplies

Charged to Patients cost center on line 55.

We note that not only is accurate cost reporting important for IPPS hospitals to ensure that accurate relative weights are computed, but hospitals that are still paid on the basis of cost, such as CAHs and cancer hospitals, and SCHs and MDHs must adhere to Medicare cost reporting principles as well.

The CY 2008 OPPS/ASC final rule with comment period (72 FR 66601) also discussed the issue of charge compression and regression-based

CCRs, and noted that RTI is currently evaluating the cost estimation process underpinning the OPPS cost-based weights, including a reassessment of the regression models using both outpatient and inpatient charges, rather than inpatient charges only. In responding to comments in the CY 2008 OPPS/ASC final rule with comment period, we emphasized that we ``fully support'' the educational initiatives of the industry and that we would ``examine whether the educational activities being undertaken by the hospital community to improve cost reporting accuracy under the IPPS would help to mitigate charge compression under the OPPS, either as an adjunct to the application of regression-based

CCRs or in lieu of such an adjustment'' (72 FR 66601). However, as we stated in the FY 2008 IPPS final rule with comment period that we would consider the results of the RAND study before considering whether to adopt regression-based CCRs, in the CY 2008 OPPS/ASC final rule with comment period, we stated that we would determine whether refinements should be proposed, after reviewing the results of the RTI study.

On February 29, 2008, we issued Transmittal 321, Change Request 5928, to inform the fiscal intermediaries/

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MACs of the hospital associations' initiative to encourage hospitals to modify their cost reporting practices with respect to costs and charges in a manner that is consistent with how charges are grouped in the

MedPAR file. We noted that the hospital cost reports submitted for FY 2008 may have costs and charges grouped differently than in prior years, which is allowable as long as the costs and charges are properly matched and the Medicare cost reporting instructions are followed.

Furthermore, we recommended that fiscal intermediaries/MACs remain vigilant to ensure that the costs of items and services are not moved from one cost center to another without moving their corresponding charges. Due to a time lag in submittal of cost reporting data, the impact of changes in providers' cost reporting practices occurring during FY 2008 would be reflected in the FY 2011 IPPS relative weights. 2. Refining the Medicare Cost Report

In developing this FY 2009 proposed rule, we considered whether there were concrete steps we could take to mitigate the bias introduced by charge compression in both the IPPS and OPPS relative weights in a way that balance hospitals' desire to focus on improving the cost reporting process through educational initiatives with device industry interest in adopting regression-adjusted CCRs. Although RTI recommended adopting regression-based CCRs, particularly for medical supplies and devices, as a short-term solution to address charge compression, RTI also recommended refinements to the cost report as a long-term solution. RTI's draft interim March 2007 report discussed a number of options that could improve the accuracy and precision of the CCRs currently being derived from the Medicare cost report and also reduce the need for statistically-based adjustments. As mentioned in the FY 2008 IPPS final rule with comment period (72 FR 47193), we believe that

RTI and many of the public commenters on the FY 2008 IPPS proposed rule concluded that, ultimately, improved and more precise cost reporting is the best way to minimize charge compression and improve the accuracy of cost weights. Therefore, in this proposed rule, we are proposing to begin making cost report changes geared to improving the accuracy of the IPPS and OPPS relative weights. However, we also received comments last year asking that we proceed cautiously with changing the Medicare cost report to avoid unintended consequences for hospitals that are paid on a cost basis (such as CAHs and, to some extent, SCHs and MDHs), and to consider the administrative burden associated with adapting to new cost reporting forms and instructions. Accordingly, we are proposing to focus at this time on the CCR for Medical Supplies and

Equipment because RTI found that the largest impact on the relative weights could result from correcting charge compression for devices and implants. When examining markup differences within the Medical Supplies

Charged to Patients cost center, RTI found that its ``regression results provide solid evidence that if there were distinct cost centers for items, cost ratios for devices and implants would average about 17 points higher than the ratios for other medical supplies'' (January 2007 RTI report, page 59). This suggests that much of the charge compression within the Medical Supplies CCR results from inclusion of medical devices that have significantly different markups than the other supplies in that CCR. Furthermore, in the FY 2007 final rule and

FY 2008 IPPS final rule with comment period, the Medical Supplies and

Equipment CCR received significant attention by the public commenters.

Although we are proposing to make improvements to lessen the effects of charge compression only on the Medical Supplies and

Equipment CCR as a first step, we are inviting public comments as to whether to make other changes to the Medicare cost report to refine other CCRs. In addition, we are open to making further refinements to other CCRs in the future. Therefore, we are proposing at this time to add only one cost center to the cost report, such that, in general, the costs and charges for relatively inexpensive medical supplies would be reported separately from the costs and charges of more expensive devices (such as pacemakers and other implantable devices). We will consider public comments submitted on this proposed rule for purposes of both the IPPS and the OPPS relative weights and, by extension, the calculation of the ambulatory surgical center (ASC) payment rates.

Under the IPPS for FY 2007 and FY 2008, the aggregate CCR for supplies and equipment was computed based on line 55 for Medical

Supplies Charged to Patients and lines 66 and 67 for DME Rented and DME

Sold, respectively. To compute the 15 national CCRs used in developing the cost-based weights under the IPPS (explained in more detail under section II.H. of the preamble of this proposed rule), we take the costs and charges for the 15 cost groups from Worksheet C, Part I of the

Medicare cost report for all hospital patients and multiply each of these 15 CCRs by the Medicare charges on Worksheet D-4 for those same cost centers to impute the Medicare cost for each of the 15 cost groups. Under this proposal, the goal would be to split the current CCR for Medical Supplies and Equipment into one CCR for medical supplies, and another CCR for devices and DME Rented and DME Sold.

In considering how to instruct hospitals on what to report in the cost center for supplies and the cost center for devices, we looked at the existing criteria for what type of device qualifies for payment as a transitional pass-through device category in the OPPS. (There are no such existing criteria for devices under the IPPS.) The provisions of the regulations under Sec. 419.66(b) state that for a medical device to be eligible for pass-through payment under the OPPS, the medical device must meet the following criteria: a. If required by the FDA, the device must have received FDA approval or clearance (except for a device that has received an FDA investigational device exemption (IDE) and has been classified as a

Category B device by the FDA in accordance with Sec. Sec. 405.203 through 405.207 and 405.211 through 405.215 of the regulations) or another appropriate FDA exemption. b. The device is determined to be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body part (as required by section 1862(a)(1)(A) of the Act). c. The device is an integral and subordinate part of the service furnished, is used for one patient only, comes in contact with human tissues, and is surgically implanted or inserted whether or not it remains with the patient when the patient is released from the hospital. d. The device is not any of the following:

Equipment, an instrument, apparatus, implement, or item of this type for which depreciation and financing expenses are recovered as depreciable assets as defined in Chapter 1 of the Medicare Provider

Reimbursement Manual (CMS Pub. 15-1).

A material or supply furnished incident to a service (for example, a suture, customized surgical kit, or clip, other than a radiological site marker).

Material that may be used to replace human skin (for example, a biological or synthetic material).

These requirements are the OPPS criteria used to define a device for pass-through payment purposes and do not include additional criteria that are used

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under the OPPS to determine if a candidate device is new and represents a substantial clinical improvement, two other requirements for qualifying for pass-through payment.

For purposes of applying the eligibility criteria, we interpret

``surgical insertion or implantation'' to include devices that are surgically inserted or implanted via a natural or surgically created orifice as well as those devices that are inserted or implanted via a surgically created incision (70 FR 68630).

In proposing to modify the cost report to have one cost center for medical supplies and one cost center for devices, we are proposing that hospitals would determine what should be reported in the Medical

Supplies cost center and what should be reported in the Medical Devices cost center using criteria consistent with those listed above that are included under Sec. 419.66(b), with some modification. Specifically, for purposes of the cost reporting instructions, we are proposing that an item would be reported in the device cost center if it meets the following criteria: a. If required by the FDA, the device must have received FDA approval or clearance (except for a device that has received an FDA investigational device exemption (IDE) and has been classified as a

Category B device by the FDA in accordance with Sec. Sec. 405.203 through 405.207 and 405.211 through 405.215 of the regulations) or another appropriate FDA exemption. b. The device is reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body part (as required by section 1862(a)(1)(A) of the Act). c. The device is an integral and subordinate part of the service furnished, is used for one patient only, comes in contact with human tissue, is surgically implanted or inserted through a natural or surgically created orifice or surgical incision in the body, and remains in the patient when the patient is discharged from the hospital. d. The device is not any of the following:

Equipment, an instrument, apparatus, implement, or item of this type for which depreciation and financing expenses are recovered as depreciable assets as defined in Chapter 1 of the Medicare Provider

Reimbursement Manual (CMS Pub. 15-1).

A material or supply furnished incident to a service (for example, a surgical staple, a suture, customized surgical kit, or clip, other than a radiological site marker).

Material that may be used to replace human skin (for example, a biological or synthetic material).

A medical device that is used during a procedure or service and does not remain in the patient when the patient is released from the hospital.

We are proposing to select the existing criteria for what type of device qualifies for payment as a transitional pass-through device under the OPPS as a basis for instructing hospitals on what to report in the cost center for Medical Supplies Charged to Patients or the cost center for Medical Devices Charged to Patients because these criteria are concrete and already familiar to the hospital community. However, the key difference between the existing criteria for devices that are eligible for pass-through payment under the OPPS at Sec. 419.66(b) and our proposed criteria stated above to be used for cost reporting purposes is that the device that is implanted remains in the patient when the patient is discharged from the hospital. Essentially, we are proposing to instruct hospitals to report only implantable devices that remain in the patient at discharge in the cost center for devices. All other devices and non-routine supplies which are separately chargeable would be reported in the medical supplies cost center. We believe that defining a device for cost reporting purposes based on criteria that specify implantation and adding that the device must remain in the patient upon discharge would have the benefit of capturing virtually all costly implantable devices (for example, implantable cardioverter defibrillators (ICDs), pacemakers, and cochlear implants) for which charge compression is a significant concern.

However, we acknowledge that a definition of device based on whether an item is implantable and remains in the patient could, in some cases, include items that are relatively inexpensive (for example, urinary catheters, fiducial markers, vascular catheters, and drainage tubes), and which many would consider to be supplies. Thus, some modest amount of charge compression could still be present in the cost center for devices if the hospital does not have a uniform markup policy. In addition, requiring as a cost reporting criterion that the device is to remain in the patient at discharge could exclude certain technologies that are moderately expensive (for example, cryoablation probes, angioplasty catheters, and cardiac echocardiography catheters, which do not remain in the patient upon discharge). Therefore, some charge compression could continue for these technologies. We believe this limited presence of charge compression is acceptable, given that the proposed definition of device for cost reporting purposes would isolate virtually all of the expensive items, allowing them to be separately reported from most inexpensive supplies.

The criteria we are proposing above for instructing hospitals as to what to report in the device cost center specify that a device is not a material or supply furnished incident to a service (for example, a surgical staple, a suture, customized surgical kit, or clip, other than a radiological site marker) (emphasis added). We understand that hospitals may sometimes receive surgical kits from device manufacturers that consist of a high-cost primary implantable device, external supplies required for operation of the device, and other disposable surgical supplies required for successful device implantation. Often the device and the attending supplies are included on a single invoice from the manufacturer, making it difficult for the hospital to determine the cost of each item in the kit. In addition, manufacturers sometimes include with the primary device other free or ``bonus'' items or supplies that are not an integral and necessary part of the device

(that is, not actually required for the safe surgical implantation and subsequent operation of that device). (We note that arrangements involving free or bonus items or supplies may implicate the Federal anti-kickback statue, depending on the circumstances.) One option is for the hospital to split the total combined charge on the invoice in a manner that the hospital believes best identifies the cost of the device alone. However, because it may be difficult for hospitals to determine the respective costs of the actual device and the attending supplies (whether they are required for the safe surgical implantation and subsequent operation of that device or not), we are soliciting comments with respect to how supplies, disposable or otherwise, that are part of surgical kits should be reported. We are distinguishing between such supplies that are an integral and necessary part of the primary device (that is, required for the safe surgical implantation and subsequent operation of that device) from other supplies that are not directly related to the implantation of that device, but may be included by the device manufacturer with or without charge as ``perks'' along with the kit. If it is difficult to break out the costs and charges of these lower cost items that are an integral and necessary

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part of the primary device, we would consider allowing hospitals to report the costs and charges of these lower cost supplies along with the costs and charges of the more expensive primary device in the cost report cost center for implantable devices. However, to the extent that device manufacturers could be encouraged to refine their invoicing practices to break out the charges and costs for the lower cost supplies and the higher cost primary device separately, so that hospitals need not ``guesstimate'' the cost of the device, this would facilitate more accurate cost reporting and, therefore, the calculation of more accurate cost-based weights. Under either scenario, even for an aggregated invoice that contains an expensive device, we believe that

RTI's findings of significant differences in supply CCRs for hospitals with a greater percentage of charges in device revenue codes demonstrate that breaking the Medical Supplies Charged to Patients cost center into two cost centers and using appropriate revenue codes for devices, and walking those costs to the new Implantable Devices Charged to Patients cost center, will result in an increase in estimated device costs.

In summary, we are proposing to modify the cost report to have one cost center for Medical Supplies Charged to Patients and one cost center for Implantable Devices Charged to Patients. We are proposing to instruct hospitals to report only devices that meet the four criteria listed above (specifically including that the device is implantable and remains in the patient at discharge) in the cost center for Implantable

Devices Charged to Patients. All other devices and nonchargeable supplies would be reported in the Medical Supplies cost center. This would allow for two distinct CCRs, one for medical supplies and one for implantable devices and DME rented and DME sold.

However, we are also soliciting comments on alternative approaches that could be used in conjunction with or in lieu of the four proposed criteria for distinguishing between what should be reported in the cost center for Implantable Devices and Medical Supplies, respectively.

Another option we are considering would distinguish between high-cost and low-cost items based on a cost threshold. Under this methodology, we would also have one cost center for Medical Supplies and one cost center for Devices, but we would instruct hospitals to report items that are not movable equipment or a capital expense but are above a certain cost threshold in the cost center for Devices. Items costing below that threshold would be reported in the cost center for Medical

Supplies.

Establishing a cost threshold for cost reporting purposes would directly address the problem of charge compression and would enable hospitals to easily determine whether an item should be reported in the supply or the device cost center. A cost threshold would also potentially allow a broader variety of expensive, single use devices that do not remain in the patient at discharge to be reported in the device cost center (such as specialized catheters or ablation probes).

While we have a number of concerns with the cost threshold approach, we are nevertheless soliciting public comments on whether such an approach would be worthwhile to pursue. Specifically, we are concerned that establishing a single cost threshold for pricing devices could possibly be inaccurate across hospitals. Establishing a threshold would require identifying a cost at which hospitals would begin applying reduced markup policies. Currently, we do not have data from which to derive a threshold. We have anecdotal reports that hospitals change their markup thresholds between $15,000 and $20,000 in acquisition costs. Recent research on this issue indicated that hospitals with average inpatient discharges in DRGs with supply charges greater than $15,000, $20,000, and $30,000 have higher supply CCRs (Advamed March 2006).

Furthermore, although a cost threshold directly addresses charge compression, it may not eliminate all charge compression from the device cost center because a fixed cost threshold may not accurately capture differential markup policies for an individual hospital. At the same time, we are also concerned that establishing a cost threshold may interfere with the pricing practices of device manufacturers in that the prices for certain devices or surgical kits could be inflated to ensure that the devices met the cost threshold. We believe our proposed approach of identifying a group of items that are relatively expensive based on the existing criteria for OPPS device pass-through payment status, rather than adopting a cost threshold, would not influence pricing by the device industry. In addition, if a cost threshold were adopted for distinguishing between high-cost devices and low-cost supplies on the cost report, we would need to periodically reassess the threshold for changes in markup policies and price inflation over time.

Another option for distinguishing between high-cost and low-cost items for purposes of the cost report would be to divide the Medical

Supplies cost center based on markup policies by placing items with lower than average markups in a separate cost center. This approach would center on documentation requirements for differential charging practices that would lead hospitals to distinguish between the reporting of supplies and devices on different cost report lines. That is, because charge compression results from the different markup policies that hospitals apply to the supplies and devices they use based on the estimated costs of those supplies and devices, isolating supplies and devices with different markup policies mitigates aggregation in markup policies that cause charge compression and is specific to a hospital's internal accounting and pricing practices. If requested by the fiscal intermediaries/MACs at audit, hospitals could be required to submit documentation of their markup policies to justify the way they have reported relatively inexpensive supplies on one line and more expensive devices on the other line. We believe that it should not be too difficult for hospitals to document their markup practices because, as was pointed out by many commenters since the implementation of cost-based weights, the source of charge compression is varying markup practices. Greater knowledge of the specifics of hospital markup practices may allow ultimately for development of standard cost reporting instructions that instruct hospitals to report an item as a device or a supply based on the type of markup applied to that item.

This option related to markup practices, the proposal to define devices based on four specific criteria, and the third alternative that would establish a cost threshold for purposes of distinguishing between high- cost and low-cost items, could be utilized separately or in some combination for purposes of cost report modification. Again, we are soliciting comments on these alternative approaches. We are also interested in other recommendations for appropriate cost reporting improvements that address charge compression. 3. Timeline for Revising the Medicare Cost Report

As mentioned in the FY 2008 IPPS final rule with comment period (72

FR 47198), we have begun a comprehensive review of the Medicare hospital cost report, and the proposed splitting of the current cost center for Medical Supplies Charged to Patients into one line for

Medical Supplies Charged to Patients and another line for Implantable

Devices Charged to Patients, is part of

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our initiative to update and revise the hospital cost report. Under an effort initiated by CMS to update the Medicare hospital cost report to eliminate outdated requirements in conjunction with the Paperwork

Reduction Act, we plan to propose the actual changes to the cost reporting form, the attending cost reporting software, and the cost report instructions in Chapter 36 of the Medicare Provider

Reimbursement Manual (PRM), Part II. We expect the proposed revision to the Medicare hospital cost report to be issued after publication of this IPPS proposed rule. If we were to adopt as final our proposal to create one cost center for Medical Supplies Charged to Patients and one cost center for Implantable Devices Charged to Patients in the FY 2009

IPPS final rule, the cost report forms and instructions would reflect those changes. We expect the revised cost report would be available for hospitals to use when submitting cost reports during FY 2009 (that is, for cost reporting periods beginning on or after October 1, 2008).

Because there is approximately a 3-year lag between the availability of cost report data for IPPS and OPPS ratesetting purposes and a given fiscal year, we may be able to derive two distinct CCRs, one for medical supplies and one for devices, for use in calculating the FY 2012 IPPS relative weights and the CY 2012 OPPS relative weights. 4. Revenue Codes Used in the MedPAR File

An important first step in RTI's study (as explained in its draft interim March 2007 report) was determining how well the cost report charges used to compute CCRs matched to the charges in the MedPAR file.

This match (or lack thereof) directly affects the accuracy of the DRG cost estimates because MedPAR charges are multiplied by CCRs to estimate cost. RTI found 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 some 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, while other hospitals include them in the Medical Supplies

Charged to Patients cost center. While the educational initiative undertaken by the national hospital associations is encouraging hospitals to consistently report costs and charges for devices and other medical supplies only in the Medical Supplies Charged to Patients cost center, equal attention must be paid to the way in which charges are grouped by hospitals in the MedPAR file. Several commenters on the

FY 2008 IPPS proposed rule supported RTI's recommendation of including additional fields in the MedPAR file to disaggregate certain cost centers. One commenter stated that the assignment of revenue codes and charges to revenue centers in the MedPAR file should be reviewed and changed to better reflect hospital accounting practices as reflected on the cost report (72 FR 47198).

In an effort to improve the match between the costs and charges included on the cost report and the charges in the MedPAR file, we are recommending that certain revenue codes be used for items reported in the proposed Medical Supplies Charged to Patients cost center and the proposed Implantable Devices Charged to Patients cost center, respectively. Specifically, under the proposal to create a cost center for implantable devices that remain in the patient upon discharge, revenue codes 0275 (Pacemaker), 0276 (Intraocular Lens), and 0278

(Other Implants) would correspond to implantable devices reported in the proposed Implantable Devices Charged to Patients cost center. Items for which a hospital may have previously used revenue code 0270

(General Classification), but actually meet the proposed definition of an implantable device that remains in the patient upon discharge should instead be billed with the 0278 revenue code. Conversely, relatively inexpensive items and supplies that are not implantable and do not remain in the patient at discharge would be reported in the proposed

Medical Supplies Charged to Patients cost center on the cost report, and should be billed with revenue codes 0271 (nonsterile supply), 0272

(sterile supply), and 0273 (take-home supplies), as appropriate.

Revenue code 0274 (Prosthetic/Orthotic devices) and revenue code 0277

(Oxygen--Take Home) should be associated with the costs reported on lines 66 and 67 for DME--Rented and DME--Sold on the cost report.

Charges associated with supplies used incident to radiology or to other diagnostic services (revenue codes 0621 and 0622 respectively) should match those items used incident to those services on the Medical

Supplies Charged to Patients cost center of the cost report, because, under this proposal, supplies furnished incident to a service would be reported in the Medical Supplies Charged to Patients cost center (see item b. listed above, in the proposed definition of a device). A revenue code of 0623 for surgical dressings would similarly be associated with the costs and charges of items reported in the proposed

Medical Supplies Charged to Patients cost center, while a revenue code of 0624 for FDA investigational device, if that device does not remain in the patient upon discharge, could be associated with items reported on the Medical Supplies Charged to Patients cost center as well.

In general, if an item is reported as an implantable device on the cost report, the associated charges should be recorded in the MedPAR file with either revenue codes 0275 (Pacemaker), 0276 (Intraocular

Lens), or 0278 (Other Implants). Likewise, items reported as Medical

Supplies should receive an appropriate revenue code indicative of supplies. We understand that many of these revenue codes have been in existence for many years and have been added for purposes unrelated to the goal of refining the calculation of cost-based weights.

Accordingly, we acknowledge that additional instructions relating to the appropriate use of these revenue codes may need to be issued. In addition, CMS or the hospital associations may need to request new revenue codes from the National Uniform Billing Committee (NUBC). In either case, we do not believe either should delay use of the new

Medical Supplies and Implantable Devices CCRs in setting payment rates.

However, in light of our proposal to create two separate cost centers for Medical Supplies Charged to Patients and Implantable Devices

Charged to Patients, respectively, we are soliciting comments on how the existing revenue codes or additional revenue codes could best be used in conjunction with the revised cost centers on the cost report.

F. Preventable Hospital-Acquired Conditions (HACs), Including

Infections 1. General

In its landmark 1999 report ``To Err is Human: Building a Safer

Health System,'' the Institute of Medicine found that medical errors, particularly hospital-acquired conditions (HACs) caused by medical errors, are a leading cause of morbidity and mortality in the United

States. The report noted that the number of Americans who die each year as a result of medical errors that occur in hospitals may be as high as 98,000. The cost burden of HACs is also high. Total national costs of these errors due to lost productivity, disability, and health care costs were estimated at $17

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billion to $29 billion.\2\ In 2000, the CDC estimated that hospital- acquired infections added nearly $5 billion to U.S. health care costs every year.\3\ A 2007 study found that, in 2002, 1.7 million hospital- acquired infections were associated with 99,000 deaths\4\ Research has also shown that hospitals are not following recommended guidelines to avoid preventable hospital-acquired infections. A 2007 Leapfrog Group survey of 1,256 hospitals found that 87 percent of those hospitals do not follow recommendations to prevent many of the most common hospital- acquired infections.\5\

\2\ Institute of Medicine: To Err Is Human: Building a Safer

Health System, November 1999. Available at: http://www.iom.edu/

Object.File/Master/4/117/ToErr-8pager.pdf.

\3\ Centers for Disease Control and Prevention: Press Release,

March 2000. Available at: http://www.cdc.gov/od/oc/media/pressrel/ r2k0306b.htm.

\4\ Klevens et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports. March-

April 2007. Volume 122.

\5\ 2007 Leapfrog Group Hospital Survey. The Leapfrog Group 2007. Available at: http://www.leapfroggroup.org/media/file/

Leapfrog_hospital_acquired_infections_release.pdf

As one approach to combating HACs, including infections, in 2005

Congress authorized CMS to adjust for Medicare IPPS hospital payments to encourage the prevention of these conditions. The preventable HAC provision at section 1886(d)(4)(D) of the Act is part of an array of

Medicare value-based purchasing (VBP) tools that CMS is using to promote increased quality and efficiency of care. Those tools include measuring performance, using payment incentives, publicly reporting performance results, applying national and local coverage policy decisions, enforcing conditions of participation, and providing direct support for providers through Quality Improvement Organization (QIO) activities. CMS' application of VBP tools through various initiatives, such as this HAC provision, is transforming Medicare from a passive payer to an active purchaser of higher value health care services. We are applying these strategies for inpatient hospital care and across the continuum of care for Medicare beneficiaries.

The President's FY 2009 Budget outlines another approach for addressing serious preventable adverse events (``never events''), including HACs. The President's Budget proposal would: (1) Prohibit hospitals from billing the Medicare program for ``never events'' and prohibit Medicare payment for these events; and (2) require hospitals to report occurrence of these events or receive a reduced annual payment update.

Medicare's IPPS encourages hospitals to treat patients efficiently.

Hospitals receive the same DRG payment for stays that vary in length and in the services provided, which gives hospitals an incentive to avoid unnecessary costs in the delivery of care. In many cases, complications acquired in the hospital do not generate higher payments than the hospital would otherwise receive for uncomplicated cases paid under the same DRG. To this extent, the IPPS encourages hospitals to avoid complications. However, complications, such as infections, acquired in the hospital can generate higher Medicare payments in two ways. First, the treatment of complications can increase the cost of a hospital stay enough to generate an outlier payment. However, the outlier payment methodology requires that a hospital experience a large loss on an outlier case, which serves as an incentive for hospitals to prevent outliers. Second, under the MS-DRGs that took effect in FY 2008, there are currently 258 sets of MS-DRGs that are split into 2 or 3 subgroups based on the presence or absence of a CC or an MCC. If a condition acquired during a hospital stay is one of the conditions on the CC or MCC list, the hospital currently receives a higher payment under the MS-DRGs (prior to the October 1, 2008 effective date of the

HAC payment provision). (We refer readers to section II.D. of the FY 2008 IPPS final rule with comment period for a discussion of DRG reforms (72 FR 47141).) The following is an example of how an MS-DRG may be paid.

Present on admission

Average

Service: MS-DRG Assignment\*\ (Examples below with CC/MCC indicate a single

(status of payment (based secondary diagnosis only)

secondary

on 50th diagnosis)

percentile)

Principal Diagnosis............................................................ ...............

$5,347.98

Intracranial hemorrhage or cerebral infarction (stroke) without CC/

MCC--MS-DRG 066...........................................................

Principal Diagnosis............................................................

Y

6,177.43

Intracranial hemorrhage or cerebral infarction (stroke) with CC--

MS-DRG 065................................................................

Example Secondary Diagnosis

Dislocation of patella-open due to a fall (code 836.4 (CC)).......

Principal Diagnosis............................................................

N

5,347.98

Intracranial hemorrhage or cerebral infarction (stroke) with CC--

MS-DRG 065................................................................

Example Secondary Diagnosis

Dislocation of patella-open due to a fall (code 836.4 (CC)).......

Principal Diagnosis............................................................

Y

8,030.28

Intracranial hemorrhage or cerebral infarction (stroke) with MCC--

MS-DRG 064................................................................

Example Secondary Diagnosis

Stage III pressure ulcer (code 707.23 (MCC))......................

Principal Diagnosis............................................................

N

5,347.98

Intracranial hemorrhage or cerebral infarction (stroke) with MCC--

MS-DRG 064................................................................

Example Secondary Diagnosis

Stage III pressure ulcer (code 707.23 (MCC))......................

\*\ Operating amounts for a hospital whose wage index is equal to the national average. 2. Statutory Authority

Section 1886(d)(4)(D) of the Act required the Secretary to select at least two conditions by October 1, 2007, that are: (a) High cost, high volume, or both; (b) assigned to a higher paying DRG when present as a secondary diagnosis; and (c) could reasonably have been prevented through the application of evidence-based guidelines. Beginning October 1, 2008, Medicare can no longer assign an inpatient hospital discharge to

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a higher paying MS-DRG if a selected HAC was not present on admission.

That is, the case will be paid as though the secondary diagnosis was not present. (Medicare will continue to assign a discharge to a higher paying MS-DRG if the selected condition was present on admission.)

Section 1886(d)(4)(D) of the Act provides that the list of conditions can be revised from time to time, as long as the list contains at least two conditions. Beginning October 1, 2007, we required hospitals to begin submitting information on Medicare claims specifying whether diagnoses were present on admission (POA).

The POA indicator reporting requirement and the HACs payment provision apply to IPPS hospitals only. At this time, non-IPPS hospitals such as CAHs, LTCHs, IRFs, and hospitals in Maryland operating under waivers, among others, are exempt from POA reporting and the HAC payment provision. Throughout this section, ``hospital'' refers to IPPS hospitals. 3. Public Input

In the FY 2007 IPPS proposed rule (71 FR 24100), we sought public input regarding conditions with evidence-based prevention guidelines that should be selected in implementing section 1886(d)(4)(D) of the

Act. The public comments we received were summarized in the FY 2007

IPPS final rule (71 FR 48051 through 48053). In the FY 2008 IPPS proposed rule (72 FR 24716), we again sought formal public comment on conditions that we proposed to select. In the FY 2008 IPPS final rule with comment period (72 FR 47200 through 47218), we summarized the public comments we received on the FY 2008 IPPS proposed rule, presented our responses, selected eight conditions to which the HAC provision will initially apply, and noted that we would be seeking comments on additional HAC candidates in this proposed rule. 4. Collaborative Process

CMS experts worked with public health and infectious disease professionals from the CDC to identify the candidate preventable HACs.

CMS and CDC staff also collaborated on the process for hospitals to submit a POA indicator for each diagnosis listed on IPPS hospital

Medicare claims.

On December 17, 2007, CMS and CDC hosted a jointly sponsored HAC and POA Listening Session to receive input from interested organizations and individuals. The agenda, presentations, audio file, and written transcript of the listening session are available on the

Web site at: http://www.cms.hhs.gov/HospitalAcqCond/07_

EducationalResources.asp. CMS and CDC also received informal comments during the listening session and subsequently received numerous written comments. 5. Selection Criteria for HACs

CMS and CDC staff evaluated each candidate condition against the criteria established by section 1886(d)(4)(D)(iv) of the Act.

Cost or Volume--Medicare data \6\ must support that the selected conditions are high cost, high volume, or both. At this point, there are no Medicare claims data indicating which secondary diagnoses were POA because POA indicator reporting began only recently; therefore, the currently available data for candidate conditions includes all secondary diagnoses.

\6\ For this FY 2009 IPPS proposed rule, the DRG analysis is based on data from the September 2007 update of the FY 2007 MedPAR file, which contains hospital bills received through September 30, 2007, for discharges through September 30, 2007.

Complicating Condition (CC) or Major Complicating

Condition (MCC)--Selected conditions must be represented by ICD-9-CM diagnosis codes that clearly identify the condition, are designated as a CC or an MCC, and result in the assignment of the case to an MS-DRG that has a higher payment when the code is reported as a secondary diagnosis. That is, selected conditions must be a CC or an MCC that would, in the absence of this provision, result in assignment to a higher paying MS-DRG.

Evidence-Based Guidelines--Selected conditions must be reasonably preventable through the application of evidence-based guidelines. By reviewing guidelines from professional organizations, academic institutions, and entities such as the Healthcare Infection

Control Practices Advisory Committee (HICPAC), we evaluated whether guidelines are available that hospitals should follow to prevent the condition from occurring in the hospital.

Reasonably Preventable--Selected conditions must be reasonably preventable through the application of evidence-based guidelines. 6. HACs Selected in FY 2008 and Proposed Changes to Certain Codes

The HACs that were selected for the HAC payment provision through the FY 2008 IPPS final rule with comment period are listed below. The payment provision for these selected HACs will take effect on October 1, 2008. We refer readers to section II.F.6. of the FY 2008 IPPS final rule with comment period (72 FR 47202 through 47218) for a detailed analysis supporting the selection of each of these HACs.

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We are seeking public comments on the following refinements to two of the previously selected HACs: a. Foreign Object Retained After Surgery: Proposed Inclusion of ICD-9-

CM Code 998.7 (CC)

In the FY 2008 IPPS final rule with comment period (72 FR 47206), we indicated that a foreign body accidentally left in the patient during a procedure (ICD-9-CM code 998.4) was one of the conditions selected. It has come to our attention that ICD-9-CM diagnosis code 998.7 (Acute reaction to foreign substance accidentally left during a procedure) should also be included. ICD-9-CM code 998.7 describes instances in which a patient developed an acute reaction due to a retained foreign substance. Therefore, we are proposing to make this code subject to the HAC payment provision. b. Pressure Ulcers: Proposed Changes in Code Assignments

As discussed in the FY 2008 IPPS final rule with comment period (72

FR 47205-47206), we referred the need for more detailed ICD-9-CM pressure ulcer codes to the CDC. The topic of expanding pressure ulcer codes to capture the stage of the ulcer was addressed at the September 27-28, 2007, meeting of the ICD-9-CM Coordination and Maintenance

Committee. A summary report of this meeting is available on the Web site at: http://www.cdc.gov/nchs/about/otheract/icd9/maint/maint.htm.

Numerous wound care professionals supported modifying the pressure ulcer codes to capture staging information. The stage of the pressure ulcer is a powerful predictor of severity and resource utilization. At its September 27-28, 2007 meeting, the ICD-9-CM Coordination and

Maintenance Committee discussed the creation of pressure ulcer codes to capture this information. The new codes, along with their proposed CC/

MCC classifications, are shown in Table 6A of the Addendum to this proposed rule. The new codes are as follows: 707.20 (Pressure ulcer, unspecified stage). 707.21 (Pressure ulcer stage I). 707.22 (Pressure ulcer stage II). 707.23 (Pressure ulcer stage III). 707.24 (Pressure ulcer stage IV).

While the code titles are final, we are soliciting comment on the proposed MS-DRG classifications of these codes, as indicated in Table 6A of the Addendum to this proposed rule. We are proposing to remove the CC/MCC classifications from the current pressure ulcer codes that show the site of the ulcer (ICD-9-CM codes 707.00 through 707.09).

Therefore, the following codes would no longer be a CC: 707.00 (Decubitus ulcer, unspecified site). 707.01 (Decubitus ulcer, elbow). 707.09 (Decubitus ulcer, other site). The following codes would no longer be an MCC: 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).

We are proposing to instead assign the CC/MCC classifications to the stage of the pressure ulcer as shown in Table 6A of the Addendum to this proposed rule. We are proposing to classify ICD-9-CM codes 707.23 and 707.24 as MCCs. We are proposing to classify codes 707.20, 707.21, and 707.22 as non-CCs.

Therefore, we are proposing that, beginning October 1, 2008, the codes used to make MS-DRG adjustments for pressure ulcers under the HAC provision would include the proposed MCC codes 707.23 and 707.24. 7. HACs Under Consideration as Additional Candidates

CMS and CDC have diligently worked together and with other stakeholders to identify additional HACs that might appropriately be subject to the HAC payment provision. If the additional candidate HACs are selected in the FY 2009 IPPS final rule, the payment provision will take effect for these candidate HACS on October 1, 2008. The statutory criteria for each HAC candidate are presented in tabular format. Each table contains the following:

HAC Candidate--We are seeking public comment on all HAC candidates.

Medicare Data--We are seeking public comment on the statutory criterion of high cost, high volume, or both as it applies to the HAC candidate.

CC/MCC--We are seeking public comment on the statutory criterion that an ICD-9-CM diagnosis code(s) clearly identifies the HAC candidate.

Selected Evidence-Based Guidelines--We are seeking public comment on the degree to which the HAC candidate is reasonably preventable through the application of the identified evidence-based guidelines. a. Surgical Site Infections Following Elective Surgeries

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In the FY 2008 IPPS final rule with comment period (72 FR 47213), surgical site infections were identified as a broad category for consideration, and we selected mediastinitis after coronary artery bypass graft (CABG) as one of the initial eight HACs for implementation. We are now considering the addition of other surgical site infections, particularly those following elective procedures. In most cases, patients selected as candidates for elective surgeries should have a relatively low-risk profile for surgical site infections.

The following elective surgical procedures are under consideration:

Total Knee Replacement (81.54): ICD-9-CM codes 996.66 (CC) and 998.59 (CC)

Laparoscopic Gastric Bypass (44.38) and Laparoscopic

Gastroenterostomy (44.39): ICD-9-CM code 998.59 (CC)

Ligation and Stripping of Varicose Veins (38.50 through 38.53, 38.55, 38.57, and 38.59): ICD-9-CM code 998.59 (CC)

Evidence-based guidelines for preventing surgical site infections emphasize the importance of appropriately using prophylactic antibiotics, using clippers rather than razors for hair removal and tightly controlling postoperative glucose.

While we are seeking public comments on the applicability of each of the statutory criteria to surgical site infections following elective procedures, we are particularly interested in receiving comments on the degree of preventability of surgical site infections following elective procedures generally, as well as specifically for those listed above. We also are seeking public comments on additional elective surgical procedures that would qualify for the HAC provision by meeting all of the statutory criteria. Based on the public comments we receive, we may select some combination of the four procedures presented here along with additional conditions that qualify and are supported by the comments. b. Legionnaires' Disease

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We discussed Legionnaires' Disease in the FY 2008 IPPS final rule with comment period (72 FR 47216). Legionnaires' Disease is a type of pneumonia caused by the bacterium Legionella pneumophila. It is contracted

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by inhaling contaminated water vapor or droplets. It is not spread person to person. Individuals at risk include those who are elderly, immunocompromised, smokers, or persons with underlying lung disease.

The bacterium thrives in warm aquatic environments and infections have been linked to large industrial water systems, including hospital water systems such as air conditioning cooling towers and potable water plumbing systems. Prevention depends primarily on regular monitoring and decontamination of these water systems. While we are seeking public comments regarding the applicability of each of the statutory criteria to Legionnaires' Disease, we are particularly interested in receiving comments on the degree of preventability of Legionnaires' Disease through the application of hospital water system maintenance guidelines.

Legionnaires' Disease is typically acquired outside of the hospital setting and may be difficult to diagnose as present on admission. We are seeking comments on the degree to which hospital-acquired

Legionnaires' Disease can be distinguished from community-acquired cases.

We also are seeking public comments on additional water-borne pathogens that would qualify for the HAC provision by meeting the statutory criteria. Based on the public comments we receive, we may finalize some combination of Legionnaires' Disease and additional conditions that qualify and are supported by the public comments. c. Glycemic Control

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During the December 17, 2007 HAC and POA Listening Session, one of the commenters suggested that we explore hyperglycemia and hypoglycemia as HACs for selection. NQF's list of Serious Reportable Adverse Events includes death or serious disability associated with hypoglycemia that occurs during hospitalization.

Hyperglycemia and hypoglycemia are extremely common laboratory findings in hospitalized patients and can be complicating features of underlying diseases and some therapies. However, we believe that extreme forms of poor glycemic control should not occur while under medical care in the hospital setting. Thus, we are considering whether the following forms of extreme glucose derangement should be subject to the HAC payment provision:

Diabetic Ketoacidosis: ICD-9-CM codes 250.10-250.13 (CC)

Nonketotic Hyperosmolar Coma: ICD-9-CM code 251.0 (CC)

Diabetic Coma: ICD-9-CM codes 250.30-250.33 (CC)

Hypoglycemic Coma: ICD-9-CM codes 250.30-251.0 (CC)

While we are seeking public comments regarding the applicability of each of the statutory criteria to these extreme aberrations in glycemic control, we are particularly interested in receiving comments on the degree to which these extreme aberrations in glycemic control are reasonably preventable, in the hospital setting, through the application of evidence-based guidelines. Based on the public comments we receive, we may select some combination of these glycemic control- related conditions as HACs. d. Iatrogenic Pneumothorax

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Iatrogenic pneumothorax refers to the accidental introduction of air into the pleural space, which is the space between the lung and the chest wall. When air is introduced into this space it partially or completely collapses the lung. Iatrogenic pneumothorax can occur during any procedure where there is the possibility of air entering pleural space, including needle biopsy of the lung, thoracentesis, central venous catheter placement, pleural biopsy, tracheostomy, and liver biopsy. Iatrogenic pneumothorax can occur secondary to positive pressure mechanical ventilation when an air sac in the lung ruptures allowing air into the pleural space.

While we are seeking public comments on the applicability of each of the statutory criteria to iatrogenic pneumothorax, we are particularly interested in receiving comments on the degree to which iatrogenic pneumothorax is reasonably preventable through the application of evidence-based guidelines. Based on the public comments we receive, we may select iatrogenic pneumothorax as an HAC. e. Delirium

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Delirium is a relatively abrupt deterioration in a patient's ability to sustain attention, learn, or reason. Delirium is strongly associated with aging and treatment of illnesses that are associated with hospitalizations. Delirium affects nearly half of hospital patient days for individuals age 65 and older, and approximately three-quarters of elderly individuals in intensive care units have delirium. About 14 to 24 percent of hospitalized elderly individuals have delirium at the time of admission. Having delirium is a very serious risk factor, with 1-year mortality of 35 to 40 percent, a rate as high as those associated with heart attacks and sepsis. The adverse effects of delirium routinely last for months. Delirium is a clinical diagnosis, commonly assisted by screening tests such as the Confusion Assessment

Method.

Well-established practices, such as reducing certain medications, reorienting the patient, assuring sensory input and sleep, and avoiding malnutrition and dehydration, prevent 30 to 40 percent of the possible cases. While we are seeking public comments on the applicability of each of the statutory criteria to delirium, we are particularly interested in receiving comments on the degree to which delirium is reasonably preventable through the application of evidence-based guidelines. Based upon the public comments we receive, we may select delirium as an HAC. f. Ventilator-Associated Pneumonia (VAP)

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We discussed ventilator-associated pneumonia (VAP) in the FY 2008

IPPS final rule with comment period (72 FR 47209-47210). VAP is a serious hospital-acquired infection associated with high mortality, significantly increased hospital length of stay, and high cost. It is typically caused by the aspiration of contaminated gastric and/or oropharyngeal secretions. The presence of an endotracheal tube facilitates both the contamination of secretions as well as aspiration.

During the past year, the ICD-9-CM Coordination and Maintenance

Committee discussed the creation of a new ICD-9-CM code 997.31 to identify VAP. This new code is shown in Table 6A of the Addendum to this proposed rule. The lack of a specific code was one of the barriers to including VAP as an HAC that we discussed in the FY 2008 IPPS final rule with comment period. We also discussed the degree to which VAP may be reasonably preventable through the application of evidence-based guidelines. Specifically, the FY 2008 IPPS final rule with comment period referenced the American Association for Respiratory Care's

Clinical Practice Guidelines at the Web site: http://www.rcjournal.com/ cpgs/09.03.0869.html.

To further investigate the extent to which VAP is reasonably preventable, we reviewed published clinical research. The literature, including recommendations by CDC and the HICPAC, from 2003 shows numerous prevention guidelines that can significantly reduce the incidence of VAP in the hospital setting. These guidelines include interventions such as educating staff, hand washing, using gowns and gloves, properly positioning the patient, elevating the head of the bed, changing ventilator tubing, sterilizing reusable equipment, applying chlorhexadine solution for oral decontamination, monitoring sedation daily, administering stress ulcer prophylaxis, and administering pneumococcal vaccinations. Further review of the literature, specifically regarding the proportion of VAP cases that might be preventable, revealed two large-scale analyses that were completed recently. One study concluded that an estimated 40 percent of

VAP cases are preventable. A second study concluded that at least 20 percent of nosocomial infections in general (not just VAP) are preventable.\7\

\7\ American Association for Respiratory Care Clinical Practice:

Guideline: Care of the Ventilator Circuit and Its Relation to

Ventilator Associated Pneumonia. Available at the Web site: http:// www.rcjournal.com/cpgs/09.03.0869.html.

During the December 17, 2007 HAC and POA Listing Session, we also received comments on evidence-based guidelines for preventing VAP.

Commenters referenced two articles \8\ \9\ that both state there is a high degree of risk associated with endotracheal tube insertions, suggesting that VAP may not always be preventable.

\8\ Ramirez et al.: Prevention Measures for Ventilator-

Associated Pneumonia: A New Focus on the Endotracheal Tube. Current

Opinion in Infectious Disease, April 2007, Vol.20 (2), pp. 190-197.

\9\ Safdar et al.: The Pathogenesis of Ventilator-Associated

Pneumonia: Its Relevance to Developing Effective Strategies for

Prevention. Respiratory Care, June 2005, Vol. 50, No. 6, pp.725-741.

While we are seeking public comments on the applicability of each of the statutory criteria to VAP, we are particularly interested in receiving comment on the degree to which VAP

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is reasonably preventable through the application of evidence-based guidelines. Based on the public comments we receive, we may select VAP as an HAC. g. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)

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We discussed deep vein thrombosis (DVT) and pulmonary embolism (PE) in the FY 2008 IPPS final rule with comment period (72 FR 47215). DVT and PE are common events. DVT occurs when a blood clot forms in the deep veins of the leg and causes local swelling and inflammation. PE occurs when a clot or a piece of a clot migrates from its original site into the lungs, causing the death of lung tissue, which can be fatal.

Risk factors for DVTs and PEs include inactivity, smoking, use of oral contraceptives, prolonged bed rest, prolonged sitting with bent knees, certain types of cancer and other disease states, certain blood clotting disorders, and certain types of orthopedic and other surgical procedures. DVT is not always clinically apparent because the manifestations of pain, redness, and swelling may develop some time after the venous clot forms.

As we discussed in the FY 2008 IPPS final rule with comment period,

DVTs and PEs may be preventable in certain circumstances, but it is possible that a patient may have a DVT that is difficult to detect on admission. We also received comments during the December 17, 2007 HAC and POA Listening Session reiterating that not all cases of DVTs and

PEs are preventable. For example, common patient characteristics such as immobility, obesity, severe vessel trauma, and venous stasis put certain trauma and joint replacement surgery patients at high risk for these conditions.

In our review of the literature, we found that there are definite pharmacologic and nonpharmacologic interventions that may reduce the likelihood of developing DVTs and PEs, including exercise, compression stockings, intermittent pneumatic boots, aspirin, enoxaparin, dalteparin, heparin, coumadin, clopidogrel, and fondaparinux. However, the evidence[pi]based guidelines indicate that some patients may still develop clots despite these therapies.

While we are seeking public comments on the applicability of each of the statutory criteria to DVTs and PEs, we are particularly interested in receiving comments on the degree of preventability of

DVTs and PEs. We are also interested in comments on determining the presence of DVT and PE at admission. Based on the public comments we receive, we may select DVTs and PEs as HACs. h. Staphylococcus aureus Septicemia

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We discuss Staphylococcus aureus Septicemia in the FY 2008 IPPS final rule with comment period (72 FR 47208). Staphylococcus aureus is a bacterium that lives in the nose and on the skin of a large percentage of the population. It usually does not cause physical illness, but it can cause infections ranging from superficial boils to cellulitis to pneumonia to life threatening bloodstream infections

(septicemia). It usually enters the body through traumatized tissue, such as cuts or abrasions, or at the time of invasive procedures.

Staphylococcus aureus Septicemia can also be a late effect of an injury or a surgical procedure. Risk factors for developing Staphylococcus aureus Septicemia include advanced age, debilitated state, immunocompromised status, and a history of an invasive medical procedure.

CDC has developed evidence-based guidelines for the prevention of the Staphylococcus aureus Septicemia. Most preventable cases of septicemia are primarily related to the presence of a central venous or vascular catheter. During the December 17, 2007 HAC and POA Listening

Session, commenters noted that intravascular catheter-associated infections are only one cause of septicemia. Therefore, catheter- oriented evidence-based guidelines would not cover all cases of

Staphylococcus aureus Septicemia.\10\

\10\ Jensen, A.G. Importance of Focus Identification in the

Treatment of Staphylococcus aureus Bacteremia. 2002. Vol. 52, pp. 29-36.

We identified evidence-based guidelines that suggest Staphylococcus aureus Septicemia is reasonably preventable. These guidelines emphasize the importance of effective and fastidious hand washing by both staff and visitors, using gloves and gowns where appropriate, applying proper decontamination techniques, and exercising contact isolation where clinically indicated.

While we are seeking public comments on the applicability of each of the statutory criteria to Staphylococcus aureus infections generally, we are particularly interested in receiving comments on the degree of preventability of Staphylococcus aureus infections generally, and specifically Staphylococcus aureus Septicemia. Based on the public comments we receive, we may select Staphylococcus aureus Septicemia as an HAC. i. Clostridium Difficile-Associated Disease (CDAD)

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We discussed Clostridium difficile-associated disease (CDAD) in the

FY 2008 IPPS final rule with comment period. Clostridium difficile is a bacterium that colonizes the gastrointestinal (GI) tract of a certain number of healthy people. Under conditions where the normal flora of the gastrointestinal tract is altered, Clostridium difficile can flourish and release large enough amounts of a toxin to cause severe diarrhea or even life threatening colitis. Risk factors for CDAD include prolonged use of broad spectrum antibiotics, gastrointestinal surgery, prolonged nasogastric tube insertion, and repeated enemas.

CDAD can be acquired in the hospital or in the community. Its spores can live outside of the body for months and thus can be spread to other patients in the absence of meticulous hand washing by care providers and others who contact the infected patient.

We continue to receive strong support in favor of selecting CDAD as an HAC. During the December 17, 2007 HAC and POA Listening Session, representatives of consumers and purchasers advocated to include CDAD as an HAC.

The evidence-based guidelines for CDAD prevention emphasize that hand washing by staff and visitors and effective decontamination of environmental surfaces prevent the spread of Clostridium difficile.

While we are seeking public comments on the applicability of each of the statutory criteria to CDADs, we are particularly interested in receiving comments on the degree of preventability of CDAD. Based on the public comments we receive, we may select CDAD as an HAC. j. Methicillin-Resistant Staphylococcus aureus (MRSA)

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We discussed the special case of methicillin-resistant

Staphylococcus aureus (MRSA) in the FY 2008 IPPS final rule with comment period (72 FR 47212). In October 2007, the CDC published in the

Journal of the American Medical Association an article citing high mortality rates from MRSA, an antibiotic-resistant ``superbug.'' The article estimates 19,000 people died from MRSA infections in the United

States in 2005. The majority of invasive MRSA cases are health care- related--contracted in hospitals or nursing homes--though community- acquired MRSA also poses a significant public health concern. Hospitals have been focused for years on controlling MRSA through the application of CDC's evidence-based guidelines outlining best practices for combating the bacterium in that setting.

MRSA is currently addressed by the HAC payment provision. For every infectious condition selected, MRSA could be the etiology of that infection. For example, if MRSA were the cause of a vascular catheter- associated infection (one of the eight conditions selected in the FY 2008 IPPS final rule with comment period), the HAC payment provision would apply to that MRSA infection.

As we noted in the FY 2008 IPPS final rule with comment period, colonization by MRSA is not a reasonably preventable HAC according to the current evidence-based guidelines; therefore, MRSA does not meet the reasonably preventable statutory criterion for an HAC. An estimated 32.4 percent of Americans are colonized with MRSA, which may reside in the nose or on the skin of asymptomatic carriers.\11\ In addition, in last year's final rule with comment period, we noted that there is no

CC/MCC code available for MRSA, and therefore it also does not meet the codeable CC/MCC statutory criterion for an HAC. Only when MRSA causes an infection does a codeable condition occur. However, we referenced the possibility that new codes for MRSA were being considered by the

ICD-9-CM Coordination and Maintenance Committee. The creation of unique codes to capture MRSA was discussed during the March 19-20, 2008

Committee meeting. While these codes will enhance the data available and our understanding of MRSA, the availability and use of these codes will not change the fact that the mere presence of MRSA as a colonizing bacterium does not constitute an HAC.

\11\ Kuehnert, M.J., et al.: Prevalence of Staphylococcusa aureus Nasal Colonization in the United States, 2001-2002. The

Journal of Infectious Disease, January 15, 2006; Vol. 193.

Because MRSA as a bacterium does not meet two of our statutory criteria, codeable CC/MCC and reasonably preventable through evidence- based guidelines, we are not proposing MRSA as an HAC. However, we recognize the significant public health concerns that were raised by representatives of consumers and purchasers at the HAC and POA

Listening Session, and we are committed to reducing the spread of multi-drug resistant organisms, such as MRSA.

In addition, we are pursuing collaborative efforts with other HHS agencies to combat MRSA. The Agency for Healthcare Research and Quality

(AHRQ) has launched a new initiative in collaboration with CDC and CMS to identify and suppress the spread of MRSA and related infections. In support of this work, Congress has appropriated $5 million to fund research, implementation, management, and evaluation practices that mitigate such infections.

CDC has carried out extensive research on the epidemiology of MRSA and effective techniques that could be used to treat the infection and reduce its spread. The following Web sites contain information that reflect CDC's commitment: (1) http://www.cdc.gov/ncidod/dhqp/ar_ mrsa.html (health care-associated MRSA); (2) http://www.cdc.gov/ncidod/ dhqp/ar_mrsa_ca_public.html (community-acquired MRSA); (3) http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm4908a1.htm; and (4) http:// www.cdc.gov/handhygiene/.

AHRQ has made previous investments in systems research to help monitor MRSA and related infections in hospital settings, as reflected in material on the Web site at: http://www.guideline.gov/browse/ guideline_index.aspx and http://www.ahrq.gov/clinic/ptsafety/pdf/ ptsafety.pdf. 8. Present on Admission (POA) Indicator Reporting

POA indicator information is necessary to identify which conditions were acquired during hospitalization for the HAC payment provision and for broader public health uses of Medicare data. Through Change Request

No. 5679 (released June 20, 2007), CMS issued instructions requiring

IPPS hospitals to submit the POA indicator data for all diagnosis codes on Medicare claims. Specific instructions on how to select the correct

POA indicator for each diagnosis code are included in the ICD-9-CM

Official Guidelines for Coding and Reporting, available at the Web site: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide07.pdf

(POA

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reporting guidelines begin on page 92). Additional instructions, including information regarding CMS's phased implementation of POA indicator reporting and application of the POA reporting options, are available at the Web site: http://www.cms.hhs.gov/HospitalAcqCond.

There are five POA indicator reporting options: ``Y,'' ``N,''

``W,'' ``U,'' and ``1.'' Under the HAC payment provision, we are proposing to pay the CC/MCC MS-DRGs only for those HACs coded as ``Y'' and ``W'' indicators. The ``Y'' option indicates that the condition was present on admission. The ``W'' indicator affirms that the provider has determined, based on data and clinical judgment, that it is not possible to document when the onset of the condition occurred. We expect that this approach will encourage better documentation and promote the public health goals of POA reporting by providing more accurate data about the occurrence of HACs in the Medicare population.

We anticipate that true clinical uncertainty will occur in only a very small number of cases. We plan to analyze how frequently the ``W'' indicator is used, and we leave open the possibility of proposing in future IPPS rulemaking not paying the CC/MCC MS-DRGs for HACs coded with the ``W'' indicator. In addition, we plan to analyze whether both the ``Y'' and ``W'' indicators are being used appropriately. Medicare program integrity initiatives closely monitor for inaccurate coding and coding that is inconsistent with medical record documentation. We are seeking public comments regarding the proposed treatment of the ``Y'' and ``W'' POA reporting options under the HAC payment provision.

We are proposing to not pay the CC/MMC MS-DRGs for HACs coded with the ``N'' indicator. The ``N'' option indicates that the condition was not present on admission. We are also proposing to not pay the CC/MCC

MS-DRGs for HACs coded with the ``U'' indicator. The ``U'' option indicates that the medical record documentation is insufficient to determine whether the condition was present at the time of admission.

Not paying for the CC/MCC MS-DRGs for HACs that are coded with the

``U'' indicator is expected to foster better medical record documentation.

Although we are proposing not paying the CC/MCC MS-DRG for HACs coded with the ``U'' indicator, we do recognize there may be some exceptional circumstances under which payment might be made. Death, elopement (leaving against medical advice), and transfers out of a hospital may preclude making an informed determination of whether an

HAC was present on admission. We are seeking public comments on the potential use of the following current patient discharge status codes to identify the exceptional circumstances:

Patient Discharge Status Codes

Form locator code

Code descriptor

Exception for Patient Death

20.................................... Expired.

Exception for Patient Elopement (Leaving Against Medical Device)

7..................................... Left against medical advice or discontinued care.

Exception for Transfer

02.................................... Discharged/transferred to a short-term general hospital for inpatient care. 03.................................... Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification in anticipation of skilled care. 04.................................... Discharged/transferred to an intermediate care facility

(ICF). 05.................................... Discharged/transferred to a designated cancer center or children's hospital. 06.................................... Discharged/transferred to home under care of organized home health service organization. 43.................................... Discharged/transferred to a

Federal health care facility. 50.................................... Hospice-home. 51.................................... Hospice-medical facility

(certified) providing hospice level of care. 61.................................... Discharged/transferred to a hospital-based Medicare approved swing bed. 62.................................... Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital. 63.................................... Discharged/transferred to a

Medicare certified long term care hospital (LTCH). 64.................................... Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare. 65.................................... Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital. 66.................................... Discharged/transferred to a critical access hospital (CAH). 70.................................... Discharged/transferred to another type of health care institution not otherwise defined in this code list.

We plan to analyze whether both the ``N'' and ``U'' POA reporting options are being used appropriately. The American Health Information

Management Association (AHIMA) has promulgated Standards of Ethical

Coding that require accurate coding regardless of the payment implications of the diagnoses. That is, diagnoses must be reported accurately regardless of their effect on payment. Medicare program integrity initiatives closely monitor for inaccurate coding and coding inconsistent with medical record documentation. We are seeking public comments regarding the proposal to not pay the CC/MCC MS-DRGs for HACs coded with ``N'' and ``U'' indicators. 9. Enhancement and Future Issues

The preventable HAC payment provision is one of CMS' VBP initiatives, as noted earlier in this section. VBP ties payment to performance through the use of incentives based on quality measures and cost of care. The implementation of VBP is rapidly transforming CMS from being a passive payer of claims to an active purchaser of higher quality, more efficient health care for Medicare beneficiaries. Other

VBP initiatives include hospital pay for reporting (the RHQDAPU program discussed in section IV.B. of the preamble of this proposed rule), physician pay for reporting (the Physician Quality Reporting

Initiative), home health pay for reporting, the Hospital VBP Plan

Report to Congress (discussed in section IV.C. of the preamble of this proposed rule), and various VBP demonstration

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programs across payment settings, including the Premier Hospital

Quality Incentive Demonstration and the Physician Group Practice

Demonstration.

The success of CMS' VBP initiatives depends in large part on the validity of the performance measures and on the effectiveness of incentives in driving desired changes in behavior that will result in greater quality and efficiency. We are committed to enhancing the

Medicare VBP programs, in close collaboration with stakeholders, to fulfill VBP's potential to promise of promoting higher value health care for Medicare beneficiaries. It is in this spirit that we seek public comment on enhancements to the preventable HACs payment policy and to concomitant POA indicator reporting.

We welcome all public comments presenting ideas and models for combating preventable HACs through the application of VBP principles.

To stimulate reflection and creativity, we present several options:

Risk adjustment could be applied to make the HAC payment provision more precise.

Rates of HACs could be collected to obtain a more robust longitudinal measure of a hospital's incidence of these conditions.

POA information could be used in various ways to decrease the incidence of preventable HACs.

The adoption of ICD-10-PCS could facilitate more precise identification of HACs.

The principle behind the HAC payment provision (Medicare not paying more for preventable HACs) could be applied to Medicare payments in settings of care other than the IPPS.

CMS is using authority other than the HAC payment provision to address other events on the NQF's list of Serious

Reportable Adverse Events.

We note that we are not proposing new Medicare policy in this

Enhancements and Future Issues discussion, as some of these approaches may require new statutory authority. a. Risk Adjustment

To make the HAC payment provision more precise, the adjustments to payment made when one of the selected HACs occurs during the hospitalization could be further adjusted to account for patient- specific risk factors. The expected occurrence of an HAC may be greater or lesser depending on the health status of the patient, as reflected by severity of illness, presence of comorbidities, or other factors.

Rather than not paying any additional amount for the complication, the additional payment for the complication could range from zero for the lowest risk patient to the full amount for the highest risk patient. An option may be individualized adjustment for every hospitalization based on the patient's unique characteristics, but state-of-the-art risk adjustment currently precludes such individualized adjustment. b. Rates of HACs

Given our limited capability at present for precise patient-level risk adjustment, adding a consideration of risk to the criteria for selecting HACs could be an alternative. If primarily high-risk patients are acquiring a certain condition during hospitalization, that condition could be considered a less-fit candidate for selection. Other alternatives to precise individualized risk adjustment could be adjustment for overall facility case mix or facility case-mix by condition. At the highest level, national Medicare program data could be used to make adjustments to the payment implications for the selected HACs based on expected rates of complications. Another option could be to designate certain patient risk factors as exemptions that would prohibit or mitigate the application of the HAC payment policy to the claims of patients with those risk factors.

The Medicare Hospital VBP Plan was submitted in a Report to

Congress on November 21, 2007. The plan includes a performance assessment model that scores a hospital's attainment or improvement on various measures. The scores for each measure would be summed within each domain, such as the clinical process of care domain or the patient experience domain, and then the domains would be weighted and summed to yield a total performance score. The total performance score would then be translated into an incentive payment, proposed to be a certain percentage of each MS-DRG payment, using an exchange function. The plan also calls for public reporting of hospitals' performance scores by domain and in total. (Section IV.C. of this preamble included a related discussion of the Hospital VBP Plan Report to Congress.)

In accordance with this hospital VBP model, a hospital's rates of

HACs could be included as a domain within each hospital's total performance score. The measurement of rates over time could be a more meaningful, actionable, and fair way to adjust a hospital's MS-DRG payments for the incidence of HACs. The consequence of a higher incidence of measured conditions would be a lower VBP incentive payment. Public reporting of the measured rates of HACs would give hospitals an additional, nonfinancial incentive to prevent occurrence of the conditions to avoid lower public ratings. c. Use of POA Information

Information obtained from hospitals' reporting of POA data could be used in various ways to better understand and prevent the occurrence of

HACs. The POA information could be provided to health services researchers to analyze factors that lead to HACs and disseminate the best practices for prevention of HACs. At least two states, New York and California, already collect POA data from their hospitals.

Comparison of the State POA data with the Medicare data could fill in gaps in the databases and yield valuable insights about POA data validity.

POA data could also be used to calculate the incidence of HACs by hospital. This application of the POA data would be particularly powerful if the Medicare POA data were combined with state or private sector payer POA data. The Medicare-only or combined quality of care information could be initially shared with hospitals and thereafter publicly reported to support better healthcare decision making by

Medicare beneficiaries, other health care consumers, professionals, and caregivers. d. Transition to ICD-10-PCS

Accurate identification of HACs requires unambiguous and precise diagnosis codes. The current ICD-9-CM diagnosis coding system is three decades old. It is outdated and contains numerous instances of broad and vague codes. Attempts to add necessary detail to the ICD-9-CM system are inhibited by lack of expansion capacity. These factors negatively affect CMS' attempts to identify HAC cases.

ICD-10-PCS codes are more precise and capture information using more current medical terminology. For example, ICD-9-CM codes for pressure ulcers do not provide information about the size, depth, or exact location of the ulcer, while ICD-10-PCS has 60 codes to capture this information. ICD-10-PCS would also provide codes, beyond the current ICD-9-CM codes, that would enable the selection of additional surgical complications and adverse drug events. e. Application of Nonpayment for HACs to Other Settings

The broad principle of Medicare not paying for preventable health care-associated conditions could potentially be applied to Medicare payment settings other than IPPS hospitals. Other

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possible settings of care might include hospital outpatient departments, SNFs, HHAs, end-stage renal disease facilities, and physician practices. The implications would be different for each setting, as each payment system is different and the reasonable preventability through the application of evidence-based guidelines would vary for candidate conditions over the different settings.

However, alignment of incentives across settings of care is an important goal for all of CMS' VBP initiatives, including the HAC provision.

A related application of the broad principle behind the HAC payment could be accomplished through modification to the Medicare secondary payer policy which would allow us to directly recoup from the provider that failed to prevent the occurrence of a preventable condition in one setting to pay for all or part of the necessary followup care in a second setting. This would help shield the Medicare program from inappropriately paying for the downstream effects of a preventable condition acquired in the first setting but treated in the second setting. f. Relationship to NQF's Serious Reportable Adverse Events

CMS is applying its authority to address the events on the NQF's list of Serious Reportable Adverse Events (also known as ``never events''). In May 2006 testimony before the Senate Finance Committee, the CMS Administrator noted that paying hospitals for serious preventable events is contrary to the promise that hospital payments should support higher quality and efficiency. There is growing consensus that health care purchasers should not be paying for these events when they occur during a hospitalization. In January 2005,

HealthPartners, a Minnesota-based not-for-profit HMO, announced that it would no longer reimburse hospitals for services associated with events enumerated in the Minnesota Adverse Health Care Events Reporting Act

(essentially the NQF's list of Serious Reportable Adverse Events).

Further, HealthPartners' contracts preclude hospitals from seeking reimbursement from the patient for these costs. During 2007, several

State hospital associations adopted policies stating that their members will not bill payers or patients when these events occur in their hospitals.

In the FY 2008 IPPS final rule with comment period, we adopted several items from the NQF's list of events as HACs, including retained foreign object after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, falls, electric shock, and burns. In this proposed rule, we are seeking public comments regarding adding hypoglycemic coma, which is closely related to NQF's listing of death or serious disability associated with hypoglycemia. However, as we discussed in the FY 2008 IPPS final rule with comment period, the HAC payment provision is not ideally suited to address every condition on the NQF's list of Serious Reportable Adverse Events. To address the events on the NQF's list beyond the effect of the HAC policy, CMS is exploring the application of Medicare authority, including other payment provisions, coverage policy, conditions of participation, and

Quality Improvement Organization (QIO) retrospective review.

We note that we are not proposing new Medicare policy in this discussion of the HAC payment provision for IPPS hospitals, as some of these approaches may require new statutory authority. We are seeking public comments on these and other options for enhancing the preventable HACs payment provision and maximizing the use of POA indicator reporting data. We look forward to working with stakeholders in the fight against HACs.

G. Proposed Changes to Specific MS-DRG Classifications 1. Pre-MDCs: Artificial Heart Devices

Heart failure affects more than 5 million patients in the United

States with 550,000 new cases each year, and causes more than 55,000 deaths annually. It is a progressive disease that is medically managed at all stages, but over time leads to continued deterioration of the heart's ability to pump sufficient amounts of adequately oxygenated blood throughout the body. When medical management becomes inadequate to continue to support the patient, the patient's heart failure would be considered to be the end stage of the disease. At this point, the only remaining treatment options are a heart transplant or mechanical circulatory support. A device termed an artificial heart has been used only for severe failure of both the right and left ventricles, also known as biventricular failure. Relatively small numbers of patients suffer from biventricular failure, but the exact numbers are unknown.

There are about 4,000 patients approved and waiting to receive heart transplants in the United States at any given time, but only about 2,000 hearts per year are transplanted due to a scarcity of donated organs. There are a number of mechanical devices that may be used to support the ventricles of a failing heart on either a temporary or permanent basis. When it is apparent that a patient will require long- term support, a ventricular support device is generally implanted and may be considered either as a bridge to recovery or a bridge to transplantation. Sometimes a patient's prognosis is uncertain, and with device support the native heart may recover its function. However when recovery is not likely, the patient may qualify as a transplant candidate and require mechanical circulatory support until a donor heart becomes available. This type of support is commonly supplied by ventricular assist devices, (VADs), which are surgically attached to the native ventricles but do not replace them.

Devices commonly called artificial hearts are biventricular heart replacement systems that differ from VADs in that a substantial part of the native heart, including both ventricles, is removed. When the heart remains intact, it remains possible for the native heart to recover its function after being assisted by a VAD. However, because the artificial heart device requires the resection of the ventricles, the native heart is no longer intact and such recovery is not possible. The designation

``artificial heart'' is somewhat of a misnomer because some portion of the native heart remains and there is no current mechanical device that fully replaces all four chambers of the heart. Over time, better descriptive language for these devices may be adopted.

In 1986, CMS made a determination that the use of artificial hearts was not covered under the Medicare program. To conform to that decision, we placed ICD-9-CM procedure code 37.52 (Implantation of total replacement heart system) on the GROUPER program's MCE in the noncovered procedure list.

On August 1, 2007, CMS began a national coverage determination process for artificial hearts. SynCardia Systems, Inc. submitted a request for reconsideration of the longstanding noncoverage policy when its device, the CardioWest Temporary Total Artificial Heart (TAH-t)

System, is used for ``bridge to transplantation'' in accordance with the FDA-labeled indication for the device. ``Bridge to transplantation'' is a phrase meaning that a patient in end-stage heart failure may qualify as a heart transplant candidate, but will require mechanical circulatory support until a donor heart becomes available.

The CardioWest TAH-t System is indicated for use as a bridge to transplantation in cardiac transplant-eligible candidates at risk of imminent death from biventricular

Page 23563

failure. The system is intended for use inside the hospital as the patient awaits a donor heart. The ultimate desired outcome for insertion of the TAH-t is a successful heart transplant, along with the potential that offers for cure from heart failure.

CMS determined that a broader analysis of artificial heart coverage was deemed appropriate, as another manufacturer, Abiomed, Inc. has developed an artificial heart device, AbioCor[reg] Implantable

Replacement Heart Device, with different indications. SynCardia

Systems, Inc has received approval of its device from the FDA for humanitarian use as destination therapy for patients in end-stage biventricular failure who cannot qualify as transplant candidates. The

AbioCor[reg] Implantable Replacement Heart Device is indicated for use in severe biventricular end-stage heart disease patients who are not cardiac transplant candidates and who are less than 75 years old, who require multiple inotropic support, who are not treatable by VAD destination therapy, and who cannot be weaned from biventricular support if they are on such support. The desired outcome for this device is prolongation of life and discharge to home.

On February 1, 2008, CMS published a proposed coverage decision memorandum for artificial hearts which stated, in part, that while the evidence is inadequate to conclude that the use of an artificial heart is reasonable and necessary for Medicare beneficiaries, the evidence is promising for the uses of artificial heart devices as described above.

CMS supports additional research for these devices, and therefore proposed that the artificial heart will be covered by Medicare when performed under the auspices of a clinical study. The study must meet all of the criteria listed in the proposed decision memorandum. This proposed coverage decision memorandum may be found on the CMS Web site at: http://www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=211.

Following consideration of the public comments received, CMS expects to make a final decision on or about May 1, 2008.

The topic of coding of artificial heart devices was discussed at the September 27-28, 2007 ICD-9-CM Coordination and Maintenance

Committee meeting held at CMS in Baltimore, MD. We note that this topic was placed on the Committee's agenda because any proposed changes to the ICD-9-CM coding system must be discussed at a Committee meeting, with opportunity for comment from the public. At the September 2007

Committee meeting, the Committee accepted oral comments from participants and encouraged attendees or anyone with an interest in the topic to comment on proposed changes to the code, inclusion terms, or exclusion terms. We accepted written comments until October 12, 2007.

As a result of discussion and comment from the Committee meeting, the

Committee revised the title of procedure code 37.52 for artificial hearts to read ``Implantation of internal biventricular heart replacement system.'' In addition, the Committee created new code 37.55

(Removal of internal biventricular heart replacement system) to identify explantation of the artificial heart prior to heart transplantation.

To make conforming changes to the IPPS system with regard to the proposed revision to the coverage decision for artificial hearts, in this proposed rule, we are proposing to remove procedure code 37.52 from MS-DRG 215 (Other Heart Assist System Implant) and assign it to

MS-DRG 001 (Heart Transplant or Implant of Heart Assist System with

Major Comorbidity or Complication (MCC)) and MS-DRG 002 (Heart

Transplant or Implant of Heart Assist System without Major Comorbidity or Complication (MCC)). In addition, we are proposing to remove procedure code 37.52 from the MCE ``Non-Covered Procedure'' edit and assign it to the ``Limited Coverage'' edit. We are proposing to include in this proposed edit the requirement that ICD-9-CM diagnosis code

V70.7 (Examination of participant in clinical trial) also be present on the claim. We are proposing that claims submitted without both procedure code 37.52 and diagnosis code V70.7 would be denied because they would not be in compliance with the proposed coverage policy.

During FY 2008, we are making mid-year changes to portions of the

GROUPER program that do not affect MS-DRG assignment or ICD-9-CM coding. However, as the proposed coverage decision memorandum for artificial hearts was published after the CMS contractor's testing and release of the mid-year product, the above proposed changes to the MCE will not be included in that revision of the GROUPER Version 25.0.

GROUPER Version 26.0, which will be in use for FY 2009, will contain the proposed changes if they are approved. If the proposed revisions to the MCE are accepted, the edits in the MCE Version 25.0 will be effective retroactive to May 1, 2008. (To reduce confusion, we note that the version number of the MCE is one digit lower than the current

GROUPER version number; that is, Version 26.0 of the GROUPER uses

Version 25.0 of the MCE.) 2. MDC 1 (Diseases and Disorders of the Nervous System) a. Transferred Stroke Patients Receiving Tissue Plasminogen Activator

(tPA)

In 1996, the FDA approved the use of tissue plasminogen activator

(tPA), one type of thrombolytic agent that dissolves blood clots. In 1998, the ICD-9-CM Coordination and Maintenance Committee created code 99.10 (Injection or infusion of thrombolytic agent) in order to be able to uniquely identify the administration of these agents. Studies have shown that tPA can be effective in reducing the amount of damage the brain sustains during an ischemic stroke, which is caused by blood clots that block blood flow to the brain. tPA is approved for patients who have blood clots in the brain, but not for patients who have a bleeding or hemorrhagic stroke. Thrombolytic therapy has been shown to be most effective when used within the first 3 hours after the onset of an embolic stroke, but it is contraindicated in hemorrhagic strokes.

For FY 2006, we modified the structure of CMS DRGs 14 (Intracranial

Hemorrhage or Cerebral Infarction) and 15 (Nonspecific CVA and

Precerebral Occlusion without Infarction) by removing the diagnostic ischemic (embolic) stroke codes. We created a new CMS DRG 559 (Acute

Ischemic Stroke with Use of Thrombolytic Agent) which increased reimbursement for patients who sustained an ischemic or embolic stroke and who also had administration of tPA. The intent of this DRG was not to award higher payment for a specific drug but to recognize the need for better overall care for this group of patients. Even though tPA is indicated only for a small proportion of stroke patients, that is, those patients experiencing ischemic strokes treated within 3 hours of the onset of symptoms, our data suggested that there was a sufficient quantity of patients to support the DRG change. While our goal is to make payment relate more closely to resource use, we also note that use of tPA in a carefully selected patient population may lead to better outcomes and overall care and may lessen the need for postacute care.

For FY 2008, with the adoption of MS-DRGs, CMS DRG 559 became MS-

DRGs 061 (Acute Ischemic Stroke with Use of Thrombolytic Agent with

MCC), 062 (Acute Ischemic Stroke with Use of Thrombolytic Agent with

CC), and 063 (Acute Ischemic Stroke with Use of Thrombolytic Agent without CC/MCC). Stroke cases in which no thrombolytic

Page 23564

agent was administered were grouped to MS-DRGs 064 (Intracranial

Hemorrhage or Cerebral Infarction with MCC), 065 (Intracranial

Hemorrhage or Cerebral Infarction with CC), or 066 (Intracranial

Hemorrhage or Cerebral Infarction without CC/MCC). The MS-DRGs that reflect use of a thrombolytic agent, that is, MS-DRGs 061, 062, and 063, have higher relative weights than the hemorrhagic or cerebral infarction MS-DRGs 064, 065, and 066.

The American Society of Interventional and Therapeutic

Neuroradiology (ASITN) has made us aware of a treatment issue that is of concern to the stroke provider's community. In some instances, patients suffering an embolytic or thrombolytic stroke are evaluated and given tPA in a community hospital's emergency department, and then are transferred to a larger facility's stroke center that is able to provide the level of services required by the increased severity of these cases. The facility providing the administration of tPA in its emergency department does not realize increased reimbursement, as the patient is often transferred as soon a possible to a stroke center. The facility to which the patient is transferred does not realize increased reimbursement, as the tPA was not administered there. The ASITN has requested that CMS give permission to code the administration of tPA as if it had been given in the receiving facility. This would result in the receiving facility being paid the higher weighted MS-DRGs 061, 062, or 063 instead of MS-DRGs 064, 065, or 066. The ASITN's rationale is that the patients who received tPA in another facility (even though administration of tPA may have alleviated some of the worst consequences of their strokes) are still extremely compromised and require increased health care services that are much more resource consumptive than patients with less severe types of stroke. We have advised the ASITN that hospitals may not report services that were not performed in their facility.

We recognize that the ASITN's concerns potentially have merit but the quantification of the increased resource consumption of these patients is not currently possible in the existing ICD-9-CM coding system. Without specific length of stay and average charges data, we are unable to determine an appropriate MS-DRG for these cases.

Therefore, we have advised the ASITN to present a request at the diagnostic portion of the ICD-9-CM Coordination and Maintenance

Committee meeting on March 20, 2008, for a code that would recognize the fact that the patient had received a thrombolytic agent for treatment of the current stroke. If this request is presented at the

March 20, 2008 meeting, it will not be approved in time to be published as a final code in this proposed rule. However, if a diagnosis code is created by the National Centers for Health Statistics as a result of that meeting, it can be added to the list of codes published in the FY 2009 IPPS final rule that will go into effect on October 1, 2008. With such information appearing on subsequent claims, we will have a better idea of how to classify these cases within the MS-DRGs. Therefore, because we lack the data to identify these patients, we are not proposing an MS-DRG modification for the stroke patients receiving tPA in one facility prior to being transferred to another facility. b. Intractable Epilepsy With Video Electroencephalogram (EEG)

As we did for FY 2008, we received a request from an individual representing the National Association of Epilepsy Centers to consider further refinements to the MS-DRGs describing seizures. Specifically, the representative recommended that a new MS-DRG be established for patients with intractable epilepsy who receive an electroencephalogram with video monitoring (vEEG) during their hospital stay. Similar to the initial recommendation, the representative stated that patients who suffer from uncontrolled seizures or intractable epilepsy are admitted to an epilepsy center for a comprehensive evaluation to identify the epilepsy seizure type, the cause of the seizure, and the location of the seizure. These patients are admitted to the hospital for 4 to 6 days with 24-hour monitoring that includes the use of EEG video monitoring along with cognitive testing and brain imaging procedures.

Effective October 1, 2007, MS-DRG 100 (Seizures with MCC) and MS-

DRG 101 (Seizures without MCC) were implemented as a result of refinements to the DRG system to better recognize severity of illness and resource utilization. Once again, the representative applauded CMS for making changes in the DRG structure to better recognize differences in patient severity. However, the representative stated that a subset of patients in MS-DRG 101 who have a primary diagnosis of intractable epilepsy and are treated with vEEG are substantially more costly to treat than other patients in this MS-DRG and represent the majority of patients being evaluated by specialized epilepsy centers.

Alternatively, the representative stated that he was not requesting any change in the structure of MS-DRG 100. According to the representative, the number of cases that would fall into this category is not significant. The representative further noted that this is a change from last year's request.

Epilepsy is currently identified by ICD-9-CM diagnosis codes 345.0x through 345.9x. There are two fifth digits that may be assigned to a subset of the epilepsy codes depending on the physician documentation:

``0'' for without mention of intractable epilepsy.

``1'' for with intractable epilepsy.

With the assistance of an outside reviewer, the representative analyzed cost data for MS-DRGs 100 and 101, which focused on three subsets of patients identified with a primary diagnosis of epilepsy or convulsions who also received vEEG (procedure code 89.19):

Patients with a primary diagnosis of epilepsy with intractability specified (codes 345.01 through 345.91).

Patients with a primary diagnosis of epilepsy without intractability specified (codes 345.00 through 345.90).

Patients with a primary diagnosis of convulsions (codes 780.39).

The representative acknowledged that the association did not include any secondary diagnoses in its analyses. Based on its results, the representative recommended that CMS further refine MS-DRG 101 by subdividing cases with a primary diagnosis of intractable epilepsy

(codes 345.01 through 345.91) when vEEG (code 89.19) is also performed into a separate MS-DRG that would be defined as ``MS-DRG XXX''

(Epilepsy Evaluation without MCC).

According to the representative, these cases are substantially more costly than the other cases within MS-DRG 101 and are consistent with the criteria for dividing MS-DRGs on the basis of CCs and MCCs. In addition, the representative stated that the request would have a minimal impact on most hospitals but would substantially improve the accuracy of payment to hospitals specializing in epilepsy care.

We performed an analysis using FY 2007 MedPAR data. As shown in the table below, we found a total of 54,060 cases in MS-DRG 101 with average charges of $14,508 and an average length of stay of 3.69 days.

There were 879 cases with intractable epilepsy and vEEG with average charges of $19,227 and an average length of stay of 5 days.

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Number of

Average length

Average

MS-DRG

cases

of stay

charges

MS-DRG 100--All Cases...........................................

16,142

6.34

$27,623

MS-DRG 100--Cases with Intractable Epilepsy with vEEG (Codes

69

6.6

26,990 345.01, 345.11, 345.41, 345.51, 345.61, 345.71, 345.81, 345.91)

MS-DRG 100--Cases with Intractable Epilepsy without vEEG........

328

7.81

32,539

MS-DRG 101--All cases...........................................

54,060

3.69

14,508

MS-DRG 101--Cases with Intractable Epilepsy with vEEG (Codes

879

5.0

19,227 345.01, 345.11, 345.41, 345.51, 345.61, 345.71, 345.81, 345.91)

MS-DRG 101--Cased with Intractable Epilepsy without vEEG........

1,351

4.25

14,913

In applying the criteria to establish subgroups, the data do not support the creation of a new subdivision for MS-DRG 101 for cases with intractable epilepsy and vEEG nor does the data support moving the 879 cases from MS-DRG 101 to MS-DRG 100. Moving the 879 cases to MS-DRG 100 would mean moving cases with average charges of approximately $19,000 into an MS-DRG with average charges of $28,000. Therefore, we are not proposing to refine MS-DRG 101 by subdividing cases with a primary diagnosis of intractable epilepsy (codes 345.01 through 345.91) when vEEG (code 89.19) is also performed into a separate MS-DRG. 3. MDC 5 (Diseases and Disorders of the Circulatory System) a. Automatic Implantable Cardioverter-Defibrillators (AICD) Lead and

Generator Procedures

In the FY 2008 IPPS final rule with comment period (72 FR 47257), we created a separate, stand alone DRG for automatic implantable cardioverter-defibrillator (AICD) generator replacements and defibrillator lead replacements. The new MS-DRG 245 (AICD lead and generator procedures) contains the following codes: 00.52, Implantation or replacement of transvenous lead

electrode

into left ventricular coronary venous system. 00.54, Implantation or replacement of cardiac resynchronization defibrillator pulse generator device only [CRT-D]. 37.95, Implantation of automatic cardioverter/ defibrillator leads(s) only. 37.96, Implantation of automatic cardioverter/ defibrillator pulse generator only. 37.97, Replacement of automatic cardioverter/defibrillator leads(s) only. 37.98, Replacement of automatic cardioverter/defibrillator pulse generator only.

Commenters on the FY 2008 IPPS proposed rule supported this new MS-

DRG, which recognizes the distinct differences in resource utilization between pacemaker and defibrillator generators and leads, but suggested that CMS should consider additional refinements for the defibrillator generator and leads. In reviewing the standardized charges for the AICD leads, the commenter believed that the leads may be more appropriately assigned to another DRG such as MS-DRG 243 (Permanent Cardiac Pacemaker

Implant with CC) or MS-DRG 258 (Cardiac Pacemaker Device Replacement with MCC). The commenter recommended that CMS consider moving the defibrillator leads back into a pacemaker DRG, either MS-DRG 243 or MS-

DRG 258.

In response to the commenters, we indicated that the data supported separate DRGs for these very different devices (72 FR 47257). We indicated that moving the defibrillator leads back into a pacemaker MS-

DRG defeated the purpose of creating separate MS-DRGs for defibrillators and pacemakers. Therefore, we finalized MS-DRG 245 as proposed with the leads and generator codes listed above.

After publication of the FY 2008 IPPS final rule with comment period, we received a request from a manufacturer that recommended a subdivision for MS-DRG 245 (AICD Lead and Generator Procedures). The requestor suggested creating a new MS-DRG to separate the implantation or replacement of the AICD leads from the implantation or replacement of the AICD pulse generators to better recognize the differences in resource utilization for these distinct procedures.

The requestor applauded CMS' decision to create separate MS-DRGs for the pacemaker device procedures from the AICD procedures in the FY 2008 IPPS final rule (72 FR 47257). The requestor further acknowledged its support of the clinically distinct MS-DRGs for pacemaker devices.

Currently, MS-DRGs 258 and 259 (Cardiac Pacemaker Device Replacement with MCC and without MCC, respectively) describe the implantation or replacement of pacemaker generators while MS-DRGs 260, 261, and 262

(Cardiac Pacemaker Revision Except Device Replacement with MCC, with

CC, without CC/MCC, respectively) describe the insertion or replacement of pacemaker leads.

The requestor believed that the IPPS ``needs to continue to evolve to accurately reflect clinical differences and costs of services.'' As such, the requestor recommended that CMS follow the same structure as it did with the pacemaker MS-DRGs for MS-DRG 245 to separately identify the implantation or replacement of the defibrillator leads (codes 37.95, 37.97, and 00.52) from the implantation or replacement of the pulse generators (codes 37.96, 37.98, 00.54).

In our analysis of the FY 2007 MedPAR data, we found a total of 5,546 cases in MS-DRG 245 with average charges of $62,631 and an average length of stay of 3.3 days. We found 1,894 cases with implantation or replacement of the defibrillator leads (codes 37.95, 37.97, and 00.52) with average charges of $42, 896 and an average length of stay of 3.4 days. We also found a total of 3,652 cases with implantation or replacement of the pulse generator (codes 37.96, 37.98, 00.54) with average charges of $72, 866 and an average length of stay of 3.2 days.

We agree with the requestor that the IPPS should accurately recognize differences in resource utilization for clinically distinct procedures. As the data demonstrate, average charges for the implantation or replacement of the AICD pulse generators are significantly higher than for the implantation or replacement of the

AICD leads. Therefore, we are proposing to create a new MS-DRG 265 to separately identify these distinct procedures. The proposed new MS-DRG 265 would be titled ``AICD Lead Procedures'' and would include procedure codes that identify the AICD leads (codes 37.95, 37.97 and 00.52). The title for MS-DRG 245 would be revised to ``AICD Generator

Procedures'' and include procedure codes 37.96, 37.98, 00.54. We believe these changes would better reflect the clinical differences and resources utilized for these distinct procedures.

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b. Left Atrial Appendage Device

Atrial fibrillation (AF) is the primary cardiac abnormality associated with ischemic or embolytic stroke. Most ischemic strokes associated with AF are possibly due to an embolism or thrombus that has formed in the left atrial appendage. Evidence from studies such as transesophageal echocardiography shows left atrial thrombi to be more frequent in AF patients with ischemic stroke as compared to AF patients without stroke. While anticoagulation medication can be efficient in ischemic stroke prevention, there can be problems of safety and tolerability in many patients, especially those older than 75 years.

Chronic warfarin therapy has been proven to reduce the risk of embolism but there can be difficulties concerning its administration. Frequent blood tests to monitor warfarin INR are required at some cost and patient inconvenience. In addition, because warfarin INR is affected by a large number of drug and dietary interactions, it can be unpredictable in some patients and difficult to manage. The efficacy of aspirin for stroke prevention in AF patients is less clear and remains controversial. With the known disutility of warfarin and the questionable effectiveness of aspirin, a device-based solution may provide added protection against thromboembolism in certain patients with AF.

At the April 1, 2004 ICD-9-CM Coordination and Maintenance

Committee meeting, a proposal was presented for the creation of a unique procedure code describing insertion of the left atrial appendage filter system. Subsequently, ICD-9-CM code 37.90 (Insertion of left atrial appendage device) was created for use beginning October 1, 2004.

This code was designated as a non-operating room (non-O.R.) procedure, and had an effect only on cases in MDC 5, CMS DRG 518 (Percutaneous

Cardiovascular Procedure without Coronary Artery Stent or Acute

Myocardial Infarction). With the adoption of MS-DRGs in FY 2008, CMS

DRG 518 was divided into MS-DRGs 250 and 251 (Percutaneous

Cardiovascular Procedure without Coronary Artery Stent or AMI with MCC, and without MCC, respectively).

We have reviewed the data concerning this procedure code annually.

Using FY 2005 MedPAR data for the FY 2007 IPPS final rule, 24 cases were reported, and the average charges ($27,620) closely mimicked the average charges of the other 22,479 cases in CMS DRG 518 ($28,444). As the charges were comparable, we made no recommendations to change the

CMS DRG assignment for FY 2007.

Using FY 2006 MedPAR data for the FY 2008 final rule with comment period, we divided CMS DRG 518 into the cases that would be reflected in the MS-DRG configuration; that is, we divided the cases based on the presence or absence of an MCC. There were 35 cases without an MCC with average charges of $24,436, again mimicking the 38,002 cases with average charges of $32,546. There were 3 cases with MCC with average charges of $62,337, compared to the 5,458 cases also with an MCC with average charges of $53,864. Again it was deemed that cases with code 37.90 were comparable to the rest of the cases in CMS DRG 518, and the decision was made not to make any changes in the DRG assignment for this procedure code. As noted above, CMS DRG 518 became MS-DRGs 250 and 251 in FY 2008.

We have received a request regarding code 37.90, and its placement within the MS-DRG system for FY 2009. The requestor asked for either the reassignment of code 37.90 to an MS-DRG that would adequately cover the costs associated with the complete procedure or the creation of a new MS-DRG that would reimburse hospitals adequately for the cost of the device. The requestor, a manufacturer's representative, reported that the device's IDE clinical trial is nearing completion, with the conclusion of study enrollment in May 2008. The requestor will continue to enroll patients in a Continued Use Registry following completion of the trial. The requestor reported that it did not charge hospitals for the atrial appendage device, estimated to cost $6,000, during the trial period, but it will begin to charge hospitals upon the completion of the trial in May. The requestor provided us with its data showing what it believed to be a differential of $107 more per case than the payment average for MS-DRG 250, and a shortfall of $3,808 per case than the payment average for MS-DRG 251.

The requestor pointed out that code 37.90 is assigned to both MS-

DRGs 250 and 251, but stated that the final MS-DRG assignment would be

MS-DRG 251 when the patient has a principal diagnosis of atrial fibrillation (code 427.31) because AF is not presently listed as a CC or an MCC. We would take this opportunity to note that the principal diagnosis is used to determine assignment of a case to the correct MDC.

Secondary or additional diagnosis codes are the only codes that can be used to determine the presence of a CC or an MCC.

With regard to the request to create a specific DRG for the insertion of this device entitled ``Percutaneous Cardiovascular

Procedures with Implantation of a Left Atrial Appendage Device without

CC/MCC'', we would point out that the payments under a prospective payment system are predicated on averages. The device is already assigned to MS-DRGs containing other percutaneous cardiovascular devices; to create a new MS-DRG specific to this device would be to remove all other percutaneously inserted devices and base the MS-DRG assignment solely on the presence of code 37.90. This approach negates our longstanding method of grouping like procedures, and removes the concept of averaging. Further, to ignore the structure of the MS-DRG system solely for the purpose of increasing payment for one device would set an unwelcome precedent for defining all of the other MS-DRGs in the system. We would also point out that the final rule establishing the MS-DRGs set forth five criteria, all five of which are required to be met, in order to warrant creation of a CC or an MCC subgroup within a base MS-DRG. The criteria can be found in the FY 2008 IPPS final rule with comment period (72 FR 47169). One of the criteria specifies that there will be at least 500 cases in the CC or MCC subgroup. To date, there are not enough cases of code 37.90 reported within the MedPAR data.

Using FY 2007 MedPAR data, for this FY 2009 IPPS proposed rule, we reviewed MS-DRGs 250 and 251 for the presence of the left atrial appendage device. The following table displays our results:

Number of

Average length

Average

MS-DRG

cases

of stay

charges

250--All Cases....................................

6,424

7.72

$60,597.58 250--Cases with code 37.90........................

4

6.50

65,829.51 250--Cases without code 37.90.....................

6,420

7.72

60,594.32 251--All Cases....................................

39,456

2.84

35,719.81

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251--Cases with code 37.90........................

101

1.30

20,846.09 251--Cases without code 37.90.....................

39,335

2.85

35,757.98

There were a total of 105 cases with code 37.90 reported for

Medicare beneficiaries in the 2007 MedPAR data. There are 4 cases with an atrial appendage device in MS-DRG 250 that have higher average charges than the other 6,420 cases in the MS-DRG, and that have slightly shorter lengths of stay by 1.25 days. However, the more telling data are located in MS-DRG 251, which shows that the 101 cases in which an atrial appendage device was implanted have much lower average charges ($20,846.09) than the other 39,355 cases in the MS-DRG, with average charges of $35,758.98. The difference in the average charges is approximately $14,912, so even when the manufacturer begins charging the hospitals the estimated $6,000 for the device, there is still a difference of approximately $8,912 in average charges based on the comparison within the total MS-DRG 251. Interestingly, the 101 cases also have an average length of stay of less than half of the average length of stay compared to the other cases assigned to that MS-

DRG.

Because the data do not support either the creation of a unique MS-

DRG or the assignment of procedure code 37.90 to another higher- weighted MS-DRG, we are not proposing any change to MS-DRGs 250 and 251, or to code 37.90 for FY 2009. We believe, based on the past 3 year's comparisons, that this code is appropriately located within the

MS-DRG structure. 4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and

Connective Tissue): Hip and Knee Replacements and Revisions

For FY 2009, we again received a request from the American

Association of Hip and Knee Surgeons (AAHKS), a specialty group within the American Academy of Orthopedic Surgeons (AAOS), concerning modifications of the lower joint procedure MS-DRGs. The request is similar, in some respects, to the AAHKS's request in FY 2008, particularly as it relates to separating routine and complex procedures. For the benefit of the reader, we are republishing a history of the development of DRGs for hip and knee replacements and a summary of the AAHKS FY 2008 request that were included in the FY 2008

IPPS final rule with comment period (72 FR 47222 through 47224) before we discuss the AAHKS's more recent request. a. Brief History of Development of Hip and Knee Replacement Codes

In the FY 2006 IPPS final rule (70 FR 47303), we deleted CMS DRG 209 (Major Joint and Limb Reattachment Procedures of Lower Extremity) and created two new CMS DRGs: 544 (Major Joint Replacement or

Reattachment of Lower Extremity) and 545 (Revision of Hip or Knee

Replacement). The two new CMS DRGs were created because revisions of joint replacement procedures are significantly more resource intensive than original hip and knee replacements procedures. CMS DRG 544 included 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.

CMS DRG 545 included 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 being performed. In the

FY 2006 IPPS final rule (70 FR 47305), we indicated 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 CMS DRGs to determine if future additional DRG modifications are needed. b. Prior Recommendations of the AAHKS

Prior to this year, the AAHKS had recommended that we make further refinements to the CMS DRGs for knee and hip arthroplasty procedures.

The AAHKS previously presented data to CMS on the important differences in clinical characteristics and resource utilization between primary and revision total joint arthroplasty procedures. The AAHKS stated that

CMS's 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. The 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.

The 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, the

AAHKS recommended that CMS examine Medicare claims data and consider the creation of separate DRGs for total hip and total knee arthroplasty procedures. The AAHKS stated that based on the differences between patient

Page 23568

characteristics, procedure characteristics, resource utilization, and procedure code payment rates between total hip and total knee replacements, separate DRGs were warranted. Furthermore, the 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 head 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.

The AAHKS also recommended the continuation of CMS DRG 471

(Bilateral or Multiple Major Joint Procedures of Lower Extremity) without modifications. CMS DRG 471 included 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. c. Adoption of MS-DRGs for Hip and Knee Replacements for FY 2008 and

AAHKS's Recommendations

In the FY 2008 IPPS final rule with comment period (72 FR 47222 through 47226), we adopted MS-DRGs to better recognize severity of illness for FY 2008. The MS-DRGs include two new severity of illness levels under the then current base DRG 544. We also added three new severity of illness levels to the base DRG for Revision of Hip or Knee

Replacement. The new MS-DRGs are as follows:

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

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

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

CC/MCC)

MS-DRG 469 (Major Joint Replacement or Reattachment of

Lower Extremity with MCC)

MS-DRG 470 (Major Joint Replacement or Reattachment of

Lower Extremity without MCC)

We found that the MS-DRGs greatly improved our ability to identify joint procedures with higher resource costs. In the final rule, we presented data indicating the average charges for each new MS-DRG for the joint procedures.

In the FY 2008 IPPS final rule with comment period, we acknowledged the valuable assistance the AAHKS had 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. Commenters on the FY 2008 proposed rule had encouraged CMS to continue working with the orthopedic community, including the AAHKS, to monitor the need for additional new

DRGs. The commenters stated that MS-DRGs 466 through 470 are a good first step. However, they stated that CMS should continue to evaluate the data for these procedures and consider additional refinements to the MS-DRGs, including the need for additional severity levels. AAHKS stated that its data suggest that all three base DRGs (primary replacement, revision of major joint replacement, and bilateral joint replacement) should be separated into three severity levels (that is,

MCC, CC, and non-CC). (We had proposed three severity levels for revision of hip and knee replacement (MS-DRGs 466, 467, and 468), and

AAHKS agreed with this 3-level subdivision.)

The AAHKS recommended that the base DRG for the proposed two severity subdivision MS-DRGs for major joint replacement or reattachment of lower extremity with and without CC/MCC (MS-DRGs 483 and 484) be subdivided into three severity levels, as was the case for the revision of hip and knee replacement MS-DRGs. AAHKS also recommended that the two severity subdivision MS-DRGs for bilateral or multiple major joint procedures of lower extremity with and without MCC

(MS-DRGs 461 and 462) be subdivided three ways for this base DRG. AAHKS acknowledged that the three way split would not meet all five of the criteria for establishing a subgroup, and stated that these criteria were too restrictive, lack face validity, and create perverse admission selection incentives for hospitals by significantly overpaying for cases without a CC and underpaying for cases with a CC. It recommended that the existing five criteria be modified for low volume subgroups to assure materiality. For higher volume MS-DRG subgroups, the AAHKS recommended that two other criteria be considered, particularly for nonemergency, elective admissions:

Is the per-case underpayment amount significant enough to affect admission vs. referral decisions on a case-by-case basis?

Is the total level of underpayments sufficient to encourage systematic admission vs. referral policies, procedures, and marketing strategies?

The AAHKS also recommended refining the five existing criteria for

MCC/CC/without subgroups as follows:

Create subgroups if they meet the five existing criteria, with cost difference between subgroups ($1,350) substituted for charge difference between subgroups ($4,000);

If a proposed subgroup meets criteria number 2 and 3 (at least 5 percent and at least 500 cases) but fails one of the others, then create the subgroup if either of the following criteria are met:

supsqu

At least $1,000 cost difference per case between subgroups; or

supsqu

At least $1 million overall cost should be shifted to cases with a CC (or MCC) within the base DRG for payment weight calculations.

Page 23569

In response, we indicated that we did not believe it was appropriate to modify our five criteria for creating severity subgroups. Our data did not support creating additional subdivisions based on the criteria. At that time, we believed the criteria we established to create subdivisions within a base DRG were reasonable and establish the appropriate balance between better recognition of severity of illness, sufficient differences between the groups, and a reasonable number of cases in each subgroup. However, we indicated that we may consider further modifications to the criteria at a later date once we have had some experience with MS-DRGs created using the proposed criteria.

The AAHKS indicated in its response to the FY 2008 proposed rule that it continued to support the separation of routine and complex joint procedures. It believed that certain joint replacement procedures have significantly lower average charges than do other joint replacements. The AAKHS's data suggest that more routine joint replacements are associated with substantially less resource utilization than other more complex revision procedures. The AAHKS stated that leaving these procedures in the revision MS-DRGs results in substantial overpayment for these relatively simple, less costly revision procedures, which in turn results in a relative underpayment for the more complex revision procedures.

In response, we examined data on this issue and identified two procedure codes for partial knee revisions that had significantly lower average charges than did other joint revisions. The two codes are as follows: 00.83 Revision of knee replacement, patellar component 00.84 Revision of total knee replacement, tibial insert

(liner)

The data suggest that these less complex partial knee revisions are less resource intensive than other cases assigned to MS-DRGs 466, 467, or 468. We examined other orthopedic DRGs to which these two codes could be assigned. We found that these cases have very similar average charges to those in MS-DRG 485 (Knee Procedures with Principal

Diagnosis of Infection with MCC), MS-DRG 486 (Knee Procedures with

Principal Diagnosis of Infection with CC), MS-DRG 487 (Knee Procedures with Principal Diagnosis of Infection without CC), MS-DRG 488 (Knee

Procedures without Principal Diagnosis of Infection with CC or MCC), and MS-DRG 489 (Knee Procedures without Principal Diagnosis of

Infection without CC).

Given the very similar resource requirements of MS-DRG 485 and the fact that these DRGs also contain knee procedures, we moved codes 00.83 and 00.84 out of MS-DRGs 466, 467, and 468 and into MS-DRGs 485, 486, 487, 488, and 489. We also indicated that we would continue to monitor the revision DRGs to determine if additional modifications are needed. d. AAHKS' Recommendations for FY 2009

The AAHKS' current request involves the following recommendations:

That CMS consolidate and reassign certain joint procedures that have a diagnosis of an infection or malignancy into MS-DRGs that are similar in terms of clinical characteristics and resource utilization. The AAKHS further identifies groups called Stage 1 and 2 procedures that it believes require significant differences in resource utilization.

That CMS reclassify certain specific joint procedures, which AAHKS refers to as ``routine,'' out of their current MS-DRG assignments. The three joint procedures that AAHKS classifies as

``routine'' are codes 00.73 (Revision of hip replacement, acetabular liner and/or femoral head only), 00.83 (Revision of knee replacement, patellar component), and 00.84 (Revision of total knee replacement, tibial insert (liner)). The AAHKS advocated removing these three

``routine'' procedures from the following DRGs: MS-DRGs 466, 467, and 468, MS-DRGs 485, 486, and 487, and MS-DRGs 488 and 489. The AAHKS refers to MS-DRGs 466, 467, and 468 as ``complex'' revision DRGs, and recommended that the three ``routine'' procedures be moved out of MS-

DRGs 466, 467, and 468 and MS-DRGs 485, 486, and 489 and into MS-DRGs 469 and 470 (Major Joint Replacement or Reattachment of Lower Extremity with and without MCC, respectively). The AAHKS contended that the three

``routine'' procedures have similar clinical characteristics and resource utilization to those in MS-DRGs 469.

The recommendations suggested by AAHKS are quite complex and involve a number of specific code lists and MS-DRG assignment changes.

We discuss each of these requests in detail below.

(1) AAHKS Recommendation 1: Consolidate and reassign patients with hip and knee prosthesis related infections or malignancies.

The AAHKS pointed out that deep infection is one of the most devastating complications associated with hip and knee replacements.

These infections have been reported to occur in approximately 0.5 percent to 3 percent of primary and 4 percent to 6 percent of revision total joint replacement procedures. These infections often result in the need for multiple reoperations, prolonged use of intravenous and oral antibiotics, extended inpatient and outpatient rehabilitation, and frequent followup visits. Furthermore, clinical outcomes following single- and two-stage revision total joint arthroplasty procedures have been less favorable than revision for other causes of failure not associated with infection.

In addition to the clinical impact, the AAHKS stated that infected total joint replacement procedures also have substantial economic implications for patients, payers, hospitals, physicians, and society in terms of direct medical costs, resource utilization, and the indirect costs associated with lost wages and productivity. The AAHKS stated that the considerable resources required to care for these patients has resulted in a strong financial disincentive for physicians and hospitals to provide care for patients with infected total joint replacements, an increased economic burden on the high volume tertiary care referral centers where patients with infected hip replacement procedures are frequently referred for definitive management. The AAHKS further stated that, in some cases, there are compromised patient outcomes due to treatment delays as patients with infected joint replacements seek providers who are willing to care for them.

Once a deep infection of a total joint prosthesis is identified, the first stage of treatment involves a hospital admission for removal of the infected prosthesis and debridement of the involved bone and surrounding tissue. During the same procedure, an antibiotic- impregnated cement spacer is typically inserted to maintain alignment of the limb during the course of antibiotic therapy. The patient is then discharged to a rehabilitation facility/nursing home (or to home if intravenous therapy can be safely arranged for the patient) for a 6- week course of IV antibiotic treatment until the infection has cleared.

After the completion of antibiotic therapy, the hip or knee may be reaspirated to look for evidence of persistent infection or eradication of infection. A second stage procedure is then undertaken, where the patient is readmitted, the hip or knee is reexplored, and the cement spacer removed. If there are no signs of persistent infection, a hip or knee prosthesis is reimplanted, often using bone graft and costly revision implants in order to address extensive bone loss

Page 23570

and distorted anatomy. Thus, the entire course of treatment for patients with infected joint replacements is 4 to 6 months, with an additional 6 to 12 months of rehabilitation. Furthermore, clinical outcomes following revision for infection are poor relative to outcomes following revision for other, aseptic causes. The AAHKS noted that patients with bone malignancy have a similar treatment focus--surgery to remove diseased tissue, chemotherapy to treat the malignancy, and implantation of the new prosthesis. They also have similar resource use. For simplicity, the AAHKS' discussion focused on infected joint prostheses, but it suggested that the issues it raises would apply to patients with a malignancy as well.

The AAHKS stated that these patients are currently grouped in multiple MS-DRGs, and the cases are often ``outliers'' in each one.

AAHKS proposed to consolidate these patients with similar clinical characteristics and treatment into MS-DRGs reflective of their resource utilization.

The AAHKS states that these more severe patients are currently classified into the following MS-DRGs:

MS-DRGs 463, 463, and 465 (Wound Debridement and Skin

Graft Excluding Hand, for Musculoskeletal-Connective Tissue Disease with MCC, with CC, without CC/MCC, respectively).

MS-DRGs 480, 481, and 482 (Hip and Femur Procedures Except

Major Joint with MCC, with CC, without CC/MCC, respectively).

MS-DRGs 485, 486, and 487 (Knee Procedures with Principal

Diagnosis of Infection and with MCC, with CC, and without CC/MCC, respectively).

MS-DRGs 488 and 489 (Knee Procedures without Principal

Diagnosis of Infection and with CC/MCC and without CC/MCC, respectively).

MS-DRGs 495, 496, and 497 (Local Excision and Removal of

Internal Fixation Devices Except Hip and Femur with MCC, with CC, and without CC/MCC, respectively).

Other MS-DRGs (The AAHKS did not specify what these other

MS-DRGs were.).

The AAHKS indicated that cases with the severe diagnoses of infections, neoplasms, and structural defects have similarities. These similarities are due to an overlap of a severe diagnosis (including a principal diagnosis of code 996.66 (Infected joint prosthesis) and the resulting need for more extensive surgical procedures. The AAHKS stated that currently these patients are grouped into MS-DRGs by major procedure alone. AAHKS recommended that these cases be grouped into what it refers to as Stages 1 and 2 as follows:

Stage 1 would include the removal of an infected prosthesis and includes cases in MS-DRGs 463, 464, and 465, 480, 481, and 482, 485 through 489, and 495, 496, and 497. Stage 1 joint procedure codes would include codes 80.05 (Arthrotomy for removal of prosthesis, hip), 80.06 (Arthrotomy for removal of prosthesis, knee), 00.73 (Revision of hip replacement, acetabular liner and/or femoral head only), and 00.84 (Revision of knee replacement, tibial insert

(liner)).

Stage 2 would include the implant of a new prosthesis and includes cases in MS-DRGs 461 and 462, 463, 464, and 465, 466, 467, and 468, and 469 and 470. Stage 2 joint procedure codes would include codes 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), 00.80 (Revision of knee replacement, total (all components)), 00.81 (Revision of knee replacement, tibial component), 00.82 (Revision of knee replacement, femoral component), 00.85 (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 (Revise hip replacement), 81.54

(Total knee replacement), 81.55 (Revise knee replacement), and 81.56

(Total ankle replacement).

As stated earlier, the AAHKS recommended patients with certain more severe diagnoses be grouped into a higher severity level. While most of

AAHKS' comments focused on joint replacement patients with infections, the AAHKS also believed that patients with certain neoplasms require greater resources. To this group of infections and neoplasms, the AAHKS recommended the addition of four codes that capture acquired deformities. The AAHKS believed that these codes would capture admissions for the second stage of the treatment for an infected joint.

The AAHKS stated that the significance of these diagnoses when they are reported as the principal code position was significant in predicting resource utilization. However, the impact was not as significant when the diagnosis was reported as a secondary diagnosis. The AAHKS recommended that patients with one of the following infection/neoplasm/ defect principal diagnosis codes be segregated into a higher severity level.

Stage 1 Infection/Neoplasm/Defect Principal Diagnosis Codes 170.7 (Malignant neoplasm of long bones of lower limb). 171.3 (Malignant neoplasm of soft tissue, lower limb, including hip). 711.05 (Pyogenic arthritis, pelvic region and thigh). 711.06 (Pyogenic arthritis, lower leg). 730.05 (Acute osteomyelitis, pelvic region and thigh). 730.06 (Acute osteomyelitis, lower leg). 730.15 (Chronic osteomyelitis, pelvic region and thigh). 730.16 (Chronic osteomyelitis, lower leg). 730.25 (Unspecified osteomyelitis, pelvic region and thigh). 730.26 (Unspecified osteomyelitis, lower leg). 996.66 (Infection and inflammatory reaction due to internal joint prosthesis). 996.67 (Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft).

Stage 2 Infection/Neoplasm/Defect Principal Diagnosis Codes (an

Asterisk * Shows the Diagnoses Included in Stage 2 That Were Not Listed in Stage 1) 170.7 (Malignant neoplasm of long bones of lower limb). 171.3 (Malignant neoplasm of soft tissue, lower limb, including hip). 198.5 (Secondary malignant neoplasm of bone and bone marrow) .* 711.05 (Pyogenic arthritis, pelvic region and thigh). 711.06 (Pyogenic arthritis, lower leg). 730.05 (Acute osteomyelitis, pelvic region and thigh). 730.06 (Acute osteomyelitis, lower leg). 730.15 (Chronic osteomyelitis, pelvic region and thigh). 730.16 (Chronic osteomyelitis, lower leg). 730.25 (Unspecified osteomyelitis, pelvic region and thigh). 730.26 (Unspecified osteomyelitis, lower leg). 736.30 (Acquired deformities of hip, unspecified deformity). 736.39 (Other acquired deformities of hip) .* 736.6 (Other acquired deformities of knee) .* 736.89 (Other acquired deformities of other parts of limbs). * 996.66 (Infection and inflammatory reaction due to internal joint prosthesis). * 996.67 (Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft). *

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For the Stage 2 procedures, AAHKS also suggested the use of the following secondary diagnosis codes to assign the cases to a higher severity level. These conditions would not be the reason the patient was admitted to the hospital. They would instead represent secondary conditions that were also present on admission or conditions that were diagnosed after admission.

Stage 2 Infection/Neoplasm/Defect Secondary Diagnosis Codes 170.7 (Malignant neoplasm of long bones of lower limb). 171.3 (Malignant neoplasm of soft tissue, lower limb, including hip). 711.05 (Pyogenic arthritis, pelvic region and thigh). 711.06 (Pyogenic arthritis, lower leg). 730.05 (Acute osteomyelitis, pelvic region and thigh). 730.06 (Acute osteomyelitis, lower leg). 730.15 (Chronic osteomyelitis, pelvic region and thigh). 730.16 (Chronic osteomyelitis, lower leg). 730.25 (Unspecified osteomyelitis, pelvic region and thigh). 730.26 (Unspecified osteomyelitis, lower leg). 996.66 (Infection and inflammatory reaction due to internal joint prosthesis). 996.67 (Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft).

(2) AAHKS Recommendation 2: Reclassify certain specific joint procedures.

The AAHKS suggested that cases with the infection/neoplasm/defect diagnoses listed above be segregated according to the Stage 1 and 2 groups listed above. The AAHKS made one final recommendation concerning joint procedure cases with infections. It identified a subset of patients who had a principal diagnosis of 996.66 (Infection and inflammatory reaction due to internal joint prosthesis) and who also had a secondary diagnosis of sepsis or septicemia. The AAHKS believed that these patients are for the most part admitted with both the joint infection and sepsis/septicemia present at the time of admission. The codes for sepsis/septicemia are classified as MCCs under MS-DRGs. The

AAHKS believed it is inappropriate to count the secondary diagnosis of sepsis/septicemia as a MCC when it is reported with code 996.66. The

AAHKS believed that counting sepsis and septicemia as a MCC results in double counting the infections. It believed that the joint infection and septicemia are the same infection. The AAHKS recommended that the following sepsis and septicemia codes not count as a MCC when reported with code 996.66: 038.0 (Streptococcal septicemia). 038.10 (Staphylococcal septicemia, unspecified). 038.11 (Staphylococcal aureus septicemia). 038.19 (Other staphylococcal septicemia). 038.2 (Pneumococcal septicemia [streptococcus pneumonia septicemia]). 038.3 (Septicemia due anaerobes). 038.40 (Septicemia due to gram-negative organisms). 038.41 (Hemophilus influenzae [H. Influenzae]). 038.42 (Escherichia coli [E. Coli]). 038.43 (Pseudomonas). 038.44 (Serratia). 038.49 (Other septicemia due to gram-negative organisms). 038.8 (Other specified septicemias). 038.9 (Unspecified septicemia). 995.91 (Sepsis). 995.92 (Severe sepsis). e. CMS' Response to AAHKS' Recommendations

The MS-DRG modifications proposed by the AAHKS are quite complex and have many separate parts. We made changes to the MS-DRGs in FY 2008 as a result of a request by the AAHKS as discussed above, to recognize two types of partial knee replacements as less complex procedures. We have no data on how effective the new MS-DRGs for joint procedures are in differentiating patients with varying degrees of severity.

Therefore, we analyzed data reported prior to the adoption of MS-DRGs to analyze each of the recommendations made. We begin our analysis by focusing first on the more simple aspects of the recommendations made by the AAHKS.

(1) Changing the MS-DRG Assignment for Codes 00.73, 00.83, and 00.84

As discussed previously, in FY 2008, the AAHKS recommended that CMS classify certain joint procedures as either routine or complex. We examined the data for these cases and found that the following two codes had significantly lower charges than the other joint revisions: 00.83 (Revision of knee replacement, patellar component) and 00.84

(Revision of knee replacement, tibial insert (liner)). Therefore, we moved these two codes to MS-DRGs 485, 486, and 487, and MS-DRGs 488 and 489.

As a result of AAHKS' most recent recommendations, we once again examined claims data for these two knee procedures (codes 00.83 and 00.84) as well as its request that we move code 00.73 (Revision of hip replacement, acetabular liner and/or femoral head only). Code 00.73 is assigned to MS-DRGs 466, 467, and 468. The following tables show our findings.

Number of

Average length

Average

MS-DRG

cases

of stay

charges

485--All Cases..................................................

1,122

12.20

$64,672.47 485--Cases with Code 00.83 or 00.84.............................

179

11.83

64,446.68 485--Cases without Code 00.83 or 00.84..........................

943

12.27

64,715.33 486--All Cases..................................................

2,061

8.03

40,758.55 486--Cases with Code 00.83 or 00.84.............................

464

7.34

39,864.39 486--Cases without Code 00.83 or 00.84..........................

1,597

8.23

41,018.34 487--All Cases..................................................

1,236

5.67

29,180.88 487--Cases with Code 00.83 or 00.84.............................

284

5.61

31,231.79 487--Cases without Code 00.83 or 00.84..........................

952

5.68

28,569.06 488--All Cases..................................................

2,374

5.17

30,180.80 488--Cases with code 00.83 or 00.84.............................

754

4.09

28,432.06 488--Cases without code 00.83 or 00.84..........................

1,620

5.67

30,994.73 489--All Cases..................................................

5,493

3.04

21,385.67 489--Cases with code 00.83 or 00,.84............................

2,154

3.07

23,122.18 489--Cases without code 00.83 or 00.84..........................

3,339

3.03

20,265.44 469--All cases..................................................

29,030

8.17

56,681.64 470--All Cases..................................................

385,123

3.93

36,126.23 466--All Cases..................................................

3,888

9.18

76,015.66 466--Cases with Code 00.73......................................

273

10.02

71,293.33

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466--Cases without Code 00.73...................................

3,616

9.12

76,372.06 467--All Cases..................................................

13,551

5.50

53,431.63 467--Cases with Code 00.73......................................

1,078

5.94

43,635.63 467--Cases without Code 00.73...................................

12,484

5.47

54,284.13 468--All Cases..................................................

19,917

3.94

44,055.62 468--Cases with Code 00.73......................................

1,688

3.93

33,449.22 468--Cases without Code 00.73...................................

18,232

3.94

45,037.09 469--All Cases..................................................

29,030

8.17

56,681.64 470--All Cases..................................................

385,123

3.93

36,126.23

The tables show that codes 00.73, 00.83, and 00.84 are appropriately assigned to their current MS-DRGs. The data do not support moving these three codes to MS-DRGs 469 and 470. Therefore, we are not proposing a change of MS-DRG assignment for codes 00.73, 00.83, and 00.84.

(2) Excluding Sepsis and Septicemia From Being a MCC With Code 996.66

There are cases where a patient may be admitted with an infection of a joint prosthesis (code 996.66) and also have sepsis. In these cases, it may be possible to perform joint procedures as suggested by

AAHKS. However, in other cases, a patient may be admitted with an infection of a joint prosthesis and then develop sepsis during the stay. Because our current data do not indicate whether a condition is present on admission, we could not determine whether or not the sepsis occurred after admission. Our data have consistently shown that cases of sepsis and septicemia require significant resources. Therefore, we classified the sepsis and septicemia codes as MCCs. Our clinical advisors do not believe it is appropriate to exclude all cases of sepsis and septicemia that are reported as a secondary diagnosis with code 996.66 from being classified as a MCC. We discuss septicemia as part of hospital acquired conditions provision under section II.F. of the preamble of this proposed rule. For the purposes of classifying sepsis and septicemia as non-CCs when reported with code 996.66, we do not support this recommendation. Therefore, we are not proposing that the sepsis and septicemia codes be added to the CC exclusion list for code 996.66.

(3) Differences Between Stage 1 and 2 Cases With Severe Diagnoses

We next examined data on AAHKS' suggestion that there are significantly differences in resource utilization for cases they refer to as Stage 1 and 2. AAHKS stated that this is particularly true for those with infections, neoplasms, or structural defects. We used the list of procedure codes listed above that AAHKS describes as Stage 1 and 2 procedures. We also used AAHKS' designated lists of Stage 1 and 2 principal diagnosis codes to examine this proposal. This proposal entails moving cases with a Stage 1 or 2 principal diagnosis and procedure out of their current MS-DRG assignment in the following 19

MS-DRGs and into a newly consolidated set of MS-DRGs: MS-DRGs 463, 464, and 465, 480, 481, and 482, 485 through 489, and 495, 496, and 497.

As can be seen from the information below, there was not a significant difference in average charges between these Stage 1 and

Stage 2 cases that have an MCC.

Stage 1.--Cases With Infection, Neoplasm, or Structural Defect

Average length

Average

Stage 1

Total cases

of stay

charges

With MCC........................................................

1,306

14.1

$79,232

Without MCC.....................................................

4,115

7.6

44,716

Stage 2.--Cases With Infection, Neoplasm, or Structural Defect

Average length

Average

Stage 2

Total cases

of stay

charges

With MCC........................................................

1,072

10.9

$80,781

Without MCC.....................................................

5,413

6.0

57,355

Average charges for Stage 1 cases with an MCC was $79,232 compared to $80,781 for Stage 2. Stage 1 cases without an MCC had average charges of $44,716 compared to $57,355. These data do not support reconfiguring the current MS-DRGs based on this new subdivision.

(4) Moving Joint Procedure Cases to New MS-DRGs Based on Secondary

Diagnoses of Infection

We examined AAHKS' recommendation that Stage 2 joint cases with specific secondary diagnoses of infection or neoplasm be moved out of their current MS-DRG assignments and into a newly constructed MS-DRG.

We are reluctant to make this type of significant DRG change to the joint MS-DRGs based on the presence of a secondary diagnosis. This results in the movement of cases out of MS-DRGs which were configured based on the reason for the admission (for example, principal diagnosis) and surgery. The cases would instead be assigned based on conditions that are reported as secondary diagnoses. In some cases, the infection may have developed or be diagnosed during the admission. This would be a significant logic change to the MS-DRGs for joint procedures. We have not had an opportunity to examine

Page 23573

claims data based on hospital discharges under the MS-DRGs which began

October 1, 2008. Our clinical advisors believe it would be more appropriate to wait for data under the new MS-DRG system to determine how well the new severity levels are addressing accurate payment for these cases before considering this approach to assigning cases to a

MS-DRG.

(5) Moving Cases With Infection, Neoplasms, or Structural Defects Out of 19 MS-DRGs and Into Two Newly Developed MS-DRGs

The last recommended by AAHKS that we considered was moving cases with a principal diagnosis of infection, neoplasm, or structural defect from their list of Stage 1 and 2 diagnoses and consolidated them into newly constructed and modified MS-DRGs. AAHKS could not identify an existing set of MS-DRGs with similar resource utilizations into which the Stage 1 cases could be assigned. Therefore, the AAHKS recommended that CMS create three new MS-DRGs for Stage 1 cases with infections, neoplasms and structural defects which would be titled ``Arthrotomy/

Removal/Component exchange of Infected Hip or Knee Prosthesis with MCC, with CC, and without CC/MCC'', respectively.

The AAHKS recommended moving Stage 2 cases out of MS-DRGs 466, 467, and 468, and 469 and 470 and into MS-DRGs 461 and 462. AAHKS recommended that MS-DRGs 461 and 462 be renamed ``Major Joint

Procedures of Lower Extremity--Bilateral/Multiple/Infection/

Malignancy''.

In reviewing these proposed changes, we had a number of concerns.

The first concern was that these proposed changes would result in the removal of cases with varying average charges from 19 current MS-DRGs and consolidating them into two separate sets of MS-DRGs. As the data below indicate, the average charges vary from as low as $29,181 in MS-

DRG 487 to $81,089 in MS-DRG 463. Furthermore, the average charges for these infection/neoplasm/structural defect cases are very similar to other cases in their respective MS-DRG assignments for many of these

MS-DRGs. There are cases where the average charges are higher. In MS-

DRG 469 and 470, the infection/neoplasm/structural defect cases are significantly higher. However, there are only 136 cases in MS-DRG 469 out of a total of 29,030 cases with these diagnoses. There are only 673 cases in MS-DRG 470 out of a total of 385,123 cases with one of these diagnoses. The table below clearly demonstrates the wide variety of charges for cases with these diagnoses.

Number of

Average length

Average

MS-DRGs

cases

of stay

charges

463--All Cases..................................................

4,747

16.25

$73,405.46 463--Cases with PDX of Infection/Malignancy/React...............

1,009

17.79

81,089.07 464--All Cases..................................................

5,499

10.21

44,387.73 464--Cases with PDX of Infection/Malignancy/React...............

1,420

10.59

46,800.60 465--All Cases..................................................

2,271

5.95

26,631.57 465--Cases with PDX of Infection/Malignancy/React...............

557

10.59

29,816.40 466--All Cases..................................................

3,888

9.18

76,015.66 466--Cases with PDX of Infection/Malignancy/React...............

890

10.67

79,334.69 467--All Cases..................................................

13,551

5.50

53,431.63 467--Cases with PDX of Infection/Malignancy/React...............

2,401

6.71

58,506.86 468--All Cases..................................................

19,917

3.94

44,055.62 468--Cases with PDX of Infection/Malignancy/React...............

1,994

4.76

54,322.03 469--All Cases..................................................

29,030

8.17

56,681.64 469--Cases with PDX of Infection/Malignancy/React...............

136

11.74

85,256.07 470--All Cases..................................................

385,123

3.93

36,126.23 470--Cases with PDX of Infection/Malignancy/React...............

673

6.44

59,676.31 480--All Cases..................................................

25,391

9.32

52,281.65 480--Cases with PDX of Infection/Malignancy/React...............

880

14.53

76,355.15 481--All Cases..................................................

68,655

5.94

32,963.64 481--Cases with PDX of Infection/Malignancy/React...............

878

8.78

48,655.30 482--All Cases..................................................

45,832

4.86

27,266.20 482--Cases with PDX of Infection/Malignancy/React...............

577

6.19

37,572.38 485--All Cases..................................................

1,122

12.20

64,672.47 485--Cases with PDX of Infection/Malignancy/React...............

1,122

12.20

64,672.47 486--All Cases..................................................

2,061

8.03

40,758.55 486--Cases with PDX of Infection/Malignancy/React...............

2,061

8.03

40,758.55 487--All Cases..................................................

1,236

5.67

29,180.88 487--Cases with PDX of Infection/Malignancy/React...............

1,236

5.67

29,180.88 488--All Cases..................................................

2,374

5.17

30,180.80 488--Cases with PDX of Infection/Malignancy/React...............

31

7.13

50,155.42 489--All Cases..................................................

5,493

3.04

21,385.67 489--Cases with PDX of Infection/Malignancy/React...............

36

3.72

35,313.84 495--All Cases..................................................

1,860

10.94

55,103.91 495--Cases with PDX of Infection/Malignancy/React...............

1,025

11.74

59,453.69 496--All Cases..................................................

5,203

5.95

32,177.29 496--Cases with PDX of Infection/Malignancy/React...............

2,759

6.98

36,940.99 497--All Cases..................................................

6,259

3.01

21,445.60 497--Cases with PDX of Infection/Malignancy/React...............

1,500

5.18

29,966.98

Given the wide variety of charges and the small number of cases where there are differences in charges, we do not believe the data support the AAHKS' recommendations. The data do not support removing these cases from the 19 MS-DRGs above and consolidating them into a new set of MS-DRGs, either newly created, or by adding them to

Page 23574

MS-DRG 461 or 462, which have average charges of $80,718 and $57,355, respectively.

A second major concern involves redefining MS-DRGs 461 and 462 is that these MS-DRG currently captures bilateral and multiple joint procedures. These MS-DRGs were specifically created to capture a unique set of patients who undergo procedures on more than one lower joint.

Redefining these MS-DRGs to include both single and multiple joints undermines the clinical coherence of this MS-DRG. It would create a widely diverse group of patients based on either a list of specific diagnoses or the fact that the patient had multiple lower joint procedures. f. Conclusion

The AAHKS recommended a number of complicated, interrelated MS-DRG changes to the joint procedure MS-DRGs. We have not yet had the opportunity to review data for these cases under the new MS-DRGs. We did analyze the impact of these recommendations using cases prior to the implementation of MS-DRGs. The recommendations were difficult to analyze because there were so many separate logic changes that impacted a number of MS-DRGs. We did examine each major suggestion separately, and found that our data and clinical analysis did not support making these changes. Therefore, we are not proposing any revisions to the joint procedure MS-DRGs for FY 2009. We look forward to examining these issues once we receive data under the MS-DRG system. We also welcome additional recommendations from the AAHKS and others on a more incremental approach to resolving its concerns about the ability of the current MS-DRGs to adequately capture differences in severity levels for joint procedure patients. 5. MDC 18 (Infections and Parasitic Diseases (Systemic or Unspecified

Sites)): Severe Sepsis

We received a request from a manufacturer to modify the titles for three MS-DRGs with the most significant concentration of severe sepsis patients. The manufacturer stated that modification of the titles will assist in quality improvement efforts and provide a better reflection on the types of patients included in these MS-DRGs. Specifically, the manufacturer urged CMS to incorporate the term ``severe sepsis'' into the titles of the following MS-DRGs that became effective October 1, 2007 (FY 2008)

MS-DRG 870 (Septicemia with Mechanical Ventilation 96+

Hours).

MS-DRG 871 (Septicemia without Mechanical Ventilation 96+

Hours with MCC).

MS-DRG 872 (Septicemia without Mechanical Ventilation 96+

Hours without MCC).

These MS-DRGs were created to better recognize severity of illness among patients diagnosed with conditions including septicemia, severe sepsis, septic shock, and systemic inflammatory response syndrome

(SIRS) who are also treated with mechanical ventilation for a specified duration of time.

According to the manufacturer, ``severe sepsis is a common, deadly and costly disease, yet the number of patients impacted and the outcomes associated with their care remain largely hidden within the administrative data set.'' The manufacturer further noted that, although improvements have been made in the ICD-9-CM coding of severe sepsis (diagnosis code 995.92) and septic shock (diagnosis code 785.52), results of an analysis demonstrated an unacceptably high mortality rate for patients reported to have those conditions. The manufacturer believed that revising the titles to incorporate ``severe sepsis'' will provide various clinicians and researchers the opportunity to improve outcomes for these patients. Therefore, the manufacturer recommended revising the current MS-DRG titles as follows:

Proposed Revised MS-DRG 870 (Septicemia or Severe Sepsis with Mechanical Ventilation 96+ Hours).

Proposed Revised MS-DRG 871 (Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with MCC).

Proposed Revised MS-DRG 872 (Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours without MCC).

We agree with the manufacturer that revising the current MS-DRG titles to include the term ``severe sepsis'' would better assist in the recognition and identification of this disease, which could lead to better clinical outcomes and quality improvement efforts. In addition, both severe sepsis (diagnosis code 995.92) and septic shock (diagnosis code 785.52) are currently already assigned to these three MS-DRGs.

Therefore, we are proposing to revise the titles of MS-DRGs 870, 871, and 872 to reflect severe sepsis in the titles as suggested by the manufacturer and listed above for FY 2009. 6. MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs): Traumatic

Compartment Syndrome

Traumatic compartment syndrome is a condition in which increased pressure within a confined anatomical space that contains blood vessels, muscles, nerves, and bones causes a decrease in blood flow and may lead to tissue necrosis.

There are five ICD-9-CM diagnosis codes that were created effective

October 1, 2006, to identify traumatic compartment syndrome of various sites. 958.90 (Compartment syndrome, unspecified). 958.91 (Traumatic compartment syndrome of upper extremity). 958.92 (Traumatic compartment syndrome of lower extremity). 958.93 (Traumatic compartment syndrome of abdomen). 958.99 (Traumatic compartment syndrome of other sites) .

Cases with one of the diagnosis codes listed above reported as the principal diagnosis and no operating room procedure are assigned to either MS-DRG 922 (Other Injury, Poisoning and Toxic Effect Diagnosis with MCC) or MS-DRG 923 (Other Injury, Poisoning and Toxic Effect

Diagnosis without MCC) in MDC 21.

In the FY 2008 IPPS final rule with comment period when we adopted the MS-DRGs, we inadvertently omitted the addition of these traumatic compartment syndrome codes 958.90 through 958.99 to the multiple trauma

MS-DRGs 963 (Other Multiple Significant Trauma with MCC), MS-DRG 964

(Other Multiple Significant Trauma with CC), and MS-DRG 965 (Other

Multiple Significant Trauma without CC/MCC) in MDC 24 (Multiple

Significant Trauma). Cases are assigned to MDC 24 based on the principal diagnosis of trauma and at least two significant trauma diagnosis codes (either as principal or secondary diagnoses) from different body site categories. There are eight different body site categories as follows:

Significant head trauma.

Significant chest trauma.

Significant abdominal trauma.

Significant kidney trauma.

Significant trauma of the urinary system.

Significant trauma of the pelvis or spine.

Significant trauma of the upper limb.

Significant trauma of the lower limb.

Therefore, we are proposing to add traumatic compartment syndrome codes 958.90 through 958.99 to MS-DRGs 963 and MS-DRG 965 in MDC 24.

Under

Page 23575

this proposal, codes 958.90 through 958.99 would be added to the list of principal diagnosis of significant trauma. In addition, code 958.91 would be added to the list of significant trauma of upper limb, code 958.92 would be added to the list of significant trauma of lower limb, and code 958.93 would be added to the list of significant abdominal trauma. 7. Medicare Code Editor (MCE) Changes

As explained under section II.B.1. of the preamble of this proposed rule, 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), and demographic information are entered 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 2009, we are proposing to make the following changes to the MCE edits: a. List of Unacceptable Principal Diagnoses in MCE

Diagnosis code V62.84 (Suicidal ideation) was created for use beginning October 1, 2005. At the time the diagnosis code was created, it was not clear that the creation of this code was requested in order to describe the principal reason for admission to a facility or the principal reason for treatment. The NCHS Official ICD-9-CM Coding

Guidelines therefore categorized the group of codes in V62.X for use only as additional or secondary diagnoses. It has been brought to the government's attention that the use of this code is hampered by its designation as an additional-only diagnosis. NCHS has therefore modified the Official Coding Guidelines for FY 2009 by making this code acceptable as a principal diagnosis as well as an additional diagnosis.

In order to conform to this change by NCHS, we are proposing to remove code V62.84 from the MCE list of ``Unacceptable Principal Diagnoses'' for FY 2009. b. Diagnoses Allowed for Males Only Edit

There are four diagnosis codes that were inadvertently left off of the MCE edit titled ``Diagnoses Allowed for Males Only.'' These codes are located in the chapter of the ICD-9-CM diagnosis codes entitled

``Diseases of Male Genital Organs.'' We are proposing to add the following four codes to this MCE edit: 603.0 (Encysted hydrocele), 603.1 (Infected hydrocele), 603.8 (Other specified types of hydrocele), and 603.9 (Hydrocele, unspecified). We have had no reported problems or confusion with the omission of these codes from this section of the

MCE, but in order to have an accurate product, we are proposing that these codes be added for FY 2009. c. Limited Coverage Edit

As explained in section II.G.1. of the preamble of this proposed rule, we are proposing to remove procedure code 37.52 (Implantation of internal biventricular heart replacement system) from the MCE ``Non-

Covered Procedure'' edit and to assign it to the ``Limited Coverage'' edit. We are proposing to include in this proposed edit the requirement that ICD-9-CM diagnosis code V70.7 (Examination of participant in clinical trial) also be present on the claim. We are proposing that claims submitted without both procedure code 37.52 and diagnosis code

V70.7 would be denied because they would not be in compliance with the proposed coverage policy explained in section II.G.1. of this preamble. 8. Surgical Hierarchies

Some inpatient stays entail multiple surgical procedures, each one of which, occurring by itself, could result in assignment of the case to a different MS-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 MS-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 MS-DRG associated with the most resource-intensive surgical class.

Because the relative resource intensity of surgical classes can shift as a function of MS-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 MS-DRGs. For example, in MDC 11, the surgical class ``kidney transplant'' consists of a single MS-DRG (MS-DRG 652) and the class ``kidney, ureter and major bladder procedures'' consists of three MS-DRGs (MS-DRGs 653, 654, and 655). Consequently, in many cases, the surgical hierarchy has an impact on more than one MS-DRG. The methodology for determining the most resource-intensive surgical class involves weighting the average resources for each MS-DRG by frequency to determine the weighted average resources for each surgical class. For example, assume surgical class A includes MS-DRGs 1 and 2 and surgical class B includes MS-DRGs 3, 4, and 5. Assume also that the average charge of MS-DRG 1 is higher than that of MS-DRG 3, but the average charges of MS-DRGs 4 and 5 are higher than the average charge of MS-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 MS-DRG in the class by frequency (that is, by the number of cases in the MS-

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 MS-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 MS-DRG or MS-

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

Page 23576

average charge than the class ordered below it.

For FY 2009, we are proposing a revision of the surgical hierarchy for MDC 5 (Diseases and Disorders of the Circulatory System) by placing

MS-DRG 245 (AICD Generator Procedures) above proposed new MS-DRG 265

(AICD Lead Procedures). 9. CC Exclusions List a. Background

As indicated earlier in the preamble of this proposed rule, under the IPPS DRG classification system, we have developed a standard list of diagnoses that are considered 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 the FY 2008 IPPS final rule with comment period for a discussion of the refinement of CCs in relation to the MS-DRGs we adopted for FY-2008 (72 FR 47152 through 47121). b. CC Exclusions List for FY 2009

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.\12\

\12\ 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; the FY 2007 final rule

(71 FR 47870) for the FY 2007 revisions; and the FY 2008 final rule

(72 FR 47130) for the FY 2008 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 2009, 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-9-CM diagnosis coding system effective October 1, 2008. (See section II.G.11. of the preamble of this proposed rule with comment period 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 indicating on the CC exclusion list some updates to reflect the exclusion of a few codes from being an MCC under the MS-DRG system that we adopted for FY 2008.

Tables 6G and 6H, Additions to and Deletions from the CC Exclusion

List, respectively, which will be effective for discharges occurring on or after October 1, 2008, are not being published in this proposed rule because of the length of the two tables. Instead, we are making them available through the Internet on the CMS Web site at: http:// www.cms.hhs.gov/AcuteInpatientPPS. Each of these principal diagnoses for which there is a CC exclusion is shown in Tables 6G and 6H 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.

A complete updated MCC, CC, and Non-CC Exclusions List is 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, 2008, the indented diagnoses will not be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis.

To assist readers in the review of changes to the MCC and CC lists that occurred as a result of updates to the ICD-9-CM codes, as described in Tables 6A, 6C, and 6E, we are providing the following summaries of those MCC and CC changes.

Summary of Additions to the MS-DRG MCC List.--Table 6I.1

Code

Description

249.10................................ Secondary diabetes mellitus with ketoacidosis, not stated as uncontrolled, or unspecified. 249.11................................ Secondary diabetes mellitus with ketoacidosis, uncontrolled. 249.20................................ Secondary diabetes mellitus with hyperosmolarity, not stated as uncontrolled, or unspecified.

Continued on page 23577

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

]

pp. 23577-23626

Medicare Program; Proposed Changes to the Hospital Inpatient

Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed

Changes to Disclosure of Physician Ownership in Hospitals and Physician

Self-Referral Rules; Proposed Collection of Information Regardi[Page 23577]

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249.21................................ Secondary diabetes mellitus with hyperosmolarity, uncontrolled. 249.30................................ Secondary diabetes mellitus with other coma, not stated as uncontrolled, or unspecified. 249.31................................ Secondary diabetes mellitus with other coma, uncontrolled. 707.23................................ Pressure ulcer, stage III. 707.24................................ Pressure ulcer, stage IV. 777.50................................ Necrotizing enterocolitis in newborn, unspecified. 777.51................................ Stage I necrotizing enterocolitis in newborn. 777.52................................ Stage II necrotizing enterocolitis in newborn. 777.53................................ Stage III necrotizing enterocolitis in newborn. 780.72................................ Functional quadriplegia.

Summary of Deletions From the MS-DRG MCC List.--Table 6I.2

Code

Description

136.2................................. Specific infections by free- living amebae. 511.8................................. Other specified forms of pleural effusion, except tuberculous. 707.02................................ Pressure ulcer, upper back. 707.03................................ Pressure ulcer, lower back. 707.04................................ Pressure ulcer, hip. 707.05................................ Pressure ulcer, buttock. 707.06................................ Pressure ulcer, ankle. 707.07................................ Pressure ulcer, heel. 777.5................................. Necrotizing enterocolitis in fetus or newborn.

Summary of Additions to the MS-DRG CC List.--Table 6J.1

Code

Description

046.11................................ Variant Creutzfeldt-Jakob disease. 046.19................................ Other and unspecified

Creutzfeldt-Jakob disease. 046.71................................ Gerstmann-Str[auml]ussler-

Scheinker syndrome. 046.72................................ Fatal familial insomnia. 046.79................................ Other and unspecified prion disease of central nervous system. 059.01................................ Monkeypox. 059.21................................ Tanapox. 136.29................................ Other specific infections by free-living amebae. 199.2................................. Malignant neoplasm associated with transplant organ. 203.02................................ Multiple myeloma, in relapse. 203.12................................ Plasma cell leukemia, in relapse. 203.82................................ Other immunoproliferative neoplasms, in relapse. 204.02................................ Acute lymphoid leukemia, in relapse. 204.12................................ Chronic lymphoid leukemia, in relapse. 204.22................................ Subacute lymphoid leukemia, in relapse. 204.82................................ Other lymphoid leukemia, in relapse. 204.92................................ Unspecified lymphoid leukemia, in relapse. 205.02................................ Acute myeloid leukemia, in relapse. 205.12................................ Chronic myeloid leukemia, in relapse. 205.22................................ Subacute myeloid leukemia, in relapse. 205.32................................ Myeloid sarcoma, in relapse. 205.82................................ Other myeloid leukemia, in relapse. 205.92................................ Unspecified myeloid leukemia, in relapse. 206.02................................ Acute monocytic leukemia, in relapse. 206.12................................ Chronic monocytic leukemia, in relapse. 206.22................................ Subacute monocytic leukemia, in relapse. 206.82................................ Other monocytic leukemia, in relapse. 206.92................................ Unspecified monocytic leukemia, in relapse. 207.02................................ Acute erythremia and erythroleukemia, in relapse. 207.12................................ Chronic erythremia, in relapse. 207.22................................ Megakaryocytic leukemia, in relapse. 207.82................................ Other specified leukemia, in relapse. 208.02................................ Acute leukemia of unspecified cell type, in relapse. 208.12................................ Chronic leukemia of unspecified cell type, in relapse. 208.22................................ Subacute leukemia of unspecified cell type, in relapse. 208.82................................ Other leukemia of unspecified cell type, in relapse. 208.92................................ Unspecified leukemia, in relapse. 209.00................................ Malignant carcinoid tumor of the small intestine, unspecified portion. 209.01................................ Malignant carcinoid tumor of the duodenum. 209.02................................ Malignant carcinoid tumor of the jejunum. 209.03................................ Malignant carcinoid tumor of the ileum.

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209.10................................ Malignant carcinoid tumor of the large intestine, unspecified portion. 209.11................................ Malignant carcinoid tumor of the appendix. 209.12................................ Malignant carcinoid tumor of the cecum. 209.13................................ Malignant carcinoid tumor of the ascending colon. 209.14................................ Malignant carcinoid tumor of the transverse colon. 209.15................................ Malignant carcinoid tumor of the descending colon. 209.16................................ Malignant carcinoid tumor of the sigmoid colon. 209.17................................ Malignant carcinoid tumor of the rectum. 209.20................................ Malignant carcinoid tumor of unknown primary site. 209.21................................ Malignant carcinoid tumor of the bronchus and lung. 209.22................................ Malignant carcinoid tumor of the thymus. 209.23................................ Malignant carcinoid tumor of the stomach. 209.24................................ Malignant carcinoid tumor of the kidney. 209.25................................ Malignant carcinoid tumor of foregut, not otherwise specified. 209.26................................ Malignant carcinoid tumor of midgut, not otherwise specified. 209.27................................ Malignant carcinoid tumor of hindgut, not otherwise specified. 209.29................................ Malignant carcinoid tumor of other sites. 209.30................................ Malignant poorly differentiated neuroendocrine carcinoma, any site. 238.77................................ Post-transplant lymphoproliferative disorder

(PTLD). 279.50................................ Graft-versus-host disease, unspecified. 279.51................................ Acute graft-versus-host disease. 279.52................................ Chronic graft-versus-host disease. 279.53................................ Acute on chronic graft-versus- host disease. 346.60................................ Persistent migraine aura with cerebral infarction, without mention of intractable migraine without mention of status migrainosus. 346.61................................ Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, without mention of status migrainosus. 346.62................................ Persistent migraine aura with cerebral infarction, without mention of intractable migraine with status migrainosus. 346.63................................ Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, with status migrainosus. 511.81................................ Malignant pleural effusion. 511.89................................ Other specified forms of effusion, except tuberculous. 649.70................................ Cervical shortening, unspecified as to episode of care or not applicable. 649.71................................ Cervical shortening, delivered, with or without mention of antepartum condition. 649.73................................ Cervical shortening, antepartum condition or complication. 695.12................................ Erythema multiforme major. 695.13................................ Stevens-Johnson syndrome. 695.14................................ Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome. 695.15................................ Toxic epidermal necrolysis. 695.53................................ Exfoliation due to erythematous condition involving 30-39 percent of body surface. 695.54................................ Exfoliation due to erythematous condition involving 40-49 percent of body surface. 695.55................................ Exfoliation due to erythematous condition involving 50-59 percent of body surface. 695.56................................ Exfoliation due to erythematous condition involving 60-69 percent of body surface. 695.57................................ Exfoliation due to erythematous condition involving 70-79 percent of body surface. 695.58................................ Exfoliation due to erythematous condition involving 80-89 percent of body surface. 695.59................................ Exfoliation due to erythematous condition involving 90 percent or more of body surface. 997.31................................ Ventilator associated pneumonia. 997.39................................ Other respiratory complications. 998.30................................ Disruption of wound, unspecified. 998.33................................ Disruption of traumatic wound repair. 999.81................................ Extravasation of vesicant chemotherapy. 999.82................................ Extravasation of other vesicant agent.

Summary of Deletions to the MS-DRG CC List.--Table 6J.2

Code

Description

046.1............................. Jakob-Creutzfeldt disease. 337.0............................. Idiopathic peripheral autonomic neuropathy. 695.1............................. Erythema multiforme. 707.00............................ Pressure ulcer, unspecified site. 707.01............................ Pressure ulcer, elbow. 707.09............................ Pressure ulcer, other site. 997.3............................. Respiratory complications. 999.8............................. Other transfusion reaction.

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 25.0, is available for $225.00, which includes $15.00 for shipping and handling. Version 26.0 of this manual, which will include the final FY 2009 DRG changes, will be available in hard copy for $250.00. Version 26.0 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. 10. Review of Procedure Codes in MS DRGs 981, 982, and 983; 984, 985, and 986; and 987, 988, and 989

Each year, we review cases assigned to former 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

Page 23579

these CMS DRGs. Under the MS-DRGs that we adopted for FY 2008, CMS DRG 468 was split three ways and became 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 became 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 became MS-DRGs 987, 988, and 989 (Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC).

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 DRGs are intended to capture atypical cases, that is, those cases not occurring with sufficient frequency to represent a distinct, recognizable clinical group. 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 MS-DRGs 981 through 983 and 987 through 989, with MS-DRGs 987 through 989 assigned to those discharges in which the only procedures performed are nonextensive procedures that are unrelated to the principal diagnosis.\13\

\13\ 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 placed 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. In FY 2008, no procedures were moved, as noted in the final rule with comment period (72 FR 46241).

For FY 2009, we are not proposing to change the procedures assigned among these DRGs. a. Moving Procedure Codes From MS-DRGs 981 Through 983 or MS-DRGs 987

Through 989 to MDCs

We annually conduct a review of procedures producing assignment to

MS-DRGs 981 through 983 (formerly CMS DRG 468) or MS-DRGs 987 through 989 (formerly CMS DRG 477) 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. For

FY 2009, we are not proposing to remove any procedures from MS-DRGs 981 through 983 or MS-DRGs 987 through 989. b. Reassignment of Procedures Among 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 MS-DRGs 981 through 983, 984 through 986, and 987 through 989 (formerly, CMS DRGs 468, 476, and 477, 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.

For FY 2009, we are not proposing to move any procedure codes among these DRGs. 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 2009. 11. Changes to the ICD-9-CM Coding System

As described in section II.B.1. of the preamble of this proposed rule, 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 $27.00 by calling (202) 512-1800.) Complete information on ordering the CD-ROM is also available at: http://www.cdc.gov/nchs/products/prods/subject/ icd96ed.htm. The Official

Page 23580

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 2009 at a public meeting held on September 27-28, 2007 and finalized the coding changes after consideration of comments received at the meetings and in writing by December 3, 2007. Those coding changes are announced in Tables 6A through 6F in the Addendum to this proposed rule. The Committee held its 2008 meeting on March 19-20, 2008. 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 2008 will be included in the October 1, 2008 update to ICD-9-CM.

Code revisions that were discussed at the March 19-20, 2008 Committee meeting but that could not be finalized in time to include them in the

Addendum to this proposed rule are not included in Tables 6A through 6F. These additional codes will be included in Tables 6A through 6F of the final rule with comment period and are marked with an asterisk (*).

Copies of the minutes of the procedure codes discussions at the

Committee's September 27-28, 2007 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 27-28, 2007 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, 2008. 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 comments on the proposed classification of these new codes.

For codes that have been replaced by new or expanded codes, and 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, 2008. 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, 2008. Revisions to diagnosis code titles are in Table 6E (Revised

Diagnosis Code Titles), which also includes the MS-DRG assignments for these revised codes. Table 6F includes revised procedure code titles for FY 2009.

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 19-20, 2008 Committee meeting that received consensus and that are finalized by May 2008, 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

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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 published on the 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 approved for an expedited April l, 2008 implementation of an ICD-9-CM code at the September 27-28, 2007 Committee meeting. Therefore, there were no new ICD-9-CM codes implemented on April 1, 2008.

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: 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: 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 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. 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.

H. Recalibration of MS-DRG Weights

In section II.E. of the preamble of this proposed rule, we state that we are proposing to fully implement the cost-based DRG relative weights for FY 2009, which is the third year in the 3-year transition period to calculate the relative weights at 100 percent based on costs.

In the FY 2008 IPPS final rule with comment period (72 FR 47267), as recommended by RTI, for FY 2008, we added two new CCRs for a total of 15 CCRs: one for ``Emergency Room'' and one for ``Blood and Blood

Products,'' both of which can be derived directly from the Medicare cost report.

In developing the FY 2009 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 2007 MedPAR data used in this proposed rule include discharges occurring on October 1, 2006, through September 30, 2007, based on bills received by CMS through December 2007, 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 2007 MedPAR file used in calculating the relative weights includes data for approximately 11,433,806 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-based relative weighting methodology is the FY 2006 Medicare cost report data files from HCRIS

(that is, cost reports beginning on or after October 1, 2005, and before October 1, 2006), which represents the most recent full set of cost report data available. We used the

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December 31, 2007 update of the HCRIS cost report files for FY 2006 in setting the relative cost-based weights.

The methodology we used to calculate the DRG cost-based relative weights from the FY 2007 MedPAR claims data and FY 2006 Medicare cost report data is as follows:

To the extent possible, all the claims were regrouped using the proposed FY 2009 MS-DRG classifications discussed in sections

II.B. and G. of the preamble of this proposed rule.

The transplant cases that were used to establish the relative weights for heart and heart-lung, liver and/or intestinal, and lung transplants (MS-DRGs 001, 002, 005, 006, and 007, respectively) were limited to those Medicare-approved transplant centers that have cases in the FY 2007 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 room charges, cardiology charges, laboratory charges, radiology charges, other service charges, labor and delivery charges, inhalation therapy charges, emergency room charges, blood charges, and anesthesia charges were also deleted.

At least 96.1 percent of the providers in the MedPAR file had charges for 10 of the 15 cost centers. Claims for providers that did not have charges greater than zero for at least 10 of the 15 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 15 cost groups for each claim were standardized to remove the effects of differences in area wage levels,

IME and DSH payments, and for hospitals in Alaska and Hawaii, the applicable cost-of-living adjustment. Because hospital charges include charges for both operating and capital costs, we standardized total charges to remove the effects of differences in geographic adjustment factors, cost-of-living adjustments, DSH payments, and IME adjustments under the capital IPPS as well. Charges were then summed by DRG for each of the 15 cost groups so that each DRG had 15 standardized charge totals. These charges were then adjusted to cost by applying the national average CCRs developed from the FY 2006 cost report data.

The 15 cost centers that we used in the relative weight calculation are shown in the following table. The table shows the lines on the cost report and the corresponding revenue codes that we used to create the 15 national cost center CCRs.

BILLING CODE 4120-01-P

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GRAPHIC

TIFF OMITTEDTP30AP08.012

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GRAPHIC

TIFF OMITTEDTP30AP08.013

Page 23585

GRAPHIC

TIFF OMITTEDTP30AP08.014

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GRAPHIC

TIFF OMITTEDTP30AP08.015

Page 23587

GRAPHIC

TIFF OMITTEDTP30AP08.016

Page 23588

GRAPHIC

TIFF OMITTEDTP30AP08.017

BILLING CODE 4120-01-C

We developed the national average CCRs as follows:

Taking the FY 2006 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

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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 the Medicare charges for each line item from

Worksheet D-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-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 15 cost centers by the corresponding national average CCR, we summed the 15 ``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 relative weights were then normalized by an adjustment factor of 1.50612 so that the average case weight after recalibration was equal to the average case weight before recalibration. 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 15 proposed national average CCRs for FY 2009 are as follows:

Group

CCR

Routine Days..................................................

0.527

Intensive Days................................................

0.476

Drugs.........................................................

0.205

Supplies & Equipment..........................................

0.341

Therapy Services..............................................

0.419

Laboratory....................................................

0.166

Operating Room................................................

0.293

Cardiology....................................................

0.186

Radiology.....................................................

0.171

Emergency Room................................................

0.291

Blood and Blood Products......................................

0.449

Other Services................................................

0.419

Labor & Delivery..............................................

0.482

Inhalation Therapy............................................

0.198

Anesthesia....................................................

0.150

As we explained in section II.E. of the preamble of this proposed rule, we are proposing to complete our 2-year transition to the MS-

DRGs. For FY 2008, the first year of the transition, 50 percent of the relative weight for an MS-DRG was based on the two-thirds cost-based weight/one-third charge-based weight calculated using FY 2006 MedPAR data grouped to the Version 24.0 (FY 2007) DRGs. The remaining 50 percent of the FY 2008 relative weight for an MS-DRG was based on the two-thirds cost-based weight/one-third charge-based weight calculated using FY 2006 MedPAR grouped to the Version 25.0 (FY 2008) MS-DRGs. In

FY 2009, we are proposing that the relative weights will be based on 100 percent cost weights computed using the Version 26.0 (FY 2009) MS-

DRGs.

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 are proposing to use that same case threshold in recalibrating the MS-DRG weights for FY 2009. Using the FY 2007 MedPAR data set, there are 8 MS-DRGs that contain fewer than 10 cases. Under the 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 to 17 years or age 17 years 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 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 MS-

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 2009, because we do not have sufficient MedPAR data to set accurate and stable cost weights for these low-volume MS-DRGs, we are proposing to compute weights for the low-volume MS-DRGs by adjusting their FY 2008 weights by the percentage change in the average weight of the cases in other MS-DRGs. The crosswalk table is shown below:

Low-volume MS-DRG

MS-DRG title

Crosswalk to MS-DRG

768................. Vaginal Delivery with

FY 2008 FR weight

O.R. Procedure Except

(adjusted by percent

Sterilization and/or

change in average

D&C.

weight of the cases in other MS-DRGs). 789................. Neonates, Died or

FY 2008 FR weight

Transferred to Another

(adjusted by percent

Acute Care Facility.

change in average weight of the cases in other MS-DRGs). 790................. Extreme Immaturity or

FY 2008 FR weight

Respiratory Distress

(adjusted by percent

Syndrome, Neonate.

change in average weight of the cases in other MS-DRGs). 791................. Prematurity with Major

FY 2008 FR weight

Problems.

(adjusted by percent change in average weight of the cases in other MS-DRGs). 792................. Prematurity without

FY 2008 FR weight

Major Problems.

(adjusted by percent change in average weight of the cases in other MS-DRGs). 793................. Full-Term Neonate with

FY 2008 FR weight

Major Problems.

(adjusted by percent change in average weight of the cases in other MS-DRGs). 794................. Neonate with Other

FY 2008 FR weight

Significant Problems.

(adjusted by percent change in average weight of the cases in other MS-DRGs). 795................. Normal Newborn.......... FY 2008 FR weight

(adjusted by percent change in average weight of the cases in other MS-DRGs).

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I. Proposed Medicare Severity Long-Term Care (MS-LTC-DRG)

Reclassifications and Relative Weights for LTCHs for FY 2009 1. Background

Section 123 of the BBRA requires that the Secretary implement a PPS for LTCHs (that is, a per discharge system with a diagnosis-related group (DRG)-based patient classification system reflecting the differences in patient resources and costs). Section 307(b)(1) of the

BIPA modified the requirements of section 123 of the BBRA by requiring that the Secretary examine ``the feasibility and the impact of basing payment under such a system [the long-term care hospital (LTCH) PPS] on the use of existing (or refined) hospital DRGs that have been modified to account for different resource use of LTCH patients, as well as the use of the most recently available hospital discharge data.''

When the LTCH PPS was implemented for cost reporting periods beginning on or after October 1, 2002, we adopted the same DRG patient classification system (that is, the CMS DRGs) that was utilized at that time under the IPPS. As a component of the LTCH PPS, we refer to the patient classification system as the ``long-term care diagnosis-related groups (LTC-DRGs).'' As discussed in greater detail below, although the patient classification system used under both the LTCH PPS and the IPPS are the same, the relative weights are different. The established relative weight methodology and data used under the LTCH PPS result in

LTC-DRG relative weights that reflect ``the differences in patient resource use * * *'' of LTCH patients (section 123(a)(1) of the BBRA

(Pub. L. 106-113). As part of our efforts to better recognize severity of illness among patients, in the FY 2008 IPPS final rule with comment period (72 FR 47130), the MS-DRGs and the Medicare severity long-term care diagnosis related groups (MS-LTC-DRGs) were adopted for the IPPS and the LTCH PPS, respectively, effective October 1, 2007 (FY 2008).

For a full description of the development and implementation of the MS-

DRGs and MS-LTC-DRGs, we refer readers to the FY 2008 IPPS final rule with comment period (72 FR 47141 through 47175 and 47277 through 47299). (We note that, in that same final rule, we revised the regulations at Sec. 412.503 to specify that for LTCH discharges occurring on or after October 1, 2007, when applying the provisions of 42 CFR Part 412, Subpart O applicable to LTCHs for policy descriptions and payment calculations, all references to LTC-DRGs would be considered a reference to MS-LTC-DRGs. For the remainder of this section, we present the discussion in terms of the current MS-LTC-DRG patient classification unless specifically referring to the previous

LTC-DRG patient classification system (that was in effect before

October 1, 2007).) We believe the MS-DRGs (and by extension, the MS-

LTC-DRGs) represent a substantial improvement over the previous CMS

DRGs in their ability to differentiate cases based on severity of illness and resource consumption.

The MS-DRGs represent an increase in the number of DRGs by 207

(that is, from 538 to 745) (72 FR 47171). In addition to improving the

DRG system's recognition of severity of illness, we believe the MS-DRGs are responsive to the public comments that were made on the FY 2007

IPPS proposed rule with respect to how we should undertake further DRG reform. The MS-DRGs use the CMS DRGs as the starting point for revising the DRG system to better recognize resource complexity and severity of illness. We have generally retained 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.

Consistent with section 123 of the BBRA as amended by section 307(b)(1) of the BIPA and Sec. 412.515, we use information derived from LTCH PPS patient records to classify LTCH discharges into distinct

MS-LTC-DRGs based on clinical characteristics and estimated resource needs. We then assign an appropriate weight to the MS-LTC-DRGs to account for the difference in resource use by patients exhibiting the case complexity and multiple medical problems characteristic of LTCHs.

Generally, under the LTCH PPS, a Medicare payment is made at a predetermined specific rate for each discharge; and that payment varies by the MS-LTC-DRG to which a beneficiary's stay is assigned. Cases are classified into MS-LTC-DRGs for payment based on the following six data elements:

Principal diagnosis.

Up to eight additional diagnoses.

Up to six procedures performed.

Age.

Sex.

Discharge status of the patient.

Upon the discharge of the patient from a LTCH, the LTCH must assign appropriate diagnosis and procedure codes from the most current version of the International Classification of Diseases, Ninth Revision,

Clinical Modification (ICD-9-CM). HIPAA Transactions and Code Sets

Standards regulations at 45 CFR Parts 160 and 162 require that no later than October 16, 2003, all covered entities must comply with the applicable requirements of Subparts A and I through R of Part 162.

Among other requirements, those provisions direct covered entities to use the ASC X12N 837 Health Care Claim: Institutional, Volumes 1 and 2,

Version 4010, and the applicable standard medical data code sets for the institutional health care claim or equivalent encounter information transaction (see 45 CFR 162.1002 and 45 CFR 162.1102). For additional information on the ICD-9-CM Coding System, we refer readers to the FY 2008 IPPS final rule with comment period (72 FR 47241 through 47243 and 47277 through 47281). We also refer readers to the detailed discussion on correct coding practices in the August 30, 2002 LTCH PPS final rule

(67 FR 55981 through 55983). Additional coding instructions and examples are published in the Coding Clinic for ICD-9-CM, a product of the American Hospital Association.

Medicare contractors (that is, fiscal intermediaries or MACs) enter the clinical and demographic information into their claims processing systems and subject this information to a series of automated screening processes called the Medicare Code Editor (MCE). These screens are designed to identify cases that require further review before assignment into a MS-LTC-DRG can be made. During this process, the following types of cases are selected for further development:

Cases that are improperly coded. (For example, diagnoses are shown that are inappropriate, given the sex of the patient. Code 68.69 (Other and unspecified radical abdominal hysterectomy) would be an inappropriate code for a male.)

Cases including surgical procedures not covered under

Medicare. (For example, organ transplant in a nonapproved transplant center.)

Cases requiring more information. (For example, ICD-9-CM codes are required to be entered at their highest level of specificity.

There are valid 3-digit, 4-digit, and 5-digit codes. That is, code 262

(Other severe protein-calorie malnutrition) contains all appropriate digits, but if it is reported with either fewer or more than 3 digits, the claim will be rejected by the MCE as invalid.)

After screening through the MCE, each claim is classified into the appropriate MS-LTC-DRG by the Medicare LTCH GROUPER software.

Page 23591

The Medicare GROUPER software, which is used under the LTCH PPS, is specialized computer software, and is the same GROUPER software program used under the IPPS. The GROUPER software was developed as a means of classifying each case into a MS-LTC-DRG on the basis of diagnosis and procedure codes and other demographic information (age, sex, and discharge status). Following the MS-LTC-DRG assignment, the Medicare contractor determines the prospective payment amount by using the

Medicare PRICER program, which accounts for hospital-specific adjustments. Under the LTCH PPS, we provide an opportunity for the LTCH to review the MS-LTC-DRG assignments made by the Medicare contractor and to submit additional information within a specified timeframe as specified in Sec. 412.513(c).

The GROUPER software is used both to classify past cases to measure relative hospital resource consumption to establish the DRG weights and to classify current cases for purposes of determining payment. The records for all Medicare hospital inpatient discharges are maintained in the MedPAR file. The data in this file are used to evaluate possible

MS-DRG classification changes and to recalibrate the MS-DRG and MS-LTC-

DRG relative weights during our annual update under both the IPPS

(Sec. 412.60(e)) and the LTCH PPS (Sec. 412.517), respectively.

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 DRGs as those used under the IPPS for acute care hospitals, in that same final rule, we explained that the annual update of the LTC-DRG classifications and relative weights will continue to remain linked to the annual reclassification and recalibration of the

DRGs used under the IPPS. Therefore, we specified that we will continue to update the LTC-DRG 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 RY 2009 LTCH PPS proposed rule (73 FR 5351-5352), due to administrative considerations as well as in response to numerous comments urging CMS to establish one rulemaking cycle that would encompass the update of the LTCH PPS payment rates (currently updated on a rate year basis, effective July 1) as well as the development of the LTC-DRG weights (currently updated on a fiscal year basis, effective October 1), we proposed to amend the regulations at Sec. 412.535 in order to consolidate the rate year and fiscal year rulemaking cycles. Specifically, we proposed that the annual update of the LTCH PPS payment rates (and description of the methodology and data used to calculate these payment rates) and the annual update of the MS-

LTC-DRG classifications and associated weighting factors for LTCHs would be effective on October 1 each Federal fiscal year. In order to revise the payment rate update (currently on a rate year cycle of July 1 through June 30) to an October 1 through September 30 cycle, we proposed to extend the 2009 rate period to September 30, 2009, so that

RY 2009 would be 15 months. This proposed 15-month rate period would extend from July 1, 2008, through September 30, 2009. We believe that extending RY 2009 by 3 months (July, August, and September) would provide for a smooth transition to a consolidated annual update for both the LTCH PPS payment rates and the LTCH PPS MS-LTC-DRG classifications and weighting factors. (We believe that proposing to shorten the 2009 rate year period to an October 1 through September 30 period so that RY 2009 would only be 3 months (that is, July 1, 2008 through September 30, 2008) would exacerbate the current time- consuming, biannual update process by resulting in two payment rate changes within a very short period of time.) Consequently, under the proposal to extend RY 2009 to a 15-month rate period, after September 30, 2009, when the RY 2009 cycle ends, the LTCH PPS payment rates and other policy changes would subsequently be updated on an October 1 through September 30 cycle in conjunction with the annual update to the

MS-LTC-DRG classifications and relative weights. Accordingly, the next update to the LTCH PPS payment rates, after the proposed 15-month RY 2009, would begin October 1, 2009, coinciding with the 2010 Federal fiscal year.

In the past, the annual update to the DRGs used under the IPPS has been based on the annual revisions to the ICD-9-CM codes and was effective each October 1. As discussed in the RY 2009 LTCH PPS proposed rule (73 FR 5348-5349), 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 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). 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 HIPAA.

As noted above, the patient classification system used under the

LTCH PPS is the same patient classification system that is used under the IPPS. Therefore, the ICD-9-CM codes currently used under both the

IPPS and the LTCH PPS have the potential of being updated 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 in the Federal Register. 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.11. of the preamble of this proposed rule). Any coding updates will be available through the Web sites provided in section II.G.11. of the preamble of this proposed rule 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 system. If new codes are implemented on April 1, revised code books and software systems, including the GROUPER

Page 23592

software program, will be necessary because the most current ICD-9-CM codes must be reported. Therefore, for purposes of the LTCH PPS, because each ICD-9-CM code must be included in the GROUPER algorithm to classify each case under the correct LTCH PPS, 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 diagnosis and procedure code revisions are requested and approved. We note that any new codes created for April 1 implementation will be limited to those 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.11. of the preamble of this proposed rule).

At the September 27, 2007 ICD-9-CM Coordination and Maintenance

Committee meeting, there were no requests for an April 1, 2008 implementation of ICD-9-CM codes. Therefore, the next update to the

ICD-9-CM coding system will occur on October 1, 2008 (FY 2009). Because there were no coding changes suggested for an April 1, 2008 update, the

ICD-9-CM coding set implemented on October 1, 2008, will continue through September 30, 2009 (FY 2009). The update to the ICD-9-CM coding system for FY 2009 is discussed in section II.G.11. of the preamble of this proposed rule. Accordingly, in this proposed rule, as discussed in greater detail below, we are proposing to modify and revise the MS-LTC-

DRG classifications and relative weights to be effective October 1, 2008 through September 30, 2009 (FY 2009). As discussed in greater detail below, the MS-LTC-DRGs for FY 2009 in this proposed rule are the same as the MS-DRGs proposed for the IPPS for FY 2009 (GROUPER Version 26.0) discussed in section II.B. of the preamble to this proposed rule. 2. Proposed Changes in the MS-LTC-DRG Classifications a. Background

As discussed earlier, 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.

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.''

Consistent 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 section

II.D. of the preamble of this proposed rule, for FY 2008, we adopted

MS-DRGs under the IPPS because we believe that this system results in a significant improvement in the DRG system's recognition of severity of illness and resource usage. We stated that we believe these improvements in the DRG system are equally applicable to the LTCH PPS.

The changes we are proposing to make for the FY 2009 IPPS are reflected in the proposed FY 2009 GROUPER, Version 26.0, that would be effective for discharges occurring on or after October 1, 2008 through September 30, 2009.

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, under the LTCH PPS for FY 2008, we adopted the use of MS-LTC-DRGs, which correspond to the MS-DRGs we adopted under the IPPS. In addition, as stated above, we are proposing to use the FY 2009 GROUPER Version 26.0 to classify cases effective for LTCH discharges occurring on or after October 1, 2008, through September 30, 2009. The changes to the MS-DRG classification system that we are proposing to use under the IPPS for FY 2009 (GROUPER Version 26.0) are discussed in section II.B. of the preamble to this proposed rule.

Under the LTCH PPS, as described in greater detail below, we determine relative weights for each of the MS-LTC-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 2007 update of the FY 2007 MedPAR file, which contains hospital bills received through

December 31, 2007, for discharges occurring in FY 2007.)

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 2008 IPPS final rule with comment period (72 FR 47283), we use low-volume quintiles in determining the DRG relative weights for DRGs with less than 25 LTCH cases (low-volume MS-LTC-DRGs). Specifically, we group those low-volume DRGs into 5 quintiles based on average charges per discharge. (A listing of the composition of low-volume quintiles for the FY 2008 MS-LTC-DRGs (based on FY 2006 MedPAR data) appears in section II.I.3. of the FY 2008 IPPS final rule with comment period (72

FR 47281 through 47288).) 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, as discussed below in section II.I.4. of the preamble of this proposed rule. b. Patient Classifications Into MS-LTC-DRGs

Generally, under the LTCH PPS, Medicare payment is made at a predetermined specific rate for each discharge; that is, payment varies by the DRG to which a beneficiary's stay is assigned. Just as cases have been classified into the MS-DRGs for acute care hospitals under the IPPS (section II.B. of the preamble of this proposed rule), cases have been classified into 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 demographic information about the patient. The diagnosis and procedure information is reported by the hospital using the ICD-9-CM coding system. Under the

MS-DRGs for the IPPS and the 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 MS-DRGs, which we are maintaining under the MS-LTC-DRG system. As noted above, the patient classification system for the LTCH PPS is derived from the IPPS DRGs and is similarly organized into 25 major diagnostic categories (MDCs).

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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 MS-DRGs, some surgical and medical DRGs are further defined for severity purposes based on the presence or absence of MCCs or CCs. The existing MS-LTC-DRGs are similarly categorized. (We refer readers to section II.B. of the preamble of this proposed rule for further discussion of surgical DRGs and medical DRGs.)

Therefore, consistent with the MS-DRGs, a base MS-LTC-DRG may be subdivided according to three alternatives. The first alternative includes division of the DRG into one, two, or three severity levels.

The most severe level has cases with 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 do not support the creation of three severity levels, the base DRG is divided into either two levels or the base is not subdivided.

The two-level subdivisions consist of one of the following subdivisions: ``with CC/MCC'' or ``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 `` CC/MCC'' DRG. Cases without a CC or an MCC are assigned to the ``without CC/MCC'' DRG.

The other type of two-level subdivision is as follows: ``with MCC'' and ``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. 3. Development of the Proposed FY 2009 MS-LTC-DRG Relative Weights a. General Overview of Development of the 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 relative weight in determining payment to LTCHs for each case. (As we have noted above, in last year's final rule, we adopted the MS-LTC-DRGs for the LTCH PPS beginning in FY 2008. However, this 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.

Although the adoption of the MS-LTC-DRGs resulted in some modifications of existing procedures for assigning weights in cases of zero volume and/or nonmonotonicity, as discussed in the FY 2008 IPPS final rule with comment period (72 FR 47289 through 47295) and discussed in detail in the following sections, the basic methodology for developing the proposed FY 2009 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). Under the LTCH PPS, relative weights for each

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

MS-LTC-DRG have access to an appropriate level of services and to encourage efficiency, we calculate a relative weight for each MS-LTC-

DRG that represents the resources needed by an average inpatient LTCH case in that MS-LTC-DRG. For example, cases in an MS-LTC-DRG with a relative weight of 2 will, on average, cost twice as much to treat as cases in an MS-LTC-DRG with a weight of 1. b. Data

To calculate the proposed MS-LTC-DRG relative weights for FY 2009, we obtained total Medicare allowable charges from FY 2007 Medicare LTCH bill data from the December 2007 update of the MedPAR file, which are the best available data at this time, and we used the proposed Version 26.0 of the CMS GROUPER that is also proposed for use under the IPPS to classify cases for FY 2009. We also are proposing that if more recent data are available, we will use those data and the finalized Version 26.0 of the CMS GROUPER in establishing the FY 2009 MS-LTC-DRG relative weights in the final rule.

Consistent with our historical methodology, we have excluded the data from LTCHs that are all-inclusive rate providers and LTCHs that are reimbursed in accordance with demonstration projects authorized under section 402(a) of Pub. L. 90-248 or section 222(a) of Pub. L. 92- 603 (We refer readers to the FY 2008 IPPS final rule with comment period (72 FR 47282)). Therefore, in the development of the proposed FY 2009 MS-LTC-DRG relative weights in this proposed rule, we have excluded the data of the 17 all-inclusive rate providers and the 2

LTCHs that are paid in accordance with demonstration projects that had claims in the FY 2007 MedPAR file. c. Hospital-Specific Relative Value (HSRV) 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 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 are proposing to use a hospital-specific relative value (HSRV) methodology to calculate the MS-LTC-DRG relative weights instead of the methodology used to determine the MS-DRG relative weights under the IPPS described in section II.H. of the preamble of this proposed rule. We believe this method will remove this hospital-specific source of bias in measuring

LTCH average charges. Specifically, we are proposing to reduce the impact of the variation in charges across providers on any particular

MS-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 methodology, 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

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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 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 are cases with a length of stay that is less than or equal to five-sixths the average length of stay of the MS-LTC-DRG (Sec. 412.529 and Sec. 412.503). 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. Treatment of Severity Levels in Developing Proposed Relative Weights

Under the proposed MS-LTC-DRGs, for purposes of the proposed setting of the relative weights, there would be three different categories of DRGs based on volume of cases within specific MS-LTC-

DRGs. MS-LTC-DRGs with at least 25 cases are each assigned a unique relative weight; low-volume MS-LTC-DRGs (that is, MS-LTC-DRGs that contain between one and 24 cases annually) are grouped into quintiles

(described below) and assigned the weight of the quintile. No-volume

MS-LTC-DRGs (that is, no cases in the database were assigned to those

MS-LTC-DRGs) are crosswalked to other MS-LTC-DRGs based on the clinical similarities and assigned the relative weight of the crosswalked MS-

LTC-DRG. (We provide in-depth discussions of our proposed policy regarding weight setting 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 5 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 developed a severity-adjusted patient classification system which we adopted for both the IPPS and the LTCH PPS in FY 2008. As described in greater detail above, the MS-

LTC-DRG system can accommodate three severity levels: ``with MCC''

(most severe); ``with CC,'' and ``without CC/MCC'' (the least severe) 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''. For example, under the

MS-LTC-DRG system, multiple sclerosis and cerebellar ataxia with MCC is

MS-LTC-DRG 58; multiple sclerosis and cerebellar ataxia with CC is MS-

LTC-DRG 59; and multiple sclerosis and cerebellar ataxia without CC/MCC is MS-LTC-DRG 60. For purposes of discussion in this section, the term

``base DRG'' is used to refer to the DRG category that encompasses all levels of severity for that DRG. For example, when referring to the entire DRG category for multiple sclerosis and cerebellar ataxia, which includes the above three severity levels, we would use the term ``base-

DRG.''

As noted above, 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, consistent with the methodology we used when we adopted the MS-LTC-DRGs in the FY 2008 IPPS final rule with comment period (72

FR 47278 through 47281), we are proposing to determine the FY 2009 relative 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-DRG has between 1 and 24 cases, it is assigned to a quintile for which we will compute a relative weight; and (3) if an MS-LTC-DRG has no cases, it is crosswalked to another MS-LTC-DRG based upon clinical similarities to assign an appropriate relative weight (as described below in detail in Step 5 of the Steps for

Determining the proposed FY 2009 MS-LTC-DRG Relative Weights).

Furthermore, in determining the proposed FY 2009 MS-LTC-DRG relative weights, when necessary, we are proposing to make adjustments to account for nonmonotonicity, as explained below.

Theoretically, cases under the 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 relative weight methodology outlined above, the MS-LTC-DRG with MCC would have a lower relative weight than one with CC, or the MS-LTC-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 weights in order to maintain monotonicity by grouping both sets of cases together and establishing a new relative weight for both

LTC-DRGs. We continue to believe that utilizing nonmonotonic relative weights to adjust Medicare payments would result in inappropriate payments because, in a nonmonotonic system, cases that are more severe and require greater expenditure of medical care resources would be paid based on a lower relative weight than cases that are less severe and require lower resource use. The procedure for dealing with nonmonotonicity under the MS-LTC-DRG classification system is discussed in greater detail below in section II.I.4. (Step 6) of the preamble of this proposed rule. e. Proposed Low-Volume MS-LTC-DRGs

In order to account for MS-LTC-DRGs with low volume (that is, with fewer than 25 LTCH cases), consistent with the methodology we established when we implemented the LTCH PPS (August 30, 2002; 67 FR 55984 through 55995), we group those ``low-volume MS-LTC-DRGs'' (that is, MS-LTC-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 (72 FR 47283 through 47288).

In determining the proposed FY

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2009 MS-LTC-DRG relative weights in this proposed rule, we are proposing to continue to employ this quintile methodology for proposed low-volume MS-LTC-DRGs. In addition, in cases where the initial assignment of a low-volume MS-LTC-DRG to quintiles results in nonmonotonicity within a base DRG, in order to ensure appropriate

Medicare payments, consistent with our historical methodology, we are proposing to make adjustments to the treatment of low-volume MS-LTC-

DRGs to preserve monotonicity, as discussed in detail below in section

II.I.4 (Step 6 of the methodology for determining the proposed FY 2009

MS-LTC-DRG relative weights). In this proposed rule, using LTCH cases from the December 2007 update of the FY 2007 MedPAR file, we identified 290 MS-LTC-DRGs that contained between 1 and 24 cases. This list of proposed MS-LTC-DRGs was then divided into one of the proposed 5 low- volume quintiles, each containing 58 MS-LTC-DRGs (290/5 = 58). We are proposing to make the assignment of a low-volume MS-LTC-DRG to a specific low-volume quintile by sorting the proposed low-volume MS-LTC-

DRGs in ascending order by average charge in accordance with our established methodology. Specifically, for this proposed rule, the 290 proposed low-volume MS-LTC-DRGs are sorted by ascending order by average charge and assigned to a specific proposed low-volume quintile

(as described below). After sorting the 290 proposed low-volume MS-LTC-

DRGs by average charge in ascending order, we are proposing to group the first fifth (1st through 58th) of proposed low-volume MS-LTC-DRGs

(with the lowest average charge) into Quintile 1. This process is repeated through the remaining proposed low-volume MS-LTC-DRGs so that each of the 5 proposed low-volume quintiles contains 58 proposed MS-

LTC-DRGs. The highest average charge cases would be grouped into

Quintile 5. (We note that, consistent with our historical methodology, if the number of proposed low-volume MS-LTC-DRGs had not been evenly divisible by 5, we would have used the average charge of the proposed low-volume MS-LTC-DRG to determine which proposed low-volume quintile would have received the additional proposed low-volume MS-LTC-DRG.)

Accordingly, in order to determine the proposed relative weights for the proposed MS-LTC-DRGs with low-volume for FY 2009, we are proposing to use the five low-volume quintiles described above. 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 2009 (Table 11 of the Addendum of this proposed rule). 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 are proposing to apply to the regular MS-LTC-DRGs (25 or more cases), as described 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 low-volume MS-LTC-DRGs that make up an individual 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.

Proposed Composition of Low-Volume Quintiles for FY 2009

Proposed MS-LTC-DRG (version Proposed MS-LTC-DRG description (version 26.0)

26.0)

PROPOSED QUINTILE 1

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. 79........................... Hypertensive encephalopathy w/o CC/MCC. 87........................... 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. 103.......................... Headaches w/o MCC. 121.......................... Acute major eye infections w CC/MCC. 122.......................... Acute major eye infections w/o CC/MCC. 124.......................... Other disorders of the eye w MCC. 153.......................... Otitis media & URI w/o MCC. 156.......................... Nasal trauma & deformity w/o CC/MCC. 157.......................... Dental & Oral Diseases w MCC. 158.......................... Dental & Oral Diseases w CC. 182.......................... Respiratory neoplasms w/o CC/MCC.* 188.......................... Pleural effusion w/o CC/MCC.* 203.......................... Bronchitis & asthma w/o CC/MCC. 254.......................... Other vascular procedures w/o CC/MCC. 294.......................... Deep vein thrombophlebitis w CC/MCC. 354.......................... Hernia procedures except inguinal & femoral w CC. 376.......................... Digestive malignancy w/o CC/MCC. 379.......................... G.I. hemorrhage w/o CC/MCC. 381.......................... Complicated peptic ulcer w CC. 390.......................... G.I. obstruction w/o CC/MCC. 409.......................... Biliary tract proc except only cholecyst w or w/o c.d.e. w CC. 433.......................... Cirrhosis & alcoholic hepatitis w CC. 440.......................... Disorders of pancreas except malignancy w/ o CC/MCC. 446.......................... Disorders of the biliary tract w/o CC/

MCC.* 489.......................... Knee procedures w/o pdx of infection w/o

CC/MCC. 533.......................... Fractures of femur w MCC. 534.......................... Fractures of femur w/o MCC. 553.......................... Bone diseases & arthropathies w MCC. 578.......................... Skin graft &/or debrid exc for skin ulcer or cellulitis w/o CC/MCC. 584.......................... Breast biopsy, local excision & other breast procedures w CC/MCC. 624.......................... Skin grafts & wound debrid for endoc, nutrit & metab dis w/o CC/MCC. 661.......................... Kidney & ureter procedures for non- neoplasm w/o CC/MCC. 663.......................... Minor bladder procedures w CC. 665.......................... Prostatectomy w MCC.***

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669.......................... Transurethral procedures w CC. 671.......................... Urethral procedures w CC/MCC. 688.......................... Kidney & urinary tract neoplasms w/o CC/

MCC. 696.......................... Kidney & urinary tract signs & symptoms w/ o MCC. 722.......................... Malignancy, male reproductive system w

MCC. 759.......................... Infections, female reproductive system w/ o CC/MCC.* 815.......................... Reticuloendothelial & immunity disorders w CC. 835.......................... Acute leukemia w/o major O.R. procedure w

CC.*** 842.......................... Lymphoma & non-acute leukemia w/o CC/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. 866.......................... Viral illness w/o MCC. 876.......................... O.R. procedure w principal diagnoses of mental illness. 881.......................... Depressive neuroses 923.......................... Other injury, poisoning & toxic effect diag w/o MCC. 929.......................... Full thickness burn w skin graft or inhal inj w/o CC/MCC. 964.......................... Other multiple significant trauma w CC. 976.......................... HIV w major related condition w/o CC/MCC.

PROPOSED QUINTILE 3

23........................... Craniotomy w major device implant or acute complex CNS PDX w MCC.*** 27........................... Craniotomy & endovascular intracranial procedures w/o CC/MCC. 53........................... Spinal disorders & injuries w/o CC/MCC. 58........................... Multiple sclerosis & cerebellar ataxia w

MCC. 82........................... Traumatic stupor & coma, coma >1 hr w

MCC. 98........................... Non-bacterial infect of nervous sys exc viral meningitis w CC. 113.......................... Orbital procedures w CC/MCC. 116.......................... Intraocular procedures w CC/MCC. 136.......................... Sinus & mastoid procedures w/o CC/MCC.*** 152.......................... Otitis media & URI w MCC. 165.......................... Major chest procedures w/o CC/MCC. 168.......................... Other resp system O.R. procedures w/o CC/

MCC. 238.......................... Major cardiovascular procedures w/o MCC. 241.......................... Amputation for circ sys disorders exc upper limb & toe w/o CC/MCC. 261.......................... Cardiac pacemaker revision except device replacement w CC.** 262.......................... Cardiac pacemaker revision except device replacement w/o CC/MCC.** 284.......................... Circulatory disorders w AMI, expired w

CC.* 287.......................... Circulatory disorders except AMI, w card cath w/o MCC. 369.......................... Major esophageal disorders w CC. 370.......................... Major esophageal disorders w/o CC/MCC. 380.......................... Complicated peptic ulcer w MCC. 384.......................... Uncomplicated peptic ulcer w/o MCC. 424.......................... Other hepatobiliary or pancreas O.R. procedures w CC. 471.......................... Cervical spinal fusion w MCC. 472.......................... Cervical spinal fusion w CC. 476.......................... Amputation for musculoskeletal sys & conn tissue dis w/o CC/MCC. 482.......................... Hip & femur procedures except major joint w/o CC/MCC. 494.......................... Lower extrem & humer proc except hip, foot, femur w/o CC/MCC. 497.......................... Local excision & removal int fix devices exc hip & femur w/o CC/MCC.* 502.......................... Soft tissue procedures w/o CC/MCC. 504.......................... Foot procedures w CC. 505.......................... Foot procedures w/o CC/MCC. 510.......................... Shoulder, elbow or forearm proc, exc major joint proc w MCC.** 511.......................... Shoulder, elbow or forearm proc, exc major joint proc w CC.** 535.......................... Fractures of hip & pelvis w MCC. 542.......................... Pathological fractures & musculoskelet & conn tiss malig w MCC. 555.......................... Signs & symptoms of musculoskeletal system & conn tissue w MCC. 562.......................... Fx, sprn, strn & disl except femur, hip, pelvis & thigh w MCC. 598.......................... Malignant breast disorders w CC. 599.......................... Malignant breast disorders w/o CC/MCC.** 600.......................... Non-malignant breast disorders w CC/MCC. 626.......................... Thyroid, parathyroid & thyroglossal procedures w CC. 630.......................... Other endocrine, nutrit & metab O.R. proc w/o CC/MCC. 665.......................... Prostatectomy w MCC.** 666.......................... Prostatectomy w CC.** 668.......................... Transurethral procedures w MCC. 686.......................... Kidney & urinary tract neoplasms w MCC. 687.......................... Kidney & urinary tract neoplasms w CC. 693.......................... Urinary stones w/o esw lithotripsy w MCC.

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725.......................... Benign prostatic hypertrophy w MCC. 744.......................... D&C, conization, laparoscopy & tubal interruption w CC/MCC. 755.......................... Malignancy, female reproductive system w

CC. 800.......................... Splenectomy w CC. 809.......................... Major hematol/immun diag exc sickle cell crisis & coagul w CC. 814.......................... Reticuloendothelial & immunity disorders w MCC. 824.......................... Lymphoma & non-acute leukemia w other

O.R. proc w CC. 834.......................... Acute leukemia w/o major O.R. procedure w

MCC. 835.......................... Acute leukemia w/o major O.R. procedure w

CC.** 836.......................... Acute leukemia w/o major O.R. procedure w/ o CC/MCC.** 843.......................... Other myeloprolif dis or poorly diff neopl diag w MCC. 883.......................... Disorders of personality & impulse control. 903.......................... Wound debridements for injuries w/o CC/

MCC. 905.......................... Skin grafts for injuries w/o CC/MCC. 922.......................... Other injury, poisoning & toxic effect diag w MCC. 941.......................... O.R. proc w diagnoses of other contact w health services w/o CC/MCC. 963.......................... Other multiple significant trauma w MCC. 989.......................... Non-extensive O.R. proc unrelated to principal diagnosis w/o CC/MCC.

PROPOSED QUINTILE 4

23........................... Craniotomy w major device implant or acute complex CNS PDX w MCC.** 24........................... Craniotomy w major device implant or acute complex CNS PDX w/o MCC.** 28........................... Spinal procedures w MCC. 29........................... Spinal procedures w CC. 30........................... Spinal procedures w/o CC/MCC. 37........................... Extracranial procedures w MCC. 38........................... Extracranial procedures w CC.** 42........................... Periph & cranial nerve & other nerv syst proc w/o CC/MCC.* 77........................... Hypertensive encephalopathy w MCC. 133.......................... Other ear, nose, mouth & throat O.R. procedures w CC/MCC. 164.......................... Major chest procedures w CC. 237.......................... Major cardiovascular procedures w MCC. 242.......................... Permanent cardiac pacemaker implant w

MCC.*** 246.......................... Percutaneous cardiovascular proc w drug- eluting stent w MCC. 247.......................... Percutaneous cardiovascular proc w drug- eluting stent w/o MCC. 248.......................... Percutaneous cardiovasc proc w non-drug- eluting stent w MCC. 249.......................... Percutaneous cardiovasc proc w non-drug- eluting stent w/o MCC.** 259.......................... Cardiac pacemaker device replacement w/o

MCC. 260.......................... Cardiac pacemaker revision except device replacement w MCC. 262.......................... Cardiac pacemaker revision except device replacement w/o CC/MCC.*** 286.......................... Circulatory disorders except AMI, w card cath w MCC. 327.......................... Stomach, esophageal & duodenal proc w CC. 328.......................... Stomach, esophageal & duodenal proc w/o

CC/MCC.** 348.......................... Anal & stomal procedures w CC. 358.......................... Other digestive system O.R. procedures w/ o CC/MCC.* 405.......................... Pancreas, liver & shunt procedures w MCC. 406.......................... Pancreas, liver & shunt procedures w

CC.** 417.......................... Laparoscopic cholecystectomy w/o c.d.e. w

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.*** 478.......................... Biopsies of musculoskeletal system & connective tissue w CC. 481.......................... Hip & femur procedures except major joint w CC. 485.......................... Knee procedures w pdx of infection w 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. 492.......................... Lower extrem & humer proc except hip, foot, femur w MCC. 493.......................... Lower extrem & humer proc except hip, foot, femur w CC. 503.......................... Foot procedures w MCC. 511.......................... Shoulder, elbow or forearm proc, exc major joint proc w CC.*** 513.......................... Hand or wrist proc, except major thumb or joint proc w CC/MCC. 514.......................... Hand or wrist proc, except major thumb or joint proc w/o CC/MCC.** 597.......................... Malignant breast disorders w MCC. 599.......................... Malignant breast disorders w/o CC/MCC.*** 625.......................... Thyroid, parathyroid & thyroglossal procedures w MCC. 659.......................... Kidney & ureter procedures for non- neoplasm w MCC. 660.......................... Kidney & ureter procedures for non- neoplasm w CC. 666.......................... Prostatectomy w CC.***

Page 23599

695.......................... Kidney & urinary tract signs & symptoms w

MCC. 711.......................... Testes procedures w CC/MCC. 717.......................... Other male reproductive system O.R. proc exc malignancy w CC/MCC. 739.......................... Uterine, adnexa proc for non-ovarian/ adnexal malig w MCC. 749.......................... Other female reproductive system O.R. procedures w CC/MCC. 754.......................... Malignancy, female reproductive system w

MCC. 802.......................... Other O.R. proc of the blood & blood forming organs w MCC. 808.......................... Major hematol/immun diag exc sickle cell crisis & coagul w MCC. 823.......................... Lymphoma & non-acute leukemia w other

O.R. proc w MCC. 896.......................... Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC. 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. 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. 985.......................... Prostatic O.R. procedure unrelated to principal diagnosis w CC.

PROPOSED QUINTILE 5

11........................... Tracheostomy for face, mouth & neck diagnoses w MCC. 12........................... Tracheostomy for face, mouth & neck diagnoses w CC. 24........................... Craniotomy w major device implant or acute complex CNS PDX w/o MCC.*** 25........................... Craniotomy & endovascular intracranial procedures w MCC. 26........................... Craniotomy & endovascular intracranial procedures w CC. 31........................... Ventricular shunt procedures w MCC. 32........................... Ventricular shunt procedures w CC. 38........................... Extracranial procedures w CC.*** 132.......................... Cranial/facial procedures w/o CC/MCC. 137.......................... Mouth procedures w CC/MCC. 226.......................... Cardiac defibrillator implant w/o cardiac cath w MCC. 227.......................... Cardiac defibrillator implant w/o cardiac cath w/o MCC. 242.......................... Permanent cardiac pacemaker implant w

MCC.** 243.......................... Permanent cardiac pacemaker implant w CC. 244.......................... Permanent cardiac pacemaker implant w/o

CC/MCC. 249.......................... Percutaneous cardiovasc proc w non-drug- eluting stent w/o MCC.*** 250.......................... Perc cardiovasc proc w/o coronary artery stent or AMI w MCC. 326.......................... Stomach, esophageal & duodenal proc w

MCC. 328.......................... Stomach, esophageal & duodenal proc w/o

CC/MCC.*** 330.......................... Major small & large bowel procedures w

CC. 331.......................... Major small & large bowel procedures w/o

CC/MCC. 335.......................... Peritoneal adhesiolysis w MCC. 344.......................... Minor small & large bowel procedures w

MCC. 347.......................... Anal & stomal procedures w MCC. 353.......................... Hernia procedures except inguinal & femoral w MCC. 406.......................... Pancreas, liver & shunt procedures w

CC.*** 411.......................... Cholecystectomy w c.d.e. w MCC. 414.......................... Cholecystectomy except by laparoscope w/o c.d.e. w MCC. 415.......................... Cholecystectomy except by laparoscope w/o c.d.e. w CC. 417.......................... Laparoscopic cholecystectomy w/o c.d.e. w

MCC.** 418.......................... Laparoscopic cholecystectomy w/o c.d.e. w

CC. 423.......................... Other hepatobiliary or pancreas O.R. procedures w MCC. 456.......................... Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w MCC. 457.......................... Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w CC. 459.......................... Spinal fusion except cervical w MCC. 469.......................... Major joint replacement or reattachment of lower extremity w MCC.** 470.......................... Major joint replacement or reattachment of lower extremity w/o MCC. 477.......................... Biopsies of musculoskeletal system & connective tissue w MCC. 480.......................... Hip & femur procedures except major joint w MCC. 487.......................... Knee procedures w pdx of infection w/o CC/

MCC.*** 488.......................... Knee procedures w/o pdx of infection w CC/

MCC. 496.......................... Local excision & removal int fix devices exc hip & femur w CC.* 498.......................... Local excision & removal int fix devices of hip & femur w CC/MCC. 507.......................... Major shoulder or elbow joint procedures w CC/MCC. 514.......................... Hand or wrist proc, except major thumb or joint proc w/o CC/MCC.*** 582.......................... Mastectomy for malignancy w CC/MCC. 619.......................... O.R. procedures for obesity w MCC. 653.......................... Major bladder procedures w MCC. 656.......................... Kidney & ureter procedures for neoplasm w

MCC.

Page 23600

662.......................... Minor bladder procedures w MCC. 709.......................... Penis procedures w CC/MCC. 713.......................... Transurethral prostatectomy w CC/MCC. 746.......................... Vagina, cervix & vulva procedures w CC/

MCC. 826.......................... Myeloprolif disord or poorly diff neopl w maj O.R. proc w MCC. 827.......................... Myeloprolif disord or poorly diff neopl w maj O.R. proc w CC. 829.......................... Myeloprolif disord or poorly diff neopl w other O.R. proc w CC/MCC. 836.......................... Acute leukemia w/o major O.R. procedure w/ o CC/MCC.*** 855.......................... Infectious & parasitic diseases w O.R. procedure w/o CC/MCC.* 906.......................... Hand procedures for injuries. 927.......................... Extensive burns or full thickness burns w

MV 96+ hrs w skin graft. 970.......................... HIV w extensive O.R. procedure w/o

MCC.***

*One of the original 290 proposed low-volume MS-LTC-DRGs initially assigned to this proposed low-volume quintile; removed from this proposed low-volume quintile in addressing nonmonotonicity (refer to step 6 in section II.I.4..of the preamble of this proposed rule).

**One of the original 290 proposed low-volume MS-LTC-DRGs initially assigned to a different proposed low-volume quintile but moved to this proposed low-volume quintile in addressing nonmonotonicity (refer to step 6 in section II.I.4. of the preamble of this proposed rule).

***One of the original 290 proposed low-volume MS-LTC-DRGs initially assigned to this proposed low-volume quintile but moved to a different proposed low-volume quintile in addressing nonmonotonicity (refer to step 6 in section II.I.4. of the preamble of this proposed rule).

We note that we will continue to monitor the volume (that is, the number of LTCH cases) in the 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 2009 MS-LTC-DRG Relative

Weights

In general, the proposed FY 2009 MS-LTC-DRG relative weights in this proposed rule were determined based on the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991).

In summary, for FY 2009, we are proposing to group LTCH cases to the appropriate proposed MS-LTC-DRG, while taking into account the proposed low-volume MS-LTC-DRGs (as described above), before the proposed FY 2009 MS-LTC-DRG relative weights are determined. After grouping the cases to the appropriate proposed MS-LTC-DRG (or proposed low-volume quintile), we would calculate the proposed relative weights for FY 2009 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 would adjust the number of cases in each proposed MS-LTC-DRG (or proposed low-volume quintile) for the effect of short-stay outlier cases (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 (or proposed low-volume quintile) using the HSRV method (described above). In general, to determine the proposed FY 2009 MS-LTC-DRG relative weights in this proposed rule, we are proposing to use the same methodology we used in determining the FY 2008 MS-LTC-DRG relative weights in the FY 2008 IPPS final rule with comment period (72 FR 47281 through 47299).

However, we are proposing to make a modification to our methodology for determining proposed relative weights for MS-LTC-DRGs with no LTCH cases (as discussed in greater detail in Step 5 below). Also, we note that, although we are generally proposing to use the same methodology in this proposed rule (with the exception noted above) as the methodology used in the FY 2008 IPPS final rule with comment, the discussion presented below of the steps for determining the proposed FY 2009 MS-LTC-DRG relative weights varies slightly from the discussion of the steps for determining the FY 2008 MS-LTC-DRG relative weights

(presented in the FY 2008 IPPS final rule with comment) because we are taking this opportunity to refine our description to more precisely explain our methodology for determining the MS-LTC-DRG relative weights.

As discussed in the FY 2008 IPPS final rule with comment when we adopted the MS-LTC-DRGs, the adoption of the MS-LTC-DRGs with either two or three severity levels resulted in some slight modifications of procedures for assigning relative weights in cases of zero volume and/ or nonmonotonicity (described in detail below) from the methodology we established when we implemented the LTCH PPS in the August 30, 2002

LTCH PPS final rule. As also discussed in the FY 2008 IPPS final rule with comment when we adopted the MS-LTC-DRGs, we implemented the MS-

LTC-DRGs with a 2-year transition beginning in FY 2008. For FY 2008, the first year of the transition, 50 percent of the relative weight for a MS-LTC-DRG was based on the average LTC-DRG relative weight under

Version 24.0 of the LTC-DRG GROUPER. The remaining 50 percent of the relative weight was based on the MS-LTC-DRG relative weight under

Version 25.0 of the MS-LTC-DRG GROUPER. In FY 2009, the MS-LTC-DRG relative weights are based on 100 percent of the MS-LTC-DRG relative weights. Accordingly, in determining the proposed FY 2009 MS-LTC-DRG relative weights in this proposed rule, there is no longer a need to include a step to calculate MS-LTC-DRG transition blended relative weights (see Step 7 in the FY 2008 IPPS final rule with comment period

(72 FR 47295)). Therefore, in this proposed rule, we determined the proposed FY 2009 MS-LTC-DRG relative weights based solely on the proposed MS-LTC-DRG relative weight under proposed Version 26.0 of the

MS-LTC-DRG GROUPER, which is discussed in section II.B. of the preamble of this proposed rule. Furthermore, we are proposing that we would determine the final FY 2009 MS-LTC-DRG relative weights in the final rule based on the final Version 26.0 of the MS-LTC-DRG GROUPER that will be presented in that same final rule.

Below we discuss in detail the steps for calculating the proposed

FY 2009 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

Page 23601

are paid in accordance with demonstration projects that had claims in the FY 2007 MedPAR file.

Step 1--Remove statistical outliers.

The first step in the calculation of the proposed FY 2009 MS-LTC-

DRG relative weights is to remove statistical outlier cases. Consistent with our historical relative weight methodology, we are proposing to continue to 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 because 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 proposed 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 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. If we were to include stays of 7 days or less in the computation of the proposed FY 2009 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. Therefore, consistent with our historical relative weight methodology, in determining the proposed FY 2009 MS-LTC-DRG relative weights, we are proposing to 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. As the next step in the calculation of the proposed FY 2009

MS-LTC-DRG relative weights, consistent with our historical relative weight methodology, we are proposing 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) in conjunction with Sec. 412.503 for LTCH discharges occurring on or after October 1, 2008). (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.)

We would 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 nonshort-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.

Counting short-stay outlier cases as full discharges with no adjustment in determining the proposed FY 2009 MS-LTC-DRG relative weights would lower the proposed FY 2009 MS-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 are proposing to 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 2009 MS-LTC-DRG relative weights on an iterative basis.

Consistent with our historical relative weight methodology, we are proposing to calculate the proposed MS-LTC-DRG relative weights using the HSRV methodology, which is an iterative process. 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 MS-LTC-DRG, the proposed FY 2009 relative weight is calculated by dividing the average of the adjusted hospital-specific relative charge values (from above) for the MS-LTC-DRG by the overall average hospital-specific relative charge value across all cases for all LTCHs. Using these recalculated MS-LTC-DRG relative weights, each

LTCH's average relative weight for all of its cases (that is, its case- mix) is calculated by dividing the sum of all the LTCH's MS-LTC-DRG relative weights by its total number of cases. The LTCH's hospital- specific relative charge values above are multiplied by these hospital- specific case-mix indexes. These hospital-specific case-mix adjusted relative charge values are then used to calculate a new set of MS-LTC-

DRG relative weights across all LTCHs. 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 2009 relative weight for proposed

MS-LTC-DRGs with no LTCH cases.

As we stated above, we determine the proposed FY 2009 relative weight for each proposed MS-LTC-DRG using total Medicare allowable charges reported in the best available LTCH claims data (that is, the

December 2007 update of the FY 2007 MedPAR file for this proposed rule). Of the proposed FY 2009 MS-LTC-DRGs, we identified a number of proposed MS-LTC-DRGs for which there were no LTCH cases in the database. That is, based on data from the FY 2007 MedPAR file used for this proposed rule, no patients who would have been classified to those proposed MS-LTC-DRGs were treated in LTCHs during FY 2007 and, therefore, no charge data are available for those proposed MS-LTC-DRGs.

Thus, in the process of determining the proposed MS-LTC-DRG relative weights, we are unable to calculate proposed relative weights for these proposed MS-LTC-DRGs with no LTCH cases 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, consistent with our historical methodology, we are proposing to assign relative weights to each of the proposed no-volume MS-LTC-DRGs based on clinical similarity and relative costliness (with the

Page 23602

exception of proposed ``transplant'' MS-LTC-DRGs and proposed ``error''

MS-LTC-DRGs as discussed below). In general, we are proposing to determine proposed FY 2009 relative weights for the proposed MS-LTC-

DRGs with no LTCH cases in the FY 2007 MedPAR file used in this proposed rule (that is, proposed ``no-volume MS-LTC-DRGs) by cross- walking each proposed no-volume MS-LTC-DRG to another proposed MS-LTC-

DRG with a proposed relative weight (determined in accordance with the proposed methodology described above). Then, under our proposed methodology presented in this proposed rule, the proposed ``no-volume''

MS-LTC-DRG would be assigned the same proposed relative weight of the proposed MS-LTC-DRG to which it would be cross-walked (as described in greater detail below). As noted above, we are proposing to make a modification to our methodology for determining proposed relative weights for MS-LTC-DRGs with no LTCH cases in this proposed rule, which is discussed in greater detail below. As also noted above, even where we are not proposing changes to our existing methodology, we are taking this opportunity to refine our description to more precisely explain our proposed methodology for determining the MS-LTC-DRG relative weights in this proposed rule.

Specifically, in this proposed rule, we are proposing to determine the relative weight for each proposed MS-LTC-DRG using total Medicare allowable charges reported in the December 2007 update of the FY 2007

MedPAR file. Of the 746 proposed MS-LTC-DRGs for FY 2009, we identified 203 proposed MS-LTC-DRGs for which there were no LTCH cases in the database (including the 8 proposed ``transplant'' MS-LTC-DRGs and 2 proposed ``error'' MS-LTC-DRGs). For this proposed rule, as noted above, we are proposing to assign proposed relative weights for each of the 203 proposed no-volume MS-LTC-DRGs (with the exception of the 8 proposed ``transplant'' proposed MS-LTC-DRGs and the 2 proposed

``error'' MS-LTC-DRGs, which are discussed below) based on clinical similarity and relative costliness to one of the remaining 543 (746 - 203 = 543) proposed MS-LTC-DRGs for which we are able to determine relative weights, based on FY 2007 LTCH claims data. (For the remainder of this discussion, we refer to one of the 543 proposed MS-LTC-DRGs for which we are able to determine relative weight as the proposed ``cross- walked'' MS-LTC-DRG.) Then we are proposing to assign the proposed no- volume MS-LTC-DRG the proposed relative weight of the proposed cross- walked MS-LTC-DRG. This proposed approach differs from the one we used to determine the FY 2008 MS-LTC-DRG relative weights when there were no

LTCH cases (see 72 FR 47290). Specifically, in determining the FY 2008

MS-LTC-DRG relative weights in the FY 2008 IPPS final rule with comment period, if the no volume MS-LTC-DRG was cross-walked to a MS-LTC-DRG that had 25 or more cases and, therefore, was not in a low-volume quintile, we assigned the relative weight of a quintile to a no-volume

MS-LTC-DRG (rather than assigning the relative weight of the cross- walked MS-LTC-DRG). While we believe this approach would result in appropriate LTCH PPS payments (because it is consistent with our methodology for determining relative weights for MS-LTC-DRGs that have a low volume of LTCH cases (which is discussed above in section

II.I.3.e. of this preamble)), upon further review during the development of the proposed FY 2009 MS-LTC-DRG relative weights in this proposed rule, we now believe that proposing to assign the proposed relative weight of the proposed cross-walked MS-LTC-DRG to the proposed no-volume MS-LTC-DRG would result in more appropriate LTCH PPS payments because those cases generally require equivalent relative resource (and therefore should generally have the same LTCH PPS payment). The relative weight of each MS-LTC-DRG should reflect relative resource of the LTCH cases grouped to that MS-LTC-DRG. Because the proposed no- volume MS-LTC-DRGs would be cross-walked to other proposed MS-LTC-DRGs based on clinical similarity and relative costliness, which usually require equivalent relative resource use, we believe that assigning the proposed no-volume MS-LTC-DRG the proposed relative weight of the proposed cross-walked MS-LTC-DRG would result in appropriate LTCH PPS payments. (As explained below in Step 6, when necessary, we are proposing to make adjustments to account for nonmonotonicity.)

Our proposed methodology for determining the proposed relative weights for the proposed no-volume MS-LTC-DRGs is as follows: We cross- walk the proposed no-volume MS-LTC-DRG to a proposed MS-LTC-DRG for which there are LTCH cases in the FY 2007 MedPAR file and to which it is similar clinically in intensity of use of resources and relative costliness as determined by criteria such as 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. We then assign the proposed relative weight of the proposed cross-walked MS-LTC-DRG as the proposed relative weight for the proposed no-volume MS-LTC-DRG such that both of these proposed MS-LTC-

DRGs (that is, the proposed no-volume MS-LTC-DRG and the proposed cross-walked MS-LTC-DRG) would have the same proposed relative weight.

We note that if the proposed cross-walked MS-LTC-DRG had 25 cases or more, its proposed relative weight, which was calculated using the proposed methodology described in steps 1 through 4 above, would be assigned to the proposed no-volume MS-LTC-DRG as well. Similarly, if the proposed MS-LTC-DRG to which the proposed no-volume MS-LTC-DRG is cross-walked has 24 or less cases, and therefore was designated to one of the proposed low-volume quintiles for purposes of determining the proposed relative weights, we would assign the proposed relative weight of the applicable proposed low-volume quintile to the proposed no- volume MS-LTC-DRG such that both of these proposed MS-LTC-DRGs (that is, the proposed no-volume MS-LTC-DRG and the proposed cross-walked MS-

LTC-DRG) would have the same proposed relative weight. (As we noted above, in the infrequent case where nonmonotonicity involving a proposed no-volume MS-LTC-DRG results, additional measures as described in Step 6 would be required in order to maintain monotonically increasing relative weights.)

For this proposed rule, a list of the proposed no-volume FY 2009

MS-LTC-DRGs and the proposed FY 2009 MS-LTC-DRG to which it is cross- walked (that is, the proposed cross-walked MS-LTC-DRG) is shown in the chart below.

Page 23603

Proposed No-Volume MS-LTC-DRG Crosswalk for FY 2009

Proposed cross-

Proposed MS-LTC-DRG (Version 26.0)

Proposed MS-LTC-DRG description (version 26.0)

walked MS-LTC-

DRG

9........................................ Bone marrow transplant..............................

823 13....................................... Tracheostomy for face, mouth & neck diagnoses w/o CC/

12

MCC. 20....................................... Intracranial vascular procedures w PDX hemorrhage w

31

MCC. 21....................................... Intracranial vascular procedures w PDX hemorrhage w

32

CC. 22....................................... Intracranial vascular procedures w PDX hemorrhage w/

32 o CC/MCC. 33....................................... Ventricular shunt procedures w/o CC/MCC.............

32 34....................................... Carotid artery stent procedure w MCC................

37 35....................................... Carotid artery stent procedure w CC.................

38 36....................................... Carotid artery stent procedure w/o CC/MCC...........

38 39....................................... Extracranial procedures w/o CC/MCC..................

38 61....................................... Acute ischemic stroke w use of thrombolytic agent w

70

MCC. 62....................................... Acute ischemic stroke w use of thrombolytic agent w

71

CC. 63....................................... Acute ischemic stroke w use of thrombolytic agent w/

72 o CC/MCC. 76....................................... Viral meningitis w/o CC/MCC.........................

75 88....................................... Concussion w MCC....................................

89 90....................................... Concussion w/o CC/MCC...............................

89 114...................................... Orbital procedures w/o CC/MCC.......................

113 115...................................... Extraocular procedures except orbit.................

125 117...................................... Intraocular procedures w/o CC/MCC...................

125 123...................................... Neurological eye disorders..........................

125 129...................................... Major head & neck procedures w CC/MCC or major

146 device. 130...................................... Major head & neck procedures w/o CC/MCC.............

148 131...................................... Cranial/facial procedures w CC/MCC..................

132 134...................................... Other ear, nose, mouth & throat O.R. procedures w/o

133

CC/MCC. 138...................................... Mouth procedures w/o CC/MCC.........................

137 139...................................... Salivary gland procedures...........................

137 150...................................... Epistaxis w MCC.....................................

152 151...................................... Epistaxis w/o MCC...................................

153 215...................................... Other heart assist system implant...................

238 216...................................... Cardiac valve & oth maj cardiothoracic proc w card

237 cath w MCC. 217...................................... Cardiac valve & oth maj cardiothoracic proc w card

238 cath w CC. 218...................................... Cardiac valve & oth maj cardiothoracic proc w card

238 cath w/o CC/MCC. 219...................................... Cardiac valve & oth maj cardiothoracic proc w/o card

237 cath w MCC. 220...................................... Cardiac valve & oth maj cardiothoracic proc w/o card

238 cath w CC. 221...................................... Cardiac valve & oth maj cardiothoracic proc w/o card

238 cath w/o CC/MCC. 222...................................... Cardiac defib implant w cardiac cath w AMI/HF/shock

242 w MCC. 223...................................... Cardiac defib implant w cardiac cath w AMI/HF/shock

243 w/o MCC. 224...................................... Cardiac defib implant w cardiac cath w/o AMI/HF/

242 shock w MCC. 225...................................... Cardiac defib implant w cardiac cath w/o AMI/HF/

243 shock w/o MCC. 228...................................... Other cardiothoracic procedures w MCC...............

252 229...................................... Other cardiothoracic procedures w CC................

253 230...................................... Other cardiothoracic procedures w/o CC/MCC..........

254 231...................................... Coronary bypass w PTCA w MCC........................

237 232...................................... Coronary bypass w PTCA w/o MCC......................

238 233...................................... Coronary bypass w cardiac cath w MCC................

237 234...................................... Coronary bypass w cardiac cath w/o MCC..............

238 235...................................... Coronary bypass w/o cardiac cath w MCC..............

237 236...................................... Coronary bypass w/o cardiac cath w/o MCC............

238 245...................................... AICD generator procedures...........................

244 251...................................... Perc cardiovasc proc w/o coronary artery stent or

250

AMI w/o MCC. 258...................................... Cardiac pacemaker device replacement w MCC..........

259 265...................................... AICD lead procedures................................

259 285...................................... Circulatory disorders w AMI, expired w/o CC/MCC.....

284 295...................................... Deep vein thrombophlebitis w/o CC/MCC...............

294 296...................................... Cardiac arrest, unexplained w MCC...................

283 297...................................... Cardiac arrest, unexplained w CC....................

284 298...................................... Cardiac arrest, unexplained w/o CC/MCC..............

284 332...................................... Rectal resection w MCC..............................

356 333...................................... Rectal resection w CC...............................

357 334...................................... Rectal resection w/o CC/MCC.........................

358 336...................................... Peritoneal adhesiolysis w CC........................

335 337...................................... Peritoneal adhesiolysis w/o CC/MCC..................

335 338...................................... Appendectomy w complicated principal diag w MCC.....

371 339...................................... Appendectomy w complicated principal diag w CC......

372 340...................................... Appendectomy w complicated principal diag w/o CC/MCC

373 341...................................... Appendectomy w/o complicated principal diag w MCC...

371 342...................................... Appendectomy w/o complicated principal diag w CC....

372 343...................................... Appendectomy w/o complicated principal diag w/o CC/

373

MCC. 345...................................... Minor small & large bowel procedures w CC...........

344 346...................................... Minor small & large bowel procedures w/o CC/MCC.....

344

Page 23604

349...................................... Anal & stomal procedures w/o CC/MCC.................

348 350...................................... Inguinal & femoral hernia procedures w MCC..........

348 351...................................... Inguinal & femoral hernia procedures w CC...........

348 352...................................... Inguinal & femoral hernia procedures w/o CC/MCC.....

348 355...................................... Hernia procedures except inguinal & femoral w/o CC/

354

MCC. 383...................................... Uncomplicated peptic ulcer w MCC....................

384 407...................................... Pancreas, liver & shunt procedures w/o CC/MCC.......

406 408...................................... Biliary tract proc except only cholecyst w or w/o

409 c.d.e. w MCC. 410...................................... Biliary tract proc except only cholecyst w or w/o

409 c.d.e. w/o CC/MCC. 412...................................... Cholecystectomy w c.d.e. w CC.......................

411 413...................................... Cholecystectomy w c.d.e. w/o CC/MCC.................

411 416...................................... Cholecystectomy except by laparoscope w/o c.d.e. w/o

415

CC/MCC. 419...................................... Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MCC..

418 420...................................... Hepatobiliary diagnostic procedures w MCC...........

424 421...................................... Hepatobiliary diagnostic procedures w CC............

424 422...................................... Hepatobiliary diagnostic procedures w/o CC/MCC......

424 425...................................... Other hepatobiliary or pancreas O.R. procedures w/o

424

CC/MCC. 434...................................... Cirrhosis & alcoholic hepatitis w/o CC/MCC..........

433 453...................................... Combined anterior/posterior spinal fusion w MCC.....

457 454...................................... Combined anterior/posterior spinal fusion w CC......

457 455...................................... Combined anterior/posterior spinal fusion w/o CC/MCC

457 458...................................... Spinal fusion exc cerv w spinal curv, malig or 9+

457 fusions w/o CC/MCC. 460...................................... Spinal fusion except cervical w/o MCC...............

459 461...................................... Bilateral or multiple major joint procs of lower

480 extremity w MCC. 462...................................... Bilateral or multiple major joint procs of lower

482 extremity w/o MCC. 473...................................... Cervical spinal fusion w/o CC/MCC...................

472 479...................................... Biopsies of musculoskeletal system & connective

478 tissue w/o CC/MCC. 483...................................... Major joint & limb reattachment proc of upper

480 extremity w CC/MCC. 484...................................... Major joint & limb reattachment proc of upper

482 extremity w/o CC/MCC. 491...................................... Back & neck procedures except spinal fusion w/o CC/

490

MCC. 499...................................... Local excision & removal int fix devices of hip &

498 femur w/o CC/MCC. 506...................................... Major thumb or joint procedures.....................

514 508...................................... Major shoulder or elbow joint procedures w/o CC/MCC.

507 509...................................... Arthroscopy.........................................

505 512...................................... Shoulder, elbow or forearm proc, exc major joint

511 proc w/o CC/MCC. 517...................................... Other musculoskelet sys & conn tiss O.R. proc w/o CC/

516

MCC. 538...................................... Sprains, strains, & dislocations of hip, pelvis &

537 thigh w/o CC/MCC. 583...................................... Mastectomy for malignancy w/o CC/MCC................

582 585...................................... Breast biopsy, local excision & other breast

584 procedures w/o CC/MCC. 614...................................... Adrenal & pituitary procedures w CC/MCC.............

629 615...................................... Adrenal & pituitary procedures w/o CC/MCC...........

630 620...................................... O.R. procedures for obesity w CC....................

619 621...................................... O.R. procedures for obesity w/o CC/MCC..............

619 627...................................... Thyroid, parathyroid & thyroglossal procedures w/o

626

CC/MCC. 654...................................... Major bladder procedures w CC.......................

653 655...................................... Major bladder procedures w/o CC/MCC.................

653 657...................................... Kidney & ureter procedures forneoplasm w CC.........

656 658...................................... Kidney & ureter procedures for neoplasm w/o CC/MCC..

656 664...................................... Minor bladder procedures w/o CC/MCC.................

663 667...................................... Prostatectomy w/o CC/MCC............................

666 670...................................... Transurethral procedures w/o CC/MCC.................

669 672...................................... Urethral procedures w/o CC/MCC......................

671 675...................................... Other kidney & urinary tract procedures w/o CC/MCC..

674 691...................................... Urinary stones w esw lithotripsy w CC/MCC...........

694 692...................................... Urinary stones w esw lithotripsy w/o CC/MCC.........

694 697...................................... Urethral stricture..................................

688 707...................................... Major male pelvic procedures w CC/MCC...............

660 708...................................... Major male pelvic procedures w/o CC/MCC.............

661 710...................................... Penis procedures w/o CC/MCC.........................

709 712...................................... Testes procedures w/o CC/MCC........................

711 714...................................... Transurethral prostatectomy w/o CC/MCC..............

713 715...................................... Other male reproductive system O.R. proc for

717 malignancy w CC/MCC. 716...................................... Other male reproductive system O.R. proc for

717 malignancy w/o CC/MCC. 718...................................... Other male reproductive system O.R. proc exc

717 malignancy w/o CC/MCC. 724...................................... Malignancy, male reproductive system w/o CC/MCC.....

723 734...................................... Pelvic evisceration, rad hysterectomy & rad

717 vulvectomy w CC/MCC. 735...................................... Pelvic evisceration, rad hysterectomy & rad

717 vulvectomy w/o CC/MCC. 736...................................... Uterine & adnexa proc for ovarian or adnexal

754 malignancy w MCC. 737...................................... Uterine & adnexa proc for ovarian or adnexal

755 malignancy w CC. 738...................................... Uterine & adnexa proc for ovarian or adnexal

756 malignancy w/o CC/MCC.

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740...................................... Uterine, adnexa proc for non-ovarian/adnexal malig w

739

CC. 741...................................... Uterine, adnexa proc for non-ovarian/adnexal malig w/

739 o CC/MCC. 742...................................... Uterine & adnexa proc for non-malignancy w CC/MCC...

755 743...................................... Uterine & adnexa proc for non-malignancy w/o CC/MCC.

756 745...................................... D&C, conization, laparascopy & tubal interruption w/

744 o CC/MCC. 747...................................... Vagina, cervix & vulva procedures w/o CC/MCC........

746 748...................................... Female reproductive system reconstructive procedures

749 750...................................... Other female reproductive system O.R. procedures w/o

749

CC/MCC. 760...................................... Menstrual & other female reproductive system

744 disorders w CC/MCC. 761...................................... Menstrual & other female reproductive system

744 disorders w/o CC/MCC. 765...................................... Cesarean section w CC/MCC...........................

744 766...................................... Cesarean section w/o CC/MCC.........................

744 767...................................... Vaginal delivery w sterilization &/or D&C...........

744 768...................................... Vaginal delivery w O.R. proc except steril &/or D&C.

744 769...................................... Postpartum & post abortion diagnoses w O.R.

744 procedure. 770...................................... Abortion w D&C, aspiration curettage or hysterotomy.

744 774...................................... Vaginal delivery w complicating diagnoses...........

744 775...................................... Vaginal delivery w/o complicating diagnoses.........

744 776...................................... Postpartum & post abortion diagnoses w/o O.R.

744 procedure. 777...................................... Ectopic pregnancy...................................

744 778...................................... Threatened abortion.................................

759 779...................................... Abortion w/o D&C....................................

759 780...................................... False labor.........................................

759 782...................................... Other antepartum diagnoses w/o medical complications

781 789...................................... Neonates, died or transferred to another acute care

781 facility. 790...................................... Extreme immaturity or respiratory distress syndrome,

781 neonate. 791...................................... Prematurity w major problems........................

781 792...................................... Prematurity w/o major problems......................

781 793...................................... Full term neonate w major problems..................

781 794...................................... Neonate w other significant problems................

781 795...................................... Normal newborn......................................

781 799...................................... Splenectomy w MCC...................................

800 801...................................... Splenectomy w/o CC/MCC..............................

800 803...................................... Other O.R. proc of the blood & blood forming organs

802 w CC. 804...................................... Other O.R. proc of the blood & blood forming organs

802 w/o CC/MCC. 820...................................... Lymphoma & leukemia w major O.R. procedure w MCC....

823 821...................................... Lymphoma & leukemia w major O.R. procedure w CC.....

824 822...................................... Lymphoma & leukemia w major O.R. procedure w/o CC/

824

MCC. 825...................................... Lymphoma & non-acute leukemia w other O.R. proc w/o

824

CC/MCC. 828...................................... Myeloprolif disord or poorly diff neopl w maj O.R.

827 proc w/o CC/MCC. 830...................................... Myeloprolif disord or poorly diff neopl w other O.R.

829 proc w/o CC/MCC. 837...................................... Chemo w acute leukemia as sdx or w high dose chemo

829 agent w MCC. 838...................................... Chemo w acute leukemia as sdx or w high dose chemo

829 agent w CC. 839...................................... Chemo w acute leukemia as sdx or w high dose chemo

829 agent w/o CC/MCC. 848...................................... Chemotherapy w/o acute leukemia as secondary

847 diagnosis w/o CC/MCC. 887...................................... Other mental disorder diagnoses.....................

881 894...................................... Alcohol/drug abuse or dependence, left ama..........

881 915...................................... Allergic reactions w MCC............................

918 916...................................... Allergic reactions w/o MCC..........................

918 955...................................... Craniotomy for multiple significant trauma..........

26 956...................................... Limb reattachment, hip & femur proc for multiple

482 significant trauma. 959...................................... Other O.R. procedures for multiple significant

958 trauma w/o CC/MCC. 986...................................... Prostatic O.R. procedure unrelated to principal

985 diagnosis w/o CC/MCC.

To illustrate this methodology for determining the proposed relative weights for the proposed MS-LTC-DRGs with no LTCH cases, we are providing the following example, which refers to the proposed no- volume MS-LTC-DRGs crosswalk information for FY 2009 provided in the chart above.

Example: There were no cases in the FY 2007 MedPAR file used for this proposed rule for proposed MS-LTC-DRG 61 (Acute ischemic stroke w use of thrombolytic agent w MCC). We determined that MS-LTC-DRG 70

(Nonspecific cebrovascular disorders w MCC) is similar clinically and based on resource use to proposed MS-LTC-DRG 61. Therefore, we are proposing to assign the same proposed relative weight of proposed MS-

LTC-DRG 70 of 0.8718 for FY 2009 to proposed MS-LTC-DRG 61 (Table 11 of the Addendum of this proposed rule).

Furthermore, for FY 2009, consistent with our historical relative weight methodology, we are proposing to establish MS-LTC-DRG relative weights of 0.0000 for the following proposed transplant MS-LTC-DRGs:

Heart Transplant or Implant of Heart Assist System with MCC (MS-LTC-DRG 1); Heart Transplant or Implant of Heart Assist System without MCC (MS-

LTC-DRG 2); Liver Transplant with MCC or Intestinal Transplant (MS-LTC-

DRG 5);

Page 23606

Liver Transplant without MCC (MS-LTC-DRG 6); Lung Transplant (MS-LTC-

DRG 7); Simultaneous Pancreas/Kidney Transplant (MS-LTC-DRG 8);

Pancreas Transplant (MS-LTC-DRG 10); and Kidney Transplant (MS-LTC-DRG 652). 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 more than 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 MS-LTC-DRGs affected. At the present time, we would only include these eight 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.

Step 6--Adjust the proposed FY 2009 MS-LTC-DRG relative weights to account for nonmonotonically increasing relative weights.

As discussed in section II.B. of the preamble of this proposed rule, the MS-DRGs (used under the IPPS) on which the 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 those base MS-LTC-DRGs that are split into either two or three severity levels, cases classified into the ``without CC/MCC'' MS-LTC-

DRG are expected to have a lower resource use (and lower costs) than the ``with CC/MCC'' MS-LTC-DRG (in the case of a two-level split) or the ``with CC'' and ``with MCC'' MS-LTC-DRGs (in the case of a three- level split). 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 relative weights do not increase (that is, if within a base MS-LTC-DRG, a MS-LTC-DRG with MCC has a lower relative weight than one with CC, or the 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, in general, we are proposing to combine proposed MS-LTC-DRG severity levels within a base MS-LTC-DRG for the purpose of computing a relative weight when necessary to ensure that monotonicity is maintained. In determining the proposed FY 2009 MS-LTC-DRG relative weights in this proposed rule, in general, we are proposing to use the same methodology to adjust for nonmonotonicity that we used to determine the FY 2008 MS-

LTC-DRG relative weights in the FY 2008 IPPS final rule with comment

(72 FR 47293 through 47295). However, as noted above, we are taking this opportunity to refine our description to more precisely explain our methodology for determining the MS-LTC-DRG relative weights in this proposed rule. Specifically, in determining the proposed FY 2009 MS-

LTC-DRG relative weights in this proposed rule, under each of the example scenarios provided below, we would combine severity levels within a base MS-LTC-DRG as follows:

The first example of nonmonotonically increasing relative weights for a MS-LTC-DRG pertains to a base MS-LTC-DRG with a three-level split and each of the three levels has 25 or more LTCH cases and, therefore, none of those MS-LTC-DRGs is assigned to one of the five low-volume quintiles. In this proposed rule, if nonmonotonicity is detected in the proposed relative weights of the proposed MS-LTC-DRGs in adjacent severity levels (for example, the proposed 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 would combine the nonmonotonic adjacent proposed MS-LTC-DRGs and re-determine a proposed relative weight based on the case-weighted average of the combined LTCH cases of the nonmonotonic proposed MS-LTC-

DRGs. The case-weighted average charge is calculated by dividing the total charges for all LTCH cases in both severity levels by the total number of LTCH cases for both proposed MS-LTC-DRGs. The same proposed relative weight would be assigned to both affected levels of the base

MS-LTC-DRG. If nonmonotonicity remains an issue because the above process results in a proposed relative weight that is still nonmonotonic to the remaining proposed MS-LTC-DRG relative weight within the base MS-LTC-DRG, we would combine all three of the severity levels to redetermine the proposed relative weights based on the case- weighted average charge of the combined severity levels. This same proposed relative weight is then assigned to each of the proposed MS-

LTC-DRGs in that base MS-LTC-DRG.

A second example of nonmonotonically increasing relative weights for a base MS-LTC-DRG pertains to the situation where there are three severity levels and one or more of the severity levels within a base

MS-LTC-DRG has less than 25 LTCH cases (that is, low-volume). In this proposed rule, 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 the proposed relative weight of the applicable proposed low- volume quintile(s)), we would combine the data for the cases in the two adjacent proposed low-volume MS-LTC-DRGs for the purpose of determining a proposed relative weight. If the combination results in at least 25 cases,

Page 23607

we re-determine one proposed relative weight based on the case-weighted average charge of the combined severity levels and assign this same proposed relative weight to each of the severity levels. If the combination results in less than 25 cases, based on the case-weighted average charge of the combined proposed low-volume MS-LTC-DRGs, both proposed MS-LTC-DRGs would be assigned to the appropriate proposed low- volume quintile (discussed above in section II.I.3.e. of this preamble) based on the case-weighted average charge of the combined proposed low- volume MS-LTC-DRGs. Then the proposed relative weight of the affected proposed low-volume quintile would be redetermined and that proposed relative weight would be assigned to each of the affected severity levels (and all of the proposed MS-LTC-DRGs in the affected proposed low-volume quintile). If nonmonotonicity persists, we would combine all three severity levels and redetermine one proposed relative weight based on the case-weighted average charge of the combined severity levels and this same proposed relative weight would be assigned to each of the three levels.

Similarly, in nonmonotonic cases where the middle level has 25 cases or more but either or both of the lowest or highest severity level has less than 25 cases (that is, low volume), we would combine the nonmonotonic proposed low-volume MS-LTC-DRG with the middle level proposed MS-LTC-DRG of the base MS-LTC-DRG. We would redetermine one proposed relative weight based on the case-weighted average charge of the combined severity levels and assign this same proposed relative weight to each of the affected proposed MS-LTC-DRGs. If nonmonotonicity persists, we would combine all three levels for the purpose of redetermining a proposed relative weight based on the case-weighted average charge of the combined severity levels, and assign that proposed relative weight to each of the three severity levels.

In the case where all three severity levels in the base MS-LTC-DRGs are proposed low-volume MS-LTC-DRGs and two of the severity levels are nonmonotonic in relation to each other, we would combine the two adjacent nonmonotonic severity levels. If that combination results in less than 25 cases, both proposed low-volume MS-LTC-DRGs would be assigned to the appropriate proposed low-volume quintile (discussed above in section II.I.3.e. of this preamble) based on the case-weighted average charge of the combined proposed low-volume MS-LTC-DRGs. Then the proposed relative weight of the affected proposed low-volume quintile would be redetermined and that proposed relative weight would be assigned to each of the affected severity levels (and all of the proposed MS-LTC-DRGs in the affected proposed low-volume quintile). If the nonmonotonicity persists, we would combine all three levels of that base MS-LTC-DRG for the purpose of redetermining a proposed relative weight based on the case-weighted average charge of the combined severity levels, and assign that proposed relative weight to each of the three severity levels. If that combination of all three severity levels results in less than 25 cases, we would assign that ``combined'' base MS-LTC-DRG to the appropriate proposed low-volume quintile based on the case-weighted average charge of the combined proposed low-volume

MS-LTC-DRGs. Then the proposed relative weight of the affected proposed low-volume quintile would be redetermined and that proposed relative weight would be assigned to each of the affected severity levels (and all of the proposed MS-LTC-DRGs in the affected proposed low-volume quintile).

Another example of nonmonotonicity involves a base MS-LTC-DRG with three severity levels where at least one of the severity levels has no cases. As discussed above in greater detail in Step 5, based on resource use intensity and clinical similarity, we propose to cross- walk a proposed no-volume MS-LTC-DRG to a proposed MS-LTC-DRG that has at least one case. Under our proposed methodology for the treatment of proposed no-volume MS-LTC-DRGs, the proposed no-volume MS-LTC-DRG would be assigned the same proposed relative weight as the proposed MS-LTC-

DRG to which the proposed no-volume MS-LTC-DRG is cross-walked. For many proposed no-volume MS-LTC-DRGs, as shown in the chart above in

Step 5, the application of our proposed methodology results in a proposed cross-walk MS-LTC-DRG that is the adjacent severity level in the same base MS-LTC-DRG. Consequently, in most instances, the proposed no-volume MS-LTC-DRG and the adjacent proposed MS-LTC-DRG to which it is cross-walked would not result in nonmonotonicity because both of these severity levels would have the same proposed relative weight. (In this proposed rule, under our proposed methodology for the treatment of proposed no-volume MS-LTC-DRGs, in the case where the proposed no- volume MS-LTC-DRG is either the highest or lowest severity level, the proposed cross-walk MS-LTC-DRG would be the middle level (``with CC'') within the same base MS-LTC-DRG, and therefore the proposed no-volume

MS-LTC-DRG (either the ``with MCC'' or the ``without CC/MCC'') and the proposed cross-walk MS-LTC-DRG (the ``with CC'') would have the same proposed relative weight. Consequently, no adjustment for monotonicity would be necessary.) However, if our proposed methodology for determining proposed relative weights for proposed no-volume MS-LTC-

DRGs results in nonmonotonicity with the third severity level in the base-MS-LTC-DRG, all three severity levels would be combined for the purpose of redetermining one proposed relative weight based on the case-weighted average charge of the combined severity levels. This same proposed relative weight would be assigned to each of the three severity levels in the base MS-LTC-DRG.

Thus far in the discussion, we have presented examples of nonmonotonicity in a base MS-LTC-DRG that has three severity levels. We would apply the same process where the base MS-LTC-DRG contains only two severity levels. For example, if nonmonotonicity occurs in a base

MS-LTC-DRG with two severity levels (that is, the proposed relative weight of the higher severity level is less than the lower severity level), where both of the proposed MS-LTC-DRGs have at least 25 cases or where one or both of the proposed MS-LTC-DRGs is low volume (that is, less than 25 cases), we would combine the two proposed MS-LTC-DRGs of that base MS-LTC-DRG for the purpose of redetermining a proposed relative weight based on the combined case-weighted average charge for both severity levels. This same proposed relative weight would be assigned to each of the two severity levels in the base MS-LTC-DRG.

Specifically, if the combination of the two severity levels would result in at least 25 cases, we would redetermine one proposed relative weight based on the case-weighted average charge and assign that proposed relative weight to each of the two proposed MS-LTC-DRGs. If the combination results in less than 25 cases, we would assign both proposed MS-LTC-DRGs to the appropriate proposed low-volume quintile

(discussed above in section II.I.3.e. of this preamble) based on their combined case-weighted average charge. Then the proposed relative weight of the affected proposed low-volume quintile would be redetermined and that proposed relative

Page 23608

weight would be assigned to each of the affected severity levels.

Step 7--Calculate the proposed FY 2009 budget neutrality factor.

As we established in the RY 2008 LTCH PPS final rule (72 FR 26882), 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, beginning with the MS-LTC-DRG update for FY 2008, the annual update to the MS-LTC-DRG classifications and relative weights will 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 MS-LTC-DRG classification and relative weight changes. Specifically, in that same final rule, we established under Sec. 412.517(b) that the annual update to the MS-LTC-DRG classifications and relative weights be done in a budget neutral manner. For a detailed discussion on the establishment of the requirement to update the MS-LTC-DRG classifications and relative weights in a budget neutral manner, we refer readers to the RY 2008 LTCH PPS final rule (72 FR 26880 through 26884). Updating the MS-LTC-DRGs in a budget neutral manner results in an annual update to the individual MS-LTC-DRG classifications and relative weights based on the most recent available data to reflect changes in relative LTCH resource use. To accomplish this, the MS-LTC-

DRG relative weights are uniformly adjusted to ensure that estimated aggregate payments under the LTCH PPS would not be affected (that is, decreased or increased). Consistent with that provision, we are proposing to update the MS-LTC-DRG classifications and relative weights for FY 2009 based on the most recent available data and include a proposed budget neutrality adjustment that would be applied in determining the proposed MS-LTC-DRG relative weights.

To ensure budget neutrality in updating the proposed MS-LTC-DRG classifications and proposed relative weights under Sec. 412.517(b), consistent with the budget neutrality methodology we established in the

FY 2008 IPPS final rule with comment period (72 FR 47295 through 47296), in determining the proposed budget neutrality adjustment for FY 2009 in this proposed rule, we are proposing to use a method that is similar to the methodology used under the IPPS. Specifically, for FY 2009, 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 those relative weights to ensure that estimated payments are not influenced by changes in the composition of case types or the changes being proposed to the classification system. That is, the proposed 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 proposed normalization factor for FY 2009, we would use the following steps: (1) We use the most recent available claims data (FY 2007) and the proposed MS-LTC-DRG relative weights

(determined above in Steps 1 through 6 above) to calculate the average

CMI; (2) we group the same claims data (FY 2007) using the FY 2008

GROUPER (Version 25.0) and FY 2008 relative weights (established in the

FY 2008 IPPS final rule with comment period (72 FR 47295 through 47296)) and calculate the average CMI; and (3), we compute the ratio of these average CMIs by dividing the average CMI determined in step (2) by the average CMI determined in step (1). In determining the proposed

MS-LTC-DRG relative weights for FY 2009, based on the latest available

LTCH claims data, the normalization factor is estimated as 1.038266, which would be applied in determining each proposed MS-LTC-DRG relative weight. That is, each proposed MS-LTC-DRG relative weight would be multiplied by 1.038266 in the first step of the budget neutrality process. Accordingly, the proposed relative weights in Table 11 in the

Addendum of this proposed rule reflect this proposed normalization factor. We also ensure that estimated aggregate LTCH PPS payments

(based on the most recent available LTCH claims data) after reclassification and recalibration (the new proposed FY 2009 MS-LTC-DRG classifications and relative weights) are equal to estimated aggregate

LTCH PPS payments (for the same most recent available LTCH claims data) before reclassification and recalibration (the existing FY 2008 MS-DRG classifications and relative weights). Therefore, we would calculate the proposed budget neutrality adjustment factor by simulating estimated total payments under both sets of GROUPERs and relative weights using current LTCH PPS payment policies (RY 2008) and the most recent available claims data (from the FY 2007 MedPAR file).

Accordingly, we are proposing to use RY 2008 LTCH PPS rates and policies in determining the proposed FY 2009 budget neutrality adjustment in this proposed rule, using the following steps: (1) We simulate estimated total payments using the normalized proposed relative weights under GROUPER Version 26.0 (as described above); (2) we simulate estimated total payments using the FY 2008 GROUPER (Version 25.0) and FY 2008 MS-LTC-DRG relative weights (as established in the FY 2008 IPPS final rule (72 FR 47295 through 47296)); (3) we calculate the ratio of these estimated total payments by dividing the estimated total payments determined in step (2) by the estimated total payments determined in step (1). Then, each of the normalized proposed relative weights is multiplied by the proposed budget neutrality factor to determine the budget neutral proposed relative weight for each proposed

MS-LTC-DRG.

Accordingly, in determining the proposed MS-LTC-DRG relative weights for FY 2009 in this proposed rule, based on the most recent available LTCH claims data, we are proposing a budget neutrality factor of 0.99965, which would be applied to the normalized proposed relative weights (described above). The proposed FY 2009 MS-LTC-DRG relative weights in Table 11 in the Addendum of this proposed rule reflect this proposed budget neutrality factor. Furthermore, we expect that we will have established payments rates and policies for RY 2009 prior to the development of the FY 2009 IPPS final rule. Therefore, for purposes of determining the FY 2009 budget neutrality factor in the final rule, we are proposing that we would simulate estimated total payments using the most recent LTCH PPS payment policies and LTCH claims data that are available at that time.

Table 11 in the Addendum to this proposed rule lists the proposed

MS-LTC-DRGs and their respective proposed budget neutral relative weights, geometric mean length of stay, and five-sixths of the geometric mean length of stay (used in the determination of short-stay outlier payments under Sec. 412.529) for FY 2009.

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

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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, 42CFR412.87(b)(2) states that a specific medical service or technology will be considered new for purposes of new medical service or technology add-on payments until such time as

Medicare data are available to fully reflect the cost of the technology in the DRG weights through recalibration. Typically, there is a lag of 2 to 3 years from the point a new medical service or technology is first introduced on the market (generally on the date that the technology receives FDA approval/clearance) 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 2007 are used to calculate the FY 2009 DRG weights in this proposed rule.

Section 412.87(b)(2) of our existing regulations 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 on the date on which the medical service or technology received FDA approval or clearance. (We note that, for purposes of this section of the proposed rule, we refer to both FDA approval and FDA clearance as FDA

``approval.'') However, in some cases, initially there may be no

Medicare data available for the new service or technology following FDA approval. For example, the newness period could extend beyond the 2- year to 3-year period after FDA approval is received in cases where the product initially was generally unavailable to Medicare patients following FDA approval, such as in the case of a national noncoverage determination, or if 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 following 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 medical service or technology is no longer eligible for special add-on payment for new medical services or technologies (Sec. 412.87(b)(2)). For example, an approved new technology that received FDA approval in October 2007 and entered the market at that time may be eligible to receive add-on payments as a new technology for discharges occurring before October 1, 2010 (the start of FY 2011). Because the FY 2011 DRG weights would be calculated using

FY 2009 MedPAR data, the costs of such a new technology would be fully reflected in the FY 2011 DRG weights. Therefore, the new technology would no longer be eligible to receive add-on payments as a new technology for discharges occurring in FY 2011 and thereafter.

Section 412.87(b)(3) further provides that, to be eligible for the add-on payment for new medical services or technologies, the DRG prospective payment rate otherwise applicable to the discharge involving the new medical services or technologies must be assessed for adequacy. Under the cost criterion, to assess whether a new technology would be inadequately paid under the applicable DRG-prospective payment rate, we evaluate whether the charges for cases involving the new technology exceed certain threshold amounts. 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 converted 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 more than one DRG).

However, section 503(b)(1) of Pub. L. 108-173 amended section 1886(d)(5)(K)(ii)(I) of the Act to provide that, beginning in FY 2005,

CMS will apply ``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 one standard deviation for the diagnosis-related group involved.'' (We refer readers 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 in section XIX. of the interim final rule with comment period published in the Federal

Register on November 27, 2007, contained the final thresholds that are being used to evaluate applications for new technology add-on payments for FY 2009 (72 FR 66888 through 66892). An applicant must demonstrate that the cost threshold is met using information from inpatient hospital claims.

With regard to 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 addressed this issue in the September 7, 2001 final rule that established the new technology add-on payment regulations (66 FR 46917). 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 requirements by discussing how the HIPAA Privacy Rule permitted providers to share with health plans information needed to ensure correct payment, if they had 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 protected health information for treatment, payment, or health care operations, and expressly permits such entities to use or to disclose protected health information for any of these purposes. (We refer readers to 45 CFR 164.502(a)(1)(ii), and 164.506(c)(1) and (c)(3), and the Standards for Privacy of Individually

Identifiable Health Information published in the Federal

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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. (We refer readers to the September 7, 2001 final rule for a complete discussion of this criterion (66 FR 46902).)

The new medical service or technology add-on payment policy under the IPPS provides additional payments for cases with relatively high costs involving eligible new medical services or technologies while preserving some of the incentives inherent under an average-based prospective payment system. The payment mechanism is based on the cost to hospitals for the new medical service or technology. Under Sec. 412.88, if the costs of the discharge (determined by applying CCRs as described in Sec. 412.84(h)) exceed the full DRG payment, Medicare will make an add-on payment equal to the lesser of: (1) 50 percent of the estimated costs of the new technology (if the estimated costs for the case including the new technology exceed Medicare's payment) or (2) 50 percent of the difference between the full DRG payment and the hospital's estimated cost for the case. If the amount by which the actual costs of a new medical service or technology case exceeds the full DRG payment (including payments for IME and DSH, but excluding outlier payments) by more than the 50-percent marginal cost factor,

Medicare payment is limited to the full DRG payment plus 50 percent of the estimated costs of the new technology.

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. However, 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 2010 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 at: http://www.cms.hhs.gov/AcuteInpatientPPS/08_newtech.asp#TopOfPage.

To allow interested parties to identify the new medical services or technologies under review before the publication of the proposed rule for FY 2010, the Web site will also list the tracking forms completed by each applicant.

The Council on Technology and Innovation (CTI) at CMS oversees the agency's cross-cutting priority on coordinating coverage, coding and payment processes for Medicare with respect to new technologies and procedures, including new drug therapies, as well as promoting the exchange of information on new technologies between CMS and other entities. The CTI, composed of senior CMS staff and clinicians, was established under section 942(a) of Pub. L. 108-173. It is co-chaired by the Director of the Center for Medicare Management (CMM), who is also designated as the CTI's Executive Coordinator, and the Director of the Office of Clinical Standards and Quality (OCSQ).

The specific processes for coverage, coding, and payment are implemented by CMM, OCSQ, and the local claims-payment contractors (in the case of local coverage and payment decisions). The CTI supplements rather than replaces these processes by working to assure that all of these activities reflect the agency-wide priority to promote high- quality, innovative care, and at the same time to streamline, accelerate, and improve coordination of these processes to ensure that they remain up to date as new issues arise. To achieve its goals, the

CTI works to streamline and create a more transparent coding and payment process, improve the quality of medical decisions, and speed patient access to effective new treatments. It is also dedicated to supporting better decisions by patients and doctors in using Medicare- covered services through the promotion of better evidence development, which is critical for improving the quality of care for Medicare beneficiaries.

The agency plans to continue its Open Door forums with stakeholders who are interested in CTI's initiatives. In addition, to improve understanding of CMS processes for coverage, coding, and payment and how to access them, the CTI is developing an ``innovator's guide'' to these processes. This guide will, for example, outline regulation cycles and application deadlines. The intent is to consolidate this information, much of which is already available in a variety of CMS documents and in various places on CMS's Web site, in a user-friendly format. In the meantime, we invite any product developers with specific issues involving the agency to contact us early in the process of product development if they have questions or concerns about the evidence that would be needed later in the development process for the agency's coverage decisions for Medicare.

The CTI aims to provide information on CTI activities to stakeholders, including Medicare beneficiaries, advocates, medical product manufacturers, providers, and health policy experts, and other stakeholders with useful information on CTI initiatives. Stakeholders with further questions about Medicare's coverage, coding, and payment processes, or who want further guidance about how they can navigate these processes, can contact the CTI at CTI@cms.hhs.gov or from the

``Contact Us'' section of the CTI home page (http://www.cms.hhs.gov/

CouncilonTechInnov/). 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--

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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; and

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 2009 before publication of the FY 2009 IPPS proposed rule, we published a notice in the Federal Register on December 28, 2007 (72 FR 73845 through 73847), and held a town hall meeting at the CMS Headquarters

Office in Baltimore, MD, on February 21, 2008. 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 2009 new medical service and technology add-on payment applications before the publication of the FY 2009 IPPS proposed rule.

Approximately 70 individuals attended the town hall meeting in person, while approximately 20 additional participants listened over an open telephone line. Each of the four FY 2009 applicants presented information on its technology, including a focused discussion of data reflecting the substantial clinical improvement aspect of the technology. We received two comments during the town hall meeting, which are summarized below. We considered each applicant's presentation made at the town hall meeting, as well as written comments submitted on each applicant's application, in our evaluation of the new technology add-on applications for FY 2009 in this proposed rule. We have summarized these comments below or, if applicable, indicated that no comments were received at the end of the discussion of each application.

Comment: One commenter addressed the substantial clinical improvement criterion. A medical device association stated that CMS' interpretation of the statutory criteria for new technology add-on payments is narrow and makes it difficult for potential applicants, especially small manufacturing companies, to qualify for new technology add-on payments. The commenter urged CMS to ``deem a device to satisfy the substantial clinical improvement criteria if it was granted a humanitarian device exemption or priority review based on the fact that it represents breakthrough technologies, which offer significant advantages over existing approved alternatives, for which no alternatives exist, or the availability of which is in the best interests of the patients.'' In addition, the commenter remarked that this process would simplify CMS' evaluation of applications for new technology add-on payments and would promote access to innovative treatments, as intended by Congress. Although the commenter also made remarks that were unrelated to substantial clinical improvement, because the purpose of the town hall meeting was specifically to discuss substantial clinical improvement of pending new technology applications, those comments are not summarized in this proposed rule.

Response: With respect to the comment that CMS has a narrow interpretation of the statute that makes it difficult for applicants to meet the statutory criteria for a new technology add-on payment, we note that we have already specifically addressed the issue in the past

(71 FR 47997 and 72 FR 47301). In addition, we addressed the comment concerning automatically deeming technologies granted a humanitarian device exemption (HDE) at 72 FR 47302. Further, because the purpose of the new technology town hall meeting was to discuss substantial clinical improvement of pending applications, we are not providing a response to the unrelated comments in this proposed rule.

Comment: One commenter, a medical technology association, submitted comments in reference to the MS-DRGs and the need to account for complexity as well as severity in making refinements to the DRG classification system. The commenter also made the following comments:

CMS should raise the new technology marginal cost factor, adjust the newness policy to begin with the issuance of an ICD-9-CM code instead of the FDA approval date, provide access to the quarterly MedPAR updates, and allow for the use of external data for determining new technology payments (when CMS determines that the external data are unbiased and valid).

Response: Section 1886(d)(5)(K)(viii) of the Act requires that CMS accept comments, recommendations, and data from the public regarding whether a service or technology represents a substantial clinical improvement. Because the comments above are not related to the substantial clinical improvement criterion of pending applications, we are not providing a response to them in this proposed rule. 3. FY 2009 Status of Technologies Approved for FY 2008 Add-On Payments

We did not approve any applications for new technology add-on payments for FY 2008. For additional information, refer to the FY 2008

IPPS final rule with comment period (72 FR 47305 through 47307). 4. FY 2009 Applications for New Technology Add-On Payments

We received four applications to be considered for new technology add-on payment for FY 2009. A discussion of each of these applications is presented below. We note that, in the past, we have considered applications that had not yet received FDA approval, but were anticipating FDA approval prior to publication of the IPPS final rule.

In such cases, we generally provide a more limited discussion of those technologies in the proposed rule because it is not known if these technologies will meet the newness criterion in time for us to conduct a complete analysis in the final rule. This year, three out of four applicants do not yet have FDA approval. Consequently, we have presented a limited analysis of them in this proposed rule. a. CardioWestTMTemporary Total Artificial Heart System

(CardioWestTMTAH-t)

SynCardia Systems, Inc. submitted an application for approval of the CardioWestTMtemporary Total Artificial Heart system

(TAH-t) for new technology add-on payments for FY 2009. The TAH-t is a technology that is used as a bridge to heart transplant device for heart transplant-eligible patients with end-stage biventricular failure. The TAH-t pumps up to 9.5 liters of blood per minute. This high level of perfusion helps improve hemodynamic function in patients, thus making them better heart transplant candidates.

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The TAH-t was approved by the FDA on October 15, 2004, for use as a bridge to transplant device in cardiac transplant-eligible candidates at risk of imminent death from biventricular failure. The TAH-t is intended to be used in hospital inpatients. Some of the FDA's post- approval requirements include that the manufacturer agree to provide a post-approval study demonstrating that the success of the device at one center can be reproduced at other centers. The study was to include at least 50 patients who will be followed up to 1 year, including (but not limited to) the following endpoints; survival to transplant, adverse events, and device malfunction.

Presently, Medicare does not cover artificial heart devices, including the TAH-t. However, on February 01, 2008, CMS proposed to reverse a national noncoverage determination that would extend coverage to this technology within the confines of an FDA-approved clinical study. (To view the proposed National Coverage Determination (NCD), we refer readers to the CMS Web site at http://www.cms.hhs.gov/mcd/ viewdraftdecisionmemo.asp?from2=viewdraftdecisionmemo.asp&id=211&.)

Should this proposal be finalized, it would become effective on May 01, 2008. Because Medicare's existing coverage policy with respect to this device has precluded it from being paid for by Medicare, we would not expect the costs associated with this technology to be currently reflected in the data used to determine MS-DRGs relative weights. As we have indicated in the past, although we generally believe that the newness period would begin on the date that FDA approval was granted, in cases where the applicant can demonstrate a documented delay in market availability subsequent to FDA approval, we would consider delaying the start of the newness period. This technology's situation represents one such case. We also note that section 1886(d)(5)(K)(ii)(II) of the Act requires that we provide for the collection of cost data for a new medical service or technology for a period of at least 2 years and no more than 3 years ``beginning on the date on which an inpatient hospital code is issued with respect to the service or technology.'' Furthermore, the statute specifies that the term ``inpatient hospital code'' means any code that is used with respect to inpatient hospital services for which payment may be made under the IPPS and includes ICD-9-CM codes and any subsequent revisions. Although the TAH-t has been described by the ICD-9-CM code(s) (described below in the cost threshold discussion) since the time of its FDA approval, because the TAH-t has not been covered under the Medicare program (and, therefore, no Medicare payment has been made for this technology), this code is not ``used with respect to inpatient hospital services for which payment'' is made under the IPPS, and thus we assume that none of the costs associated with this technology would be reflected in the Medicare claims data used to recalibrate the MS-DRG weights. For this reason, despite its FDA approval date, it appears that this technology would still be eligible to be considered ``new'' for purposes of the new technology add-on payment if and when the proposal to reverse the national noncoverage determination concerning this technology is finalized. Therefore, based on this information, it appears that the TAH-t would meet the newness criterion on the date that Medicare coverage begins, should the proposed NCD be finalized.

In an effort to demonstrate that TAH-t would meet the cost criterion, the applicant submitted data based on 28 actual cases of the

TAH-t. The data included 6 cases (or 21.4 percent of cases) from 2005, 13 cases (or 46.5 percent of cases) from 2006, 7 cases (or 25 percent of cases) from 2007, and 2 cases (or 7.1 percent of cases) from 2008.

Currently, cases involving the TAH-t are assigned to MS-DRG 215 (Other

Heart Assist System Implant). As discussed below in this section, we are proposing to remove the TAH-t from MS-DRG 215 and reassign the TAH- t to MS-DRGs 001 (Heart Transplant or Implant of Heart Assist System with MCC) and 002 (Heart Transplant or Implant of Heart Assist System without MCC). Therefore, to determine if the technology meets the cost criterion, it is appropriate to compare the average standardized charge per case to the thresholds for MS-DRGs 001, 002, and 215 included in

Table 10 of the November 27, 2007 interim final rule (72 FR 66888 through 66889). The thresholds for MS-DRGs 001, 002, and 215 from Table 10 are $345,031, $178,142, and $151,824, respectively. Based on the 28 cases the applicant submitted, the average standardized charge per case was $731,632. Because the average standardized charge per case is much greater than the thresholds cited above for MS-DRG 215 (and MS-DRGs 001 and 002, should the proposal to reassign the TAH-t be finalized), the applicant asserted that the TAH-t meets the cost criterion whether or not the costs were analyzed by using either a case-weighted threshold or case-weighted standardized charge per case.

In addition to analyzing the costs of actual cases involving the

TAH-t, the applicant searched the FY 2006 MedPAR file to identify cases involving patients who would have potentially been eligible to receive the TAH-t. The applicant submitted three different MedPAR analyses. The first MedPAR analysis involved a search for cases using ICD-9-CM diagnosis code 428.0 (Congestive heart failure) in combination with

ICD-9-CM procedure code 37.66 (Insertion of implantable heart assist system), and an inpatient hospital length of stay greater than or equal to 60 days. The applicant found two cases that met this criterion, which had an average standardized charge per case of $821,522. The second MedPAR analysis searched for cases with ICD-9-CM diagnosis code 428.0 (Congestive heart failure) and one or more of the following ICD- 9-CM procedure codes: 37.51 (Heart transplant), 37.52 (Implantation of total heart replacement system), 37.64 (Removal of heart assist system), 37.66 (Insertion of implantable heart assist system), or 37.68

(Insertion of percutaneous external heart assist device), and a length of stay greater than or equal to 60 days. The applicant found 144 cases that met this criterion, which had an average standardized charge per case of $841,827. The final MedPAR analysis searched for cases with

ICD-9-CM procedure code 37.51 (Heart transplant) in combination with one of the following ICD-9-CM procedure codes: 37.52 (Implantation of total heart replacement system), 37.65 (Implantation of external heart system), or 37.66 (Insertion of implantable heart assist system). The applicant found 37 cases that met this criterion, which had an average standardized charge per case of $896,601. Because only two cases met the criterion for the first analysis, consistent with historical practice, we would not consider it to be of statistical significance and, therefore, would not rely upon it to demonstrate whether the TAH-t would meet the cost threshold. However, both of the additional analyses seem to provide an adequate number of cases to demonstrate whether the

TAH-t would meet the cost threshold. We assume that none of the costs associated with this technology would be reflected in the MedPAR analyses that the applicant used to demonstrate that the technology would meet the cost criterion. We note that, under all three of the analyses the applicant performed, it identified cases that would have been eligible for the TAH-t, but did not remove charges that

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were unrelated to the TAH-t, nor did the applicant insert a proxy of charges related to the TAH-t. However, as stated above, the average standardized charge per case is much greater than any of the thresholds for MS-DRGs 001, 002, and 215. Therefore, even if the applicant were to approximate what the costs of cases eligible to receive the TAH-t would have been by removing non-TAH-t associated charges and inserting charges related to the TAH-t, it appears that the average standardized charges per case for cases eligible for the TAH-t would exceed the relevant thresholds from Table 10 (as discussed above) and would therefore appear to meet the cost criterion. We invite public comment on whether TAH-t meets the cost criterion.

As noted in section II.G. of this preamble, we are proposing to remove the TAH-t from MS-DRG 215 and reassign the TAH-t to MS-DRGs 001 and 002. As stated earlier, CMS is proposing to reverse a national noncoverage determination that would extend coverage to artificial heart devices within the confines of an FDA-approved clinical study, effective May 1, 2008. If this proposal is finalized, the MCE will require both the procedure code 37.52 (Implantation of total replacement heart system) and the diagnosis code reflecting clinical trial--V70.7 (Examination of participant in clinical trial). As we have previously mentioned, the TAH-t appears to meet the cost thresholds for

MS-DRGs 001, 002, and 215. Therefore, its proposed reassignment from

MS-DRG 215 to MS-DRGs 001 and 002 should have no material effect on meeting the cost thresholds in MS-DRGs 001 and 002 should the reassignment proposal be finalized.

The manufacturer states that the TAH-t is the only mechanical circulatory support device intended as a bridge-to-transplant for patients with irreversible biventricular failure. It also asserts that the TAH-t improves clinical outcomes because it has been shown to reduce mortality in patients who are otherwise in end-stage heart failure. In addition, the manufacturer claims that the TAH-t provides greater hemodynamic stability and end-organ perfusion, thus making patients who receive it better candidates for eventual heart transplant. We welcome comments from the public regarding whether the

TAH-t represents a substantial clinical improvement.

We did not receive any written comments or public comments at the town hall meeting regarding the substantial clinical improvement aspects of this technology. b. Emphasys Medical Zephyr[reg] Endobronchial Valve (Zephyr[reg] EBV)

Emphasys Medical submitted an application for new technology add-on payments for FY 2009 for the Emphasys Medical Zephyr[reg] Endobronchial

Valve (Zephyr[reg] EBV). The Zephyr[reg] EBV is intended to treat patients with emphysema by reducing volume in the diseased, hyperinflated portion of the emphysematous lung with fewer risks and complications than with more invasive surgical alternatives.

Zephyr[reg] EBV therapy involves placing small, one-way valves in the patients' airways to allow air to flow out of, but not into, the diseased portions of the lung thus reducing the hyperinflation. A typical procedure involves placing three to four valves in the target lobe using a bronchoscope, and the procedure takes approximately 20 to 40 minutes to complete. The Zephyr[reg] EBVs are designed to be relatively easy to place, and are intended to be removable so that, unlike more risky surgical alternatives such as Lung Volume Reduction

Surgery (LVRS) or Lung Transplant, the procedure has the potential to be fully reversible.

Currently, the Zephyr[reg] EBV has yet to receive approval from the

FDA, but the manufacturer indicated to CMS that it expects to receive its FDA approval in the second or third quarter of 2008. Because the technology is not yet approved by the FDA, we will limit our discussion of this technology to data that the applicant submitted, rather than make specific proposals with respect to whether the device would meet the new technology add-on criteria.

In an effort to demonstrate that the Zephyr[reg] EBV would meet the cost criterion, the applicant searched the FY 2006 MedPAR file for cases with one of the following ICD-9-CM diagnosis codes: 492.0

(Emphysematous bleb), 492.8 (Other emphysema, NEC), or 496 (Chronic airway obstruction, NEC). Based on the diagnosis codes searched by the applicant, cases of the Zephyr[reg] EBV would be most prevalent in MS-

DRGs 190 (Chronic Obstructive Pulmonary Disease with MCC), 191 (Chronic

Obstructive Pulmonary Disease with CC), and 192 (Chronic Obstructive

Pulmonary Disease without CC/MCC). The applicant found 1,869 cases (or 12.8 percent of cases) in MS-DRG 190, 5,789 cases (or 39.5 percent of cases) in MS-DRG 191, and 6,995 cases (or 47.7 percent of cases) in MS-

DRG 192 (which equals a total of 14,653 cases). The average standardized charge per case was $21,567 for MS-DRG 190, $15,494 for

MS-DRG 191, and $11,826 for MS-DRG 192. The average standardized charge per case does not include charges related to the Zephyr[reg] EBV; therefore, it is necessary to add the charges related to the device to the average standardized charge per case in evaluating the cost threshold criteria. Although the applicant submitted data related to the estimated cost of the Zephyr[reg] EBV per case, the applicant noted that the cost of the device was proprietary information because the device is not yet available on the open market. The applicant estimates

$23,920 in charges related to the Zephyr[reg] EBV (based on a 100 percent charge markup of the cost of the device). In addition to case- weighting the data based on the amount of cases that the applicant found in the FY 2006 MedPAR file, the applicant case-weighted the data based on its own projections of how many Medicare cases it would expect to map to MS-DRGs 190, 191, and 192 in FY 2009. The applicant projects that, 5 percent of the cases would map to MS-DRG 190, 15 percent of the cases would map to MS-DRG 191, and 80 percent of the cases would map to

MS-DRG 192. Adding the charges related to the device to the average standardized charge per case (based on the applicant's projected case distribution) resulted in a case-weighted average standardized charge per case of $36,782 ($12,862 plus $23,920). Using the thresholds published in Table 10 (72 FR 66889), the case-weighted threshold for

MS-DRGs 190, 191, and 192 was $18,394. Because the case-weighted average standardized charge per case for the applicable MS-DRGs exceed the case-weighted threshold amount, the applicant maintains that the

Zephyr[reg] EBV would meet the cost criterion. As noted above, the applicant also performed a case-weighted analysis of the data based on the 14,653 cases the applicant found in the FY 2006 MedPAR file. Based on this analysis, the applicant found that the case-weighted average standardized charge per case ($38,441 based on the 14,653 cases) exceeded the case-weighted threshold ($20,606 based on the 14,653 cases). Based on both analyses described above, it appears that the applicant would meet the cost criterion. We invite public comment on whether Zephyr[reg] EBV meets the cost criterion.

The applicant asserts that the Zephyr[reg] EBV is a substantial clinical improvement because it provides a new therapy along the continuum of care for patients with emphysema that offers improvement in lung function over standard medical therapy while incurring significantly less risk than more invasive treatments such as LVRS

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and lung transplant. Specifically, the applicant submitted data from the ongoing pivotal Endobronchial Valve for Emphysema Palliation (VENT) trial,\14\ which compared 220 patients who received EBV treatment to 101 patients who received standard medical therapy, including bronchodilators, steroids, mucolytics, and supplemental oxygen. At 6 months, patients who received the Zephyr[reg] EBV had an average of 7.2 percent and 5.8 percent improvement (compared to standard medical therapy) in the primary effectiveness endpoints of the Forced

Expiratory Volume in 1 second test (FEV1), and the 6 Minute Walk Test

(6MWT), respectively. Both results were determined by the applicant to be statistically significant. The FEV1 results were determined using the t-test parametric confidence intervals (the p value determined using the one-side t-test adjusted for unequal variance) and the 6MWT results were determined using the Mann-Whitney nonparametric confidence intervals (the p value was calculated using the one-sided Wilcoxon rank sum test). However, the data also showed that patients who received the

Zephyr[reg] EBV experienced a number of adverse events, including hemoptyis, pneumonia, respiratory failure, pneumothorax, and COPD exacerbations, as well as valve migrations and expectorations that, in some cases, required repeat bronchoscopy. The manufacturer also submitted the VENT pivotal trial 1-year follow-up data, but has requested that the data not be disclosed because it has not yet been presented publicly nor published in a peer-reviewed journal.

\14\ Strange, Charlie., et al., design of the Endobronchial

Valve for Emphysema Palliation trial (VENT): A Nonsurgical Method of

Lung Volume Reduction, BMC Pulmonary Medicine. 2007; 7:10.

While CMS recognizes that the Zephyr[reg] EBV therapy is significantly less risky than LVRS and lung transplant, we are concerned that the benefits as shown in the VENT pivotal trial may not outweigh the risks when compared with medical therapy alone. Further, we note that, according to the applicant, the Zephyr[reg] EBV is intended for use in many patients who are ineligible for LVRS and/or lung transplant (including those too sick to undergo more invasive surgery and those with lower lobe predominant disease distribution), but that certain patients (that is, those with upper lobe predominant disease distribution) could be eligible for either surgery or the

Zephyr[reg] EBV. We welcome comments from the public on both the patient population who would be eligible for the technology, and whether the Zephyr[reg] EBV represents a substantial clinical improvement in the treatment of patients with emphysema.

We received written comments from the manufacturer and its presenters at the town hall meeting clarifying some questions that were raised at the town hall meeting. Specifically, these commenters explained that, in general, the target population for the Zephyr[reg]

EBV device was the same population that could benefit from LVRS, and also includes some patients who were too sick to undergo surgery. The commenters also explained that patients with emphysema with more heterogeneous lung damage were more likely to benefit from the device.

We welcome public comments regarding where exactly this technology falls in the continuum of care of patients with emphysema, and for whom the risk/benefit ratio is most favorable. c. Oxiplex[reg]

FzioMed, Inc. submitted an application for new technology add-on payments for FY 2009 for Oxiplex[reg]. Oxiplex[reg] is an absorbable, viscoelastic gel made of carboxymethylcellulose (CMC) and polyethylene oxide (PEO) that is intended to be surgically implanted during a posterior discectomy, laminotomy, or laminectomy. The manufacturer asserts that the gel reduces the potential for inflammatory mediators that injure, tether, or antagonize the nerve root in the epidural space by creating an acquiescent, semi-permeable environment to protect against localized debris. These proinflammatory mediators

(phospholipase A and nitric oxide), induced or extruded by intervertebral discs, may be responsible for increased pain during these procedures. The manufacturer also asserts that Oxiplex[reg] is a unique material in that it coats tissue, such as the nerve root in the epidural space, to protect the nerve root from the effects of inflammatory mediators originating from either the nucleus pulposus, from blood derived inflammatory cells, or cytokines during the healing process.

Oxiplex[reg] is expecting to receive premarket approval from the

FDA by June 2008. Because the technology is not yet approved by the

FDA, we will limit our discussion of this technology to data that the applicant submitted, rather than make specific proposals with respect to whether the device would meet the new technology add-on payment criteria.

With regard to the newness criterion, we are concerned that

Oxiplex[reg] may be substantially similar to adhesion barriers that have been on the market for several years. We also note that

Oxiplex[reg] has been marketed as an adhesion barrier in other countries outside of the United States. The manufacturer maintains that

Oxiplex[reg] is different from adhesion barriers in several ways, including chemical composition, method of action, surgical application

(that is, it is applied liberally to the nerve root and surrounding neural tissues as opposed to minimally only to nerve elements), and tissue response (noninflammatory as opposed to inflammatory). We welcome comments from the public on this issue.

In an effort to demonstrate that the technology meets the cost criterion, the applicant searched the FY 2006 MedPAR file for cases with ICD-9-CM procedure codes 03.09 (Other exploration and decompression of spinal canal) or 80.51 (Excision of interveterbral disc) that mapped to CMS DRGs 499 and 500 (CMS DRGs 499 and 500 are crosswalked to MS-DRGs 490 and 491 (Back and Neck Procedures except

Spinal Fusion with or without CC)). Because these cases do not include charges associated with the technology, the applicant determined it was necessary to add an additional $7,143 in charges to the average standardized charge per case of cases that map to MS-DRGs 490 and 491.

(To do this, the applicant used a methodology of inflating the costs of the technology by the average CCR computed by using the average costs and charges for supplies for cases with ICD-9-CM procedure codes 03.09 and 80.51 that map to MS-DRGs 490 and 491). Of the 221,505 cases the applicant found, 95,340 cases (or 43 percent of cases) would map to MS-

DRG 490, which has an average standardized charge of $60,301, and 126,165 cases (or 57 percent of cases) would map to MS-DRG 491, which has an average standardized charge per case of $43,888. This resulted in a case-weighted average standardized charge per case of $50,952. The case-weighted threshold for MS-DRGs 490 and 491 was $27,481. Because the case-weighted average standardized charge per case exceeds the case-weighted threshold in MS-DRGs 490 and 491, the applicant maintains that Oxiplex[reg] would meet the cost criterion. We invite public comment on whether Oxiplex[reg] meets the cost criterion.

The manufacturer maintains that Oxiplex[reg] is a substantial clinical improvement because it ``creates a protective environment around the neural tissue that limits nerve root exposure to post- surgical irritants and damage and thus reduces adverse outcomes associated with Failed Back

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Surgery Syndrome (FBSS) following surgery.'' The manufacturer also claims that the Oxiplex[reg] gel reduces leg and back pain after discectomy, laminectomy, and laminotomy. The manufacturer also asserts that the use of Oxiplex[reg] is consistent with fewer revision surgeries. (During the FDA Investigational Device Exemption (IDE) trial, one Oxiplex[reg] patient required revision surgery compared to six control patients.) However, as we noted previously in this section, we are concerned that Oxiplex[reg] may be substantially similar to adhesion barriers that have been on the market for several years. We are also concerned that even if we were to determine that Oxiplex is not substantially similar to existing adhesion barriers, there may still be insufficient evidence to support the manufacturer's claims that Oxiplex[reg] reduces pain associated with spinal surgery. In addition, we have found no evidence to support the manufacturer's claims regarding mode of action, degree of dural healing, degree of wound healing, and local tissue response such as might be shown in animal studies. We welcome comments from the public regarding whether

Oxiplex[reg] represents a substantial clinical improvement.

We did not receive any written comments or public comments at the town hall meeting regarding the substantial clinical improvement aspects of this technology. d. TherOx Downstream[reg] System

TherOx, Inc. submitted an application for new technology add-on payments for FY 2009 for the TherOx Downstream[reg] System

(Downstream[reg] System). The Downstream[reg] System uses

SuperSaturatedOxygen Therapy (SSO2) that is designed to limit myocardial necrosis by minimizing microvascular damage in acute myocardial infarction (AMI) patients following intervention with

Percutaneous Transluminal Coronary Angioplasty (PTCA), and coronary stent placement by perfusing the affected myocardium with blood that has been supersaturated with oxygen. SSO2 therapy refers to the delivery of superoxygenated arterial blood directly to areas of myocardial tissue that have been reperfused using PTCA and stent placement, but which may still be at risk. The desired effect of SSO2 therapy is to reduce infarct size and thus preserve heart muscle and function. The DownStream[reg] System is the console portion of a disposable cartridge-based system that withdraws a small amount of the patient's arterial blood, mixes it with a small amount of saline, and supersaturates it with oxygen to create highly oxygen-enriched blood.

The superoxygenated blood is delivered directly to the infarct-related artery via the TherOx infusion catheter. SSO2 therapy is a catheter laboratory-based procedure. Additional time in the catheter lab area is an average of 100 minutes. The manufacturer claims that the SSO2 therapy duration lasts 90 minutes and requires an additional 10 minutes post-procedure preparation for transfer time. The TherOx

Downstream[reg] System is currently not FDA approved; however, the manufacturer states that it expects to receive FDA approval in the second quarter of 2008. Because the technology is not yet approved by the FDA, we will limit our discussion of this technology to data that the applicant submitted, rather than make specific proposals with respect to whether the device would meet the new technology add-on criteria.

In an effort to demonstrate that it would meet the cost criterion, the applicant submitted two analyses. The applicant believes that cases that would be eligible for the Downstream[reg] System would most frequently group to MS-DRGs 246 (Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC or 4+Vessels/Stents), 247

(Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without

MCC), 248 (Percutaneous Cardiovascular Procedure with Non-Drug-Eluting

Stent with MCC or 4+Vessels/Stents), and 249 (Percutaneous

Cardiovascular Procedure with Non-Drug-Eluting Stent without MCC). The first analysis used data based on 83 clinical trial patients from 10 clinical sites. Of the 83 cases, 78 were assigned to MS-DRGs 246, 247, 248, or 249. The data showed that 32 of these patients were 65 years old or older. There were 12 cases (or 15.4 percent of cases) in MS-DRG 246, 56 cases (or 71.8 percent of cases) in MS-DRG 247, 2 cases (or 2.6 percent of cases) in MS-DRG 248, and 8 cases (or 10.3 percent of cases) in MS-DRG 249. (The remaining five cases grouped to MS-DRGs that the technology would not frequently group to and therefore are not included in this analysis.) The average standardized charge per case for MS-DRGs 246, 247, 248, and 249 was $66,730, $53,963, $54,977, and $41,594, respectively. The case-weighted average standardized charge per case for the four MS-DRGs listed above is $54,665. Based on the threshold from Table 10 (72 FR 66890), the case-weighted threshold for the four

MS-DRGs listed above was $49,303. The applicant also searched the FY 2006 MedPAR file to identify cases that would be eligible for the

Downstream[reg] System. The applicant specifically searched for cases with primary ICD-9-CM diagnosis code 410.00 (Acute myocardial infarction of anterolateral wall with episode of care unspecified), 410.01 (Acute myocardial infarction of anterolateral wall with initial episode of care), 410.10 (Acute myocardial infarction of other anterior wall with episode of care unspecified), or 410.11 (Acute myocardial infarction of other anterior wall with initial episode of care) in combination with ICD-9-CM procedure code of 36.06 (Insertion of non- drug-eluting coronary artery stent(s)) or 36.07 (Insertion of drug- eluting coronary artery stent(s)). The applicant's search found 13,527 cases within MS-DRGs 246, 247, 248, and 249 distributed as follows: 2,287 cases (or 16.9 percent of cases) in MS-DRG 246; 9,691 cases (or 71.6 percent of cases) in MS-DRG 247; 402 cases (or 3 percent of cases) in MS-DRG 248; and 1,147 cases (or 8.5 percent of cases) in MS-DRG 249.

Not including the charges associated with the technology, the geometric mean standardized charge per case for MS-DRGs 246, 247, 248, and 249 was $59,631, $42,357, $49,718 and $37,446, respectively. Therefore, based on this analysis, the total case-weighted geometric mean standardized charge per case across these MS-DRGs was $45,080. The applicant estimated that it was necessary to add an additional $21,620 in charges to the total case-weighted geometric mean standardized charge per case. The applicant included charges for supplies and tests related to the technology, charges for 100 minutes of additional procedure time in the catheter laboratory and charges for the technology itself in the additional charge amount referenced above. The inclusion of these charges would result in a total case-weighted geometric mean standardized charge per case of $66,700. The case- weighted threshold for MS-DRGs 246, 247, 248, and 249 (from Table 10

(72 FR 66889)) was $49,714. Because the total case-weighted average standardized charge per case from the first analysis and the case- weighted geometric mean standardized charge per case from the second analysis exceeds the applicable case-weighted threshold, the applicant maintains the Downstream[reg] System would meet the cost criterion. We invite public comment on whether Downstream[reg] System meets the cost criterion.

The applicant asserts that the Downstream[reg] System is a substantial clinical improvement because it reduces infarct size in acute AMI where PTCA and stent placement have also been performed. Data was submitted from the Acute Myocardial Infarction Hyperbaric

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Oxygen Treatment (AMIHOT) II trial, which was presented at the October 2007 Transcatheter Cardiovascular Therapeutics conference, but has not been published in peer reviewed literature, that showed an average of 6.5 percent reduction in infarct size as measured with Tc-99m Sestamibi imaging in patients who received supersaturated oxygen therapy. We note that those patients also showed a significantly higher incidence of bleeding complications. While we recognize that a reduction of infarct size may correlate with improved clinical outcomes, we question whether the degree of infarct size reduction found in the trial represents a substantial clinical improvement, particularly in light of the apparent increase in bleeding complications. We welcome comments from the public on this matter.

We received one written comment from the manufacturer clarifying questions that were raised at the town hall meeting. Specifically, the commenter explained the methodology of Tc-99m Sestamibi scanning and interpretation in the AMIHOT II trial. In addition, the commenter explained that the AMIHOT \15\ and AMIHOT II trials did not attempt to measure differences in heart failure outcomes nor mortality outcomes.

\15\ Oneill, WW., et al., Acute Myocardial Infarction with

Hyperoxemic Therapy (AMIHOT): A Prospective Randomized Trial of

Intracoronary Hyperoxemic Reperfusion after Percutaneous Coronary

Intervention. Journal of the American College of Cardiology, Vol. 50, No. 5, 2007, pp. 397-405.

5. Proposed Regulatory Change

Section 1886(d)(5)(K)(i) of the Act directs us to establish a mechanism to recognize the cost of new medical services and technologies under the IPPS, with such mechanism established after notice and opportunity for public comment. In accordance with this authority, we established at Sec. 412.87(b) of our regulations criteria that a medical service or technology must meet in order to qualify for the additional payment for new medical services and technologies. Specifically, we evaluate applications for new medical service or technology add-on payment by determining whether they meet the criteria of newness, adequacy of payment, and substantial clinical improvement.

As stated in section III.J.1. of the preamble of this proposed rule, Sec. 412.87(b)(2) of our existing regulations provides that a specific medical service or technology will be considered new for purposes of new medical service or technology add-on payments after the point at which data begin to become available reflecting the ICD-9-CM code assigned to the new service or technology. The point at which these data become available typically begins when the new medical service or technology is first introduced on the market, generally on the date that the medical service or technology receives FDA approval.

Accordingly, for purposes of the new medical service or technology add- on payment, a medical service or technology cannot be considered new prior to the date on which FDA approval is granted.

In addition, as stated in section III.J.1. of the preamble of this proposed rule, Sec. 412.87(b)(3) of our existing regulations provides that, to be eligible for the add-on payment for new medical services or technologies, the DRG prospective payment rate otherwise applicable to the discharge involving the new medical service or technology must be assessed for adequacy. Under the cost criterion, to assess the adequacy of payment for a new medical service or technology paid under the applicable DRG prospective payment rate, we evaluate whether the charges for cases involving the new medical service or technology exceed certain threshold amounts.

Section 412.87(b)(1) of our existing regulations provides that, to be eligible for the add-on payment for new medical services or technologies, the new medical service or technology must represent an advance that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries. In addition, Sec. 412.87(b)(1) states that CMS will announce its determination as to whether a new medical service or technology meets the substantial clinical improvement criteria in the

Federal Register as part of the annual updates and changes to the IPPS.

Since the implementation of the policy on add-on payments for new medical services and technologies, we accept applications for add-on payments for new medical services and technologies on an annual basis by a specified deadline. For example, applications for FY 2009 were submitted in November 2007. After accepting applications, CMS then evaluates them in the annual IPPS proposed and final rules to determine whether the medical service or technology is eligible for the new medical service or technology add-on payment. If an application meets each of the eligibility criteria, the medical service or technology is eligible for new medical service or technology add-on payments beginning on the first day of the new fiscal year (that is, October 1).

We have advised prior and potential applicants that we evaluate whether a medical service or technology is eligible for the new medical service or technology add-on payments prior to publication of the final rule setting forth the annual updates and changes to the IPPS, with the results of our determination announced in the final rule. We announce our results in the final rule for each fiscal year because we believe predictability is an important aspect of the IPPS and that it is important to apply a consistent payment methodology for new medical services or technologies throughout the entire fiscal year. For example, hospitals must train their billing and other staff after publication of the final rule to properly implement the coding and payment changes for the upcoming fiscal year set forth in the final rule. In addition, hospitals' budgetary process and clinical decisions regarding whether to utilize new technologies are based in part on the applicable payment rates under the IPPS for the upcoming fiscal year, including whether the new medical services or technologies qualify for the new medical service or technology add-on payment. If CMS were to make multiple payment changes under the IPPS during a fiscal year, these changes could adversely affect the decisions hospitals implement at the beginning of the fiscal year. For these reasons, we believe applications for new medical service or technology add-on payments should be evaluated prior to publication of the final IPPS rule for each fiscal year. Therefore, if an application does not meet the new medical service or technology add-on payment criteria prior to publication of the final rule, it will not be eligible for the new medical service or technology add-on payments for the fiscal year for which it applied for the add-on payments.

Because we make our determination regarding whether a medical service or technology meets the eligibility criteria for the new medical service or technology add-on payments prior to publication of the final rule, we have advised both past and potential applicants that their medical service or technology must receive FDA approval early enough in the IPPS rulemaking cycle to allow CMS enough time to fully evaluate the application prior to the publication of the IPPS final rule. Moreover, because new medical services or technologies that have not received FDA approval do not meet the newness criterion, it would not be necessary or prudent for us to make a final determination regarding whether a new

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medical service or technology meets the cost threshold and substantial clinical improvement criteria prior to the medical service or technology receiving FDA approval. In addition, we do not believe it is appropriate for CMS to determine whether a medical service or technology represents a substantial clinical improvement over existing technologies before the FDA makes a determination as to whether the medical service or technology is safe and effective. For these reasons, we first determine whether a medical service or technology meets the newness criteria, and only if so, do we then make a determination as to whether the technology meets the cost threshold and represents a substantial clinical improvement over existing medical services or technologies. For example, even if an application has FDA approval, if the medical service or technology is beyond the timeline of 2-3 years to be considered new, in the past we have not made a determination on the cost threshold and substantial clinical improvement. Further, as we have discussed in prior final rules (69 FR 49018-49019 and 70 FR 47344), it is our past and present practice to analyze the new medical service or technology add-on payment criteria in the following sequence: Newness, cost threshold, and finally substantial clinical improvement. Under our proposal in this proposed rule, we would continue this practice of analyzing the eligibility criteria in this sequence and announce in the annual Federal Register as part of the annual updates and changes to the IPPS our determination on whether a medical service or technology meets the eligibility criteria in Sec. 412.87(b).

In the interest of more clearly defining the parameters under which

CMS can fully and completely evaluate new medical service or technology add-on payment applications, we are proposing to amend the regulations at Sec. 412.87 by adding a new paragraph (c) to codify our current policy and specify that CMS will consider whether a new medical service or technology meets the eligibility criteria in Sec. 412.87(b) and announce the results in the Federal Register as part of the annual updates and changes to the IPPS. As a result, we are proposing to remove the duplicative text in Sec. 412.87(b)(1) that specifies that

CMS will determine whether a new medical service or technology meets the substantial clinical improvement criteria and announce the results of its determination in the Federal Register as part of the annual updates and changes to the IPPS. We note that this proposal is not a change to our current policy, as we have always given consideration to whether an application meets the new medical service or technology eligibility criteria in the annual IPPS proposed and final rules.

Rather, this proposal simply codifies our current practice of fully evaluating new medical service or technology add-on payment applications prior to publication of the final rule in order to maintain predictability within the IPPS for the upcoming fiscal year.

In addition, we are proposing in new paragraph (c) of Sec. 412.87 to set July 1 of each year as the deadline by which IPPS new medical service or technology add-on payment applications must receive FDA approval. This proposed deadline should provide us with enough time to fully consider all of the new medical service or technology add-on payment criteria for each application and maintain predictability in the IPPS for the coming fiscal year.

Finally, under this proposal, applications that have not received

FDA approval by July 1 would not be considered in the final rule, even if they were summarized in the corresponding IPPS proposed rule.

However, applications that receive FDA approval of the medical service or technology after July 1 would be able to reapply for the new medical service or technology add-on payment the following year (at which time they would be given full consideration in both the IPPS proposed and final rules).

In summary, for the reasons cited above, we are proposing to revise

Sec. 412.87 to remove the second sentence of (b)(1) and add a new paragraph (c) to codify our current practice of how CMS evaluates new medical service or technology add-on payment applications and establish in paragraph (c) a deadline of July 1 of each year as the deadline by which IPPS new medical service or technology add-on payment applications must receive FDA approval in order to be fully evaluated in the applicable IPPS final rule each year.

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 2009 hospital wage index based on the statistical areas, including OMB's revised definitions of

Metropolitan Areas, appears under section III.C. 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 2009 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 2009 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, 2008 (the FY 2009 wage index) appears under section III.D. of this preamble.

B. Requirements of Section 106 of the MIEA-TRHCA 1. Wage Index Study Required Under the MIEA-TRHCA

Section 106(b)(1) of the MIEA-TRHCA (Pub. L. 109-432) required

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MedPAC to submit to Congress, not later than June 30, 2007, a report on the Medicare wage index classification system applied under the

Medicare IPPS. Section 106(b) of MIEA-TRHCA required 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 the MIEA-TRHCA instructed the

Secretary of Health and Human Services, taking into account MedPAC's recommendations on the Medicare wage index classification system, to include in this 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.

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.

In its June 2007 Report to Congress, ``Report to the Congress:

Promoting Greater Efficiency in Medicare'' (Chapter 6 with Appendix),

MedPAC made three broad recommendations regarding the wage index:

(1) Congress should repeal the existing hospital wage index statute, including reclassifications and exceptions, and give the

Secretary authority to establish a new wage index system;

(2) The Secretary should establish a hospital compensation index that--

Uses wage data from all employers and industry-specific occupational weights;

Is adjusted for geographic differences in the ratio of benefits to wages;

Is adjusted at the county level and smoothes large differences between counties; and

Is implemented so that large changes in wage index values are phased in over a transition period; and

(3) The Secretary should use the hospital compensation index for the home health and skilled nursing facility prospective payment systems and evaluate its use in the other Medicare fee-for-service prospective payment systems.

The full June 2007 Report to Congress is available at the Web site: http://www.medpac.gov/documents/Jun07_EntireReport.pdf).

In the presentation and analysis of its alternative wage index system, MedPAC addressed almost all of the nine points for consideration under section 106(b)(2) of Pub. L. 109-432. Following are the highlights of the alternative wage index system recommended by

MedPAC:

Although the MedPAC recommended wage index generally retains the current labor market definitions, it supplements the metropolitan areas with county-level adjustments and eliminates single wage index values for rural areas.

In the MedPAC recommended wage index, the county-level adjustments, together with a smoothing process that constrains the magnitude of differences between and within contiguous wage areas, serve as a replacement for geographical reclassifications.

The MedPAC recommended wage index uses BLS data instead of the CMS hospital wage data collected on the Medicare cost report.

MedPAC adjusts the BLS data for geographic differences in the ratio of benefits to wages using Medicare cost report data.

The BLS data are collected from a sample of all types of employers, not just hospitals. The MedPAC recommended wage index could be adapted to other providers such as HHAs and SNFs by replacing hospital occupational weights with occupational weights appropriate for other types of providers.

In the MedPAC recommended wage index, volatility over time is addressed by the use of BLS data, which is based on a 3-year rolling sample design.

MedPAC recommends a phased implementation for its recommended wage index in order to cushion the effect of large wage index changes on individual hospitals.

MedPAC suggests that using BLS data automatically addresses occupational mix differences, because the BLS data are specific to health care occupations, and national industry-wide occupational weights are applied to all geographic areas.

The MedPAC report does not provide any evidence of the impact of its wage index on staffing practices or the quality of care and patient safety.

To assist CMS in meeting the requirements of section 106(b)(2) of

Pub. L. 109-432, in February 2008, CMS awarded a Task Order under its

Expedited Research and Demonstration Contract, to Acumen, LLC. The two general responsibilities of the Task Order are to (1) conduct a detailed impact analysis that compares the effects of MedPAC's wage and hospital compensation indexes with the CMS wage index and (2) assist

CMS in developing a proposal (or proposals) that addresses the nine points for consideration under section 106(b)(2) of Pub. L. 109-432.

Specifically, the tasks under the Task Order include, but are not limited to, an evaluation of whether differences between the two types of wage data (that is, CMS cost report and occupational mix data and

BLS data) produce significant differences in wage index values among labor market areas, a consideration of alternative methods of incorporating benefit costs into the construction of the wage index, a review of past and current research on alternative labor market area definitions, and a consideration of how aspects of the MedPAC recommended wage index can be applied to the CMS wage data in constructing a new methodology for the wage index. We will present any analyses and proposals resulting from this Task Order in the FY 2009

IPPS final rule or in a special Federal Register notice issued after the final rule is published. 2. CMS Proposals in Response to Requirements Under Section 106(b) of the MIEA-TRHCA

As discussed in section III.A. of this preamble, the purpose of the hospital wage index is to adjust the IPPS standardized payment to reflect labor market area differences in wage levels. The geographic reclassification system exists in order to assist ``hospitals which are disadvantaged by their current geographic classification because they compete with hospitals that are located in the geographic area to which they seek to be reclassified'' (56 FR 25469). Geographic reclassification is

Page 23619

established under section 1886(d)(10) of the Act and is implemented through 42 CFR Part 412, Subpart L. (We refer readers to section III.I. of this preamble for a detailed discussion of the geographic reclassification system and other area wage index exceptions.)

In its June 2007 Report to Congress, MedPAC discussed its findings that geographic reclassification, and numerous other area wage index exceptions added to the system over the years, have created major complexities and ``troubling anomalies'' in the hospital wage index. A review of the IPPS final rules reveals a long history of legislative changes that have permitted certain hospitals, that otherwise would not be able to reclassify under section 1886(d)(10) of the Act, to receive a higher wage index than calculated for their geographic area. MedPAC reports that more than one-third of hospitals now receive a higher wage index due to geographic reclassification or other wage index exceptions. We are concerned about the integrity of the current system, and agree with MedPAC that the process has become burdensome.

As noted above, MedPAC recommended the elimination of geographic reclassification and other wage index exceptions. In addition, the

President's FY 2009 Budget included a proposal to apply the geographic reclassification budget neutrality requirement at the State level rather than by adjusting the standardized rate for hospitals nationwide. Given the language in section 1886(d)(10) of the Act establishing the MGCRB, we believe a statutory change would be required to make these changes. However, we do have the authority to make some regulatory changes to the reclassification system as discussed below.

We note that these proposals do not preclude future consideration of

MedPAC's recommendations that could be implemented through additional changes to our regulations, once our analysis of those recommendations is complete (after the publication of the FY 2009 IPPS proposed rule). a. Proposed Revision of the Reclassification Average Hourly Wage

Comparison Criteria

Regulations at 42 CFR 413.230(d)(1) set forth the average hourly wage comparison criteria that an individual hospital must meet in order for the MGCRB to approve a geographic reclassification application. Our current criteria (requiring an urban hospital to demonstrate that its average hourly wage is at least 108 percent of the average hourly wage of hospitals in the area in which the hospital is located and at least 84 percent of the average hourly wage of hospitals in the area to which it seeks redesignation) were adopted in the FY 1993 IPPS final rule (57

FR 39825). In that final rule, we explained that the 108 percent threshold ``is based on the national average hospital wage as a percentage of its area wage (96 percent) plus one standard deviation

(12 percent).'' We also explained that we would use the 84-percent threshold to reflect the average hospital wage of the hospital as a percentage of its area wage less one standard deviation. We stated that

``to qualify for a wage index reclassification, a hospital must have an average hourly wage that is more than one national standard deviation above its original labor market area and not less than one national standard deviation below its new labor market area'' (57 FR 39770). In response to numerous public comments we received, we expressed our policy and legal justifications for adopting the specific thresholds.

Among other things, we stated that geographic reclassifications must be viewed not just in terms of those hospitals that are reclassifying, but also in terms of the nonreclassifying hospitals that, through a budget neutrality adjustment, are required to bear a financial burden associated with the higher wage indices received by those hospitals that reclassify. We also indicated that the Secretary has ample legal authority under section 1886(d)(10) of the Act to set the wage comparison thresholds and to revise such thresholds upon further review. We refer readers to that final rule for a full discussion of our justifications for the standards.

In the FY 2000 IPPS final rule (65 FR 47089 through 47090), the wage comparison criteria for rural hospitals seeking individual hospital reclassifications were reduced to 82 percent and 106 percent to compensate for the historic economic underperformance of rural hospitals. The 2-percent drop in both thresholds was determined to allow a significant benefit to some hospitals that were close to meeting the existing criteria but would not make the reclassification standards overly liberal for rural hospitals.

CMS has not evaluated or recalibrated the average hourly wage criteria for geographic reclassification since they were established in

FY 1993. In consideration of the MIEA-TRHCA requirements and MedPAC's finding that over one-third of hospitals are receiving a reclassified wage index or other wage index adjustment, we decided to reevaluate the average hourly wage criteria for geographic reclassification. We ran simulations with more recent wage data to determine what would be the appropriate average hourly wage criteria. We found that the average hospital average hourly wage as a percentage of its area's wage has increased from approximately 96 percent in FY 1993 to closer to 98 percent over FYs 2006, 2007, and 2008 (97.8, 98.2, and 98 percent, respectively). We also determined that the standard deviation has been reduced from approximately 12 percent in FY 1993 to closer to 10 percent over the same 3-year period (10.7, 10.4, and 10.4 percent, respectively); that is, assuming normal distributions, approximately 68 percent of all hospitals would have an average hourly wage that deviates less than 10 percentage points above or below the mean. This assessment indicates that the new baseline criteria for reclassification should be set to 88/108 percent. While the 108 criterion appears not to require adjustment, the current 84 percent standard appears to be too low a threshold to serve the purpose of establishing wage comparability with a proximate labor market area.

To assess the impact that these changes would have had on hospitals that reclassified in FY 2008, we ran models that set urban individual reclassification standards to 88/108 percent and the county group reclassification standard to 88 percent. We retained the 2-percent benefit for rural hospitals by setting an 86/106 percent standard. We used 3-year average hourly wage figures from the 2005, 2006, and 2007 wage surveys and compared them to 3-year average hourly wage figures for CBSAs over the same 3-year period.

Of the 295 hospitals that applied for and received individual reclassifications in FY 2008, 45 of them (15.3 percent) would not meet the proposed 88/86 percent threshold. Of the 66 hospitals that applied for and received county group reclassification in FY 2008, 6 hospitals

(9.1 percent) in 3 groups would not have qualified with the new standards. We also ran comparisons for hospitals that reclassified in

FY 2006 and FY 2007 to determine if they would have been able to reclassify in FY 2008, using 3-year averages available in FY 2008. We found that, of all hospitals that were reclassified in FY 2008 (that is, applications approved for FYs 2006 through 2008), 14.7 percent of individual reclassifications and 8.5 percent of county group reclassification would not have qualified to reclassify in FY 2008.

Page 23620

Section 106 of MIEA-TRHCA requires us to propose revisions to the hospital wage index system after considering the recommendations of

MedPAC. To address this requirement, we are proposing that the 84/108 criteria for urban hospital reclassifications and the 82/106 criteria for rural hospital reclassifications be recalibrated using the methodology published in the FY 1993 final rule and more recent wage data (that is, data used in computing the FYs 2006, 2007, 2008 wage indices). We believe that hospitals that are seeking to reclassify to another area should be required to demonstrate more similarity to the area than the current criteria permit, and our recent analysis demonstrates that those criteria are no longer appropriate. Therefore, we are proposing to change the criterion for the comparison of a hospital's average hourly wage to that of the area to which the hospital seeks reclassification to 88 percent for urban hospitals and 86 percent for rural hospitals for new reclassifications beginning with the FY 2010 wage index and, accordingly, revise our regulations at 42

CFR 412.230 to reflect these changes. The criterion for the comparison of a hospital's average hourly wage to that of its geographic area would be unchanged (108 percent for urban hospitals and 106 percent for rural hospitals). We also are proposing that, when there are significant changes in labor market area definitions, such as CMS' adoption of new OMB CBSA definitions based upon the decennial census

(69 FR 49027), we would again reevaluate and, if warranted, recalibrate these criteria. This would allow CMS to consider the effects of periodic changes in labor market boundaries and provide a regular timeline for updating and validating the reclassification criteria.

Finally, we are proposing to adjust the 85 percent criterion for both urban and rural county group reclassifications to be equal to the proposed 88 percent standard for urban reclassifications, and to revise the regulations at 42 CFR 412.232 and 412.234 to reflect the change.

The urban and rural county group average hourly wage standard has always been equivalent for both urban and rural county groups and has always been 1 percent higher than the 84 percent urban area individual reclassification standard. We would continue the policy of having an equivalent wage comparison criterion for both urban and rural county groups, as these groups have always used the same wage comparison criteria. We also would use the individual urban hospital reclassification standard of 88 percent because this threshold would ensure that the hospitals in the county group are at least as comparable to the proximate area as are individual hospitals within their own areas. Also, we do not believe it would be appropriate to have a group reclassification standard lower than the individual reclassification standards, thus potentially creating a situation where all of the hospitals in a county could reclassify, even though no single hospital within such county would be able to meet any average hourly wage-related comparisons for an individual reclassification.

We considered raising the group reclassification criterion to 89 percent in order to preserve the historical policy of the standard being set at 1 percent higher than the individual reclassification standard. However, we determined that making the group standard equal to the individual standard would adequately address our stated concerns.

We note that the proposed changes in the reclassification criteria apply only to new reclassifications beginning with the FY 2010 wage index. Any hospital or county group that is in the midst of a 3-year reclassification in FY 2010 will not be affected by the proposed criteria change until they reapply for a geographic reclassification.

Therefore, we are proposing the effective date for these changes would be September 1, 2008, the deadline for hospitals to submit applications for reclassification for the FY 2010 wage index. b. Within-State Budget Neutrality Adjustment for the Rural and Imputed

Floors

Section 4410 of the Balanced Budget Act of 1997 (BBA) established the rural floor by requiring that the wage index for a hospital in an urban area of a State cannot be less than the area wage index determined for that State's rural area. Section 4410(b) of the BBA imposed the budget neutrality requirement and stated that the Secretary shall ``adjust the area wage index referred to in subsection (a) for hospitals not described in such subsection.'' Therefore, in order to compensate for the increased wage indices of urban hospitals receiving the rural floor, a nationwide budget neutrality adjustment is applied to the wage index to account for the additional payment to these hospitals. As a result, urban hospitals that qualify for their State's rural floor wage index receive enhanced payments at the expense of all rural hospitals nationwide and all other urban hospitals that do not receive their State's rural floor. In the FY 2009 proposed wage index, 266 hospitals in 27 States benefit from the rural floor. The first chart below lists the percentage of total payments each State either received or contributed to fund the current rural floor and imputed floor provisions with national budget neutrality adjustments (as indicated in the discussion of the imputed floor below in this section

III.B.2.b.). The second chart below provides a graphical depiction of the proposed FY 2009 impacts.

FY 2009 IPPS Estimated Payments with Proposed Within-State Rural Floor and Imputed Floor Budget Neutrality

Proposed policy

Current policy

application of application of rural floor and

State

national rural

imputed floor floor and imputed

budget floor budget neutrality within neutrality

each state

Alabama...........................

-0.1

0.3

Alaska............................

0.0

-0.2

Arizona...........................

-0.2

0.3

Arkansas..........................

-0.1

0.3

California........................

0.7

-0.8

Colorado..........................

0.0

-0.1

Connecticut.......................

2.1

-2.2

Delaware..........................

-0.2

0.3

Washington, DC....................

-0.2

0.3

Page 23621

Florida...........................

0.0

0.0

Georgia...........................

-0.1

0.3

Hawaii............................

-0.1

0.3

Idaho.............................

-0.1

0.3

Illinois..........................

-0.2

0.1

Indiana...........................

-0.1

0.0

Iowa..............................

0.1

-0.1

Kansas............................

-0.1

0.3

Kentucky..........................

-0.1

0.3

Louisiana.........................

-0.1

0.0

Maine.............................

-0.1

0.3

Massachusetts.....................

-0.2

0.3

Michigan..........................

-0.2

0.3

Minnesota.........................

-0.2

0.3

Mississippi.......................

-0.1

0.3

Missouri..........................

-0.1

0.0

Montana...........................

-0.1

0.2

Nebraska..........................

-0.1

0.3

Nevada............................

-0.2

0.3

New Hampshire.....................

1.1

-1.2

New Jersey........................

0.7

-0.8

New Mexico........................

-0.1

0.0

New York..........................

-0.2

0.3

North Carolina....................

-0.1

0.1

North Dakota......................

0.1

-0.1

Ohio..............................

-0.1

0.1

Oklahoma..........................

-0.1

0.1

Oregon............................

-0.1

0.0

Pennsylvania......................

-0.1

0.1

Rhode Island......................

-0.2

0.3

South Carolina....................

-0.1

0.0

South Dakota......................

-0.1

0.3

Tennessee.........................

0.0

0.0

Texas.............................

-0.1

0.1

Utah..............................

-0.1

0.3

Vermont...........................

3.5

-3.4

Virginia..........................

-0.1

0.0

Washington........................

-0.1

-0.1

West Virginia.....................

0.0

-0.1

Wisconsin.........................

-0.1

-0.1

Wyoming...........................

0.0

0.1

Page 23622

GRAPHIC

TIFF OMITTEDTP30AP08.018

The above charts demonstrate how, at a State-by-State level, the rural floor is creating a benefit for a minority of States that is then funded by a majority of States, including States that are overwhelmingly rural in character. The intent behind the rural floor seems to have been to address anomalous occurrences where certain urban areas in a State have unusually depressed wages when compared to the

State's rural areas. However, because these comparisons occur at the

State level, we believe it also would be sound policy to make the budget neutrality adjustment specific to the State, redistributing payments among hospitals within the State, rather than adjusting payments to hospitals in other States.

In addition, a statewide budget neutrality adjustment would address the situation we discussed in the FY 2008 IPPS final rule with comment period (72 FR 47324) in which rural CAHs were converting to IPPS status, apparently to raise the State's rural wage index to a level whereby all urban hospitals in the State would receive the rural floor.

Medicare payments to CAHs are based on 101 percent of reasonable costs while the IPPS pays hospitals a fixed rate per discharge. In addition, as a CAH, a hospital is guaranteed to recover its costs, while an IPPS hospital is provided with incentives to increase efficiency to cover its costs. Thus, we stated that the identified CAHs were converting back to IPPS, even though the conversion would not directly benefit them. Because these hospitals' wage levels are higher than most, if not all, of the urban hospitals in the State, 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. In simulating the effect of the hospitals setting the State's rural floor, we estimated that payment to hospitals in the State would increase in excess of $220 million in a single year. The MedPAC, in its June 2007

Report to the Congress stated, ``The fact that the movement of one or two CAHs in or out of the [I]PPS system can increase (or decrease)

Medicare payments by $220 million suggests there is a flaw in the design of the wage index system.'' (We refer readers to page 131 of the report.)

For the above reasons, we are proposing to apply a State level rural floor budget neutrality adjustment to the wage index beginning in

FY 2009. States that have no hospitals receiving a rural floor wage index would no longer have a negative budget neutrality adjustment applied to their wage indices. Conversely, hospitals in States with hospitals receiving a rural floor would

Page 23623

have their wage indices downwardly adjusted to achieve budget neutrality within the State. All hospitals within each State would, in effect, be responsible for funding the rural floor adjustment applicable within that specific State.

In the FY 2005 IPPS final rule and the FY 2008 IPPS final rule with comment period (69 FR 49109 and 72 FR 47321, respectively), we temporarily adopted an ``imputed'' floor measure to address a concern by some individuals that hospitals in all-urban States were disadvantaged by the absence of rural hospitals. Because no rural wage index could be calculated, no rural floor could be applied within such

States. We originally limited application of the policy to FYs 2005 through 2007 and then extended it one additional year, through FY 2008.

We are proposing to extend the imputed floor for 3 additional years, through FY 2011, and to revise the introductory text of Sec. 412.64(h)(4) of our regulations to reflect this extension. For FY 2009, 26 hospitals in New Jersey (33.8 percent) would receive the imputed floor. Rhode Island, the only other all-urban State, has no hospitals that would receive the imputed floor. In past years, we applied a national budget neutrality adjustment to the standardized amount to ensure that payments remained constant to payments that would have occurred in the absence of the imputed floor policy. As a result, payments to all other hospitals in the Nation were adjusted downward to subsidize the higher payments to New Jersey hospitals receiving the imputed floor. As the intent of the imputed floor is to create a protection to all-urban States similar to the protection offered to urban-rural mixed States by the rural floor, and the effect of the measure is also State-specific like the rural floor, we believe that the budget neutrality adjustments for the imputed floor and the rural floor should be applied in the same manner. Therefore, beginning with

FY 2009, we are also proposing to apply the imputed floor budget neutrality adjustment to the wage index and at the State level.

Based on our impact analysis of these proposals for FY 2009, of the 49 States (Maryland is excluded because it is under a State waiver), the District of Columbia, and Puerto Rico, 39 would see either no change or an increase in total Medicare payments as a result of applying a budget neutrality adjustment to the wage index for the rural and imputed floors at the State level rather than the national level.

The total payments of the remaining 12 States would decrease 0.1 percent to 3.4 percent compared to continuing our prior national adjustment policy. The full impact analysis is reflected in the two charts presented earlier in this section III.B.2.b. of the preamble of this proposed rule. Tables 4D-1 and 4D-2 in the Addendum to this proposed rule reflect the proposed FY 2009 State level budget neutrality adjustments for the rural and imputed floors. We are specifically requesting public comments from national and State hospital associations regarding these proposals, particularly the national associations, as they represent member hospitals that are both positively and negatively affected by our proposed policies, and are, therefore, in the best position to comment on the policy merits of these proposals. We will view the absence of any comments from the national hospital associations as a sign that they do not object to our proposed policies. c. Within-State Budget Neutrality Adjustment for Geographic

Reclassification

Currently, section 1886(d)(8)(D) of the Act requires us to adjust the standardized amount to ensure that the effects of geographic reclassification do not increase aggregate IPPS payments. This means that, in the case of a reclassification, budget neutrality is achieved by reducing the standardized amount for all hospitals nationwide. The

FY 2009 President's Budget includes a legislative proposal to apply geographic reclassification budget neutrality at the State level

(available at the Web site: www.hhs.gov/budget/09budget/ 2009BudgetInBrief.pdf under FY 2009 Medicare Proposals, page 54). If this proposal is enacted by the Congress, budget neutrality would be achieved by adjusting the wage index for all hospitals within the State rather than reducing the standardized amount for all hospitals nationwide.

As noted also in MedPAC's June 2007 Report to Congress, over the years, there have been many changes to the Medicare law that are intended to broaden the ability for a hospital to receive a wage index that is higher than the value that is calculated for its geographic area and not be subject to the proximity or wage level criteria for geographic reclassification established under section 1886(d)(10) of the Act. These more targeted geographic reclassification provisions are creating inequities in the wage index by sometimes allowing hospitals to be reclassified to areas where other hospitals that are closer in proximity are ineligible to reclassify. Applying budget neutrality at the State level would focus the costs of geographic reclassification closer to the areas where hospitals that benefit from the reclassification are located. We expect that a legislative provision on applying geographic reclassification budget neutrality at the State level would be applied to all reclassifications and wage index exceptions that are implemented through 42 CFR Part 412, Subpart L, and certain provisions of the Social Security Act that permit hospitals to receive a higher wage index than is calculated for their geographic area. (As discussed above, as a proposed regulatory matter, there also would be a separate within-State budget neutrality adjustment for the imputed and rural floors.) We expect that reclassification budget neutrality at the State level would operate through adjustments to the

IPPS payments to hospitals in the State in which the reclassifying hospital is geographically located.

We are seeking public comments regarding MedPAC's recommendations for reforming the wage index, our plan for our contractor's review of the wage index, and the regulatory proposals for modifying the current hospital wage index system. We also welcome additional suggestions for reforming the hospital wage index.

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

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).

As with the FY 2008 final rule, for FY 2009 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 2009 employing wage index data from FY 2005 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, it has been our longstanding policy that where an

MSA has been divided into Metropolitan Divisions, we consider the

Metropolitan Division to comprise the labor market areas for purposes of calculating the

Page 23624

wage index (69 FR 49029). We are proposing to codify this longstanding policy into our regulations at Sec. 412.64(b)(1)(ii)(A).

On November 20, 2007, OMB announced the revision of titles for eight urban areas (OMB Bulletin No. 08-01). The revised titles are as follows:

Hammonton, New Jersey qualifies as a new principal city of the Atlantic City, New Jersey CBSA. The new title is Atlantic City-

Hammonton, New Jersey CBSA;

New Brunswick, New Jersey, located in the Edison, New

Jersey Metropolitan Division, qualifies as a new principal city of the

New York-Northern New Jersey-Long Island, New York, New Jersey,

Pennsylvania CBSA. The new title for the Metropolitan Division is

Edison-New Brunswick, New Jersey CBSA;

Summerville, South Carolina qualifies as a new principal city of the Charleston-North Charleston, South Carolina CBSA. The new title is Charleston-North Charleston-Summerville, South Carolina;

Winter Haven, Florida qualifies as a new principal city of the Lakeland, Florida CBSA. The new title is Lakeland-Winter Haven,

Florida;

Bradenton, Florida replaces Sarasota, Florida as the most populous principal city of the Sarasota-Bradenton-Venice, Florida CBSA.

The new title is Bradenton-Sarasota-Venice, Florida. The new CBSA code is 14600;

Frederick, Maryland replaces Gaithersburg, Maryland as the second most populous principal city in the Bethesda-Gaithersburg-

Frederick, Maryland CBSA. The new title is Bethesda-Frederick-

Gaithersburg, Maryland;

North Myrtle Beach, South Carolina replaces Conway, South

Carolina as the second most populous principal city of the Myrtle

Beach-Conway-North Myrtle Beach, South Carolina CBSA. The new title is

Myrtle Beach-North Myrtle Beach-Conway, South Carolina;

Pasco, Washington replaces Richland, Washington as the second most populous principal city of the Kennewick-Richland-Pasco,

Washington CBSA. The new title is Kennewick-Pasco-Richland, Washington.

The OMB bulletin is available on the OMB Web site at https:// www.whitehouse.gov/OMB-- go to ``Bulletins'' or ``Statistical Programs and Standards.'' CMS will apply these changes to the IPPS beginning

October 1, 2008.

D. Proposed Occupational Mix Adjustment to the Proposed FY 2009 Wage

Index

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 2009 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 beginning and ending dates to accommodate some hospitals' biweekly 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 entire 6-month 2006 survey data to calculate the occupational mix adjustment for the FY 2009 wage index.

The original timelines for the collection, review, and correction of the 2006 occupational mix data were discussed in detail in the FY 2007

IPPS final rule (71 FR 48008). The revision and correction process for all of the data, including the 2006 occupational mix survey data to be used for computing the FY 2009 wage index, is discussed in detail in section III.K. of the preamble of this proposed rule.

Page 23625

2. Calculation of the Proposed Occupational Mix Adjustment for FY 2009

For FY 2009 (as we did for FY 2008), 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.G. 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.G. 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. The proposed FY 2009 occupational mix adjusted national average hourly wage is $32.2252.

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 proposed FY 2009 occupational mix adjusted Puerto Rico specific average hourly wage is $13.7851.

The table below is an illustrative example of the proposed occupational mix adjustment.

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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 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 2009 wage index.

For the FY 2008 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 (72 FR 47314). 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 2008 occupational mix adjusted wage index. We indicated in the FY 2008 IPPS final rule that we reserve the right to apply a different approach in future years, including potentially penalizing nonresponsive hospitals (72 FR 47314).

For the FY 2009 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 2008 wage index. In addition, if a hospital submits 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 proposed FY 2009 occupational mix adjustment factor. Lastly, if a hospital submits a survey(s), but that survey data can not be used because we determine it to be aberrant, we will also assign the hospital the average occupational mix adjustment for its labor market area. For example, if a hospital's individual nurse category average hourly wages are out of range (that is, unusually high or low), and the hospital does not provide sufficient documentation to explain the aberrancy, or the hospital does not submit any registered nurse staff salaries or hours data, we will assign 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 0.8968 (CBSA 39820, Redding, CA), to a high of 1.0775 (CBSA 43300,

Sherman-Denison, TX). 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 2009, there was one CBSA for which we did not have occupational mix data for any of its providers (CBSA 12020,

Athens-Clark County, GA). 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.

In the FY 2008 IPPS proposed rule, we solicited comments and suggestions for a hospital-specific penalty for hospitals that do not submit occupational mix survey data. In response to the FY 2008 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. We noted that any penalty that we would determine for nonresponsive hospitals would apply to a future wage index, not the

FY 2008 wage index.

In the FY 2008 final rule with comment period, we assigned nonresponsive hospitals the average occupational mix adjustment for the labor market area. For areas where no hospital submitted survey data, we applied the national occupational mix adjustment factor of 1.0000 in calculating the area's FY 2008 occupational mix adjusted wage index. We appreciate the suggestions we received regarding future penalties for hospitals that do not submit occupational mix survey data. We stated in the FY 2008 final rule with comment period that we may consider proposing a policy to penalize hospitals that do not submit occupational mix survey data for FY 2010, the first year of the application of the new 2007-2008 occupational mix survey, and that we expected that any such penalty would be proposed in the FY 2009 IPPS proposed rule so hospitals would be aware of the policy before the deadline for submitting the data to the fiscal intermediaries/MAC. At this time, however, we are not proposing a penalty for FY 2010. Rather, we are reserving the right to propose a penalty in the FY 2010 IPPS proposed rule, once we collect and analyze the FY 2007-2008 occupational mix survey data. Hospitals are still on notice that any failure to submit occupational mix data for the FY 2007-2008 survey year may result in a penalty in FY 2010, thus achieving our policy goal of ensuring that hospitals are aware of the consequences of failure to submit data in response to the most recent survey. 3. 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 used occupational mix data collected on the 2006 survey to compute the proposed occupational mix adjustment for FY 2009. In the FY 2008 IPPS final rule with comment period (72 FR 47315), we discussed how we modified the occupational mix survey. The revised 2007-2008 occupational mix survey provides for the collection of hospital- specific wages and hours data for the 1-year period of 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 occupational mix survey will be applied beginning with the FY 2010 wage index.

On February 2, 2007, we published in the Federal Register a notice soliciting comments on the proposed revisions to the occupational mix survey (72 FR 5055). The comment period for the notice ended on April 3, 2007. After considering the comments we received, we made a few minor editorial changes

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and published the final 2007-2008 occupational mix survey on September 14, 2007 (72 FR 52568). OMB approved the survey without change on

February 1, 2008 (OMB Control Number 0938 0907). The 2007-2008 Medicare occupational mix survey (Form CMS-10079 (2008)) is available on the CMS

Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/ list.asp#TopOfPage, and through the fiscal intermediaries/MAC.

Hospitals must submit their completed surveys to their fiscal intermediaries/MAC by September 1, 2008. The preliminary, unaudited 2007-2008 occupational mix survey data will be released in early

October 2008, along with the FY 2006 Worksheet S-3 wage data, for the

FY 2010 wage index review and correction process.

E. Worksheet S-3 Wage Data for the Proposed FY 2009 Wage Index

The proposed FY 2009 wage index values (to be effective for hospital discharges occurring on or after October 1, 2008, and before

October 1, 2009) 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 2005

(the FY 2008 wage index was based on FY 2004 wage data). 1. Included Categories of Costs

The proposed FY 2009 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, and certain contract indirect patient care services (as discussed in the FY 2008 final rule with comment period (72 FR 47315).

Wage-related costs, including pensions and other deferred compensation costs. We note that, on March 28, 2008, CMS published a technical clarification to the cost reporting instructions for pension and deferred compensation costs (sections 2140 through 2142.7 of the

Provider Reimbursement Manual, Part I). These instructions are used for developing pension and deferred compensation costs for purposes of the wage index, as discussed in the instructions for Worksheet S-3, Part

II, Lines 13 through 20 and in the FY 2006 final rule (70 FR 47369). 2. Excluded Categories of Costs

Consistent with the wage index methodology for FY 2008, the proposed wage index for FY 2009 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 2009 wage index 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). 3. 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.

F. Verification of Worksheet S-3 Wage Data

The wage data for the proposed FY 2009 wage index were obtained from Worksheet S-3, Parts II and III of the FY 2005 Medicare cost reports. Instructions for completing Worksheet S-3, Parts II and III are in the Provider Reimbursement Manual (PRM), Part II, sections 3605.2 and 3605.3. The data file used to construct the proposed wage index includes FY 2005 data submitted to us as of February 29, 2008. As in past years, we performed an intensive review of the wage data, mostly through the use of edits designed to identify aberrant data.

We asked our fiscal intermediaries/MAC to revise or verify data elements that resulted in specific edit failures. For the proposed FY 2009 wage index, we identified and excluded 37 providers with data that was too aberrant to include in the proposed wage index, although if data elements for some of these providers are corrected, we intend to include some of these providers in the FY 2009 final 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 14, 2008. 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 FY 2009 IPPS final rule.

In constructing the proposed FY 2009 wage index, we included the wage data for facilities that were IPPS hospitals in FY 2005; inclusive of those facilities that have since terminated their participation in the program as hospitals, as long as those data did 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 and to ensure that the current wage index represents the labor market area's current wages as compared to the national average of wages. However, we excluded the wage data for CAHs as discussed in the

FY 2004 IPPS final rule (68 FR 45397). For this proposed rule, we removed 20 hospitals that converted to CAH status between February 16, 2007, the cut-off date for CAH exclusion from the FY 2008 wage index, and February 18, 2008, the cut-off date for CAH exclusion from the FY 2009 wage index. After removing hospitals with aberrant data and hospitals that converted to CAH status, the proposed FY 2009 wage index is calculated based on 3,533 hospitals. 1. Wage Data for Multicampus Hospitals

In the FY 2008 final rule with comment period (72 FR 47317), we discussed our policy for allocating a multicampus hospital's wages and hours data, by full-time equivalent (FTE) staff, among the different labor market areas where its campuses are located. During the FY 2009 wage index desk review process, we requested fiscal intermediaries/MACs to contact multicampus hospitals that had campuses in different labor market areas to collect the data for the allocation. The proposed FY 2009 wage index in this proposed rule includes separate wage data for campuses of three multicampus hospitals.

As with the FY 2008 wage index, we allowed hospitals the option of allocating their wages and hours for the FY 2009 wage index based on either FTE staff or discharge data. Again, we

Page 23630

are providing this option until a revised cost report is available that will allow a multicampus hospital to report the number of FTEs by location of its different campuses. Two of the three multicampus hospitals chose to have their wage data allocated by their Medicare discharge data. One of the hospitals provided FTE staff data for the allocation. The average hourly wage associated with each geographical location of a multicampus hospital is reflected in Table 2 of the

Addendum to this proposed rule. 2. New Orleans' Post-Katrina Wage Index

Since 2005 when Hurricane Katrina devastated the Gulf States, we have received numerous comments suggesting that current Medicare payments to hospitals in New Orleans, Louisiana are inadequate, and the wage index does not accurately reflect the increase in labor costs experienced by the city after the storm. The post-Katrina effects on the New Orleans wage index will not be realized in the wage index until

FY 2010, when the wage index will be based on cost reporting periods beginning during FY 2006 (that is, beginning on or after October 1, 2005 and before October 1, 2006).

In responding to the health-related needs of people affected by the hurricane, the Federal Government, through the Deficit Reduction Act of 2005 (DRA), appropriated $2 billion in FY 2006. These funds allowed the

Secretary to make available $160 million in February 2007 to Louisiana,

Mississippi, and Alabama for payments to hospitals and skilled nursing facilities facing financial stress because of changing wage rates not yet reflected in Medicare payment methodologies. In March and May 2007, the Department provided two additional DRA grants of $15 million and

$35 million, respectively, to Louisiana for professional health care workforce recruitment and sustainability in the greater New Orleans area, namely the Orleans, Jefferson, St. Bernard, and Plaquemines

Parishes. In addition, the Department issued a supplemental award of

$60 million in provider stabilization grant funding to Louisiana,

Mississippi, and Alabama to continue to help health care providers meet changing wage rates not yet reflected by Medicare's payment policies.

On July 23, 2007, HHS awarded to Louisiana a new $100 million Primary

Care Grant to help increase access to primary care in the Greater New

Orleans area. The resulting stabilization and expansion of the community based primary care infrastructure, post Katrina, helps provide a viable alternative to local hospital emergency rooms for all citizens of New Orleans, especially those who are poor and uninsured.

In other Department efforts, the OIG has performed an in-depth review of the post-Katrina infrastructure of five New Orleans hospitals, including the hospitals' staffing levels and wage costs. The OIG's final reports and recommendations are scheduled to be published in

Spring 2008.

G. Method for Computing the Proposed FY 2009 Unadjusted Wage Index

The method used to compute the proposed FY 2009 wage index without an occupational mix adjustment follows:

Step 1--As noted above, we based the proposed FY 2009 wage index on wage data reported on the FY 2005 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, 2004, and before October 1, 2005. In addition, we included data from some hospitals that had cost reporting periods beginning before October 2004 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 2005 data. We note that, if a hospital had more than one cost reporting period beginning during FY 2005 (for example, a hospital had two short cost reporting periods beginning on or after October 1, 2004, and before October 1, 2005), we included 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 included 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.

(We note that, beginning with FY 2008 (72 FR 47315), we include lines 22.01, 26.01, and 27.01 of Worksheet S-3, Part II for overhead services in the wage index. However, we note that the wages and hours on these lines are not incorporated into line 101, column 1 of Worksheet A, which, through the electronic cost reporting software, flows directly to line 1 of Worksheet S-3, Part II. Therefore, the first step in the wage index calculation for FY 2009 is to compute a ``revised'' Line 1, by adding to the Line 1 on Worksheet S-3, Part II (for wages and hours respectively) the amounts on Lines 22.01, 26.01, and 27.01.) 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 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 minus the sum of lines 22.01, 26.01, and 27.01) to revised hours excluding the sum of lines 22.01, 26.01, and 27.01 (Line 1 minus the sum of

Page 23631

Lines 2, 3, 4.01, 5, 5.01, 6, 6.01, 7, 8, 8.01, 22.01, 26.01, and 27.01). (We note that for the FY 2008 and subsequent wage index calculations, we are excluding the sum of lines 22.01, 26.01, and 27.01 from the determination of the ratio of overhead hours to revised hours, since hospitals typically do not provide fringe benefits (wage-related costs) to contract personnel. Therefore, it is not necessary for the wage index calculation to exclude overhead wage-related costs for contract personnel. Further, if a hospital does contribute to wage- related costs for contracted personnel, the instructions for lines 22.01, 26.01, and 27.01 require that associated wage-related costs be combined with wages on the respective contract labor lines.); (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. 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

Adjustment

After

Before

factor

10/14/2004.................................... 11/15/2004

1.05390 11/14/2004.................................... 12/15/2004

1.05035 12/14/2004.................................... 01/15/2005

1.04690 01/14/2005.................................... 02/15/2005

1.04342 02/14/2005.................................... 03/15/2005

1.03992 03/14/2005.................................... 04/15/2005

1.03641 04/14/2005.................................... 05/15/2005

1.03291 05/14/2005.................................... 06/15/2005

1.02940 06/14/2005.................................... 07/15/2005

1.02596 07/14/2005.................................... 08/15/2005

1.02264 08/14/2005.................................... 09/15/2005

1.01943 09/14/2005.................................... 10/15/2005

1.01627 10/14/2005.................................... 11/15/2005

1.01308 11/14/2005.................................... 12/15/2005

1.00987 12/14/2005.................................... 01/15/2006

1.00661 01/14/2006.................................... 02/15/2006

1.00333 02/14/2006.................................... 03/15/2006

1.00000 03/14/2006.................................... 04/15/2006

0.99670

For example, the midpoint of a cost reporting period beginning

January 1, 2005, and ending December 31, 2005, is June 30, 2005. An adjustment factor of 1.02596 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 2005 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 Step5 for all hospitals in the Nation and then divide the sum by the national sum of total hours from Step 4 to arrive at a national average hourly wage. Using the data as described above, the proposed national average hourly wage (unadjusted for occupational mix) is $32.2489.

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 (unadjusted for occupational mix) of $13.7956 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 2009, this proposed change would affect 266 hospitals in 69 urban areas. The areas affected by this provision are identified by a footnote in Table 4A in the Addendum of this proposed rule.

In the FY 2005 IPPS final rule (69 FR 49109), we adopted the

``imputed'' floor as a temporary 3-year measure to address a concern by some individuals that hospitals in all-urban States were disadvantaged by the absence of rural hospitals to set a wage index floor in those

States. The imputed floor was originally set to expire in FY 2007, but we extended it an additional year in the FY 2008 IPPS final rule with comment period (72FR47321). As explained in section III.B.2.b. of the preamble of this proposed rule, we are proposing to extend the imputed floor for an additional 3 years, through FY 2011.

H. Analysis and Implementation of the Proposed Occupational Mix

Adjustment and the Proposed FY 2009 Occupational Mix Adjusted Wage

Index

As discussed in section III.D. of this preamble, for FY 2009, we are proposing to apply the occupational mix adjustment to 100 percent of the FY

Page 23632

2009 wage index. We calculated the occupational mix adjustment using data from the 2006 occupational mix survey data, using the methodology described in section III.D.3. of this preamble.

Using the 1st and 2nd quarter occupational mix survey data and applying the occupational mix adjustment to 100 percent of the proposed

FY2009 wage index results in a proposed national average hourly wage of

$32.2252 and a proposed Puerto-Rico specific average hourly wage of

$13.7851. After excluding data of hospitals that either submitted aberrant data that failed critical edits, or that do not have FY 2005

Worksheet S-3 cost report data for use in calculating the proposed

FY2009 wage index, we calculated the proposed FY 2009 wage index using the occupational mix survey data from 3,364 hospitals. Using the

Worksheet S-3 cost report data of 3,533 hospitals and occupational mix 1st and/or 2nd quarter survey data from 3,364 hospitals represents a 95.2 percent survey response rate. The proposed FY2009 national average hourly wages for each occupational mix nursing subcategory as calculated in Step 2 of the occupational mix calculation are as follows:

Average

Occupational mix nursing subcategory

hourly wage

National RN Management.....................................

$38.6341

National RN Staff..........................................

$33.4795

National LPN...............................................

$19.2316

National Nurse Aides, Orderlies, and Attendants............

$13.6954

National Medical Assistants................................

$15.7714

National Nurse Category....................................

$28.7291

The proposed national average hourly wage for the entire nurse category as computed in Step 5 of the occupational mix calculation is

$28.7291. 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 42.99 percent, and the proposed national percentage of hospital employees in the All Other Occupations category is 57.01 percent. At the CBSA level, the percentage of hospital employees in the

Nurse category ranged from a low of 27.26 percent in one CBSA, to a high of 85.30 percent in another CBSA.

The proposed wage index values for FY 2009 (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 2007, 2008, and 2009 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 2003 and FY 2004 cost reporting periods, as well as the FY 2005 period used to calculate the proposed

FY 2009 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 2, 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.

The proposed wage index values in Tables 2, 4A, 4B, and 4C also include the proposed State-specific rural floor and imputed floor budget neutrality adjustments that are discussed in section III.B.2. of this preamble. The proposed State budget neutrality adjustments for the rural and imputed floors are included in Tables 4D-1 and 4D-2 in the

Addendum to this proposed rule.

I. Proposed Revisions to the Wage Index Based on Hospital

Redesignations 1. General

Under section 1886(d)(10) of the Act, the MGCRB considers applications by hospitals for geographic reclassification for purposes of payment under the IPPS. Hospitals must apply to the MGCRB to reclassify 13 months prior to the start of the fiscal year for which reclassification is sought (generally by September 1). 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 42 CFR 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 average hourly wage data from the 3 most recently published hospital wage surveys 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 42 CFR 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 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. Eligible counties are discussed and identified under section

III.I.5. 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

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redesignated hospitals are applicable both to the hospitals 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:

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 2009 MGCRB Reclassifications

Under section 1886(d)(10) of the Act, the MGCRB considers applications by hospitals for geographic reclassification for purposes of payment under the IPPS. The specific procedures and rules that apply to the geographic reclassification process are outlined in 42 CFR 412.230 through 412.280.

At the time this proposed rule was constructed, the MGCRB had completed its review of FY 2009 reclassification requests. There were 314 hospitals approved for wage index reclassifications by the MGCRB for FY 2009. Because MGCRB wage index reclassifications are effective for 3 years, hospitals reclassified during FY 2007 or FY 2008 are eligible to continue to be reclassified based on prior reclassifications to current MSAs during FY 2009. There were 175 hospitals approved for wage index reclassifications in FY 2007 and 324 hospitals approved for wage index reclassifications in FY 2008. Of all of the hospitals approved for reclassification for FY 2007, FY 2008, and FY 2009, 813 hospitals are in a reclassification status for FY 2009.

Under 42 CFR 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 2009 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 within 45 days of publication of this proposed rule 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 (42 CFR 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 (42 CFR 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 42 CFR 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 FY 2009 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 2010 reclassifications are due to the MGCRB by

September 2, 2008 (the first working day of September 2008). We note that this is also the deadline for canceling a previous wage index reclassification withdrawal or termination under 42 CFR 412.273(d).

Applications and other information about MGCRB reclassifications may be obtained, beginning in mid-July 2008, 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. FY 2008 Policy Clarifications and Revisions

We note below several policies related to geographic reclassification that were clarified or revised in the FY 2008 IPPS final rule with comment period (72 FR 47333):

Reinstating Reclassifications--As provided for in 42 CFR 412.273(b)(2), once a hospital (or hospital group) accepts a newly approved reclassification, any previous reclassification is permanently terminated.

Geographic Reclassification for Multicampus Hospitals--

Because campuses of a multicampus hospital can now have their wages and hours data allocated by FTEs or discharge data, a hospital campus located in a geographic area distinct from the geographic area associated with the provider number of the multicampus hospital will have official wage data to supplement an individual or group reclassification application (Sec. 412.230(d)(2)(v)).

New England Deemed Counties--Hospitals in New England deemed counties are treated the same as Lugar hospitals in calculating the wage index. That is, the area is considered rural, but the hospitals within the area are deemed to be urban (Sec. 412.64(b)(3)(ii)).

``Fallback'' Reclassifications--A hospital will automatically be given its most recently approved reclassification

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

Section 1886(d)(8)(B) of the Act requires 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 are met. Effective beginning FY 2005, we use OMB's 2000 CBSA standards and the Census 2000 data to identify counties in which hospitals qualify under section 1886(d)(8)(B) of the Act to receive the wage index of 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 proposed FY 2009 chart below with the listing of the rural counties containing the hospitals designated as urban under section 1886(d)(8)(B) of the Act. For discharges occurring on or after October 1, 2008, hospitals located in the rural county 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 Containing Hospitals 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

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

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

Davidson, NC........................... Greensboro-High Point, 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

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

As discussed in last year's FY 2008 IPPS final rule with comment period (72 FR 47336-47337), Lugar hospitals are treated like reclassified hospitals for purposes of determining their applicable wage index and 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 42 CFR 412.230. The procedural rules set forth at Sec. 412.230 list the criteria that a hospital must meet in order to reclassify as a rural hospital. Lugar hospitals are subject to the proximity criteria and payment thresholds that apply to rural hospitals. Specifically, the hospital must be no more than 35 miles from the area to which it seeks reclassification (Sec. 412.230(b)(1)); and the hospital must 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)). Under current rules, the hospital must also 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)). However, we are proposing to increase this threshold to 86 percent (as discussed in section III.B.2.a. of this preamble).

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

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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. As discussed in the FY 2008 final rule with comment period, we treat New England deemed counties in a manner consistent with how we treat Lugar counties. (We refer readers to 72 FR 47337 for a discussion of this policy.)

J. Proposed FY 2009 Wage Index Adjustment Based on Commuting Patterns of Hospital Employees

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

``out-migration'' adjustment). The process, 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 three 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. Beginning with the FY 2008 wage index, we use post-reclassified wage indices when determining the out- migration adjustment (72 FR 47339).

For the proposed FY 2009 wage index, we calculated the out- migration adjustment using the same formula described in the FY 2005

IPPS final rule (69 FR 49064), with the addition of 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 index areas, multiply this result by the result obtained 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 index 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. For example, hospitals that received the adjustment for the first time in FY 2008 will be eligible to retain the adjustment for

FY 2009. 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, 2008.

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, 2007, and 2008

IPPS 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 within 45 days from the publication of this proposed rule that they elect to receive the out-migration adjustment instead. 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 2009. 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 would 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 would automatically receive the wage index adjustment listed in Table 4J in the Addendum to this proposed rule.

K. Process for Requests for Wage Index Data Corrections

The preliminary, unaudited Worksheet S-3 wage data and occupational mix survey data files for the FY 2009 wage index were made available on

October 5, 2007, through the Internet on the CMS Web site at: http:// www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage.

In the interest of meeting the data needs of the public, beginning with the proposed FY 2009 wage index, we posted an additional public use file on our Web site that reflects the actual data that are used in computing the proposed wage index. The release of this new file does not alter the current wage index process or schedule. We notified the hospital community of the availability of these data as we do with the current public use wage data files through our Hospital Open Door forum. We encourage hospitals to sign up for automatic notifications of information about hospital issues and the scheduling of the Hospital

Open Door forums at: http://www.cms.hhs.gov/OpenDoorForums/.

In a memorandum dated October 5, 2007, we instructed all fiscal

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intermediaries/MACs 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/MACs to advise hospitals that these data were 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 5, 2007 wage and occupational mix data files, the hospital was to submit corrections along with complete, detailed supporting documentation to its fiscal intermediary/MAC by December 7, 2007.

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 files on the Internet, through the October 5, 2007 memorandum referenced above.

In the October 5, 2007 memorandum, we also specified that 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 Web site in October, highlight the revised cells on its spreadsheet, and submit its spreadsheet(s) and complete documentation to its fiscal intermediary/

MAC no later than December 7, 2007.

The fiscal intermediaries (or, if applicable, the MACs) notified the hospitals by mid-February 2008 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/

MACs also submitted the revised data to CMS by mid-February 2008. CMS published the proposed wage index public use files that included hospitals' revised wage index data on February 25, 2008. In a memorandum also dated February 25, 2008, we instructed fiscal intermediaries/MACs 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 11, 2008 to submit requests to the fiscal intermediaries/MACs for reconsideration of adjustments made by the fiscal intermediaries/MACs 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/MACs are to transmit any additional revisions resulting from the hospitals' reconsideration requests by April 14, 2008. 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 21, 2008.

Hospitals should also examine Table 2 in the Addendum to this proposed rule. Table 2 in the Addendum to this proposed rule contains each hospital's adjusted average hourly wage used to construct the wage index values for the past 3 years, including the FY 2005 data used to construct the proposed FY 2009 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 29, 2008.

We will release the final wage index data public use files in early

May 2008 on the Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/

WIFN/list.asp#TopOfPage. The May 2008 public use files will be made available solely for the limited purpose of identifying any potential errors made by CMS or the fiscal intermediary/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/MACs by

April 14, 2008). If, after reviewing the May 2008 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

MACs) must receive these requests no later than June 9, 2008. 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 2008 wage index data files, changes to the wage and occupational mix data will only be 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 MACs on or before April 21, 2008.

Requests for correction of errors that were not, but could have been, identified during the hospital's review of the February 25, 2008 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 MACs (that is, by June 9, 2008) will be incorporated into the final wage index in the FY 2009 IPPS final rule, which will be effective October 1, 2008.

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 2009 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 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

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hospitals will have access to the final wage index data by early May 2008, 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 2009 wage index by August 1, 2008, and the implementation of the FY 2009 wage index on October 1, 2008. If hospitals availed 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 9, 2008, we retain the right to make midyear changes to the wage index under very limited circumstances.

Specifically, in accordance with 42 CFR 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 42 CFR 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 9, 2008 deadline for the FY 2009 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 requested 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 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 2009

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 interpret this to mean 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 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 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

Page 23639

percent for discharges occurring on or after October 1, 2008. Tables 1A and 1B in the Addendum to this proposed rule 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, 2008. 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 proposed Puerto Rico labor-related share of 58.7 percent for FY 2008 is reflected in the

Table 1C of the Addendum to this proposed rule.

IV. Other Decisions and Proposed Changes to the IPPS for Operating

Costs and GME Costs

A. Proposed Changes to the Postacute Care Transfer Policy (Sec. 412.4) 1. Background

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, the transferring hospital is paid based on a per diem rate for each day of the stay, not to exceed the full MS-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 MS-DRG payment by the geometric mean length of stay for the MS-DRG. Based on an analysis that showed that the first day of hospitalization is the most expensive (60 FR 5804), our policy generally provides for payment that is double the per diem amount for the first day, with each subsequent day paid at the per diem amount up to the full DRG payment (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

(adjusted for geographic variations in costs), divided by the geometric mean length of stay for the MS-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, a SNF, or home under a written plan of care for home health services early in the patients'' stay in order to minimize costs while still receiving the full MS-DRG payment. The transfer policy adjusts the payments to approximate the reduced costs of transfer cases.

Beginning with the FY 2006 IPPS, the regulations at Sec. 412.4 specified that, effective October 1, 2005, a DRG would be 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.

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 made 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 adopted for FY 2008 were a significant revision to the CMS DRG system (72 FR 47141). Because the MS-DRGs were not reflected in Version 23.0 of the DRG Definitions Manual, consistent with Sec. 412.4, we established policy to recalculate the 55th percentile thresholds in order to determine which MS-DRGs would be subject to the postacute care transfer policy (72 FR 47186 through 47188). Further, under

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the MS-DRGs, the subdivisions within the base DRGs are different than those under the previous CMS DRGs. Unlike the CMS DRGs, the MS-DRGs are not divided based on the presence or absence of a CC or MCV. Rather, the MS-DRGs have up to three subdivisions based on: (1) The presence of a MCC; (2) the presence of a CC; or (3) the absence of either an MCC or

CC. Consistent with our previous policy under which both CMS DRGs in a

CC/non-CC pair were qualifying DRGs if one of the pair qualified, we established that each MS-DRG that shared a base MS-DRG will be a qualifying DRG if one of the MS-DRGs that shared the base DRG qualifies. We revised Sec. 412.4(d)(3)(ii) to codify this policy.

Similarly, the adoption of the MS-DRGs also necessitated 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.

In addition, the hospital will receive 50 percent of the per diem amount for each subsequent day of the stay, up to the full MS-DRG payment amount. A CMS DRG was subject to the special payment methodology if it met the criteria of Sec. 412.4(f)(5). Section 412.4(f)(5)(iv) specifies that, for discharges occurring on or after

October 1, 2005, and prior to October 1, 2007, 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 was no longer applicable under the MS-DRG system, in the FY 2008 final rule with comment period, we added a new Sec. 412.4(f)(6)

(42 FR 47188 and 47410). Section 412.4(f)(6) provides that, for discharges on or after October 1, 2007, if an MS-DRG meets the criteria specified under Sec. Sec. 412.4(f)(6)(i) through (f)(6)(iii), any other MS-DRG that is part of the same MS-DRG group is also subject to the special payment methodology. We updated this criterion so that it conformed to the changes associated with adopting MS-DRGs for FY 2008.

The revision makes 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 1886(d)(5)(J) of the Act provides that, effective for discharges on or after October 1, 1998, a ``qualified discharge'' from one of DRGs selected by the Secretary to a postacute care provider would be treated as a transfer case. This section required the

Secretary to define and pay as transfers all cases assigned to one of the DRGs selected by the Secretary, if the individuals are discharged to one of the following postacute care settings:

A hospital or hospital unit that is not a subsection 1886(d) hospital. (Section 1886(d)(1)(B) of the Act identifies the hospitals and hospital units that are excluded from the term

``subsection (d) hospital'' as psychiatric hospitals and units, rehabilitation hospitals and units, children's hospitals, long-term care hospitals, and cancer hospitals.)

A SNF (as defined at section1819(a) of the Act).

Home health services provided by a home health agency, if the services relate to the condition or diagnosis for which the individual received inpatient hospital services, and if the home health services are provided within an appropriate period (as determined by the Secretary). In the FY 1999 IPPS final rule (63 FR 40975 through 40976 and 40979 through 40981), we specified that a patient discharged to home would be considered transferred to postacute care if the patient received home health services within 3 days after the date of discharge. In addition, in the FY 1999 IPPS final rule, we did not include patients transferred to a swing-bed for skilled nursing care in the definition of postacute care transfer cases (63 FR 40977). 2. Proposed Policy Change Relating to Transfers to Home with a Written

Plan for the Provision of Home Health Services

As noted above, in the FY 1999 IPPS final rule (63 FR 40975 through 40976 and 40979 through 40981), we determined that 3 days is an appropriate period within which home health services should begin following a beneficiary's discharge to the home in order for the discharge to be considered a ``qualified discharge'' subject to the payment adjustment for postacute care transfer cases. In that same final rule, we noted that we would monitor whether 3 days would remain an appropriate timeframe.

Section 1886(d)(5)(J)(ii)(III) of the Act provides that the discharge of an individual who receives home health services upon discharge will be treated as a transfer if ``such services are provided within an appropriate period as determined by the Secretary * * *''.

The statute thus confers upon the Secretary the authority to determine an appropriate timeframe for the application of the postacute care transfer policy in cases where home health services commence subsequent to discharge from an acute care hospital. In the FY 1999 final IPPS rule, we established the policy that the postacute care transfer policy would apply to cases in which the home health care begins within 3 days of the discharge from an acute care policy. We noted in that rule that we did not believe that it was appropriate to limit the transfer definition to cases in which home health care begins on the same day as the patient is discharged from the hospital. We observed that data indicated that less than 8 percent of discharged patients who receive home health care begin receiving those services on the date of discharge. It is unreasonable to expect that patients who are discharged later in the day would receive a home health visit that same day. Furthermore, we believed that the financial incentive to delay needed home health care for only a matter of hours would be overwhelming if we limited the timeframe to one day. At the time of that final rule, we explained that we believed that 3 days would be a more appropriate timeframe because it would mitigate the incentive to delay home health services to avoid the application of the postacute care transfer policy, and because a 3-day timeframe was consistent with existing patterns of care.

In that final rule, we also noted that a number of commenters had raised issues and questions concerning the proposal to adopt 3 days as the appropriate timeframe for the application of the postacute care transfer policy in these cases. While most of the commenters advocated shorter timeframes, on the grounds that postacute care beginning 3 days after a discharge should not be considered a substitute for inpatient hospital care, others suggested that a 3-day window might still allow for needlessly prolonged hospital care or delayed home health in order to avoid the application of the postacute care transfer policy.

Although MedPAC agreed with the commenters who asserted that home health care services furnished after a delay of more than one day may not necessarily be regarded as substituting for inpatient acute care, they also noted that a 3-day window allows for the fact that most home health patients do not receive care every day, as well as for those occasions in which there may be a delay in arranging for the provision of planned care (for

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example, an intervening weekend). The commission also stated that a shorter period may create a stronger incentive to delay the provision of necessary care beyond the window so that the hospital will receive the full DRG payment. In the light of these comments and, in particular, of the concern that a 3-day timeframe still allowed for some incentive to delay necessary home health services in order to avoid the application of the postacute care transfer policy, we indicated that we would continue to monitor this policy in order to track any changes in practices that may indicate the need for revising the window.

Since the adoption of this policy in FY 1999, we have continued to receive reports that some providers discharge patients prior to the geometric mean length of stay but intentionally delay home health services beyond 3 days after the acute hospital discharge in order to avoid the postacute care transfer payment adjustment policy. These reports, and the concerns expressed by some commenters in FY 1999 about the adequacy of a 3-day window to reduce such incentives, have prompted us to examine the available data concerning the initiation and program payments for home health care subsequent to discharge from postacute care.

We merged the FY 2004 MedPAR file with postacute care bill files matching beneficiary identification numbers and discharge and admission dates and looked at the 10 DRGs that were subject to the postacute care transfer policy from FYs 1999 through 2003 (DRG 14 (Intracranial

Hemorrhage and Stroke with Infarction (formerly ``Specific

Cerebrovascular Disorders Except Transient Ischemic Attack'')); DRG 113

(Amputation for Circulatory System Disorders Except Upper Limb and

Toe); DRG 209 (Major Joint Limb Reattachment Procedures of Lower

Extremity); DRG 210 (Hip and Femur Procedures Except Major Joint

Procedures 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 Angiotensin Converting Enzyme (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 Angiotensin Converting Enzyme (ACE) Inhibitor given to the patient?

Pneumonia (PN)

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?

This starter set of 10 quality measures was endorsed by the NQF.

The 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 hospital inpatient certification program.

We chose these 10 quality measures in order to collect data that would: (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 secure Web site (formerly known as QualityNet Exchange) (www.qualitynet.org). 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, 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 hospitals provide to patients, thereby providing an additional incentive to improve the quality of care that they furnish. c. Hospital Quality Data Reporting Under Section 501(b) of Pub. L. 108- 173

Section 1886(b)(3)(B)(vii) of the Act, as added by section 501(b) of Pub. L. 108-173, revised the mechanism used to update the standardized amount of payment for inpatient hospital operating costs.

Specifically, the statute provided for a reduction of 0.4 percentage points to the update percentage increase (also known as the market basket update) for each of FYs 2005 through 2007 for any subsection (d) hospital that does not submit data on a set of 10 quality indicators established by the Secretary as of November 1, 2003. The statute also provided that any reduction would apply only to the fiscal year involved, and would not be taken into account in computing the applicable percentage increase for a subsequent fiscal year. This measure established an incentive for IPPS hospitals to submit data on the quality measures established by the Secretary.

We initially implemented section 1886(b)(3)(B)(vii) of the Act in the FY 2005 IPPS final rule (69 FR 49078). In addition, we established the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program and added 42 CFR 412.64(d)(2) to our regulations. We adopted additional requirements under the RHQDAPU program in the FY 2006 IPPS final rule (70 FR 47420). d. Hospital Quality Data Reporting Under Section 5001(a) of Pub. L. 109-171

Section 5001(a) of the Deficit Reduction Act of 2005, Pub. L. 109- 171 (DRA), further amended section 1886(b)(3)(B) of the Act to revise 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 be reduced by 2.0 percentage points for any subsection (d) hospital that does not

Page 23644

submit certain quality data in a form and manner, and at a time, specified by the Secretary. Section 1886(b)(3)(B)(viii)(III) of the Act requires that the Secretary expand the ``starter set'' of 10 quality measures that were established by the Secretary as of November 1, 2003, as the Secretary determines to be appropriate for the measurement of the quality of care furnished by a hospital in inpatient settings. In expanding this set of measures, section 1886(b)(3)(B)(viii)(IV) of the

Act requires that, effective for payments beginning with FY 2007, the

Secretary begin to adopt the baseline set of performance measures as set forth in a December 2005 report issued by the Institute of Medicine

(IOM) of the National Academy of Sciences under section 238(b) of the

MMA.\16\

\16\ Institute of Medicine, ``Performance Measurement:

Accelerating Improvement,'' December 1, 2005, available at: www.iom.edu/CMS/3809/19805/31310.aspx.

The IOM measures include: 21 HQA quality measures (including the

``starter set'' of 10 quality measures); the HCAHPS patient experience of care survey; and 3 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 NQF'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, the Secretary add other quality measures that reflect consensus among affected parties, and to the extent feasible and practicable, have been set forth by one or more national consensus building entities, 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 is granted broad discretion to replace measures that are no longer appropriate for the RHQDAPU program.

Section 1886(b)(3)(B)(viii)(VII) of the Act requires that the

Secretary establish procedures for making quality data available to the public after ensuring that a hospital would have the opportunity to review its data before these data are made public. In addition, this section requires that the Secretary report quality measures of process, structure, outcome, patients' perspective of 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.

In the FY 2007 IPPS final rule (71 FR 48045), we amended our regulations at 42 CFR 412.64(d)(2) to reflect the 2.0 percentage point reduction in the payment update for FY 2007 and subsequent fiscal years for subsection (d) hospitals that do not comply with requirements for reporting quality data, as provided for under section 1886(b)(3)(B)(viii) of the Act. In the FY 2007 IPPS final rule, we also added 11 additional quality measures to the 10-measure starter set to establish an expanded set of 21 quality measures (71 FR 48033 through 48037).

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 measure 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/ASC final rule with comment period (71 FR 68201), we adopted six additional quality measures for the FY 2008 IPPS update, for a total of 27 measures. The measure set that we adopted for the FY 2008 payment determination was as follows:

Topic

Quality measure

Heart Attack (Acute Myocardial

Aspirin at arrival.*

Infarction)..

Aspirin prescribed at discharge.*

Angiotensin Converting

Enzyme Inhibitor (ACE-I) or

Angiotensin II Receptor

Blocker (ARB) for left ventricular systolic dysfunction.*

Beta blocker at arrival.*

Beta blocker prescribed at discharge.*

Fibrinolytic

(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.*

Angiotensin Converting

Enzyme Inhibitor (ACE-I) or

Angiotensin II Receptor

Blocker (ARB) for left ventricular systolic dysfunction.

Discharge instructions.**

Adult smoking cessation advice/counseling.**

Pneumonia (PN)......................... 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.**

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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/ASC final rule with comment period

(data submission required as of January 2007 for three additional SCIP measures).

For FY 2008, hospitals were required to submit data on 25 of the 27 measures. No data submission was required for the two mortality outcome measures (30-Day Risk Standardized Mortality Rates for Heart Failure and AMI), because they were calculated using existing administrative

Medicare claims data. The measures used for the payment determination included, for the first time, the HCAHPS patient experience of care survey as well as two outcome measures. These measures expanded the types of measures available for public reporting as required under section 1886(b)(3)(B)(viii) of the Act. In addition, the outcome measures, which are claims-based measures, did not increase the data submission requirements for hospitals, thereby reducing the burden associated with collection of data for quality reporting.

In the FY 2008 IPPS proposed rule (72 FR 24805), we proposed 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 under the

RHQDAPU program for the FY 2009 IPPS annual payment determination. We proposed to add the following five measures for the FY 2009 IPPS annual payment determination:

PN 30-day mortality measure (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

We stated that we planned to formally adopt these measures a year in advance in order to provide time for hospitals to prepare for changes related to the RHQDAPU program. We also stated that we anticipated that the proposed measures would be endorsed by the NQF, as a national consensus building entity. Finally, we stated that any proposed measure that was not endorsed by the NQF by the time that we published the FY 2008 IPPS final rule with comment period would not be finalized in that final rule.

At the time we published the FY 2008 IPPS final rule with comment period, only the PN 30-day mortality measure had been endorsed by the

NQF. Therefore, we finalized only that measure as part of the FY 2009

IPPS measure set and stated that we would further address adding additional measures in the CY 2008 OPPS/ASC final rule and, if necessary, in the FY 2009 IPPS proposed and final rules. We also responded to comments we had received on the five proposed measures (72

FR 47348 through 47351).

In the CY 2008 OPPS/ASC final rule with comment period (72 FR 66875), we noted that the NQF had endorsed the following additional process measures that we had proposed to include in the FY 2009 RHQDAPU program measure set:

SCIP Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative

Serum Glucose

SCIP Infection 6: Surgery Patients with Appropriate Hair

Removal

As we stated in the FY 2008 IPPS proposed rule (72 FR 24805), these measures reflect our continuing commitment to quality improvement in both clinical care and quality. These quality measures reflect consensus among affected parties as demonstrated by endorsement by a national consensus building entity. The addition of these two measures for the FY 2009 measure set bring the total number of measures in that measure set to 30 (72 FR 66876).

The measure set to be used for FY 2009 annual payment determination is as follows:

Topic

Quality measure

Heart Attack (Acute Myocardial

Aspirin at arrival*.

Infarction).

Aspirin prescribed at discharge*.

Angiotensin Converting

Enzyme Inhibitor (ACE-I) or

Angiotensin II Receptor

Blocker (ARB) for left ventricular systolic dysfunction*.

Beta blocker at arrival*.

Beta blocker prescribed at discharge*.

Fibrinolytic

(thrombolytic) agent received within 30 minutes of hospital arrival**.

Primary Percutaneous

Coronary Intervention (PCI) received within 120 minutes of hospital arrival**.

Adult smoking cessation advice/counseling**.

Heart Failure (HF)..................... Left ventricular function assessment*.

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Angiotensin Converting

Enzyme Inhibitor (ACE-I) or

Angiotensin II Receptor

Blocker (ARB) for left ventricular systolic dysfunction*.

Discharge instructions**.

Adult smoking cessation advice/counseling**.

Pneumonia (PN)......................... 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***.

SCIP-Infection 4:

Cardiac Surgery Patients with

Controlled 6AM Postoperative

Serum Glucose*****.

SCIP Infection 6:

Surgery Patients with

Appropriate Hair Removal*****.

Mortality Measures (Medicare patients). Acute Myocardial

Infarction 30-day mortality

Medicare patients***.

Heart Failure 30-day mortality Medicare patients***.

Pneumonia 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/ASC final rule with comment period.

**** Measure added in FY 2008 IPPS final rule with comment period.

***** Measure added in CY 2008 OPPS/ASC final rule with comment period

(data submission required effective with discharges starting January 1, 2008).

We also stated in the FY 2008 IPPS final rule with comment period and the CY 2008 OPPS/ASC final rule with comment period that the

RHQDAPU program participation requirements for the FY 2009 program would apply to additional measures we adopt for the FY 2009 program (72

FR 47361; 72 FR 66877).

Therefore, hospitals are required to start submitting data for SCIP

Infection 4 and SCIP Infection 6 starting with first quarter calendar year 2008 discharges and subsequent quarters until further notice.

Hospitals must submit their aggregate population and sample size counts for Medicare and non-Medicare patients. These requirements are consistent with the requirements for the other AMI, HF, PN, and SCIP process measures included in the FY 2009 measure set. The complete list of procedures for participating in the RHQDAPU program for FY 2009 are provided in the FY 2008 IPPS final rule with comment period (72 FR 47359 through 47361).

Because SCIP Cardiovascular 2 and SCIP Infection 7 had not been endorsed by a national consensus building entity by the publishing deadline for the CY 2008 OPPS/ASC final rule with comment period, we did not adopt these measures as part of the FY 2009 IPPS measure set.

In the FY 2008 IPPS proposed rule, we also solicited public comments on 18 measures and 8 measure sets that could be selected for future inclusion in the RHQDAPU program (72 FR 24805). These measures and measure sets highlight our 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 included measures that have not yet received endorsement by a national consensus review process for public reporting. The list also included measures developed by organizations other than CMS as well as measures that can be calculated using administrative data (such as claims).

We solicited public comment not only on the measures and measure sets that were listed, but also on whether there were any critical gaps or ``missing'' measures or measure sets. We specifically requested input concerning the following issues:

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?

In the FY 2008 IPPS final rule with comment period (72 FR 47351), after consideration of the public comments received, we decided not to adopt any of these measures or measure sets for FY 2009. We indicated that we will continue to consider some of these measures and measure sets for subsequent years. 2. Proposed Quality Measures for FY 2010 and Subsequent Years a. Proposed Quality Measures for FY 2010

For FY 2010, we are proposing to require continued submission of data on 26 of the 30 existing AMI, Heart Failure,

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Pneumonia, HCAHPS, and SCIP measures adopted for FY 2009. As noted above, the three outcome measures do not require hospitals to submit data. In addition, we are proposing to remove the Pneumonia Oxygenation

Assessment measure from the RHQDAPU program measure set. We are proposing to discontinue requiring hospitals to submit data on the

Pneumonia Oxygenation Assessment measure, effective with discharges beginning January 1, 2009. Section 1886(b)(3)(B)(viii)(VI) of the Act provides 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. We interpret this to authorize the Secretary to remove or retire measures from the

RHQDAPU program.

In the case of the Pneumonia Oxygenation Assessment measure, the vast majority of hospitals are performing near 100 percent. In addition, oxygenation assessment is routinely performed by hospitals for admitted patients without regard to the specific diagnosis. Thus, the measure is topped out so completely across virtually all hospitals as to provide no significant opportunity for improvement. We believe that the burden to hospitals to abstract and report these data outweighs the benefit in publicly reporting hospital level data with very little variation among hospitals. We do not expect that the retirement of the Pneumonia Oxygenation Assessment measure will result in the deterioration of care. However, if we determine otherwise, we may seek to reintroduce the measure.

The proposed removal of the Pneumonia Oxygenation Assessment measure for FY 2010 represents the first instance of retiring a measure. We intend to review other existing chart-abstracted measures recognizing the significant burden to hospitals that chart abstraction requires. In this way, we seek to maximize the value of the RHQDAPU program to promote quality improvement by hospitals and to report information that the public will find beneficial in choosing inpatient hospital services. We invite comment on the retirement of the Pneumonia

Oxygenation Assessment measure. In addition, we invite comment on other measures that may be suitable for retirement from the RHQDAPU program measure set. Finally, we invite comment on the following general considerations relevant to retiring measures:

Should CMS retire a RHQDAPU program measure when hospital performance on the measure has reached a high threshold (that is, performance on the measure has topped out) even if the measure still reflects best practice?

Are there reasons to consider retiring a measure other than high overall performance?

When a measure is retired on the basis of substantially complete compliance by hospitals, should data collection on the measure again be required after 1 or 2 years to assure that a high compliance level remains, or should some other way of monitoring continued hospital compliance be used?

The specifications for two of the existing measures have been updated by the NQF, effective May 2007, with respect to the applicable timing interval. For the measures previously identified as:

AMI--Primary Percutaneous Coronary Intervention (PCI) received within 120 minutes of hospital arrival, the NQF has revised its endorsement of the specifications to reflect that the timing interval has been changed to PCI within 90 minutes of arrival.

Pneumonia--Initial antibiotic received within 4 hours of hospital arrival, the NQF has revised its endorsement of the specifications to reflect that the initial antibiotic must be received within 6 hours of arrival.

In the FY 2008 IPPS final rule with comment period, one commenter

``urged CMS to develop a policy to harmonize measures that related to payment, such as the NQF's move from a 4-hour timeframe for initial antibiotic administration for pneumonia patients to a 6-hour timeframe

(72 FR 47357).'' Another commenter raised the issue of the timing for

PCI in the AMI topic (72 FR 47347-8). In response to these comments, we responded that if we believe that a change is an appropriate change for the RHQDAPU program, we would expect to adopt it.

Because the NQF is now endorsing different timing intervals with respect to these measures, we are proposing to also update these measures for the purposes of the FY 2010 RHQDAPU program. The updated measures are as follows:

AMI--Timing of Receipt of Primary Percutaneous Coronary

Intervention (PCI); and

Pneumonia--Timing of receipt of initial antibiotic following hospital arrival.

We note that the technical specifications for these measures will not change, and hospitals will continue to submit the same data that they currently submit. However, beginning with discharges on or after

January 1, 2009, CMS will calculate the measures using the updated timing intervals.

The NQF updated these two measures to reflect the most current consensus standards effective May 2007. Because this was after we issued the FY 2008 IPPS proposed rule, we could not adopt the updated measures in the FY 2008 IPPS final rule with comment period or CY 2008

OPPS/ASC final rule with comment period. We also recognized that we did not have in place a subregulatory process that would have permitted us to update the measures. Therefore, we announced that hospitals could suppress the public reporting of the quality data for the two measures for hospital discharges starting with April 1, 2007 discharges. We did this because we believe that hospitals should not be held to out-of- date consensus standards for public reporting pending the next regulatory cycle.

We propose, in the future, to act on updates to existing RHQDAPU program measures made by a consensus building entity such as the NQF through a subregulatory process. This is necessary to be able to utilize the most up-to-date consensus standards in the RHQDAPU program, and recognizes that neither scientific advances nor consensus building entity standard updates are linked to the timing of regulatory actions.

We propose to implement updates to existing RHQDAPU program measures and provide notification through the Qualitynet Web site, and additionally in the CMS/Joint Commission Specifications Manual for

National Hospital Inpatient Quality Measures where data collection and measure specifications changes are necessary. We invite comment on this proposal.

Under section 1886(b)(3)(B)(viii)(III) of the Act, the Secretary shall expand the RHQDAPU program measures beyond the measures specified as of November 1, 2003. Under section 1886(b)(3)(B)(viii)(V) of the

Act, these measures, to the extent feasible and practicable, shall include measures set forth by one or more national consensus building entities.

We are proposing to add the following 43 measures for the FY 2010 payment determination: a SCIP measure that we proposed last year; 4 nursing sensitive measures; 3 readmission measures; 6 Venous

Thromboembolism measures; 5 stroke measures; 9 AHRQ measures; and 15 cardiac surgery measures.

We are proposing to add SCIP Cardiovascular 2, Surgery Patients on a Beta Blocker Prior to Arrival Who Received a Beta Blocker During the

Perioperative Period. This measure was initially proposed last year in the FY 2008 IPPS proposed rule, but because the NQF had not endorsed this measure

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at the time we issued the FY 2008 IPPS final rule with comment period or the CY 2008 OPPS/ASC final rule with comment period, we did not adopt it. For the purposes of proposing the FY 2010 RHQDAPU program measure set, CMS believes that NQF endorsement of a measure represents a standard for consensus among affected parties as specified in section 1886(b)(3)(B)(viii)(V) of the Act. The NQF is an independent health care quality endorsement organization with a diverse representation of consumer, purchaser, provider, academic, clinical, and other health care stakeholder organizations.

In November 2007, the NQF endorsed SCIP Cardiovascular 2. CMS believes that this measure targets an important process of care, beta blocker administration for noncardiac surgery patients. Therefore, we are now proposing to add SCIP Cardiovascular 2 to the RHQDAPU program measures for FY 2010. The specifications and data collection tools are currently available through the Qualitynet Web site and in the CMS/

Joint Commission Specifications Manual for National Hospital Inpatient

Quality Measures for hospitals to utilize and submit data for this measure. We are proposing that hospitals be required to submit data on this measure beginning with January 1, 2009 discharges.

We also are proposing to add four nursing sensitive measures to the

RHQDAPU program measure set for FY 2010. The four measures are:

Failure to Rescue

Pressure Ulcer Prevalence and Incidence by Severity (Joint

Commission developed measure; all patient data from chart abstraction)

Patient Falls Prevalence

Patient Falls with Injury

These measures broaden the ability of the RHQDAPU program measure set to assess care generally associated with nursing staff. In addition, these measures are directed toward outcomes that are underrepresented among the RHQDAPU program measures. These measures apply to the vast majority of inpatient stays and provide a great deal of critical information about hospital quality to consumers and stakeholders. The specifications and data collection tools are scheduled to be available in the specifications manual by December 2008 for hospitals to utilize and submit data for these measures. We are proposing that hospitals be required to submit data on these four measures effective with discharges beginning April 1, 2009. While these measures are endorsed by NQF, the Joint Commission has initiated rigorous field testing of the measures, which may not be completed until late 2008. Therefore, it is possible that the endorsement status of these measures may change in the next several months. If this rigorous field testing results in uncertainty as to the NQF endorsement status at the time we issue the FY 2009 IPPS final rule, we will defer our final decision on whether to require these measures for the RHQDAPU program for FY 2010 until the time that we issue the CY 2009 OPPS/ASC final rule with comment period. This deferral is consistent with our measure expansion during the past 2 years, when we finalized some

RHQDAPU program measures in the annual OPPS/ASC final rules.

We are proposing to adopt three readmission measures for FY 2010 that will be calculated using Medicare administrative claims data. The proposed measures are:

Pneumonia (PN) 30-Day Risk Standardized Readmission

Measure (Medicare patients)

Heart Attack (AMI) 30-Day Risk Standardized Readmission

Measure (Medicare patients)

Heart Failure (HF) 30-Day Risk Standardized Readmission

Measure (Medicare patients)

These readmission measures assess both quality of care and efficiency of care. They also promote coordination of care among hospitals and other providers. They compliment the existing 30-Day Risk

Standardized Mortality Measures for Pneumonia, Heart Attack, and Heart

Failure. These measures require no additional data collection from hospitals. The measures are risk adjusted to account for differences between hospitals in the characteristics of their patient populations.

These three claims-based readmission measures are pending NQF endorsement. The NQF endorsement decision on these three measures is expected before we issue the FY 2009 IPPS final rule. We are proposing to add these three measures contingent upon NQF endorsement. We are also proposing to defer our decision on whether to include these measures until we issue the CY 2009 OPPS/ASC final rule, in the event that NQF endorsement status is still pending when we issue the FY 2009

IPPS final rule. This deferral is consistent with our measure expansion during the past 2 years, when we finalized some RHQDAPU program measures in the annual OPPS/ASC final rules.

We are also proposing to add six Venous Thromboembolism (VTE) measures. These measures comprehensively address a major cause of morbidity and mortality among hospitalized patients.

VTE-1: VTE Prophylaxis

VTE-2: VTE Prophylaxis in the ICU

VTE-4: Patients with overlap in anticoagulation therapy

VTE-5/6: (as combined measure) Patients with UFH dosages who have platelet count monitoring and adjustment of medication per protocol or nomogram

VTE-7: Discharge instructions to address: follow-up monitoring, compliance, dietary restrictions and adverse drug reactions/interactions

VTE-8: Incidence of preventable VTE

These VTE measures are pending NQF endorsement. The NQF endorsement decision on these measures is expected before we issue the FY 2009 IPPS final rule. We are proposing to add these measures contingent upon NQF endorsement. We also are proposing to defer our decision on whether to include these measures until we issue the CY 2009 OPPS/ASC final rule with comment period, in the event that NQF endorsement status is still pending when we issue the FY 2009 IPPS final rule. This deferral is consistent with our measure expansion during the past 2 years, when we finalized some RHQDAPU program measures in the annual OPPS/ASC final rules. We are proposing that hospitals be required to submit data on these six measures effective with discharges beginning January 1, 2009.

We also are proposing to add five Stroke measures that will apply only to certain identified groups under specific ICD-9-CM codes as specified in the specifications manual. These measures comprehensively address an important condition not currently covered by the RHQDAPU program that is associated with significant morbidity and mortality.

STK-1 DVT Prophylaxis

STK-2 Discharged on Antithrombotic Therapy

STK-3 Patients with Atrial Fibrillation Receiving

Anticoagulation Therapy

STK-5 Antithrombotic Medication By End of Hospital Day Two

STK-7 Dysphasia Screening

These Stroke measures are pending NQF endorsement. The NQF endorsement decision on these measures is expected before we issue the

FY 2009 IPPS final rule. We are proposing to add these measures contingent upon NQF endorsement. We also are proposing to defer our adoption of these measures until we issue the CY 2009 OPPS/ASC final rule with comment period in the event that NQF

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endorsement status is still pending as of the time we issue the FY 2009

IPPS final rule. This approach is consistent with our measure expansion during the past 2 years, when CMS finalized some RHQDAPU program measures in the annual OPPS/ASC final rules. We are proposing that hospitals be required to submit data on these five measures effective with discharges beginning July 1, 2009.

We also are proposing to add the following nine AHRQ Patient Safety

Indicators (PSI) and Inpatient Quality Indicators (IQI) that have been endorsed by the NQF:

Patient Safety Indicator (PSI) 4--Death among surgical patients with treatable serious complications

PSI 6--Iatrogenic pneumothorax, adult

PSI 14--Postoperative wound dehiscence

PSI 15--Accidental puncture or laceration

Inpatient Quality Indicator (IQI) 4 and 11--Abdominal aortic aneurysm (AAA) mortality rate (with or without volume)

IQI 19--Hip fracture morality rate

IQI Mortality for selected medical conditions (composite)

IQI Mortality for selected surgical procedures (composite)

IQI Complication/patient safety for selected indicators

(composite)

These are claims-based outcome measures. They are important additional measures that can be calculated for hospital inpatients without the burden of additional chart abstraction. Hospitals currently collect and submit these data to CMS and other insurers for reimbursement. These measures will be calculated using all-payer claims data that hospitals currently collect with respect to each patient discharge. We are proposing to require hospitals to submit to CMS the all-payer claims data that we specify in the technical specifications manual as necessary to calculate the AHRQ PSI/IQI measures. We are proposing that hospitals begin submitting data on a quarterly basis on these measures to CMS by April 1, 2010 beginning with October 1, 2009 discharges.

However, we are aware that a large number of hospitals already submit these data on a voluntary basis to third party data aggregators such as State health agencies or State hospital associations. We seek comments on whether a hospital that already submits the data necessary to calculate these measures to such entities should be permitted to authorize such an entity to transmit these data to CMS, in accordance with applicable confidentiality laws, on their behalf. This would relieve the hospital of the burden of having to submit the same data directly to CMS via the QIO Clinical Warehouse.

As an alternative to requiring that hospitals submit all-payer claims data for purposes of calculating the AHRQ PSI/IQI measures, CMS is considering whether it should initially calculate the AHRQ PSI/IQI measures using Medicare claims data only, and at a subsequent date require submission of all-payer claims data. We also seek comment on this alternative.

We also are proposing to add 15 cardiac surgery measures. Cardiac surgical procedures carry a significant risk of morbidity and mortality. We believe that the nationwide public reporting of these cardiac surgery measures would provide highly meaningful information for the public.

Currently, over 85 percent of hospitals with a cardiac surgery program submit data on the proposed cardiac surgery measures listed below to the Society of Thoracic Surgeons (STS) Cardiac Surgery

Clinical Data Registry. We are proposing to accept these data from the

STS registry beginning on July 1, 2009, on a quarterly basis for discharges on or after January 1, 2009. Hospitals that participate in the RHQDAPU program, but that do not submit data on the proposed cardiac surgery measures to the STS registry for discharges on or after

January 1, 2009, would need to submit such data to CMS. Although we would accept cardiac surgery data from other clinical data registries, we are unaware of any other registries that collect all of the data necessary to support calculation of the proposed cardiac surgery measures. Hospitals and CMS would need to establish appropriate legal arrangements, to the extent such arrangements are necessary, to ensure that the transfer of these data from the STS registry to CMS complies with all applicable laws. By accepting these registry-based data, only those hospitals with cardiac surgery programs that do not already collect such data to submit to the STS registry will have any additional data submission burden. All of the proposed measures are currently NQF-endorsed. We are proposing that hospitals begin submitting data by July 1, 2009, on a quarterly basis on the following 15 cardiac surgery measures to the STS data registry or CMS for 1st quarter calendar year 2009 discharges:

Participation in a Systematic Database for Cardiac Surgery

Pre-Operative Beta Blockade

Prolonged Intubation

Deep Sternal Wound Infection Rate

Stroke/CVA

Post-Operative Renal Insufficiency

Surgical Reexploration

Anti-Platelet Medication at Discharge

Beta Blockade Therapy at Discharge

Anti-Lipid Treatment at Discharge

Risk-Adjusted Operative Mortality for CABG

Risk-Adjusted Operative Mortality for Aortic Valve

Replacement

Risk-Adjusted Operative Mortality for Mitral Valve

Replacement/Repair

Risk-Adjusted Mortality for Mitral Valve Replacement and

CABG Surgery

Risk-Adjusted Mortality for Aortic Valve Replacement and

CABG Surgery

The following table lists the 72 proposed measures for FY 2010:

Topic

Quality measure

Heart Attack (Acute Myocardial

AMI-1 Aspirin at

Infarction).

arrival *.

AMI-2 Aspirin prescribed at discharge *.

AMI-3 Angiotensin

Converting Enzyme Inhibitor

(ACE-I) or Angiotensin II

Receptor Blocker (ARB) for left ventricular systolic dysfunction *.

AMI 6 Beta blocker at arrival *.

AMI-5 Beta blocker prescribed at discharge *.

AMI-7a Fibrinolytic

(thrombolytic) agent received within 30 minutes of hospital arrival**.

AMI-4 Adult smoking cessation advice/counseling**.

AMI-8a Timing of

Receipt of Primary

Percutaneous Coronary

Intervention (PCI).

Heart Failure (HF)..................... HF-2 Left ventricular function assessment *.

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HF-3 Angiotensin

Converting Enzyme Inhibitor

(ACE-I) or Angiotensin II

Receptor Blocker (ARB) for left ventricular systolic dysfunction *.

HF-1 Discharge instructions**.

HF-4 Adult smoking cessation advice/counseling**.

Pneumonia (PN)......................... PN-2 Pneumococcal vaccination status *.

PN-3b Blood culture performed before first antibiotic received in hospital**.

PN-4 Adult smoking cessation advice/counseling**.

PN-6 Appropriate initial antibiotic selection**.

PN-7 Influenza vaccination status**.

PN-5c Timing of receipt of initial antibiotic following hospital arrival******.

Surgical Care Improvement Project

SCIP-1 Prophylactic

(SCIP)--named SIP for discharges prior antibiotic received within 1 to July 2006 (3Q06).

hour prior to surgical incision**.

SCIP-3 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***.

SCIP-Infection 4:

Cardiac Surgery Patients with

Controlled 6AM Postoperative

Serum Glucose*****.

SCIP Infection 6:

Surgery Patients with

Appropriate Hair Removal*****.

SCIP Cardiovascular 2:

Surgery Patients on a Beta

Blocker Prior to Arrival Who

Received a Beta Blocker During the Perioperative

Period******.

Mortality Measures (Medicare patients). MORT-30-AMI Acute

Myocardial Infarction 30-day mortality Medicare patients***.

MORT-30-HF Heart

Failure 30-day mortality

Medicare patients***.

MORT-30-PN Pneumonia 30-day mortality Medicare patients****.

Patients' Experience of Care........... HCAHPS patient survey***.

Readmission Measures (Medicare

Heart Attack (AMI) 30- patients).

Day Risk Standardized

Readmission Measure (Medicare patients)******.

Heart Failure (HF) 30-

Day Risk Standardized

Readmission Measure (Medicare patients)******.

Pneumonia (PN) 30-Day

Risk Standardized Readmission

Measure (Medicare patients)

******.

Inpatient Stroke Care.................. STK-1 DVT

Prophylaxis******.

STK-2 Discharged on

Antithrombotic Therapy******.

STK-3 Patients with

Atrial Fibrillation Receiving

Anticoagulation Therapy******.

STK-5 Antithrombotic

Medication By End of Hospital

Day Two******.

STK-7 Dysphasia

Screening******.

Venous Thromboembolic Care............. VTE-1: VTE

Prophylaxis******.

VTE-2: VTE Prophylaxis in the ICU******.

VTE-4: Patients with overlap in anticoagulation therapy******.

VTE-5/6: (as combined measure) patients with UFH dosages who have platelet count monitoring and adjustment of medication per protocol or nomagram******.

VTE-7: Discharge instructions to address: followup monitoring, compliance, dietary restrictions, and adverse drug reactions/interactions******.

VTE-8: Incidence of preventable VTE******.

AHRQ Patient Safety Indicators......... Death among surgical patients with treatable serious complications******.

Iatrogenic pneumothorax, adult******.

Postoperative wound dehiscence******.

Accidental puncture or laceration******.

AHRQ Inpatient Quality Indicators (IQI) Abdominal aortic aneurysm (AAA) mortality rate

(with or without volume)

******.

Hip fracture morality rate******.

AHRQ IQI Composite Measures............ Mortality for selected surgical procedures

(composite) ******.

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Complication/patient safety for selected indicators

(composite) ******.

Mortality for selected medical conditions (composite)

******.

Nursing Sensitive Measures............. Failure to

Rescue******.

Pressure Ulcer

Prevalence and Incidence by

Severity ******.

Patient Falls

Prevalence******.

Patient Falls with

Injury******.

Cardiac Surgery Measures............... Participation in a

Systematic Database for

Cardiac Surgery ******.

Pre-operative Beta

Blockade******.

Prolonged

Intubation******.

Deep Sternal Wound

Infection Rate******.

Stroke/CVA******.

Postoperative Renal

Insufficiency******.

Surgical

Reexploration******.

Anti-platelet

Medication at Discharge******.

Beta Blockade Therapy at Discharge******.

Anti-lipid Treatment at Discharge******.

Risk-Adjusted

Operative Mortality for

CABG******.

Risk-Adjusted

Operative Mortality for Aortic

Valve Replacement******.

Risk-Adjusted

Operative Mortality for Mitral

Valve Replacement/

Repair******.

Risk-Adjusted

Mortality for Mitral Valve

Replacement and CABG

Surgery******.

Risk-Adjusted

Mortality for Aortic Valve

Replacement and CABG Surgery

******.

*Measure included in 10 measure starter set.

**Measure included in 21 measure expanded set.

***Measure added in CY 2007 OPPS/ASC final rule with comment period.

****Measure added in FY 2008 IPPS final rule with comment period.

*****Measure added in CY 2008 OPPS/ASC final rule with comment period.

******Measure proposed in FY 2009 IPPS proposed rule.

In summary, we are proposing to increase the RHQDAPU program measures from 30 measures for FY 2009 to a total of 72 measures for FY 2010. The following table lists the increase in the RHQDAPU program measure set since the program's inception:

Number of

RHQDAPU

IPPS payment year

program

Topics covered quality measures

2005-2006...........................

10 AMI, HF, PN. 2007................................

21 AMI, HF, PN, SCIP. 2008................................

27 AMI, HF, PN, SCIP, Mortality, HCAHPS. 2009................................

30 AMI, HF, PN, SCIP, Mortality, HCAHPS. 2010................................

72 AMI, HF, PN, SCIP, Mortality, HCAHPS, Nursing Sensitive,

Readmission, VTE, Stroke, AHRQ IQI/PSI measures and composites, Cardiac Surgery.

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.

To the extent that the proposed measures have not already been endorsed by a consensus building entity such as the NQF, we anticipate that they will be endorsed prior to the time that we issue the FY 2009

IPPS final rule. We intend to finalize the FY 2010 RHQDAPU program measure set in the FY 2009 IPPS final rule, contingent on the endorsement status of the proposed measures. However, to the extent that a measure has not received NQF endorsement by the time we issue the FY 2009 IPPS final rule, we intend to finalize that measure for the

FY 2010 RHQDAPU program measure set in the CY 2009 OPPS/ASC final rule with comment period if the measure is endorsed prior to the time we issue the CY-2009-OPPS/ASC final rule with comment period. We are requesting public comment on these measures. b. Possible New Quality Measures, Measure Sets, and Program

Requirements for FY 2011 and Subsequent Years

The following table contains a list of 59 measures and 4 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

Page 23652

been considered for approval by the HQA or endorsed by a consensus review process such as the NQF. 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 are seeking public comment on the measures and measure sets that are listed as well as any critical gaps or missing measures or measure sets. We specifically request input concerning the following:

Which of the measures or measure sets should be included in the RHQDAPU program for FY 2011 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?

We are soliciting public comment on the following measure sets for consideration in FY 2011 and subsequent years:

Possible Measures and Measure Sets for the RHQDAPU Program for FY 2011 and Subsequent Years

Topic

Quality measure

Chronic Pulmonary Obstructive Disease

Measures:

Complications of Vascular Surgery.. AAA stratified by open and endovascular methods.

Carotid Endarterectomy.

Lower extremity bypass.

Inpatient Diabetes Care Measures:

Healthcare Associated Infection.... Central Line-Associated Blood

Stream Infections.

Surgical Site Infections.

Timeliness of Emergency Care Measures, Median Time from ED Arrival to including Timeliness.

ED Departure for Admitted ED

Patients.

Median Time from ED Arrival to

ED Departure for Discharged ED

Patients.

Admit Decision Time to ED

Departure Time for Admitted

Patients.

Surgical Care Improvement Project

SCIP Infection 8--Short Half-

(SCIP)--named SIP for discharges prior life Prophylactic Administered to July 2006 (3Q06).

Preoperatively Redosed Within 4 Hours After Preoperative

Dose.

SCIP Cardiovascular 3--Surgery

Patients on a Beta Blocker

Prior to Arrival Receiving a

Beta Blocker on Postoperative

Days 1 and 2.

Complication Measures (Medicare patients):

Healthcare Acquired Conditions..... Serious reportable events in healthcare (never events).

Pressure ulcer prevalence and incidence by severity.

Catheter-associated UTI.

Hospital Inpatient Cancer Care Measures Patients with early stage breast cancer who have evaluation of the axilla.

College of American

Pathologists breast cancer protocol.

Surgical resection includes at least 12 nodes.

College of American

Pathologists Colon and rectum protocol.

Completeness of pathologic reporting.

Serious Reportable Events in Healthcare Surgery performed on the wrong

(``Never Events'').

body part.

Surgery performed on the wrong patient.

Wrong surgical procedure on a patient.

Retention of a foreign object in a patient after surgery or other procedure.

Intraoperative or immediately post-operative death in a normal health patient (defined as a Class 1 patient for purposes of the American

Society of Anesthesiologists patient safety initiative).

Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility.

Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended.

Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility.

Patient death or serious disability associated with patient elopement

(disappearance) for more than four hours.

Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility.

Patient death or serious disability associated with a medication error (e.g., error involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration).

Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO- incompatible blood or blood products.

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Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility.

Stage 3 or 4 pressure ulcers acquired after admission to a health care facility.

Patient death or serious disability due to spinal manipulative therapy.

Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility.

Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances.

Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility.

Patient death associated with a fall while being cared for in a health care facility.

Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility.

Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.

Abduction of a patient of any age.

Sexual assault on a patient within or on the grounds of a health care facility.

Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a health care facility.

Average Length of Stay Coupled with

Global Readmission Measure:

Preventable Hospital-Acquired

Catheter-Associated Urinary

Conditions (HACs).

Tract Infection (UTI).

Vascular Catheter-Associated

Infection.

Surgical Site Infections--

Mediastinitis after Coronary

Artery Bypass Graft (CABG).

Surgical Site Infections following Elective Procedures--

Total Knee Replacement,

Laparoscopic Gastric Bypass,

Litigation and Stripping of

Varicose Veins.

Legionnaires' Disease.

Glycemic Control--Diabetic

Ketoacidosis, Nonketotic

Hypersmolar Coma, Hypoglycemic

Coma.

Iatrogenic pneumothorax.

Delirium.

Ventilator-Associated Pneumonia

(VAP).

Deep Vein Thrombosis (DVT)/

Pulmonary Embolism (PE).

Staphylococcus aureus

Septicemia.

Clostridium-Difficile

Associated Disease (CDAD).

Methicillin-Resistant

Staphylococcus aureus (MRSA).

c. Considerations in Expanding and Updating Quality Measures Under the

RHQDAPU Program

The RHQDAPU program has significantly expanded from an initial set of 10 measures to 30 measures for the FY 2009 payment determination.

Initially, the conditions covered by the RHQDAPU program measures were limited to Acute Myocardial Infarction, Heart Failure, and Pneumonia, three high-cost and high-volume conditions. In expanding the process measures, Surgical Infection Prevention was the first additional focus, now supplemented by the two Venous Thromboembolism SCIP measures SCIP

VTE-1 and SCIP VTE-2 for surgical patients. Of the 30 current measures, 27 require data collection from chart abstraction and surveying patients and submission of detailed data elements.

In looking forward to further expansion of the RHQDAPU program, we believe it is important to take several goals into consideration. These include: (a) Expanding the types of measures beyond process of care measures to include an increased number of outcome measures, efficiency measures, and experience-of-care measures; (b) expanding the scope of hospital services to which the measures apply; (c) considering the burden on hospitals in collecting chart-abstracted data; (d) harmonizing the measures used in the RHQDAPU program with other CMS quality programs to align incentives and promote coordinated efforts to improve quality; (e) seeking to use measures based on alternative sources of data that do not require chart abstraction or that utilize data already being broadly reported by hospitals, such as clinical data registries or all-payer claims data bases; and (f) weighing the meaningfulness and utility of the measures compared to the burden on hospitals in submitting data under the RHQDAPU program.

We request comments on how to reduce burden on the hospitals participating in the RHQDAPU program. We realize that our proposal to expand the RHQDAPU program measure set from submission of 30 measures in FY 2009 to 72 measures in FY 2010 is potentially burdensome.

However, to minimize hospitals' burden, the proposed expansion uses many existing

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data sources, including Medicare claims and registry data. We also request comment about which measures would be most useful while minimizing burden.

(1) Expanding the Types of Measures

Section 1886(b)(3)(B)(viii)(III) of the Act requires the Secretary to add other quality measures that the Secretary determines to be appropriate for the measurement of the quality of care furnished by hospitals in inpatient settings. We intend to expand outcome measures such as mortality measures and measures of complications. For FY 2010, the proposed measure set includes:

Patient Experience of Care. HCAHPS collects data regarding a patient's experience of care in the hospital and provides a very meaningful perspective from the patient standpoint.

Efficiency. Efficiency is a Quality Domain, as defined by the IOM, that relates Quality and Cost. The three proposed readmission measures address hospital efficiency. These are considered efficiency measures because higher hospital readmission rates are linked to higher costs and also to lower quality of care received during hospitalization and after the initial hospital stay. We are also seeking additional ways in which to address efficiency.

Outcomes. The three 30-day mortality measures, the STS cardiac surgery measures, the AHRQ PSI/IQI measures, and the four outcome-related nursing sensitive measures represent significant expansion of the RHQDAPU program outcome measures. Additional outcome measures are provided in the list under consideration for inclusion in the RHQDAPU program for FY 2010 and beyond.

(2) Expanding the Scope of Hospital Services To Which Measures Apply

Many of the most common and high-cost Medicare DRGs were posted on the Hospital Compare Web site in March 2008 as part of the President's transparency initiative. We have assessed these DRGs and have found that the FY 2009 RHQDAPU program measure set does not capture data regarding care in important areas such as Inpatient Diabetes Care,

Chronic Obstructive Pulmonary Disease (COPD), and Chest Pain. These are areas for which we currently do not have quality measures but which constitute a significant portion of the top paying DRGs for Medicare beneficiaries. We intend to develop measures in these areas in order to provide additional quality information on the most common and high-cost conditions that affect Medicare beneficiaries. In the proposed FY 2010 measure set, measures have been expanded to comprehensively address services related to preventing Venous Thromboembolism, treatment of stroke, and nursing services.

(3) Considering the Burden on Hospitals in Collecting Chart-Abstracted

Data for Measures

Although we are proposing to add additional chart-abstracted measures for FY 2010, we also are proposing to stagger the dates for which data collection for these measures must begin, which we believe will lessen the burden on hospitals as they incorporate these new measures into their systems. We also intend to work to simplify the data abstraction specifications that add to the burden of data collection.

(4) Harmonizing With Other CMS Programs

We intend to harmonize measures across settings and other CMS programs as evidenced by the implementation of the readmission measures not only for the RHQDAPU program but also for the QIOs' 9th Scope of

Work (SOW) Patient Pathways/Care Transitions Theme, which also uses the 30-Day Readmission Measures and will provide assistance to engage hospitals in improving care. The 9th SOW also focuses on disparities in health care, which is another important area of interest for CMS. We plan to analyze current RHQDAPU measures to identify particular RHQDAPU program measures needed to evaluate the existence of health care disparities, to require data elements that would support better identification of health care disparities, and to find more efficient ways to ascertain this information from claims data. In addition, at least some of the CY 2008 Physician Quality Reporting Initiative (PQRI) measures align with the current RHQDAPU program AMI and SCIP measures reported starting with the FY 2007 RHQDAPU measure set. In other words, there are financial incentives that cover the same clinical processes of care across different providers and settings. For example, Aspirin for Heart Attack corresponds to PQRI measure number 28, and Surgical

Infection Antibiotic Timing corresponds to PQRI measure number 20.

Outpatient quality measures under the Hospital Outpatient Data Quality

Data Reporting Program (HOP QDRP) are also aligned with the RHQDAPU program measures. For example, the HOP QDRP addresses Acute Myocardial

Infarction treatment for transferred patients and surgical infection prevention for outpatient surgery.

(5) Using Alternative Data Sources Not Requiring Chart Abstraction

We are actively pursuing alternative data sources, including data sources that are electronically maintained. Alternative data submission methodologies that we are proposing in this rule include:

Use of registry-collected clinical data for which there is broad existing hospital participation as previously described with the

STS registry.

Use of data collected by State data organizations, State hospital associations, Federal entities such as AHRQ, and/or other data warehouses.

In addition, we are considering adopting the following methods of data collection in the future and request comments on these methods:

Use of the CMS Continuity Assessment Record & Evaluation

(CARE) tool, a standardized data collection instrument, which would allow data to be transmitted in ``real time.'' This recently developed,

Internet-based, quality data collection tool was developed as a part of the Post Acute Care Reform Demonstration Program mandated by section 5008 of the DRA. The CARE tool consists of a core set of assessment items, common to all patients and all care settings (meeting criteria of being predictive of cost, utilization, outcomes, among others), organized under five major domains: Medical, Functional, Social,

Environmental, and Cognitive--Continuity of Care. The Internet-based

CARE tool will communicate critical information across settings accurately, quickly, and efficiently with reduced time burden to providers and is intended to enhance beneficiaries' safe transitions between settings to prevent avoidable, costly events such as unnecessary rehospitalizations or medication errors. We believe that the CARE tool may provide a vehicle for collection of data elements to be used for calculating RHQDAPU program quality measures. CMS is considering utilizing the CARE tool in this manner. The Care tool is available at: www.cms.hhs.gov/PaperworkReductionActof1995/PRAL/ list.asp#TopOfPage. (Viewers should select ``Show only items with the word ``10243'', click on show items, select CMS-10243, click on downloads, and open Appendices A & B, pdf files.)

We are particularly interested in receiving public comment on this tool. Our goal is to have a standardized, efficient, effective, interoperable, common assessment tool to capture key

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patient characteristics that will help CMS capture information related to resource utilization; expected costs as well as clinical outcomes; and post-discharge disposition. The CARE tool will also be useful for guiding payment and quality policies.

Specifically, we are interested in receiving public comments on how

CARE might advance the use of health information technology in automating the process for collecting and submitting quality data.

Submission of data derived from electronic versions of laboratory test reports that are issued by the laboratory in accordance with CLIA to the ordering provider and maintained by the hospital as part of the patient's medical record during and after the patient's course of treatment at the hospital. We are considering using these data to support risk adjustment for claims-based outcome measures (for example, mortality measures) and to develop other outcomes measures.

This would support use of electronically maintained data and our goal of reducing manual data collection burden on hospitals.

Submission of data currently being collected by clinical data registries in addition to the STS registry. This would support and leverage existing clinical data registries and existing voluntary clinical data collection efforts, such as:

American College of Cardiology (ACC) data registry for

Cardiac Measures.

ACC data registry for ICD.

ACC data registry for Carotid Stents.

Vascular Surgery Registry for Vascular Surgical

Procedures.

ACC-sponsored ``Get with the Guidelines'' registry for

Stroke Care.

(6) Weighing the Meaningfulness and Utility of the Measures Compared to the Burden on Hospitals in Submitting Data Under the RHQDAPU Program

We are proposing to retire one measure from the RHQDAPU program for

FY 2010 because we have determined that the burden on hospitals in abstracting the data outweighs the meaningful benefit that we can ascertain from the measure. As we explained more fully above, we are seeking comments on the applicability to the RHQDAPU program of criteria currently described in the Hospital VBP Issues Paper for inclusion and retirement of measures. The Hospital VBP Issues Paper is located on the CMS Web site at the following location: http:// www.cms.hhs.gov/AcuteInpatientPPS/downloads/hospital_VBP_plan_ issues_paper.pdf. 3. Form and Manner and Timing of Quality Data Submission

In the FY 2007 IPPS final rule (71 FR 48031 through 48045), we set out RHQDAPU program procedures for data submission, program withdrawal, data validation, attestation, public display of hospitals'' quality data, and reconsiderations. Section 1886(b)(3)(B)(viii)(I) of the Act requires that subsection (d) hospitals submit data on measures selected under that clause with respect to the applicable fiscal year. In addition, section 1886(b)(3)(B)(viii)(II) of the Act requires that each subsection (d) hospital submit data on measures selected under that clause to the Secretary in a form and manner, and at a time, specified by the Secretary. The technical specifications for each RHQDAPU program measure are listed in the CMS/Joint Commission Specifications Manual for National Inpatient Hospital Quality Measures (Specifications

Manual). We update this manual semiannually or more frequently in unusual cases, and include detailed instructions and calculation algorithms for hospitals to collect and submit the data for the required measures.

The maintenance of the specifications for the measures selected by the Secretary occurs through publication of the Specifications Manual.

Thus, measure selection by the Secretary occurs through the rulemaking process; whereas the maintenance of the technical specifications for the selected measures occurs through a subregulatory process so as to best maintain the specifications consistent with current science and consensus. The data submission, Specifications Manual, and submission deadlines are posted on the QualityNet Web site at www.qualitynet.org.

We require that hospitals submit data in accordance with the specifications for the appropriate discharge periods. When measure specifications are updated, we are proposing to require that hospitals submit all of the data required to calculate the required measures as outlined in the Specifications Manual current as of the patient discharge date. 4. Current and Proposed RHQDAPU Program Procedures a. RHQDAPU Program Procedures for FY 2009

In the FY 2008 IPPS final rule with comment period, we stated that the requirements for FY 2008 would continue to apply for FY 2009 (72 FR 47361). The ``Reporting Hospital Quality Data for Annual Payment Update

Reference Checklist'' section of the QualityNet Web site contains all of the forms to be completed by hospitals participating in the RHQDAPU program.

Under these requirements hospitals must--

Register with QualityNet, before participating hospitals initially begin reporting data, regardless of the method used for submitting data.

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Identify a QualityNet Administrator who follows the registration process located on the QualityNet Web site

(www.qualitynet.org).

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Complete the revised RHQDAPU program Notice of

Participation form (only for hospitals that did not submit a form prior to August 15, 2007). For hospitals that share the same Medicare

Provider Number (now CMS Certification Number (CCN)), report the name and address of each hospital on this form.

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Collect and report data for each of the required measures except the Medicare mortality measures (AMI, HF, and PN 30-day

Mortality for Medicare Patients). Hospitals must continuously report these data. Hospitals must submit the data to the QIO Clinical

Warehouse using the CMS Abstraction & Reporting Tool (CART), The Joint

Commission ORYX[supreg] Core Measures Performance Measurement System, or another third-party vendor tool that has met the measurement specification requirements for data transmission to QualityNet. All submissions will be executed through QualityNet. 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.

Submit complete data regarding the quality measures in accordance with the joint CMS/Joint Commission sampling requirements located on the QualityNet Web site for each quality measure that requires hospitals to collect and report data. These requirements specify that hospitals must submit a random sample or complete population of cases for each of the topics covered by the quality measures. Hospitals must meet the sampling requirements for these quality measures for discharges in each quarter.

Submit to CMS on a quarterly basis aggregate population and sample size counts for Medicare and non-Medicare discharges for the four topic areas (AMI, HF, PN, and SCIP).

Continuously collect and submit HCAHPS data in accordance with the HCAHPS Quality Assurance Guidelines, Version 3.0, located at the Web site: www.hcahpsonline.org. The QIO

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Clinical Warehouse has been modified to accept zero HCAHPS-eligible discharges. We remind the public to refer to the QualityNet Web site for any questions about how to submit ``zero cases'' information.

For the AMI 30-day, HF 30-day, and PN 30-day mortality measures,

CMS uses Part A and Part B claims for Medicare fee-for-service patients to calculate the mortality measures. For FY 2009, hospital inpatient claims (Part A) from July 1, 2006 to June 30, 2007, will be used to identify the relevant patients and the index hospitalizations.

Inpatient claims for the index hospitalizations 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 the Web site: 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. Proposed RHQDAPU Program Procedures for FY 2010

We are proposing to continue requiring the FY 2009 RHQDAPU program procedures for FY 2010 for hospitals participating in the RHQDAPU program, with the following modifications:

Notice of Participation. New subsection (d) hospitals and existing hospitals that wish to participate in RHQDAPU for the first time must complete a revised ``Reporting Hospital Quality Data for

Annual Payment Update Notice of Participation'' that includes the name and address of each hospital that shares the same CCN.

Data Submission. In order to reduce the burden on hospitals that treat a low number of patients who are covered by the submission requirements, we are proposing the following:

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AMI. We are proposing that a hospital that has five or fewer AMI discharges (both Medicare and non-Medicare combined) in a quarter will not be required to submit AMI patient level data for that quarter. We are proposing to begin implementing this requirement with discharges on or after January 1, 2009. However, the hospital must still submit its aggregate AMI population and sample size counts to CMS for that quarter as part of its quarterly RHQDAPU data submission.

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HCAHPS. We are proposing that a hospital that has five or fewer HCAHPS-eligible discharges in any month will not be required to submit HCAHPS surveys for that month. However, the hospital must still submit its total number of HCAHPS-eligible cases for that month as part of its quarterly HCAHPS data submission. We are proposing to begin implementing this requirement with discharges on or after January 1, 2009.

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HF. We are proposing that a hospital that has five or fewer HF discharges (both Medicare and non-Medicare combined) in a quarter will not be required to submit HF patient level data for that quarter. However, the hospital must still submit its aggregate HF population and sample size counts to CMS for that quarter as part of its quarterly RHQDAPU data submission. We are proposing to begin implementing this requirement with discharges on or after January 1, 2009.

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PN. We are proposing that a hospital that has five or fewer PN discharges (both Medicare and non-Medicare combined) in a quarter will not be required to submit PN patient level data for that quarter. However, the hospital must still submit its aggregate PN population and sample size counts to CMS for that quarter as part of its quarterly RHQDAPU data submission. We are proposing to begin implementing this requirement with discharges on or after January 1, 2009.

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SCIP. We are proposing that a hospital that has five or fewer SCIP discharges (both Medicare and non-Medicare combined) in a quarter will not be required to submit SCIP patient level data for that quarter. However, the hospital must still submit its aggregate SCIP population and sample size counts to CMS for that quarter as part of its quarterly RHQDAPU data submission. We are proposing to begin implementing this requirement with discharges on or after January 1, 2009.

In addition, we are proposing the following quarterly deadlines for hospitals to submit the FY 2010 AMI, HF, SCIP, PN, Stroke, VTE, and nursing sensitive measure data:

The data submission deadline for hospitals to submit the patient level measure data for 1st calendar quarter of 2009 discharges would be August 15, 2009. Data must be submitted for each of these measures 4.5 months after the end of the preceding quarter. The specific deadlines will be listed on the QualityNet Web site.

Even though data on applicable measures will not be due until 4.5 months after the end of the preceding quarter, hospitals must submit their aggregate population and sample size counts no later than 4 months after the end of the preceding quarter (the exact dates will be posted on the QualityNet Web site). This deadline falls approximately 15 days before the data submission deadline for the clinical process measures, and we are proposing it so that we can inform hospitals about their data submission status for the quarter before the 4.5 month clinical process measure deadline. We have found from past experience that hospitals need sufficient time to submit additional data when their counts differ from Medicare claims counts generated by CMS. We will provide hospitals with these Medicare claims counts and submitted patient level data counts on the QualityNet Web site approximately 2 weeks before the quarterly submission deadline. We plan to use the aggregate population and sample size data to assess submission completeness and adherence to sampling requirements for

Medicare and non-Medicare patients.

We propose the following quarterly deadlines for hospitals to submit cardiac surgery and the AHRQ PSI/IQI measure data to CMS or other entities:

The data submission deadline for hospitals to submit cardiac surgery patient level measure data to CMS or STS data registry for 1st calendar quarter of 2009 discharges would be June 1, 2009. Data must be submitted for each of these measures 2 months after the end of the preceding quarter. The specific deadlines will be listed on the

QualityNet Web site.

The data submission deadline for hospitals to submit the

AHRQ PSI/IQI measure data to CMS for 4th calendar quarter of 2009 discharges would be April 1, 2010. Data must be submitted for each of these measures 3 months after the end of the preceding quarter. The specific deadlines will be listed on the QualityNet Web site.

We are proposing these quarterly submission deadlines for cardiac surgery and AHRQ PSI/IQI measure data to coordinate submission deadlines with external data registries and provide more timely information to the consumers. We are proposing this quarterly submission deadline for cardiac surgery measure data to coincide with the STS quarterly submission deadline that is approximately 2 months following the discharge quarter. We also propose to shorten the time lag between the date of discharge and the public reporting of these quality measures to provide more timely consumer information. 5. Current and Proposed HCAHPS Requirements a. FY 2009 HCAHPS Requirements

For FY 2009, hospitals must continuously collect and submit HCAHPS data to the QIO Clinical

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Warehouse by the data submission deadlines posted on the Web site at: www.hcahpsonline.org. The data submission deadline for first quarter CY 2008 (January through March) discharges is July 9, 2008. To collect

HCAHPS data, a hospital can either contract with an approved HCAHPS survey vendor that will conduct the survey and submit data on the hospital's behalf to the QIO Clinical Warehouse, or a hospital can self-administer the survey without using a survey vendor, provided that the hospital meets Minimum Survey Requirements as specified on the Web site at: www.hcahpsonline.org. A current list of approved HCAHPS survey vendors can be found on the Web site at: www.hcahpsonline.org.

Every hospital choosing to contract with a survey vendor should provide the sample frame of hospital-eligible discharges to its survey vendor with sufficient time to allow the survey vendor to begin contacting each sampled patient within 6 weeks of discharge from the hospital (see the Quality Assurance Guidelines for details about HCAHPS eligibility and sample frame creation) and must authorize the survey vendor to submit data via QualityNet on the hospital's behalf. CMS strongly recommends that the hospitals employing a survey vendor promptly review the two HCAHPS Feedback Reports (the Provider Survey

Status Summary Report and the Data Submission Detail Report) that are available after the survey vendor submits the data to the QIO Clinical

Warehouse. These reports enable a hospital to ensure that its survey vendor has submitted the data on time and it has been accepted into the

Warehouse.

In the FY 2008 IPPS final rule with comment period (72 FR 47362), we stated that hospitals and survey vendors must participate in a quality oversight process conducted by the HCAHPS project team.

Starting in July 2007, we began asking hospitals/survey vendors to correct any problems that were found and provide followup 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 HCAHPS data that meet the requirements for the RHQDAPU program. As part of these activities, HCAHPS project staff reviews and discusses 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 procedures. b. Proposed FY 2010 HCAHPS Requirements

For FY 2010, we are proposing continuous collection of HCAHPS in accordance with the Quality Assurance Guidelines located at the Web site: www.hcahpsonline.org, by the quarterly data submission deadlines posted on the Web site: www.hcahpsonline.org. As stated above, starting with January 1, 2009 discharges, we are proposing that hospitals that have five or fewer HCAHPS-eligible discharges in a month would not be required to submit HCAHPS patient-level data for that month as part of the quarterly data submission that includes that month, but they would still be required to submit the number of HCAHPS-eligible cases for that month as part of their HCAHPS quarterly data submission.

With respect to HCAHPS oversight, we are proposing that the HCAHPS

Project Team will continue to conduct site visits and/or conference calls with hospitals/survey vendors to ensure the hospital's compliance with the HCAHPS requirements. During the onsite visit or conference call, the HCAHPS Project Team will review the hospital's/survey vendor's survey systems and will assess protocols based upon the most recent Quality Assurance Guidelines. All materials relevant to survey administration will be subject to review. The systems and program review includes, but it is not necessarily limited to: (a) survey management and data systems; (b) printing and mailing materials and facilities; (c) telephone/IVR materials and facilities; (d) data receipt, entry and storage facilities; and (e) written documentation of survey processes. Organizations will be given a defined time period in which to correct any problems and provide followup documentation of corrections for review. Hospitals/survey vendors will be subject to followup site visits and/or conference calls, as needed. If CMS determines that a hospital is noncompliant with HCAHPS program requirements, CMS may determine that the hospital is not submitting

HCAHPS data that meet the requirements of the RHQDAPU program. 6. Current and Proposed Chart Validation Requirements a. Chart Validation Requirements for FY 2009

In the FY 2008 IPPS final rule with comment period (72 FR 47361), we stated that, until further notice, we would continue to require that hospitals meet the chart validation requirements that we implemented in the FY 2006 IPPS final rule (70 FR 47421 and 47422). These requirements, as well as additional information on validation requirements, continue and are being placed on the QualityNet Web site.

We also stated in the FY 2008 IPPS final rule with comment period that, until further notice, hospitals must pass our validation requirement that requires a minimum of 80-percent reliability, based upon our chart-audit validation process (72 FR 47361).

In the FY 2008 IPPS final rule with comment period (72 FR 47362), we indicated that, for the FY 2009 update, all FY 2008 validation requirements would apply, except for the following modifications. We would modify the validation requirement to pool the quarterly validation estimates for 4th quarter CY 2006 through 3rd quarter 2007 discharges. We would 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 would also drop the current two-step process to determine if the hospital is submitting validated data. For the FY 2009 update, we stated that we will pool validation estimates covering the four quarters (4th quarter CY 2006 discharges through 3rd quarter 2007 discharges) in a similar manner to the current 3rd quarter pooled confidence interval.

In summary, the following chart validation requirements apply for the FY 2009 RHQDAPU program:

The 21-measure expanded set will be validated using 4th quarter CY 2006 (4Q06) through 3rd quarter CY 2007 (3Q07) discharges.

SCIP VTE-1, VTE-2, and SCIP Infection 2 will be validated using 2nd quarter CY 2007 and 3rd quarter CY 2007 discharges.

SCIP Infection 4 and SCIP Infection 6 must be submitted starting with 1st quarter CY 2008 discharges but will not be validated.

HCAHPS data must continuously be submitted and will be reviewed as discussed above.

AMI, HF, and PN 30-day mortality measures will be calculated as discussed below.

In the FY 2008 IPPS final rule with comment period (72 FR 47364), we stated that, for the FY 2008 update and in subsequent years, we would revise and post up-to-date confidence interval information on the

QualityNet 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

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ensure the integrity of the submitted data; there are external edit checks to verify expectations about the volume of the data received. b. Proposed Chart Validation Requirements for FY 2010

For FY 2010, we are proposing the following chart validation requirements to reflect the proposed 72-measure set:

The following 21 measures from the FY 2009 RHQDAPU program measure set will be validated using data from 4th quarter 2007 through 3rd quarter 2008 discharges.

Quality measure validated from

Topic

4th quarter 2007 through 3rd quarter 2008 discharges

Heart Attack (Acute Myocardial

Aspirin at arrival

Infarction).

Aspirin prescribed at discharge

Angiotensin Converting Enzyme

Inhibitor (ACE-I) or

Angiotensin II Receptor

Blocker (ARB) for left ventricular systolic dysfunction

Beta blocker at arrival

Beta blocker prescribed at discharge

Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival

Adult smoking cessation advice/ counseling

Heart Failure (HF)..................... Left ventricular function assessment

Angiotensin Converting Enzyme

Inhibitor (ACE-I) or

Angiotensin II Receptor

Blocker (ARB) for left ventricular systolic dysfunction

Discharge instructions

Adult smoking cessation advice/ counseling

Pneumonia (PN)......................... 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 antibiotic

(SCIP)--named SIP for discharges prior received within 1 hour prior to July 2006 (3Q06).

to surgical incision

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***

SCIP-Infection 3: Prophylactic antibiotics discontinued within 24 hours after surgery end time

SCIP Infection 4 and Infection 6 will be validated using data from 2nd and 3rd quarter CY 2008 discharges.

In addition, we are proposing to include the following three measures in the FY 2010 RHQDAPU program validation process that are included the FY 2009 RHQDAPU program measure set but have been updated or deleted for the FY 2010 measure set:

Pneumonia antibiotic prophylaxis timing within 4 hours will be validated using data from 4th quarter 2007 through 3rd quarter 2008 discharges.

Percutaneous Coronary Intervention (PCI) Timing within 120 minutes will be validated using data from 4th quarter 2007 through 3rd quarter 2008 discharges.

Pneumonia Oxygenation Assessment will be validated using data from 4th quarter through 3rd quarter 2008 discharges.

These measures will be submitted by hospitals during 2008 and early 2009, and are available to be validated by CMS in time for the FY 2010

RHQDAPU program payment eligibility determination.

As explained above, will also revise and post up-to-date confidence interval information on the QualityNet Web site explaining the application of the confidence interval to the overall validation results. c. Chart Validation Methods and Requirements Under Consideration for FY 2011 and Subsequent Years

Under the current and proposed RHQDAPU program chart validation process, we validate measures by reabstracting on a quarterly basis a random sample of five patient records for each hospital. This quarterly sample results in an annual combined sample of 20 patient records across 4 calendar quarters, but because the samples are random, they do not necessarily include patient records covering each of the clinical topics.

We anticipate that the proposed expansion of the RHQDAPU program measure set to include additional clinical topics will decrease the percentage of RHQDAPU clinical topics, as well as the total number of measures, covered in many hospitals' annual chart validation. In addition to the measures for which hospitals must submit data for FY 2009 (with the exception of the Pneumonia Oxygenation Assessment measure), we have proposed that hospitals will submit data on the proposed five stroke measures, six VTE measures, and four nursing sensitive measures for FY 2010 using chart abstraction. CMS is considering the addition of these measures to the current RHQDAPU program validation process for FY 2011 and future years.

However, we are considering whether registries and other external parties that may be collecting data on proposed RHQDAPU program measures could validate the accuracy of those measures beginning in FY 2011. In addition, we note that the proposed readmission measures are calculated using Medicare claims information and do not require chart validation.

We are interested in receiving public comments from a broad set of stakeholders on the impact of adding measures to the validation process, as well as modifications to the current validation process that could improve

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the reliability and validity of the methodology. We specifically request input concerning the following:

Which of the measures or measure sets should be included in the FY 2010 RHQDAPU program chart validation process or in the chart validation process for subsequent years?

What validation challenges are posed by the RHQDAPU program measures and measure sets? What improvements could be made to validation or reporting that might offset or otherwise address those challenges?

Should CMS switch from its current quarterly validation sample of five charts per hospital to randomly selecting a sample of hospitals, and selecting more charts on an annual basis to improve reliability of hospital level validation estimates?

Should CMS select the validation sample by clinical topic to ensure that all publicly reported measures are covered by the validation sample? 7. Data Attestation Requirements a. Proposed Change to Requirements for FY 2009

In the FY 2008 IPPS final rule with comment period (72 FR 47364), we stated that we would 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 stated that we would provide additional information to explain this attestation requirement, as well as provide the relevant form to be completed on the QualityNet Web site, at the same time as the publication of the FY 2008 IPPS final rule with comment period.

We are now proposing to defer the requirement in FY 2009 for hospitals to separately attest to the accuracy and completeness of their submitted data due to the burden placed on hospitals to report paper attestation forms on a quarterly basis. We continue to expect that hospitals will submit quality data that are accurate to the best of their knowledge and ability. b. Proposed Requirements for FY 2010

For FY 2010 and subsequent years, we are soliciting public comment on the electronic implementation of the attestation requirement at the point of data submission to the QIO Clinical Warehouse. Hospitals would electronically pledge to CMS that their submitted data are accurate and complete to the best of their knowledge. Hospitals would be required to designate an authorized contact to CMS for attestation in their patient-level data submission.

Resubmissions would continue to be allowed before the quarterly submission deadline, and hospitals would be required to electronically update their pledges about data accuracy at the time of resubmission.

We welcome comments on this approach. 8. Public Display Requirements

Section 1886(b)(3)(B)(viii)(VII) of the Act provides that the

Secretary shall establish procedures for making data submitted under the RHQDAPU program available to the public. The RHQDAPU program quality measures are posted on the Hospital Compare Web site (http:// www.hospitalcompare.hhs.gov). CMS requires that hospitals sign a

``Reporting Hospital Quality Data for Annual Payment Update Notice of

Participation'' form when they first register to participate in the

RHQDAPU program. Once a hospital has submitted a form, the hospital is considered to be an active RHQDAPU program participant until such time as the hospital submits a withdrawal form to CMS (72 FR 47360).

Hospitals signing this form agree that they will allow CMS to publicly report the quality measures as required in the applicable year's

RHQDAPU program requirements.

We are proposing to 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 CCN (formerly known as

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 CCNs. Beginning with the FY 2008 RHQDAPU program, hospitals must report the name and address of each hospital that shares the same CCN.

This information will be gathered through the RHQDAPU program Notice of

Participation form for new hospitals participating in the RHQDAPU program. To increase transparency in public reporting and improve the usefulness of the Hospital Compare Web site, we will note on the Web site where publicly reported measures combine results from two or more hospitals. 9. Proposed Reconsideration and Appeal Procedures

For FY 2009, we are proposing to continue the current RHQDAPU program reconsideration and appeal procedures finalized in the FY 2008

IPPS final rule with comment period. The deadline for submitting a request for reconsideration in connection with the FY 2009 payment determination is November 1, 2008. We also are proposing to use the same procedural rules finalized in the FY 2008 IPPS final rule with comment period (72 FR 47365). We posted these rules on the QualityNet

Web site for the FY 2008 RHQDAPU program reconsideration process.

Under the procedural rules, in order to receive reconsideration for

FY 2009, the hospital must--

Submit to CMS, via QualityNet, a Reconsideration Request form (available on the QualityNet Web site) containing the following information:

cir

Hospital Medicare ID number.

cir

Hospital Name.

cir

CMS-identified reason for failure (as provided in the CMS notification of failure letter to the hospital).

cir

Hospital basis for requesting reconsideration. (This must identify the hospital's specific reason(s) for believing it met the

RHQDAPU program requirements and should receive the full FY 2009 IPPS annual payment update.)

cir

CEO contact information, including name, e-mail address, telephone number, and mailing address (must include physical address, not just the post office box).

cir

QualityNet System Administrator contact information, including name, e-mail address, telephone number, and mailing address

(must include physical address, not just the post office box).

The request must be signed by the hospital's CEO.

Following receipt of a request for reconsideration, CMS will--

Provide an e-mail acknowledgement, using the contact information provided in the reconsideration request, to the CEO and the

QualityNet Administrator that the letter has been received.

Provide a formal response to the hospital CEO, using the contact information provided in the reconsideration request, notifying the facility of the outcome of the reconsideration process. CMS expects the process to take 60 to 90 days from the due date of November 1, 2008.

If a hospital is dissatisfied with the result of a RHQDAPU program

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reconsideration decision, the hospital may file a claim under 42 CFR part 405, subpart R (a Provider Reimbursement Review Board (PRRB) appeal). 10. Proposed RHQDAPU Program Withdrawal Deadline for FYs 2009 and 2010

We propose to accept RHQDAPU program withdrawal forms for FY 2009 from hospitals through August 15, 2008. We are proposing this deadline to provide CMS with sufficient time to update the RHQDAPU FY 2009 payment to hospitals starting on October 1, 2008. If a hospital withdraws from the program for FY 2009, it will receive a 2.0 percentage point reduction in its FY 2009 annual payment update.

We also propose to accept RHQDAPU program withdrawal forms for FY 2010 from hospitals through August 15, 2009. If a hospital withdraws from the program for FY 2010, it will receive a 2.0 percentage point reduction in its FY 2010 annual payment update. 11. Requirements for New Hospitals

In the FY 2008 IPPS final rule with comment period (72 FR 47366), we stated that a new hospital that receives a provider number on or after October 1 of each year (beginning with October 1, 2007) will be required to report RHQDAPU program 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 CCN on

October 2, 2008, and signs up to participate in the RHQDAPU program on

November 1, 2007, will be expected to meet all of the data submission requirements for discharges on or after January 1, 2009.

In addition, we strongly recommend that each new hospital participate in an HCAHPS dry run, if feasible, prior to beginning to collect HCAHPS data on an ongoing basis to meet RHQDAPU program requirements. We refer readers to the Web site at www.hcahpsonline.org for a schedule of upcoming dry runs. The dry run will give newly participating hospitals the opportunity to gain first-hand experience collecting and transmitting HCAHPS data without the public reporting of results. Using the official survey instrument and the approved modes of administration and data collection protocols, hospitals/survey vendors will collect HCAHPS data and submit the data to QualityNet. 12. 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 establishment of Federal Health Architecture (FHA) data standards. We encouraged hospitals that are developing systems to conform them to industry standards, and in particular to FHA data standards, once identified, taking measures to ensure that the data necessary for quality measures are captured. Ideally, such systems will also provide point-of-care decision support that enables detection of 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 FY 2007 IPPS proposed (71 FR 24095), we again invited public comment on these requirements and related options. In the FY 2007 IPPS final rule (71 FR 48045), we summarized and addressed the additional comments we received. In the FY 2008 IPPS proposed rule (72 FR 24809), we noted that we would welcome additional comments on this issue.

In the FY 2008 IPPS final rule with comment period (72 FR 47366), we responded to the additional comments we received and noted that CMS plans to continue working with the American Health Information

Community (AHIC) and other entities to explore processes through which an EMR could speed the collection and minimize the resources necessary for quality reporting. (The AHIC is a Federal advisory body, chartered in 2005 to make recommendations to the Secretary on how to accelerate the development and adoption of health information technology.) In addition, we noted that we will continue to participate in appropriate

HHS studies and workgroups, as mentioned by a GAO report (GAO-07-320) about hospital quality data and their use of information technology. As appropriate, CMS will inform interested parties regarding progress in the implementation of HIT for the collection and submission of hospital quality data as specific steps, including timeframes and milestones, are identified. Current mechanisms include publication in the Federal

Register as well as ongoing collaboration with external stakeholders such as the HQA, the AHA, the FAH, the AAMC, and the Joint Commission.

We further anticipate that as HIT is implemented, a formal plan, including training, will be developed to assist providers in understanding and utilizing HIT in reporting quality data. In addition, we will assess the effectiveness of our communications with providers and stakeholders as it relates to all information dissemination pertinent to collecting hospital quality data as part of an independent and comprehensive external evaluation of the RHQDAPU program.

We are again soliciting comments on the issues and challenges associated with EMRs. Specifically, we invite comment on our proposed changes to our data submission requirements to be more aligned with currently implemented HIT systems, including data collection from registries and laboratory data.

We recognize the potential burden on hospitals of increased data reporting requirements for process measures that require chart abstraction. In FY 2007 IPPS rulemaking, we listed a variety of additional possible measures for future years. The measures included and emphasized additional outcomes measures. Additional measures were included for which the data sources are claims. For these, no additional data abstraction or submission would be required for reporting hospitals beyond the claims data. In proposing measures for

FY 2010, we seek to emphasize outcome measures and to minimize any additional data collection burden. In addition, as provided in section 1886(b)(3)(B)(viii)(VI) and discussed in section IV.B.2.a. of this proposed rule, we are proposing to retire one measure where there is no meaningful difference among hospitals as a means of reducing data collection burden.

C. Medicare Hospital Value-Based Purchasing (VBP) 1. Medicare Hospital VBP Plan Report to Congress

Through section 5001(b) of the Deficit Reduction Act of 2005,

Congress authorized the development of a plan to implement value-based purchasing (VBP) beginning FY 2009 for IPPS hospital services. By statute, the plan must address: (a) The ongoing development, selection, and modification process for measures of quality and efficiency in hospital inpatient settings; (b) reporting, collection, and validation of quality

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data; (c) the structure, size, and source of value-based payment adjustments; and (d) public disclosure of hospital performance data.

To develop the plan, CMS created a Hospital VBP Workgroup with members from various CMS components and the Office of the Assistant

Secretary for Planning and Evaluation. The Workgroup completed an environmental scan of existing hospital VBP programs, an issue paper outlining the topics to be addressed in the plan, and an options paper presenting design alternatives for the plan.

CMS hosted two public Listening Sessions in early 2007 to solicit comments from interested parties on outstanding design questions associated with development of the plan. The perspectives expressed by stakeholders (including hospitals, consumers, and purchasers) during these sessions and in writing assisted the Workgroup in creating the

Medicare Hospital VBP Plan Report to Congress. The Report was submitted to Congress on November 21, 2007.

The Medicare Hospital VBP Plan builds on the foundation of

Medicare's current RHQDAPU program (discussed in section IV.B. of the preamble of this proposed rule), which, since FY 2005, has provided differential payments to hospitals that report their performance on a defined set of inpatient measures for public posting on the Hospital

Compare Web site. If authorized by Congress, the VBP Plan would replace the current quality reporting program with a new program that would include both public reporting and financial incentives to drive improvements in clinical quality, patient-centeredness, and efficiency.

The proposed plan contains the following key components: (a) A performance assessment model that incorporates measures from different quality domains (that is, clinical process of care, patient experience of care, outcomes, among others) to calculate a hospital's total performance score; (b) options for translating this score into an incentive payment that would make a portion of the hospital's base DRG payment contingent on its total performance score; (c) criteria for selecting performance measures for the financial incentive and candidate measures for FY 2009 and beyond; (d) a phased approach for transitioning from the RHQDAPU program to the VBP plan; (e) proposed enhancements to the current data transmission and validation infrastructure to support VBP program requirements; (f) refinements to the Hospital Compare Web site to support expanded public reporting; and

(g) an approach to monitoring VBP impacts.

The Medicare Hospital VBP Plan Report to Congress is available on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/ downloads/HospitalVBPPlanRTCFINALSUBMITTED2007.pdf. 2. Testing and Further Development of the Medicare Hospital VBP Plan

The Hospital VBP Workgroup has undertaken testing of the VBP Plan.

This ``dry run'' or ``simulation'' of the Plan will use the most recent clinical process-of-care and HCAHPS measurement data available from the

RHQDAPU program. New information generated by the VBP Plan testing will include: (a) Performance scores by domain; (b) total performance scores; and (c) financial impacts. Following a process similar to that used in developing the Plan, CMS will analyze this information by individual IPPS hospital, by segment of the hospital industry (that is, geographic location, size, teaching status, among others), and in aggregate for all IPPS hospitals.

The results of VBP Plan testing will be used to further develop the

Plan. Priorities for Plan completion include addressing the small numbers issue (described on pages 74 and 75 of the Hospital VBP Plan

Report to Congress) and developing a scoring methodology for the outcomes domain (pages 57-58 of the Hospital VBP Plan Report to

Congress), which will become an additional aspect of the performance model. After completion, the Plan will be retested.

We are seeking public comments on how to take full advantage of the new information generated through this testing and further Plan development. For example: Should the testing and retesting results be publicly posted? If the testing results were to be posted, would the best location be the Hospital Compare Web site or the CMS Web site at: http://www.cms.hhs.gov? In what format would public posting be most useful to potential audiences? At what level would the data be posted-- individual hospital or some higher level? Which data elements from the testing results would be most useful to share?

D. Sole Community Hospitals (SCHs) and Medicare-Dependent, Small Rural

Hospitals (MDHs): Volume Decrease Adjustment (Sec. Sec. 412.92 and 412.108) 1. Background

Under the IPPS, special payment protections are provided to a sole community hospital (SCH). Section 1886(d)(5)(D)(iii) of the Act defines an SCH as a hospital that, by reason of factors such as isolated location, weather conditions, travel conditions, absence of other like hospitals (as determined by the Secretary), or historical designation by the Secretary as an essential access community hospital, is the sole source of inpatient hospital services reasonably available to Medicare beneficiaries. The regulations that set forth the criteria that a hospital must meet to be classified as an SCH are located in 42 CFR 412.92 of the regulations.

Under the IPPS, separate special payment protections also are provided to a Medicare-dependent, small rural hospital (MDH). Section 1886(d)(5)(G)(iv) of the Act defines an MDH as a hospital that is located in a rural area, has not more than 100 beds, is not an SCH, and has a high percentage of Medicare discharges (not less than 60 percent in its 1987 cost reporting year or in 2 of its most recent 3 audited and settled Medicare cost reporting years). The regulations that set forth the criteria that a hospital must meet to be classified as an MDH are located in 42 CFR 412.108.

Although SCHs and MDHs are paid under special payment methodologies, they are hospitals that are paid under section 1886(d) of the Act. Like all IPPS hospitals paid under section 1886(d) of the

Act, SCHs and MDHs are paid for their discharges based on the DRG weights calculated under section 1886(d)(4) of the Act.

Effective with hospital cost reporting periods beginning on or after October 1, 2000, section 1886(d)(5)(D)(i) of the Act (as amended by section 6003(e) of Pub. L. 101-239) and section 1886(b)(3)(I) of the

Act (as added by section 405 of Pub. L. 106-113 and further amended by section 213 of Pub. L. 106-554), provide that SCHs are paid based on whichever of the following rates yields the greatest aggregate payment to the hospital for the cost reporting period:

The Federal rate applicable to the hospital;

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.

For purposes of payment to SCHs for which the FY 1996 hospital- specific rate yields the greatest aggregate payment, payments for discharges during FYs 2001, 2002, and 2003 were based on a blend of the

FY 1996 hospital-specific rate and the greater of the Federal rate or the updated FY 1982 or FY 1987

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hospital-specific rate. For discharges during FY 2004 and subsequent fiscal years, payments based on the FY 1996 hospital-specific rate are 100 percent of the updated FY 1996 hospital-specific rate.

Through and including FY 2006, under section 1886(d)(5)(G) of the

Act, MDHs are paid based on the Federal rate or, if higher, the Federal rate plus 50 percent of the difference between the Federal rate and the updated hospital-specific rate based on FY 1982 or FY 1987 costs per discharge, whichever is higher. However, section 5003 of Pub. L. 109- 171 (DRA) modified these rules for discharges occurring on or after

October 1, 2006. Section 5003(c) changed the 50 percent adjustment to 75 percent. Section 5003(b) requires that an MDH use the 2002 cost reporting year as its base year (that is, the FY 2002 updated hospital- specific rate), if that use results in a higher payment. MDHs do not have the option to use their FY 1996 hospital-specific rate.

For each cost reporting period, the fiscal intermediary/MAC determines which of the payment options will yield the highest aggregate payment. Interim payments are automatically made at the highest rate using the best data available at the time the fiscal intermediary/MAC makes the determination. However, it may not be possible for the fiscal intermediary/MAC to determine in advance precisely which of the rates will yield the highest aggregate payment by year's end. In many instances, it is not possible to forecast the outlier payments, the amount of the DSH adjustment, or the IME adjustment, all of which are applicable only to payments based on the

Federal rate and not to payments based on the hospital-specific rate.

The fiscal intermediary/MAC makes a final adjustment at the close of the cost reporting period after it determines precisely which of the payment rates would yield the highest aggregate payment to the hospital.

If a hospital disagrees with the fiscal intermediary's or MAC's determination regarding the final amount of program payment to which it is entitled, it has the right to appeal the fiscal intermediary's or

MAC's decision in accordance with the procedures set forth in 42 CFR

Part 405, Subpart R, which concern provider payment determinations and appeals. 2. Volume Decrease Adjustment for SCHs and MDHs: Data Sources for

Determining Core Staff Values

Section 1886(d)(5)(D)(ii) of the Act requires that the Secretary make a payment adjustment to an SCH that experiences a decrease of more than 5 percent in its total number of inpatient discharges from one cost reporting period to the next, if the circumstances leading to the decline in discharges were beyond the SCH's control. Section 1886(d)(5)(G)(iii) of the Act requires that the Secretary make a payment adjustment to an MDH that experiences a decrease of more than 5 percent in its total number of inpatient discharges from one cost reporting period to the next, if the circumstances leading to the decline in discharges were beyond the MDH's control. These adjustments were designed to compensate an SCH or MDH for the fixed costs it incurs in the year in which the reduction in discharges occurred, which it may be unable to reduce. Such costs include the maintenance of necessary core staff and services. Our records indicate that less than 10 SCHs/

MDHs request and receive this payment adjustment each year.

We believe that not all staff costs can be considered fixed costs.

Using a standardized formula specified by us, the SCH or MDH must demonstrate that it appropriately adjusted the number of staff in inpatient areas of the hospital based on the decrease in the number of inpatient days. This formula examines nursing staff in particular. If an SCH or MDH has an excess number of nursing staff, the cost of maintaining those staff members is deducted from the total adjustment.

One exception to this policy is that no SCH or MDH may reduce its number of staff to a level below what is required by State or local law. In other words, an SCH or MDH will not be penalized for maintaining a level of staff that is consistent with State or local requirements.

The process for determining the amount of the volume decrease adjustment can be found in Section 2810.1 of the Provider Reimbursement

Manual, Part 1 (PRM-1). Fiscal intermediaries/MACs are responsible for establishing whether an SCH or MDH is eligible for a volume decrease adjustment and, if so, the amount of the adjustment. To qualify for this adjustment, the SCH or MDH must demonstrate that: (a) a decrease of more than 5 percent in total number of inpatient discharges has occurred; and (b) the circumstance that caused the decrease in discharges was beyond the control of the hospital. Once the fiscal intermediary/MAC has established that the SCH or MDH satisfies these two requirements, it will calculate the adjustment. The adjustment amount is determined by subtracting the second year's DRG payment from the lesser of: (a) the second year's costs minus any adjustment for excess staff; or (b) the previous year's costs multiplied by the appropriate IPPS update factor minus any adjustment for excess staff.

The SCH or MDH receives the difference in a lump-sum payment.

In order to determine whether or not the hospital's nurse staffing level is appropriate, the fiscal intermediary/MAC compares the hospital's actual number of nursing staff in each area with the staffing of like-size hospitals in the same census region. If a hospital employs more than the reported average number of nurses for hospitals of its size and census region, the fiscal intermediary/MAC reduces the amount of the adjustment by the cost of maintaining the additional staff. The amount of the reduction is calculated by multiplying the actual number of nursing staff above the reported average by the average nurse salary for that hospital as reported on the Medicare cost report. The complete process for determining the amount of the adjustment can be found at Section 2810.1 of the PRM-1.

Prior to FY 2007, our policy was for fiscal intermediaries/MACs to obtain average nurse staffing data from the AHA HAS/Monitrend Data

Book. However, in light of concerns that the Data Book had been published in 1989 and is no longer updated, in the FY 2007 IPPS rule, we proposed and finalized our policy to update the data sources and methodology used to determine the core staffing factors (that is, the average nursing staff for similar bed size and census region) for purposes of calculating the volume decrease adjustment (71 FR 48056 through 48060). We specified that for adjustment requests for decreases in discharges beginning with FY 2007 (that is, a decrease in discharges in 2007 as compared to 2006), an SCH or MDH could opt to use one of two data sources: the AHA Annual Survey or the Occupational Mix Survey, but could not use the HAS/Monitrend Data Book. (For any open adjustment requests prior to FY 2007, we allowed SCHs and MDHs the option of using the results of any of three sources: (1) The 2006 Occupational Mix

Survey for cost reporting periods beginning in FY 2006; (2) the AHA

Annual Survey (where available); or (3) the AHA HAS/Monitrend Data

Book. We also specified a methodology for calculating those core staffing factors. For purposes of explaining the methodology, we applied it to the 2003 Occupational Mix Survey data. In our explanation, we recognized that some of the 2003 data seemed anomalous, and we solicited comments on a possible alternative methodology.

However, there were no suggested alternative methodologies from the

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commenters. We also explained that, while we used the 2003 Occupational

Mix Survey data ``for purposes of describing how we would implement this methodology,'' the final policy was to use FY 2006 Occupational

Mix Survey data going forward. At the time we published the proposed and final rules, however, we had not yet processed the FY 2006 data, and could not present the core staffing figures that resulted from such data.

We have now processed the 2006 Occupational Mix Survey data using the methodology specified in the FY 2007 IPPS final rule and continue to see some results that cause us to believe that the methodology for calculating the core staffing factors should be slightly revised from the methodology discussed in the FY 2007 IPPS final rule (71 FR 48056 through 48060). The new methodology uses a revised formula to remove outliers from the core staffing values. a. Occupational Mix Survey

In the FY 2007 IPPS final rule (71 FR 48055), we explained the methodology we would use for calculating core staffing values from the

Occupational Mix Survey. We stated that we would calculate the nursing hours per patient day for each SCH or MDH by dividing the number of paid nursing hours (for registered nurses, licensed practical nurses and nursing aides) reported on the Occupational Mix Survey by the number of patients days reported on the Medicare cost report. The results would be grouped in the same bed-size groups and census regions as were used in the HAS/Monitrend Data Book.

We indicated that we would publish the mean number of nursing hours per patient day, for each census region and bed-size group, in the

Federal Register and on the CMS Web site. For purposes of the volume decrease adjustment, the published data would be utilized in the same way as the HAS/Monitrend data: The fiscal intermediary/MAC would multiply the SCH's and MDH's number of patient days by the applicable published hours per patient day. This figure would be divided by the average number of worked hours per year per nurse (for example, 2,080 for a standard 40-hour week). The result would be the target number of core nursing staff for the particular SCH or MDH. If necessary, the cost of any excess staff (number of FTEs that exceed the published number) would be removed from the second year's costs or, if applicable, the previous year's costs multiplied by the IPPS update factor when determining the volume decrease adjustment.

In the FY 2007 IPPS final rule (71 FY 48057), we stated that we would use the results of the FY 2006 Occupational Mix Survey and begin applying the methodology for adjustments resulting from a decrease in discharges in FY 2007. Because the occupational mix survey is conducted once every 3 years, we would update the data set every 3 years.

However, at the time of the FY 2007 IPPS final rule, the FY 2006

Occupational Mix Survey data were not available. In that final rule, we described our methodology using the FY 2003 occupational mix data and the FY 2003 Medicare cost report file. However, these data were used only in order to present an example of how our methodology would work.

Our final policy was to use FY 2006 occupational mix and cost report data when actually processing adjustment requests.

In the FY 2007 IPPS final rule, to illustrate how we would calculate the average number of nursing hours per patient day by bed size and region, we first merged the FY 2003 Occupational Mix Survey data with the FY 2003 Medicare cost report file. We eliminated all observations for non-IPPS providers, providers who failed to complete the occupational mix survey and the providers for which provider numbers, bed counts, and/or days counts were missing.

For each provider in the pool, we calculated the number of nursing hours by adding the number of registered nurses, licensed practical nurses, and nursing aide hours reported on the Occupational Mix Survey.

We divided the result of this calculation by the total number of inpatient days reported on the cost report to determine the number of nursing hours per patient day. For purposes of calculating the census regional averages for the various bed-size groups, we finalized our rule to only include observations that fell within three standard deviations of the mean of all observations, thus removing potential outliers in the data.

When the FY 2006 Occupational Mix Survey data became available, our analysis of the results indicated that the methodology for computing core staffing factors should be further revised in order to further eliminate outlier data.

After consulting with the Office of the Actuary on appropriate statistical methods to remove outlier data, we are proposing to modify our methodology for calculating the average nursing hours per patient day using the FY 2006 Occupational Mix Survey data and FY 2006 Medicare cost report data. Similar to what was finalized in the FY 2007 IPPS rule, we are proposing to merge the FY 2006 Occupational Mix Survey data with the FY 2006 Medicare cost report file. We would then eliminate all observations for non-IPPS providers, providers who failed to complete the occupational mix survey and the providers for which provider numbers, bed counts and/or days counts were missing. We would annualize the results so that the nursing hours from the Occupational

Mix Survey and the patient days reported on the Medicare cost report is representative of one year.

For each provider in the pool, we would calculate the number of nursing hours by adding the number of registered nurses, licensed practical nurses, and nursing aide hours reported on the Occupational

Mix Survey. We would divide the result of this calculation by the total number of patient days reported on line 12 on Worksheet S-3, Part I,

Column 6 of the Medicare cost report. This includes patient days in the general acute care area and the intensive care unit area. The result is the number of nursing hours per patient day.

For purposes of calculating the census regional averages for the various bed-size groups, we are proposing a different method to remove outliers in the data. First, we would calculate the difference between the observations in the 75th percentile and the 25th percentile, which is the inter-quartile range. We would remove observations that are greater than the 75th percentile plus 1.5 times the inter-quartile range and less than the 25th percentile minus 1.5 times the inter- quartile range. This methodology, known as the Tukey method, is a common statistical method used by the Office of the Actuary. Under the standard deviation method described in the FY 2007 IPPS final rule, the mean and standard deviation can be influenced by extreme values

(because the standard deviation is increased by the very observations that would otherwise be discarded from the analysis). Our proposed methodology is a more robust technique because it uses the quartile values instead of variance to describe the spread of the data, and quartiles are less influenced by extreme outlier values that may be present in the data.

Our proposed method would prevent the mean from being influenced by extreme observations and assumes that the middle 50 percent of the data has no outlier observations. The application of this methodology would result in a pool of approximately 2,578 providers. Each census region and bed group category required at least three providers in order for their average to be published. The results of the average nursing hours per patient day by bed size and region using

Page 23664

the FY 2006 Occupational Mix Survey Data and the FY 2006 hospital cost report data are shown in the table below. As stated in the FY 2007 IPPS final rule (71 FR 48059), the results of the FY 2006 Occupational Mix

Survey may be used for the volume decrease adjustment calculations for decreases in discharges beginning with cost reporting periods beginning in FYs 2006, 2007, and 2008.

Paid Nursing Hours per Patient Day

Census Region

Number of beds

New

Middle

South

East North East South West North West South

England

Atlantic

Atlantic

Central

Central

Central

Central

Mountain

Pacific

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

0-49........................................

25.47

20.60

21.08

24.52

20.27

25.92

22.16

24.52

20.99 50-99.......................................

20.99

18.51

20.36

23.44

19.00

22.44

20.44

22.54

18.89 100-199.....................................

18.12

16.31

17.31

18.87

17.43

19.50

17.01

18.70

16.25 200-399.....................................

16.92

13.80

16.23

17.79

16.06

18.66

14.56

16.82

16.63 400+........................................

17.52

14.43

16.68

18.41

14.14

16.90

16.25

15.50

18.15

b. AHA Annual Survey

In the FY 2007 IPPS final rule (71 FR 48058), we also allowed SCHs or MDHs that experienced a greater than 5 percent reduction in the number of discharges in a cost reporting period the option of using the

AHA Annual Survey results, where available, to compare the number of hospital's core staff with other like-sized hospitals in its geographic area. Our methodology for calculating the nursing hours per patient day using the AHA Annual Survey data and the Medicare hospital cost report was similar to the methodology using the Occupational Mix Survey data

(eliminating outliers outside of three standard deviations from the mean). For this reason, as with the occupational mix data, both standard deviations and the mean could be influenced by extreme values.

Therefore, we are proposing to refine our methodology to calculate the core staffing factors using the AHA Annual Survey data as well. The AHA

Annual Survey contains FTE counts for registered nurses, practical and vocational nurses, nursing assistive personnel, and other personnel in both inpatient and outpatient areas of the hospital. This is consistent with the Occupational Mix Survey which collects data on both the inpatient and outpatient areas of the hospital.

In the FY 2007 IPPS final rule, we stated we would calculate the nursing hours per patient day using the AHA Annual Survey data in a similar method to the Occupational Mix Survey. Consistent with the HAS/

Monitrend Data book, we would only calculate the average number of nursing staff for a bed-size/census group if there are data available for three or more hospitals. First, we would merge the AHA Annual

Survey Data with the corresponding Medicare cost report. We would eliminate all observations for non-IPPS providers, providers with hospital-based SNFs, and the providers for which provider numbers, bed counts, and/or days counts were missing. We would multiply the number of nurse, licensed practical nurse, and nursing aide FTEs reported on the AHA Annual Survey by 2,080 hours to derive the number of nursing hours per year (based on a 40-hour work week). We would then divide this number by the total number of patient days reported on line 12 on

Worksheet S-3, Part I, Column 6 of the Medicare cost report. In the FY 2007 IPPS final rule (71 FR 48060), we had stated that we would eliminate all providers with results beyond three standard deviations from the mean. However, to be consistent with our methodology with the

Occupational Mix Survey data, we are also proposing that we would remove outliers from the AHA Annual Survey data by calculating the difference between the observations in the 75th percentile and the 25th percentile, which is the inter-quartile range. Then, we are proposing to remove observations that are greater than the 75th percentile plus 1.5 times the inter-quartile range and less than the 25th percentile minus 1.5 times the inter-quartile range. After removing the outliers, we would group the hospitals by bed size and census area to calculate the average number of nursing hours per patient day for each category.

Using the 2006 AHA Annual Survey data as an example, this would result in a pool of approximately 1,205 providers. The results of the nursing hours per patient day using the 2006 AHA Annual Survey data and the

Medicare cost report data are shown below. The 2006 Survey would be used for the volume decrease adjustment calculations for decreases in discharges occurring during cost reporting periods beginning in FY 2006. As we stated in the FY 2007 IPPS final rule, for other years, the corresponding AHA Annual Survey would be used for the year in which the decreased occurred. For example, if a hospital experienced a decrease between its 2004 and 2005 cost reporting periods, the fiscal intermediary/MAC would compare the hospital's 2005 staffing with the results of the 2005 AHA Annual Survey, using the methodology discussed above.

Paid Nursing Hours per Patient Day

Census Region

Number of beds

New

Middle

South

East North East South West North West South

England

Atlantic

Atlantic

Central

Central

Central

Central

Mountain

Pacific

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

0-49........................................

25.82

23.48

21.77

26.12

17.25

24.75

23.66

25.44

24.50 50-99.......................................

23.42

19.40

20.69

23.47

22.06

23.28

20.55

19.28

19.91

Page 23665

100-199.....................................

18.89

17.46

18.43

20.08

19.64

20.23

19.02

18.80

18.71 200-399.....................................

18.89

14.96

15.75

17.02

15.07

19.81

15.85

18.17

18.01 400+........................................

18.98

16.66

17.39

21.59

16.47

17.71

15.06

17.76

21.11

E. Rural Referral Centers (RRCs) (Sec. 412.96)

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 the average hourly wage of the labor market area where the hospital is located by a certain percentage (106/108 percent in FY 2008).

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 reinstated RRC status for all hospitals that lost the status due to triennial review or MGCRB reclassification, but did not reinstate the status of 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.

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) and 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.) 1. Case-Mix Index

Section 412.96(c)(1) provides that CMS 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 used to determine the national and regional CMI values is set forth in the regulations at Sec. 412.96(c)(1)(ii). The proposed national median CMI value for FY 2009 includes all urban hospitals nationwide, and the proposed regional values for FY 2009 are the median CMI values of urban hospitals within each census region, excluding those hospitals with approved teaching programs (that is, those hospitals that train residents in an approved GME program as provided in Sec. 413.75).

These values are based on discharges occurring during FY 2007 (October 1, 2006 through September 30, 2007), and include bills posted to CMS' records through December 2007.

We are proposing that, in addition to meeting other criteria, if rural hospitals with fewer than 275 beds are to qualify for initial RRC status for cost reporting periods beginning on or after October 1, 2008, they must have a CMI value for FY 2007 that is at least-- 1.4285; or

The median CMI value (not transfer-adjusted) for urban hospitals (excluding hospitals with approved teaching programs as identified in Sec. 413.75) 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)...............

1.2515 2. Middle Atlantic (PA, NJ, NY).......................

1.2691 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)

1.3589

Page 23666

4. East North Central (IL, IN, MI, OH, WI)............

1.3572 5. East South Central (AL, KY, MS, TN)................

1.3040 6. West North Central (IA, KS, MN, MO, NE, ND, SD)....

1.3557 7. West South Central (AR, LA, OK, TX)................

1.4405 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..........

1.4692 9. Pacific (AK, CA, HI, OR, WA).......................

1.3872

The preceding numbers will be revised in the FY 2009 IPPS final rule to the extent required to reflect the updated FY 2007 MEDPAR file, which will contain data from additional bills received through March 2008.

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. 2. Discharges

Section 412.96(c)(2)(i) provides that CMS 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 2006 (that is, October 1, 2005 through September 30, 2006), which is the latest cost report data available at the time this proposed rule was developed.

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, 2008, must have as the number of discharges for its cost reporting period that began during FY 2006 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)...............

8,158 2. Middle Atlantic (PA, NJ, NY).......................

10,443 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)

10,344 4. East North Central (IL, IN, MI, OH, WI)............

8,900 5. East South Central (AL, KY, MS, TN)................

7,401 6. West North Central (IA, KS, MN, MO, NE, ND, SD)....

7,988 7. West South Central (AR, LA, OK, TX)................

5,816 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..........

9,919 9. Pacific (AK, CA, HI, OR, WA).......................

8,600

These numbers will be revised in the FY 2009 IPPS final rule based on the latest available cost reports.

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, 2008, the hospital would be required to have at least 3,000 discharges for its cost reporting period that began during FY 2005.

F. Indirect Medical Education (IME) Adjustment (Sec. 412.105) 1. Background

Section 1886(d)(5)(B) of the Act provides for an additional payment amount under the IPPS for hospitals that have residents in an approved graduate medical education (GME) program in order 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, for cost reporting periods beginning on or after October 1, 1997, a hospital's unweighted FTE count of residents for purposes of direct GME 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, a similar limit on the

FTE resident count for IME purposes is effective for discharges occurring on or after October 1, 1997. 2. IME Adjustment Factor for FY 2009

The IME adjustment to the MS-DRG payment is based in part on the applicable IME adjustment factor. The IME adjustment factor is calculated by 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. In the FY 2005

IPPS final rule, we announced the schedule of formula multipliers to be used in the calculation of the IME adjustment and incorporated the schedule in our

Page 23667

regulations at Sec. 412.105(d)(3)(viii) through (d)(3)(xii). Section 502(a) modifies the formula multiplier beginning midway through FY 2004 and provides for a new schedule of formula multipliers for FYs 2005 and thereafter as follows:

For discharges occurring on or after April 1, 2004, and before October 1, 2004, the formula multiplier is 1.47.

For discharges occurring during FY 2005, the formula multiplier is 1.42.

For discharges occurring during FY 2006, the formula multiplier is 1.37.

For discharges occurring during FY 2007, the formula multiplier is 1.32.

For discharges occurring during FY 2008 and fiscal years thereafter, the formula multiplier is 1.35.

Accordingly, for discharges occurring during FY 2009, the formula multiplier would be 1.35. We estimate that application of this formula multiplier for FY 2009 IME adjustment will result in an increase in IME payment of 5.5 percent for every approximately 10-percent increase in the hospital's resident-to-bed ratio.

G. Medicare GME Affiliation Provisions for Teaching Hospitals in

Certain Emergency Situations; Technical Correction (Sec. 413.79(f)(6)(iv)) 1. Background

Under section 1886(h) of the Act, as amended by section 9202 of the

Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (Pub. L. 99-272), the Secretary is authorized to make payments to hospitals for the direct costs of approved GME programs. Section 1886(d)(5)(B) of the

Act provides that prospective payment acute care hospitals that have residents in an approved GME program receive an additional payment for a Medicare discharge to reflect the higher patient care costs of teaching hospitals, that is, IME costs. Sections 1886(h)(4)(F) and 1886(d)(5)(B)(v) of the Act establish limits on the number of allopathic and osteopathic residents that hospitals may count for purposes of calculating direct GME payments and the IME adjustment, respectively, establishing hospital-specific direct GME and IME FTE resident caps. Under the authority granted by section 1886(h)(4)(H)(ii) of the Act, the Secretary issued rules to allow institutions that are members of the same affiliated group to apply their direct GME and IME

FTE resident caps on an aggregate basis through a Medicare GME affiliation agreement. The Medicare regulations at Sec. Sec. 413.75 and 413.76 permit hospitals, through a Medicare GME affiliation agreement, to adjust IME and direct GME FTE resident caps to reflect the rotation of residents among affiliated hospitals.

In response to circumstances in the aftermath of Hurricanes Katrina and Rita, we supplemented regulations in the April 12, 2006 interim final rule with comment period published in the Federal Register (71 FR 18654). The regulatory changes allowed certain hospitals to engage in emergency Medicare GME affiliations so that Medicare funding for GME is maintained while there are displaced residents training at various host hospitals even as the hurricane-affected hospitals are rebuilding their training programs. The modifications to the regulations at Sec. 413.75(b) and Sec. 413.76(f) provided flexibility for home hospitals whose residency programs have been disrupted due to an emergency to enter into emergency Medicare GME affiliation agreements with host hospitals where the hospitals may not otherwise meet the regulatory requirements to form Medicare GME affiliations. (We note that on

November 27, 2007, we issued a second interim final rule with comment period providing further flexibility relating to emergency Medicare GME affiliation agreements (72 FR 66893 through 66898). We expect to address the public comments received on both interim final rules with comment period and finalize our policies in the FY 2009 IPPS final rule scheduled to be published in August 2008.) 2. Technical Correction

In the April 12, 2006 interim final rule, we revised Sec. 413.79(f) by adding a new paragraph (6) to provide for more flexibility in Medicare GME affiliations for home hospitals located in section 1135 emergency areas to allow the home hospitals to efficiently find training sites for displaced residents. We have discovered that, under

Sec. 413.79(f)(6)(iv), in our provisions on the host hospital exception from the rolling average for the period from August 29, 2005 to June 30, 2006, we included an incorrect cross-reference to the rolling average requirements for direct GME as ``Sec. 413.75(d).'' The correct citation to the rolling average requirements for direct GME is

Sec. 413.79(d). We are proposing to correct the cross-reference under

Sec. 413.79(f)(6)(iv) to read ``paragraph (d) of this section''.

H. Payments to Medicare Advantage Organizations: Collection of Risk

Adjustment Data (Sec. 422.310)

Section 1853 of the Act requires CMS to make advance monthly payments to a Medicare Advantage (MA) organization for each beneficiary enrolled in an MA plan offered by the organization for coverage of

Medicare Part A and Part B benefits. Section 1853(a)(1)(C) of the Act requires CMS to adjust the monthly payment amount for each enrollee to take into account the health status of the MA plan's enrollees. Under the CMS-Hierarchical Condition Category (HCC) risk adjustment payment methodology, CMS determines risk scores for MA enrollees for a year and adjusts the monthly payment amount using the appropriate enrollee risk score.

Under section 1853(a)(3)(B) of the Act, MA organizations are required to ``submit data regarding inpatient hospital services . . . and data regarding other services and other information as the

Secretary deems necessary'' in order to implement a methodology for

``risk adjusting'' payments made to MA organizations. Risk adjustments to payments are made in order to take into account ``variations in per capita costs based on [the] health status'' of the Medicare beneficiaries enrolled in an MA plan offered by the organization.

Submission of data on inpatient hospital services has been required with respect to services beginning on or after July 1, 1997. Submission of data on other services has been required since July 1, 1998.

While we initially required the submission of comprehensive data regarding services provided by MA organizations, including comprehensive inpatient hospital encounter data, we subsequently permitted MA organizations to submit an ``abbreviated'' set of data.

Our regulations at 42 CFR 422.310(d)(1) currently explicitly provide MA organizations with the option of submitting an abbreviated data set.

Under this provision, we currently collect limited risk adjustment data from MA organizations, primarily diagnosis data.

From calendar years 2000 through 2006, application of risk adjustment to MA payments was ``phased in'' with an increasing percentage of the monthly capitation payment subjected to risk adjustment. Beginning with calendar year 2007, 100 percent of payments to MA organizations are risk-adjusted. Given the increased importance of the accuracy of our risk adjustment methodology, we are proposing to amend Sec. 422.310 to provide that CMS will collect data from MA organizations regarding each item and service provided to an MA plan enrollee. This will allow us to include utilization data and other factors that CMS can use in developing the CMS-HCC risk

Page 23668

adjustment models in order to reflect patterns of diagnoses and expenditures in the MA program.

Specifically, we are proposing to revise Sec. 422.310(a) to clarify that risk adjustment data are data used not only in the application of risk adjustment to MA payments, but also in the development of risk adjustment models. For example, once encounter data for MA enrollees are available, CMS would have beneficiary-specific information on the utilization of services by MA plan enrollees. These data could be used to calibrate the CMS-HCC risk adjustment models using MA patterns of diagnoses and expenditures.

We are proposing to revise Sec. Sec. 422.310(b), (c), (d)(3), and

(g) to clarify that the term ``services'' includes items and services.

We are proposing to revise Sec. 422.310(d) to clarify that CMS has the authority to require MA organizations to submit encounter data for each item and service provided to an MA plan enrollee. The proposed revision also would clarify that CMS will determine the formats for submitting encounter data, which may be more abbreviated than those used for the fee-for-service claims data submission process.

We are proposing to revise Sec. 422.310(f) to clarify that one of the ``other'' purposes for which CMS may use risk adjustment data collected under this section would be to update risk adjustment models with data from MA enrollees. In addition, when providing that CMS may use risk adjustment data for purposes other than adjusting payments as described at Sec. Sec. 422.304(a) and (c), we are proposing to delete the phrase ``except for medical records data'' from paragraph (f). Any use of medical records data collected under paragraph (e) of Sec. 422.310 is governed by the Privacy Act and the privacy provisions in the HIPAA. Furthermore, there may be occasions when we learn from analysis of medical record review data that some organizations have misunderstood our guidance on how to implement an operational instruction. We want to be able to provide improved guidance to MA organizations based on any insights that may emerge during analysis of the medical record review data.

In addition, we are proposing a technical correction to Sec. 422.310(f) to clarify that risk adjustment data are used not only to adjust payments to plans described at Sec. Sec. 422.301(a)(1), (a)(2), and (a)(3) (which refer to coordinated care plans and private fee-for- service plans), but also to adjust payments for ESRD enrollees and payments to MSA plans and Religious Fraternal Benefit society plans, as described at Sec. 422.301(c).

Under Sec. 422.310(g), we would continue to provide that data that

CMS receives after the final deadline for a payment year will not be accepted for purposes of the reconciliation. However, we are proposing to revise paragraph (g)(2) of Sec. 422.310 to change the deadline from

``December 31'' of the payment year to ``January 31'' of the year following the payment year. We are also proposing to add language to provide that CMS may adjust deadlines as appropriate.

I. Hospital Emergency Services under EMTALA (Sec. 489.24) 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 a medical condition, 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 incorporated these antidumping provisions within the Social Security Act to ensure that individuals with emergency medical conditions are not denied essential lifesaving services. Under section 1866(a)(1)(I)(i) of the Act, a hospital that fails to fulfill its EMTALA obligations under these provisions may be subject to 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 medical 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. The regulations at 42 CFR 489.20(l), (m), (q), and (r) also refer to certain EMTALA requirements. The Interpretive Guidelines concerning EMTALA are found at Appendix V of the CMS State Operations Manual. 2. EMTALA Technical Advisory Group (TAG) Recommendations

Section 945 of the Medicare Prescription Drug, Improvement, and

Modernization Act of 2003 (MMA), Pub. L. 108-173, required the

Secretary to establish a Technical Advisory Group (TAG) to advise the

Secretary on issues related to the regulations and implementation of

EMTALA. The MMA specified that the EMTALA TAG be composed of 19 members, including the Administrator of CMS, the Inspector General of

HHS, hospital representatives and physicians representing specific specialties, patient representatives, and representatives of organizations involved in EMTALA enforcement.

The EMTALA TAG's functions, as identified in the charter for the

EMTALA TAG, were as follows: (1) Review EMTALA regulations; (2) provide advice and recommendations to the Secretary concerning these regulations and their application to hospitals and physicians; (3) solicit comments and recommendations from hospitals, physicians, and the public regarding the implementation of such regulations; and (4) disseminate information concerning the application of these regulations to hospitals, physicians, and the public. The TAG met 7 times during its 30-month term, which ended on September 30, 2007. At its meetings, the TAG heard testimony from representatives of physician groups, hospital associations, and others regarding EMTALA issues and concerns.

During each meeting, the three subcommittees established by the TAG

(the On-Call Subcommittee, the Action Subcommittee, and the Framework

Subcommittee) developed

Page 23669

recommendations, which were then discussed and voted on by members of the TAG. In total, the TAG submitted 55 recommendations to the

Secretary. If implemented, some of the recommendations would require regulatory changes. Of the 55 recommendations developed by the TAG, 5 have already been implemented by CMS. A complete list of TAG recommendations will be available shortly in the Emergency Medical

Treatment and Labor Act Technical Advisory Group final report available at the Web site: http://www.cms.hhs.gov/FACA/07_emtalatag.asp. The following recommendations have already been implemented by CMS:

That CMS revise, in the EMTALA regulations [42 CFR 489.24(b)], the following sentence contained in the definition of

``labor'': ``A woman experiencing contractions is in true labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor.''

This recommendation was adopted with modification in the FY 2007

IPPS final rule (71 FR 48143). We revised the definition of ``labor'' in the regulations at Sec. 489.24(b) to permit a physician, certified nurse-midwife, or other qualified medical person, acting within his or her scope of practice in accordance with State law and hospital bylaws, to certify that a woman is experiencing false labor. We issued Survey and Certification Letter S&C-06-32 on September 29, 2006, to clarify the regulation change. (The Survey and Certification Letter can be found at the following Web site: http://www.cms.hhs.gov/

SurveyCertificationGenInfo/PMSR/list.asp).

That hospitals with specialized capabilities (as defined in the EMTALA regulations) that do not have a dedicated emergency department be bound by the same responsibilities under EMTALA as hospitals with specialized capabilities that do have a dedicated emergency department.

This recommendation was adopted in the FY 2007 IPPS final rule (71

FR 48143). We added language at Sec. 489.24(f) that makes explicit the current policy that all Medicare-participating providers with specialized capabilities are required to accept an appropriate transfer if they have the capacity to treat the individual. We issued Survey and

Certification Letter S&C-06-32 on September 29, 2006, to clarify the regulation change. (The Survey and Certification Letter can be found at the following Web site: http://www.cms.hhs.gov/

SurveyCertificationGenInfo/PMSR/list.asp).

That CMS clarify the intent of regulations regarding obligations under EMTALA to receive individuals who arrive by ambulance. Specifically, the TAG recommended that CMS revise a letter of guidance that had been issued by the agency to clarify its position on the practice of delaying the transfer of an individual from an emergency medical service provider's stretcher to a bed in a hospital's emergency department.

This recommendation was adopted with modification by CMS in Survey and Certification Letter S&C-07-20, which was released on April 27, 2007. (The Survey and Certification Letter can be found at the following Web site: http://www.cms.hhs.gov/SurveyCertificationGenInfo/

PMSR/list.asp).

That CMS clarify that a hospital may not refuse to accept an individual appropriately transferred under EMTALA on the grounds that it (the receiving hospital) does not approve the method of transfer arranged by the attending physician at the sending hospital

(for example, a receiving hospital may not require the sending hospital to use an ambulance transport designated by the receiving hospital). In addition, CMS should improve its communication of such clarifications with its regional offices.

This recommendation was adopted and implemented by CMS in Survey and Certification Letter S&C-07-20, which was released on April 27, 2007. (The Survey and Certification Letter can be found at the following Web site: http://www.cms.hhs.gov/SurveyCertificationGenInfo/

PMSR/list.asp).

That CMS strike the language in the Interpretive

Guidelines (CMS State Operations Manual, Appendix V) that addresses telehealth/telemedicine (relating to the regulations at Sec. 489.24(j)(1)) and replace it with language that clarifies that the treating physician ultimately determines whether an on-call physician should come to the emergency department and that the treating physician may use a variety of methods to communicate with the on-call physician.

A potential violation occurs only if the treating physician requests that the on-call physician come to the emergency department and the on- call physician refuses.

This recommendation was adopted and implemented by CMS in Survey and Certification Letter S&C-07-23, which was released on June 22, 2007. (The Survey and Certification Letter can be found at the following Web site: http://www.cms.hhs.gov/SurveyCertificationGenInfo/

PMSR/list.asp).

We are considering the remaining recommendations of the EMTALA TAG and may address them through future changes to or clarifications of the existing regulations or the Interpretive Guidelines, or both.

At the end of its term, the EMTALA TAG compiled a final report to the Secretary. This report includes, among other materials, minutes from each TAG meeting as well as a comprehensive list of all of the

TAG's recommendations. The final report will be available shortly at the following Web site: http://www.cms.hhs.gov/FACA/07_emtalatag.asp. 3. Proposed Changes Relating to Applicability of EMTALA Requirements to

Hospital Inpatients

While many issues pertaining to EMTALA involve individuals presenting to a hospital's dedicated emergency department, questions have been raised regarding the applicability of the EMTALA requirements to inpatients. We have previously discussed the applicability of the

EMTALA requirements to hospital inpatients in both the May 9, 2002 IPPS proposed rule (67 FR 31475) and the September 9, 2003 stand alone final rule on EMTALA (68 FR 53243). As we stated in both of the aforementioned rules, in 1999, the United States Supreme Court considered a case (Roberts v. Galen of Virginia, 525 U.S. 249 (1999)) that involved, in part, the question of whether EMTALA applies to inpatients in a hospital. In the context of that case, the United

States Solicitor General advised the Court that HHS would develop a regulation clarifying its position on that issue. In the 2003 final rule, CMS took the position that a hospital's obligation under EMTALA ends when that hospital, in good faith, admits an individual with an unstable emergency medical condition as an inpatient to that hospital.

In that rule, CMS noted that other patient safeguards protected inpatients, including the CoPs as well as State malpractice law.

However, in the 2003 final rule, CMS did not directly address the question of whether EMTALA's ``specialized care'' requirements (section 1867(g) of the Act) applied to inpatients.

As noted in section IV.I.2. of this preamble, the EMTALA TAG has developed a set of recommendations to the Secretary. One of those recommendations calls for CMS to revise its regulations to address the situation of an individual who: (1)

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Presents to a hospital that has a dedicated emergency department and is determined to have an unstabilized emergency medical condition; (2) is admitted to the hospital as an inpatient; and (3) the hospital subsequently determines that stabilizing the individual's emergency medical condition requires specialized care only available at another hospital.

We believe that the obligation of EMTALA does not end for all hospitals once an individual has been admitted as an inpatient to the hospital where the individual first presented with a medical condition that was determined to be an emergency medical condition. Rather, once the individual is admitted, admission only impacts on the EMTALA obligation of the hospital where the individual first presented.

(Throughout this section of the preamble of this proposed rule, we will refer to the hospital where the individual first presented as the

``admitting hospital.'') Section 1867(g) of the Act states:

``Nondiscrimination--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 such specialized capabilities or facilities if the hospital has the capacity to treat the individual.'' Section 1867(g) of the Act therefore requires a receiving hospital with specialized capabilities to accept a request to transfer an individual with an unstable emergency medical condition as long as the hospital has the capacity to treat that individual, regardless of whether the individual had been an inpatient at the admitting hospital. Furthermore, in the September 9, 2003 final rule (68 FR 53263), we amended the regulations at Sec. 489.24(d)(2)(i) to state: ``If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual'' (emphasis added). We did not intend for the regulation to end the EMTALA obligation for any other hospital to which the individual may appropriately be transferred to stabilize his or her emergency medical condition. Permitting inpatient admission at the admitting hospital to end EMTALA obligations for another hospital to which an unstabilized individual is being appropriately transferred to receive specialized care would seemingly contradict the intent of section 1867(g) of the Act to ensure that hospitals with specialized capabilities provide medical treatment to individuals with emergency medical conditions to stabilize their conditions.

We also note that, as we discussed in the preamble of the September 9, 2003 stand alone final rule, once a hospital has admitted an individual as an inpatient, the individual is protected under the

Medicare CoPs and may also have additional protections under State law.

Accordingly, we believe it is consistent with the intent of EMTALA to limit its protections to individuals who need them most; for example, individuals who present to a hospital but may not have been formally admitted as patients and thus are not covered by other protections applicable to inpatients of the hospital. As noted above, once the individual is admitted, the CoPs apply to the admitting hospital's care of that individual. A hospital that fails to provide treatment to such individuals could face termination of its Medicare provider agreement for a violation of the CoPs. However, these CoPs do not, of course, apply to a hospital with specialized capabilities to which the individual might be transferred unless and until the individual is formally admitted as a patient at that hospital. Therefore, in order to ensure an individual the protections intended by the EMTALA statute, especially section 1867(g) of the Act (obligating a hospital with specialized capabilities to accept an appropriately transferred individual if it has the capacity to treat that individual), we believe it is appropriate to propose to clarify that section 1867(g) of the Act continues to apply so as to protect even an individual who has been admitted as an inpatient to the admitting hospital who has not been stable since becoming an inpatient. We believe that this proposed clarification is necessary to ensure that EMTALA protections are continued for individuals who are not otherwise protected by the hospital CoPs. (We note that this proposed clarification is consistent with the EMATLA TAG's recommendation that EMTALA does not apply when an individual is admitted to the hospital for an elective procedure and subsequently develops an emergency medical condition.)

We recognize that this proposed clarification that EMTALA applies to a hospital with specialized capabilities when an inpatient (who presented to the admitting hospital under EMTALA) is in need of specialized care to stabilize his or her emergency medical condition may raise concerns among the provider community that such a clarification in policy could hypothetically result in an increase in the number of transfers. However, the intention of this proposed clarification is not to encourage patient dumping to hospitals with specialized capabilities. Rather, even if the hospital with specialized capabilities has an EMTALA obligation to accept an individual who was an inpatient at the admitting hospital, the admitting hospital transferring the individual should take all steps necessary to ensure that it is providing needed treatment within its capabilities prior to transferring the individual. This means that an individual with an unstabilized emergency medical condition should be transferred only when the capabilities of the admitting hospital have been exceeded.

Accordingly, we are proposing to revise Sec. 489.24(f) by adding to the existing text a provision that specifies that paragraph (f) also applies to an individual who has been admitted under paragraph

(d)(2)(i) of the section and who has not been stabilized.

While we are not including the following in our proposed clarification, we are seeking public comments on whether the EMTALA obligation imposed on hospitals with specialized capabilities to accept appropriate transfers should apply to a hospital with specialized capabilities in the case of an individual who had a period of stability during his or her stay at the admitting hospital and is in need of specialized care available at the hospital with specialized capabilities. CMS takes seriously its duty to protect patients with emergency medical conditions as required by EMTALA. Thus, we are seeking public comments as to whether, with respect to the EMTALA obligation on the hospital with specialized capabilities, it should or should not matter if an individual who currently has an unstabilized emergency medical condition (which is beyond the capability of the admitting hospital) (1) remained unstable after coming to the hospital emergency department or (2) subsequently had a period of stability after coming to the hospital emergency department.

In summary, to implement the recommendation by the EMTALA TAG and clarify our policy regarding the applicability of EMTALA to hospital inpatients, we are proposing to amend Sec. 489.24(f) to add a provision to state that when an individual covered by EMTALA was admitted as an inpatient and remains unstabilized with an

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emergency medical condition, a receiving hospital with specialized capabilities has an EMTALA obligation to accept that individual, assuming that the transfer of the individual is an appropriate transfer and the participating hospital with specialized capabilities has the capacity to treat the individual. 4. Proposed Changes to the EMTALA Physician On-Call Requirements a. Relocation of Regulatory Provisions

During its term, the EMTALA TAG dedicated a significant portion of its discussion to a hospital's physician on-call obligations under

EMTALA and made several recommendations to the Secretary regarding physician on-call requirements that are included in its final report

(will be available shortly at the Web site: http://www.cms.hhs/gov/

FACA/07_emtalatag.asp). The TAG recommended that CMS move the regulation discussing the obligation to maintain an on-call list from the EMTALA regulations at Sec. 489.24(j)(1) to the regulations implementing provider agreements at Sec. 489.20(r)(2). We agree with the TAG's recommendation. The requirement to maintain an on-call list is found at section 1866(a)(1)(I)(iii) of the Act, the section of the

Act that refers to provider agreements. Section 1867 of the Act, which outlines the EMTALA requirements, makes no mention of the requirement to maintain an on-call list.

To implement the EMTALA TAG's recommendation, we are proposing to delete the provision relating to maintaining a list of on-call physicians from Sec. 489.24(j)(1). We note that a provision for an on- call physician list is already included in the regulations as a hospital provider agreement requirement at Sec. 489.20(r)(2). We are proposing to incorporate the language of Sec. 489.24(j)(1) as replacement language for the existing Sec. 489.20(r)(2) and amend the regulatory language to make it more consistent with the statutory language found at section 1866(a)(1)(I)(iii) of the Act. Proposed revised Sec. 489.20(r)(2) would read: ``An on-call list of physicians on its medical staff available to provide treatment necessary after the initial examination to stabilize individuals with emergency medical conditions who are receiving services required under Sec. 489.24 in accordance with the resources available to the hospital; and''. These proposed changes would make the regulations consistent with the statutory basis for maintaining an on-call list.

The EMTALA TAG made additional recommendations regarding how a hospital would satisfy its on-call list obligations, including calling for an annual plan by the hospital and medical staff for on-call coverage that would include an assessment of factors such as the hospital's capabilities and services, community need for emergency department services as indicated by emergency department visits, emergent transfers, physician resources, and past performance of previous on-call plans. The TAG also recommended that a hospital have a backup plan for viable patient care options when an on-call physician is not available, including such factors as telemedicine, other staff physicians, transfer agreements, and regional or community call arrangements. While community call arrangements are discussed below, we intend to address the remainder of the TAG recommendations at a later date. b. Shared/Community Call

As noted in the previous section, section 1866(a)(1)(I)(iii) of the

Act states, as a requirement for participation in the Medicare program, that a hospital must keep a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition. If a physician on the list is called by a hospital to provide stabilizing treatment and either fails or refuses to appear within a reasonable period of time, the hospital and that physician may be in violation of

EMTALA as provided for under section 1867(d)(1)(C) of the Act. Thus, hospitals are required to maintain a list of on-call physicians, and physicians or hospitals, or both, may be held responsible under the

EMTALA statute if a physician who is on call fails or refuses to appear within a reasonable period of time.

In the May 9, 2002 proposed rule (67 FR 31471), we stated that we were aware of hospitals' increasing concerns regarding their physician on-call requirements. Specifically, we noted that we were aware of reports of physicians, particularly specialty physicians, severing their relationships with hospitals because of on-call obligations, especially when those physicians belong to more than one hospital medical staff. We further noted that physician attrition from these medical staffs could result in hospitals having no specialty physician service coverage for their patients. In the September 9, 2003 final rule (68 FR 53264), we clarified the regulations at Sec. 489.24(j) to permit on-call physicians to schedule elective surgery during the time that they are on call and to permit on-call physicians to have simultaneous on-call duties. We also specified that physicians, including specialists and subspecialists, are not required to be on call at all times, and that the hospital must have policies and procedures to be followed when a particular specialty is not available or the on-call physician cannot respond because of situations beyond his or her control. We expected these clarifications would help to improve access to physician services for all hospital patients by permitting hospitals flexibility to determine how best to maximize their available physician resources. Furthermore, we expected that these clarifications would permit hospitals to continue to attract physicians to serve on their medical staffs, thereby continuing to provide services to all patients, including those individuals who are covered by EMTALA.

As part of its recommendations concerning physician on-call requirements, the EMTALA TAG recommended that hospitals be permitted to participate in ``community call.'' Specifically, the language of the recommendation states: ``The TAG recommends that CMS clarify its position regarding shared or community call: that such community call arrangements are acceptable if the hospitals involved have formal agreements recognized in their policies and procedures, as well as backup plans. It should also be clarified that a community call arrangement does not remove a hospital's obligation to perform an MSE

medical screening examination

.'' The TAG also recommended in a subsequent recommendation that ``A hospital may satisfy its on-call coverage obligation by participation in an approved community/regional call coverage program. (CMS to determine appropriate approval process).''

We believe that community call (as described below) would afford additional flexibility to hospitals providing on-call services and improve access to specialty physician services for individuals in an emergency department. Therefore, we are proposing to amend our regulations at Sec. 489.24(j) to provide that hospitals may comply with the on-call list requirement specified at Sec. 489.20(r)(2)

(under our proposed revision), by participating in a formal community call plan so long as the plan meets the elements outlined below. We are further proposing to revise the regulations to state that, notwithstanding participation in a community call plan, hospitals are still required to perform medical screening examinations on individuals who present seeking treatment and to

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provide for an appropriate transfer when appropriate.

We propose ``community call,'' to be a formal on-call plan that permits a specific hospital in a region to be designated as the on-call facility for a specific time period, or for a specific service, or both. For example, if there are two hospitals that choose to participate in community call, Hospital A could be designated as the on-call facility for the first 15 days of each month and Hospital B could be designated as the on-call facility for the rest of each month.

Alternatively, Hospital A could be designated as on-call for cases requiring specialized interventional cardiac care, while Hospital B could be designated as on-call for neurosurgical cases. We anticipate that hospitals and their communities would have the flexibility to develop a plan that reflects their local resources and needs. Such a community on-call plan will allow various physicians in a certain specialty in the aggregate to be on continuous call (24 hours a day, 7 days a week), without putting a continuous call obligation on any one physician. We note that generally if an individual arrives at a hospital other than the designated on-call facility, is determined to have an unstabilized emergency medical condition, and requires the services of an on-call specialist, the individual would be transferred to the designated on-call facility in accordance with the community call plan.

As noted above, we are proposing that a community call plan must be a formal plan among the participating hospitals. While we do not believe it is necessary for the formal community call plan to be subject to preapproval by CMS, if an EMTALA complaint investigation is initiated, the plan will be subject to review and enforcement by CMS.

We are proposing that, at a minimum, hospitals must include the following elements when devising a formal community call plan:

The community call plan would include a clear delineation of on-call coverage responsibilities, that is, when each hospital participating in the plan is responsible for on-call coverage.

The community call plan would define the specific geographic area to which the plan applies.

The community call plan would be signed by an appropriate representative of each hospital participating in the plan.

The community call plan would ensure that any local and regional EMS system protocol formally includes information on community on-call arrangements.

Hospitals participating in the community call plan would engage in an analysis of the specialty on-call needs of the community for which the plan is effective.

The community call plan would include a statement specifying that even if an individual arrives at the hospital that is not designated as the on-call hospital, that hospital still has an

EMTALA obligation to provide a medical screening examination and stabilizing treatment within its capability, and hospitals participating in community call must abide by the EMTALA regulations governing appropriate transfers.

There would be an annual reassessment of the community call plan by the participating hospitals.

Proposed revised Sec. 489.24(j) would read ``Availability of on- call physicians. In accordance with the on-call list requirements specified in Sec. 489.20(r)(2), a hospital must have written policies and procedures in place--(1) To respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control; and

(2) To provide that emergency services are available to meet the needs of individuals with emergency medical conditions if a hospital elects to--(i) Permit on-call physicians to schedule elective surgery during the time that they are on call; (ii) Permit on-call physicians to have simultaneous on-call duties; and (iii) Participate in a formal community call plan. Notwithstanding participation in a community call plan, hospitals are still required to perform medical screening examinations on individuals who present seeking treatment and to conduct appropriate transfers. The formal community call plan must include the following elements: [proposed elements noted above in the bullets are included in regulations text].''

We welcome public comments on the proposed elements of the formal community call plan noted above. We are also soliciting public comments on whether individuals believe it is important that, in situations where there is a governing State or local agency that would have authority over the development of a formal community call plan, the plan be approved by that agency. In summary, we are proposing that, as part of the obligation to have an on-call list, hospitals may choose to participate in community call, provided that the formal community call plan includes, at a minimum, the elements noted in bullets above.

Additionally, each hospital participating in the community call plan must have written policies and procedures in place to respond to situations in which the on-call physician is unable to respond due to situations beyond his or her control. We are further proposing that a hospital would still be responsible for performing medical screening examinations on individuals who present to the hospital seeking treatment and conducting appropriate transfers, regardless of which hospital has on-call responsibilities on a particular day. 5. Proposed Technical Change to Regulations

In the FY 2008 IPPS final rule with comment period (72 FR 47413), we revised Sec. 489.24(a)(2) (which refers to the nonapplicability of the EMTALA provisions in an emergency area during an emergency period) to conform it to the changes made to section 1135 of the Act by the

Pandemic and All-Hazards Preparedness Act. When we made the change to the regulations, we inadvertently left out language consistent with the following statutory language found in section 1135: ``pursuant to an appropriate State emergency preparedness plan; or in the case of a public health emergency described in subsection (g)(1)(B) that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan or a plan referred to in clause (i), whichever is applicable in the State.'' We also inadvertently left out the phrase in section 1135 ``during an emergency period'' when we state the nonapplicability of the sanctions in an emergency area. We are proposing to revise the language at Sec. 489.24(a)(2) to include the aforementioned language to conform the regulation text to the statutory language. Proposed revised Sec. 489.24(a)(2) would read as follows:

``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 pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a

State pandemic preparedness plan do not apply to a hospital with a dedicated emergency department located in an emergency area during an emergency period, as specified in section 1135(g)(1) of 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

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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.''

J. Application of Incentives To Reduce Avoidable Readmissions to

Hospitals 1. Introduction

A significant portion of Medicare spending--$15 billion each year-- is related to hospital readmissions. According to a 2005 MedPAC analysis ,\17\ nearly 18 percent of beneficiaries who are discharged from the hospital are readmitted within 30 days, resulting in approximately 2 million readmissions. By MedPAC's method, over 13 percent of 30-day hospital readmissions and an associated $12 billion in spending (\4/5\ of all Medicare spending for readmissions) were found to be potentially avoidable. Beyond cost considerations, readmissions may reflect poor quality of care and affect beneficiaries'' quality of life. Though not all readmissions are avoidable, hospitals should share accountability for readmission rates that could be much lower through the application of evidence-based best practices. Interventions that have been shown to reduce readmissions include better quality of care during the hospitalization, more complete care plans, emphasis on coordination of care at the point of transitions to home or postacute care, better use of after-hospital care, and more active involvement of patients and caregivers in decision making.

\17\ Medicare Payment Advisory Commission: Report to Congress:

Promoting Greater Efficiency in Medicare. June 2007, Chapter 5, page 103.

The application of incentives to reduce hospital readmissions, including payment and public reporting approaches, could promote the adoption and development of best practice interventions for averting avoidable readmissions, resulting in higher quality of care for

Medicare beneficiaries and reduction in unnecessary costs for the program. Under the current payment system, readmissions are financially rewarding for hospitals. Application of payment incentives to encourage reduction of avoidable readmissions could help address unintended incentives in the current payment system.

In this section, following discussion of readmission issues related to measurement, accountability, and interventions, we are presenting three approaches to applying incentives to reduce avoidable readmissions for public comment: (1) Direct adjustment to hospital DRG payments for avoidable readmissions, (2) adjustments to hospital DRG payments through a performance-based payment methodology, and (3) public reporting of readmission rates. We note that either type of adjustment to hospital payments for readmissions would likely require new statutory authority for the Medicare program. We are seeking public comments on all of the ideas presented in this section. 2. Measurement

Routine, valid, and reliable measurement of hospital-specific rates of readmissions would be a prerequisite to any method of applying incentives for reducing hospital readmissions. Measurement data should be meaningful and actionable for hospitals and should be fair to encourage trust and engagement in the effort. Risk adjustment of measurement data is necessary to account for patient[pi]specific factors that influence the likelihood of readmission, such as age, disease severity, and comorbidities.

Another important consideration in measurement of readmission rates is the time period from discharge to readmission (for example, 7, 15, 30, or 90 days). In section IV.B. of the preamble of this proposed rule, measures of risk-adjusted 30-day readmission rates are proposed for the RHQDAPU program. The 9th Scope of Work for Medicare Quality

Improvement Organizations (QIO 9th SOW) also includes 30-day readmission measures for communities.

Measures should be aligned across settings of care. Hospitals are not the only providers that affect the occurrence of readmissions. For example, the care delivered by SNFs and HHAs also has an important impact on whether a beneficiary is readmitted. Data from aligned readmissions measures, applicable to various settings of care, would provide better information about care coordination problems within and between settings. Alignment of readmissions measures would also facilitate more powerful application of incentives across Medicare's payment systems.

Another consideration is whether to focus on all readmissions or to focus on those that are known to be higher cost, more easily preventable, or most frequently occurring. For example, numerous hospitals have successfully implemented programs to reduce readmissions of heart failure patients, so more is known about the prevention of heart failure readmissions. Further, heart failure readmissions may be more costly than readmissions for other conditions. Another focus of efforts to prevent readmissions could be patients with multiple chronic conditions, who may be at the highest risk to experience readmissions. 3. Accountability

In the assignment of accountability for readmissions, risk adjustment of measurement data is one consideration of fairness; however, other factors must also be considered, including avoidability and shared accountability. Most clinicians would agree that a goal of zero readmissions may not be appropriate, as an extremely low rate of readmissions could indicate restricted access to needed medical services, overuse of hospital resources during the initial hospitalization (for example, prolonged length of stay), or excessive intensity of post-acute care services. Adequate risk adjustment could help to elucidate the avoidability of readmissions by identifying an expected readmission rate for a given patient or patient population.

Shared accountability is another important consideration. Hospitals are clearly accountable for the care provided during hospitalization and can also affect the quality of care provided after the hospitalization, but hospitals are not the only accountable entity.

Both during and after hospitalization, physicians and other health professionals share accountability for the quality of care. Other provider entities, including skilled nursing facilities, rehabilitation facilities, home health agencies, and end-stage renal disease facilities, also share accountability for avoidable readmissions.

Medicare beneficiaries themselves and their caregivers and social support systems play important roles in avoiding readmissions, particularly when beneficiaries have been discharged to home.

Assignment of accountability also requires consideration of situations where the patient presents for readmission with a different diagnosis or presents to a different hospital. If the

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locus of accountability were at the hospital level, a second hospital should not be held accountable for a readmission resulting from a first hospital's lack of adherence to evidence-based best practices for averting readmissions. If the locus of accountability were at the community level, then shared accountability could encourage hospitals to work together to reduce readmissions. 4. Interventions

A number of interventions have been identified as best practices for averting avoidable readmissions.\18,19,20,21,22,23,24,25,26\ Some of these evidence-based interventions are listed below:

\18\ Coleman, E.A., C. Parry, S. Chalmers, et al. 2006. The care transitions intervention: Results of a randomized controlled trial.

Archives of Internal Medicine, 166 (September 25): 1822-1828.

\19\ Coleman, E.A., J.D. Smith, R. Devbani, et al. 2005.

Posthospital medication discrepancies: Prevalence and contributing factors. Archives of Internal Medicine 165, (September 12): 1842- 1847.

\20\ Coleman, E., and R. Berenson. 2004. Lost in transition:

Challenges and opportunities for improving the quality of transitional care. Annals of Internal Medicine, 141, no. 7 (October 5): 533-536.

\21\ Institute for Healthcare Improvement. 2004a. Reducing readmissions for heart failure patients: Hackensack University

Medical Center. Available at http://www.ihi.org.

\22\ Institute for Healthcare Improvement. 2004b. The

MedProvider inpatient care unit-congestive heart failure project.

Available at: http://www.ihi.org.

\23\ Lappe, J.M., J.B. Muhlestein, D.L. Lappe, et al. 2004.

Improvements in 1-year cardiovascular clinical outcomes associated with a hospital-based discharge medication program. Annals of

Internal Medicine, 141, no.6 (September 21): 446-453.

\24\ Naylor, M.D., D. Brooton, R. Campbell, et al. 1999.

Comprehensive discharge planning and home follow-up of hospitalized elders. Journal of the American Medical Association, 281, no.7

(February 17): 613-620.

\25\ VanSuch, M., J.M. Naessens, R.J. Stroebel, et al. 2006.

Effect of discharge instructions on readmission of hospitalized patients with heart failure: Do all of the Joint Commission on

Accreditation of Healthcare Organizations heart failure core measures reflect better care? Quality and Safety in Healthcare, 15: 414-417.

\26\ Weinberg D.B., J.H. Gittell, R.W. Lusenhop, et al. 2007.

Beyond our walls: Impact of patient and provider coordination across the continuum on outcomes for surgical patients. Health Services

Research, 42, no. 1, pt. 1 (February): 7-24.

Better, safer care during the hospitalization.

Improved communication among providers and with the patient and caregivers.

Care planning that begins with assessment at admission.

Clear discharge instructions, with specific attention to medication management.

Shared accountability for care coordination, with attention to transitions and hand-offs.

Discharge to a proper setting of care.

Better, safer care in the post-acute setting of care.

Appropriate use of palliative care and honest planning for the likely course.

Timely physician follow up visits.

Active involvement of patients and their caregivers.

Interventions such as these have been employed by several participants in CMS Physician Group Practice Demonstration and have contributed to improvements in the quality and cost-efficiency of care provided to Medicare beneficiaries. For example, the University of

Michigan Faculty Group Practice's transitional care call-back program contacts Medicare patients discharged from the emergency department and acute care hospital to address gaps in care during the transition between care settings. The program provides short-term care coordination with linkages to visiting nurse and community services, as well as coordination with primary care and specialty clinics. The

Everett Clinic utilizes hospital coaches to guide patients and caregivers through complicated care processes during hospital stays and on discharge. The clinic proactively reaches out to recently hospitalized patients to assure that they have a physician followup visit within 10 days after discharge to address any unresolved or new health problems.

CMS is considering strategies for distributing a discharge checklist that the agency developed to help beneficiaries and their caregivers prepare for discharge from a hospital or nursing home. The checklist includes a range of issues to consider and address with physicians and other health care providers to facilitate a smooth transition to home or postacute care setting. In addition, the checklist provides information about supportive home and community- based services.

The QIO 9th SOW includes a theme entitled Patient Pathways (Care

Transitions). The goal of this theme is to measurably improve the quality of care for Medicare beneficiaries who transition among care settings, resulting in reduced readmissions and replicable strategies to sustain reduced readmission rates. The QIO 8th SOW included initiatives to reduce avoidable readmissions of home health patients. 5. Financial Incentive: Direct Payment Adjustment

The first of three approaches presented for comment is direct adjustment to hospital DRG payments for readmissions. This approach would likely require new statutory authority for the Medicare program.

In section II.F. of the preamble of this proposed rule, we discuss direct adjustments to MS-DRG payment for selected preventable HACs. Similarly, a payment adjustment could be applied for readmissions determined to be avoidable because the hospital did not follow evidence-based best practices for averting readmissions. The magnitude of the payment adjustment could be based on patient-specific risk factors and on the apportionment of shared accountability among the involved entities.

A variation of this approach could be adjustment of all hospital payments for readmissions, nationwide or by some regional designation, based on aggregate information about avoidable readmissions for the entire relevant Medicare population (national or regional) under typical circumstances. Under this approach, hospitals would receive less Medicare payment for readmissions for conditions with lower expected rates of readmission and less shared accountability.

Potential unintended consequences resulting from a financial incentive to avert readmissions also need to be considered. For example, hospitals could begin discharging patients to settings that provide more intensive postacute care to avoid readmissions, thereby potentially driving up total costs for episodes of care and total

Medicare spending. As another example of potential unintended consequences, hospitals could begin to resist medically necessary readmissions from postacute care providers, creating an access problem. 6. Financial Incentive: Performance-Based Payment Adjustment

The second approach presented for comment is adjustment to hospital

MS-DRG payments using a performance-based payment methodology, such as the Medicare Hospital VBP Plan referenced in section IV.C. of the preamble of this proposed rule and available at: http:// www.cms.hhs.gov/AcuteInpatientPPS/downloads/

HospitalVBPPlanRTCFINALSUBMITTED2007.pdf. The intent of the VBP Plan methodology is to promote adherence to evidence-based best practices in the delivery of care and to provide rewards for those who are successful in improving their measured performance. Implementation of the VBP methodology would require new statutory authority for the

Medicare program.

Under the VBP Plan, measures of clinical processes of care, patient experience (HCAHPS), and outcomes (30-day mortality) would be scored and translated into an incentive payment. These measures of process, outcome, and patient-centeredness address areas of quality that are important to reducing readmissions; however, other measures could be added to more fully adjust payments for readmissions. Direct measures of hospital-specific, risk adjusted readmission rates could be included in the VBP Plan performance

Page 23675

assessment model. In addition, other measures of care coordination that indirectly address readmissions could also be included.

The direct adjustment approach and the VBP Plan approaches for applying financial incentives to the reduction of avoidable readmissions could be implemented separately or in combination. 7. Nonfinancial Incentive: Public Reporting

A third approach presented for comment is public reporting of hospital-specific, risk adjusted readmission rates. The

Administration's Value-Driven Health Care initiative, which stems from the President's Executive Order Promoting Quality and Efficient Health

Care in Federal Government Health Care Programs, calls for Federal agencies to make health care quality and cost information more transparent. Health care consumers, including Medicare beneficiaries, and their providers and caregivers need better information to support more informed decision making about their care. The public reporting of readmission rates would likely not require new statutory authority for the Medicare program.

The Hospital Compare Web site could be used to report readmission rates along with the other quality and cost of care parameters displayed on that site. Public reporting has been demonstrated to be a strong non-financial incentive with a competitive effect, as hospitals appropriately focus on maintaining and enhancing their reputations as providers of high quality of care. The VBP Plan envisions public reporting in concert with the VBP financial incentive, but the public reporting incentive could be applied regardless of statutory authority to implement the VBP Plan. 8. Conclusion

The purpose of this section is to solicit and encourage public comments on considerations and options for applying incentives to reduce avoidable hospital readmissions. We welcome public comments on readmission issues related to measurement, accountability, and interventions, as well as on potential approaches to applying financial and nonfinancial incentives to reduce avoidable readmissions.

K. Rural Community Hospital Demonstration Program

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.

Section 410A(a)(4) of Pub. L. 108-173 states that no more than 15 such hospitals may participate in the demonstration program.

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. (Of the 13 hospitals that participated in the first 2 years of the demonstration program, 4 hospitals located in

Nebraska have become CAHs and have withdrawn from the program.)

In a notice published in the Federal Register on February 6, 2008

(73 FR 6971 through 6973), we announced a solicitation for up to six additional hospitals to participate in the demonstration program.

Hospitals that enter the demonstration under this solicitation will be able to participate for no more than 2 years. The February 6, 2008 notice specifies the eligibility requirements for the demonstration program.

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 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 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

Page 23676

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 2009, 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, FY 2007 and FY 2008 IPPS final rules (69 FR 49183; 70 FR 47462; 71 FR 48100; and 72 FR 47392), 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 2009, using data from the cost reports from each of the nine hospitals' first year of participation in the demonstration program, that is, cost reports for years beginning in CY 2005, and estimating the cost of six additional hospitals based on these data, we estimate that the additional cost would be $32,011,849. (In the final rule, we should know the exact number of hospitals participating in the demonstration program and would revise our estimates accordingly.) This 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 payment rate adjustment that is required to ensure the budget neutrality of the demonstration program for FY 2009 in section II.A.4. of the Addendum to this proposed rule.

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

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 Federal fiscal year (FY) 1992 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).

FY 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 hospitals receiving certain exception payments and certain new hospitals). 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. 1. Exception Payments

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 FY 2003 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 the 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 are 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), we refer readers to the FY 2002 IPPS final rule (66

FR 39911 through 39914) and the FY 2003 IPPS final rule (67 FR 50102).) 2. New Hospitals

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 FY 1992 IPPS 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, as discussed in the FY 2003 IPPS final rule (67 FR 50101), we believe that special protection to new hospitals is also appropriate even after the transition period, 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 FY 2002 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

Continued on page 23677

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

]

pp. 23677-23726

Medicare Program; Proposed Changes to the Hospital Inpatient

Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed

Changes to Disclosure of Physician Ownership in Hospitals and Physician

Self-Referral Rules; Proposed Collection of Information Regardi[Page 23677]

Continued from page 23676

Page 23677

determine capital-related payments to hospitals both during and after the transition period, and the policy for providing exception payments.) 3. Hospitals Located in Puerto Rico

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 hospitals located in Puerto Rico 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 located 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 located 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. Revisions to the Capital IPPS Based on Data on Hospital Medicare

Capital Margins

As noted above, under the Secretary's broad authority under the statute in establishing and implementing the IPPS for hospital inpatient capital-related costs, we have established a standard Federal payment rate for capital-related costs, as well as the mechanism for updating that rate each year. 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.

In the FY 2008 IPPS final rule with comment period (72 FR 47398 through 47401), based on our analysis of data on inpatient hospital

Medicare capital margins that we obtained through our monitoring and comprehensive review of the adequacy of the standard Federal payment rate for capital-related costs and the updates provided under the existing regulations, we made changes in the payment structure under the capital IPPS beginning with FY 2008. We summarize these changes below. We refer readers to section V.B. of the preamble of the FY 2008 final rule with comment period (72 FR 47393 through 47401) for a detailed discussion of the data used as a basis for these changes.

These data showed that hospital inpatient Medicare capital margins were very high across all hospitals during the period from FY 1996 through

FY 2004.

In the FY 2008 IPPS final rule with comment period, as background, we noted that, 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 demonstrate 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 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,

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 FYs1992 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.

As we also discussed in the FY 2008 IPPS final rule with comment period, we believed 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

Page 23678

have experienced in recent years. 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 DSH 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), disproportionate share hospitals (8.4 percent), and urban hospitals (8.3 percent) have had significant positive margins. Other classes of hospitals have experienced much lower margins, especially rural hospitals (0.3 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 adjustment under the system. We believed 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.

Therefore, in the FY 2008 IPPS final rule with comment period, we made two changes to the structure of payments under the capital IPPS, as discussed under items 1. and 2. below. 1. Elimination of the Large Add-On Payment Adjustment

In the FY 2008 IPPS final rule with comment period, we determined that the data we had gathered on inpatient hospital Medicare capital margins provided sufficient evidence to warrant elimination of the large urban add-on payment adjustment starting in FY 2008 under the capital IPPS. Therefore, for FYs 2008 and beyond, we discontinued the 3.0 percent additional payment that had been provided to hospitals located in large urban areas (72 FR 24822). This decision was supported by comments from MedPAC. 2. Changes to the Capital IME Adjustment a. Background and Changes Made for FY 2008

In the FY 2008 IPPS proposed rule, we noted that margin analysis indicated that several classes of hospitals had experienced continuous, significant positive margins. The analysis indicated that the existing payment adjustments for teaching hospitals and disproportionate share hospitals were contributing to excessive payment levels for these classes of hospitals. Therefore, we stated that it may be appropriate to reduce these adjustments significantly, or even to eliminate them altogether, within the capital IPPS. These payment adjustments, unlike 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 in section 1886(g)(1) of the Act to include appropriate adjustments and exceptions within a capital IPPS. In the FY 2008 final rule with comment period, we also noted a MedPAC recommendation that we seriously reexamine the appropriateness of the existing capital IME adjustment, that the margin analysis indicated such adjustment may be too high, and that MedPAC's previous analysis also suggested the adjustment may be too high. In light of MedPAC's recommendation, we extended the margin analysis discussed in the FY 2008 IPPS proposed rule in order to distinguish the experience of teaching hospitals from the experience of urban and rural hospitals generally. Specifically, we isolated the margins of urban, large urban, and rural teaching hospitals, as opposed to urban, large urban, and rural nonteaching hospitals. In conducting this analysis, we employed updated cost report information, which allowed us to incorporate the margins for an additional year, FY 2005, into the analysis. The data on the experience of urban, large urban, and rural teaching hospitals as opposed to nonteaching hospitals provided significant new information. As the analysis demonstrated, teaching hospitals in each class (urban, large urban, and rural) performed significantly better than comparable nonteaching hospitals. For the period covering FYs 1998 through 2005, urban teaching hospitals realized aggregate positive margins of 11.9 percent, compared to a positive margin of 0.9 percent for urban nonteaching hospitals.

Similarly, large urban teaching hospitals realized an aggregate positive margin of 12.8 percent during that period, while large urban nonteaching hospitals had an aggregate positive margin of only 2.9 percent. Finally, rural teaching hospitals experienced an aggregate positive margin of 4.5 percent, as compared to a negative 1.3 percent margin for nonteaching rural hospitals. We noted that the positive margins for teaching hospitals did not exhibit a decline to the same degree as the margins for all hospitals. For example, the positive margins for all IPPS hospitals declined from 8.7 percent in FY 2002 to 5.3 percent in FY 2004 and 3.7 percent in FY 2005. For urban hospitals, aggregate margins decreased from 10.3 percent in FY 2002 to 6.4 percent in FY 2004 and 4.8 percent in FY 2005. Rural hospitals experienced a decrease from 1.5 percent in FY 2001 to a negative margin of -4.2 percent in FY 2005. In comparison, the aggregate margin for teaching hospitals was 12.1 percent in FY 2001 and 10.6 percent in FY 2005. For urban teaching hospitals, margins were 12.5 percent in FY 2001, 14.0 percent in FY 2002, 13.6 percent in FY 2003, 11.9 percent in FY 2004, and 10.9 percent in FY 2005. Rural teaching hospital margins were more variable, but did not exhibit a pattern of significant decline. In FY 2001, rural teaching hospitals had a positive margin of 3.2 percent; in

FY 2002, 8.2 percent; in FY 2003, 4.7 percent; in FY 2004, 5.7 percent; and in FY 2005, 4.0 percent. We are reprinting below the table found in the FY 2008 IPPS final rule with comment period showing our analysis

(72 FR 47400).

Hospital Inpatient Medicare Capital Margins

Aggregate

Aggregate 1996

1997

1998

1999

2000

2001

2002

2003

2004

2005 1996-2005 1998-2005

U.S.................................

17.6

13.4

7.0

6.8

7.3

8.1

8.7

7.6

5.3

3.7

8.5

6.8

URBAN...............................

17.7

13.8

7.8

7.5

8.4

9.2

10.3

9.0

6.4

4.8

9.4

7.9

RURAL...............................

16.8

11.0

2.1

2.4

1.0

1.5

-1.7

-1.4

-2.3

-4.2

2.6

-0.4

No DSH Payments.....................

16.2

11.7

4.2

4.3

5.6

5.5

4.7

4.4

-1.3

-4.7

5.9

3.2

Has DSH Payments....................

18.5

14.4

8.6

8.1

8.2

9.0

10.0

8.5

7.0

5.9

9.5

8.1

Page 23679

$1-$249,999.........................

14.5

12.9

-0.4

3.1

1.6

4.1

3.2

1.4

-1.7

-4.8

3.2

1.9

$250,000-$999,999...................

15.5

9.0

2.3

1.6

2.8

2.7

-2.4

-1.5

-4.3

-7.3

1.5

-0.9

$1,000,000-$2,999,999...............

16.8

13.0

8.7

9.0

8.7

7.0

10.1

5.2

3.2

2.0

8.2

6.6

$3,000,000 or more..................

20.3

16.6

10.4

9.3

9.7

12.1

13.2

12.5

10.6

9.5

12.2

11.0

TEACHING............................

19.5

15.7

9.8

9.7

11.2

12.1

13.8

13.2

11.7

10.6

12.7

11.6

Urban...............................

19.7

15.9

10.2

10.0

11.4

12.5

14.0

13.6

11.9

10.9

13.0

11.9

Large Urban.........................

20.5

16.8

11.0

10.1

12.5

13.9

15.2

14.7

12.0

11.9

13.9

12.8

Rural...............................

13.9

8.5

1.0

2.9

5.8

3.2

8.2

4.7

5.7

4.0

5.7

4.5

NONTEACHING.........................

15.3

10.5

3.4

2.8

2.2

2.6

1.7

0.0

-3.2

-5.1

2.8

0.3

Urban...............................

14.4

10.1

3.8

3.0

3.0

3.1

3.6

0.9

-2.9

-4.9

3.1

0.9

Large Urban.........................

15.5

11.3

6.2

6.1

5.7

5.2

5.3

1.7

-0.9

-3.2

5.1

2.9

Rural...............................

17.3

11.4

2.3

2.4

0.2

1.2

-3.7

-2.6

-3.9

-6.0

2.0

-1.3

Census Division:

New England (1).................

27.9

25.9

17.1

15.1

18.2

20.7

21.3

21.1

20.5

20.3

21.0

19.5

Middle Atlantic (2).............

19.1

15.5

11.1

11.6

14.1

16.5

18.7

18.0

14.7

16.0

15.6

15.2

South Atlantic (3)..............

18.1

13.9

5.9

4.0

6.0

5.0

6.6

6.9

5.8

2.8

7.4

5.4

East North Central (4)..........

18.2

12.7

6.4

7.1

8.8

8.5

6.1

7.1

6.6

3.2

8.4

6.7

East South Central (5)..........

14.9

11.1

3.3

4.1

3.8

3.8

3.8

-0.9

-3.4

-5.8

3.2

0.9

West North Central (6)..........

14.3

7.0

0.1

--0.3

-1.5

2.0

1.9

3.4

1.6

-0.4

2.8

0.9

West South Central (7)..........

13.2

8.3

3.3

2.6

-0.7

0.0

1.2

-2.0

-4.0

-6.5

1.2

-1.0

Mountain (8)....................

17.2

14.7

8.5

7.7

7.2

6.4

2.9

3.3

0.8

-4.7

5.8

3.6

Pacific (9).....................

20.4

16.1

12.3

11.3

11.9

13.3

14.7

12.1

9.8

8.8

13.0

11.7

Code 99.........................

23.7

24.1

14.5

16.8

19.8

20.7

20.5

25.1

21.6

24.8

21.4

20.8

Bed Size:

= 1000 beds....................

8.2

14.0

2.2

-1.3

-6.6

-3.6

6.5

8.1

6.5

2.1

3.5

2.3

Notes:

Based on Medicare Cost Report hospital data updated as of the 1st quarter of 2007.

Medicare payments 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 with MedPAC.

Code 99 applies when census division information was not specified in the Medicare Cost Report hospital data.

As we indicated in the FY 2008 IPPS final rule with comment period

(72 FR 47401), the statutory history of the capital IPPS suggests that the system in the aggregate should not provide for continuous, large positive margins. As we also indicated, a possible reason for the relatively high margins of many capital IPPS hospitals may be that the payment adjustments provided under the system are too high, or perhaps even unnecessary. We agreed with MedPAC's recommendation and reexamined the appropriateness of the teaching adjustment. We concluded that the record of relatively high and persistent positive margins for teaching hospitals under the capital IPPS indicated that the teaching adjustment is unnecessary, and that it was therefore appropriate to exercise our discretion under the capital IPPS to eliminate this adjustment. At the same time, we believed that we should mitigate abrupt changes in payment policy and that we should provide time for hospitals to adjust to changes in the payments that they can expect under the program.

Therefore, in the FY 2008 IPPS final rule with comment period, we adopted a policy to phase out the capital teaching adjustment over a 3- year period beginning in FY 2008. Specifically, we maintained the adjustment for FY 2008, in order to give teaching hospitals an opportunity to plan and make adjustments to the change. During the second year of the transition, FY 2009, the formula for determining the amount of the teaching adjustment was revised so that adjustment amounts will be half of the amounts provided under the current formula.

For FY 2010 and after, hospitals will no longer receive an adjustment for teaching activity under the capital IPPS. b. Public Comments Received on Phase Out of Capital IPPS Teaching

Adjustment Provisions Included in the FY 2008 Final Rule With Comment

Period and Further Solicitation of Public Comments

As indicated above, in the FY 2008 IPPS final rule with comment period, we formally adopted as final policy a phase out of the capital

IPPS teaching adjustment over a 3-year period, maintaining the current adjustment for FY 2008, making a 50-percent reduction in FY 2009, and eliminating the adjustment for FY 2010 and subsequent years. However, because we concluded that this change to the structure of payments under the capital IPPS was significant, we provided the public with an opportunity for further comment on these provisions through a 90-day comment period after publication of the FY 2008 IPPS final rule with comment period (72 FR 47401). In addition, as we indicated in that final rule with comment period, to provide a more than adequate opportunity for hospitals, associations, and other interested parties to raise issues and concerns related to our policy, we are providing additional opportunity for public comment during this FY 2009 proposed rulemaking cycle for the IPPS.

We received numerous timely pieces of correspondence that commented on the policy of phasing out the capital IPPS teaching adjustment as described in the FY 2008 IPPS final rule with comment period. These comments are available on our e-rulemaking Web site, at http:// www.cms.hhs.gov/eRulemaking/ECCMSR/list.asp. We will also accept public comments on this policy during the comment period for this proposed rule. We will respond to

Page 23680

both sets of public comments when we issue the FY 2009 IPPS final rule, which is scheduled for publication in August 2008.

VI. Proposed Changes for Hospitals and Hospital Units Excluded From the

IPPS

A. Proposed Payments to 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, which include 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.)

In this FY 2009 IPPS proposed rule, we are proposing that the percentage increase in the rate-of-increase limits for cancer and children's hospitals and RNHCIs would be the proposed percentage increase in the FY 2009 IPPS operating market basket, which is estimated to be 3.0 percent. Consistent with our historical approach, we calculated the proposed IPPS operating market basket for FY 2009 using the most recent data available. However, if more recent data are available for the final rule, we will use them to calculate the IPPS operating market basket. For cancer and children's hospitals and

RNHCIs, the proposed FY 2009 rate-of-increase percentage that is applied to FY 2008 target amounts in order to calculate FY 2009 target amounts is 3.0 percent, based on Global Insight, Inc.'s 2008 first quarter forecast of the IPPS operating market basket increase, in accordance with the applicable regulations in 42 CFR 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 provided transition periods of varying lengths during which time a portion of the prospective payment 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 period as applicable under 42 CFR Part 412, Subparts N, O, and P). We note that the various transition periods provided for under the IRF PPS, the IPF

PPS, and the LTCH PPS have ended.

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 42 CFR

Part 413. Similarly, for cost reporting periods beginning on or after

October 1, 2006, all LTCHs are paid 100 percent of the adjusted Federal prospective payment 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. (We note that, to the extent a portion of a LTCH's PPS payment was subject to reasonable cost principles, the Secretary utilized his broad authority under section 123 of the BBRA, as amended by section 307 of the BIPA, to make such portion subject to 42 CFR Part 413 and various provisions in section 1886(b) of the Act.) Likewise, for cost reporting periods beginning on or after January 1, 2008, all IPFs are paid 100 percent of the Federal per diem amount under the IPF PPS. Therefore, for cost reporting periods beginning on or after January 1, 2008, no portion of an IPF PPS payment is subject to 42 CFR Part 413.

B. IRF PPS

Section 1886(j) of the Act, as added by section 4421(a) of Pub. L. 105-33, 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 for services furnished under the PPS for inpatient rehabilitation hospitals and inpatient rehabilitation units of hospitals (referred to as 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 blended 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. LTCH PPS

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 under Sec. 412.533(a) for LTCHs. For cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the adjusted Federal prospective payment rate.

D. IPF PPS

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 requirements of that final rule, we computed 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

Page 23681

adjustment, rural location, indirect teaching costs, the presence of a full-service emergency department, and COLAs for IPFs located in Alaska and Hawaii.

We established a 3-year transition period during which IPFs whose cost reporting periods began on or after January 1, 2005, and before

January 1, 2008, would be paid a PPS payment, a portion of which was based on reasonable cost principles and a portion of which was the

Federal per diem payment amount. For cost reporting periods beginning on or after January 1, 2008, all IPFs are paid 100 percent of the

Federal per diem payment amount.

E. Determining Proposed LTCH Cost-to-Charge Ratios (CCRs) Under the

LTCH PPS

In general, we use a LTCH's overall CCR, which is computed based on either the most recently settled cost report or the most recent tentatively settled cost report, whichever is from the latest cost reporting period, in accordance with Sec. 412.525(a)(4)(iv)(B) and

Sec. 412.529(c)(4)(iv)(B) for high cost outliers and short-stay outliers, respectively. (We note that, in some instances, we use an alternative CCR, such as the statewide average CCR in accordance with the regulations at Sec. 412.525(a)(4)(iv)(C) and Sec. 412.529(c)(4)(iv)(C), or a CCR that is specified by CMS or that is requested by the hospital under the provisions of the regulations at

Sec. 412.525(a)(4)(iv)(A) and Sec. 412.529(c)(4)(iv)(A).) Under the

LTCH PPS, a single prospective payment per discharge is made for both inpatient operating and capital-related costs. 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).

Generally, 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). This is because CCRs above this threshold are 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, generally, 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.

In the FY 2008 IPPS final rule with comment period, in accordance with Sec. 412.525(a)(4)(iv)(C)(2) for high-cost outliers and Sec. 412.529(c)(4)(iv)(C)(2) for short-stay outliers, using our established methodology for determining the LTCH total CCR ceiling, based on IPPS total CCR data from the March 2007 update to the Provider-Specific File

(PSF), we established a total CCR ceiling of 1.284 under the LTCH PPS effective October 1, 2007, through September 30, 2008. (For further detail on our methodology for annually determining the LTCH total CCR ceiling, we refer readers to the FY 2007 IPPS final rule (71 FR 48117 through 48121) and the FY 2008 IPPS final rule with comment period (72

FR 47403 through 47404).)

Our general methodology established for determining the statewide average CCRs used under the LTCH PPS is similar to our established methodology for determining the LTCH total CCR ceiling (described above) because it is based on ``total'' IPPS CCR data. Under the LTCH

PPS high-cost outlier policy at Sec. 412.525(a)(4)(iv)(C) and the short-stay outlier policy at Sec. 412.529(c)(4)(iv)(C), the fiscal intermediary (or MAC) 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 circumstances: (1) A new LTCH that has not yet submitted its 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) a LTCH whose CCR is in excess of the LTCH CCR ceiling (as discussed above); and (3) any other LTCH 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

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.)

In this proposed rule, in accordance with Sec. 412.525(a)(4)(iv)(C)(2) for high-cost outliers and Sec. 412.529(c)(4)(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 2007 update to the PSF), we are proposing a total CCR ceiling of 1.262 under the LTCH

PPS, effective for discharges occurring on or after October 1, 2008, and before October 1, 2009. If more recent data become available before publication of the final rule, we will use such data to determine the final total CCR ceiling under the LTCH PPS for FY 2009.

In this FY 2009 IPPS proposed rule, in accordance with Sec. 412.525(a)(4)(iv)(C) for high-cost outliers and Sec. 412.529(c)(4)(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 2007 update of the PSF, we are proposing LTCH PPS statewide average total CCRs for urban and rural hospitals that would be effective for discharges occurring on or after October 1, 2008, and before October 1, 2009, presented in Table 8C of the Addendum to this proposed rule. If more recent data become available before publication of the final rule, we will use such data to determine the final statewide average total CCRs for urban and rural hospitals under the

LTCH PPS for FY 2009 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 were no short-term acute care IPPS hospitals or LTCHs located in those areas as of December 2007. Therefore, for this proposed rule, there is no proposed rural statewide average total CCR listed for rural

Massachusetts in Table 8C of the

Page 23682

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 use, 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 PSF for Maryland hospitals may not be accurate (as discussed in greater detail in that same final rule (71 FR 48120)).

F. Proposed Change to the Regulations Governing Hospitals-Within-

Hospitals

On September 1, 1994, we published hospital-within-hospital (HwH) regulations for LTCHs to address inappropriate Medicare payments to entities that were effectively units of other hospitals (59 FR 45330).

There was concern that the HwH model was being used by some acute care hospitals paid under the IPPS as a way of inappropriately receiving higher payments for a subset of their cases. Moreover, IPPS-exclusion of long-term care ``units'' was and remains inconsistent with the statutory scheme.

Therefore, we established the HwH regulations at 42 CFR 412.23

(currently at Sec. 412.22) for a LTCH HwH that is co-located with another hospital. A co-located hospital is a hospital that occupies space in the same building or on the same campus as another hospital.

The regulations at Sec. 412.23(e) required that, to be excluded from the IPPS, long-term care HwHs must have a separate governing body, chief medical officer, medical staff, and chief executive officer from that of the co-located hospital. In addition, the HwH must meet either of the following two criteria: The HwH must perform certain specified basic hospital functions on its own and not receive them from the host hospital or a third entity that controls both hospitals; or the HwH must receive at least 75 percent of its inpatients from sources other than the co-located hospital. A third option was added to the regulations on September 1, 1995 (60 FR 45778) that allowed HwHs to demonstrate their separateness by showing that the cost of the services that the hospital obtains under contracts or other agreements with the co-located hospital or a third entity that controls both hospitals is no more than 15 percent. In 1997, we extended application of the HwH rules at Sec. 412.22 to all classes of IPPS excluded hospitals.

Therefore, effective for cost reporting periods beginning on or after

October 1, 1997, psychiatric, rehabilitation, cancer, and children's hospitals that are co-located with another hospital are also required to meet the ``separateness'' criteria at Sec. 412.22(e).

In addition, a ``grandfathering'' provision was added to the regulations at Sec. 412.22(f), as provided for under section 4417 of the Balanced Budget Act (BBA) of 1997 (Pub. L. 105-33). This provision of the regulations allowed a LTCH that was excluded from the IPPS on or before September 30, 1995, and at that time occupied space in a building also used by another hospital, or in one or more buildings located on the same campus as buildings used by another hospital, to retain its IPPS-excluded status even if the HwH criteria at Sec. 412.22(e) could not be met, as long as the hospital continued to operate under the same terms and conditions as were in effect on

September 30, 1995. Consistent with the grandfathering provision under the BBA, which only applied to LTCHs, we extended the application of the grandfathering rule to the other classes of IPPS-excluded hospitals that are HwHs but did not meet the criteria at Sec. 412.22(e). (We subsequently expanded this provision to allow for a grandfathered hospital to make specified changes during particular timeframes.)

Despite our efforts to allow those HwHs for whom the IPPS-exclusion status is appropriate to meet the HwH criteria, it appears that there may be a gap in our regulations. There remain certain HwHs under current rules that may be unnecessarily restricted from expanding their bed size. These HwHs are State hospitals that are co-located with another State hospital and that are grandfathered under Sec. 412.22(f). Where a State law defines the structure and authority of the

State's agencies and institutions, and the State hospital is co-located with another hospital that is under State governance, each hospital may have control over the day-to-day operations of its respective facility and have separate management, patient intake, and billing systems and medical staff, as well as a governing board. However, State law may require that the legal accountability for the budgets and activities of entities operating within a State-run institution rests with the State.

Therefore, the co-located State hospitals may also be governed by a common governing body. Because of State law requirements, these HwHs are, therefore, precluded from meeting the HwH criteria at Sec. 412.22(e)(1)(i) that requires the governing body of a co-located hospital to be separate from the governing body of the hospital with which it shares space. The excluded hospital's governing body cannot be under the control of the hospital occupying space in the same building or on the same campus, or of any third entity that controls both hospitals. Currently, there are State HwHs in these types of arrangements that have been able to retain their IPPS-excluded status solely because of the grandfathering provision in Sec. 412.22(f).

These HwHs were IPPS-excluded even before the HwH criteria were implemented and only remain excluded HwHs under Sec. 412.22(f) as long as they continue to meet the requirements specified under Sec. 412.22(f)(1), (f)(2), and (f)(3). Because they are grandfathered, these

HwHs cannot increase their bed size without losing their IPPS-excluded status under the grandfathering provisions (Sec. 412.22(f)).

Furthermore, if a grandfathered State-run HwH increased its bed size, it would be unable to qualify as an IPPS-excluded HwH under Sec. 412.22(e) because it cannot meet the HwH criteria at Sec. 412.22(e)(1)(i) as a result of State law requirements regarding its organizational structure and governance. These HwHs are precluded from the flexibility to expand their bed size, which is available to other

HwHs whose organizational structure is not bound by State law.

As discussed in the previous paragraph, the organizational arrangements were in place for these State-operated HwHs before the HwH regulations were adopted. To the extent the arrangements are required by State law, we believe they do not reflect attempts by entities to establish a nominal hospital and, in turn, seek inappropriate exclusions. We also believe it may be unnecessary to prevent hospitals that were created before the HwH requirements, and that because of

State statutory requirements cannot meet the subsequently issued separate governing body requirements, from being excluded from the

IPPS. Accordingly, we are proposing to add a provision to the regulations that would apply only to State hospitals that were in existence when the HwH regulations were established. This proposed provision would not apply to other State hospitals that chose to open as a HwH subsequent to the establishment of the HwH regulations in FY 1994, under an organizational structure the same as or similar to the one described in this section. These hospitals knew, in advance of becoming a HwH, the requirements that had to be met in order to be an

IPPS-excluded HwH, unlike

Page 23683

those hospitals that existed before the HwH regulations were established.

Accordingly, we are proposing to add a new paragraph (e)(1)(vi) to

Sec. 412.22 to provide that if a hospital cannot meet the criteria in

Sec. 412.22(e)(1)(i) solely because it is a State hospital occupying space with another State hospital, the HwH can nevertheless qualify for an exclusion from the IPPS if that hospital meets the other applicable criteria in Sec. 412.22(e) and--

Both State hospitals share the same building or same campus and have been continuously owned and operated by the State since

October 1, 1995;

Is required by State law to be subject to the governing authority of the State hospital with which it shares space or the governing authority of a third entity that controls both hospitals; and

Was excluded from the inpatient prospective payment system before October 1, 1995, and continues to be excluded from the IPPS through September 30, 2008.

We believe the proposed criteria capture the segment of grandfathered, State-operated HwHs that are unable to increase their bed size because of State law regarding governance. We emphasize that we intend to allow an exception to the criteria in Sec. 412.22

(e)(1)(i) only if the hospital that meets the proposed criteria above cannot meet the separate governing body requirement because of State law. We do not intend to provide similar treatment for hospitals that are not subject to State statutory requirements regarding governance but have chosen not to organize in a manner that would allow them to be an IPPS-excluded hospital that meets the HwH criteria at Sec. 412.22(e)(1)(i).

VII. Disclosure Required of Certain Hospitals and Critical Access

Hospitals Regarding Physician Ownership (Sec. 489.2(u) and (v))

Section 1866 of the Act states that any provider of services

(except a fund designated for purposes of sections 1814(g) and 1835(e) of the Act) shall be qualified to participate in the Medicare program and shall be eligible for Medicare payments if it files with the

Secretary 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.

Section 1861(e) of the Act defines the term ``hospital.'' Section 1861(e)(9) of the Act authorizes the Secretary to establish requirements for hospitals 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.''

In the FY 2008 IPPS final rule with comment period, we revised our regulations governing Medicare provider agreements, specifically Sec. 489.20(u), to require a hospital to disclose to all patients whether it is physician-owned and, if so, the names of its physician owners (72 FR 47385 through 47387). In addition, we added a definition of physician- owned hospital at Sec. 489.3. The disclosure requirement in current

Sec. 489.20(u) is applicable only to those hospitals with physician ownership. (For purposes of this proposal, the term ``hospital'' also includes ``critical access hospital'' (CAH).) We neglected to include those hospitals in which no physician held an ownership or investment interest, but in which an immediate family member of a physician held an ownership or investment interest. However, it was always our intent to have consistency between the disclosure requirements and the physician self-referral statute and regulations. The physician self- referral statute and regulations, which recognize the potential for program and patient abuse where a financial relationship exists, are applicable to both a physician and the immediate family member of the physician. We believe that it is necessary to revise our definition of physician-owned hospital because a physician's potential conflict of interest occurs not only in those instances where he or she has a financial relationship in the form of an ownership or investment interest, but also where his or her immediate family member has a similar interest, and patients should be informed of this as part of making an informed decision concerning treatment. Therefore, we are proposing to revise the language in Sec. 489.3 to define a

``physician-owned hospital'' as a participating hospital in which a physician, or an immediate family member of a physician (as defined at

Sec. 411.351), has an ownership or investment interest in the hospital.

To effectuate the changes made in the FY 2008 IPPS final rule with comment period, we relied on our authority in sections 1861(e)(9), 1820(e)(3) and 1866 of the Act, and on our general rulemaking authority in sections 1871 and 1102 of the Act. Following publication of the FY 2008 IPPS final rule with comment period, we became aware that some physician-owned hospitals have no physician owners who refer patients to the hospital (for example, in the case of a hospital whose physician-owners have retired from the practice of medicine). We believe that requiring a hospital with no referring physician owners to disclose to all patients that it is physician-owned and to provide the patients with a list of the (nonreferring) physician owners would be an unnecessary burden on the hospital and of no value in assisting a patient in making an informed decision as to where to seek treatment.

Similarly, we do not believe that it is useful to require a hospital to make such disclosures when no referring physician has an immediate family member who has an ownership or investment interest in the hospital. Accordingly, we are proposing to include in Sec. 489.20(v) new language to provide for an exception to the disclosure requirements for a physician-owned hospital (as defined at Sec. 489.3) that does not have any physician owners who refer patients to the hospital (and that has no referring physicians (as defined at Sec. 411.351) who have an immediate family member with an ownership or investment interest in the hospital), provided that the hospital attests, in writing, to that effect and maintains such attestation in its files for review by State and Federal surveyors or other government officials. (We note that, as explained below, we are proposing to redesignate the existing paragraphs (v) and (w) of Sec. 489.20 as paragraphs (w) and (x), respectively.)

We are proposing to revise Sec. 489.20(u) to specify that a hospital must furnish to patients the list of owners and investors who are physicians (or immediate family members of physicians) at the time the list is requested by or on behalf of the patient. In response to the FY 2008 IPPS proposed rule, we received public comments that noted that our proposal did not establish a timeframe within which the hospital must furnish to patients the required list of the hospital's physician owners or investors. These commenters suggested that we require that the list be provided to the patient at the time the request for the list is made by or on behalf of the patient. We stated in the preamble of the FY 2008 IPPS final rule with comment period that we would not revise the provision to include any specific timeframe for making the list available because we believed that it was important to allow hospitals some degree of flexibility regarding the manner and form in which it notified patients of the identity of its physician owners and investors (72 FR 47386). However, we also stated later in the preamble that we were revising proposed Sec. 489.20(u) to specify that the

Page 23684

hospital should furnish a list of physician owners to a patient at the beginning of his or her hospital stay or outpatient visit, but the regulation text did not reflect this change (72 FR 47387).

We have reconsidered the issue and are proposing in Sec. 489.20(u)(1) that the list of the hospital's owners or investors who are physicians or immediate family members of physicians (as defined at

Sec. 411.351) must be furnished at the time the patient or someone on the patient's behalf requests it. We are proposing this change for two reasons. First, in the FY 2008 IPPS final rule with comment period, in response to public comments received on the FY 2008 IPPS proposed rule, we stated that we believed that the physician ownership disclosure proposal would permit an individual to make more informed decisions regarding his or her treatment and to evaluate whether the existence of a financial relationship, in the form of an ownership interest, suggests a conflict of interest that is not in his or her best interest. However, we maintain that the provision of a generic notice that the hospital is owned by physicians or immediate family members of physicians is insufficient to permit an individual to make a truly informed decision. We believe that it is critical that the patient receives the list of names of the relevant owners or investors at the time the request is made by or on behalf of the patient so that the patient may make a determination as to whether his or her admitting or referring physician has a potential conflict of interest. Second, furnishing the list at the time the request is made by the patient or on behalf of the patient is crucial to affording the patient an opportunity to make an informed decision before treatment is furnished at the hospital. We are not specifying a form to be used for the list; rather, we are addressing the timeframe for the hospital to furnish the list to the patient.

In addition, we are proposing to add new Sec. 489.20(u)(2) to require a hospital to require all physicians who are members of the hospital's medical staff to agree, as a condition of continued medical staff membership or admitting privileges, to disclose in writing to all patients who they refer to the hospital any ownership or investment interest in the hospital held by themselves or by an immediate family member. We would require that physicians agree to make such disclosures at the time they refer patients to the hospital. We proposed a similar requirement in the FY 2008 IPPS proposed rule, but decided not to adopt it as final. In response to a public comment, we stated that we would not finalize the proposal because we believed that it would not provide any additional protections for patients that would not already be offered by the requirement for hospitals to disclose their physician ownership to patients. We have revisited this issue.

In the FY 2008 IPPS final rule with comment period, we stated that the scheduling of most hospital inpatient or outpatient services is performed by a staff member in the physician's office, often weeks, or even months, in advance of the furnishing of the service. As discussed previously, we believe that early notification of physician ownership or investment in the hospital is beneficial to the patient's decisionmaking concerning his or her treatment. Currently, under Sec. 489.20(u), scheduling of inpatient stays and outpatient visits at physician-owned hospitals would be permitted without notification to the patient of the referring physician's ownership or investment interest in the hospital. If a patient were notified of the physician ownership or investment at the time of the referral, he or she would have an opportunity to discuss the physician's ownership or investment in the hospital and make a more informed decision. We believe that it would be in the best interests of the patient and the physician owner or investor to disclose the physician's (or his or her immediate family member's) ownership in the hospital at the time the physician is referring the patient to the hospital. We are revising Sec. 489.20(u) accordingly.

We note that notification of physician ownership or investment in a hospital may not be viewed negatively by all interested parties. For instance, some physician owners or investors in hospitals believe that disclosing their ownership or investment interests in the hospital to their patients at the time of the referral is extremely beneficial for both the physician and the patient. They communicate to patients their belief that their ownership in the hospital permits them to have total control over scheduling, staffing, and quality mechanisms. Section 5006 of the Medicare, Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) required, among other things, that HHS study the quality of care and patient satisfaction with specialty hospitals. HHS concluded that specialty hospital patients have very favorable perceptions of the clinical quality of care they receive, and that overall patient satisfaction is very high.

We are also proposing to revise Sec. 489.53 to permit CMS to terminate the Medicare provider agreement if the hospital fails to comply with the provisions of proposed Sec. 489.20(u)(1) or (u)(2). We believe that these revisions would be necessary to enforce the proposed disclosure requirements set forth in Sec. 489.20.

We are not inclined to make a corresponding change to the medical staff bylaws condition of participation (CoP) in Sec. 482.22(c). We believe that the proposed disclosure requirement is appropriate for inclusion in the regulations governing Medicare provider agreements for the following reasons. As stated in the FY 2008 IPPS final rule with comment period, each participating provider must comply with all applicable provisions of the provider agreement regulations found in 42

CFR Part 489, and CMS may terminate a provider agreement if the provider is not in substantial compliance with these requirements (72

FR 47391). A provider's compliance with applicable provider agreement regulations is reviewed through a variety of means, including onsite investigation of complaints. Thus, compliance with this proposed requirement could be easily monitored. We also note that any revisions to the medical staff bylaws concerning the requirement that the disclosure be given at the time of the referral would be difficult to enforce as a CoP because the required notification generally would be given outside of the hospital's or CAH's premises. However, we are considering whether these proposed changes would be better effectuated through changes to our regulations governing the CoPs applicable to hospitals and CAHs, which appear at 42 CFR Part 482 and 42 CFR Part 485, Subpart F, respectively, and, therefore, we are soliciting public comments on this issue.

In the FY 2008 IPPS final rule with comment period, we added a new provision at Sec. 489.20(v) to require that hospitals and CAHs: (1)

Furnish all patients written notice at the beginning of their inpatient 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 per week; and (2) describe how the hospital or CAH 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 (72 FR 47387). (We are proposing to redesignate existing Sec. 489.20(v) and

(w) as Sec. 489.20(w) and (x), respectively, to accommodate the addition of the proposed exception to the requirements in Sec. 489.20(v) discussed above.) We stated that it is important to ensure that consumers are provided accurate information on the availability of

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physician services at the point when they are about to become patients of a hospital or CAH. In order to be fully informed, consumers should be made aware of whether a hospital or CAH has a physician on-site 24 hours per day, 7 days per week, and should be made aware of the hospital's or CAH's processes for addressing medical emergencies that may occur when a physician is not on site. Given the patient safety measures addressed by these provisions, we are proposing to set forth penalties for failure to comply with these requirements. Specifically, we are proposing to revise Sec. 489.53 to permit CMS to terminate the provider agreement of any hospital or CAH that fails to comply with the requirements set forth in proposed redesignated Sec. 489.20(w).

We are also soliciting public comments on whether hospitals and

CAHs should educate patients about the availability of information regarding physician ownership under the proposed disclosure requirements and, if so, by what means (for example, by a posting in the admissions office or in a patient brochure).

VIII. Physician Self-Referral Provisions (Sec. Sec. 411.351, 411.352 and 411.354)

A. Stand in the Shoes Provisions 1. Physician ``Stand in the Shoes'' Provisions a. Background

Section 1877 of the Act, also known as the physician self-referral law: (1) Prohibits a physician from making referrals for certain designated health services (``DHS'') payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment or compensation), unless an exception applies; and (2) prohibits the entity from filing claims with

Medicare (or billing another individual, entity, or third party payor) for those referred services. The statute establishes a number of specific exceptions and grants the Secretary the authority to create regulatory exceptions for financial relationships that pose no risk of program or patient abuse. Determining whether DHS entities and referring physicians (or their immediate family members) have direct or indirect financial relationships is a key step in applying the statute.

In the final rule entitled ``Medicare Program; Physicians'

Referrals to Health Care Entities With Which They Have Financial

Relationships (Phase III),'' published in the Federal Register on

September 5, 2007 (72 FR 51012) (``Phase III''), we interpreted certain provisions of section 1877 of the Act, including provisions relating to direct and indirect compensation arrangements. Specifically, the Phase

III final rule included provisions under which referring physicians are treated as standing in the shoes of their physician organizations for purposes of applying the rules that describe direct and indirect compensation arrangements in Sec. 411.354 (72 FR 51026 through 51030).

A ``physician organization'' is defined at Sec. 411.351 as ``a physician (including a professional corporation of which the physician is the sole owner), a physician practice, or a group practice that complies with the requirements of Sec. 411.352.'' Therefore, when determining whether a direct or indirect compensation arrangement exists between a physician and an entity to which the physician refers

Medicare patients for DHS, the referring physician stands in the shoes of: (1) Another physician who employs the referring physician; (2) his or her wholly-owned professional corporation (``PC''); (3) a physician practice (that is, a medical practice) that employs or contracts with the referring physician or in which the physician has an ownership interest; or (4) a group practice of which the referring physician is a member or independent contractor. The referring physician is considered to have the same compensation arrangements (with the same parties and on the same terms) as the physician organization in whose shoes the referring physician stands.

Subsequent to the publication of Phase III, industry stakeholders, including academic medical centers (``AMCs''), integrated tax-exempt health care delivery systems, and their representatives, expressed concern about the application of the Phase III ``stand in the shoes'' provisions to compensation arrangements involving ``mission support payments'' and ``similar payments'' (referred to in this proposed rule generally as ``support payments''). The stakeholders believed that certain payments did not previously trigger application of the physician self-referral law but, after Phase III, need to satisfy the requirements of an exception. One example offered was a DHS entity component (such as a hospital) of an AMC that transfers funds to the faculty practice plan component of the AMC. If a referring physician stands in the shoes of his or her faculty practice plan, the compensation arrangement between the hospital providing the support payment and the faculty practice plan will be considered to be a direct compensation arrangement between the hospital and the physician and would need to satisfy the requirements of a direct compensation arrangement exception, if the physician is to continue referring

Medicare patients to the component for DHS. According to the industry stakeholders, before Phase III, such arrangements would have been analyzed under the rules regarding indirect compensation arrangements and would, in their view, have been permitted. After Phase III, in their view, it is unlikely that the requirements of an available exception could be satisfied given the nature of support payments; that is, support payments usually are not tied to specific items or services provided by the faculty practice plan (or group practice within an integrated health care delivery system), but rather are intended to support the overall mission of the AMC or maintain operations in an integrated health care delivery system. For this reason, support payments likely do not satisfy the requirement, present in many exceptions, that the compensation be fair market value for items or services provided. Similarly, some stakeholders raised concerns about support payments made from faculty practice plans to AMC components.

Although AMCs are free to use the exception for services provided by an

AMC in Sec. 411.355(e) (which would protect support payments made among AMC components if all of the conditions of the exception are met), industry stakeholders explained that many AMCs do not do so, preferring instead to rely on other available exceptions and the rules regarding indirect compensation arrangements (especially prior to Phase

III).

To provide CMS sufficient time to study the ``stand in the shoes'' provisions as they relate to compensation arrangements involving support payments, seek additional public comment, and develop an approach for addressing this issue, on November 15, 2007, we issued a final rule entitled ``Medicare Program; Delay of the Date of

Applicability for Certain Provisions of Physicians' Referrals to Health

Care Entities With Which They Have Financial Relationships (Phase

III)'' (72 FR 64164) that delayed the effective date of the provisions in Sec. 411.354(c)(1)(ii), Sec. 411.354(c)(2)(iv), and Sec. 411.354(c)(3) for 12 months after the effective date of Phase III (that is, until December 4, 2008). That final rule was applicable to the following compensation arrangements between the following physician organizations and entities ONLY:

With respect to an AMC as described in Sec. 411.355(e)(2),

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compensation arrangements between a faculty practice plan and another component of the same AMC; and

With respect to an integrated section 501(c)(3) health care system, compensation arrangements between an affiliated DHS entity and an affiliated physician practice in the same integrated section 501(c)(3) health care system.

Following the publication of the November 15, 2007 final rule, other industry stakeholders asserted that, in addition to section 501(c)(3) health care systems, most integrated health care delivery systems, including ones involving for-profit entities, make support payments. The stakeholders further asserted that, although under the

``stand in the shoes'' provisions such payments must now satisfy a direct compensation arrangement exception, there is, in fact, no applicable exception. These stakeholders urged that any approach to addressing the impact of the Phase III ``stand in the shoes'' provisions on support payments and other monetary transfers within integrated health care delivery systems should have universal applicability that is not dependent on whether the system meets the definition of an AMC or has a particular status under the rules of the

Internal Revenue Service. b. Proposals

Given the potential widespread impact of the ``stand in the shoes'' provisions, as well as the considerable industry interest in their application, we are revisiting the ``stand in the shoes'' policy and regulations issued in Phase III. We believe that a more refined approach to the ``stand in the shoes'' provisions would accomplish our goals of simplifying the analysis of many financial arrangements and reducing program abuse by bringing more financial relationships within the scope of the physician self-referral law (such as certain potentially abusive arrangements between DHS entities and physician organizations that may not have met the definition of an ``indirect compensation arrangement''). We note that we are not suggesting that support payments and other similar compensation arrangements are without risk of program or patient abuse, nor are we endorsing such payments and arrangements.

We are proposing here two alternative ways to address the ``stand in the shoes'' issues described above, and are seeking industry input on each proposal, as well as on other possible approaches. The first is a multi-faceted approach to revising the Phase III ``stand in the shoes'' provisions. The second proposal would leave the Phase III

``stand in the shoes'' provisions as promulgated and would, instead, create a new exception using our authority under section 1877(b)(4) of the Act for nonabusive arrangements that warrant protection not available under existing exceptions. We are also interested in public comments on other approaches and on whether changes to the existing

``stand in the shoes'' provisions are needed at all.

For the first proposal, we propose revising Sec. 411.354(c)(2)(iv) to provide that a physician would be deemed not to stand in the shoes of his or physician organization if the compensation arrangement between the physician organization and the physician satisfies the requirements of the exception in Sec. 411.357(c) (for bona fide employment relationships), the exception in Sec. 411.357(d) (for personal service arrangements), or the exception in Sec. 411.357(l)

(for fair market value compensation). Currently, all physicians stand in the shoes of their physician organizations, regardless of the nature of the compensation they receive from the physician organization. Under our proposal, the first step in the analysis would be to look at the compensation a referring physician receives from his or her physician organization. A compensation arrangement between a physician organization and a physician that satisfies the requirements of Sec. 411.357(c), (d), or (l) would be consistent with fair market value by design and not determined in a manner that takes into account (directly or indirectly) the volume or value of any referrals by the physician to the physician organization. Although such compensation could, in some circumstances, be determined in a manner that takes into account

(directly or indirectly) the volume or value of the physician's referrals to the DHS entity (see 66 FR 869), we believe that the risk of program or patient abuse will be addressed sufficiently by analyzing such arrangements between DHS entities and referring physicians who do not stand in the shoes of their physician organizations using the rules regarding indirect compensation arrangements. Therefore, under this proposal, if the compensation arrangement between a physician organization and one of its referring physicians satisfies the requirements of one of the exceptions noted above, the referring physician would be deemed not to stand in the shoes of the physician organization for purposes of applying the definitions of, and provisions related to, direct and indirect compensation arrangements in

Sec. 411.354(c). Arrangements between DHS entities and physician organizations whose physicians do not stand in their shoes may still create indirect compensation arrangements that would need to satisfy the requirements of the exception for indirect compensation arrangements in Sec. 411.357(p).

Under this first proposed approach, physician owners and investors would continue to stand in the shoes of their physician organizations.

However, we are concerned that considering all physician owners of, or physician investors in, a physician organization to stand in the shoes of the physician organization, as they currently do under the Phase III

``stand in the shoes'' provisions, might be over-inclusive. For example, in a State that prohibits the corporate practice of medicine, a physician owner of a captive or ``friendly'' PC who has no right to the distribution of profits would stand in the shoes of his or her physician organization, even though his or her employment arrangement with the group satisfies the requirements of the exception for bona fide employment relationships in Sec. 411.357(c). We are considering whether these and similarly situated physician owners should have to stand in the shoes of their physician organizations when their ownership interest is nominal in nature and their compensation arrangement with the physician organization satisfies the requirements of one of the exceptions in Sec. 411.357(c), (d), or (l). We are soliciting public comments on this issue.

As described above, a physician-employee or contractor whose compensation arrangement with a physician organization does not satisfy the requirements of Sec. 411.357(c), (d), or (l) would stand in the shoes of the physician organization. This is necessary to address our concern that an arrangement between a DHS entity and a physician organization that compensates its physicians in a manner that does not satisfy the requirements of an exception may be particularly prone to abuse. For example, where a physician-employee's compensation arrangement with his or her group practice exceeds fair market value for services provided to the group practice employer (and, thus, does not satisfy the requirements of the exception in Sec. 411.357(c)), and the physician-employee's DHS referrals to the group practice instead are protected under the exception for in-office ancillary services in

Sec. 411.355(b), there is risk that the physician-employee's above- fair-market-value compensation may reflect the volume or value of referrals to the DHS

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entity. This could be the result of a support or other payment between the DHS entity and the group practice that is designed to channel compensation to the physician-employee for referrals to the DHS entity.

We are also considering, and solicit comments on, an approach under which only owners of a physician organization would stand in the shoes of that physician organization (in which case, a physician would not stand in the shoes of a physician organization unless he or she holds an ownership or investment interest, even if the physician's compensation arrangement with that physician organization does not satisfy the requirements of Sec. 411.357(c), (d), or (l)). In conjunction with this approach, we are interested in receiving comments on whether and under what circumstances the ``stand in the shoes'' provisions should apply to a physician organization that has no physician owners.

In this first approach, we also propose to revise Sec. 411.354(c)(3)(ii) to provide that the provisions of Sec. Sec. 411.354(c)(1)(ii) and (c)(2)(iv) do not apply when the requirements of

Sec. 411.355(e) are satisfied. In other words, a physician would not stand in the shoes of his or her physician organization (for example, a faculty practice plan) when his or her referral for DHS is protected under the exception in Sec. 411.355(e) for services provided by an

AMC. We note that, if all of the requirements of the exception in Sec. 411.355(e) are not satisfied, a physician would stand in the shoes of his or her physician organization unless, as discussed above with respect to proposed revised Sec. 411.354(c)(2)(iv), the compensation from the physician organization to the physician satisfies the requirements of the exception for bona fide employment relationships, the exception for personal service arrangements, or the exception for fair market value compensation in Sec. 411.357(c), (d), and (l), respectively. We are proposing to include a specific revision to the regulation in Sec. 411.354(c)(2)(iv); however, we are seeking public comment as to whether this policy is better achieved by revising Sec. 411.354(c)(3) to delete the reference to applying the exceptions in

Sec. 411.355, and thereby providing that the ``stand in the shoes'' provisions do not apply where the prohibition on referrals is not applicable because all of the requirements of any of the exceptions in

Sec. 411.355 are satisfied.

In this first approach, we also propose to revise Sec. 411.354(c)(3)(ii) to provide that the provisions of Sec. 411.354(c)(1)(ii) and (c)(2)(iv) do not apply when compensation is provided by a component of an AMC to a physician organization affiliated with that AMC through a written contract to provide services required to satisfy the AMC's obligations under the Medicare graduate medical education (GME) rules where the contract is limited to only services necessary to fulfill the GME obligations as set forth in 42

CFR, Part 413, Subpart F. We have in mind certain arrangements between a hospital component of an AMC and a community physician group to serve as a teaching site for the AMC's residents, as required by the GME rules. If adopted, this proposal would not mean that such arrangements necessarily are lawful, but rather that they would be analyzed by applying the rules regarding indirect compensation arrangements.

Under this first proposal, if adopted, some referring physicians would no longer stand in the shoes of their physician organizations as they currently do under the Phase III ``stand in the shoes'' provisions. In such circumstances, the rules regarding direct and indirect compensation arrangements would still apply, and financial relationships would still need to be analyzed for compliance with the statute and regulations. We are concerned that, where physicians do not stand in the shoes of their physician organizations, some potentially abusive arrangements between DHS entities and physician organizations might be viewed incorrectly as falling outside the definition of an

``indirect compensation arrangement'' at Sec. 411.354(c)(2) and, therefore, as not within the scope of the physician self-referral law.

The definition of ``indirect compensation arrangement'' generally requires that three elements be present: (1) An unbroken chain of financial relationships between the DHS entity and the referring physician; (2) aggregate compensation to the referring physician (from the entity in the chain closest to the physician) that varies with or takes into account in any manner the volume or value of referrals to, or other business generated for, the DHS entity; and (3) knowledge by the DHS entity that the referring physician receives such compensation.

(We refer readers to 66 FR 864 through 870, 69 FR 16057 through 16063, and 72 FR 51026 through 51031 for further explanation.) We believe that some parties may be construing these elements (particularly the second and the third) too narrowly. For example, we believe that aggregate compensation can vary with or take into account the volume or value of referrals to, or business generated for, DHS entities in a wide range of circumstances, including, without limitation, arrangements involving: variable, per-click, or percentage-based compensation; exclusive contracts; inflated fixed payments; or explicit or implicit tying of compensation to other referrals. To address this issue, we may provide additional guidance on the application of the three elements of the definition of ``indirect compensation arrangement'' in the FY 2009

IPPS final rule. We are interested in public comments regarding ways in which we can ensure that the full range of potentially abusive arrangements between DHS entities and physician organizations are appropriately addressed in situations where physicians do not stand in the shoes of their physician organizations.

As discussed above, we are proposing an alternative approach to addressing the Phase III ``stand in the shoes'' provisions. (However, we are proposing regulation text for the first proposal only.) Our alternative proposal is to make no revisions to the Phase III ``stand in the shoes'' provisions in Sec. Sec. 411.354(c)(1)(ii), (c)(2)(iv), and, (c)(3) and, to the extent necessary to protect nonabusive arrangements, promulgate a separate exception using our authority under section 1877(b)(4) of the Act to create exceptions for arrangements that do not pose a risk of program or patient abuse. The new exception would apply to specific types of nonabusive payments or arrangements that are not otherwise covered by existing exceptions (for example, certain support payments, as described above), subject to conditions necessary to protect against program and patient abuse, similar to those conditions incorporated into the existing exception for services provided by an AMC in Sec. 411.355(e). Specifically, we are considering establishing a new exception, using our authority under section 1877(b)(4) of the Act, for compensation arrangements between

DHS entities and physician organizations and physicians for ``mission support'' payments (or similar compensation arrangements) and, if so, how we should define those payments (or similar compensation arrangements), and what criteria such an exception should include to protect against program or patient abuse. We are soliciting comments about this proposal, including whether an exception should be limited to ``mission support'' payments, whether other specific types of payments or compensation arrangements should be eligible for such an exception, the types of parties that should be permitted to use the

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exception (for example, AMC components, physician practices), and the conditions that should apply to such an exception to ensure that a protected compensation arrangement poses no risk of program or patient abuse. We are concerned that some ``mission support'' payments or similar payments are subject to fraud and abuse. We are interested in public comments that identify with specificity the types of compensation agreements that should be permitted under an applicable exception.

Under this approach, the proposed exception might address compensation arrangements between components of certain well-defined integrated delivery systems, perhaps with tightly-crafted conditions similar to those in the existing exception for services provided by an

AMC in Sec. 411.355(e). For example, some industry stakeholders have recommended that we establish an exception for compensation arrangements between a DHS entity component of an integrated health care delivery system and a physician organization component of the same integrated health care delivery system. We are concerned that the term

``integrated health care delivery system'' is loosely used in the industry to describe a wide variety of systems, with varying degrees of actual integration, and that it may prove infeasible to craft a sufficiently circumscribed definition. In many circumstances, payment arrangements between components of ``integrated health care delivery systems,'' as well as payments from ``integrated health care delivery systems'' to physicians affiliated with those systems are susceptible to fraud and abuse. However, we are soliciting public comments defining a fully integrated health care delivery system, what types of compensation arrangements should be protected (for example, support payments), and what conditions should be included in an exception that would ensure no risk of program or patient abuse. We note that any exception established using our authority under section 1877(b)(4) of the Act would include documentation requirements and a requirement that the arrangement not violate the anti-kickback statute or any Federal or

State law or regulation governing billing or claims submission, consistent with the existing exceptions created under this authority.

According to some industry stakeholders, an ``integrated health care delivery system'' could be defined, for example, as a health care delivery system comprised of two or more entities that are related and substantially integrated by common ownership or control, and which includes at least one hospital and one physician organization that has no physician owners or investors who make referrals for DHS to any component of the health care delivery system. Entities that file consolidated financial statements could be deemed to be substantially integrated for purposes of this definition. For purposes of this approach, ownership could exist if an individual or individuals possess 50 percent ownership or equity in the component of the integrated health care delivery system, and control would exist if an individual or an organization has the power, directly or indirectly, significantly to influence or direct the actions or policies of the component of the integrated health care delivery system. As noted above, it would be necessary to define ``integrated health care delivery system,'' as well as ``ownership'' and ``control,'' and to determine whether to permit integrated health care delivery systems to include entities related through written contractual affiliation agreements and, if so, what limitations (if any) should be placed on the types of contractually affiliated entities we would permit to be included as components of an integrated health care delivery system. We would need also to determine what characteristics indicate substantial integration and identify the types of compensation arrangements that exist between components of integrated health care delivery systems. We are seeking public comments regarding this possible approach (including the specific issues noted), as well as public comments on other alternative approaches to addressing the concerns regarding support payments and similar monetary transfers noted by industry stakeholders and described above. 2. DHS Entity ``Stand in the Shoes'' Provisions

On July 12, 2007, we published in the Federal Register a proposed rule entitled ``Medicare Program; Proposed Revisions to Payment

Policies Under the Physician Fee Schedule, and Other Part B Payment

Policies for CY 2008; Proposed Revisions to the Payment Policies of

Ambulance Services Under the Ambulance Fee Schedule for CY 2008; and the Proposed Elimination of the E-Prescribing Exemption for Computer-

Generated Facsimile Transmissions; Proposed Rule'' (the ``CY 2008 PFS proposed rule'') (72 FR 38122). In that rule, we proposed a corollary provision to the Phase III ``stand in the shoes'' provisions that addressed the DHS entity side of physician--DHS entity financial relationships. Specifically, we proposed to amend Sec. 411.354(c) to provide that, where a DHS entity owns or controls an entity to which a physician refers Medicare patients for DHS, the DHS entity would stand in the shoes of the entity that it owns or controls and would be deemed to have the same compensation arrangements with the same parties and on the same terms as does the entity that it owns or controls. For example, a hospital would stand in the shoes of a medical foundation that it owns or controls (such as where the hospital is the sole member of a nonprofit corporation). Thus, under the CY 2008 PFS proposed rule proposal, if a hospital owns or controls a medical foundation that contracts with a physician to provide physician services at a clinic owned by the medical foundation, the hospital would stand in the shoes of the medical foundation and would be deemed to have a direct compensation relationship with the contractor physician. We solicited public comments as to whether and how we would employ a ``stand in the shoes'' approach for these types of relationships, as well as for other types of financial relationships.

In response to the CY 2008 PFS proposed rule, we received comments from a variety of industry stakeholders, including physicians, medical associations, and their representatives. Although several commenters supported the proposed entity ``stand in the shoes'' provisions because they share our concerns regarding parties ability to avoid application of the physician self-referral law by simply inserting an entity in the chain of financial relationships linking a DHS entity and a referring physician, many commenters expressed concern that the proposal was unclear and potentially overly broad. Commenters requested guidance regarding the level of ownership or control that would trigger the application of the entity ``stand in the shoes'' provisions. One commenter recommended that, instead of finalizing the entity ``stand in the shoes'' provisions, we issue, through a notice of proposed rulemaking, a more detailed proposal that would give industry stakeholders the opportunity to provide more meaningful comments.

We did not finalize the DHS entity ``stand in the shoes'' provisions in the CY 2008 PFS final rule published in the Federal

Register on November 27, 2007 (72 FR 66222, 66306). Because the DHS entity ``stand in the shoes'' provisions are integrally related to the physician ``stand in the shoes'' provisions that we finalized in Phase

III and for which we

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are proposing the regulatory revisions described above, we are re- proposing here the DHS entity ``stand in the shoes'' provisions, with some modification. We believe that a comprehensive approach to the

``stand in the shoes'' provisions that addresses both physicians and physician organizations, as well as DHS entities and other entities that they own or control, is the best vehicle to address the goals outlined in the Phase III final rule, namely: (1) Simplifying the analysis of many financial arrangements; and (2) reducing program abuse by bringing more financial relationships within the ambit of the physician self-referral law.

We are proposing to revise Sec. 411.354(a) to provide that an entity that furnishes DHS would be deemed to stand in the shoes of an organization in which it has a 100 percent ownership interest and would be deemed to have the same compensation arrangements with the same parties and on the same terms as does the organization that it owns. We believe this approach is straightforward and can be readily applied. We note that, under this approach (as compared to our CY 2008 PFS proposal), a DHS entity would stand in the shoes of any wholly-owned organization, not merely a wholly-owned DHS entity. An organization may be in any legal form (for example, a limited liability company, partnership, or corporation, regardless of status as nonprofit or exempt from taxation). We are seeking public comments specifically as to whether we should consider a DHS entity to stand in the shoes of another organization in which the DHS entity holds less than a 100 percent ownership interest and, if so, what amount of ownership should trigger application of the entity ``stand in the shoes'' provisions. In addition, we are seeking public comments as to whether we should deem a

DHS entity to stand in the shoes of an organization that it controls

(for example, an entity would stand in the shoes of a nonprofit organization of which it is the sole member); we would consider a DHS entity to control an organization if the DHS entity has the power, directly or indirectly, significantly to influence or direct the actions or policies of the organization. We are seeking public comments as to what level of control should trigger the application of the entity ``stand in the shoes'' provisions. 3. Application of the Physician ``Stand in the Shoes'' and the Entity

``Stand in the Shoes'' Provisions

In order to protect against program and patient abuse when multiple links involving various corporate and other entities exist in a chain of financial relationships between a DHS entity and a referring physician, we are proposing that, when applying the physician ``stand in the shoes'' provisions and the entity ``stand in the shoes'' provisions to a chain of financial relationships between a physician and a DHS entity, the following conventions would apply:

First, parties would apply the physician ``stand in the shoes'' provisions and deem the physician to stand in the shoes of his or her physician organization (in those instances where the physician

``stand in the shoes'' provisions apply to the particular physician and physician organization).

However, if applying the physician ``stand in the shoes'' provisions would result in only one financial relationship remaining between the DHS entity and the ``collapsed'' physician/physician organization and that relationship is an ownership interest, the physician ``stand in the shoes'' provisions would not be applied, and the entity ``stand in the shoes'' provisions instead would be applied first.

If more than two organizations remain after first

``collapsing'' the physician and the physician organization (that is, if at least two links remain in the chain of financial relationships between the physician who is standing in the shoes of his or her physician organization and the DHS entity), the next step would be to apply the entity ``stand in the shoes'' provisions.

These conventions ensure that at least one compensation arrangement remains between the DHS entity and the referring physician for purposes of analyzing the chain of relationships under the physician-self referral rules. For example, if a chain of financial relationships runs: hospital--wholly-owned home health agency--group practice-- physician owner of the group practice, the first step would be to apply the physician ``stand in the shoes provisions'' such that the physician owner would stand in the shoes of the group practice. The next step would be to apply the entity ``stand in the shoes'' provisions and deem the hospital to stand in the shoes of its wholly-owned home health agency. Assuming that the financial relationship between the home health agency and the group practice is a compensation arrangement, the remaining financial relationship would be deemed to be a direct compensation arrangement between the hospital (standing in the shoes of the home health agency) and the physician (standing in the shoes of the group practice). By contrast, the example of a chain of financial relationships that runs: hospital--group practice wholly-owned by the hospital--employed physician of the group practice (whose compensation does not satisfy the requirements of the exception in Sec. 411.357(c)), is illustrative. If the relationship between the hospital and the group practice is solely an ownership interest (that is, there is no separate compensation arrangement between them), applying the physician ``stand in the shoes'' provisions first, so that the physician-employee stands in the shoes of the group practice, would result in one remaining financial link between the group practice and the hospital, and that relationship would be an ownership interest. In those circumstances, the entity ``stand in the shoes'' provisions would be applied first and the hospital would stand in the shoes of its wholly-owned group practice. The physician would not stand in the shoes of the group practice. The remaining financial relationship would be deemed to be a direct compensation arrangement between the hospital

(standing in the shoes of the group practice) and the physician. (We note that, in this example, the physician's compensation from the group practice does not satisfy the requirements of the exception for bona fide employment relationships in Sec. 411.357(c) and, thus, no direct exception would apply to that compensation arrangement.) Using the same chain of financial relationships, but assuming instead that the hospital has a compensation arrangement with (in addition to being the sole owner of) the group practice (for example, an office space rental agreement), under the proposals described above, the physician would stand in the shoes of the group practice, but the hospital would not stand in the shoes of the group practice because, after first applying the physician ``stand in the shoes'' provisions, only two organizations would remain (that is, only one link in the chain of financial relationships remains). The remaining financial relationship created by the rental agreement would be deemed to be a direct compensation arrangement between the hospital and the physician, which would need to satisfy the requirements of an exception.

We are not proposing regulation text at this time with respect to the application of the physician and entity ``stand in the shoes'' provisions. At such time as these provisions are finalized, we would amend the regulation text, as appropriate, to codify requirements

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related to the application of the provisions. 4. Definitions: ``Physician'' and ``Physician Organization''

In an interim final rule with comment period entitled ``Medicare

Program; Physicians' Referrals to Health Care Entities With Which They

Have Financial Relationships (Phase II); Interim Final Rule,'' published in the Federal Register on March 26, 2004 (72 FR 16054)

(``Phase II''), we revised the definition of ``referring physician'' at

Sec. 411.351 to provide that a referring physician is deemed to stand in the shoes of his or her wholly-owned PC (69 FR 16060). In that rule, we stated that it is not necessary to treat a referring physician as separate from his or her wholly-owned PC. In the Phase III final rule, for purposes of implementing the physician ``stand in the shoes'' provisions, the term ``physician organization'' was newly defined at

Sec. 411.351 as ``a physician (including a professional corporation of which the physician is the sole owner), a physician practice, or a group practice that complies with the requirements of Sec. 411.352.''

Our intent was that, when applying the physician ``stand in the shoes'' provisions in Sec. 411.354, a physician would stand in the shoes of:

(1) Another physician who employs the physician; (2) his or her wholly- owned PC; (3) a physician practice that employs or contracts with the physician or in which the physician has an ownership interest; or (4) a group practice of which the physician is a member or independent contractor.

Essentially, we intended this definition to incorporate the Phase

II policy that a physician stands in the shoes of, or is considered the same as, the PC of which he or she is the sole owner. In determining whether a direct or indirect compensation arrangement exists between a

DHS entity and a referring physician, we intended that parties should first ``collapse'' the physician into his or her wholly-owned PC, and then deem that ``collapsed'' physician/PC unit to stand in the shoes of the physician organization (if one exists). However, we are concerned that parties may interpret the rules, using the definition of

``physician organization'' exclusive of the definition of ``referring physician,'' as requiring only that they deem a physician to stand in the shoes of his or her wholly-owned PC without further deeming the

``collapsed'' physician/PC unit to stand in the shoes of the physician organization. That is, with respect to a chain of financial relationships that runs: hospital--group practice--PC--physician, parties might interpret our rules as requiring only that the physician stand in the shoes of the PC and not in the shoes of the group practice, so that the resulting chain of financial relationships (after the application of the ``stand in the shoes'' provisions) would run: hospital--group practice--PC/physician. However, our intention was that, after application of the ``stand in the shoes'' provisions, the chain of financial relationships would run: hospital--group practice/

PC/physician.

Therefore, we are proposing revisions to the definitions of

``physician'' and ``physician organization'' to clarify that: (1) A physician and the PC of which he or she is the sole owner are always treated the same for purposes of applying the physician self-referral rules; and (2) a physician who stands in the shoes of his or her wholly-owned PC also stands in the shoes of his or her physician organization in accordance with Sec. 411.354(c)(1)(ii) and (c)(2)(iv).

B. Period of Disallowance

In response to the Phase II interim final rule with comment period, several commenters questioned what the time period would be for which the physician could not refer patients for DHS to an entity and for which the entity could not bill Medicare (the ``period of disallowance'') where a financial relationship between a referring physician and an entity failed to satisfy the requirements of an exception to the general prohibition on self-referral. (See 72 FR 51024 through 51025; and 72 FR 38183.) In the Phase III final rule, in response to these inquiries, we stated that the statute provides no explicit limitation on the billing and claims submission prohibition

(72 FR 51025). In the CY 2008 PFS proposed rule, we stated that the statute contemplates that the period of disallowance begins with the date that a financial relationship failed to comply with the statute and the regulations, and ends with the date that the arrangement came into compliance or ended (72 FR 38183). We noted that, in some cases, it may not be clear when a financial relationship has ended. We provided the example of an entity leasing space to a physician at a rental price that is substantially below fair market value. We stated that such an arrangement may raise the inference that the below-market rent was in exchange for future referrals, including referrals made beyond the expiration of the lease. We solicited comments with respect to: (1) The types of noncompliance for which it is not clear when a financial relationship ended; and (2) whether we should always employ a case-by-case approach or deem certain types of financial relationships to continue for a prescribed period of time. We also solicited public comments as to whether we should allow a prescribed period of disallowance to terminate where the parties have returned (or paid back the value of) any excess compensation. For example, if we were to impose a period of disallowance for a prescribed period of time because it would not be clear when a noncompliant compensation arrangement ended, we stated that we might allow the parties to terminate the period of disallowance sooner than the prescribed period if the prohibited compensation were returned. In the CY 2008 PFS proposed rule, we cautioned that we did not envision allowing such an option where the parties knew or, in our judgment, reasonably should have known, that the arrangement did not satisfy the requirements of an exception. Finally, we sought public comments as to whether we should impose a period of disqualification, prohibiting the parties from using an exception where an arrangement has failed to satisfy the requirements of that exception. We gave the example of nonmonetary compensation provided by an entity to a physician that greatly exceeded the permissible limit prescribed in Sec. 411.357(k), and questioned whether, in addition to whatever period of disallowance would apply, the parties should be disqualified, for some period of time, from using this exception.

We received few public comments in response to the CY 2008 PFS proposed rule solicitation of comments; however, with respect to the length of the period of disallowance, one commenter asserted that the appropriate period of disallowance should match the period that the financial relationship did not satisfy the requirements of an exception, but that the period should be limited to a maximum term. In addition, commenters asserted that, if the parties unwind the relationship and return the prohibited compensation, the period of disallowance should end. Another commenter suggested that the period of disallowance should end once the hospital corrects or terminates the arrangement and the physician repays to the hospital any compensation in excess of what is permitted. Alternatively, according to the commenter, if the physician does not repay the excess compensation, the period of disallowance should end once the hospital repays to Medicare the excess compensation, and the hospital should be prohibited from paying any further compensation to the physician until the

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physician reimburses the hospital for the excess compensation. One commenter asserted that certain circumstances warrant no period of disallowance. For instance, according to the commenter, if parties to an arrangement were unaware that the arrangement violates the physician self-referral law but later were notified by CMS or its contractor of the possible violation, they should be able to amend the arrangement so that it satisfies the requirements of an exception without any period of disallowance. The commenter also asserted that there should be no period of disqualification preventing the parties from using an exception in light of the onerous penalties under the physician self- referral law.

At this time, we are proposing to amend Sec. 411.353(c) to provide that, where the reason(s) a financial relationship does not meet any applicable exception is not related to compensation (for example, a signature is missing or an agreement is not in writing as required by the applicable exception), the period of disallowance would begin on the date the arrangement first was out of compliance and end no later than the date the arrangement was brought into compliance (for example, by obtaining a missing signature on an agreement or executing a written agreement as required by the applicable exception). For example, where a hospital and a physician enter into a personal service arrangement for medical director services and begin performing under the arrangement on January 1, but do not execute a written agreement until

January 31, provided that all of the requirements of Sec. 411.357(d)

(the exception for personal service arrangements) are satisfied as of

January 31, the period of disallowance would begin on January 1 and end no later than January 31. As discussed below, we believe that it is possible that a financial arrangement may end prior to the arrangement being brought into compliance. In such circumstances, a determination as to the duration of the period of disallowance necessarily would be made on a case-by-case basis considering the facts and circumstances, and we are not proposing a prescribed period of disallowance for such a situation.

We are also proposing that, where the reason a financial relationship does not meet any applicable exception is related to the payment or receipt of excess compensation (for example, the compensation paid to a physician is greater than fair market value or exceeds the limits in Sec. 411.357(k) or (m)), the period of disallowance would begin on the date the arrangement first was out of compliance and end no later than the date the excess compensation

(including interest, as appropriate) was returned by the party receiving it to the party that provided it and all other requirements of the applicable exception are met. For example, if a hospital provided nonmonetary compensation totaling $100 in excess of the limits in Sec. 411.357(k) on February 1 and the parties did not discover the noncompliance until October 1 (and, therefore, could not avail themselves of the provisions in Sec. 411.357(k)(3) permitting parties to remain in compliance with the exception if excess nonmonetary compensation (within certain limits) provided inadvertently is discovered and returned with 180 days of its receipt), the period of disallowance would begin on February 1 and end no later than the date that the physician returned the excess nonmonetary compensation or its value ($100 plus interest, as appropriate) to the hospital. Assuming that the physician paid the hospital $100 (plus interest, as appropriate) on October 15, the period of disallowance would run from

February 1 through no later than October 15.

Our proposal would also prescribe a period of disallowance where the reason a financial relationship does not meet any applicable exception is related to the payment or receipt of compensation that is insufficient to satisfy the requirements of an exception (for example, office space or equipment rental payments that are below fair market value). We are proposing that the period of disallowance would begin on the date the arrangement first was out of compliance and end no later than the date the shortfall was paid to the party to which it is owed and all other requirements of the applicable exception are met. The

``shortfall'' would be that amount (including interest, as appropriate) necessary to bring the arrangement into compliance from the date of its inception. For example, assume a hospital and physician entered into a 2-year office space rental agreement on January 1 (of Year 1) which specified rental charges (consistent with fair market value) of $20 per square foot during Year 1 and automatically adjusted upward each

January 1 by any increase in the CPI-U. If, on January 1 of Year 2 of the agreement, the rental charges increased to $21 per square foot based on the amount of increase in the CPI-U, but the physician continued to pay $20 per square foot until the compliance failure was identified on June 30 of Year 2, the period of disallowance would run from January 1 of Year 2 until no later than June 30 of Year 2, provided that the physician paid the hospital on June 30 of Year 2 the shortfall of $1 per square foot for the 6-month shortfall period (plus interest, as appropriate) and, as of July 1 through the term of the agreement, the physician paid $21 per square foot for the office space, and the arrangement otherwise satisfied the requirements of the exception in Sec. 411.357(d). As discussed below, we believe that it is possible that an arrangement may end prior to excess compensation being returned or a shortfall being paid; however, such a determination as to the duration of the period of disallowance necessarily would be made on a case-by-case basis considering the facts and circumstances, and we are not proposing a prescribed period of disallowance for such a situation.

We also note that an arrangement may be noncompliant for reasons that are related to compensation, but which do not involve the payment or receipt of excess compensation or a shortfall in compensation paid or received. For example, many of our exceptions require that the compensation not take into account the volume or value of referrals or other business generated between the parties and that the compensation be commercially reasonable, even if no referrals were made between the parties. It is possible that the amount of compensation provided under an arrangement is fair market value or is consistent with a prescribed limit in one of the exceptions (such as in Sec. 411.357(k)), but, for example, takes into account the volume or value of referrals and this results in a noncompliant arrangement. We are not proposing a prescribed period of disallowance for arrangements that are noncompliant for reasons that are related to compensation but which do not involve only the payment or receipt of excess compensation or a shortfall in compensation paid or received. Rather, the appropriate period of disallowance for such arrangements would need to be determined on a case-by-case basis.

Essentially, our proposals place an outside limit on the period of disallowance in certain circumstances. That is, where the reason(s) for noncompliance does not relate to compensation, the latest the period of disallowance would end would be the date the arrangement was brought into compliance. Where the reason for noncompliance is the fact that excess compensation was provided or too little compensation was paid, the latest the

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period of disallowance would end would be the date that the party receiving the excess compensation returned it to the party that provided it or the party owing the shortfall in compensation paid it to the party to which it was owed (assuming the arrangement otherwise satisfies the requirements of an applicable exception).

We recognize, of course, that parties to a financial relationship that is noncompliant may never bring the relationship into compliance with an applicable exception. The financial relationship may expire according to the terms of the underlying agreement (such as the date of expiration of a personal service contract), or it may end earlier or later than the expiration date provided in the underlying agreement.

However, we do not propose to prescribe with specificity when such a noncompliant financial relationship (and, thus, the period of disallowance) might end. Likewise, if a party that receives excess compensation never repays the excess compensation, or a party who owes additional compensation (the shortfall) never pays it, the question arises as to when the financial relationship ends. To return to the example that we gave in the CY 2008 PFS proposed rule and that we reference above, if an entity leases space to a physician at a rental price that is substantially below fair market value, the inference may be raised that the below-market rent was in exchange for future referrals, including referrals made beyond the expiration of the lease agreement. Therefore, in such a situation, if the physician does not pay the rental charges shortfall, the financial relationship may not end at the expiration of the written lease agreement, but rather could extend for some period beyond the expiration of the written lease agreement. We are not proposing to establish any specific time period or even guidelines for when the financial relationship in the above example would be deemed to end (so that future referrals would not be tainted); rather the determination of when the financial relationship ends must depend on the facts and circumstances. We note that our proposals pertain only to placing an outside limit on the period of disallowance for making referrals and billing the Medicare program in the case of certain noncompliant financial relationships; they do not address whether the anti-kickback statute is implicated and/or whether civil monetary penalties under the physician self-referral statute are potentially applicable due to noncompliant financial relationships.

We are not proposing, as one commenter suggested, that, in a situation involving noncompliance due to excess compensation paid by an entity to a physician (or the physician's immediate relative), the period of disallowance would end no later than the date the entity repays the excess compensation to the Medicare program, should the physician not repay the excess compensation to the entity. This approach is not consistent with the statute. We are also not proposing, as another commenter suggested, to impose no period of disallowance for the situation in which parties allegedly were unaware of the noncompliant nature of a financial relationship. We do not have the authority under section 1877 of the Act to waive violations of the physician self-referral law. We note also that there would be practical problems in determining whether parties were unaware of the noncompliant nature of the arrangement and that we would be discouraging parties from carefully structuring arrangements and monitoring them. In the CY 2008 PFS proposed rule, we proposed an alternative method of compliance that may address some of the commenter's concerns, and that proposal is still under consideration for final rulemaking. Finally, we are not proposing to impose a period of disqualification during which the parties to a noncompliant financial relationship would be prohibited from using a particular exception due to that relationship. We may propose rulemaking on this subject in the future.

C. Gainsharing Arrangements 1. Background

The term ``gainsharing'' typically refers to an arrangement under which a hospital gives physicians a share of the reduction in the hospital's costs (that is, the hospital's cost savings) attributable in part to the physicians' efforts. Gainsharing may take several forms.

Some arrangements are narrowly targeted, giving the physician a financial incentive to select specific medical devices and products that are less expensive or to adopt specific clinical practices or protocols that reduce costs. Other, more problematic arrangements are not targeted at utilization of specific supplies or specific clinical practices, but instead offer the physician payments to reduce total average costs per case below target amounts.

Gainsharing arrangements seek to align physician incentives with those of hospitals by offering physicians a share of the hospital's variable cost savings attributable to the physicians' efforts in controlling the cost of providing patient care. Following the institution of the Medicare Part A DRG system of hospital reimbursement and with the growth of managed care, hospitals have experienced significant financial pressure to reduce costs. However, because physicians are paid separately under Medicare Part B and Medicaid, physicians do not share necessarily a hospital's incentive to control the hospital's patient care costs. Gainsharing arrangements are designed to align hospital and physician incentives by offering physicians a portion of the hospital's cost savings in exchange for identifying and implementing cost-saving strategies. 2. Statutory Impediments to Gainsharing Arrangements

Whereas gainsharing promotes hospital cost reductions by aligning physician incentives with those of the hospital, these arrangements also implicate the physician self-referral statute (section 1877 of the

Act). Section 1877(a)(1) of the Act states that, except as provided in section 1877(b) of the Act, if a physician (or an immediate family member of such physician) has a financial relationship with an entity, the physician may not make a referral to the entity for the furnishing of DHS for which payment otherwise may be made under title XVIII of the

Act. The provision of monetary or nonmonetary remuneration by a hospital to a physician through a gainsharing arrangement would constitute a financial relationship with an entity for purposes of the physician self-referral statute.

Gainsharing arrangements also implicate two specific fraud and abuse statutes. First, sections 1128A(b)(1) and (b)(2) of the Act, commonly referred to as the Civil Monetary Penalty, or CMP, statute, prohibit a hospital from knowingly making a payment directly or indirectly to a physician as an inducement to reduce or limit items or services furnished to Medicare or Medicaid beneficiaries, and a physician from knowingly accepting such payment. Second, gainsharing arrangements implicate section 1128B(b) of the Act (the ``anti-kickback statute'') if one purpose of the cost savings payment is to influence referrals of Federal health care program business. 3. Office of Inspector General (OIG) Approach Towards Gainsharing

Arrangements

The HHS Office of Inspector General (``OIG'') historically has been wary of

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gainsharing arrangements. In July 1999, OIG issued a Special Advisory

Bulletin that addressed the application of sections 1128A(b)(1) and (2) of the Act to gainsharing arrangements. Although OIG recognized that appropriately structured gainsharing arrangements may offer significant benefits where there is no adverse impact on the quality of care received by patients, section 1128A(b) of the Act clearly prohibits arrangements that are intended as an inducement to limit or reduce services to Medicare or Medicaid patients. In addition, OIG stated that regulatory relief from the CMP prohibition would require statutory authorization.

OIG has issued several favorable advisory opinions regarding individual gainsharing arrangements, although the opinions (like all

OIG advisory opinions) do not have general applicability. When evaluating the risks posed by a gainsharing arrangement, OIG has generally looked for three types of safeguards, namely: (1) Measures that promote accountability and transparency; (2) adequate quality controls; and (3) controls on payments related to referrals. Properly structured, gainsharing arrangements may offer opportunities for hospitals to reduce costs without causing inappropriate reductions in medical services or rewarding referrals of Federal health care program patients. In a number of specific cases involving limited proposed arrangements, OIG has issued advisory opinions in which it concluded that the proposed arrangement presents a low risk of abuse and, therefore, it would exercise its prosecutorial discretion not to impose sanctions. In these cases, OIG has concluded, based on the totality of facts and circumstances and the presence of adequate safeguards, that:

(1) The proposed arrangement would constitute an improper payment to induce the reduction or limitation of services as prohibited by sections 1128A(b)(1) and (2) of the Act, but that OIG would not impose sanctions on the requestors of the advisory opinion; and (2) the proposed arrangement would potentially generate prohibited remuneration under the anti-kickback statute if the requisite intent to induce or reward referrals of Federal health care program business were present, but that OIG would not impose administrative sanctions on the requestors under section 1128A(a), or under section 1128(b)(7) or section 1128A(a)(7), as those sections relate to the commission of acts described in the anti-kickback statute. 4. MedPAC Recommendation

MedPAC, in its March 2005 Report to Congress, ``Physician-owned

Specialty Hospitals,'' recommended that gainsharing arrangements between physicians and hospitals be permitted. Specifically, MedPAC stated that, ``[t]he Congress should grant the Secretary the authority to allow gainsharing arrangements between physicians and hospitals and to regulate those arrangements to protect the quality of care and minimize financial incentives that could affect physician referrals.''

(See http://www.medpac.gov/publications/congressional repots/

Mar05EntireReport.pdf, at page 47). In addition, MedPAC stated that, drawing on OIG's work, the Secretary could require that gainsharing arrangements:

Identify specific actions that would produce savings, such as limiting the inappropriate use of supplies;

Are transparent and disclosed to patients;

Include periodic reviews of quality of care by an independent organization;

Limit the amount of time during which physicians can share cost savings in order to prevent hospitals from using these agreements as a mechanism to induce physician referrals;

Avoid rewarding physicians for increasing referrals to the hospitals, such as capping potential savings based on the number of prior year admissions; and

Monitor changes in the severity, age, and insurance coverage of patients affected by the gainsharing arrangement. 5. Demonstration Programs

CMS has long been interested in evaluating the association between payments and the quality of care. In 1991, CMS initiated a demonstration program entitled the ``Medicare Participating Heart

Bypass Center Demonstration.'' This demonstration was conducted to assess the feasibility and cost effectiveness of a negotiated all- inclusive bundled payment arrangement for coronary artery bypass graft

(CABG) surgery while maintaining high quality care. CMS originally negotiated contracts with four applicants. In 1993, the demonstration was expanded to include three more participants. The results of the demonstration showed that an all-inclusive bundled payment arrangement can provide an incentive to physicians and hospitals to work together to provide services more efficiently, improve quality, and reduce costs. The bundling of the physician and hospital payments did not have a negative impact on the post-discharge health improvements of the demonstration patients. Three of the four original hospitals were able to make major changes in physician practice patterns and operations that generated significant cost savings. A hospital's participation in the demonstration appeared to have little or no effect on physician referral patterns.

A second demonstration project that involves gainsharing arrangements is authorized by section 646 of the MMA, which added a new section 1866C of the Act and established the Medicare Health Care

Quality MHCQ Demonstration Program. MHCQ demonstration projects are intended to ``* * * examine health delivery factors that encourage the delivery of improved quality in patient care.'' Using the authority provided by section 1866C of the Act, CMS decided to implement a 3-year demonstration that would test gainsharing models involving physicians and collaborations between hospitals working with physicians in a single geographic area to improve the quality of inpatient hospital care. In contrast to traditional models of gainsharing, the proposed demonstration approaches must be across single or multiple organizations and involve long-term followup to ensure both documented improvements in quality and reductions in the overall costs of care.

CMS is particularly interested in demonstration designs that: (1) Track patients well beyond a hospital episode to determine the impact of hospital-physician collaborations on preventing short and longer-term complications, duplication of services, and coordination of care across settings; and (2) offer other quality improvements for eliminating preventable complications and unnecessary costs.

A third series of demonstration projects was authorized by section 5007 of the Deficit Reduction Act of 2005 (the ``DRA'') (Pub. L. 109- 171). This provision requires the Secretary to establish a qualified gainsharing demonstration under which the Secretary shall approve up to six demonstration projects. Section 5007 demonstration projects would involve arrangements between a hospital and physicians and practitioners under which the hospital provides for remuneration (that is, gainsharing payments) to certain physicians and to certain practitioners (as defined in 1842(b)(18)(C) of the Act) that represents solely a share of the savings incurred directly as a result of collaborative efforts between the hospital and a particular physician

(or practitioner) to improve overall quality and efficiency. Each demonstration

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project must also provide measures to monitor quality and efficiency in the participating project hospital(s). 6. Solicitation of Comments

In the CY 2008 PFS proposed rule, we noted that we are concerned about compensation arrangements between entities and physicians under which compensation is determined on a percentage basis (for example, rental charges for office space that are determined based on a percentage of a group practice's revenues) (72 FR 38184). We proposed to clarify that percentage-based compensation arrangements may be used only for paying for personally performed physician services and that such arrangements must be based on the revenues directly resulting from the physician services rather than based on some other factor such as a percentage of the savings by the hospital department. The proposed changes, if finalized, might prevent typical gainsharing arrangements between physicians and hospitals to which they refer for DHS. We have not yet finalized our proposal in the CY 2008 PFS final rule; however, it remains under active consideration.

Notwithstanding our general concern with arrangements that involve the use of a percentage-based compensation formula (other than payment to a physician for work personally performed by the physician), we recognize the value to the Medicare program and its beneficiaries where the alignment of hospital and physician incentives results in improvements in quality of care. Therefore, we are considering whether to issue an exception specific to gainsharing arrangements. Under section 1877(b)(4) of the Act, we may issue additional exceptions (that is, exceptions not specified in the statute) only where doing so would create no risk of program or patient abuse. At this time, we decline to issue a specific proposal concerning an exception for gainsharing arrangements, but rather are soliciting comments as to whether we should establish an exception for gainsharing arrangements, and, if so, what safeguards should be included in the exception. Specifically, we are interested in receiving comments on: (1) What types of requirements and safeguards should be included in any exception for gainsharing arrangements; and (2) whether certain services, clinical protocols, or other arrangements should not qualify for the exception.

D. Physician-Owned Implant and Other Medical Device Companies 1. Background

We have recently become aware of an increase in physician investment in implant and other medical device manufacturing, distribution, and purchasing companies. We recognize that physician involvement often adds value to device manufacturing companies and that many physicians may have legitimate investment interests in these companies. Physicians participate in the research, development, and testing involved in creating and producing many lifesaving and quality- of-life enhancing medical devices. The added value of physician involvement in distribution and purchasing companies, essentially middlemen companies, is less clear. When physicians profit from the referrals they make to hospitals through physician-owned implant and medical device companies (``POCs''), we are concerned about possible program or patient abuse. POCs exist in three primary forms: manufacturers, distributors, and group purchasing organizations

(``GPOs''). Our understanding, however, is that many POCs are not manufacturers, but rather are companies that profit from the purchase and resale of products made by another organization (that is, they act as distributors) or from GPO fees paid by device vendors. In many cases, the physician investors bear little, if any, economic risk with respect to the medical devices. It is also our understanding that some physicians are offered investment interests in ``private label'' or similar manufacturing entities when the physicians have provided little, if any, necessary research, design, or testing services. We are concerned that some physician-owned organizations may serve little purpose other than providing physicians the opportunity to earn economic benefits in exchange for nothing more than ordering medical devices or other products that the physician-investors use on their own patients. The financial incentives paid to the physicians may foster an anti-competitive climate, raise quality of care concerns, and lead to overutilization of the device or other product to which the physician is linked. Physicians are responsible for selecting or recommending the devices ordered for the hospital's patients. It is reasonable to believe that medical device or implant companies without physician investment will have difficulty finding referral sources in areas where many physicians are invested in a POC that offers competing products.

In response to our proposed change to the definition of ``entity'' at Sec. 411.351 in the CY 2008 PFS proposed rule, we received public comments regarding whether a physician-owned implant or other medical device company should or should not be considered to be an ``entity.''

One commenter noted that orthopedic surgeons may have an ownership interest in a manufacturer of spinal implants that sells its implants to the hospital where the surgeon performs his or her surgeries.

According to the commenter, because the proposed definition of

``entity'' would extend to an entity that ``performs the DHS,'' the manufacturer arguably could be considered to be an ``entity'' under

Sec. 411.351. This commenter urged us to exclude such manufacturers from the definition of ``entity.'' The commenter stated that indirect arrangements involving spinal implants would trigger the self-referral prohibition if they are not at fair market value. Comments submitted on behalf of a manufacturer of spinal implants asserted that, despite superficial similarities, joint ventures involving medical devices differ in many material ways from the types of arrangements about which we expressed concern. This commenter also asserted that the meaning of

``has performed the DHS'' is unclear and that we should clarify that the proposal applied only to ``true'' ``under arrangement'' relationships with hospitals, but that, in any event, implantable devices are not DHS. According to the commenter, even if implantable devices were deemed to be DHS, the rigorous physician self-referral exceptions (for example, the exception for indirect compensation arrangements in Sec. 411.357(p)) are still available to protect the arrangement and against program or patient abuse.

In an October 6, 2006 letter response to a request for guidance regarding certain physician investments in the medical device industry,

OIG stated that it was aware of an apparent proliferation of physician investments in medical device and distribution companies, including

GPOs, and that, given the strong potential for improper inducements between and among the physician investors, the companies, device vendors, and medical device purchasers, it believed that all of these ventures should be closely scrutinized under the fraud and abuse laws.

OIG also clarified that its 1989 Special Fraud Alert on Joint Ventures applies to all physician joint ventures and would, therefore, apply to physician investments in medical device manufacturing and distribution

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companies, as well as GPOs. OIG confirmed that the fact that a substantial portion of a venture's gross revenues is derived from participant-driven referrals is a potential indicator of a problematic joint venture. The October 6, 2006 letter response is available at http://oig.hhs.gov/fraud/docs/alertsandbulletins/

GuidanceMedicalDevice%20(2).pdf. See also http://oig.hhs.gov/testimony/ docs/2008/demske--testimony022708.pdf.

A medical device company requested that we take a closer look at the current prevalence of POCs and the impact that these companies may have on program or patient abuse, as well as the negative impact on competition among POCs and nonphysician owned medical device companies.

This company noted that, in the CY2008 PFS proposed rule, we proposed revising the definition of ``entity'' to include, among other things, an entity that causes a claim to be submitted to Medicare. It suggested that we finalize our proposal and that we deem POCs to be DHS entities under certain circumstances. It also suggested that, in certain circumstances, physician investors in POCs should be deemed to have a direct compensation relationship with the hospitals that order and use implantable devices furnished by the POCs. The company suggested that a

POC should not be considered to have caused a claim to be presented where the referring physician is named as an inventor on an issued patent for the implantable item, provided that the physician does not receive any remuneration from the POC based on the volume or value of his or her referrals, or where the physician's investment interest satisfies the requirements of the exception in Sec. 411.356(a) for large, publicly traded entities. We note that it is not clear to us under what circumstances a patent holder physician, who presumably receives royalty payments from the POC, would receive remuneration that does not relate to the volume or value of referrals or other business generated by the physician. In the Phase II final rule with comment period, we noted that we received a comment that questioned whether the payment of a royalty by an equipment manufacturer to a physician inventor for a device implanted during surgeries performed by the physician inventor is permitted or whether that arrangement would create an indirect compensation relationship with the hospital that purchased the device. We stated, in response, that the physician inventor would have an indirect compensation arrangement with the hospital in which the surgeries are performed but, provided the royalty payment was fair market value, the relationship should satisfy the exception for indirect compensation arrangements in Sec. 411.357(p)

(69FR 16060). 2. Solicitation of Comments

At this time, we are not issuing a specific proposal regarding

POCs. The statute and our existing regulations, specifically those related to indirect compensation arrangements, address many POCs. In some problematic circumstances, an unbroken chain of financial relationships will connect the physician owner of a POC to a DHS entity to which the physician makes referrals, and the other elements of an indirect compensation arrangement contained in Sec. 411.354(c)(2) will also be present, including the requisite knowledge by the DHS entity of the physician's interest in the POC. In many instances, the arrangement would not satisfy the requirements of the exception for indirect compensation arrangements in Sec. 411.357(p), and would, therefore, run afoul of the physician self-referral statute. However, we are soliciting public comments as to whether our physician self-referral rules should address POCs and similar physician owned companies more specifically, or whether the concerns surrounding POCs and similar organizations, to the extent that they are not addressed by the statute and our current rules, are better addressed through enforcement of the

False Claims Act, the anti-kickback statute and similar fraud and abuse laws, other public laws, and through other applicable Federal, State, and local regulations. In this regard, we are seeking comments as to whether, and to what degree, physician investment in POCs and similar organizations presents risks of overutilization, substandard care, and increased costs to the Medicare program and its beneficiaries, or whether the risk is confined to possible anti-competitive behavior. To the extent that commenters believe that certain physician investment in

POCs and similar organizations should be addressed more specifically under our physician self-referral rules, commenters are encouraged to provide us with suggestions as to specific actions we should take (for example, considering POCs to be DHS entities under certain circumstances, considering physician investors in POCs who influence hospitals as to the ordering of medical devices to have direct compensation relationships with the hospitals, excepting certain investment interests from coverage under our rules, etc.).

IX. Financial Relationships Between Hospitals and Physicians

A. Background

As stated earlier, under section 1877 of the Act, a physician is prohibited from referring a Medicare patient for DHS to an entity

(including an individual) with which the physician (or an immediate family member of the physician) has a financial relationship, unless an exception applies. In addition, section 1877 of the Act provides that an entity may not present or cause to be presented a claim or bill to

Medicare or any individual, third party payor, or other entity for DHS furnished as a result of a prohibited referral. Also, section 1877 of the Act prohibits us from making payment for DHS furnished pursuant to a prohibited referral. The statute contains several exceptions for certain types of compensation arrangements and ownership or investment interests, including the exception in section 1877(d)(3) of the Act for ownership or investment by a physician in the hospital itself and not merely in a subdivision of the hospital (that is, the ``whole'' hospital). Section 1877(b)(4) of the Act authorizes us to create additional exceptions, provided that they do not create a risk of program or patient abuse. As a result of the statutory exceptions in section 1877 of the Act, and the exceptions we have created using our authority under section 1877(b)(4) of the Act, our regulations contain approximately 40 exceptions to the prohibition on physician self- referrals. (We refer readers to 42 CFR 411.351 through 411.357 of our regulations and the September 5, 2007 ``Phase III'' final rule (72 FR 51012).)

Section 1877(f) of the Act provides that: ``Each entity providing covered items or services for which payment may be made under this title [42 USCS 1395 et seq.] shall provide the Secretary with the information concerning the entity's ownership, investment, and compensation arrangements, including: (1) The covered items and services provided by the entity, and (2) the names and unique physician identification numbers of all physicians with an ownership or investment interest (as described in subsection (a)(2)(A)), or with a compensation arrangement (as described in subsection (a)(2)(B)), in the entity, or whose immediate relatives have such an ownership or investment interest or who have a compensation relationship with the entity. Such information shall be provided in such form, manner, and

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at such times as the Secretary shall specify.'' (Emphasis added)

Some industry representatives have argued that the reference to financial relationships as described in section 1877(a)(2)(A) and

(a)(2)(B) of the Act limits our ability to obtain information on financial relationships that do not satisfy one of the statutory or regulatory exceptions. We disagree. The statute clearly contains a broad authorization for the Secretary to obtain information concerning an entity's financial relationships, ``including,'' but not limited to, financial relationships that satisfy an exception. We believe that there would have been little point to the Congress providing us with the authority to compel information on excepted arrangements only, because, as we have noted previously, ``an entity could decide that one or more of its financial relationships falls within an exception, fail to retain data concerning those financial relationships, and thereby prevent the government from reviewing the arrangements to determine if they qualify for an exception.'' (72 FR 51069.) Accordingly, our regulation in Sec. 411.361 requires entities to report ``any ownership or investment interest, as defined at Sec. 411.354(b), or any compensation arrangement, as defined at Sec. 411.354(c), except for ownership or investment interests that satisfy the exceptions set forth in Sec. 411.356(a) and Sec. 411.356(b) regarding publicly-traded securities and mutual funds'' (emphasis added). The statute provides that an ownership or investment interest in the entity may be through equity, debt, or other means, and includes an interest in an entity that holds an ownership or investment interest in any entity that furnishes DHS.

Our regulations have been drafted to reflect clearly our commonsense interpretation of the statutory reporting requirements. In the proposed rule entitled ``Medicare and Medicaid Programs;

Physicians'' Referrals to Health Care Entities With Which They Have

Financial Relationships,'' published in the Federal Register on January 9, 1998 (63 FR 1703), we proposed to modify Sec. 411.361 to require that entities report information concerning their reportable financial relationships to us on a prescribed form and thereafter report annually all changes to the submitted information that occurred in the previous 12 months. In addition, we revisited the statute and interpreted the opening paragraph of section 1877(f) of the Act to permit us to gather any data on financial relationships, including, but not necessarily limited to, financial relationships for which there are no exceptions under section 1877(a)(2)(A) or (a)(2)(B) of the Act. Therefore, we proposed to amend Sec. 411.361 to reflect explicitly our authority to ask for a broader scope of information than the regulation permitted at that time.

In the Phase II final rule with comment period (69 FR 16121), we modified the reporting requirement in Sec. 411.361 to remove all references to the use of a prescribed form, to require entities to make information available only upon request, and to maintain the information only for the length of time specified by the applicable regulatory requirements for the information (that is, the rules of the

Internal Revenue Service, Securities and Exchange Commission, Medicare,

Medicaid, or other programs). In addition, we modified Sec. 411.361 to provide that entities need not report ownership or investment interests that satisfy the exceptions in Sec. 411.356(a) and (b) for publicly- traded securities and mutual funds.

Most, if not all, hospitals have financial relationships with referring physicians. These financial relationships may involve ownership or investment interests, compensation arrangements, or both.

The financial relationships can be direct or they may be indirect (such as through a physician group practice or limited liability company).

The physician self-referral statute was first enacted in 1989, and the reporting requirements in the regulations in Sec. 411.361 were first implemented in our December 3, 1991 interim final rule with comment period, published in the Federal Register at 56 FR 61374. Since that time, CMS has not engaged in a comprehensive reporting initiative to examine financial relationships between hospitals and physicians.

Consistent with congressional intent in enacting the physician self- referral statute, we believe it is important to query hospitals concerning their financial relationships with physicians.

B. Section 5006 of the Deficit Reduction Act (DRA) of 2005

Section 5006 of the DRA required the Secretary to develop a strategic and implementing plan to address certain issues relating to physician-owned specialty hospitals. The specific issues the Secretary was required to address were: (1) Proportionality of investment return;

(2) bona fide investment; (3) annual disclosure of investment information; (4) the provision by specialty hospitals of (i) care to patients who are eligible for Medicaid (or who are not eligible for

Medicaid but who are regarded as such because they receive benefits under a section 1115 waiver) and (ii) charity care; and (5) appropriate enforcement. In order to assist us in preparing the report and implementing plan required by section 5006 of the DRA, we sent a voluntary survey to 130 specialty hospitals and 220 competitor hospitals, which sought information regarding, among other things, the hospitals' ownership and investment relationships, and their compensation arrangements with physicians. In the enforcement section of the strategic and implementing plan that was 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, 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 we would require all hospitals (that is, not just specialty hospitals) to provide us information on a periodic basis concerning the investment interests in the hospital of physicians and the hospital's compensation arrangements with physicians (DRA Report to Congress 69). We stated that we would not limit our requirement to information concerning physician investments in specialty hospitals for two reasons. First, physician investments in any type of hospital raise potential issues concerning compensation arrangements that can be associated with the investment.

For example, a disproportionate return on investment or non-bona fide investment (through, for example, a sham loan), creates a prohibited compensation arrangement under the physician self-referral law and raises the possibility of an illegal kickback scheme. Second, other types of compensation arrangements (that is, those that are not associated with an investment interest), implicate the physician self- referral law, such as leasing, employment, and personal service arangements. It is also important to note that, although a physician may be highly motivated to refer patients to a hospital in which he or she has an ownership interest, the physician may be just as likely to refer patients to a hospital with which he or she has a compensation relationship, given that the physician may see a more direct and immediate financial benefit from the compensation arrangement. In the

DRA Report to Congress, we stated that we would implement a regular disclosure process, but that we had not designed

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the process at that point, and that we would consider such issues as whether we should: (1) Survey all hospitals annually; (2) stagger our survey so that all hospitals are queried but not all in the same year; and/or (3) focus our inquiry on certain types of relationships or certain hospitals. We stated that we would also consider whether, having once provided information, hospitals need only submit updated information on a yearly or other periodic basis.

C. Disclosure of Financial Relationships Report (DFRR)

Following up on our commitment to capture information concerning financial relationships between all types of hospitals and physicians, and to assist in enforcement of the physician self-referral statute and implementing regulations, we created an information collection instrument, referred to as the Disclosure of Financial Relationships

Report (``DFRR''). The DFRR is designed to collect information concerning the ownership and investment interests and compensation arrangements between hospitals and physicians. (Appendix C of this proposed rule contains the DFRR instrument and instructions for public comment.) We believe information submitted by hospitals would permit us to analyze the types of financial relationships involving hospitals and physicians, the structure of various compensation arrangements and trends therein, and potentially whether the hospitals are in compliance with the physician self-referral law and implementing regulations.

Using our authority under section 1877(f) of the Act and 42 CFR 411.361, we are proposing to send the DFRR to 500 hospitals, a number that we believe is necessary to provide us with sufficient information:

(1) To determine compliance; and (2) to assist us in any future rulemaking concerning the reporting requirements and other physician self-referral provisions.

We intend for our sample size to be a significant percentage of the total number of Medicare-participating hospitals. The 2007 CMS

Statistics Handbook determined that, as of December 2006, there were approximately 6,200 Medicare-participating hospitals. Our goal is to begin by sending the DFRR to 8 to 10 percent of the Medicare- participating hospitals (496 to 620 hospitals). We reviewed our available funding and determined that our resources would permit us to review data from 500 hospitals (both general acute care hospitals and specialty hospitals).

As discussed further below, the DFRR also may assist us in making an informed decision as to whether to propose rulemaking for an annual

(or other periodic) disclosure requirement for all hospitals. By posing a comprehensive set of questions to a significant number of hospitals, we believe that we will be informed not only as to whether we should engage in such rulemaking, but also as to what the design of the proposed information collection should look like.

Originally, we had planned to pilot this information collection request in advance of rulemaking. Thus, we prepared a proposed information collection request in accordance with the Paperwork

Reduction Act. We announced and sought public comment on the information collection request in a 60-day Federal Register notice

(CMS-10236) that was published on May 18, 2007 (72 FR 28056). On

September 14, 2007, we published in the Federal Register a revised information collection request in which we increased the time estimate for completing the DFRR and increased the time for submission of the

DFRR from 45 days to 60 days (72 FR 52568). (For additional information, we refer the reader to 72 FR 28056 and 72 FR 52568.)

In this proposed rule, we are providing a discussion of the potential burden associated with completing the DFRR, including an analysis that provides estimates of the burden for small, medium, and large hospitals. To better understand the potential burden for completing the DFRR collection, we reviewed the bed size of Medicare- participating hospitals and developed three categories of hospitals

(small, medium, and large hospitals). We randomly selected 20 hospitals from each category and requested that these 60 hospitals estimate the aggregate number of hours it would take them to complete and submit the entire DFRR collection. The 33 hospitals that responded included 11 small, 11 medium, and 11 large hospitals. We reviewed the responses from the 33 hospitals and determined that the average number of hours to complete the DFRR was 31 hours. This figure represents a significant increase from our most recent time and burden estimate. Therefore, we believe it would be beneficial to seek further comments on the accuracy of the time and burden estimates associated with this information collection instrument. Because the information that we seek is that which hospitals should already be keeping in the normal course of their business activities (even apart from the need to document compliance with the physician self-referral law), we anticipate that the majority of the time spent completing the DFRR will be spent by administrative staff. We believe that the tasks involved would include retrieving the information and printing it from electronic files or copy it from hard files, which largely should involve administrative personnel. In addition, the review and organization of the materials would also impose burden on the respondent. Nevertheless, in order to err on the side of more potential burden rather than less, we have calculated costs using an hourly rate for accountants.

D. Civil Monetary Penalties

We are proposing that the DFRR be completed, certified by the appropriate officer of the hospital, and received by CMS within 60 days of the date that appears on the cover letter or e-mail transmission of the DFRR. We are soliciting comment on the proposed 60-day timeframe for completing the DFRR.

Section 411.361(f) provides that failure to timely submit the requested information concerning an entity's ownership, investment, and compensation arrangements may result in civil monetary penalties of up to $10,000 for each day beyond the deadline established for disclosure.

Although we have the authority to impose civil monetary penalties, we seek not to invoke this authority and will work with entities to comply with the reporting requirements. Prior to imposing a civil monetary penalty in any amount, we would issue a letter to any hospital that does not return the completed DFRR, inquiring as to why the hospital did not return timely the completed DFRR. In addition, a hospital may, upon a demonstration of good cause, receive an extension of time to submit the requested information.

E. Uses of Information Captured by the DFRR

As noted above, we anticipate that the DFRR will be useful in determining whether the financial relationships between 500 hospitals and the physicians associated with those hospitals are in compliance with the physician self-referral statute and regulations. In addition, the results of the DFRR may assist us in other rulemaking efforts.

In the CY 2008 PFS proposed rule, we proposed certain changes to our physician self-referral rules (72 FR 38179 through 38187). With the exception of the anti-markup provisions, however, we have not yet finalized any of the proposals. We are actively working on the proposals, and although we expect to finalize the proposals before receiving and

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analyzing the completed DFRRs, information gleaned from the completed

DFRRs may shape our final rulemaking if that rulemaking is delayed. Our analysis of the DFRRs may affect subsequent proposals on these and other related issues.

F. Solicitation of Comments

We are soliciting comments on the DFRR information collection instrument through this proposed rule as follows:

Whether the collection effort should be recurring, and, if so, whether it should be implemented on an annual or some other periodic basis.

Whether we are collecting too much or not enough information, and whether we are collecting the correct (or incorrect) type of information.

The amount of time it will take hospitals to complete the

DFRR and the costs associated with completing the DFRR; the amount of time we should give hospitals to complete and return their responses to us.

Whether we should direct the collection instrument to all hospitals, and, if so, whether we should stagger the collection so that only a certain number of hospitals are subject to it in any given year.

Whether hospitals, once having completed the DFRR, should have to send in yearly updates and report only changed information.

X. MedPAC Recommendations

We are required by section 1886(e)(4)(B) of the Act to respond to

MedPAC's recommendations regarding hospital inpatient payments in our annual proposed and final IPPS rules. We have reviewed MedPAC's March 2008 ``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 2009 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 ``The Congress should reduce the indirect medical education adjustment in 2009 by 1 percentage point to 4.5 percent per 10 percent increment in the resident-to-bed ratio. The funds obtained by reducing the indirect medical education adjustment should be used to fund a quality incentive payment program.''

Response: Redirecting funds obtained by reducing the IME adjustment to fund a quality incentive payment program is consistent with the VBP initiatives to improve the quality of care and, therefore, merits consideration. However, section 502(a) of Pub. L. 108-173 modified the formula multiplier (c) to be used in the calculation of the IME adjustment beginning midway through FY 2004 and provided for a new schedule of formula multipliers for FYs 2005 and thereafter.

Consequently, CMS could not implement MedPAC's recommendation to reduce the IME adjustment in 2009 without a statutory change. We note that included in the President's FY 2009 budget proposal was a proposal to reduce the IME adjustment from 5.5 percent to 2.2 percent over 3 years, starting in FY 2009, in order to better align IME payments with the estimated costs per case that teaching hospitals may face.

In its June 2007 ``Report to Congress: Promoting Greater Efficiency in Medicare,'' MedPAC made recommendations concerning the Medicare hospital wage index. Section 106(b)(1) of the MIEA-TRHCA (Pub. L. 109- 432) required MedPAC to submit to Congress, not later than June 30, 2007, a report on the Medicare hospital wage index classification system applied under the Medicare IPPS, including any alternatives that

MedPAC recommended to the method to compute the wage index under section 1886(d)(3)(E) of the Act. In addition, section 106(b)(2) of the

MIEA-TRHCA instructed the Secretary taking into account MedPAC's recommendations on the Medicare hospital wage index classification system, to include in this 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 MedPAC recommendations and our proposals concerning the Medicare hospital wage index are discussed in section III.B. of the preamble of this proposed rule.

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 Web site at: http://www.medpac.gov.

XI. 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 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

This file contains the hospital hours and salaries for FY 2005 used to create the proposed FY 2009 prospective payment system wage index.

The file is currently available for the NPRM and will be available by the beginning of May for the final rule.

Wage data

PPS fiscal

Processing year

year

year

2008..........................................

2005

2009 2007..........................................

2004

2008 2006..........................................

2003

2007 2005..........................................

2002

2006 2004..........................................

2001

2005 2003..........................................

2000

2004 2002..........................................

1999

2003 2001..........................................

1998

2002 2000..........................................

1997

2001 1999..........................................

1996

2000 1998..........................................

1995

1999 1997..........................................

1994

1998 1996..........................................

1993

1997 1995..........................................

1992

1996 1994..........................................

1991

1995 1993..........................................

1990

1994 1992..........................................

1989

1993 1991..........................................

1988

1992

These files support the following:

Notice of proposed rulemaking published in the Federal

Register.

Final rule published in the Federal Register.

Media: Diskette/most recent year on the Internet.

File Cost: $165.00 per year.

Periods Available: FY 2009 PPS Update. 2. CMS Hospital Wages Indices (Formerly: Urban and Rural Wage Index

Values Only)

This file contains a history of all wage indices since October 1, 1983.

Media: Diskette/most recent year on the Internet.

File Cost: $165.00 per year.

Periods Available: FY 2009 PPS Update.

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3. FY 2009 Proposed Rule Occupational Mix Adjusted and Unadjusted AHW by Provider

This file includes each hospital's adjusted and unadjusted average hourly wage.

Media: Internet.

Periods Available: FY 2009 PPS Update. 4. FY 2009 Proposed Rule Occupational Mix Adjusted and Unadjusted AHW and Pre-Reclassified Wage Index by CBSA

This file includes each CBSA's adjusted and unadjusted average hourly wage.

Media: Internet.

Periods Available: FY 2009 PPS Update. 5. Provider Occupational Mix Adjustment Factors for Each Occupational

Category

This file contains each hospital's occupational mix adjustment factors by occupational category.

Media: Internet.

Periods Available: FY 2009 PPS Update. 6. PPS SSA/FIPS MSA State and County Crosswalk

This file contains a crosswalk of State and county codes used by the Social Security Administration (SSA) and the Federal Information

Processing Standards (FIPS), county name, and a historical list of

Metropolitan Statistical Areas (MSAs).

Media: Diskette/Internet.

File Cost: $165.00 per year.

Periods Available: FY 2009 PPS Update. 7. Reclassified Hospitals New Wage Index (Formerly: Reclassified

Hospitals by Provider Only)

This file contains a list of hospitals that were reclassified for the purpose of assigning a new wage index. Two versions of these files are created each year. They support the following:

Notice of proposed rulemaking published in the Federal

Register.

Final rule published in the Federal Register.

Media: Diskette/Internet.

File Cost: $165.00 per year.

Periods Available: FY 2009 PPS Update. 8. 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: Tape/Cartridge.

File Cost: $770.00 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, PPS-XXII, and PPS-XXIII 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, PPS-XXII, and PPS-XXIII Hospital Data Set

Files (refer to item 10 below).) 9. PPS-IX to PPS-XII Capital Data Set

The Capital Data Set contains selected data for capital-related costs, interest expense and related information and complete balance sheet data from the Medicare hospital cost report. The data set includes only the most current cost report (as submitted, final settled or reopened) submitted for a Medicare certified hospital by the

Medicare fiscal intermediary to 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: Tape/Cartridge.

File Cost: $770.00 per year.

Periods beginning and before on or after

PPS-IX........................................

10/01/91

10/01/92

PPS-X.........................................

10/01/92

10/01/93

PPS-XI........................................

10/01/93

10/01/94

PPS-XII.......................................

10/01/94

10/01/95

(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII,

PPS-XIX PPS-XX, PPS-XXI, PPS-XXII, and PPS-XXIII Capital Data Sets are part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII,

PPS-XIX, PPS-XX, PPS-XXI, PPS-XXII, and PPS-XXIII Hospital Data Set

Files (refer to item 10 below).) 10. PPS-XIII to PPS-XXIII 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 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: Diskette/Internet.

File Cost: $2,500.00.

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

PPS-XXIII.....................................

10/01/05

10/01/06

11. Provider-Specific File

This file is a component of the PRICER program used in the fiscal intermediary's or the MAC's system to compute DRG payments for individual bills. The file contains records for all prospective payment system eligible hospitals, including hospitals in waiver States, and data elements used in the prospective payment system recalibration processes and related activities. Beginning with December 1988, the individual records were enlarged to include pass-through per diems and other elements.

Media: Diskette/Internet.

File Cost: $265.00.

Periods Available: FY 2009 PPS Update. 12. CMS Medicare Case-Mix Index File

This file contains the Medicare case-mix index by provider number as published in each year's update of the Medicare hospital inpatient prospective payment system. The case-mix index is a measure of the costliness of cases treated by a hospital relative to the cost of the national average of all Medicare hospital cases, using DRG weights as a measure of relative costliness of cases. Two versions of this file are created each year. They support the following:

Notice of proposed rulemaking published in the Federal

Register.

Final rule published in the Federal Register.

Media: Diskette/most recent year on Internet.

Price: $165.00 per year/per file.

Periods Available: FY 1985 through FY 2009.

Page 23700

13. MS-DRG Relative Weights (Formerly Table 5 DRG)

This file contains a listing of MS-DRGs, MS-DRG narrative descriptions, relative weights, and geometric and arithmetic mean lengths of stay as published in the Federal Register. The hard copy image has been copied to diskette. There are two versions of this file as published in the Federal Register:

Notice of proposed rulemaking.

Final rule.

Media: Diskette/Internet.

File Cost: $165.00.

Periods Available: FY 2009 PPS Update. 14. PPS Payment Impact File

This file contains data used to estimate payments under Medicare's hospital inpatient prospective payment systems for operating and capital-related costs. The data are taken from various sources, including the Provider-Specific File, Minimum Data Sets, and prior impact files. The data set is abstracted from an internal file used for the impact analysis of the changes to the prospective payment systems published in the Federal Register. This file is available for release 1 month after the proposed and final rules are published in the Federal

Register.

Media: Diskette/Internet.

File Cost: $165.00.

Periods Available: FY 2009 PPS Update. 15. AOR/BOR Tables

This file contains data used to develop the MS-DRG relative weights. It contains mean, maximum, minimum, standard deviation, and coefficient of variation statistics by MS-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:

Notice of proposed rulemaking published in the Federal

Register.

Final rule published in the Federal Register.

Media: Diskette/Internet.

File Cost: $165.00.

Periods Available: FY 2009 PPS Update. 16. 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:

Notice of proposed rulemaking published in the Federal

Register.

Final rule published in the Federal Register.

Media: Internet.

File Cost: No charge.

Periods Available: FY 2009 PPS Update.

For further information concerning these data tapes, contact the

CMS Public Use Files Hotline at (410) 786-3691.

Commenters interested in discussing any data used in constructing this proposed rule should contact Nisha Bhat at (410) 786-5320.

B. Collection of Information Requirements 1. Legislative Requirement for Solicitation of Comments

Under the Paperwork Reduction Act of 1995, 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 Paperwork Reduction Act of 1995 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. 2. Solicitation of Comments on Proposed Requirements in Regulatory Text

We are soliciting public comment on each of the issues listed under section XI.B.1. of this preamble for the following sections of this document that contain information collection requirements (ICRs): a. ICRs Regarding Physician Reporting Requirements (Sec. 411.361)

Section 411.361(a) of the regulations states that except for entities that furnish 20 or fewer Part A and Part B services during a calendar year or for Medicare covered services furnished outside the

United States, all entities furnishing services for which payment may be made under Medicare must submit information to CMS or to the Office of the Inspector General (OIG) concerning their reportable financial relationships (any ownership or investment interest, or compensation arrangement) in the form, manner, and at times that CMS or OIG specifies. As described in section IX. of the preamble of this proposed rule, and in accordance with its authority under 42 CFR 411.361(e), CMS is requiring that hospitals provide information concerning their ownership, investment and compensation arrangements with physicians by completing the DFRR instrument.

An information collection request concerning the DFRR was previously submitted to OMB for approval. We announced and sought public comment on the information collection request in both 60-day and 30-day Federal Register notices that published on May 18, 2007 (72 FR 28056), and September 14, 2007 (72 FR 52568), respectively. As further discussed in section IX. of this preamble, we have decided to obtain additional input from the public concerning the time and cost burden associated with completing and submitting the DFRR instrument. (The instrument is included as Appendix C to this proposed rule.) We believe that hospital accounting personnel would be responsible for: (1)

Ensuring that the appropriate data or supporting documentation is retrieved; (2) completing the DFRR; and (3) submitting the DFRR to the

Chief Executive Officer, Chief Financial Officer, or comparable officer of the hospital for his or her signature on the certification statement.

Initially, CMS would require 500 hospitals to complete and submit the DFRR instrument. We estimate that these tasks would require 31 hours for each of the 500 hospitals to complete the DFRR. Thus, the total number of burden hours required for 500 hospitals to complete the

DFRR instrument is 15,500 hours. b. ICRs Regarding Risk Adjustment Data (Sec. 422.310)

As discussed in section IV.H. of the preamble of this proposed rule, Sec. 422.310(b) states that each MA organization must submit to

CMS (in accordance with CMS instructions) the data necessary to characterize the context and purposes of each item and service provided to a Medicare enrollee by a provider, supplier, physician, or other practitioner. In addition, Sec. 422.310(b) states that CMS may collect data necessary to characterize the functional limitations of enrollees of

Page 23701

each MA organization. Section 422.310(c) lists the nature of the data elements to be submitted to CMS.

The burden associated with these requirements is the time and effort necessary for the MA organization to submit the necessary data to CMS. These requirements are subject to the PRA and the associated burden is currently approved under OMB control number 0938-0878.

However, under notice and comment periods separate from this proposed rule, we intend to revise the currently approved information collection to include burden estimates as they pertain to Sec. 422.310. The preliminary burden estimate for this proposed rule is as follows:

Currently, there are 676 MA organizations. Assuming that 99 percent of encounter data claims are submitted electronically and 1 percent are submitted manually, we estimate that it will take 1,089 hours annually for submission of electronic claims and 73,335 hours annually for submission of manual claims. The estimated annual burden associated with these requirements is an annual average of 110 hours per MA organization. c. ICRs Regarding Basic Commitments of Providers (Sec. 489.20)

As discussed in section IV.I. of the preamble of this proposed rule, proposed Sec. 489.20(r)(2) states that a hospital, as defined in

Sec. 489.24(b), must maintain an on-call list of physicians on its medical staff to provide treatment necessary to stabilize patients who are receiving services required under Sec. 489.24 in accordance with the resources available to the hospital. The burden associated with this requirement is the time and effort necessary to draft, maintain, and periodically update the list of on-call physicians. We estimate that it will take 3 hours for each of the 100 Medicare-participating hospitals to comply with this recordkeeping requirement. The estimated annual burden associated with this requirement is 300 hours.

As discussed in section VII. of the preamble of this proposed rule, proposed Sec. 489.20(u)(1) states that, in the case of a physician- owned hospital as defined in Sec. 489.3, the hospital must furnish written notice to all patients at the beginning of their hospital stay or outpatient visit that the hospital is a physician-owned facility. In addition, patients must be advised that a list of the hospital's owners or investors who are physicians (or immediate family members of physicians) is available upon request. Upon receiving the request of the patient or an individual on behalf of the patient, a hospital must immediately disseminate the list to the requesting patient.

The burden associated with the requirements in this section is the time and effort necessary for a hospital to furnish written notice to all patients that the hospital is a physician-owned hospital. Whereas this requirement is subject to the PRA, the associated burden is currently approved under OMB control number 0938-1034, with an expiration date of February 28, 2011.

In addition, there is burden associated with furnishing a patient with the list of the hospital's owners or investors who are physicians

(or immediate family members of physicians) at the time of the patient request. However, CMS has no way to accurately quantify the burden because we cannot estimate the number of this type of request that a hospital may receive. We are soliciting public comments on the annual number of requests a hospital may receive for lists of physician-owners and investors, and will reevaluate this issue in the final rule stage of rulemaking.

Proposed Sec. 489.20(u)(2) would require disclosure of physician ownership as a condition of continued medical staff membership or admitting privileges. The burden associated with this requirement is the time and effort required for a hospital to develop, draft, and implement changes to its medical staff bylaws and other policies governing admitting privileges. Approximately 175 physician-owned hospitals would be required to comply with this requirement. We estimate that it will require a hospital's general counsel 4 hours to revise a hospital's medical staff bylaws and policies governing admitting privileges. Therefore, the total annual hospital burden would be 700 hours.

In addition, the proposed Sec. 489.20(u)(2) imposes a burden on physicians. As stated earlier, all physicians who are also members of the hospital's medical staff must agree, as a condition of continued medical staff membership or admitting privileges, to disclose, in writing, to all patients they refer to the hospital any ownership or investment interest in the hospital held by themselves or by an immediate family member. The disclosure must be made at the time the referral is made. The burden associated with this requirement is the time and effort necessary for a physician to draft a disclosure and to provide it to the patient at the time the referral is made to the physician-owned hospital. We estimate that it will take each physician, or designated office staff member, 1 hour to develop a disclosure notice and make copies that will be distributed to patients. In addition, we estimate 30 seconds to provide the disclosure to each patient and an additional 30 seconds to record the proof of disclosure into each patient's medical record.

Although we can estimate the number of physician-owned hospitals, we are unable to quantify the number of physicians that possess an ownership or investment interest in hospitals. There is limited data available concerning physician ownership in hospitals. The studies to date, including those by CMS and the Government Accountability Office, pertain to physician ownership in specialty hospitals (cardiac, orthopedic, and surgical hospitals). These specialty hospital studies published data concerning the average percentage of shares of direct ownership by physicians (less than 2 percent), indirect ownership through group practices, and the aggregate percentage of physician ownership, but did not publish the number of physician owners in these types of hospitals. More importantly, proposed Sec. 489.20(u)(2) would apply to physician ownership in any type of hospital. Our other research involved a review of enrollment data. However, the CMS enrollment application (CMS-855) requires the reporting of ownership interests that exceed 5 percent or greater, and, thus, most physician ownership is not captured. In summary, because we are unable to estimate the total physician burden associated with this reporting requirement, we are seeking public comment pertaining to this burden and will reevaluate this issue in the final rule stage of rulemaking.

Proposed Sec. 489.20(v) states that the aforementioned requirements in Sec. 489.20(u)(1) and (u)(2) do not apply to a physician-owned hospital that does not have at least one referring physician who has an ownership or investment interest in the hospital or who has an immediate family member who has an ownership or investment interest in the hospital. To comply with this exception, an eligible hospital must sign an attestation to that effect and maintain the document in its records. Therefore, the number of hospitals that are now subject to the disclosure requirement would be slightly reduced. However, there may be a minimal burden attributable to the proposed requirement that the hospital maintain an attestation statement in its records.

The burden associated with this requirement will be limited to those physician-owned hospitals that do not have at least one referring physician who has an ownership or investment interest in the hospital or who has an immediate family member who has an

Page 23702

ownership or investment interest in the hospital. The burden would include the time and effort for these hospitals to develop, sign, and maintain the attestations in their records. We estimate that 10 percent, or approximately 18, of the estimated 175 physician-owned hospitals would be subject to this requirement. We estimate that it would take each of these physician-owned hospitals an average of 1 hour to develop, sign, and maintain the attestation in its records. The estimated annual burden associated with this requirement is 18 hours.

However, because we have no way of knowing for certain the number of physician-owned hospitals that do not have at least one referring physician who has an ownership or investment interest in the hospital or who has an immediate family member who has an ownership or investment interest in the hospital, we are requesting public comment regarding the accuracy of our estimate and the associated burden with the attestation requirement.

Section 489.20(w) requires 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. Whereas this requirement is subject to the

PRA, the associated burden is approved under OMB control number 0938- 1034 with a current expiration date of February 28, 2011.

Estimated Annual Reporting and Recordkeeping Burden

Burden per

Regulation section(s)

OMB control No.

Respondents

Responses

response

Total annual

(hours)

burden (hours)

Sec. 411.361................. 0938-New........

500

500

31

15,500

Sec. 422.310(b).............. 0938-0878.......

676

676

110

* 74,424

Sec. 489.20(r)............... 0938-New........

100

100

3

300

Sec. 489.20(u)(1) and (w).... 0938-1034.......

2,679

49,735,635

**

839,599

Sec. 489.20(u)(2)............ 0938-New........

175

175

4

700

Sec. 489.20(v)............... 0938-New........

18

18

1

18

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

930,541

* Burden estimate is based on proposed revisions to the currently approved OMB control number.

** There are multiple requirements associated with the regulation section approved under this OMB control number. There is no uniform estimate of the burden per response. 3. Associated Information Collections Not Specified in Regulatory Text

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 OMB approval. a. Present on Admission (POA) Indicator Reporting

Section II.F.8 of the preamble of this proposed rule discusses the present on admission indicator (POA) reporting requirements. As stated earlier, POA indicator information is necessary to identify which conditions were acquired during hospitalization for the hospital- acquired condition (HAC) payment provision and for broader public health uses of Medicare data. Through Change Request No. 5499 (released

May 11, 2007), CMS issued instructions requiring IPPS hospitals to submit the POA indicator data for all diagnosis codes on Medicare claims.

The burden associated with this requirement is the time and effort necessary to place the appropriate POA codes on Medicare claims. While the requirement is subject to the PRA; the associated burden is approved under 0938-0997 with an expiration date of August 31, 2009. b. Proposed Add-On Payments for New Services and Technologies

Section II.J. 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 2010 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 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 an individual case-by-case basis. c. Reporting of Hospital Quality Data for Annual Hospital Payment

Update

As noted in section IV.B. of the preamble of this proposed rule, the RHQDAPU program was originally established to implement section 501(b) of Pub. L. 108-173, thereby expanding our voluntary Hospital

Quality Initiative. The RHQDAPU program originally consisted of a

``starter set'' of 10 quality measures. OMB approved the collection of data associated with the original starter set of quality measures under

OMB control number 0938-0918, with a current expiration date of January 31, 2010.

We added additional quality measures to the RHQDAPU program and submitted the information collection request to OMB for approval. This expansion of the RHQDAPU measures was part of our implementation of section 5001(a) of the DRA. Section 1886(b)(3)(B)(viii)(III) of the

Act, added

Page 23703

by section 5001(a) of the DRA, requires that the Secretary expand the

``starter set'' of 10 quality measures that were established by the

Secretary as of November 1, 2003, to include measures ``that the

Secretary determines to be appropriate for the measurement of the quality of care furnished by hospitals in inpatient settings.'' The burden associated with these reporting requirements is currently approved under OMB control number 0938-1022 with a current expiration date of December 31, 2008.

However, for FY 2009, we submitted to OMB for approval a revised information collection request using the same OMB control number (0938- 1022). In the revised request, we proposed to add three new RHQDAPU quality measures that we adopted for the FY 2009 RHADAPU program to the

PRA process. These three measures are as follows:

Pneumonia 30-day Mortality (Medicare patients);

SCIP Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose; and

SCIP Infection 6: Surgery Patients with Appropriate Hair

Removal.

The revised information collection request was announced in the

Federal Register via an emergency notice on January 28, 2008 (73 FR 4868). The information collection request is currently under review by

OMB. Once approved, we will submit another revision of the information collection request to obtain approval for the new measures contained in this proposed rule.

Section IV.B.5. of the preamble of this proposed rule also discusses the requirements for the continuous collection of HCAHPS quality data. The HCAHPS 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. We also added the HCAHPS survey to the PRA process in the information collection request currently approved under OMB control number 0938-1022 with a current expiration date of December 31, 2008.

Section IV.B.9. 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. d. Occupational Mix Adjustment to the FY 2009 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.D. addresses the proposed occupational mix adjustment to the proposed FY 2009 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.

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 February 28, 2011. 4. Addresses for Submittal of Comments on Information Collection

Requirements

If you comment on these information collection and recordkeeping requirements, please do either of the following: 1. Submit your comments electronically as specified in the

ADDRESSES section of this proposed rule; or 2. Mail copies to the address specified in the ADDRESSES section of this proposed rule and to-- Office of Information and Regulatory

Affairs, Office of Management and Budget, Room 10235, New Executive

Office Building, Washington, DC 20503, Attn: Carolyn L. Raffaelli, CMS

Desk Officer, CMS-1390-P; E-mail: Carolyn_L._Raffaelli@omb.eop.gov.

Fax (202) 395-6974.

C. Response to Comments

Because of the large number of public 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 422

Administrative practice and procedure, Grant programs--health,

Health care, Health insurance, Health maintenance organizations (HMO),

Loan programs--health, Medicare, 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-1 through 1860D-42, 1871, and 1877 of the Social Security Act (42 U.S.C. 1302, 1395w-101 through 1395w- 152, 1395hh, and 1395nn). 2. Section 411.351 is amended by-- a. Revising the definition of ``physician''. b. Revising the definition of ``physician organization''.

The revisions read as follows:

Sec. 411.351 Definitions.

* * * * *

Physician means a doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor, as defined in section 1861(r) of the Act. A physician and the

Page 23704

professional corporation of which he or she is a sole owner are the same for purposes of this subpart.

* * * * *

Physician organization means a physician, a physician practice, or a group practice that complies with the requirements of Sec. 411.352.

* * * * * 3. Section 411.353 is amended by revising paragraph (c) to read as follows:

Sec. 411.353 Prohibition on certain referrals by physicians and limitations on billing.

* * * * *

(c) Denial of payment. Except as provided in paragraph (e) of this section, no Medicare payment may be made for a designated health service that is furnished pursuant to a prohibited referral. The period during which referrals are prohibited is the period of disallowance.

For purposes of this section, with respect to the following types of noncompliance, the period of disallowance begins at the time the financial relationship fails to satisfy the requirements of an applicable exception and ends no later than--

(1) Where the noncompliance is unrelated to compensation, the date that the financial relationship satisfies all of the requirements of an applicable exception;

(2) Where the noncompliance is due to the payment of excess compensation, the date on which the excess compensation is returned to the party that paid it and the financial relationship satisfies all of the requirements of an applicable exception; or

(3) Where the noncompliance is due to the payment of compensation that is of an amount insufficient to satisfy the requirements of an applicable exception, the date on which the additional required compensation is paid to the party to which it is owed such that the financial relationship would satisfy all of the requirements of the exception as of its date of inception.

* * * * * 4. Section 411.354 is amended by-- a. Adding a new paragraph (a)(1)(iii). b. Revising paragraph (c)(2)(iv). c. Revising paragraph (c)(3)(ii).

The addition and revisions read as follows:

Sec. 411.354 Financial relationship, compensation, and ownership or investment interest.

(a) * * *

(1) * * *

(iii) For purposes of paragraph (c) of this section, an entity that furnishes DHS is deemed to stand in the shoes of an organization in which it has a 100 percent ownership interest.

* * * * *

(c) * * *

(2) * * *

(iv) For purposes of paragraph (c)(2)(i) of this section, a physician is deemed to ``stand in the shoes'' of his or her physician organization unless the total compensation from the physician organization to the physician satisfies the requirements of Sec. 411.357(c), (d), or (l).

(3) * * *

(ii) The provisions of paragraphs (c)(1)(ii) and (c)(2)(iv) of this section--

(A) Need not apply during the original term or current renewal term of an arrangement that satisfied the requirements of Sec. 411.357(p) as of September 5, 2007 (42 CFR parts 400-413, revised as of October 1, 2007);

(B) Do not apply to an arrangement that satisfies the requirements of Sec. 411.355(e); and

(C) Do not apply with respect to an arrangement between a physician organization and a component of an academic medical center listed in

Sec. 411.355(e)(2) for the provision to that academic medical center of only services required to satisfy the academic medical center's obligations under the Medicare graduate medical education (GME) rules in part 413, subpart F of this chapter.

* * * * *

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL

SERVICES 5. The authority citation for part 412 continues to read as follows:

Authority: Secs. 1102 and 1871 of the Social Security Act (42

U.S.C. 1302 and 1395hh), and sec. 124 of Pub. L. 106-113 (113 Stat. 1501A-332). 6. Section 412.4 is amended by revising paragraph (c)(3) to read as follows:

Sec. 412.4 Discharges and transfers.

* * * * *

(c) * * *

(3) To home under a written plan of care for the provision of home health services from a home health agency and those services begin--

(i) Effective for fiscal years prior to FY 2009, within 3 days after the date of discharge; and

(ii) Effective FY 2009, within 7 days after the date of discharge.

* * * * * 7. Section 412.22 is amended by-- a. In the introductory text of paragraph (e), removing the phrase

``paragraph (f) of this section'' and adding in its place ``paragraphs

(e)(1) (vi) and (f) of this section''. b. Adding a new paragraph (e)(1)(vi).

The addition reads as follows:

Sec. 412.22 Excluded hospitals and hospital units: General rules.

* * * * *

(e) * * *

(1) * * *

(vi) Effective October 1, 2008, if a State hospital that is occupying space in the same building or on the same campus as another

State hospital cannot meet the criterion under paragraph (e)(1)(i) of this section solely because its governing body is under the control of the State hospital with which it shares a building or a campus, or is under the control of a third entity that also controls the State hospital with which it shares a building or a campus, the State hospital can nevertheless qualify for an exclusion if it meets the other applicable criteria in this section and--

(A) Both State hospitals occupy space in the same building or on the same campus and have been continuously owned and operated by the

State since October 1, 1995;

(B) Is required by State law to be subject to the governing authority of the State hospital with which it shares space or the governing authority of a third entity that controls both hospitals; and

(C) Was excluded from the inpatient prospective payment system before October 1, 1995, and continues to be excluded from the inpatient prospective payment system through September 30, 2008.

* * * * * 8. Section 412.64 is amended by-- a. Republishing the introductory text of paragraph (b)(1)(ii) and revising paragraph (b)(1)(ii)(A). b. In the introductory text of paragraph (h)(4), removing the date

``September 30, 2008'' and adding in its place ``September 30, 2011''.

The revision reads as follows:

Sec. 412.64 Federal rates for inpatient operating costs for Federal fiscal year 2005 and subsequent fiscal years.

* * * * *

(b) * * *

(1) * * *

(ii) The term urban area means--

(A) A Metropolitan Statistical Area or a Metropolitan division (in the case where a Metropolitan Statistical Area is divided into

Metropolitan Divisions), as defined by the Executive Office of

Management and Budget; or

* * * * * 9. Section 412.87 is amended by--

Page 23705

a. Revising paragraph (b)(1). b. Adding a new paragraph (c).

The revision and addition read as follows:

Sec. 412.87 Additional payment for new medical services and technologies: General provisions.

* * * * *

(b) * * *

(1) A new medical service or technology represents an advance that substantially improves, relating to technologies previously available, the diagnosis or treatment of Medicare beneficiaries.

* * * * *

(c) Announcement of determinations and deadline for consideration of new medical service or technology applications. CMS will consider whether a new medical service or technology meets the eligibility criteria specified in paragraph (b) of this section and announce the results in the Federal Register as part of its annual updates and changes to the IPPS. CMS will only consider, for add-on payments for a particular fiscal year, an application for which the new medical service or technology has received FDA approval or clearance by July 1 prior to the particular fiscal year. 10. Section 412.230 is amended by-- a. Revising paragraph (d)(1)(iv)(C). b. Adding a new paragraph (d)(1)(iv)(D).

The addition and revision read as follows:

Sec. 412.230 Criteria for an individual hospital seeking redesignation to another rural area or an urban area.

* * * * *

(d) * * *

(1) * * *

(iv) * * *

(C) With respect to redesignations for fiscal years 2002 through 2009, the hospital's average hourly wage is equal to, in the case of a hospital located in a rural area, at least 82 percent, and in the case of a hospital located in an urban area, at least 84 percent of the average hourly wage of hospitals in the area to which it seeks redesignation.

(D) With respect to redesignations for fiscal year 2010 and later fiscal years, the hospital's average hourly wage is equal to, in the case of a hospital located in a rural area, at least 86 percent, and in the case of a hospital located in an urban area, at least 88 percent of the average hourly wage of hospitals in the area to which it seeks redesignation.

* * * * * 11. Section 412.232 is amended by revising paragraphs (c)(1) and

(c)(2) to read as follows:

Sec. 412.232 Criteria for all hospitals in a rural county seeking urban redesignation.

* * * * *

(c) * * *

(1) Aggregate hourly wage for fiscal years before fiscal year 2010--(i) Aggregate hourly wage. With respect to redesignations effective beginning fiscal year 1999 and before fiscal year 2010, the aggregate average hourly wage for all hospitals in the rural county must be equal to at least 85 percent of the average hourly wage in the adjacent urban area.

(ii) Aggregate hourly wage weighted for occupational mix. For redesignations effective before fiscal year 1999, the aggregate hourly wage for all hospitals in the rural county, weighed for occupational categories, is at least 90 percent of the average hourly wage in the adjacent urban area.

(2) Aggregate hourly wage for fiscal year 2010 and later fiscal years. With respect to redesignations effective for fiscal year 2010 and later fiscal years, the aggregate average hourly wage for all hospitals in the rural county must be equal to at least 88 percent of the average hourly wage in the adjacent urban area.

* * * * * 12. Section 412.234 is amended by revising paragraphs (b)(1) and

(b)(2) to read as follows:

Sec. 412.234 Criteria for all hospitals in an urban county seeking redesignation to another urban area.

* * * * *

(b) * * *

(1) Aggregate hourly wage for fiscal years before fiscal year 2010--(i) Aggregate hourly wage. With respect to redesignations effective beginning fiscal year 1999 and before fiscal year 2010, the aggregate average hourly wage for all hospitals in the urban county must be at least 85 percent of the average hourly wage in the urban area to which the hospitals in the county seek reclassification.

(ii) Aggregate hourly wage weighted for occupational mix. For redesignations effective before fiscal year 1999, the aggregate hourly wage for all hospitals in the county, weighed for occupational categories, is at least 90 percent of the average hourly wage in the adjacent urban area.

(2) Aggregate hourly wage for fiscal year 2010 and later fiscal years. With respect to redesignations effective for fiscal year 2010 and later fiscal years, the aggregate average hourly wage for all hospitals in the urban county must be at least 88 percent of the average hourly wage in the urban area to which the hospitals in the county seek reclassification.

* * * * *

PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR

END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT

RATES FOR SKILLED NURSING FACILITIES 13. The authority citation for Part 413 continues 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).

Sec. 413.79 [Amended] 14. In Sec. 413.79(f)(6)(iv), remove the cross-reference ``Sec. 413.75(d)'' and add the cross-reference ``paragraph (d) of this section'' in its place.

PART 422--MEDICARE ADVANTAGE PROGRAM 15. The authority citation for Part 422 continues to read as follows:

Authority: Secs. 1102 and 1871 of the Social Security Act (42

U.S.C. 1302 and 1395hh). 16. Section 422.310 is revised to read as follows:

Sec. 422.310 Risk adjustment data.

(a) Definition of risk adjustment data. Risk adjustment data are all data that are used in the development and application of a risk adjustment payment model.

(b) Data collection: Basic rule. Each MA organization must submit to CMS (in accordance with CMS instructions) the data necessary to characterize the context and purposes of each item and service provided to a Medicare enrollee by a provider, supplier, physician, or other practitioner. CMS may also collect data necessary to characterize the functional limitations of enrollees of each MA organization.

(c) Sources and extent of data. (1) To the extent required by CMS, risk adjustment data must account for the following:

(i) Items and services covered under the original Medicare program.

(ii) Medicare-covered items and services for which Medicare is not the primary payer.

(iii) Other additional or supplemental benefits that the MA organization may provide.

(2) The data must account separately for each provider, supplier, physician,

Page 23706

or other practitioner that would be permitted to bill separately under the original Medicare program, even if they participate jointly in the same service.

(d) Other data requirements. (1) MA organizations must submit data that conform to CMS' requirements for data equivalent to Medicare fee- for-service data, when appropriate, and to all relevant national standards. CMS may specify abbreviated formats for data submission required of MA organizations.

(2) The data must be submitted electronically to the appropriate

CMS contractor.

(3) MA organizations must obtain the risk adjustment data required by CMS from the provider, supplier, physician, or other practitioner that furnished the item or service.

(4) MA organizations may include in their contracts with providers, suppliers, physicians, and other practitioners, provisions that require submission of complete and accurate risk adjustment data as required by

CMS. These provisions may include financial penalties for failure to submit complete data.

(e) Validation of risk adjustment data. MA organizations and their providers and practitioners will be required to submit a sample of medical records for the validation of risk adjustment data, as required by CMS. There may be penalties for submission of false data.

(f) Use of data. CMS uses the data obtained under this section to determine the risk adjustment factors used to adjust payments, as required under Sec. Sec. 422.304(a) and (c). CMS may also use the data for other purposes, including updating of risk adjustment models.

(g) Deadlines for submission of risk adjustment data. Risk adjustment factors for each payment year are based on risk adjustment data submitted for items and services furnished during the 12-month period before the payment year that is specified by CMS. As determined by CMS, this 12-month period may include a 6-month data lag that may be changed or eliminated as appropriate. CMS may adjust these deadlines, as appropriate.

(1) The annual deadline for risk adjustment data submission is the first Friday in September for risk adjustment data reflecting items and services furnished during the 12-month period ending the prior June 30, and the first Friday in March for data reflecting services furnished during the 12-month period ending the prior December 31.

(2) CMS allows a reconciliation process to account for late data submissions. CMS continues to accept risk adjustment data submitted after the March deadline until January 31 of the year following the payment year. After the payment year is completed, CMS recalculates the risk factors for affected individuals to determine if adjustments to payments are necessary. Risk adjustment data that are received after the annual January 31 late data submission deadline will not be accepted for the purposes of reconciliation.

PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL 17. The authority citation for part 489 continues to read as follows:

Authority: Secs. 1102, 1819, 1820(e), 1861, 1864(m), 1866, 1869, and 1871 of the Social Security Act (42 U.S.C. 1302, 1395i-3, 1395x, 1395aa(m), 1395cc, 1395ff, and 1395hh). 18. Section 489.3 is amended by revising the definition of

``physician-owned hospital'' 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 an immediate family member of a physician (as defined in Sec. 411.351 of this chapter), has 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. This definition does not include a hospital with physician ownership or investment interests that satisfy the requirements at Sec. 411.356(a) or (b) of this chapter.

* * * * * 19. Section 489.20 is amended by-- a. Revising paragraph (r)(2). b. Revising paragraph (u). c. Redesignating paragraphs (v) and (w) as paragraphs (w) and (x), respectively. d. Adding a new paragraph (v).

The revisions and addition read as follows:

Sec. 489.20 Basic commitments.

* * * * *

(r) * * *

(2) An on-call list of physicians on its medical staff available to provide treatment necessary after the initial examination to stabilize individuals with emergency medical conditions who are receiving services required under Sec. 489.24 in accordance with the resources available to the hospital; and

* * * * *

(u) Except as provided in paragraph (v) of this section, in the case of a physician-owned hospital as defined in Sec. 489.3--

(1) To furnish written notice to all patients at the beginning of their hospital stay or outpatient visit that the hospital is a physician-owned hospital, in order to assist the patients in making an informed decision regarding their care, in accordance with Sec. 482.13(b)(2) of this subchapter. 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 owners or investors who are physicians or immediate family members of physicians (as defined at Sec. 411.351 of this chapter) must be provided to the patients at the time the request for the list is made by or on behalf of the patient. For purposes of this paragraph (u)(1), 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 physicians who are members of the hospital's medical staff to agree, as a condition of continued medical staff membership or admitting privileges, to disclose, in writing, to all patients they refer to the hospital any ownership or investment interest in the hospital that is held by themselves or by an immediate family member (as defined in Sec. 411.351 of this chapter). Disclosure must be required at the time the referral is made.

(v) The requirements of paragraph (u) of this section do not apply to any physician-owned hospital that does not have at least one referring physician (as defined at Sec. 411.351 of this chapter) who has an ownership or investment interest in the hospital or who has an immediate family member who has an ownership or investment interest in the hospital, provided that such hospital signs an attestation statement to that effect and maintain such a notice in its records.

* * * * * 20. Section 489.24 is amended by-- a. Revising paragraph (a)(2). b. Revising paragraph (f). c. Revising paragraph (j).

The revisions 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

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alternate location pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan do not apply to a hospital with a dedicated emergency department located in an emergency area during an emergency period, as specified in section 1135(g)(1) of 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 135(e)(1)(B) of the Act.

* * * * *

(f) Recipient hospital responsibilities. A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive case units, or, with respect to rural areas, regional referral centers (which, for purposes of this subpart, mean hospitals meeting the requirements of referral centers found at Sec. 412.96 of this chapter)) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual.

This provision applies to--

(1) Any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department; and

(2) An individual who has been admitted under paragraph (d)(2)(i) of this section and who has not been stabilized.

* * * * *

(j) Availability of on-call physicians. In accordance with the on- call list requirements specified in Sec. 489.20(r)(2), a hospital must have written policies and procedures in place--

(1) To respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control; and

(2) To provide that emergency services are available to meet the needs of individuals with emergency medical conditions if a hospital elects to--

(i) Permit on-call physicians to schedule elective surgery during the time that they are on call;

(ii) Permit on-call physicians to have simultaneous on-call duties; and

(iii) Participate in a formal community call plan. Notwithstanding participation in a community call plan, hospitals are still required to perform medical screening examinations on individuals who present seeking treatment and to conduct appropriate transfers. The formal community plan must include the following elements:

(A) A clear delineation of on-call coverage responsibilities; that is, when each hospital participating in the plan is responsible for on- call coverage.

(B) A description of the specific geographic area to which the plan applies.

(C) A signature by an appropriate representative of each hospital participating in the plan.

(D) Assurances that any local and regional EMS system protocol formally includes information on community on-call arrangements.

(E) Evidence of engagement of the hospitals participating in the community call plan in an analysis of the specialty on-call needs of the community for which the plan is effective.

(F) A statement specifying that even if an individual arrives at a hospital that is not designated as the on-call hospital, that hospital still has an obligation under Sec. 489.24 to provide a medical screening examination and stabilizing treatment within its capability, and that hospitals participating in the community call plan must abide by the regulations under Sec. 489.24 governing appropriate transfers.

(G) An annual assessment of the community call plan by the participating hospitals. 21. Section 489.53 is amended by revising paragraph (c) to 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) or (w).

* * * * *

(Catalog of Federal Domestic Assistance Program No. 93.773,

Medicare--Hospital Insurance; and Program No. 93.774, Medicare--

Supplementary Medical Insurance Program)

Dated: April 1, 2008.

Kerry Weems,

Acting Administrator, Centers for Medicare & Medicaid Services.

Dated: April 10, 2008.

Michael O. Leavitt,

Secretary.

Editorial Note: The following Addendum and appendixes 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, 2008

I. Summary and Background

In this Addendum, we are setting forth the methods and data we used 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 was higher.

(MDHs did not have the option to use their FY 1996 hospital-specific rate.) However, section 5003(a)(1) of Pub. L. 109-171 extended and modified the MDH special payment provision that was previously set to expire on October 1, 2006, to include 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 an MDH's target amount, an MDH must rebase its hospital-specific rates to its FY 2002 cost report. Section 5003(c) of Pub. L. 109-171 further required that MDHs be 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 on the provisions of section 5003(d) of Pub. L. 109-171, MDHs are no longer subject to the 12- percent cap on their DSH payment adjustment factor.

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For hospitals located in Puerto Rico, the payment per discharge is based on the sum of 25 percent of an updated Puerto Rico-specific rate based on average costs per case of Puerto Rico hospitals for the base year and 75 percent of the Federal national rate. (We refer readers to 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 2009. In section III. of this Addendum, we discuss our proposed policy changes for determining the prospective payment rates for Medicare inpatient capital-related costs for FY 2009. 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 2009. The tables to which we refer in the preamble of this proposed rule are presented in section V. of this Addendum of this proposed rule.

II. Proposed Changes to Prospective Payment Rates for Hospital

Inpatient Operating Costs for FY 2009

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, and 1C, 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 3.0 percent for all areas (that is, the estimated full market basket percentage increase of 3.0 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.

A proposed update of 3.0 percent to the Puerto Rico- specific standardized amount (that is, the full estimated rate-of- increase in the hospital market basket for IPPS hospitals), as provided for under Sec. 412.211(c), which states that we update the

Puerto Rico-specific standardized amount using the percentage increase specified in Sec. 412.64(d)(1), or the percentage increase in the market basket index for prospective payment hospitals for all areas.

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 2008 budget neutrality factor and applying a revised factor.

An adjustment to remove the FY 2008 outlier offset and apply an offset for FY 2009.

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, as discussed below and in section II.D. of the preamble to this proposed rule.

We note that, beginning in FY 2008, we applied the budget neutrality adjustment for the rural floor to the hospital wage indices rather than the standardized amount. For FY 2009, we are proposing to continue to apply the rural floor budget neutrality adjustment to hospital wage indices rather than the standardized amount. In addition, instead of applying the budget neutrality adjustment for the imputed rural floor adopted under section 1886(d)(3)(E) of the Act to the standardized amounts, beginning with

FY 2009, we are proposing to apply the imputed rural floor budget neutrality adjustment to the wage indices. Beginning in FY 2009, we are also proposing to apply the budget neutrality adjustments for the rural floor and imputed rural floor at the State level rather than the national level. For a complete discussion of the budget neutrality proposals concerning the rural floor and the imputed rural floor, including the proposal for a within-State budget neutrality adjustment, we refer readers to section III.B.2.b. of the preamble to this proposed rule.

A. Calculation of the 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 for urban and rural hospitals 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 to be 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 2009, we are not proposing to change the national and

Puerto Rico-specific labor-related and nonlabor-related shares from the percentages established for FY 2008. Therefore, the labor- related share continues 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 are applying 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 are applying the wage index to a labor-related share of 69.7 percent of the national standardized amount. For hospitals located in Puerto Rico, we are applying a labor-related share of 58.7 percent if its Puerto Rico- specific wage index is less than or equal to 1.0000. For hospitals located in Puerto Rico whose Puerto Rico-specific wage index values are greater than 1.0000, we are applying 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)(II) of the Act requires that, beginning with FY-2004 and thereafter, an equal standardized amount 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)(ii)(II) of the Act equalizes the

Puerto Rico-specific urban and rural area rates. Accordingly, we are calculating FY 2009 national and Puerto Rico

Page 23709

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 2009 is 3.0 percent. Thus, for FY 2009, the proposed update to the average standardized amount is 3.0 percent for hospitals in all areas. The estimated market basket increase of 3.0 percent is based on the 2008 first quarter forecast of the hospital market basket increase (as discussed in Appendix B of this proposed rule).

Section 1886(b)(3)(B) of the Act specifies the mechanism to be 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 from 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 V. of the Addendum to this proposed rule reflect these differential amounts.

Section 412.211(c) states that we update the Puerto Rico- specific standardized amount using the percentage increase specified in Sec. 412.64(d)(1) or the percentage increase in the market basket index for prospective payment hospitals for all areas. We are proposing to apply the full rate-of-increase in the hospital market basket for IPPS hospitals to the Puerto Rico-specific standardized amount. Therefore, the proposed update to the Puerto Rico-specific standardized amount is estimated to be 3.0 percent.

Although the update factors for FY 2009 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 2009 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 2009 standardized amount to remove the effects of the FY 2008 geographic reclassifications and outlier payments before applying the FY 2009 updates. We then applied budget neutrality offsets for outliers and geographic reclassifications to the standardized amount based on proposed FY 2009 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 updates in the DRG relative weights and wage index should equal estimated aggregate payments prior to the changes. If we removed the prior year's adjustment, we would not have satisfied these conditions.

Budget neutrality is determined by comparing aggregate IPPS payments before and after making 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 included 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 did not exceed the amount of payments that would have been made in the absence of the rural community hospital demonstration program, as 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 2009, we are proposing to no longer apply budget neutrality for the imputed rural floor to the standardized amount, and to apply it instead to the wage index, as discussed in section of II.B.2. of the preamble to this proposed rule. For FY 2009, we are also proposing an adjustment to eliminate the effect of coding or classification changes that did not reflect real changes in case-mix using the Secretary's authority under section 1886(d)(3)(A)(vi) of the Act, by the percentage specified in section 7 of Pub. L. 110-90. 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 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 made 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 2009, we are adjusting 100 percent of the wage index factor for occupational mix. We describe the occupational mix adjustment in section III.D. 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 used FY 2007 discharge data to simulate payments and compared aggregate payments using the FY 2008 relative weights and wage indices to aggregate payments using the proposed FY 2009 relative weights and wage indices. The same methodology was used for the FY 2008 budget neutrality adjustment. Based on this comparison, we computed a proposed budget neutrality adjustment factor equal to 0.999525 to be applied to the national standardized amount. We are also adjusting the Puerto Rico-specific standardized amount for the effect of DRG reclassification and recalibration. We computed a proposed budget neutrality adjustment factor of 0.998700 to be applied to the Puerto Rico-specific standardized amount. These proposed budget neutrality adjustment factors are applied to the standardized amounts for FY 2008 without removing the prior year's budget neutrality adjustments. In addition, as discussed in section

IV. of this Addendum, we are applying the same proposed DRG reclassification and recalibration budget neutrality factor of 0.998700 to the hospital-specific rates that would be effective for cost reporting periods beginning on or after October 1, 2008. 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 proposed budget neutrality factor for FY 2009, we used FY 2007 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.

Page 23710

Based on these simulations, we calculated a proposed adjustment factor of 0.992333 to ensure that the effects of these provisions are budget neutral, consistent with the statute.

The proposed adjustment factor is applied to the standardized amount after removing the effects of the FY 2008 budget neutrality adjustment factor. We note that the FY 2009 adjustment reflects FY 2009 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 2009 geographic reclassification could either be the continuation of a 3-year reclassification that began in FY 2007 or FY 2008, or a new one beginning in FY 2009.) c. Case-Mix Budget Neutrality Adjustment

As stated earlier, beginning in FY 2008, we adopted the new MS-

DRG patient classification system for the IPPS to better recognize severity of illness in Medicare payment rates. In the FY 2008 IPPS final rule with comment period, we indicated that we believe the adoption of the MS-DRGs had the potential to lead to increases in aggregate payments without a corresponding increase in actual patient severity of illness due to the incentives for improved documentation and coding. In that final rule, using the Secretary's authority under section 1886(d)(3)(A)(vi) of the Act to maintain budget neutrality by adjusting the national standardized amounts to eliminate the effect of changes in coding or classification that do not reflect real change in case-mix, we established prospective documentation and coding adjustments of -1.2 percent for FY 2008, - 1.8 percent for FY 2009, and -1.8 percent for FY 2010. On September 29, 2007, Pub. L. 110-90 was enacted. Section 7 of Pub. L. 110-90 included a provision that reduces the documentation and coding adjustment for the MS-DRG system that we adopted in the FY 2008 IPPS final rule with comment period to -0.6 percent for FY 2008 and -0.9 percent for FY 2009. To comply with the provision of section 7 of

Pub. L. 110-90, in a final rule that appeared in the Federal

Register on November 27, 2007 (72 FR 66886), we changed the IPPS documentation and coding adjustment for FY 2008 to -0.6 percent, and revised the FY 2008 national standardized amounts (as well as other payment factors and thresholds) accordingly, with these revisions effective October 1, 2007. For FY 2009, section 7 of Pub. L. 110-90 requires a documentation and coding adjustment of -0.9 percent instead of the -1.8 percent adjustment specified in the FY 2008 IPPS final rule with comment period. As required by statute, we are applying a documentation and coding adjustment of -0.9 percent to the FY 2009 IPPS national standardized amounts. The documentation and coding adjustments established in the FY 2008 IPPS final rule with comment period are cumulative. As a result, the -0.9 percent documentation and coding adjustment in FY 2009 is in addition to the

-0.6 percent adjustment in FY 2008, yielding a combined effect of - 1.5 percent.

As discussed in more detail in section II.D. of the preamble of this proposed rule, in calculating the FY 2008 Puerto Rico standardized amount, we made an inadvertent error and applied the documentation and coding adjustment established using our authority in section 1886(d)(3)(A)(vi) of the Act (which only applies to the national standardized amounts) to the Puerto Rico-specific standardized amount. We are currently in the process of developing a

Federal Register notice to remove the -0.6 percent documentation and coding adjustment from the FY 2008 Puerto Rico-specific standardized amount retroactive to October 1, 2007. As discussed in section II.D. of the preamble of this proposed rule, we are not applying the documentation and coding adjustment to the Puerto Rico-specific standardized amount for FY 2009, but we may consider doing so for the FY 2010 Puerto Rico-specific standardized amount in the FY 2010 rulemaking. In calculating the FY 2009 Puerto Rico-specific standardized amount for this proposed rule, we have removed the -0.6 percent documentation and coding adjustment that was inadvertently applied to the FY 2008 Puerto Rico-specific standardized amount. 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 2009 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 located 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 2009 Outlier Fixed-Loss Cost Threshold

For FY 2009, we are proposing to use the same methodology used for FY 2008 (72 FR 47417) to calculate the outlier threshold.

Similar to the methodology used in the FY 2008 final rule with comment period, for FY 2009, 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 2009 outlier threshold, we simulated payments by applying FY 2009 rates and policies using cases from the FY 2007 MedPAR files.

Therefore, in order to determine the proposed FY 2009 outlier threshold, we inflate the charges on the MedPAR claims by 2 years, from FY 2007 to FY 2009.

We are proposing to continue using a refined methodology that takes into account the lower inflation in hospital charges that are occurring as a result of the outlier final rule (68 FR 34494), which changed our methodology for determining outlier 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 2006 in combination with the first quarter of FY 2007

(July 1, 2006 through December 31, 2006) to the last quarter of FY 2007 in combination with the first quarter of FY 2008 (July 1, 2007 through December 31, 2007). This rate of change was 5.84 percent

(1.0585) or 12.03 percent (1.1204) over 2 years.

As we have done in the past, we are proposing to establish the proposed FY 2009 outlier threshold using hospital CCRs from the

December 2007 update to the Provider-Specific File (PSF)--the most recent available data at the time of this proposed rule. This file includes CCRs that reflected 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 Office of Actuary to derive the methodology described below to develop the CCR adjustment factor. For FY 2009, we are proposing to use the same methodology to calculate the CCR adjustment by using the FY 2007 operating cost per discharge increase in combination with the actual FY 2007 operating market basket increase determined by Global Insight, Inc., as well as the charge inflation factor described above to estimate the adjustment to the CCRs. (We note that the FY 2007 actual (otherwise referred to as ``final'') operating market basket increase reflects historical data whereas the published FY 2007 operating market basket update factor was based on Global Insight, Inc.'s 2006 second quarter forecast with historical data through the first quarter of 2007.) By using the operating 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

Page 23711

2009, we determined the adjustment by taking the percentage increase in the operating costs per discharge from FY 2005 to FY 2006

(1.0538) from the cost report and dividing it by the final operating market basket increase from FY 2006 (1.0420). We repeated this calculation for 2 prior years to determine the 3-year average of the rate of adjusted change in costs between the operating market basket rate-of-increase and the increase in cost per case from the cost report (FY 2003 to FY 2004 percentage increase of operating costs per discharge of 1.0629 divided by FY 2004 final operating market basket increase of 1.0400, FY 2004 to FY 2005 percentage increase of operating costs per discharge of 1.0565 divided by FY 2005 final operating market basket increase of 1.0430). For FY 2009, we averaged the differentials calculated for FY 2004, FY 2005, and FY 2006, which resulted in a mean ratio of 1.0154. We multiplied the 3- year average of 1.0154 by the 2007 operating market basket percentage increase of 1.0340, which resulted in an operating cost inflation factor of 5.0 percent or 1.05. We then divided the operating cost inflation factor by the 1-year average change in charges (1.058474) and applied an adjustment factor of 0.9920 to the operating CCRs from the PSF.

As stated in the FY 2008 final rule with comment period, we continue to believe it is appropriate to apply only a 1-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 2008 is approximately 1 year. Therefore, as stated above, we believe a 1-year adjustment factor to the CCRs is appropriate.

We used the same methodology for the capital CCRs and determined the adjustment by taking the percentage increase in the capital costs per discharge from FY 2005 to FY 2006 (1.0462) from the cost report and dividing it by the final capital market basket increase from FY 2006 (1.0090). We repeated this calculation for 2 prior years to determine the 3-year average of the rate of adjusted change in costs between the capital market basket rate-of-increase and the increase in cost per case from the cost report (FY 2003 to FY 2004 percentage increase of capital costs per discharge of 1.0315 divided by FY 2004 final capital market basket increase of 1.0050, FY 2004 to FY 2005 percentage increase of capital costs per discharge of 1.0311 divided by FY 2005 final capital market basket increase of 1.0060). For FY 2009, we averaged the differentials calculated for

FY 2004, FY 2005, and FY 2006, which resulted in a mean ratio of 1.0294. We multiplied the 3-year average of 1.0294 by the 2007 capital market basket percentage increase of 1.0120, which resulted in a capital cost inflation factor of 4.17 percent or 1.0417. We then divided the capital cost inflation factor by the 1-year average change in charges (1.058474) and applied an adjustment factor of 0.9842 to the capital CCRs from the PSF. 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.

For purposes of estimating the proposed outlier threshold for FY 2009, we assume 3.0 percent case-mix growth in FY 2009 compared with our FY 2007 claims data (that is, a 1.2 percent increase in FY 2008 and an additional 1.8 percent increase in FY 2009). The 3 percent case-mix growth was projected by the Office of the Actuary as the amount case-mix is expected to increase in response to adoption of the MS-DRGs as a result of improvements in documentation and coding that do not reflect real changes in patient severity of illness. It is necessary to take the 3 percent expected case-mix growth into account when calculating the outlier threshold that results in outlier payments being 5.1 percent of total payments for FY 2009. If we did not take this 3 percent projected case-mix growth into account, our estimate of total payments would be too low, and as a result, our estimate of the outlier threshold would be too high.

While we assume 3 percent case-mix growth for all hospitals in our outlier threshold calculations, the FY 2009 national standardized amounts used to calculate the outlier threshold reflect the statutorily mandated documentation and coding adjustment of -0.9 percent for FY 2009, on top of the -0.6 percent adjustment for FY 2008.

Using this methodology, we are proposing an outlier fixed-loss cost threshold for FY 2009 equal to the prospective payment rate for the DRG, plus any IME and DSH payments, and any add-on payments for new technology, plus $21,025.

As we did in establishing the FY 2008 outlier threshold (72 FR 47417), in our projection of FY 2009 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 some factors that contributed to a proposed lower fixed loss outlier threshold for FY 2009 compared to

FY 2008. First, the case-weighted national average operating CCR declined by approximately an additional 1 percentage point from the

March 2007 update (used to calculate the FY 2008 outlier threshold) to the December 2007 update of the PSF (used to calculate the proposed FY 2009 outlier threshold). In addition, as discussed in sections II.C. and II.H. of the preamble of this proposed rule, we began a 2-year phase-in of the MS-DRGs in FY 2008, with the DRG relative weights based on a 50 percent blend of the CMS DRGs and MS-

DRGs in FY 2008 and based on 100 percent of the MS-DRGs beginning in

FY 2009. Better recognition of severity of illnesses 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 need to decrease the fixed-loss outlier threshold so that more cases qualify for outlier payments. In addition, as noted previously, in our modeling of the outlier threshold, we included a 3-percent adjustment for expected case-mix growth between FY 2007 and FY 2009. Together, we believe that the above factors cumulatively contributed to a lower proposed fixed- loss outlier threshold in FY 2009 compared to FY 2008.

(2) Other Proposed Changes Concerning Outliers

As stated in the FY 1994 IPPS final rule (58 FR 46348), we establish an outlier threshold that is 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 threshold resulted in a lower percentage of outlier payments for capital-related costs than for operating costs. We are projecting that the proposed thresholds for

FY 2009 will result in outlier payments that will equal 5.1 percent of operating DRG payments and 5.73 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 2009 standardized amount by the same percentage to account for the projected proportion of payments paid as outliers.

The outlier adjustment factors that are applied to the standardized amount for the proposed FY 2009 outlier threshold are as follows:

Operating standardized

Capital amounts federal rate

National....................................

0.948928

0.942711

Puerto Rico.................................

0.955988

0.925627

Consistent with current policy, we are applying the outlier adjustment factors to FY 2009 rates after removing the effects of the FY 2008 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

Page 23712

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 fell 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 1.213 or capital CCRs greater than 0.148, 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), we still use statewide average CCRs to determine whether a hospital qualifies for outlier payments.\27\ Table 8A in 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, 2008, these statewide average ratios would replace the ratios published in the IPPS final rule for FY 2008 (72 FR 48126-48127). Table 8B in this Addendum contains the comparable statewide average capital CCRs. Again, the CCRs in Tables 8A and 8B would be used during FY 2009 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, we refer readers to section V. of this Addendum.

\27\ 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 our outlier policy 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 if applicable) 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 that 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, visit the Web site: http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf.

(3) FY 2007 and FY 2008 Outlier Payments

In the FY 2008 IPPS final rule (72 FR 47420), we stated that, based on available data, we estimated that actual FY 2007 outlier payments would be approximately 4.6 percent of actual total DRG payments. This estimate was computed based on simulations using the

FY 2006 MedPAR file (discharge data for FY 2006 bills). That is, the estimate of actual outlier payments did not reflect actual FY 2007 bills, but instead reflected the application of FY 2007 rates and policies to available FY 2006 bills.

Our current estimate, using available FY 2007 bills, is that actual outlier payments for FY 2007 were approximately 4.64 percent of actual total DRG payments. Thus, the data indicate that, for FY 2007, the percentage of actual outlier payments relative to actual total payments is lower than we projected before FY 2007. 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 2007 are equal to 5.1 percent of total DRG payments.

We currently estimate that actual outlier payments for FY 2008 will be approximately 4.8 percent of actual total DRG payments, 0.3 percentage points lower than the 5.1 percent we projected in setting the outlier policies for FY 2008. This estimate is based on simulations using the FY 2007 MedPAR file (discharge data for FY 2007 bills). We used these data to calculate an estimate of the actual outlier percentage for FY 2008 by applying FY 2008 rates and policies, including an outlier threshold of $22,185 to available FY 2007 bills. 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.K. 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. There are currently nine hospitals participating in the demonstration program. CMS is currently conducting a solicitation for up to six additional hospitals to participate in the demonstration program. For this proposed rule, we used data from the cost reports of the 9 currently participating hospitals to estimate a total cost number for 15 hospitals that could potentially participate in the demonstration program in FY 2009. (In the final rule, we will know the exact number of hospitals participating in the demonstration program, and we will revise our estimates accordingly.) We estimate that the average additional annual payment that will be made to each participating hospital under the demonstration will be approximately $2,134,123. 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 program. As an estimate of the cost for a total of 15 hospitals that may participate, the total annual impact of the demonstration program for FY 2009 is projected to be $32,011,849. The required adjustment to the Federal rate used in calculating Medicare inpatient prospective payments as a result of the demonstration is 0.999666.

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 2009 Standardized Amount

The adjusted proposed standardized amount is divided into labor- related and nonlabor-related portions. Tables 1A and 1B of this

Addendum contain the national standardized amounts that we are proposing to apply to all hospitals, except hospitals located in

Puerto Rico, for FY 2009. The proposed Puerto Rico-specific amounts are shown in Table 1C of this Addendum. 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 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 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 full 3.0 percent update for FY 2009, and proposed standardized amounts reflecting the 2.0 percentage point reduction to the update (a 1.0 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 2009 are set forth in Table 1C of this Addendum. This table also includes the proposed Puerto Rico standardized amounts. The labor-related share applied to the 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

Page 23713

that the labor-related share for hospitals located in Puerto Rico 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 2008 national average standardized amount. The second and third columns show the proposed changes from the FY 2008 standardized amounts for hospitals that satisfy the quality data submission requirement for receiving the full update (3.0 percent) with the different labor-related shares that apply to hospitals. The fourth and fifth columns show the proposed changes for hospitals receiving the reduced update (1.0 percent) with the different labor-related shares that apply to hospitals. The first row of the table shows the updated (through FY 2008) average standardized amount after restoring the FY 2008 offsets for outlier payments, demonstration budget neutrality, the New Jersey imputed floor budget neutrality, and the geographic reclassification budget neutrality. The DRG reclassification and recalibration and wage index budget neutrality factor is cumulative. Therefore, the FY 2008 factor is not removed from this table. Also, in order to properly apply the documentation and coding adjustment, it was necessary to first remove the FY 2008 adjustment from the FY 2008 rate in the first row of the table and then later in the table to cumulatively apply the sum of the FY 2008 and FY 2009 adjustments (that is, 1-(.006 + .009)) to the FY 2009 rate. (For a complete discussion on the documentation and coding adjustment, we refer readers to section II.D of the preamble to this proposed rule.)

Comparison of FY 2008 Standardized Amounts to the Proposed FY 2009 Single Standardized Amount With Full Update and Reduced Update

Reduced update

Full update (3.0

Full update (3.0

(1.0 percent);

Reduced update percent); wage

percent); wage

wage index is

(1.0 percent); index is greater index is less than

greater than

wage index is less than 1.0000

1.0000

1.0000

than 1.0000

FY 2008 Base Rate, after

Labor: $3,723.07.. Labor: $3,311.77.. Labor: $3,723.07.. Labor: $3,311.77 removing geographic

Nonlabor:

Nonlabor:

Nonlabor:

Nonlabor: reclassification budget

$1,618.50.

$2,029.80.

$1,618.50.

$2,029.80 neutrality, demonstration budget neutrality, documentation and coding adjustment, NJ imputed floor budget neutrality and outlier offset (based on the labor and market share percentage for FY 2009).

FY 2009 Update Factor........... 1.030............. 1.030............. 1.010............. 1.010

FY 2009 DRG Recalibrations and 0.999525.......... 0.999525.......... 0.999525.......... 0.999525

Wage Index Budget Neutrality

Factor.

FY 2009 Reclassification Budget 0.992333.......... 0.992333.......... 0.992333.......... 0.992333

Neutrality Factor.

FY 2009 Outlier Factor.......... 0.948928.......... 0.948928.......... 0.948928.......... 0.948928

Rural Demonstration Budget

0.999666.......... 0.999666.......... 0.999666.......... 0.999666

Neutrality Factor.

FY 2009 Documentation and Coding 0.985............. 0.985............. 0.985............. 0.985

Adjustment and Actual FY 2008

Adjustment.

Proposed Rate for FY 2009....... Labor: $3,553.98.. Labor: $3,161.36.. Labor: $3,484.97.. Labor: $3,099.97

Nonlabor:

Nonlabor:

Nonlabor:

Nonlabor:

$1,544.98.

$1,937.60.

$1,514.98.

$1,899.98

Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion of the Puerto Rico payment rate is based on the national average standardized amounts. The labor-related and nonlabor-related portions of the national average standardized amounts for hospitals located in Puerto Rico are set forth in Table 1C 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 located in Puerto Rico 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 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 2009. This section addresses two types of adjustments to the standardized amounts that were made in determining the 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 FY 2009 wage index. 2. Proposed Adjustment for Cost-of-Living in Alaska and Hawaii

Section 1886(d)(5)(H) of the Act authorizes the Secretary to make 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 2009, 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) radius

1.24 by road............................................

Page 23714

City of Fairbanks and 80-kilometer (50-mile) radius

1.24 by road............................................

City of Juneau and 80-kilometer (50-mile) radius by

1.24 road...............................................

Rest of Alaska......................................

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.)

C. Proposed MS-DRG Relative Weights

As discussed in section II.H. of the preamble of this proposed rule, we have developed proposed relative weights for each MS-DRG that reflect the resource utilization of cases in each MS-DRG relative to Medicare cases in other MS-DRGs. Table 5 of this

Addendum contains the proposed relative weights that we will apply to discharges occurring in FY 2009. 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 2009

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 2009 equals the Federal rate.

The prospective payment rate for SCHs for FY 2009 equals the higher of the applicable Federal rate, or the hospital-specific rate as described below. The prospective payment rate for MDHs for FY 2009 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 hospitals located in Puerto Rico for FY 2009 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 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 nonlabor-related portion of the standardized amount by the applicable cost-of-living adjustment factor.

Step 4--Add the amount from Step 2 and the nonlabor-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 this

Addendum).

The Federal rate as determined in Step 5 is then 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 and 42 CFR 412.101(b), the payment in Step 5 is 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 are no longer 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 III. of this Addendum. 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 2009

We are proposing to increase the hospital-specific rates by 3.0 percent (the proposed estimated hospital market basket percentage increase) for FY 2009 for those SCHs and MDHs that submit qualifying quality data and by 1.0 percent for SCHs and MDHs that fail to submit qualifying quality data. 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 2008, is the market basket rate-of-increase for hospitals that submit qualifying quality data and the market basket rate-of-increase minus 2 percent for hospitals that fail to submit qualifying quality data. 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 for under section 1886(b)(3)(B)(iv) of the Act, which, for FY 2009, is the market basket rate-of-increase for hospitals that submit qualifying quality data and the market basket rate-of-increase minus 2 percent for hospitals that fail to submit qualifying quality data. 3. General Formula for Calculation of Proposed Prospective Payment

Rates for Hospitals Located in Puerto Rico Beginning On or After

October 1, 2008, and Before October 1, 2009

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 (Table 1C of this Addendum).

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.

Page 23715

Step 4--Multiply the amount from Step 3 by the applicable MS-DRG relative weight (Table 5 of this 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 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--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 (Table 5 of this 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 is then 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 2009

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 the regulations at 42 CFR 412.308 through 412.352. Below we discuss the factors that we are proposing to use to determine the capital Federal rate for FY 2009, which would be effective for discharges occurring on or after October 1, 2008.

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 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 be 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 (GAF) 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 respective fiscal year. That provision expired in FY 1996. Section 412.308(b)(2) describes the 7.4 percent reduction to the capital

Federal rate that was made in FY 1994, and Sec. 412.308(b)(3) describes the 0.28 percent reduction to the capital Federal rate made in FY 1996 as a result of the revised policy for 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 as of 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 to the unadjusted capital payment rates 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 made under the regular exception policy effective with cost reporting periods beginning in FY 2002, we discontinued use of 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 hospitals located in Puerto Rico under the IPPS for acute care hospital inpatient capital-related costs. Accordingly, under the capital PPS, we compute a separate payment rate specific to hospitals located in Puerto Rico 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 located 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 located 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, the methodology for operating payments made to hospitals located in Puerto Rico under the IPPS was revised to make payments 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 located 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 hospitals located in Puerto Rico 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 hospitals located in Puerto Rico 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 located 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 2008 IPPS final rule with comment period (72 FR 66886 through 66888), we established a capital Federal rate

Page 23716

of $426.14 for FY 2008. In the discussion that follows, we explain the factors that we are proposing to use to determine the proposed

FY 2009 capital Federal rate. In particular, we explain why the proposed FY 2009 capital Federal rate would decrease approximately 1.14 percent, compared to the FY 2008 capital Federal rate. However, taking into account an estimated increase in Medicare fee-for- service discharges in FY 2009 as compared to FY 2008, as well as the estimated increase in payments due to documentation and coding

(discussed in section VIII. of Appendix A to this proposed rule), we estimate that the increase in aggregate capital payments would be negligible during this same period (approximately $6 million). Total payments to hospitals under the IPPS are relatively unaffected by changes in the capital prospective payments. Because capital payments constitute about 10 percent of hospital payments, a 1- percent change in the capital Federal rate yields only about a 0.1 percent change in actual payments to hospitals. As noted above, aggregate payments under the capital IPPS are projected to increase in FY 2009 compared to FY 2008. 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 2009 under that framework is 0.7 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 -0.5 percent adjustment for the FY 2007 DRG reclassification and recalibration, and a forecast error correction of 0.0 percent. As discussed below in section III.C. of the Addendum to this proposed rule, we continue to 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 2009 CIPI projection in that same section of this Addendum. In addition, as also noted below, the proposed capital rates would be further adjusted to account for documentation and coding improvements under the MS-DRGs discussed in section II.D. of the preamble of this proposed rule. Below we describe the policy adjustments that we are proposing to apply in the update framework for FY 2009.

The case-mix index is the measure of the average MS-DRG weight for cases paid under the IPPS. Because the MS-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 MS-DRG assignments (``coding effects''); and

The annual MS-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 MS-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 no longer use an update framework to make 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 projected increase in case-mix resulting from documentation and coding improvements under the recently adopted MS-

DRGs, for FY 2009, 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 for FY 2009. 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 2009 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's 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 2007 DRG reclassification and recalibration as part of our proposed update for FY 2009. We estimate that FY 2007 DRG reclassification and recalibration resulted in a 0.5 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 -0.5 percent adjustment for DRG reclassification in the proposed update for FY 2009 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 availability of data to develop a measurement of the forecast error.

A forecast error of 0.10 percentage point was calculated for the FY 2007 update. That is, current historical data indicate that the forecasted FY 2007 CIPI (1.1 percent) used in calculating the FY 2007 update factor slightly understated the actual realized price increases (1.2 percent) by 0.10 percentage point. This slight underprediction was mostly due to the incorporation of newly available source data for fixed asset prices and moveable 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 2009.

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 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 the combination of quality-enhancing new technologies and complexity within the DRG system, we assume 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 increases within DRG severity 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 increase of 1.0 to 1.5 percent per year.

Page 23717

However, we used 1.4 percent as the upper bound because the RAND study did not take into account that hospitals may have induced doctors to document medical records more completely in order to improve payment.

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 2009 is based on data from the 5-year period beginning with FY 2003 and extending through FY 2007. There continues to be a substantial increase in hospital charges for three of those 5 years without a corresponding increase in the hospital case-mix index. Most dramatically, for FY 2003, the change in hospitals' charges is over 16 percent, which is reflective of the large increases in charges that we found in the 4 years prior to FY 2003 and before our revisions to the outlier policy in 2003 (discussed below). For FY 2004 and FY 2005, the change in hospitals' charges is somewhat lower in comparison to FY 2003, but is still significantly large. For FY 2006 and FY 2007, the change in hospitals' charges appears to be slightly moderating. However, the change in hospitals' charges for

FYs 2003 and 2004 and to a somewhat lesser extent FY 2005 remains similar to the considerable increase in hospitals' charges that we found when examining hospitals' charge data in determining the intensity factor in the update recommendations for the past few years, 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), the FY 2007 IPPS final rule (72 FR 47500), and the FY 2008 IPPS final rule with comment period (72 FR 47426). 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 most recently in the FY 2008 IPPS final rule with comment period (72 FR 47426), 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 2008 just as we did for FYs 2004 through 2007.

On June 9, 2003, we published in the Federal Register 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 increase in charges for FYs 2004 and 2005 are somewhat less than the previous 4 years, they still show a significant annual increase in charges without a corresponding increase in hospital case-mix. Specifically, the increases in charges in FY 2004 and FY 2005 (approximately 12 percent and 8 percent, respectively), for example, which, while less than the increase in the previous 3 years, are still much higher than increases in years prior to FY 2001. In addition, these increases in charges for FYs 2003, FY 2004, and FY 2005 significantly exceed the respective case-mix increases for the same period. Based on the significant increases in charges for FYs 2003 through 2005 that remain in the 5-year average used for the intensity adjustment, 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 it may have taken hospitals some time to adopt changes in their behavior in response to the new outlier policy. Thus, we believe that the FY 2003, FY 2004, FY 2005 charge data may still be skewed. Although it appears that the change in hospitals' charges is more reasonable 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 costs, continue to skew the charge data.

Therefore, we are proposing to make a 0.0 percent adjustment for intensity for FY 2009. 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 2009 until any increase in charges during the 5-year period upon which the intensity adjustment is based 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 0.7 percent capital update factor for all hospitals under the capital update framework for FY 2009 as shown in the table below.

CMS Proposed FY 2009 Update Factor to the Capital Federal Rate

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.............................................

1.2

Effect of FY 2007 Reclassification and Recalibration.........

-0.5

Forecast Error Correction....................................

0.0

Total Update for Hospitals...............................

0.7

b. Comparison of CMS and MedPAC Update Recommendation

In its March 2008 Report to Congress, MedPAC did not make a specific update recommendation for capital IPPS payments for FY 2009. However, in that same report, in assessing the adequacy of current payments and costs, MedPAC recommended an update to the hospital inpatient and outpatient PPS rates equal to the increase in the hospital market basket in FY 2009, concurrent with a quality incentive program. (MedPAC's Report to the Congress: Medicare

Payment Policy, March 2008, Section 2A.) 2. Proposed Outlier Payment Adjustment Factor

Section 412.312(c) establishes a unified outlier payment 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 FY 2008 IPPS final rule with comment (72 FR 66887), we estimated that outlier payments for capital would equal 4.77 percent of inpatient capital-related payments based on the capital Federal rate in FY 2008. Based on the proposed thresholds as set forth

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in section II.A. of this Addendum, we estimate that proposed outlier payments for capital-related costs would equal 5.73 percent for inpatient capital-related payments based on the proposed capital

Federal rate in FY 2009. Therefore, we are proposing to apply an outlier adjustment factor of 0.9427 to the capital Federal rate.

Thus, we estimate that the percentage of capital outlier payments to total capital standard payments for FY 2009 will be higher than the percentages for FY 2008. This increase is primarily due to the proposed decrease to the fixed-loss amount, which is discussed section II.A. of this Addendum.

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 2009 outlier adjustment of 0.9427 is a -1.01percent change from the FY 2008 outlier adjustment of 0.9523. Therefore, the net change in the proposed outlier adjustment to the capital Federal rate for FY 2009 is 0.9899 (0.9427/0.9523). Thus, the proposed outlier adjustment decreases the FY 2009 capital Federal rate by 1.01 percent compared with the FY 2008 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. of this Addendum, beginning in FY 2002, an adjustment for regular exception payments is no longer necessary. Therefore, we will no longer use 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 2009, we compared

(separately for the national capital rate and the Puerto Rico capital rate) estimated aggregate capital Federal rate payments based on the FY 2008 DRG relative weights and the FY 2008 GAF to estimated aggregate capital Federal rate payments based on the proposed FY 2009 relative weights and the proposed FY 2009 GAFs. We established the final FY 2008 budget neutrality factors of 0.9902 for the national capital rate and 0.9955 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 GAFs, based on calculations using updated data, we are proposing to apply an incremental budget neutrality adjustment of 1.0013 for FY 2009 to the previous cumulative FY 2008 adjustments of 0.9902, yielding a proposed adjustment of 0.9915, through FY 2009.

For the Puerto Rico GAFs, we are proposing to apply a proposed incremental budget neutrality adjustment of 1.0009 for FY 2009 to the previous cumulative FY 2008 adjustment of 0.9955, yielding a proposed cumulative adjustment of 0.9965 (calculated with unrounded numbers) through FY 2009.

We then compared estimated aggregate capital Federal rate payments based on the FY 2008 DRG relative weights and the proposed

FY 2009 GAFs to estimated aggregate capital Federal rate payments based on the cumulative effects of the proposed FY 2009 DRG relative weights and the proposed FY 2009 GAFs. The proposed incremental adjustment for proposed DRG classifications and proposed changes in relative weights is 0.9994 both nationally and for Puerto Rico. The proposed cumulative adjustments for DRG classifications and changes in relative weights and for proposed changes in the GAFs through FY 2009 are 0.9909 nationally and 0.9959 for Puerto Rico. The following table summarizes the adjustment factors for each fiscal year:

BILLING CODE 4120-01-P

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GRAPHIC

TIFF OMITTEDTP30AP08.021

BILLING CODE 4120-01-C

The methodology used to determine the recalibration and geographic (DRG/GAF) budget neutrality adjustment factor is similar to the methodology 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 or indirect medical education payments.

In the FY 2008 IPPS correction notice (72 FR 57636), we calculated a GAF/DRG budget neutrality factor of 0.9996 for FY 2008.

For FY 2009, we are proposing to establish a GAF/DRG budget neutrality factor of 1.0007. The GAF/DRG budget neutrality factors are

Page 23720

built permanently into the capital rates; that is, they are applied cumulatively in determining the capital Federal rate. This follows 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 GAFs. The incremental change in the proposed adjustment from FY 2008 to FY 2009 is 1.0007. The cumulative change in the proposed capital

Federal rate due to this proposed adjustment is 0.9909 (the product of the incremental factors for FYs 1994 though 2008 and the proposed incremental factor of 1.0007 for FY 2009). (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 0.9909 for FY 2009.)

The proposed factor accounts for DRG reclassifications and recalibration and for changes in the GAFs. It also incorporates the effects on the proposed GAFs of FY 2009 geographic reclassification decisions made by the MGCRB compared to FY 2008 decisions. However, it does not account for changes in payments due to changes in the

DSH and IME adjustment factors. 4. Exceptions Payment Adjustment Factor

Section 412.308(c)(3) of our regulations 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 2009 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 are 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 2008 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 the following criteria: (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 2005 for all of these hospitals, we calculated the adjustment based on actual cost experience. Using data from cost reports ending in FY 2005 from the December 2007 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 2005, this ratio is rounded to 0.0002. We also computed the ratios for FY 2004 and FY 2003, which both round to 0.0003. Since the ratios are trending downward, we are proposing an adjustment of 0.0002. Because special exceptions are budget neutral, we are proposing to offset the proposed capital Federal rate by 0.02 percent for special exceptions payments for FY 2009. Therefore, the proposed exceptions adjustment factor is equal to 0.9998 (1-0.0002) to account for special exceptions payments in FY 2009.

In the FY 2008 IPPS final rule with comment period (72 FR 47430), we estimated that total (special) exceptions payments for FY 2008 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) to determine the FY 2008 capital

Federal rate. As we stated above, we estimate that exceptions payments in FY 2009 would equal 0.02 percent of aggregate payments based on the proposed FY 2009 capital Federal rate. Therefore, we are proposing to apply an exceptions payment adjustment factor of 0.9998 to the proposed capital Federal rate for FY 2009. The proposed exceptions adjustment factor for FY 2009 is slightly lower than the factor used in determining the FY 2008 capital Federal rate in the FY 2008 IPPS final rule. 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 2009 capital

Federal rate is 1.0001 (0.9998/0.9997). 5. Proposed Capital Standard Federal Rate for FY 2009

In the FY 2008 IPPS final rule with comment period (72 FR 66888), we established a capital Federal rate of $426.14 for all hospitals for FY 2008. We are proposing to establish an update of 0.7 percent in determining the proposed FY 2009 capital Federal rate for all hospitals. However, under the statutory authority at section 1886(d)(3)(A)(vi) of the Act, and as specified in section 7 of Pub.

L. 110-90, we are proposing an additional 0.9 percent reduction to the proposed standardized amounts for both capital and operating

Federal payment rates in FY 2009. The proposed 0.9 percent reduction is based on our Actuary's analysis of the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix in light of the adoption of the MS-DRGs.

Although the proposed 0.9 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 proposed national capital Federal payment rate proposed in this proposed rule was determined by applying the proposed 0.9 percent reduction. (As discussed below in section II.A.6. of this

Addendum, we are not proposing to apply the proposed 0.9 percent reduction in developing the proposed FY 2009 Puerto Rico-specific capital rate.) As a result of the proposed 0.70 percent update and other proposed budget neutrality factors discussed above, we are proposing to establish a capital Federal rate of $421.29 for FY 2009. The proposed capital Federal rate for FY 2009 was calculated as follows:

The proposed FY 2009 update factor is 1.0070, that is, the update is 0.70 percent.

The proposed FY 2009 budget neutrality adjustment factor that is applied to the capital standard Federal payment rate for changes in the DRG relative weights and in the GAFs is 1.0007.

The proposed FY 2009 outlier adjustment factor is 0.9427.

The proposed FY 2009 (special) exceptions payment adjustment factor is 0.9998.

The proposed FY 2009 reduction for improvements in documentation and coding under the MS-DRGs is 0.9 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 proposing to make additional adjustments in the proposed capital standard Federal rate for these factors, other than the budget neutrality factor for changes in the DRG relative weights and the

GAFs.

We are providing the following chart that shows how each of the proposed factors and adjustments for FY 2009 affected the computation of the proposed FY 2009 capital Federal rate in comparison to the FY 2008 capital Federal rate. The proposed FY 2009 update factor has the effect of increasing the proposed capital

Federal rate by 0.70 percent compared to the FY 2008 capital Federal rate. The proposed GAF/DRG budget neutrality factor has the effect of increasing the proposed capital Federal rate by 0.07 percent. The proposed FY 2009 outlier adjustment factor has the effect of decreasing the proposed capital Federal rate by 1.01 percent compared to the FY 2008 capital Federal rate. The proposed FY 2009 exceptions payment adjustment factor has the effect of increasing the proposed capital Federal rate by 0.01 percent. The proposed adjustment for improvements in documentation and coding

Page 23721

under the MS-DRGs has the effect of decreasing the proposed FY 2009 capital Federal rate by 0.9 percent as compared to the FY 2008 capital Federal rate. The combined effect of all the proposed changes decreases the proposed capital Federal rate by 1.14 percent compared to the FY 2008 capital Federal rate.

Comparison of Factors and Adjustments: FY 2008 Capital Federal Rate and Proposed FY 2009 Capital Federal Rate

Proposed FY

Percent change

FY 2008

2009 \4\

Change

\5\

Update Factor \1\...............................

1.0090

1.0070

1.0070

0.70

GAF/DRG Adjustment Factor \1\...................

0.9996

1.0007

1.0007

0.07

Outlier Adjustment Factor \2\...................

0.9523

0.9427

0.9899

-1.01

Exceptions Adjustment Factor \2\................

0.9997

0.9998

1.0001

0.01

MS-DRG Coding and Documentation Improvements

0.9940

0.9910

0.9910

-0.90

Adjustment Factor \3\..........................

Capital Federal Rate............................

$426.14

$421.29

0.9886

-1.14

\1\ The update factor and the GAF/DRG budget neutrality factors are built permanently into the capital rates.

Thus, for example, the incremental change from FY 2008 to FY 2009 resulting from the application of the proposed 1.0007 GAF/DRG budget neutrality factor for FY 2009 is 1.0007.

\2\ The outlier reduction factor and the 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 2009 outlier adjustment factor is 0.9427/0.9523, or 0.9899.

\3\ Proposed adjustment to FY 2009 IPPS rates to account for documentation and coding improvements expected to result from the adoption of the MS-DRGs, as discussed above in section III.D. of the Addendum to this proposed rule.

\4\ Proposed factors for FY 2009, as discussed above in section III. of this Addendum.

\5\ Percent change of individual factors may not sum due to rounding. 6. Proposed Special Capital Rate for Puerto Rico Hospitals

Section 412.374 provides for the use of a blended payment system for payments to hospitals located in Puerto Rico under the PPS for acute care hospital inpatient capital-related costs. Accordingly, under the capital PPS, we compute a separate payment rate specific to hospitals located in Puerto Rico 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 1, 2004, capital payments to hospitals located 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 0.9994, for a combined proposed cumulative adjustment of 1.0004.

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 2008, before application of the GAF, the special capital rate for hospitals located in Puerto Rico was $201.67 for discharges occurring on or after October 1, 2007, through September 30, 2008

(72 FR 66888). However, as discussed in greater detail in section

II.D. of the preamble of this proposed rule, we are revising this rate in a forthcoming correction notice that will be retroactive to

October 1, 2007, to remove the application of the 0.6 percent documentation and coding adjustment for FY 2008, consistent with the correction to the Puerto Rico specific standardized amount for FY 2008. The statute gives broad authority to the Secretary under section 1886(g) of the Act, with respect to the development of and adjustments to a capital PPS. Although we would not be outside the authority of section 1886(g) of the Act in applying the documentation and coding adjustment to the Puerto Rico-specific portion of the capital payment rate, we have historically made changes to the capital PPS consistent with those changes made to the

IPPS. Thus, we are removing the documentation and coding adjustment from the FY 2008 Puerto Rico-specific portion of the blended capital payment rate, consistent with its removal from the Puerto Rico- specific standardized amount under the IPPS for operating costs.

Furthermore, we are not proposing to apply the 0.9 percent documentation and coding adjustment to the proposed FY 2009 Puerto

Rico-specific portion of the blended capital payment. However, as also discussed in section II.D. of the preamble of this proposed rule, we may propose to apply such an adjustment to the Puerto Rico operating and capital rates in the future. With the changes we are proposing to make to the other factors used to determine the capital rate, the proposed FY 2009 special capital rate for hospitals in

Puerto Rico is $197.19.

B. Calculation of the Proposed Inpatient Capital-Related

Prospective Payments for FY 2009

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 the following adjustments:

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 2009, 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 eliminated 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

Page 23722

set of thresholds to identify outlier cases for both inpatient operating and inpatient capital-related payments. The proposed outlier thresholds for FY 2009 are in section II.A. of this

Addendum. For FY 2009, 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 $21,025.

An eligible hospital may also qualify for a special exceptions payment under Sec. 412.348(g) up through the 10th year beyond the end of the capital transition period if it meets the following criteria: (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 2009

Based on the latest forecast by Global Insight, Inc. (first quarter of 2008), we are forecasting the CIPI to increase 1.2 percent in FY 2009. This reflects a projected 1.9 percent increase in vintage-weighted depreciation prices (building and fixed equipment, and movable equipment), and a 2.9 percent increase in other capital expense prices in FY 2009, partially offset by 2.8 percent decline in vintage-weighted interest expenses in FY 2009.

The weighted average of these three factors produces the 1.2 percent increase for the CIPI as a whole in FY 2009.

IV. Proposed Changes to Payment Rates for Excluded Hospitals and

Hospital Units: Rate-of-Increase Percentages

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 services furnished in 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 of the regulations.)

We are proposing that the FY 2009 rate-of-increase percentage for cancer and children's hospitals and RNHCIs is the percentage increase in the FY 2009 IPPS operating market basket, estimated to be 3.0 percent. Consistent with our historical approach, if more recent data are available for the final rule, we will use those data to calculate the IPPS operating market basket. For this proposed rule, we are proposing to calculate the IPPS operating market basket for FY 2009 using the most recent data available. For cancer and children's hospitals and RNHCIs, the proposed FY 2009 rate-of- increase percentage that is applied to FY 2008 target amounts in order to calculate the proposed FY 2009 target amounts is based on

Global Insight, Inc.'s 2008 forecast of the IPPS operating market basket increase, in accordance with the applicable regulations at 42

CFR 413.40.

IRFs, IPFs, and LTCHs were previously paid 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 transitioning periods of varying lengths of time during which a portion of the prospective payment is based on cost-based reimbursement rules under 42 CFR Part 413 (certain providers do not receive a transitioning period or may elect to bypass the transition as applicable under 42 CFR part 412, subparts

N, O, and P.) We note that the various transitioning periods provided for under the IRF PPS, the IPF PPS, and the LTCH PPS have ended. 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 42 CFR part 413. Similarly, for cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the adjusted Federal prospective payment 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. Likewise, for cost reporting periods beginning on or after January 1, 2008, all IPFs are paid 100 percent of the

Federal per diem amount under the IPF PPS. Therefore, for cost reporting periods beginning on or after January 1, 2008, no portion of an IPF PPS payment is subject to 42 CFR part 413.

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, 4D-1, 4D-2, 4E, 4F, 4G, 4H, 4J, 5, 6A, 6B, 6C, 6D, 6E, 6F, 7A, 7B, 8A, 8B, 8C, 9A, 9C, 10, and 11 are presented below. The following tables discussed in section II. of the preamble of this proposed rule are available only through the

Internet on the CMS Web site at: http://www.cms.hhs.gov/

AcuteInpatientPPS/: Table 6G.--Additions to the CC Exclusions List;

Table 6H.--Deletions from the CC Exclusions List; Table 6I.--

Complete List of Complication and Comorbidity (CC) Exclusions; Table 6J.--Major Complication and Comorbidity (MCC) List; and Table 6K.--

Complication and Comorbidity (CC).

Page 23723

The tables presented in this section of the Addendum 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 2007; Hospital Wage Indexes for Federal Fiscal

Year 2009; Hospital Average Hourly Wages for Federal Fiscal Years 2007 (2003 Wage Data), 2008 (2004 Wage Data), and 2009 (2005 Wage

Data); and 3-Year Average of Hospital Average Hourly Wages

Table 3A.--FY 2009 and 3-Year Average Hourly Wage for Urban Areas by

CBSA

Table 3B.--FY 2009 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 and by State--FY 2009

Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas by CBSA and by State--FY 2009

Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA and by State--FY 2009

Table 4D-1.--Rural Floor Budget Neutrality Factors--FY 2009

Table 4D-2.--Urban Areas with Hospitals Receiving the Statewide

Rural Floor or Imputed Floor Wage Index--FY 2009

Table 4E.--Urban CBSAs and Constituent Counties--FY 2009

Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment

Factor (GAF) by CBSA--FY 2009

Table 4J.--Out-Migration Adjustment--FY 2009

Table 5.--List of 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 7A.--Medicare Prospective Payment System Selected Percentile

Lengths of Stay: FY 2007 MedPAR Update--December 2007 GROUPER V25.0

MS-DRGs

Table 7B.--Medicare Prospective Payment System Selected Percentile

Lengths of Stay: FY 2007 MedPAR Update--December 2007 GROUPER V26.0

MS-DRGs

Table 8A.--Proposed Statewide Average Operating Cost-to-Charge

Ratios-- March 2008

Table 8B.--Proposed Statewide Average Capital Cost-to-Charge

Ratios--March 2008

Table 8C.--Proposed Statewide Average Total Cost-to-Charge Ratios for LTCHs--March 2008

Table 9A.--Hospital Reclassifications and Redesignations--FY 2009

Table 9C.--Hospitals Redesignated as Rural under Section 1886(d)(8)(E) of the Act--FY 2009

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 Medicare Severity Diagnosis-Related

Group (MS-DRG)--March 2008

Table 11.--Proposed FY 2009 MS-LTC-DRGs, Proposed Relative Weights,

Proposed Geometric Average Length of Stay, and Proposed Short-Stay

Outlier Threshold

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 (3.0 percent)

Reduced update (1.0 percent)

Labor-related

Nonlabor-related

Labor-related Nonlabor-related

$3,553.98

$1,544.98

$3,484.97

$1,514.98

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 (3.0 percent)

Reduced update (1.0 percent)

Labor-related

Nonlabor-related

Labor-related Nonlabor-related

$3,161.36

$1,937.60

$3,099.97

$1,899.98

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

Rates if wage index

Rates if wage index less greater than 1

than or equal to 1

Labor

Nonlabor

Labor

Nonlabor

National....................................................

$3,553.98

$1,544.98

$3,161.36

$1,937.60

Puerto Rico.................................................

1,501.82

920.46

1,421.88

1,000.40

Table 1D.--Capital Standard Federal Payment Rate

Rate

National....................................................

$421.29

Puerto Rico.................................................

197.19

Page 23724

Table 2.--Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2007; Hospital Wage Indexes for Federal Fiscal Year 2009; Hospital

Average Hourly Wages for Federal Fiscal Years 2007 (2003 Wage Data), 2008 (2004 Wage Data) and 2009 (2005 Wage Data); and 3-Year Average of Hospital

Average Hourly Wages

Average

Average

Average

Average

Provider No.

Case-mix index FY 2009 wage hourly wage FY hourly wage FY hourly wage FY hourly wage**

\2\

index

2007

2008

2009 \1\

(3 years)

010001..................................................

1.5513

0.8397

22.1989

23.2195

24.7672

23.3821 010005..................................................

1.1192

0.8636

23.6022

23.0203

25.7755

24.1406 010006..................................................

1.4819

0.7883

23.4975

23.7502

25.0258

24.0951 010007..................................................

1.0611

0.7647

19.9329

21.3492

22.0185

21.1334 010008..................................................

1.0242

0.7821

17.9533

22.0793

23.2562

20.8430 010009..................................................

0.9973

0.8636

23.5626

25.9011

25.8405

25.1048 010010..................................................

1.0945

0.8786

27.0385

22.8602

24.8375

24.7458 010011..................................................

1.6762

0.8786

27.6658

27.4668

27.1978

27.4380 010012..................................................

1.1633

0.9524

24.4059

25.5767

26.4968

25.4682 010015..................................................

1.0453

0.7693

22.3383

27.0806

23.6811

24.1695 010016..................................................

1.5794

0.8786

24.6488

26.8611

28.9705

26.8024 010018..................................................

1.4886

0.8786

23.7048

24.8974

26.9498

25.1709 010019..................................................

1.2556

0.7883

22.8766

23.3460

25.0154

23.7418 010021..................................................

1.2285

0.7677

19.7367

21.0624

21.7592

20.8458 010022..................................................

0.9940

0.9760

25.8404

27.4318

28.7520

27.3475 010023..................................................

1.7665

0.8192

25.4272

26.1739

27.0693

26.2901 010024..................................................

1.5997

0.8192

22.0819

25.0715

26.6617

24.5911 010025..................................................

1.2929

0.8495

22.7635

23.6186

23.8602

23.4229 010027..................................................

0.7391

0.7662

16.4682

17.0513

18.2507

17.2827 010029..................................................

1.5947

0.8495

23.9007

25.0468

24.3605

24.4407 010032..................................................

0.8805

0.7972

19.3311

18.5545

20.8446

19.6445 010033..................................................

2.1342

0.8786

27.4181

29.1471

29.2005

28.6046 010034..................................................

1.0166

0.8192

17.7457

19.1549

21.2713

19.3572 010035..................................................

1.2478

0.8786

24.2425

24.2746

26.5285

25.0065 010036..................................................

1.1526

0.7647

21.5796

24.2887

23.7923

23.2285 010038..................................................

1.3336

0.8054

23.7039

27.0752

28.9624

26.4786 010039..................................................

1.6454

0.8987

26.9919

28.6462

29.8012

28.4927 010040..................................................

1.6515

0.8052

24.3207

24.7657

25.9851

25.0414 010043..................................................

1.0854

0.8786

21.9774

23.9121

25.3624

23.7097 010044..................................................

1.0626

0.7647

22.5009

24.4276

23.4009

23.4233 010045..................................................

1.1529

0.7869

20.4927

23.1695

23.5160

22.3334 010046..................................................

1.5241

0.8052

23.4219

25.9105

25.4444

24.8777 010047..................................................

0.8836

0.7774

26.4851

19.7542

21.7347

22.0981 010049..................................................

1.1411

0.7662

21.7888

22.4248

23.1186

22.4564 010050..................................................

1.0831

0.8786

22.9620

24.4060

25.3663

24.2272 010051..................................................

0.8989

0.8695

18.7701

18.0305

20.0755

18.9088 010052..................................................

0.8813

0.8192

25.9233

36.3638

23.4990

28.7904 010054..................................................

1.1310

0.8636

23.3624

24.4810

25.4189

24.4485 010055..................................................

1.5957

0.8322

22.5396

22.4145

25.3295

23.4244 010056..................................................

1.5856

0.8786

23.7398

24.5754

25.7272

24.7305 010058..................................................

1.0206

0.8786

19.5092

17.0150

31.1856

21.2663 010059..................................................

1.0080

0.8636

23.0012

24.8199

27.8607

25.3457 010061..................................................

0.9842

0.8740

24.1185

25.2454

25.5878

24.9798 010062..................................................

1.0319

0.7718

21.4805

21.7112

22.9481

22.0341 010064..................................................

1.7124

0.8786

24.8155

27.6149

26.6313

26.3101 010065..................................................

1.5119

0.8786

23.0477

24.3346

24.5833

24.0058 010066..................................................

0.8885

0.7647

19.8692

25.4612

25.6055

23.6384 010068..................................................

***

*

22.7156

24.4145

*

23.5620 010069..................................................

0.9721

0.7647

23.1243

23.6272

27.3424

24.6217 010072..................................................

***

*

24.4989

*

*

24.4989 010073..................................................

0.9451

0.7647

18.3963

19.0046

20.7832

19.3949 010078..................................................

1.6130

0.8054

23.5279

24.3828

25.2879

24.4148 010079..................................................

1.2409

0.8987

22.7337

22.3034

23.1015

22.7293 010083..................................................

1.1817

0.8115

22.4279

24.0036

25.0403

23.8754 010084..................................................

***

*

26.3238

26.5079

27.5054

26.7172 010085..................................................

1.3040

0.8636

24.2609

23.6280

24.0460

23.9691 010086..................................................

1.0270

0.7647

22.2096

21.5584

26.8993

23.3292 010087..................................................

2.2105

0.7809

22.4318

24.8320

26.2401

24.3812 010089..................................................

1.2944

0.8786

25.0811

26.2628

25.9704

25.7574 010090..................................................

1.7257

0.8030

26.0494

26.3957

25.6095

26.0158 010091..................................................

0.9075

0.7693

23.1310

22.5272

23.6554

23.1156 010092..................................................

1.4953

0.8695

26.6796

26.9959

28.5598

27.4270 010095..................................................

0.8389

0.8695

16.5250

17.0024

17.8242

17.1161 010097..................................................

0.7528

0.8192

19.4511

19.2481

18.4215

18.9973 010099..................................................

0.9928

0.7647

20.8383

20.6736

22.3677

21.2837 010100..................................................

1.7251

0.8115

23.8919

25.1460

25.4338

24.8850 010101..................................................

1.1737

0.8786

24.2575

25.0974

26.2731

25.2372

Page 23725

010102..................................................

0.9506

0.8192

25.6158

26.9859

26.6935

26.4289 010103..................................................

1.8628

0.8786

27.8272

28.9636

30.4015

29.0796 010104..................................................

1.8548

0.8786

27.6471

28.3126

30.4938

28.7438 010108..................................................

1.0595

0.8192

24.6740

25.4325

26.8882

25.7625 010109..................................................

0.9572

0.8098

17.6733

21.0449

21.9296

20.0804 010110..................................................

0.7382

0.7862

26.0038

19.8738

22.1164

22.5113 010112..................................................

0.9794

0.7647

17.1833

20.4027

21.3150

19.6839 010113..................................................

1.6320

0.7809

22.3282

24.7170

25.0689

24.0138 010114..................................................

1.4032

0.8786

25.6152

25.7090

25.3646

25.5596 010118..................................................

1.2125

0.8192

21.4630

22.7191

25.3678

23.1085 010120..................................................

1.0320

0.7647

20.9019

22.1868

22.8170

21.9915 010125..................................................

1.0385

0.8123

21.5123

22.8911

23.6542

22.7013 010126..................................................

1.1498

0.8192

23.9327

24.4957

25.7234

24.7205 010128..................................................

0.9062

0.7693

23.6647

24.9881

25.9417

24.9328 010129..................................................

1.0676

0.7781

22.1574

21.8502

24.4806

22.8945 010130..................................................

1.0051

0.8786

23.7528

24.5644

25.2775

24.5383 010131..................................................

1.3760

0.8987

26.4297

27.2707

28.0468

27.2971 010137..................................................

1.2318

0.8786

27.5782

28.5843

30.4347

28.8905 010138..................................................

0.6210

0.7713

16.7602

14.5551

15.0814

15.4264 010139..................................................

1.5846

0.8786

26.8726

28.1473

29.3543

28.1531 010143..................................................

1.2041

0.8636

26.2762

24.0674

25.0859

25.0921 010144..................................................

1.7285

0.7809

22.5133

22.3916

23.8581

22.9469 010145..................................................

1.4494

0.8695

24.5092

25.8293

27.3277

25.8981 010146..................................................

1.1251

0.8054

22.6586

22.6879

23.7803

23.0525 010148..................................................

0.8893

0.7647

23.9246

23.5714

25.0949

24.1955 010149..................................................

1.2271

0.8192

24.4805

25.4354

26.8895

25.7355 010150..................................................

0.9968

0.8192

23.6080

24.4098

25.0060

24.3378 010152..................................................

1.2632

0.7809

22.4075

23.7803

26.0777

24.1152 010157..................................................

1.1630

0.7883

23.3828

24.2206

27.1156

24.7415 010158..................................................

1.2536

0.7883

23.5533

25.5905

26.2350

25.0899 010162..................................................

***

*

33.8777

*

*

33.8777 010163..................................................

***

*

*

34.0325

*

34.0325 010164..................................................

1.2261

0.8786

*

23.2447

25.6659

24.4751 010165..................................................

***

*

*

28.8040

*

28.8040 010166..................................................

***

*

*

29.7256

*

29.7256 010167..................................................

1.6912

0.8786

*

*

*

* 010168..................................................

1.3124

0.9061

*

*

*

* 020001..................................................

1.7281

1.1884

35.4232

36.5298

38.1754

36.7192 020004..................................................

***

*

31.8004

*

*

31.8004 020006..................................................

1.2847

1.1884

34.3752

37.0211

37.2838

36.2129 020008..................................................

1.2046

1.1884

36.1250

39.3432

40.6758

38.7262 020012..................................................

1.3619

1.1884

32.5975

33.9375

36.1891

34.2975 020014..................................................

1.0617

1.1884

29.4472

30.9722

30.6325

30.3727 020017..................................................

2.0201

1.1884

35.4119

35.8804

38.2137

36.5154 020018..................................................

0.9475

1.9292

*

*

*

* 020019..................................................

0.9038

*

*

*

*

* 020024..................................................

1.1768

1.1884

29.5195

38.6934

39.9916

35.5845 020026..................................................

1.5400

1.9292

*

*

*

* 020027..................................................

0.9585

1.9292

*

*

*

* 030001..................................................

1.5351

1.0271

32.4791

33.4178

35.9045

33.8225 030002..................................................

2.1087

1.0271

30.2200

31.0818

32.9061

31.4265 030006..................................................

1.7187

0.9442

27.0599

27.7421

29.1218

28.0025 030007..................................................

1.4597

1.1305

31.1928

33.7213

35.5193

33.5056 030009..................................................

***

*

26.5408

*

*

26.5408 030010..................................................

1.4417

0.9442

28.5684

30.6261

31.8606

30.4135 030011..................................................

1.5335

0.9442

28.1423

28.8203

30.2062

29.0981 030012..................................................

1.4301

1.0198

27.3895

29.1042

31.3041

29.3702 030013..................................................

1.5318

0.9903

27.0111

31.2815

31.9135

30.1305 030014..................................................

1.5815

1.0271

29.6582

29.8296

30.6276

30.0779 030016..................................................

1.2770

1.0271

29.1980

30.7896

31.1854

30.4653 030017..................................................

2.0581

1.0271

30.6007

34.4852

34.8458

33.3763 030018..................................................

1.3639

1.0271

29.4566

31.8056

31.7220

31.0137 030019..................................................

1.3016

1.0271

29.5921

30.1934

33.6528

31.0565 030022..................................................

1.8063

1.0271

30.5710

30.3746

35.0728

31.9469 030023..................................................

1.8138

1.1652

34.2142

35.8287

37.5481

35.8798 030024..................................................

2.1440

1.0271

31.9247

33.1797

35.6078

33.6344 030030..................................................

1.6952

1.0271

32.0994

34.4166

36.4747

34.2670

Page 23726

030033..................................................

1.3116

1.1305

28.7508

29.9383

32.0342

30.2702 030036..................................................

1.5415

1.0271

30.9834

33.0523

36.2020

33.6063 030037..................................................

1.9894

1.0271

31.2877

34.1079

35.1314

33.3937 030038..................................................

1.6433

1.0271

29.9314

31.7238

31.2906

31.0104 030040..................................................

***

*

27.5322

*

*

27.5322 030043..................................................

1.2301

0.8857

26.5834

27.3856

28.3147

27.4531 030055..................................................

1.4731

1.0011

27.1473

27.1621

30.9311

28.4812 030060..................................................

1.1614

*

24.8373

*

*

24.8373 030061..................................................

1.6370

1.0271

28.0696

28.1337

33.0826

29.7496 030062..................................................

1.2360

0.8857

26.6880

28.9587

29.9331

28.5898 030064..................................................

2.0334

0.9442

28.3853

29.8226

31.6603

30.0071 030065..................................................

1.6347

1.0271

29.5883

31.0817

31.4568

30.7651 030067..................................................

1.0057

0.9155

20.7591

27.4497

27.0766

25.0396 030068..................................................

1.1245

0.8857

23.1394

23.8792

26.0276

24.3896 030069..................................................

1.4761

1.1254

30.2224

29.7802

30.7696

30.2553 030071..................................................

1.0045

1.4448

*

*

*

* 030073..................................................

1.1300

1.4448

*

*

*

* 030074..................................................

0.9181

1.4448

*

*

*

* 030077..................................................

0.8053

1.4448

*

*

*

* 030078..................................................

1.1355

1.4448

*

*

*

* 030080..................................................

***

*

27.1360

28.6568

30.7660

28.9576 030083..................................................

1.3493

1.0271

27.4983

33.5302

35.8488

32.0946 030084..................................................

1.0175

1.4448

*

*

*

* 030085..................................................

1.6306

0.9442

26.8364

28.1388

29.0750

28.0469 030087..................................................

1.7040

1.0271

29.5962

31.2331

31.1070

30.6895 030088..................................................

1.3727

1.0271

27.8604

29.9758

30.5716

29.5054 030089..................................................

1.5952

1.0271

28.9068

30.1591

31.3148

30.1497 030092..................................................

1.5055

1.0271

31.7512

30.6343

30.4361

30.8516 030093..................................................

1.3209

1.0271

26.4430

27.8821

33.0699

29.2816 030094..................................................

1.5460

1.0271

31.5422

33.4050

34.2007

33.1194 030099..................................................

0.9137

0.8857

27.1402

26.9227

24.9115

26.3285 030100..................................................

2.0982

0.9442

31.5628

34.7532

35.0944

33.8057 030101..................................................

1.4909

1.1388

27.8302

30.6764

33.2110

30.6802 030102..................................................

2.4535

1.0271

31.6285

33.6247

36.9492

34.0941 030103..................................................

1.7698

1.0271

31.7322

32.2833

33.9387

32.6963 030105..................................................

2.3493

1.0271

31.2970

32.7449

33.9846

32.7833 030106..................................................

1.5634

1.0271

32.9840

36.4667

40.1625

36.8304 030107..................................................

1.9107

1.0271

35.6197

35.5386

35.4524

35.5298 030108..................................................

2.0613

1.0271

*

29.9395

34.8483

32.9293 030109..................................................

***

*

16.5906

*

*

16.5906 030110..................................................

1.6838

1.0271

31.4852

29.7949

36.2124

32.4772 030111..................................................

1.0463

0.9442

*

33.3711

28.5133

30.2230 030112..................................................

2.0028

1.0271

*

36.6601

33.4776

34.6249 030113..................................................

0.9099

1.4448

*

*

*

* 030114..................................................

1.4838

0.9442

*

*

28.8439

28.8439 030115..................................................

1.4714

1.0271

*

*

32.5857

32.5857 030117..................................................

1.2494

0.9817

*

*

*

* 030118..................................................

1.1423

1.0198

*

*

*

* 030119..................................................

1.2774

1.0271

*

*

*

* 030120..................................................

0.8689

1.0271

*

*

*

* 030121..................................................

1.0784

1.0271

*

*

*

* 040001..................................................

1.0747

0.9131

22.9327

22.9948

24.4950

23.4592 040002..................................................

1.1735

0.7641

21.2020

25.0000

24.0479

23.3250 040004..................................................

1.6814

0.9131

27.1741

28.1117

29.2695

28.2056 040007..................................................

1.7434

0.8754

40.1291

29.1941

27.4839

32.0643 040010..................................................

1.4746

0.9131

24.2315

26.5287

28.2363

26.3909 040011..................................................

1.0296

0.7641

21.0967

22.2431

22.6320

22.0004 040014..................................................

1.3517

0.8650

26.4777

28.9855

34.8259

29.4945 040015..................................................

1.1207

0.7641

20.4279

20.1061

22.3145

20.9794 040016..................................................

1.7125

0.8754

25.8056

26.5911

26.4787

26.3029 040017..................................................

1.1221

0.8952

21.9147

23.8768

24.3768

23.3605 040018..................................................

1.1123

0.7843

24.0026

25.6751

26.2511

25.2931 040019..................................................

1.0410

0.8909

23.8706

24.9113

26.4915

25.0680 040020..................................................

1.6290

0.8909

22.6497

23.9470

26.1519

24.2422 040021..................................................

1.5502

0.8754

25.4046

26.1853

27.6779

26.3611 040022..................................................

1.4648

0.9131

29.5000

27.9902

30.0234

29.1589 040026..................................................

1.5430

0.9146

27.7931

29.5299

31.8579

29.7126

Continued on page 23727

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

]

pp. 23727-23776

Medicare Program; Proposed Changes to the Hospital Inpatient

Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed

Changes to Disclosure of Physician Ownership in Hospitals and Physician

Self-Referral Rules; Proposed Collection of Information Regardi[Page 23727]

Continued from page 23726

Page 23727

040027..................................................

1.5239

0.8477

21.4252

23.8220

25.7922

23.6373 040029..................................................

1.4258

0.8754

24.8409

25.1479

27.8865

25.9688 040036..................................................

1.6268

0.8754

27.6234

29.7150

30.4885

29.2730 040039..................................................

1.2296

0.8291

21.2712

21.4819

22.9798

21.9027 040041..................................................

1.1562

0.8650

23.7787

26.4964

26.4417

25.5529 040042..................................................

1.2893

0.9329

21.1716

19.8709

23.1648

21.3821 040047..................................................

1.0408

0.7758

22.4249

23.0358

23.3547

22.9631 040050..................................................

1.1948

0.7641

17.6906

18.5119

19.6944

18.6284 040051..................................................

0.9470

0.7641

21.3342

22.0394

22.1983

21.8575 040054..................................................

***

*

18.0509

19.5353

*

18.7591 040055..................................................

1.5598

0.7843

23.0448

24.9164

26.0132

24.6243 040062..................................................

1.6247

0.7843

23.8994

25.2303

25.6541

24.9287 040067..................................................

1.1145

0.7648

19.0471

18.9872

20.9688

19.6151 040069..................................................

1.0608

0.8909

24.8060

24.9996

23.3108

24.3661 040071..................................................

1.5798

0.8650

25.4680

25.2840

26.6629

25.8031 040072..................................................

1.1274

0.7641

22.4741

22.1058

22.9668

22.5262 040074..................................................

1.2633

0.8754

25.2699

26.2661

27.3878

26.2955 040076..................................................

0.9952

0.8650

23.5742

23.0954

24.7891

23.8273 040078..................................................

1.6712

0.8650

23.5915

26.1937

25.6870

25.0529 040080..................................................

1.0467

0.8291

24.1921

24.8760

26.5895

25.2945 040081..................................................

0.8888

0.7998

16.8437

17.2536

18.4756

17.5296 040084..................................................

1.2389

0.8754

27.7626

26.6449

28.1552

27.5095 040085..................................................

1.0085

0.8909

22.9916

25.7215

26.6972

25.1591 040088..................................................

1.6650

0.7789

22.4860

23.6276

24.7107

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1.1951

0.8093

24.2398

23.1913

22.3295

23.2265 040100..................................................

***

*

21.3051

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24.5448

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1.8332

0.8754

26.7581

27.7928

28.5682

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1.5334

0.8291

26.0388

26.8908

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1.3884

0.8650

24.3680

24.2419

25.6769

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***

*

15.6985

17.3715

*

16.4167 040132..................................................

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*

*

22.0054

21.8131

21.8928 040134..................................................

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0.8754

31.9325

32.2832

34.9636

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0.8754

25.9979

27.7360

27.7619

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28.3342

33.0048

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0.9131

26.1041

30.3475

33.8758

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1.5543

0.9146

21.4222

23.8620

23.1293

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***

*

37.1976

*

*

37.1976 040144..................................................

***

*

21.4008

*

*

21.4008 040145..................................................

1.7933

0.8291

*

24.4367

20.3865

22.2702 040146..................................................

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*

*

33.7876

*

33.7876 040147..................................................

1.7491

0.8754

*

*

35.7643

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1.3585

0.8754

*

*

*

* 050002..................................................

1.4597

1.5288

35.5184

41.7336

43.1732

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43.0584

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43.4884

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36.0305

37.4135

39.4733

37.6850 050015..................................................

1.6268

*

32.2188

*

*

32.2188 050016..................................................

1.3208

1.1925

24.5768

31.0653

34.4877

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37.3760

40.3326

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45.4887

48.2283

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25.0150

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*

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34.8660

36.5384

37.4961

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1.1916

32.0133

30.4274

37.1909

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1.5278

47.3449

48.8994

48.2983

48.1333 050082..................................................

1.6600

1.1822

38.2878

37.8905

42.1694

39.4148 050084..................................................

1.5667

1.1954

35.5196

39.5748

41.0288

38.7442 050089..................................................

1.3670

1.1822

33.9593

36.4018

39.2412

36.5180 050090..................................................

1.2562

1.4879

33.8953

37.7421

41.5994

37.7203 050091..................................................

1.0354

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32.1301

37.1223

40.1032

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1.1822

36.9481

36.8486

37.7213

37.1762 050095..................................................

***

*

*

*

44.2364

44.2364 050096..................................................

1.2641

1.1916

34.9237

33.1322

33.3800

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42.4589

47.9327

48.7447

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32.5846

33.5687

36.6966

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1.2827

38.8672

42.0131

43.0409

41.3295 050110..................................................

1.2335

1.1822

26.8408

28.0670

30.9036

28.6069 050111..................................................

1.1657

1.1916

28.7875

31.8766

31.9371

30.8306 050112..................................................

1.5363

1.1916

37.7281

38.9483

39.9904

38.9358 050113..................................................

1.1706

1.5025

39.4882

42.8884

46.3447

42.8008 050114..................................................

***

*

34.0309

35.7274

37.5895

35.8060 050115..................................................

1.4716

1.1822

28.8051

32.5257

33.8575

31.7873 050116..................................................

1.6387

1.1916

36.8825

37.6018

39.1213

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*

34.2020

35.0531

*

34.3889 050118..................................................

1.2470

1.1963

39.9683

41.6701

41.8166

41.1955 050121..................................................

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1.1822

30.6105

34.6244

35.1123

33.4898 050122..................................................

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1.1954

33.9812

34.0259

36.8803

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30.2522

29.9944

31.7666

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44.9523

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43.3747

46.6619

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39.4954

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*

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48.0796

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46.7040 050146..................................................

1.8140

*

*

*

*

* 050148..................................................

1.0935

*

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*

*

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*

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*

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*

*

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1.1963

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27.1400

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33.9520

29.0623

36.7215

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44.7107

49.0030

49.8490

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1.5288

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53.5583

57.6511

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34.0956

32.8293

41.1280

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1.5758

50.0728

52.9998

55.2982

52.8587 050204..................................................

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1.1916

32.0121

35.3954

38.8654

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1.1916

29.3334

30.6322

30.6087

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*

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*

30.6661 050211..................................................

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1.5288

35.0515

35.0289

42.9220

37.8234 050214..................................................

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25.4647

*

*

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*

48.8112

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*

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34.0600

35.8490

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32.1813

33.7139

37.0216

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26.3004

34.3242

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34.8308

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30.5405

37.0858

39.1708

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33.0686

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35.9041

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*

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46.4844

50.9882

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33.2556

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*

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*

27.8452

*

*

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23.5381

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*

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33.0865

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47.7024

43.4181

48.0876

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*

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*

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*

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38.2659

40.1499

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*

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*

*

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37.0441

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23.2927

33.0390

36.7650

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1.1822

19.6352

18.6534

32.2010

21.9629 050334..................................................

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1.4671

43.9656

47.2968

50.9796

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1.3834

1.1963

30.9928

34.7192

37.2324

34.3853 050336..................................................

1.2384

1.1954

30.4664

31.5480

33.0304

31.7345 050342..................................................

1.2489

1.1822

29.2244

30.4226

29.8368

29.8437 050348..................................................

1.7714

1.1822

31.5156

32.7107

33.5253

32.6280 050349..................................................

0.9688

1.1822

24.4863

25.4266

23.1089

24.2535 050350..................................................

1.4256

1.1916

31.0136

31.7908

34.0896

32.2951 050351..................................................

1.5307

1.1916

30.6599

33.3064

35.0010

33.0083 050352..................................................

1.3551

1.2827

36.7673

37.0807

38.6234

37.4921 050353..................................................

1.5204

1.1916

29.4215

30.4206

37.1683

32.2253 050357..................................................

1.5056

1.1822

32.6763

36.2089

38.9202

35.9956 050359..................................................

1.1869

1.1822

29.8345

31.3391

30.3963

30.5262 050360..................................................

1.5234

1.5278

47.4497

52.3811

53.4113

51.1213 050366..................................................

1.1511

1.1837

33.6714

37.1527

41.8302

37.3699 050367..................................................

1.4838

1.5278

38.6330

40.1904

40.0423

39.6594 050369..................................................

1.4765

1.1916

30.6439

32.2467

33.3330

32.1001 050373..................................................

1.4477

1.1916

35.1380

34.3737

37.6802

35.7093 050376..................................................

1.7774

1.1916

34.3539

35.2837

36.6487

35.4753 050378..................................................

1.0502

1.1916

37.9904

40.1923

42.0465

40.0787 050380..................................................

1.6776

1.5766

46.0276

49.4258

52.5752

49.4098 050382..................................................

1.4478

1.1916

30.4014

32.6683

32.9220

31.9903 050385..................................................

1.2993

1.4879

36.8107

36.4188

36.5610

36.5948 050390..................................................

1.1220

1.1822

27.3183

27.9359

33.0438

29.3100 050391..................................................

***

*

17.2141

*

*

17.2141 050393..................................................

1.3848

1.1916

34.1743

35.6356

35.1855

35.0078 050394..................................................

1.6185

1.1822

27.4861

32.1894

32.1720

30.6682 050396..................................................

1.5625

1.1822

32.4918

37.3972

38.9901

36.2041 050397..................................................

0.8787

1.1822

28.3671

29.6825

31.1603

29.8101 050407..................................................

1.1900

1.4905

42.2748

44.6839

47.5560

44.8602 050411..................................................

1.3207

1.1916

38.8294

38.6328

44.7079

40.9918 050414..................................................

1.3194

1.2827

38.7585

41.8688

45.0472

42.0484 050417..................................................

1.3093

1.1822

32.9341

36.1222

37.0117

35.4225 050420..................................................

***

*

35.2869

39.9237

*

37.6935 050423..................................................

1.0114

1.1822

28.3768

31.9751

32.4104

31.1452 050424..................................................

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1.1822

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36.6091

37.5218

36.2762 050425..................................................

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1.2827

49.2245

46.6628

45.7794

47.0234 050426..................................................

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1.1822

33.2031

34.9855

37.6483

35.2291 050430..................................................

0.9394

1.1822

23.9045

24.5327

25.9363

24.7203 050432..................................................

***

*

33.1876

35.2416

*

34.2247 050433..................................................

***

*

21.3573

21.1287

23.0629

21.6609 050434..................................................

0.9988

1.1822

32.6255

33.7794

35.4799

33.9524 050435..................................................

1.1984

1.1822

30.6530

33.0372

35.7401

33.2043 050438..................................................

1.5503

1.1916

36.3026

36.2044

38.2823

36.9424 050441..................................................

1.9553

1.5766

44.5694

46.6160

49.2095

46.8421 050444..................................................

1.4083

1.2202

34.6313

37.6821

39.3915

37.5291 050447..................................................

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1.1822

26.7960

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32.6666

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40.2811

43.3674

40.8320 050455..................................................

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1.1822

30.4606

34.5445

35.0200

33.3430 050456..................................................

***

*

21.6261

27.7659

27.9693

25.0702 050457..................................................

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47.8947

50.0282

53.3144

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1.1963

38.3058

41.6235

42.6660

40.8465 050468..................................................

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1.1916

31.1111

35.7409

37.3361

34.8277 050469..................................................

***

*

30.6502

*

*

30.6502 050470..................................................

***

*

27.8678

31.0466

32.5012

30.5202 050471..................................................

1.7119

1.1916

35.4768

36.8680

36.4887

36.2903 050476..................................................

1.4110

1.4497

38.7856

41.1042

40.5395

40.1623 050477..................................................

***

*

37.7668

40.1566

*

39.0877 050478..................................................

1.0325

1.1822

40.2558

41.1668

41.5592

41.0379 050481..................................................

1.5130

1.1916

36.1394

38.8650

42.8499

39.2898 050485..................................................

1.6505

1.1916

36.1488

34.6219

34.7050

35.1967 050488..................................................

1.4378

1.5288

42.6854

45.0630

47.1937

45.0874 050491..................................................

***

*

34.3598

*

*

34.3598 050492..................................................

1.3241

1.1822

28.0826

30.7718

32.6577

30.4668 050494..................................................

1.4344

1.2710

38.1177

40.6384

42.3086

40.3782 050496..................................................

1.6970

1.5278

48.2468

51.6363

51.1433

50.4172 050498..................................................

1.3475

1.2827

37.1667

41.0350

42.2469

40.1486 050502..................................................

1.6482

1.1916

28.7046

31.8872

32.9773

31.1609 050503..................................................

1.5152

1.1822

34.0994

37.3605

37.7183

36.4438 050506..................................................

1.5249

1.1925

37.7420

39.8586

40.6497

39.4417 050510..................................................

1.3370

1.5278

52.5376

49.4533

51.3691

51.0324 050512..................................................

1.4990

1.5288

50.9264

48.8057

50.1599

49.9366 050515..................................................

1.3185

1.1822

38.9542

40.2957

41.0328

40.1925 050516..................................................

1.5093

1.2827

39.8161

43.0249

45.5247

42.8485 050517..................................................

1.2967

1.1822

20.0213

22.4096

29.3674

23.6394 050523..................................................

1.2869

1.5278

40.6535

43.4579

46.9830

43.8643 050526..................................................

1.1843

1.1822

28.1997

33.3964

35.5437

32.2787 050528..................................................

1.1507

1.1822

31.4941

36.2908

38.3022

35.4339 050531..................................................

1.0520

1.1916

27.1974

28.3348

28.4865

28.0127 050534..................................................

1.4315

1.1822

33.1666

36.6447

38.1859

36.0367 050535..................................................

***

*

34.6143

37.8174

*

36.2328 050537..................................................

1.4828

1.2827

34.9931

38.2145

40.1908

37.8814 050541..................................................

1.4378

1.5758

52.5908

48.0867

51.5270

50.6366 050543..................................................

0.7526

1.1822

29.4443

24.4913

32.8347

28.6007 050545..................................................

0.7226

1.1916

31.3080

35.3209

*

33.2475 050546..................................................

0.6945

1.1822

33.2245

36.5099

*

34.9356 050547..................................................

1.0205

1.4879

34.8401

33.8036

*

34.2850 050548..................................................

0.6180

1.1822

39.2234

41.1075

*

40.1570 050549..................................................

1.6510

1.1822

35.2792

38.3927

40.6759

38.1001 050550..................................................

***

*

30.9612

34.9476

39.2133

34.7849 050551..................................................

1.3452

1.1822

34.0467

37.2506

37.6198

36.3778 050552..................................................

0.9428

1.1916

33.0711

33.9810

35.3466

34.1389 050557..................................................

1.5993

1.1963

33.3654

35.7023

38.6871

35.9147 050561..................................................

1.4093

1.1916

38.0196

38.2543

39.1298

38.5223 050567..................................................

1.5110

1.1822

35.7063

37.6384

39.0084

37.5231 050568..................................................

1.2464

1.1822

25.2337

26.0908

26.7719

26.0576 050569..................................................

1.3207

*

31.6785

*

*

31.6785 050570..................................................

1.5519

1.1822

34.5161

38.4373

40.6719

37.8603 050571..................................................

***

*

34.7627

39.0649

*

36.9575 050573..................................................

1.5662

1.1822

34.7279

35.2842

36.8535

35.6371 050575..................................................

1.3192

1.1916

25.1457

23.7990

22.1000

23.5654 050577..................................................

***

*

32.3744

*

*

32.3744 050578..................................................

1.4310

1.1916

35.2390

31.3639

43.4883

36.9415 050579..................................................

***

*

42.5081

*

*

42.5081 050580..................................................

1.1517

1.1822

31.5806

34.1531

35.0950

33.6230 050581..................................................

1.4139

1.1916

34.0136

37.7567

40.0883

37.3040 050583..................................................

1.6442

1.1822

34.5747

37.4450

40.5818

37.4769 050584..................................................

1.4508

1.1839

30.3434

30.7839

31.9887

31.0588 050585..................................................

***

*

22.2521

*

*

22.2521 050586..................................................

1.3101

1.1822

26.4782

31.3513

31.1898

29.6927 050588..................................................

1.3759

1.1916

32.7556

37.7387

39.4229

36.6367 050589..................................................

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1.1822

34.5100

37.6886

37.2032

36.5093 050590..................................................

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38.4971

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Page 23732

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30.6106

34.7133

*

32.5892 050592..................................................

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*

27.3606

31.8053

32.2351

30.0884 050594..................................................

***

*

36.5256

42.0788

*

39.2148 050597..................................................

1.2983

1.1916

28.8294

31.5625

32.8964

31.1668 050599..................................................

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32.7835

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36.6122

34.7394 050601..................................................

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36.0572

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43.2367

39.7359 050603..................................................

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1.1822

34.0275

35.0279

35.4778

34.9101 050604..................................................

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1.5766

55.0821

49.4446

49.6225

50.8907 050608..................................................

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1.1822

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31.2909

30.7266

30.8122 050609..................................................

1.2511

1.1822

41.7208

39.7397

42.4128

41.2383 050613..................................................

***

*

42.8108

42.9930

*

42.8892 050615..................................................

***

*

35.9547

39.1299

*

37.5269 050616..................................................

1.4930

1.1822

37.7284

37.1200

40.8621

38.5549 050618..................................................

1.0232

1.1822

31.3182

33.1472

34.9156

33.1400 050624..................................................

1.3457

1.1916

33.9594

35.9346

39.2531

36.4371 050625..................................................

1.7610

1.1916

38.6591

41.0439

44.8446

41.6090 050633..................................................

1.2411

1.1925

36.8302

38.4916

40.7347

38.7394 050636..................................................

1.2748

1.1822

32.5576

33.0718

35.4525

33.7338 050641..................................................

1.3434

1.1916

39.6921

32.3586

32.0483

34.3171 050644..................................................

1.0499

1.1916

28.8237

30.7981

33.2746

30.9581 050660..................................................

1.7555

*

*

*

*

* 050662..................................................

0.7264

1.5766

33.2446

38.3017

*

35.5809 050663..................................................

1.4166

1.1916

27.7334

17.7035

17.8180

19.8971 050667..................................................

0.9359

1.3974

24.2771

25.9161

25.8444

25.2820 050668..................................................

1.2668

1.4905

56.6555

51.6049

52.6968

53.2587 050674..................................................

1.2833

1.2827

48.0893

47.0720

48.6658

47.9616 050677..................................................

1.3833

1.1916

38.5770

39.2161

40.7889

39.6370 050678..................................................

1.3254

1.1822

32.4473

33.7633

35.8378

34.1139 050680..................................................

1.2900

1.5278

38.2871

37.9856

39.0346

38.4541 050682..................................................

0.8353

1.1822

17.9077

22.2193

22.3883

20.9013 050684..................................................

1.1150

1.1822

27.5256

28.8378

33.5883

30.1544 050686..................................................

1.5945

1.1822

41.0188

39.7757

41.3815

40.7110 050688..................................................

1.2103

1.5766

44.1510

49.4062

53.2703

49.0705 050689..................................................

1.5822

1.5278

45.0951

48.8533

48.9898

47.6626 050690..................................................

1.3422

1.4879

50.9094

49.0226

51.7590

50.5850 050693..................................................

1.3899

1.1822

34.5797

39.6838

42.8232

38.9551 050694..................................................

1.0517

1.1822

30.7858

32.1065

34.8458

32.6630 050695..................................................

***

*

39.6004

49.0340

*

44.6756 050696..................................................

2.2640

1.1916

37.3837

39.8963

39.4330

38.9118 050697..................................................

1.1055

1.2730

16.6605

22.1441

26.7588

21.2675 050699..................................................

***

*

28.9083

21.5725

28.8973

26.4337 050701..................................................

1.3490

1.1822

31.9529

34.9876

37.2811

34.8704 050704..................................................

1.0435

1.1916

29.7740

31.6097

32.1995

31.2008 050707..................................................

***

*

35.7311

43.5555

44.0218

40.8918 050708..................................................

1.4932

1.1822

30.5860

31.8442

28.3051

30.2199 050709..................................................

1.4478

1.1822

26.8549

24.5621

29.5339

27.1486 050710..................................................

1.2058

1.1822

45.8022

44.2482

46.2957

45.4488 050713..................................................

***

*

21.1273

21.4825

*

21.2886 050714..................................................

1.4054

1.5818

31.9527

34.1542

42.9756

36.5738 050717..................................................

1.5439

1.1916

39.3227

38.8773

37.0867

38.4090 050718..................................................

***

*

25.5140

31.9622

*

28.5587 050720..................................................

0.9656

1.1822

29.4726

30.3595

32.1156

30.5944 050722..................................................

0.9138

1.1822

31.4867

33.7991

35.6698

33.7766 050723..................................................

1.3255

1.1916

38.5446

38.7140

41.1633

39.6081 050724..................................................

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1.1822

31.6910

35.2344

35.0980

34.1972 050725..................................................

0.8736

1.1916

24.3100

30.0580

28.8366

27.6830 050726..................................................

1.5371

1.1963

30.6479

28.6361

30.6054

29.9355 050727..................................................

1.3473

1.1916

33.9118

32.7783

33.0915

33.2499 050728..................................................

***

*

39.3581

41.8263

*

40.4993 050729..................................................

***

*

36.5432

38.1882

*

37.4033 050730..................................................

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*

37.0629

39.2046

*

38.1210 050732..................................................

2.3278

1.1822

*

33.6831

34.3456

34.0196 050733..................................................

1.5906

1.2730

*

40.1517

40.6287

40.3877 050734..................................................

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*

*

31.2883

*

31.2883 050735..................................................

1.3963

1.1916

*

*

36.6052

36.6052 050736..................................................

1.2104

1.1916

*

*

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41.8905 050737..................................................

1.4996

1.1916

*

*

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Page 23733

050738..................................................

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1.1916

*

*

43.9225

43.9225 050739..................................................

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1.1916

*

*

57.2436

57.2436 050740..................................................

1.4538

1.1916

*

*

54.0328

54.0328 050741..................................................

1.4520

1.1916

*

*

51.1485

51.1485 050742..................................................

1.4454

1.1916

*

*

39.0793

39.0793 050744..................................................

1.7412

1.1822

*

*

48.4913

48.4913 050745..................................................

1.3450

1.1822

*

*

42.5490

42.5490 050746..................................................

1.8196

1.1822

*

*

43.1981

43.1981 050747..................................................

1.5410

1.1822

*

*

44.5852

44.5852 050748..................................................

1.1344

1.1954

*

*

42.9957

42.9957 050749..................................................

1.3856

1.1822

*

*

28.1978

28.1978 050750..................................................

***

*

*

*

33.9880

33.9880 050751..................................................

2.9380

1.1916

*

*

29.5465

29.5465 050752..................................................

1.4092

1.1916

*

*

39.8004

39.8004 050753..................................................

1.6850

1.1916

*

*

*

* 050754..................................................

1.1933

1.5025

*

*

*

* 050755..................................................

1.3602

1.1916

*

*

*

* 050757..................................................

1.5947

1.1822

*

*

*

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1.3399

1.1822

*

*

*

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2.1683

1.1822

*

*

*

* 060001..................................................

1.5186

1.0070

29.6191

31.0018

32.4200

30.9988 060003..................................................

1.4098

1.0409

29.4809

31.3616

31.8621

30.9372 060004..................................................

1.1053

1.0561

32.4609

32.0095

34.8408

33.1185 060006..................................................

1.3131

0.9303

25.2139

27.2057

26.8067

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1.2609

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23.0947

26.5175

27.2059

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1.4736

1.0561

31.5210

32.4208

34.0129

32.6683 060010..................................................

1.5411

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27.1916

29.5304

30.6402

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1.5219

1.0561

35.1573

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34.4158

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1.5548

0.9738

27.3885

28.7724

29.4348

28.5090 060013..................................................

1.5942

0.9303

26.8675

27.9145

28.0786

27.6090 060014..................................................

1.8805

1.0561

31.0542

31.9389

33.0340

32.0056 060015..................................................

1.8679

1.0561

32.5285

32.2927

36.3270

33.6071 060016..................................................

1.1848

0.9303

26.5427

27.1430

28.3040

27.3080 060018..................................................

1.2897

0.9303

24.1086

25.3897

26.5770

25.3463 060020..................................................

1.5516

0.9303

24.5992

25.9147

26.7340

25.7382 060022..................................................

1.6011

0.9738

28.2944

29.3379

31.9353

29.8727 060023..................................................

1.6260

1.0409

29.5760

31.1556

32.7901

31.1705 060024..................................................

1.8688

1.0561

30.0279

31.5411

32.8183

31.5099 060027..................................................

1.5941

1.0409

29.6121

30.9212

31.6117

30.7134 060028..................................................

1.4266

1.0561

31.6900

32.1656

33.4942

32.4479 060030..................................................

1.4302

0.9734

27.8642

29.9513

31.2907

29.7046 060031..................................................

1.5357

1.0409

27.8345

29.3907

30.8385

29.3398 060032..................................................

1.4900

1.0561

31.0686

32.7383

34.6417

32.7827 060034..................................................

1.7145

1.0561

30.9359

32.1252

33.3625

32.1070 060036..................................................

1.0946

0.9303

20.3226

22.8256

20.9359

21.3443 060041..................................................

0.9254

0.9303

24.6142

25.9710

31.4722

27.2226 060043..................................................

0.9724

0.9303

18.2143

21.9955

23.3899

21.1620 060044..................................................

1.1929

0.9303

26.5611

24.8352

29.4060

26.8390 060049..................................................

1.4157

0.9581

29.3724

30.2192

32.1570

30.6358 060054..................................................

1.4812

0.9925

24.3389

25.0980

24.6714

24.6993 060064..................................................

1.7013

1.0561

32.3681

33.2428

37.2384

33.8162 060065..................................................

1.4081

1.0561

32.4735

33.8538

34.9177

33.7649 060071..................................................

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0.9303

27.6657

28.1762

31.5370

29.2648 060075..................................................

1.3842

0.9925

32.2545

37.6023

35.8069

35.2179 060076..................................................

1.2641

0.9303

26.5631

30.7808

31.6033

29.6210 060096..................................................

1.6188

1.0409

32.1310

37.8243

38.2230

36.0395 060100..................................................

1.7198

1.0561

32.6104

33.2145

33.5326

33.1192 060103..................................................

1.3654

1.0409

31.6314

32.9690

33.7519

32.8044 060104..................................................

1.4279

1.0561

32.4232

35.4409

37.1405

34.8954 060107..................................................

1.5071

1.0561

26.8388

28.0660

30.3986

28.4350 060112..................................................

1.6339

1.0561

34.9272

34.7116

35.1275

34.9373 060113..................................................

1.4241

1.0561

*

32.6073

35.2074

33.9039 060114..................................................

1.3878

1.0561

*

34.8536

35.3035

35.0938 060115..................................................

0.8560

0.9303

*

*

*

* 060116..................................................

1.2796

1.0409

*

*

33.1528

33.1528 060117..................................................

1.4396

0.9303

*

*

28.3098

28.3098 060118..................................................

1.4247

0.9303

*

*

*

*

Page 23734

060119..................................................

2.0319

0.9734

*

*

*

* 070001..................................................

1.5932

1.2038

35.8958

37.0403

37.9403

36.9862 070002..................................................

1.8116

1.1897

33.4398

34.7636

36.4240

34.8862 070003..................................................

1.1297

1.1897

34.1352

35.6320

36.0505

35.2926 070004..................................................

1.1791

1.1897

29.4448

29.9557

31.2093

30.2307 070005..................................................

1.4770

1.2038

33.7813

34.9404

36.5469

35.0801 070006..................................................

1.3529

1.2391

37.9148

39.3935

41.2133

39.5140 070007..................................................

1.2875

1.1897

35.9617

36.2914

36.8054

36.3570 070008..................................................

1.2515

1.1897

28.5506

30.7305

35.4942

31.5216 070009..................................................

1.3430

1.1897

32.9299

35.5670

36.6355

34.9997 070010..................................................

1.6851

1.2391

35.3730

36.7227

38.6086

36.9439 070011..................................................

1.4127

1.1897

31.8987

31.6843

34.1325

32.5714 070012..................................................

1.4106

1.1897

29.4216

31.9345

33.2459

31.5134 070015..................................................

1.4333

1.2391

35.3385

37.3454

39.9225

37.5863 070016..................................................

1.4989

1.2038

31.4930

33.2391

34.1238

32.9404 070017..................................................

1.3644

1.2038

34.0490

35.6456

37.5821

35.7978 070018..................................................

1.3783

1.2391

39.7515

41.8460

42.4745

41.4021 070019..................................................

1.3857

1.2038

34.5125

33.7246

35.8591

34.6869 070020..................................................

1.2985

1.1897

33.6453

32.9714

35.6515

34.1183 070021..................................................

1.1854

1.1897

36.9241

38.5623

39.7761

38.4026 070022..................................................

1.6626

1.2038

39.0462

40.2283

41.4692

40.2883 070024..................................................

1.3628

1.1897

35.2323

34.7419

36.8976

35.6415 070025..................................................

1.7385

1.1897

32.4085

34.5887

36.1293

34.3741 070027..................................................

1.4463

1.1897

29.8513

30.4433

33.5960

31.3085 070028..................................................

1.5690

1.2391

35.1966

38.0855

43.1846

38.7150 070029..................................................

1.2883

1.1897

30.9299

31.0662

32.8478

31.6076 070031..................................................

1.2891

1.2038

30.1915

30.4054

30.5906

30.4009 070033..................................................

1.4498

1.2391

40.1594

41.7955

44.6692

42.2677 070034..................................................

1.4240

1.2391

38.3965

40.1685

42.4078

40.3330 070035..................................................

1.2479

1.1897

30.7440

32.2766

33.4024

32.1114 070036..................................................

1.6115

1.1897

38.3413

42.3391

43.6345

41.4903 070038..................................................

0.8866

1.2038

25.7914

35.8053

29.9492

29.4507 070039..................................................

0.9487

1.2038

36.1369

34.7219

32.7121

34.7190 070040..................................................

1.0777

1.1897

*

*

*

* 080001..................................................

1.6391

1.0799

32.0105

33.5310

34.9490

33.5152 080002..................................................

***

*

29.6800

31.3391

33.0378

31.3601 080003..................................................

1.6226

1.0799

30.7697

34.3048

30.5113

31.8516 080004..................................................

1.5578

1.0645

30.1094

32.2443

34.3823

32.3013 080006..................................................

1.3096

1.0304

27.4749

28.8862

31.0299

29.2083 080007..................................................

1.4835

1.0909

30.1100

31.1645

33.4764

31.6259 090001..................................................

1.7487

1.1018

36.6577

38.3043

40.1629

38.3535 090003..................................................

1.2254

1.0670

31.0419

32.1960

32.8939

31.9877 090004..................................................

1.9209

1.1018

35.6964

37.3798

38.5646

37.2403 090005..................................................

1.4073

1.0670

33.0178

33.7448

35.2850

34.0306 090006..................................................

1.3917

1.0670

29.4912

31.3562

32.3448

31.0266 090008..................................................

1.2958

1.0670

32.0745

33.7471

36.6606

34.0292 090011..................................................

2.0065

1.1018

36.7579

38.0654

39.0086

37.9688 100001..................................................

1.4956

0.9092

26.4631

27.2809

27.8509

27.2111 100002..................................................

1.4292

1.0025

27.2350

28.7068

30.6650

28.8632 100006..................................................

1.6260

0.9189

29.1505

28.3673

28.9654

28.8205 100007..................................................

1.5846

0.9189

28.5702

29.0472

30.3800

29.3589 100008..................................................

1.6979

0.9865

29.1705

30.3392

32.1650

30.5829 100009..................................................

1.3613

0.9865

27.4424

27.8618

30.0468

28.3830 100012..................................................

1.6154

0.9502

28.4600

29.8353

30.8602

29.7781 100014..................................................

1.4551

0.9073

25.1524

27.4019

27.4048

26.6903 100015..................................................

1.2730

0.8993

26.0916

27.2483

28.6813

27.3086 100017..................................................

1.6234

0.9073

27.9654

28.2402

29.8685

28.7071 100018..................................................

1.6116

0.9820

30.2423

30.6545

32.8609

31.2755 100019..................................................

1.6071

0.9401

28.6630

30.3008

31.4521

30.1350 100020..................................................

***

*

27.1257

*

*

27.1257 100022..................................................

1.6470

1.0025

32.8088

36.7912

36.3330

35.3146 100023..................................................

1.5384

0.9073

25.2652

25.4270

27.1008

26.0111 100024..................................................

1.2924

0.9865

29.1894

29.5423

29.8902

29.5369 100025..................................................

1.7145

0.8633

23.3843

26.7013

27.1652

25.7513 100026..................................................

1.5761

0.8633

23.4730

26.0147

27.3027

25.6436 100027..................................................

***

*

18.9432

*

*

18.9432 100028..................................................

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0.9401

27.7497

27.5664

28.7776

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Page 23735

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31.5979

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26.3096

25.4476 100032..................................................

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27.8918

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30.2382

32.5568

30.7182 100038..................................................

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31.6657

32.8363

31.9625 100039..................................................

1.5743

1.0025

28.2531

29.3699

29.0221

28.8790 100040..................................................

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26.2429

27.2835

28.3342

27.2945 100043..................................................

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0.8993

26.4221

27.0054

26.8400

26.7591 100044..................................................

1.5389

0.9905

30.3659

33.1141

34.3895

32.6318 100045..................................................

1.3128

0.9073

29.7375

26.5413

25.5601

27.1971 100046..................................................

1.4584

0.8993

26.9469

26.7702

27.7856

27.1801 100047..................................................

1.6986

0.9648

26.7674

29.9729

31.4038

29.3525 100048..................................................

0.9293

0.8633

19.3226

20.2657

21.7684

20.4248 100049..................................................

1.2227

0.8715

24.0385

24.5571

27.6295

25.3718 100050..................................................

1.1486

0.9865

21.5101

25.3354

23.5194

23.4888 100051..................................................

1.3882

0.9189

28.0946

28.6225

30.1464

29.0839 100052..................................................

1.4592

0.8715

23.6796

23.4036

25.1096

24.0877 100053..................................................

1.3335

0.9865

28.5118

31.7415

31.9242

30.6741 100054..................................................

1.4058

0.8703

28.7646

30.5515

30.9825

30.1173 100055..................................................

1.4682

0.8993

25.6243

27.3826

29.6999

27.4746 100057..................................................

1.4366

0.9189

24.8010

26.3134

27.7025

26.3249 100061..................................................

1.5221

0.9865

31.4413

30.4528

31.9154

31.2647 100062..................................................

1.6289

0.8633

25.1280

25.9597

26.3043

25.8131 100063..................................................

1.2914

0.8993

25.5097

26.4139

27.0754

26.3647 100067..................................................

1.4240

0.8993

26.8628

27.4762

27.5486

27.3159 100068..................................................

1.6629

0.9073

26.1341

27.6576

27.6975

27.1712 100069..................................................

1.5199

0.8993

25.7450

27.2108

29.0462

27.3031 100070..................................................

1.6948

0.9757

26.8461

29.2005

29.1098

28.3496 100071..................................................

1.3016

0.8993

26.3768

25.3667

25.1867

25.6298 100072..................................................

1.3899

0.9073

25.7962

27.1889

27.6927

26.8986 100073..................................................

1.7604

1.0025

30.5845

29.4165

31.0379

30.3564 100075..................................................

1.5137

0.8993

25.7612

27.6534

26.7551

26.7473 100076..................................................

1.2093

0.9865

23.4551

24.0412

24.0262

23.8474 100077..................................................

1.3908

0.9648

30.6925

30.7564

27.9764

29.8150 100079..................................................

1.4454

*

*

*

*

* 100080..................................................

1.6170

1.0025

28.2188

29.5346

31.0487

29.6112 100081..................................................

0.9435

0.8633

16.9756

19.5711

19.7407

18.7147 100084..................................................

1.7063

0.9189

27.4947

32.7503

30.6285

30.2189 100086..................................................

1.3909

1.0025

28.5971

29.9072

31.3169

29.9261 100087..................................................

1.8447

0.9757

29.5823

30.5938

32.1290

30.7622 100088..................................................

1.5784

0.9092

26.7574

28.2825

29.5464

28.3236 100090..................................................

1.4708

0.9092

26.5703

27.6175

28.9548

27.7918 100092..................................................

1.5273

0.9401

27.8341

26.6315

28.6765

27.7162 100093..................................................

1.7183

0.8633

21.6438

22.5555

23.4836

22.5921 100099..................................................

1.0283

0.8715

25.8454

26.2395

28.0669

26.7407 100102..................................................

1.1035

0.8758

26.1015

27.8551

29.0373

27.7069 100105..................................................

1.5837

0.9741

29.9745

30.9915

30.8907

30.6081 100106..................................................

1.0497

0.8633

24.7650

24.8098

25.6284

25.0615 100107..................................................

1.1889

0.9502

27.4760

30.5764

31.2927

29.8950 100108..................................................

0.8653

0.8633

21.3540

22.6270

22.8139

22.2176 100109..................................................

1.2509

0.9073

25.5669

26.2446

26.7361

26.2234 100110..................................................

1.5739

0.9189

29.4788

29.5985

30.3729

29.8429 100113..................................................

1.9724

0.9427

28.0440

29.2429

30.5837

29.3004 100114..................................................

1.7025

0.9865

29.2862

30.2544

32.3934

30.6145 100117..................................................

1.2439

0.9092

27.7198

28.4928

30.0549

28.8365 100118..................................................

1.3879

0.8633

27.6438

27.0981

28.3179

27.7197 100121..................................................

1.1178

0.8715

26.2990

27.9353

24.9371

26.3668 100122..................................................

1.2316

0.8703

24.6285

26.7175

27.6162

26.3632 100124..................................................

1.1998

0.8633

24.0333

24.8880

26.2310

25.0380 100125..................................................

1.2235

0.9865

29.7750

31.7749

33.3469

31.6838 100126..................................................

1.3212

0.8993

29.6247

28.3213

28.9151

28.9566 100127..................................................

1.5761

0.8993

26.0923

27.4632

27.0669

26.8835 100128..................................................

2.1341

0.8993

29.2566

30.0324

30.3690

29.9099 100130..................................................

1.1458

1.0025

26.0268

28.3651

30.9735

28.5262 100131..................................................

1.4707

0.9865

27.8164

29.7647

30.9586

29.6460 100132..................................................

1.2889

0.8993

26.0526

27.8180

27.6613

27.2139

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100134..................................................

0.8985

0.8633

20.7367

21.6544

22.9624

21.8248 100135..................................................

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26.7030

29.1856

29.8423

28.5445 100137..................................................

1.3328

0.8715

24.8519

26.8391

28.2969

26.7255 100139..................................................

0.8641

0.9427

18.2197

21.1310

21.4420

20.1386 100140..................................................

1.1161

0.9092

26.1352

27.8352

28.5466

27.5007 100142..................................................

1.1395

0.8633

24.8853

25.6999

26.8978

25.8482 100150..................................................

1.2603

0.9865

26.8492

27.7740

29.3690

27.9646 100151..................................................

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0.9092

30.6447

29.7267

31.3820

30.5873 100154..................................................

1.6098

0.9865

28.2506

29.7332

31.3618

29.8234 100156..................................................

1.1428

0.9427

27.5706

28.3927

28.3041

28.1071 100157..................................................

1.5705

0.8993

29.7455

30.3086

30.3339

30.1497 100160..................................................

1.2508

0.9865

30.7454

30.6902

32.3113

31.2761 100161..................................................

1.5295

0.9189

28.0545

29.5673

30.8955

29.5189 100166..................................................

1.5059

0.9757

28.8685

30.1811

31.9053

30.2720 100167..................................................

1.2272

1.0025

30.2166

31.7813

32.4711

31.5289 100168..................................................

1.5608

1.0025

27.6739

27.0938

28.0517

27.6177 100172..................................................

***

*

20.7857

22.2183

20.5502

21.2381 100173..................................................

1.6082

0.8993

26.5436

28.6402

30.2470

28.5123 100175..................................................

0.9474

0.8633

23.9665

25.0913

26.1711

25.0707 100176..................................................

1.8223

1.0025

30.7087

33.3181

35.5821

33.1514 100177..................................................

1.3295

0.9401

28.0089

29.6284

31.0063

29.5570 100179..................................................

1.7392

0.9092

29.1111

29.2795

30.5213

29.6480 100180..................................................

1.5114

0.8993

29.9238

31.0099

31.5463

30.8513 100181..................................................

1.1566

0.9865

24.3708

23.9656

26.0656

24.7884 100183..................................................

1.2816

0.9865

29.0270

30.5042

32.9863

30.7987 100187..................................................

1.3637

0.9865

27.8144

30.7705

31.6639

30.0560 100189..................................................

1.3348

1.0025

28.8320

29.9376

30.5491

29.8033 100191..................................................

1.3365

0.8993

28.3710

29.4533

30.9183

29.5986 100200..................................................

1.3715

1.0025

28.7694

29.6400

29.0719

29.1618 100204..................................................

1.5799

0.9427

27.4763

27.2819

29.9311

28.2769 100206..................................................

1.2774

0.8993

27.0295

27.7551

28.8609

27.8936 100209..................................................

1.5193

0.9865

26.8473

28.5336

29.0435

28.1481 100210..................................................

1.5671

1.0025

29.8515

32.0830

32.4538

31.4634 100211..................................................

1.2490

0.8993

24.7533

26.2859

28.8303

26.5619 100212..................................................

1.4634

0.8633

26.1846

27.7960

29.2475

27.7618 100213..................................................

1.5367

0.9757

27.9283

29.5218

30.2251

29.2000 100217..................................................

1.3065

0.9741

27.3989

27.7683

30.3301

28.4907 100220..................................................

1.6181

0.9502

28.3868

29.3601

30.8265

29.5174 100223..................................................

1.5286

0.8703

25.0332

26.1115

27.6756

26.3160 100224..................................................

1.2624

1.0025

26.6446

28.0455

29.1992

27.9615 100225..................................................

1.3079

1.0025

28.5259

30.8782

32.6890

30.6971 100226..................................................

1.3028

0.9092

28.8165

28.8791

30.2828

29.3578 100228..................................................

1.3954

1.0025

28.1396

30.1635

31.0195

29.7490 100230..................................................

1.3499

1.0025

29.8493

31.9448

34.6099

32.1778 100231..................................................

1.7092

0.8633

25.7037

26.6773

28.3633

26.9108 100232..................................................

1.2640

0.9092

28.5537

28.3892

29.3783

28.7734 100234..................................................

1.3320

1.0025

27.4456

28.8835

29.7800

28.7289 100236..................................................

1.4357

0.9648

28.9955

28.3017

30.5701

29.2818 100237..................................................

1.8545

1.0025

31.7848

33.1536

33.9606

32.9295 100238..................................................

1.5484

0.8993

30.1094

31.4198

31.6331

31.0862 100239..................................................

1.3821

0.8993

28.6893

29.0650

30.3212

29.3632 100240..................................................

0.9591

0.9865

27.3523

29.7000

31.0943

29.4319 100242..................................................

1.5092

0.8633

25.6083

26.1988

27.8149

26.5486 100243..................................................

1.4703

0.8993

27.4534

28.3894

29.8294

28.5415 100244..................................................

1.4338

0.9502

26.6876

28.2881

29.8266

28.3031 100246..................................................

1.5457

0.9905

29.3310

30.1061

30.0261

29.8298 100248..................................................

1.5452

0.8993

28.8082

30.2133

32.4702

30.5161 100249..................................................

1.2896

0.8993

24.9876

26.4676

28.5107

26.7077 100252..................................................

1.1632

0.9741

27.8256

27.1639

29.1429

28.0419 100253..................................................

1.3893

1.0025

27.4927

28.7770

28.5597

28.3018 100254..................................................

1.4934

0.8981

26.1406

27.4900

28.5240

27.3995 100255..................................................

1.3025

0.8993

26.5571

27.3866

29.5157

27.8451 100256..................................................

1.7382

0.8993

30.3081

30.2093

33.3907

31.2430 100258..................................................

1.5591

1.0025

31.2203

33.8630

35.2197

33.4797 100259..................................................

1.2682

0.8993

27.4809

29.0612

29.9274

28.8444 100260..................................................

1.3830

0.9905

26.7129

28.2301

29.4885

28.1387 100264..................................................

1.4156

0.8993

26.8216

28.0370

30.1956

28.3177

Page 23737

100265..................................................

1.3296

0.8993

25.7432

26.3326

26.6920

26.2976 100266..................................................

1.3896

0.8633

23.0208

24.2517

25.6366

24.3555 100267..................................................

1.2811

0.9757

28.7259

28.9674

30.6033

29.4523 100268..................................................

1.1771

1.0025

29.0668

30.5750

33.6114

31.0650 100269..................................................

1.3742

1.0025

26.6047

27.8407

28.3722

27.6319 100271..................................................

2.0607

*

*

*

*

* 100275..................................................

1.3310

1.0025

26.8943

28.7797

31.0459

28.9926 100276..................................................

1.2874

1.0025

29.7606

30.5720

31.7050

30.6750 100277..................................................

1.5574

0.9865

20.4791

24.1122

25.5878

23.9890 100279..................................................

1.4040

0.9502

28.6383

29.2257

31.1921

29.7250 100281..................................................

1.3929

1.0025

29.6698

30.9131

32.8807

31.2127 100284..................................................

1.0632

0.9865

22.3134

25.2637

21.4401

22.7441 100285..................................................

1.2639

1.0025

*

41.9481

34.7963

39.4585 100286..................................................

1.5465

0.9820

28.3645

25.8085

26.5795

26.8126 100287..................................................

1.3877

1.0025

28.1051

29.7536

30.3059

29.3361 100288..................................................

1.7404

1.0025

28.7902

31.0506

32.9558

30.8729 100289..................................................

1.6231

1.0025

29.6376

31.9011

31.4701

31.0127 100290..................................................

1.2302

0.9215

27.1011

28.7111

29.7566

28.5282 100291..................................................

1.3483

0.9401

28.4722

28.1515

28.3762

28.3296 100292..................................................

1.3753

0.8633

26.7063

27.7644

28.5799

27.7205 100293..................................................

***

*

32.7963

*

*

32.7963 100294..................................................

***

*

30.7557

*

*

30.7557 100295..................................................

***

*

26.1983

*

*

26.1983 100296..................................................

1.3271

0.9865

*

29.3870

31.1449

30.2840 100297..................................................

***

*

*

32.1536

*

32.1536 100298..................................................

0.8450

0.8981

*

19.0297

21.9226

20.3569 100299..................................................

1.2918

0.9757

*

34.3697

31.6820

33.1821 100300..................................................

***

*

*

*

33.1669

33.1669 100302..................................................

1.1546

0.9189

*

*

*

* 110001..................................................

1.3724

0.8740

26.4338

26.5640

27.4189

26.8009 110002..................................................

1.3136

0.9760

26.4715

26.2228

28.9001

27.2273 110003..................................................

1.3119

0.7840

22.7066

24.2097

25.0083

23.9366 110004..................................................

1.3686

0.8880

24.9978

25.1846

27.2513

25.7796 110005..................................................

1.2944

0.9760

28.1209

27.2826

29.5994

28.4189 110006..................................................

1.5596

0.9589

28.3839

*

32.3714

30.3778 110007..................................................

1.5907

0.8770

26.6396

26.3133

28.0665

27.0191 110008..................................................

1.3589

0.9760

29.2947

30.9757

31.8366

30.6980 110010..................................................

2.1741

0.9760

31.7185

33.2396

33.9818

32.9905 110011..................................................

1.2809

0.9760

28.0598

28.5892

30.3526

29.0303 110015..................................................

1.0815

0.9760

28.1274

28.8796

30.5004

29.2479 110016..................................................

1.2537

0.8495

22.7263

24.3563

25.9193

24.3226 110018..................................................

1.1989

0.9760

26.8016

30.1849

30.9429

29.3022 110020..................................................

1.2987

0.9760

28.3822

27.5559

29.4629

28.5809 110023..................................................

1.3269

0.9760

29.8061

29.3282

29.2001

29.4297 110024..................................................

1.4712

0.8943

27.0225

27.3357

28.5637

27.6412 110025..................................................

1.4799

1.0139

31.0703

30.2845

32.6731

31.3350 110026..................................................

1.0963

0.7840

21.8018

22.8820

24.3858

23.0082 110027..................................................

1.0459

0.7840

22.6058

25.5291

25.6536

24.4936 110028..................................................

1.7426

0.9604

30.4641

31.4568

32.8679

31.5933 110029..................................................

1.7563

0.9760

27.3618

29.2134

30.0367

28.8932 110030..................................................

1.3857

0.9760

29.6841

29.9531

32.0250

30.6320 110031..................................................

1.2793

0.9760

27.1989

29.5533

30.7447

29.1990 110032..................................................

1.2564

0.7840

23.2586

25.1896

24.4949

24.3026 110033..................................................

1.7263

0.9760

30.3415

32.4178

32.7019

31.8557 110034..................................................

1.7739

0.9604

27.2338

28.7915

29.6801

28.5541 110035..................................................

1.7859

0.9760

28.9408

30.1852

31.5705

30.2749 110036..................................................

1.8235

0.8943

26.6664

27.2280

28.4022

27.4638 110038..................................................

1.5488

0.8397

22.2720

22.9685

23.3659

22.8669 110039..................................................

1.3716

0.9604

26.3503

26.2485

28.4347

26.8945 110040..................................................

1.1123

0.9760

20.9487

23.9526

21.5761

22.1590 110041..................................................

1.2061

0.9760

24.8864

26.1948

27.6593

26.2845 110042..................................................

1.0795

0.9760

34.9954

33.4391

34.5117

34.3025 110043..................................................

1.7560

0.8943

27.8477

28.8551

30.3702

28.9989 110044..................................................

1.2146

0.7840

23.3039

24.3772

27.0418

24.8928 110045..................................................

1.0279

0.9760

24.4275

27.7619

28.2217

26.7950 110046..................................................

1.1453

0.9760

26.7464

*

28.6264

27.6790 110050..................................................

1.0857

0.8499

27.5985

27.0651

27.1525

27.2626

Page 23738

110051..................................................

1.1244

0.7840

20.1756

21.4898

22.1488

21.3080 110054..................................................

1.4223

0.9760

28.9254

29.4691

31.5780

30.0224 110059..................................................

1.1567

0.7840

23.2137

24.7838

24.9265

24.3029 110064..................................................

1.5836

0.9061

24.1219

26.9363

28.7283

26.5861 110069..................................................

1.3437

0.9618

26.2085

29.9098

30.6443

28.9853 110071..................................................

1.1205

0.7840

21.3963

21.2041

23.6494

22.1661 110073..................................................

1.0228

0.7840

18.5753

23.3571

23.0067

21.5478 110074..................................................

1.4894

0.9589

27.9190

31.0062

30.3996

29.7348 110075..................................................

1.3134

0.8841

23.7585

24.8244

26.1068

24.8944 110076..................................................

1.4843

0.9760

28.7871

29.4344

31.0636

29.7176 110078..................................................

1.9462

0.9760

29.9625

30.5196

31.1064

30.5424 110079..................................................

1.5678

0.9760

26.8412

27.3274

29.0882

27.7224 110080..................................................

***

*

18.4714

*

*

18.4714 110082..................................................

1.9672

0.9760

30.8320

30.1072

31.1407

30.6976 110083..................................................

1.9525

0.9760

30.4287

34.0610

34.5768

33.0335 110086..................................................

1.2641

0.7840

21.6898

22.9959

23.4762

22.7087 110087..................................................

1.4285

0.9760

28.1633

31.0403

32.8007

30.7266 110089..................................................

1.1392

0.7840

23.9026

24.3327

26.0096

24.7677 110091..................................................

1.2915

0.9760

29.5337

27.0994

28.0609

28.1665 110092..................................................

1.1137

0.7840

20.8911

21.4168

22.8591

21.7047 110095..................................................

1.4622

0.8397

26.3075

28.0526

27.9005

27.4450 110100..................................................

0.9787

0.8630

16.2575

20.8201

20.0633

18.9182 110101..................................................

0.9836

0.7907

19.4257

21.0983

23.8601

21.3923 110104..................................................

1.2036

0.7840

20.3777

21.8966

22.2585

21.5748 110105..................................................

1.3643

0.7840

23.1405

23.4010

23.7738

23.4420 110107..................................................

1.9504

0.9815

28.9352

30.1027

31.5754

30.2370 110109..................................................

1.0213

0.7840

23.0376

21.6023

21.6011

22.0502 110111..................................................

1.1524

0.9604

25.1270

25.7084

27.2234

26.0060 110112..................................................

1.0413

0.8397

22.7672

26.4089

24.2924

24.5380 110113..................................................

0.9563

0.9604

21.3417

22.0793

22.0479

21.8312 110115..................................................

1.7706

0.9760

31.5074

32.7927

33.3880

32.5794 110121..................................................

1.0024

0.8397

26.2336

23.4571

24.5645

24.7827 110122..................................................

1.5445

0.8397

25.1934

25.4439

26.3052

25.6427 110124..................................................

1.0887

0.7840

22.9212

22.9571

24.8540

23.5883 110125..................................................

1.2577

0.9618

23.7834

24.7347

26.4991

24.9905 110128..................................................

1.2891

0.8841

25.7839

25.4190

24.5272

25.2129 110129..................................................

1.5763

0.9061

25.9625

30.0444

29.7304

28.5402 110130..................................................

0.9171

0.7840

19.1284

20.4349

21.7084

20.4154 110132..................................................

1.0348

0.7840

20.2502

21.2642

21.6033

21.0527 110135..................................................

1.2731

0.7840

22.5346

24.0945

25.1022

23.9470 110136..................................................

***

*

18.8212

*

*

18.8212 110142..................................................

0.9807

0.8025

21.3935

21.6286

22.2156

21.7484 110143..................................................

1.4253

0.9760

28.6583

29.9139

30.9590

29.8777 110146..................................................

1.0832

0.9112

27.0987

29.0193

30.1159

28.7418 110149..................................................

***

*

28.4040

*

*

28.4040 110150..................................................

1.2994

0.9760

25.3742

26.9884

27.7908

26.7261 110153..................................................

1.1210

0.9618

25.7467

29.3305

30.2424

28.4006 110161..................................................

1.5555

0.9760

30.4885

31.5001

31.9981

31.3389 110163..................................................

1.4520

0.8770

28.2169

27.7679

29.5674

28.5127 110164..................................................

1.7038

0.9815

28.8946

30.0145

31.2804

30.1111 110165..................................................

1.4333

0.9760

27.0977

28.7902

28.7898

28.2209 110168..................................................

1.7664

0.9760

28.5700

29.7774

30.8727

29.7602 110172..................................................

1.4736

0.9760

31.1234

31.3999

33.0426

31.8709 110177..................................................

1.9238

0.9604

28.8356

29.7079

30.5507

29.7260 110183..................................................

1.2868

0.9760

28.6208

28.3505

29.6606

28.9003 110184..................................................

1.2634

0.9760

28.3545

29.4071

30.2897

29.4131 110186..................................................

1.3171

0.9061

27.4925

28.2880

29.6479

28.4857 110187..................................................

1.2029

0.9760

25.2139

26.9638

31.0150

27.7895 110189..................................................

1.1025

0.9760

26.1418

26.2799

27.4200

26.6304 110190..................................................

1.0867

0.8081

23.3204

24.5224

29.4199

25.5710 110191..................................................

1.3278

0.9760

27.7760

30.9481

28.7481

29.1019 110192..................................................

1.4139

0.9760

28.8267

30.0843

31.6605

30.2562 110193..................................................

***

*

27.9161

*

*

27.9161 110194..................................................

0.8957

0.7840

19.1920

21.0826

20.5257

20.2837 110198..................................................

1.3546

0.9760

31.0557

32.8171

34.0021

32.6125 110200..................................................

2.0256

0.9061

24.9236

27.2974

29.4610

27.3150 110201..................................................

1.4532

0.9815

31.0841

32.0967

33.4267

32.2165

Page 23739

110203..................................................

0.9588

0.9760

29.7888

32.3441

32.0585

31.3300 110205..................................................

1.1768

0.8347

22.0207

23.9738

26.1963

24.0311 110209..................................................

0.6196

0.7840

21.1534

21.2428

22.4539

21.6327 110212..................................................

1.2087

0.8163

*

*

*

* 110214..................................................

***

*

37.1450

*

*

37.1450 110215..................................................

1.3584

0.9760

27.5566

29.5238

30.1770

29.1787 110219..................................................

1.4002

0.9760

28.8814

32.2603

33.4462

31.6155 110220..................................................

***

*

37.5741

*

*

37.5741 110221..................................................

***

*

28.0500

*

*

28.0500 110222..................................................

***

*

35.6189

*

*

35.6189 110223..................................................

***

*

*

25.3071

*

25.3071 110224..................................................

***

*

*

33.6464

*

33.6464 110225..................................................

1.2065

0.9760

*

29.5373

28.9757

29.2212 110226..................................................

1.1952

0.9760

*

*

32.1814

32.1814 110228..................................................

0.8800

0.9760

*

*

*

* 110229..................................................

1.2950

0.9760

*

*

*

* 110230..................................................

1.3685

0.7840

*

*

*

* 120001..................................................

1.7874

1.1608

34.1385

39.6348

39.0344

37.5738 120002..................................................

1.2448

1.1219

32.3784

34.1709

37.7249

34.7927 120004..................................................

1.2549

1.1608

30.0668

31.3555

32.5141

31.3602 120005..................................................

1.2949

1.1219

31.1985

33.6942

35.1716

33.3840 120006..................................................

1.2614

1.1608

31.6785

34.2231

35.7058

33.9086 120007..................................................

1.6360

1.1608

30.2473

30.8773

35.0167

31.9560 120010..................................................

1.9848

1.1608

29.5714

30.8526

34.3338

31.4351 120011..................................................

1.4966

1.1608

37.1792

39.1941

44.0519

40.3992 120014..................................................

1.3531

1.1219

30.3463

30.9839

34.2101

31.8841 120019..................................................

1.1710

1.1219

30.4257

33.0114

36.1586

33.2188 120022..................................................

1.8673

1.1608

29.9527

32.5326

34.9024

32.4610 120026..................................................

1.4190

1.1608

32.4566

34.2244

35.8383

34.2218 120027..................................................

1.3261

1.1608

28.7905

29.5825

31.8146

30.1238 120028..................................................

1.2595

1.1608

32.4847

34.0451

34.6327

33.7338 120029..................................................

***

*

*

44.6382

*

44.6382 130002..................................................

1.4057

0.9100

24.7871

24.7266

24.3491

24.6130 130003..................................................

1.4692

0.9560

28.6158

28.6136

29.8774

29.0074 130006..................................................

1.7566

0.9290

27.2158

28.0048

28.8325

28.0328 130007..................................................

1.7298

0.9290

28.7246

30.4958

31.2250

30.1204 130013..................................................

1.3634

0.9290

30.9609

36.1570

33.8909

33.6903 130014..................................................

1.2442

0.9290

27.2543

27.5936

28.2815

27.7157 130018..................................................

1.7489

0.9327

27.3439

28.4041

30.2030

28.6009 130024..................................................

1.1981

0.8272

23.6212

24.8035

25.3184

24.5765 130025..................................................

1.2309

0.7597

21.1998

22.7962

23.8581

22.6625 130028..................................................

1.4347

0.9103

27.2195

28.4934

29.3360

28.3737 130049..................................................

1.5627

1.0315

27.3597

29.0185

29.7190

28.7360 130062..................................................

***

*

25.6467

29.1925

28.3416

27.9024 130063..................................................

1.4068

0.9290

26.0955

27.7607

27.7664

27.1825 130065..................................................

1.9441

0.9327

21.9792

30.4547

25.8977

26.3095 130066..................................................

2.0484

0.9504

*

28.9883

28.1483

28.5227 130067..................................................

2.5439

*

*

21.3867

26.8243

23.8814 140001..................................................

1.1235

0.8797

22.3001

22.2003

23.2221

22.5895 140002..................................................

1.3464

0.8993

27.0165

27.4779

29.1084

27.9303 140007..................................................

1.4044

1.0334

30.7378

31.4024

32.4342

31.5521 140008..................................................

1.4402

1.0334

29.1767

31.8008

32.7592

31.2208 140010\3\...............................................

1.4980

1.0334

31.8806

40.1360

39.3702

36.3250 140B10\3\...............................................

***

*

*

40.1360

39.3702

39.7545 140011..................................................

1.2146

0.8428

23.8575

25.8864

26.2125

25.4083 140012..................................................

1.3120

1.0334

29.0336

31.8213

31.9498

30.8913 140013..................................................

1.4671

0.9043

23.9269

25.0951

26.4178

25.1250 140015..................................................

1.3506

0.8993

24.4687

24.6409

25.2491

24.8022 140018..................................................

1.3731

1.0334

26.3533

30.7398

31.5604

29.4466 140019..................................................

0.9139

0.8428

21.3438

22.3179

22.2899

21.9787 140026..................................................

1.1531

0.8743

25.9669

26.0493

28.1690

26.7518 140029..................................................

1.5837

1.0334

30.2688

36.7722

36.3824

34.4448 140030..................................................

1.5087

1.0334

30.2776

31.6822

32.1110

31.3500 140032..................................................

1.2668

0.8993

26.7310

27.5367

28.5229

27.5996 140033..................................................

***

*

27.9993

29.5256

31.4328

29.1997 140034..................................................

1.1683

0.8993

24.0470

24.4653

26.7233

25.0924 140040..................................................

1.2236

0.9043

23.2293

24.5589

28.4995

25.3375

Page 23740

140043..................................................

1.2647

0.8606

27.3469

29.8633

31.3736

29.5994 140046..................................................

1.4727

0.8993

24.7334

25.6230

25.7906

25.3934 140048..................................................

1.2788

1.0334

29.3877

30.6686

31.6262

30.5704 140049..................................................

1.5369

1.0334

29.0976

30.8617

32.0217

30.6556 140051..................................................

1.5614

1.0334

30.9696

32.1730

32.7506

31.9766 140052..................................................

1.3408

0.8993

25.9617

26.9907

26.7896

26.5759 140053..................................................

1.7853

0.9133

27.4518

28.4513

29.9472

28.5957 140054..................................................

1.4862

1.0334

33.1406

34.2378

34.5342

33.9734 140058..................................................

1.2320

0.8993

24.6058

25.2568

26.5660

25.4975 140059..................................................

1.0669

0.8993

22.6743

21.6230

22.8588

22.3764 140062..................................................

1.3719

1.0334

34.1230

36.8271

36.6461

35.8580 140063..................................................

1.4103

1.0334

28.6559

30.5465

31.1242

30.0979 140064..................................................

1.2191

0.9043

23.8639

25.7551

26.6231

25.4620 140065..................................................

1.4143

1.0334

30.1856

31.5510

32.4631

31.3610 140066..................................................

1.1167

0.8993

22.1524

22.0225

23.6295

22.6003 140067..................................................

1.8104

0.9043

28.3506

29.8982

30.6882

29.6686 140068..................................................

1.2321

1.0334

28.3938

26.7166

31.3440

28.7631 140075..................................................

1.2712

1.0334

26.2626

35.9507

33.6844

31.5469 140077..................................................

0.9374

0.8993

20.3999

21.6468

22.5061

21.5537 140080..................................................

1.4286

1.0334

28.8791

29.9067

30.3760

29.7135 140082..................................................

1.6302

1.0334

28.3429

31.0516

32.0539

30.4270 140083..................................................

0.9706

1.0334

26.8919

27.2189

26.1622

26.6852 140084..................................................

1.2689

1.0334

30.5036

30.7251

31.3281

30.8596 140088..................................................

1.8601

1.0334

30.5450

32.6866

34.0556

32.5121 140089..................................................

1.2292

0.8428

24.1066

24.9120

26.6942

25.2540 140091..................................................

1.7570

0.9353

27.8536

28.2095

29.4099

28.5130 140093..................................................

1.2251

0.9711

28.3298

28.6709

31.2955

29.5310 140094..................................................

1.0614

1.0334

27.3841

28.7647

28.8596

28.3324 140095..................................................

1.2067

1.0334

28.7617

29.7385

29.9452

29.4617 140100..................................................

1.4165

1.0334

41.3374

37.2961

37.3023

38.5940 140101..................................................

1.2742

1.0334

29.4081

28.9723

31.0048

29.8038 140103..................................................

1.1919

1.0334

23.6406

24.0926

25.3608

24.3942 140105..................................................

***

*

29.5274

29.6590

30.7135

29.8404 140110..................................................

1.1348

1.0334

28.6364

30.3432

31.3460

30.1323 140113..................................................

1.5825

0.9353

29.5452

30.2542

31.6124

30.5020 140114..................................................

1.5001

1.0334

28.2151

29.8316

31.1390

29.7616 140115..................................................

1.2630

1.0334

26.0383

25.4576

26.2578

25.9061 140116..................................................

1.3668

1.0341

34.5537

34.3876

34.1356

34.3550 140117..................................................

1.5097

1.0334

27.7201

30.9679

28.5785

29.0528 140118..................................................

1.4623

1.0334

32.5518

33.1987

33.6634

33.1346 140119..................................................

1.8095

1.0334

34.2118

32.2185

34.3896

33.5609 140120..................................................

1.3098

0.9043

23.9724

25.9275

26.2398

25.4006 140122..................................................

1.5055

1.0334

30.5653

30.2888

32.4728

31.1094 140124..................................................

1.2504

1.0334

35.7563

38.2191

38.8956

37.6290 140125..................................................

1.1586

0.8993

22.7571

26.5801

27.6333

25.6694 140127..................................................

1.6283

0.9520

25.6668

27.8363

29.3326

27.6412 140130..................................................

1.2280

1.0334

32.6209

32.5425

34.5053

33.2090 140133..................................................

1.4054

1.0334

31.0269

30.3259

32.8907

31.4186 140135..................................................

1.4168

0.8840

23.3196

24.6645

25.9046

24.6639 140137..................................................

1.0555

0.8993

23.4174

31.4349

*

26.5232 140143..................................................

1.1818

1.0334

27.4499

26.1126

27.0294

26.8354 140145..................................................

1.0941

0.8993

26.0875

25.2040

26.9326

26.0849 140147..................................................

1.0800

0.8428

21.0686

21.1817

22.1026

21.4534 140148..................................................

1.6364

0.9133

25.5677

27.0038

28.9453

27.2136 140150..................................................

1.6423

1.0334

52.0970

35.5951

45.8193

44.1226 140151..................................................

0.7986

1.0334

27.0312

26.0825

27.3539

26.8313 140152..................................................

***

*

30.2209

29.8647

32.2789

30.7789 140155..................................................

1.3176

1.0334

29.5734

32.7960

35.0804

32.3959 140158..................................................

1.3565

1.0334

27.3721

30.4445

32.1130

30.0627 140160..................................................

1.1748

0.9756

25.8684

27.6905

28.9023

27.4932 140161..................................................

1.1449

0.8596

25.2898

28.8266

28.8132

27.6822 140162..................................................

1.5506

0.9520

29.4121

32.1810

33.0967

31.5165 140164..................................................

1.7462

0.8993

24.6009

25.9726

27.3117

26.0022 140166..................................................

1.1830

0.8428

26.4800

26.2875

27.2398

26.6846 140167..................................................

1.1518

0.8428

22.8703

24.9904

24.2733

24.0635 140172..................................................

1.3856

1.0334

32.1220

33.0926

33.4586

32.9106 140174..................................................

1.5880

1.0334

30.5905

31.2231

34.2433

32.0655

Page 23741

140176..................................................

1.2311

1.0341

32.9794

32.6145

33.2116

32.9375 140177..................................................

0.9832

1.0334

26.4340

25.5725

26.0709

26.0349 140179..................................................

1.3098

1.0334

29.3657

30.2944

31.3599

30.3150 140180..................................................

1.1869

1.0334

27.8887

29.1352

29.7982

28.9361 140181..................................................

1.1559

1.0334

25.0226

27.6835

27.3815

26.6876 140182..................................................

1.4662

1.0334

30.1755

32.8972

26.4085

29.5346 140184..................................................

1.3087

0.8428

25.2327

26.6104

27.5837

26.4843 140185..................................................

1.4359

0.8993

25.2423

26.5398

27.9409

26.5570 140186..................................................

1.4967

1.0334

29.8022

30.7212

41.2521

33.4222 140187..................................................

1.5073

0.8993

24.8332

25.5873

26.9246

25.7702 140189..................................................

1.1619

0.8428

22.5965

24.7013

29.1349

25.4810 140191..................................................

1.3271

1.0334

28.5836

31.9943

29.7497

30.0468 140197..................................................

1.0759

1.0334

24.0463

24.9103

24.8700

24.5943 140200..................................................

1.5134

1.0334

28.8435

30.6641

31.3692

30.2724 140202..................................................

1.4541

1.0334

32.7915

32.9433

34.3762

33.4137 140206..................................................

1.2021

1.0334

29.7953

29.6275

31.1376

30.1671 140207..................................................

1.1245

1.0334

26.0535

28.2262

31.6793

28.4326 140208..................................................

1.6424

1.0334

29.5380

31.4035

26.1728

28.8260 140209..................................................

1.5750

0.9043

26.3230

29.7965

27.4032

27.7656 140210..................................................

1.0667

0.8428

20.6954

19.2053

22.2507

20.7150 140211..................................................

1.3317

1.0334

30.3286

31.4539

34.5893

32.1847 140213..................................................

1.2466

1.0334

31.6926

32.1031

33.3902

32.4246 140217..................................................

1.4736

1.0334

32.1277

32.9404

33.2151

32.8054 140223..................................................

1.4965

1.0334

31.7267

33.5083

34.6969

33.3189 140224..................................................

1.3728

1.0334

29.6181

31.2237

30.1050

30.3035 140228..................................................

1.4758

0.9862

27.9456

28.2855

28.7440

28.3351 140231..................................................

1.4738

1.0334

30.0236

34.8291

35.2199

33.3358 140233..................................................

1.6742

0.9862

29.7093

31.5168

32.3348

31.1982 140234..................................................

1.0951

0.8743

24.5476

25.7353

25.7647

25.3480 140239..................................................

1.5089

0.9862

31.1879

31.0918

33.7241

31.9840 140240..................................................

1.4543

1.0334

31.5637

32.7986

28.0966

30.7320 140242..................................................

1.5121

1.0334

34.6120

35.2351

36.6696

35.4606 140250..................................................

1.2451

1.0334

29.6305

31.2533

32.9392

31.3008 140251..................................................

1.3749

1.0334

28.0622

28.3598

29.5921

28.6552 140252..................................................

1.4509

1.0334

34.4268

35.8762

36.1503

35.4953 140258..................................................

1.5542

1.0334

34.2333

33.0093

34.5667

33.9309 140275..................................................

1.3633

0.8606

27.8186

28.5064

26.7377

27.6728 140276..................................................

1.9223

1.0334

31.6359

32.1048

32.7052

32.1538 140280..................................................

1.4877

0.8606

24.9401

26.6536

26.9815

26.2013 140281..................................................

1.7853

1.0334

33.3903

35.6589

37.5673

35.5869 140286..................................................

1.2031

1.0334

30.3237

32.0048

32.2227

31.5106 140288..................................................

1.4810

1.0334

31.5197

31.5944

32.5446

31.8981 140289..................................................

1.2801

0.8993

23.8452

25.6847

26.0851

25.2075 140290..................................................

1.3716

1.0334

31.8135

32.5247

35.9647

33.4767 140291..................................................

1.5227

1.0334

31.9052

33.8706

32.7857

32.8705 140292..................................................

1.1466

1.0334

28.5094

30.6917

32.4476

30.3851 140294..................................................

1.1034

0.8428

24.0750

26.1595

26.9772

25.8209 140300..................................................

1.1745

1.0334

35.1494

42.5240

37.1204

38.1961 140301..................................................

1.0712

1.0334

49.9507

39.4295

38.0581

40.7701 140303..................................................

2.1328

1.0334

29.6470

*

32.2920

30.8365 150001..................................................

1.1896

0.9827

28.9075

31.8089

32.9797

31.2747 150002..................................................

1.4747

1.0328

26.6222

27.6481

28.1057

27.6106 150003..................................................

1.5897

0.8960

26.7585

26.9771

29.0575

27.6017 150004..................................................

1.4569

1.0328

28.7336

30.9626

31.6781

30.3933 150005..................................................

1.2612

0.9827

29.5371

30.5367

31.6148

30.6086 150006..................................................

1.3702

0.9353

25.6265

27.1364

28.3389

27.0718 150007..................................................

1.4525

0.9254

29.4971

30.0500

31.0369

30.2270 150008..................................................

1.4479

1.0328

27.5703

27.0525

29.1473

27.9333 150009..................................................

1.4395

0.9238

25.4496

25.7616

26.1499

25.7891 150010..................................................

1.5221

0.9254

27.2272

28.4118

28.2599

27.9486 150011..................................................

1.3308

0.9707

25.3178

26.7686

27.7857

26.5785 150012..................................................

1.5537

0.9644

30.0348

31.2282

30.4819

30.5840 150015..................................................

1.3616

0.9320

28.0931

27.3811

30.1474

28.5072 150017..................................................

1.8267

0.9004

26.3973

26.3379

27.1249

26.6388 150018..................................................

1.5912

0.9353

27.3689

29.1137

30.0478

28.9018 150021..................................................

1.8098

0.9004

28.9196

30.0030

31.1140

30.0142 150022..................................................

1.0584

0.8637

23.1041

23.8971

26.8394

24.4351

Page 23742

150023..................................................

1.5869

0.9707

26.9095

27.7520

30.3560

28.3734 150024..................................................

1.4757

0.9827

28.1655

28.4170

30.6133

29.0364 150026..................................................

1.3515

0.9353

28.6517

30.4967

31.9378

30.4512 150029..................................................

1.3421

0.9644

28.7187

29.9307

29.7461

29.4587 150030..................................................

1.1963

0.9707

29.1493

29.3588

31.1964

29.9386 150033..................................................

1.4204

0.9827

28.6838

29.7744

33.1990

30.5371 150034..................................................

1.4624

1.0328

28.6429

28.0434

30.0027

28.9357 150035..................................................

1.5482

0.9320

26.9700

27.8904

29.2014

28.0374 150037..................................................

1.2521

0.9827

31.0935

29.0161

30.4623

30.1390 150038..................................................

1.1402

0.9827

29.3156

33.0112

31.9539

31.4556 150042..................................................

1.3656

0.8791

22.8786

25.1403

25.2440

24.4073 150044..................................................

1.4443

0.9238

25.2137

25.2685

25.9260

25.4830 150045..................................................

1.0453

0.9004

26.9818

27.5340

29.4308

27.9971 150046..................................................

1.5575

0.9130

24.5593

26.5876

27.6210

26.2766 150047..................................................

1.7059

0.9004

25.5194

25.8497

27.1835

26.1904 150048..................................................

1.4375

0.9583

27.1233

28.1525

29.5578

28.3255 150051..................................................

1.6111

0.9707

26.5655

28.9157

30.3742

28.6837 150056..................................................

1.9795

0.9827

28.8727

29.3500

30.5758

29.6152 150057..................................................

2.0656

0.9827

28.9529

30.3287

29.1268

29.4500 150058..................................................

1.6334

0.9644

29.1444

29.1255

31.7536

30.0001 150059..................................................

1.4852

0.9827

31.4987

31.3362

36.2553

33.0486 150061..................................................

1.1299

0.8479

21.3711

22.6746

23.2415

22.4414 150064..................................................

1.2404

0.8479

25.4987

28.7978

28.9419

27.8440 150065..................................................

1.2493

0.9707

27.9283

30.2053

30.8254

29.6617 150069..................................................

1.1831

0.9583

26.2028

26.0909

27.0720

26.4651 150072..................................................

1.1283

0.8584

21.2120

21.7644

23.0612

21.9963 150074..................................................

1.4309

0.9827

25.9321

28.5655

29.4124

28.0120 150075..................................................

1.1406

0.9004

25.1568

25.7245

26.5972

25.8595 150076..................................................

1.2974

0.9353

29.3249

30.1120

29.2703

29.5697 150082..................................................

1.5914

0.8525

28.3494

26.4544

28.1280

27.6224 150084..................................................

1.8344

0.9827

31.1720

33.1784

34.8522

33.0904 150086..................................................

1.2227

0.9583

25.1992

26.6745

27.2568

26.4089 150088..................................................

1.2980

0.9707

27.2103

29.1509

30.2378

28.8855 150089..................................................

1.5552

0.8479

24.7233

24.8045

26.7270

25.4200 150090..................................................

1.5584

1.0328

30.4835

30.6412

30.8754

30.6754 150091..................................................

1.1569

0.9004

30.4234

32.1627

33.0402

31.9030 150097..................................................

1.1855

0.9827

27.7468

29.1359

29.4776

28.7947 150100..................................................

1.6039

0.8525

25.7997

26.9724

27.6326

26.7725 150101..................................................

1.0840

0.9004

29.0301

30.5475

31.6018

30.3780 150102..................................................

1.0268

0.9320

25.7424

25.8742

25.4704

25.6892 150104..................................................

1.1443

0.9827

28.2552

28.7788

30.8970

29.3100 150109..................................................

1.5465

0.8960

25.3367

26.8464

28.7412

26.9892 150112..................................................

1.4960

0.9707

28.0068

29.8540

31.7711

29.8902 150113..................................................

1.2097

0.9707

24.7960

25.9814

26.9088

25.9097 150115..................................................

1.3474

0.8479

22.0747

22.5793

22.3560

22.3407 150125..................................................

1.5500

1.0328

27.6535

29.3596

31.2081

29.4320 150126..................................................

1.3476

1.0328

28.9454

29.4300

32.5356

30.2297 150128..................................................

1.4329

0.9827

28.7810

29.5008

31.1046

29.8290 150129..................................................

1.1906

0.9827

29.7398

31.4317

32.9621

31.3709 150132..................................................

***

*

27.6560

*

*

27.6560 150133..................................................

1.2148

0.9353

25.1322

24.2538

23.0651

24.1076 150134..................................................

***

*

26.3249

21.6740

27.3963

24.7453 150146..................................................

1.1296

0.9547

29.5256

30.3343

31.8743

30.6315 150147..................................................

1.4431

1.0328

27.2339

26.1646

28.9248

27.6245 150149..................................................

0.9337

0.8525

23.7026

24.9629

25.3324

24.7398 150150..................................................

1.3583

0.9004

27.0542

26.7700

26.5963

26.7808 150153..................................................

2.3079

0.9827

32.1022

35.0617

37.3920

35.1885 150154..................................................

2.4814

0.9827

29.8514

29.8894

30.5758

30.1310 150155..................................................

***

*

45.0121

*

*

45.0121 150156..................................................

***

*

25.9681

*

*

25.9681 150157..................................................

1.7719

0.9827

*

32.3106

32.9148

32.6153 150158..................................................

1.2495

0.9827

*

*

30.4337

30.4337 150159..................................................

***

*

*

*

27.5574

27.5574 150160..................................................

2.0971

0.9827

*

*

28.6108

28.6108 150161..................................................

1.6006

0.9827

*

*

*

* 150162..................................................

1.8254

0.9827

*

*

*

* 150163..................................................

1.0174

0.9238

*

*

*

*

Page 23743

150164..................................................

1.1402

0.9419

*

*

*

* 150165..................................................

1.3537

0.9320

*

*

*

* 150166..................................................

1.0260

0.9320

*

*

*

* 160001..................................................

1.2035

0.8881

24.5108

25.7255

25.8676

25.3903 160005..................................................

1.2221

0.8709

23.1034

24.7755

24.8586

24.2778 160008..................................................

1.0503

0.8709

22.1402

22.4758

24.1271

22.9093 160013..................................................

1.1826

0.8888

24.0956

24.4099

25.5144

24.6765 160016..................................................

1.5621

0.8881

24.5338

27.1460

26.6516

26.0785 160024..................................................

1.5070

0.9460

27.4158

29.3756

32.4228

29.7117 160028..................................................

1.3546

0.9360

27.8535

30.0576

29.8324

29.2977 160029..................................................

1.5290

0.9337

28.7324

30.6687

32.2010

30.5406 160030..................................................

1.4497

0.9457

28.7786

30.9415

30.4757

30.0901 160032..................................................

1.0815

0.8944

25.4662

26.2935

28.5629

26.7834 160033..................................................

1.6123

0.8709

26.5315

27.2060

27.4787

27.0636 160040..................................................

1.3560

0.9248

25.9032

26.8110

28.2966

27.0153 160045..................................................

1.6650

0.8746

26.6463

27.5289

28.1662

27.4620 160047..................................................

1.3438

0.9360

26.0227

28.1280

29.4261

27.7499 160057..................................................

1.3696

0.9107

25.1272

25.6274

27.7953

26.1996 160058..................................................

1.9928

0.9337

28.4167

28.9924

29.8956

29.1104 160064..................................................

1.5613

0.9248

28.7668

28.4209

33.6067

30.2004 160067..................................................

1.3956

0.9248

24.8137

26.0243

26.7671

25.8721 160069..................................................

1.5119

0.8709

27.4473

27.6157

28.4064

27.8032 160079..................................................

1.4505

0.8746

24.7372

26.1618

28.5014

26.4591 160080..................................................

1.2258

0.8709

25.8252

27.2370

27.8729

26.9717 160082..................................................

1.7394

0.9460

27.4718

28.7831

31.7482

29.3428 160083..................................................

1.6319

0.9460

27.3004

28.3921

29.9472

28.5559 160089..................................................

1.2114

0.9107

23.2149

23.2888

23.9184

23.4747 160101..................................................

1.1157

0.9460

25.0503

25.4740

26.8503

25.8119 160104..................................................

1.6343

0.8709

28.1891

29.8126

27.0516

28.2560 160110..................................................

1.4968

0.9248

26.6633

28.8134

29.9071

28.6042 160112..................................................

1.2363

0.8709

24.7957

25.2886

26.1706

25.4488 160117..................................................

1.3763

0.8709

25.4659

27.3927

24.3309

25.6596 160122..................................................

1.1372

0.8709

23.9177

24.4996

25.3176

24.5888 160124..................................................

1.1221

0.8709

22.5482

24.3063

25.5031

24.1100 160146..................................................

1.4330

0.8745

22.6949

24.8485

25.1816

24.2135 160147..................................................

1.2223

0.8881

28.6303

29.8992

33.6376

30.7344 160153..................................................

1.6977

0.8745

29.9378

30.6173

30.4338

30.3298 160155..................................................

2.0066

0.8709

*

*

*

* 170001..................................................

1.1220

0.8086

23.1260

23.8863

24.5932

23.8766 170006..................................................

1.3222

0.9351

24.2068

27.1033

28.3509

26.6135 170009..................................................

1.0785

0.9453

30.9025

29.6386

32.2817

30.9531 170010..................................................

1.2334

0.8086

23.9707

25.5573

28.1793

25.9458 170012..................................................

1.6303

0.8785

26.1367

27.1195

28.7852

27.3256 170013..................................................

1.7166

0.8785

25.2476

26.7124

28.3035

26.7042 170014..................................................

1.0389

0.9453

23.8135

24.2322

25.8151

24.6246 170016..................................................

1.5893

0.8873

25.8061

26.7536

28.6802

27.0793 170017..................................................

1.1359

0.8980

26.9657

27.2925

29.1445

27.8530 170020..................................................

1.5631

0.8785

23.2757

24.1149

25.0539

24.1602 170023..................................................

1.4632

0.8785

24.0561

23.9812

24.8758

24.3255 170027..................................................

1.4379

0.8086

23.1766

23.4037

24.1118

23.5721 170033..................................................

1.3317

0.8086

21.9709

24.1882

25.0393

23.6609 170039..................................................

0.9397

0.8980

26.9852

26.0952

23.5961

25.4102 170040..................................................

1.9332

0.9453

28.4458

30.2468

30.0807

29.6659 170049..................................................

1.5092

0.9453

25.2070

26.4086

31.8575

27.9185 170058..................................................

1.0992

0.8086

22.9210

26.5949

28.1316

25.7970 170068..................................................

1.2130

0.8885

23.0635

23.8812

23.8492

23.5912 170074..................................................

1.1942

0.8086

23.7829

23.0567

24.8855

23.9145 170075..................................................

0.8436

0.8086

19.7760

19.9351

21.1954

20.2943 170086..................................................

1.5732

0.8873

26.1362

26.3615

28.5234

27.0437 170094..................................................

0.9157

0.8086

21.5295

16.5136

17.1709

18.5438 170103..................................................

1.2784

0.8980

23.8042

24.2003

25.5653

24.5527 170104..................................................

1.4059

0.9453

26.2990

27.6211

29.5069

27.8074 170105..................................................

1.1156

0.8086

21.9606

22.7412

23.4317

22.7174 170109..................................................

1.0350

0.9453

23.1088

23.8515

29.0177

25.4500 170110..................................................

0.8962

0.8086

23.3260

23.9572

24.7910

24.0231 170114..................................................

0.5755

*

*

*

*

* 170120..................................................

1.3720

0.9351

22.0253

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23.5271

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Page 23744

170122..................................................

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28.7175

29.6314

28.2843 170123..................................................

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0.8980

27.6653

27.0843

28.7608

27.8479 170133..................................................

1.0196

0.9453

23.1226

25.2301

25.7108

24.7246 170137..................................................

1.3249

0.8086

24.7096

25.3395

26.8014

25.6444 170142..................................................

1.3711

0.8720

23.9527

24.6019

25.5550

24.7027 170145..................................................

1.0867

0.8086

23.2162

23.3967

25.3728

23.9852 170146..................................................

1.5002

0.9453

29.8858

29.0720

31.6994

30.2197 170147..................................................

***

*

22.4973

24.3268

21.4565

23.0046 170150..................................................

1.1410

0.8252

20.9448

19.6160

22.0251

20.8653 170166..................................................

1.0165

0.8086

21.0762

22.6968

24.1063

22.6638 170175..................................................

1.4832

0.8785

25.6281

26.7229

31.7582

28.0191 170176..................................................

1.5583

0.9453

27.2332

29.0735

30.1114

28.8494 170180..................................................

***

*

32.5010

*

*

32.5010 170182..................................................

1.4504

0.9453

27.3503

28.9710

30.3781

28.8971 170183..................................................

1.9858

0.8980

25.8340

26.1890

27.7178

26.5683 170185..................................................

1.2572

0.9453

27.8139

28.1780

29.3202

28.5075 170186..................................................

2.5220

0.8980

32.8392

30.2613

30.7638

31.2790 170187..................................................

1.6421

0.8086

22.8493

24.1461

24.6391

23.8933 170188..................................................

1.9852

0.9453

30.6844

32.2573

33.7221

32.2678 170190..................................................

1.0158

0.8720

22.9540

26.2625

27.3023

25.5425 170191..................................................

1.8259

0.8086

22.1197

24.3813

26.0279

24.3247 170192..................................................

1.7639

0.8980

26.2724

27.7421

30.9200

28.4741 170193..................................................

1.3485

0.8785

20.6821

24.8531

24.4126

22.9315 170194..................................................

1.2331

0.9453

29.9014

27.6989

28.1972

28.5250 170195..................................................

2.4249

0.9453

30.1001

29.5947

29.1763

29.5492 170196..................................................

2.4635

0.8980

*

32.1832

29.9641

30.9601 170197..................................................

2.3250

0.8980

*

*

*

* 170198..................................................

1.9320

0.8086

*

*

*

* 180001..................................................

1.3069

0.9590

27.6917

29.7423

29.9655

29.1412 180002..................................................

1.0662

0.8062

25.7862

26.5488

27.3339

26.5496 180004..................................................

1.0759

0.7837

22.0797

20.8805

22.0615

21.6721 180005..................................................

1.1460

0.8767

24.9779

25.6159

27.4304

26.0705 180007..................................................

1.5443

0.8950

25.7042

27.1924

26.9425

26.6126 180009..................................................

1.7525

0.9127

26.4101

27.3228

28.7030

27.5584 180010..................................................

1.8312

0.8950

25.6153

27.7600

28.1667

27.1559 180011..................................................

1.6281

0.8756

25.5463

24.9909

25.0355

25.1733 180012..................................................

1.4715

0.9123

25.6000

26.7279

27.2829

26.5352 180013..................................................

1.5001

0.9276

23.7075

24.8125

26.8088

25.0983 180016..................................................

1.2868

0.9245

24.8408

24.7091

26.9522

25.4644 180017..................................................

1.3104

0.8230

21.8885

21.9715

25.4164

23.1027 180018..................................................

1.3551

0.7837

20.9857

23.3035

23.9155

22.7447 180019..................................................

1.1134

0.7837

24.0283

24.6279

27.6787

25.4951 180020..................................................

1.0616

0.7837

24.6953

25.9975

26.8856

25.8897 180021..................................................

0.9634

0.7837

20.7950

22.0740

22.3752

21.7644 180024..................................................

1.1593

0.9123

31.1159

26.3532

26.9538

28.0398 180025..................................................

1.2308

0.9245

22.6897

28.5935

28.4153

26.7267 180027..................................................

1.2008

0.8302

20.8303

21.7639

23.3873

21.9095 180029..................................................

1.4670

0.8756

25.6479

26.1528

26.3892

26.0660 180035..................................................

1.4807

0.9590

31.0794

32.8461

34.0348

32.7266 180036..................................................

1.3287

0.9127

25.2972

25.6959

30.2621

27.0558 180037..................................................

***

*

26.3132

27.8506

33.1874

29.1431 180038..................................................

1.5441

0.8764

26.0440

26.9752

28.2413

27.1328 180040..................................................

1.8313

0.9245

27.9979

28.5162

30.2450

28.9050 180043..................................................

1.1741

0.7978

20.9326

20.6439

24.0566

21.9172 180044..................................................

1.5998

0.8767

24.4569

25.8060

25.7978

25.3776 180045..................................................

1.3277

0.9590

27.4732

29.4127

29.9346

28.9840 180046..................................................

1.0026

0.8950

27.1034

27.0962

28.5552

27.5846 180048..................................................

1.3531

0.9123

23.9230

24.3696

24.6786

24.3395 180049..................................................

1.4067

0.8756

22.4769

24.3699

23.5737

23.4731 180050..................................................

1.1306

0.7919

26.3604

25.9557

26.7714

26.3675 180051..................................................

1.2266

0.8302

23.5299

24.3916

25.2356

24.4156 180053..................................................

0.9909

0.7837

21.3044

22.1921

23.0290

22.2290 180056..................................................

1.1314

0.8531

24.3074

24.5326

26.3959

25.0679 180064..................................................

1.2227

0.8151

17.1009

20.1799

21.9508

19.7362 180066..................................................

1.1136

0.9276

22.2713

23.7860

24.9530

23.6732 180067..................................................

1.9454

0.8950

26.0238

27.9852

29.6029

27.9902 180069..................................................

1.0930

0.8767

26.3701

26.6714

27.6777

26.8870

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180070..................................................

1.1929

0.8077

20.6741

20.2189

21.3693

20.7657 180078..................................................

1.0594

0.8767

27.6806

28.2762

29.2125

28.3867 180079..................................................

1.1477

0.8096

20.2100

23.6005

24.9898

22.8630 180080..................................................

1.2693

0.7889

21.5818

23.7788

25.2996

23.5872 180087..................................................

1.2269

0.7837

20.8841

22.0302

22.1044

21.6767 180088..................................................

1.7069

0.9245

28.0916

28.6107

30.7936

29.1743 180092..................................................

1.1677

0.8950

23.7909

23.7866

25.2884

24.3103 180093..................................................

1.6170

0.8131

20.5807

21.4392

22.3324

21.4596 180095..................................................

1.0117

0.7837

17.9146

21.5639

21.2154

20.0750 180101..................................................

1.3146

0.8950

27.4506

28.1621

28.8758

28.2013 180102..................................................

1.5042

0.8302

21.0896

25.2343

27.3887

24.3942 180103..................................................

2.0473

0.8950

28.4583

28.1734

29.7626

28.8044 180104..................................................

1.5676

0.8302

25.6157

25.9689

27.1274

26.2415 180105..................................................

0.9511

0.7837

21.6002

23.1917

24.3659

23.0870 180106..................................................

0.8902

0.7837

20.2884

20.7220

21.2265

20.7447 180115..................................................

0.9040

0.7837

20.5539

20.3089

22.7088

21.1833 180116..................................................

1.1839

0.8320

23.5354

25.8927

26.8836

25.4592 180117..................................................

0.9408

0.7837

22.8469

24.7378

24.9567

24.2081 180124..................................................

1.3223

0.9276

24.8292

25.4664

27.1341

25.8362 180127..................................................

1.3584

0.9123

24.6774

26.3947

28.3610

26.4554 180128..................................................

0.9392

0.7837

22.6056

23.8144

23.7770

23.4109 180130..................................................

1.6779

0.9245

27.8900

29.1712

29.6725

28.9399 180132..................................................

1.4346

0.8756

24.5105

25.3789

29.0546

26.3805 180138..................................................

1.1879

0.9245

28.1901

28.6871

29.2584

28.7287 180139..................................................

1.0065

0.7837

23.3569

24.7575

26.2434

24.7763 180141..................................................

1.8666

0.9245

25.3357

27.5912

28.7307

27.2557 180143..................................................

1.6777

0.8950

28.1924

30.8734

28.2122

29.0557 180144..................................................

***

*

29.5052

*

*

29.5052 180147..................................................

***

*

*

31.1615

*

31.1615 180148..................................................

***

*

*

30.1250

*

30.1250 180149..................................................

1.0087

0.7837

*

*

16.4909

16.4909 180150..................................................

1.8775

0.9245

*

*

*

* 190001..................................................

1.0903

0.7682

22.1394

22.1569

22.5328

22.2811 190002..................................................

1.5733

0.8438

23.3368

24.6984

25.9371

24.6300 190003..................................................

1.4214

0.8438

25.8294

26.7844

28.0895

26.9253 190004..................................................

1.5112

0.7870

25.3473

25.0803

24.6536

25.0228 190005..................................................

1.5223

0.9140

22.6029

24.2899

28.3303

24.2844 190006..................................................

1.2838

0.8438

22.7979

24.8836

25.2490

24.3632 190007..................................................

1.1753

0.7682

21.8205

23.1426

24.0527

23.0456 190008..................................................

1.7450

0.7870

24.6074

26.3638

27.2663

26.0087 190009..................................................

1.3606

0.8127

21.1005

24.0696

25.0269

23.3881 190011..................................................

1.0090

0.7961

21.4052

21.6991

21.9165

21.6827 190013..................................................

1.5563

0.7682

21.4573

23.7333

22.8372

22.6699 190014..................................................

1.2264

0.7682

22.7151

22.6405

24.5399

23.2756 190015..................................................

1.3070

0.9140

23.7789

25.1767

26.9572

25.3336 190017..................................................

1.4841

0.8438

24.5390

24.7537

25.5465

24.9732 190019..................................................

1.7201

0.8127

24.0468

25.4624

27.5462

25.7258 190020..................................................

1.2827

0.8142

22.1967

23.4602

24.2346

23.3365 190025..................................................

1.3344

0.7682

23.5007

24.5024

26.5944

24.8092 190026..................................................

1.6101

0.8127

23.7702

24.1556

25.3736

24.4572 190027..................................................

1.6236

0.7682

24.3006

26.7132

31.5026

27.4175 190034..................................................

1.2092

0.7871

20.7334

21.2130

22.9658

21.6044 190036..................................................

1.6604

0.9140

25.4164

25.6551

30.2172

26.9231 190037..................................................

***

*

19.4071

20.7271

28.0447

21.7538 190039..................................................

1.5115

0.9140

24.4386

25.4003

24.6075

24.8194 190040..................................................

1.4212

0.9140

28.6297

28.0169

28.2426

28.2870 190041..................................................

1.4648

0.8547

28.5376

28.0050

28.7683

28.4375 190044..................................................

1.2898

0.7943

20.9993

21.2604

22.2461

21.5123 190045..................................................

1.5439

0.9140

25.8238

27.1996

27.5854

26.9044 190046..................................................

1.4309

0.9140

23.8552

24.7370

*

24.2936 190050..................................................

1.1484

0.7726

21.0259

20.9142

22.7951

21.5828 190053..................................................

1.2074

0.7783

17.9788

18.5819

20.6282

19.0432 190054..................................................

1.3250

0.7767

23.1471

22.7011

23.5129

23.1218 190060..................................................

1.4709

0.7682

23.7393

22.6291

19.8899

21.9229 190064..................................................

1.6110

0.8142

23.1358

23.7298

26.9941

24.6370 190065..................................................

1.5904

0.8142

22.1880

23.1202

22.9847

22.7749 190078..................................................

1.0906

0.7869

22.2431

22.2346

25.6940

23.4396

Page 23746

190079..................................................

1.1812

0.9140

24.0985

23.8192

25.3327

24.4472 190081..................................................

0.8736

0.7682

20.0121

21.4510

20.4101

20.6028 190086..................................................

1.2760

0.7785

22.0610

22.2895

22.2837

22.2151 190088..................................................

1.1378

0.8547

23.8562

23.1638

24.7445

23.9122 190090..................................................

1.0338

0.7682

23.1241

24.3303

25.8607

24.3672 190098..................................................

1.7595

0.8547

25.6854

25.7449

27.5043

26.3126 190099..................................................

1.0153

0.7871

22.0610

23.2343

25.7481

23.6613 190102..................................................

1.5441

0.8438

27.3126

26.9700

28.3071

27.5010 190106..................................................

1.1415

0.8127

23.5376

26.6227

24.2755

24.7510 190111..................................................

1.6311

0.8547

25.5729

26.5722

27.3180

26.5044 190114..................................................

1.0602

0.7682

17.2678

19.1586

20.3639

18.9135 190115..................................................

1.2209

0.8547

28.2066

26.0797

26.0278

26.7727 190116..................................................

1.1880

0.7767

22.3710

23.4013

24.2156

23.3424 190118..................................................

0.9844

0.8547

22.8809

21.2580

22.6571

22.2425 190122..................................................

1.4015

0.8142

22.0072

22.2371

22.8671

22.4040 190124..................................................

***

*

26.0032

27.9484

28.6694

27.4838 190125..................................................

1.5711

0.7961

25.5463

24.8256

26.6254

25.6717 190128..................................................

1.0269

0.8142

28.3257

29.6682

31.1762

29.7845 190131..................................................

1.3325

0.8142

27.8465

28.6795

28.5938

28.3736 190133..................................................

0.9162

0.7784

18.2045

22.4311

23.9545

22.0666 190135..................................................

1.6174

0.9140

27.7540

30.5646

35.0524

30.2944 190140..................................................

0.9876

0.7717

18.9652

23.0485

23.6705

21.8176 190144..................................................

1.2672

0.8547

22.9181

23.7875

24.8858

23.8764 190145..................................................

0.9764

0.7772

19.9265

20.8579

21.3982

20.7221 190146..................................................

1.5575

0.9140

27.4824

28.7200

28.5963

28.2726 190151..................................................

0.9239

0.7682

18.7467

18.8391

20.6962

19.4061 190152..................................................

1.1740

0.9140

28.1334

30.8512

34.6485

30.9971 190158..................................................

***

*

26.4787

30.6450

21.9727

27.7355 190160..................................................

1.5637

0.7961

22.9325

24.7822

25.8632

24.4460 190161..................................................

1.0278

0.7682

22.6187

22.9035

23.8066

23.1213 190162..................................................

***

*

25.2953

*

*

25.2953 190164..................................................

1.1308

0.8127

25.2560

26.6207

27.7247

26.5855 190167..................................................

1.2763

0.8438

26.4669

25.3283

27.1969

26.3225 190175..................................................

1.2783

0.9140

26.0547

27.4256

30.5928

28.0066 190176..................................................

1.7856

0.9140

25.8826

26.2596

*

26.0715 190177..................................................

1.6464

0.9140

27.7792

28.2751

29.7229

28.5969 190182..................................................

***

*

27.1682

29.8656

30.7038

29.2917 190183..................................................

1.2357

0.7870

22.6928

22.0119

23.3452

22.7038 190184..................................................

0.9592

0.7785

24.9476

24.1626

22.6137

23.9160 190185..................................................

***

*

25.6394

28.9759

36.7292

29.7365 190190..................................................

0.9248

0.7843

24.3327

26.7043

27.5056

26.1460 190191..................................................

1.3760

0.8438

24.1923

26.1628

26.9649

25.7635 190196..................................................

0.9701

0.8438

24.0385

25.8472

27.7801

25.9541 190197..................................................

***

*

25.8071

26.4825

28.7026

26.9781 190199..................................................

1.1052

0.8142

27.3304

32.0194

36.7076

31.6410 190200..................................................

***

*

28.8173

27.4781

*

28.3200 190201..................................................

1.2572

0.7682

25.1010

24.4563

26.8537

25.4868 190202..................................................

1.5245

0.8142

27.6084

29.6612

*

28.6936 190203..................................................

***

*

28.1832

29.9753

*

29.0343 190204..................................................

1.4475

0.9140

28.1033

30.5140

32.9125

30.3814 190205..................................................

1.6677

0.8438

26.6832

28.2484

30.1674

28.3935 190206..................................................

2.0426

0.9140

26.7401

29.2371

32.0163

29.3053 190208..................................................

0.8467

0.7682

28.7308

27.9908

24.9395

26.8779 190218..................................................

1.0293

0.8547

26.7262

28.1039

26.5243

27.0954 190236..................................................

1.4591

0.8547

24.7142

26.4614

26.9046

26.0708 190241..................................................

2.2461

0.7870

25.2123

25.7906

26.5307

25.8664 190242..................................................

1.1726

0.8142

24.8461

25.0035

26.9715

25.6625 190245..................................................

1.6582

0.7961

25.5751

26.7642

26.4147

26.2436 190246..................................................

1.8467

0.7843

*

22.7833

31.7133

27.5712 190247..................................................

***

*

32.7499

*

*

32.7499 190248..................................................

***

*

23.2220

*

*

23.2220 190249..................................................

1.7284

0.8142

20.0468

25.2523

27.0954

23.4238 190250..................................................

2.1126

0.9140

31.5101

33.3302

32.8347

32.5070 190251..................................................

1.3045

0.8142

21.4464

23.8389

25.1576

23.4538 190252..................................................

***

*

23.6924

*

*

23.6924 190253..................................................

***

*

22.8060

23.8037

22.2212

23.0780 190254..................................................

***

*

32.9290

*

*

32.9290

Page 23747

190255..................................................

0.7692

0.8438

22.2412

16.1593

23.8013

20.1015 190256..................................................

0.8038

0.9140

*

25.9577

25.9352

25.9454 190257..................................................

1.6689

0.7785

*

26.5505

22.7493

24.6724 190258..................................................

***

*

31.3715

26.1141

25.1970

27.3097 190259..................................................

2.0814

0.8438

*

26.5084

27.5500

27.0088 190260..................................................

***

*

*

29.3947

33.6205

31.1711 190261..................................................

1.3897

0.7961

*

27.0441

25.4725

26.2680 190262..................................................

***

*

*

30.3719

*

30.3719 190263..................................................

2.3211

0.8438

*

26.4202

29.7034

28.0032 190264..................................................

***

*

*

26.5842

*

26.5842 190265..................................................

***

*

*

22.6231

30.9242

27.1318 190266..................................................

2.3213

0.8142

*

*

24.3790

24.3790 190267..................................................

1.3728

0.9140

*

*

24.2777

24.2777 190268..................................................

1.6840

0.8438

*

*

29.1407

29.1407 190270..................................................

1.8665

0.9140

*

*

*

* 190272..................................................

1.2748

0.8438

*

*

28.4541

28.4541 190273..................................................

1.7599

0.8142

*

*

*

* 190274..................................................

1.6077

0.9140

*

*

*

* 190275..................................................

1.3329

0.9140

*

*

*

* 190276..................................................

0.8985

0.8547

*

*

*

* 190277..................................................

0.8585

0.8069

*

*

*

* 200001..................................................

1.3378

1.0115

25.2542

26.3045

28.1124

26.5658 200002..................................................

1.1591

0.8609

25.7212

27.1151

33.2665

28.3561 200008..................................................

1.3906

0.9927

27.7137

29.1836

29.3519

28.7769 200009..................................................

1.9207

0.9927

30.7510

32.5812

35.0717

32.7319 200018..................................................

1.3207

0.8609

23.5632

22.5027

24.6780

23.5929 200019..................................................

1.2779

0.9927

25.6649

27.7896

28.3393

27.2843 200020..................................................

1.3255

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32.6436

34.0916

34.5740

33.7902 200021..................................................

1.2204

0.9927

27.1381

29.2054

28.7597

28.4046 200024..................................................

1.6748

0.9644

27.5410

29.7817

30.9932

29.4721 200025..................................................

1.1710

0.9927

26.3124

28.5750

29.3588

28.1289 200031..................................................

1.3018

0.8609

21.2370

22.2151

23.7539

22.4062 200032..................................................

1.1782

0.9075

26.3322

26.8993

27.2259

26.8277 200033..................................................

1.8241

1.0115

29.3108

31.7007

33.6270

31.6171 200034..................................................

1.3255

0.9644

27.0582

27.0103

28.0397

27.3625 200037..................................................

1.1982

0.8609

24.1732

24.9418

26.7798

25.3841 200039..................................................

1.2970

0.9644

25.1179

26.6409

28.8029

26.8816 200040..................................................

1.2039

0.9927

25.9893

27.8053

25.5506

26.3685 200041..................................................

1.2079

0.8609

24.9670

26.6777

27.5049

26.3961 200050..................................................

1.2398

1.0115

27.6825

29.5033

30.1456

29.1592 200052..................................................

1.1153

0.8609

22.5159

24.4204

25.6220

24.1936 200063..................................................

1.1834

0.8609

25.8623

27.9748

28.2184

27.3991 210001..................................................

1.3549

0.9460

28.2858

29.3471

31.2328

29.6476 210002..................................................

1.9987

0.9981

32.3005

33.7388

36.0222

34.1104 210003..................................................

1.6222

1.0670

34.1109

30.7334

28.2547

30.8148 210004..................................................

1.4250

1.1018

33.6056

31.7132

33.9015

33.0686 210005..................................................

1.2610

1.1018

28.9554

29.5835

32.4052

30.3394 210006..................................................

1.0725

0.9981

25.9005

27.3620

27.9844

27.0796 210007..................................................

1.7994

0.9981

31.8767

30.7124

31.4098

31.3077 210008..................................................

1.4105

0.9981

24.3341

28.8850

31.8512

28.2947 210009..................................................

1.6490

0.9981

27.7900

30.2661

31.8249

29.9840 210011..................................................

1.3847

0.9981

30.8575

31.0966

30.7517

30.9025 210012..................................................

1.5973

0.9981

30.3078

31.1778

32.5280

31.3781 210013..................................................

1.1768

0.9981

28.5328

28.9917

32.1151

29.7726 210015..................................................

1.2997

0.9981

29.9261

32.2774

31.6875

31.3239 210016..................................................

1.6120

1.1018

32.3506

33.5493

35.3218

33.6933 210017..................................................

1.2904

0.8795

25.1890

26.8592

26.6187

26.2235 210018..................................................

1.2011

1.1018

29.5533

29.6521

31.5431

30.2539 210019..................................................

1.7205

0.9194

27.3731

28.7844

30.5458

28.9499 210022..................................................

1.4645

1.1018

35.4727

37.3092

36.1806

36.3038 210023..................................................

1.4878

1.0060

32.1812

33.0212

34.1635

33.1583 210024..................................................

1.8236

0.9981

30.6359

32.9434

34.5523

32.7596 210025..................................................

1.2388

0.8795

23.8552

24.8570

23.5138

24.0665 210027..................................................

1.4130

0.8795

24.6343

24.4821

25.2106

24.7916 210028..................................................

1.0692

0.9307

26.3469

26.7462

28.5196

27.2373 210029..................................................

1.2751

0.9981

31.0266

31.8539

32.9078

31.9592 210030..................................................

1.1883

0.8795

26.9763

32.2033

29.1777

29.4507

Page 23748

210032..................................................

1.1828

1.0645

27.0727

27.9359

29.2770

28.1114 210033..................................................

1.1640

0.9981

28.5534

29.2504

28.4332

28.7353 210034..................................................

1.2631

0.9981

30.2908

32.3827

33.0382

31.9423 210035..................................................

1.3018

1.0670

28.6484

27.3901

30.6664

28.8614 210037..................................................

1.2037

0.8795

27.3287

27.8394

28.8691

28.0163 210038..................................................

1.1889

0.9981

29.8121

32.3206

31.1537

31.0730 210039..................................................

1.1193

1.0670

30.4991

32.4139

35.1146

32.6902 210040..................................................

1.2216

0.9981

28.3559

29.2390

31.0827

29.5738 210043..................................................

1.3058

1.0060

26.6524

32.6961

29.2744

29.4113 210044..................................................

1.3653

0.9981

29.7339

30.3349

31.5436

30.5467 210045..................................................

0.9952

0.9194

14.2223

16.3724

19.6097

16.8133 210048..................................................

1.3768

0.9981

27.5043

26.0650

29.2439

27.5592 210049..................................................

1.2275

0.9981

26.0900

27.0161

28.5947

27.3346 210051..................................................

1.2948

1.0670

29.8892

29.5219

30.7936

30.0807 210054..................................................

1.2558

1.0670

27.4328

27.7607

28.6884

27.9549 210055..................................................

1.2394

1.0670

30.6941

31.4905

30.1989

30.7527 210056..................................................

1.3104

0.9981

30.0810

32.3518

32.7755

31.8047 210057..................................................

1.3542

1.1018

31.6787

32.8299

33.7244

32.7501 210058..................................................

1.1208

0.9981

31.0873

31.1988

32.0642

31.4531 210060..................................................

1.2448

1.0670

27.1764

29.9626

32.5116

29.9224 210061..................................................

1.2566

0.8983

23.1645

25.0253

26.6822

25.0230 220001..................................................

1.2273

1.1338

30.6070

31.2316

32.0820

31.3057 220002..................................................

1.3729

1.1338

32.4356

33.6649

35.9738

34.0706 220006..................................................

***

*

30.7673

33.6438

*

32.1319 220008..................................................

1.2887

1.1338

31.3385

34.7924

35.8651

34.0329 220010..................................................

1.2326

1.1338

30.7804

32.0925

33.7364

32.2148 220011..................................................

1.1369

1.1338

34.7655

36.5640

39.1211

36.8964 220012..................................................

1.4655

1.2672

37.8763

39.7564

41.7040

39.8247 220015..................................................

1.2984

1.0343

29.6315

32.4903

35.2353

32.4365 220016..................................................

1.1282

1.0343

30.4813

32.5863

33.1404

32.0656 220017..................................................

1.3194

1.1994

31.6170

33.3020

34.6550

33.1982 220019..................................................

1.0429

1.1338

24.4009

25.7855

26.3006

25.5037 220020..................................................

1.1312

1.1338

28.5288

30.8458

32.1503

30.5508 220024..................................................

1.2349

1.0343

28.7342

31.9491

32.8073

31.1791 220025..................................................

1.0377

1.1338

25.6478

30.4369

27.6958

27.7639 220028..................................................

***

*

31.7122

39.3089

*

35.2808 220029..................................................

1.1472

1.1338

30.6935

31.6363

32.6767

31.6963 220030..................................................

1.1059

1.0343

26.8849

28.1347

29.3701

28.1501 220031..................................................

1.5532

1.1994

36.8477

38.9433

39.4182

38.4392 220033..................................................

1.1976

1.1338

31.8249

32.3495

34.6977

33.0203 220035..................................................

1.4173

1.1338

31.4470

34.8739

36.1775

35.0964 220036..................................................

1.5119

1.1994

33.1436

35.9124

37.7268

35.6257 220046..................................................

1.4449

1.0445

30.4460

31.4510

33.8585

31.9500 220049..................................................

1.2309

1.1338

30.4740

32.4652

35.1108

32.7132 220050..................................................

1.0897

1.0343

28.3434

29.5194

30.3160

29.4110 220051..................................................

1.3081

1.0199

30.2552

30.1022

32.8672

31.0914 220052..................................................

1.1432

1.1994

32.4130

32.3532

34.9126

33.2019 220058..................................................

1.0116

1.1338

25.7247

27.8893

30.0325

27.9127 220060..................................................

1.1603

1.1994

32.5477

34.7336

36.8641

34.7665 220062..................................................

0.6341

1.1338

25.0766

25.4224

27.3304

25.9567 220063..................................................

1.2647

1.1338

30.2866

32.9283

32.2417

31.8295 220065..................................................

1.2613

1.0343

27.6009

30.1103

32.3793

30.0468 220066..................................................

1.3284

1.0343

27.8073

29.9736

*

28.8792 220067..................................................

1.2302

1.1994

30.2222

32.4019

33.9807

32.2180 220070..................................................

1.1429

1.1338

33.1299

34.2598

35.6244

34.3611 220071..................................................

1.8365

1.1994

36.5065

37.4087

40.0281

38.0115 220073..................................................

1.1896

1.1338

34.2989

36.0289

37.4224

35.9320 220074\4\...............................................

1.3507

1.1338

30.5607

31.4730

33.2051

31.7041 220B74\4\...............................................

***

*

*

31.4731

33.2051

32.3862 220075..................................................

1.5438

1.1994

30.9175

32.2957

33.3538

32.1942 220076..................................................

***

*

27.5148

*

*

27.5148 220077..................................................

1.6655

1.0972

31.7325

34.0168

33.7563

33.1765 220080..................................................

1.1645

1.1338

29.9595

31.1268

33.1617

31.3799 220082..................................................

1.2899

1.1338

30.0611

30.8230

32.2105

31.0609 220083..................................................

1.0693

1.1994

34.5118

34.5969

35.2728

34.8205 220084..................................................

1.2134

1.1338

30.9527

31.6955

34.6254

32.3748 220086..................................................

1.7222

1.1994

34.2388

35.3451

36.2359

35.3173

Page 23749

220088..................................................

1.9446

1.1994

35.8255

34.7637

37.0808

35.9288 220089..................................................

***

*

32.6305

34.8205

*

33.7125 220090..................................................

1.2394

1.1338

32.9011

34.1963

35.8940

34.3697 220095..................................................

1.1576

1.1338

28.0673

30.8626

31.1619

30.0333 220098..................................................

1.1400

1.1338

30.5869

31.5403

30.6593

30.9378 220100..................................................

1.3072

1.1994

31.9859

34.6599

35.7276

34.1807 220101..................................................

1.2971

1.1338

35.3464

37.7809

36.0984

36.4336 220105..................................................

1.1814

1.1338

33.2625

34.4029

35.8155

34.5228 220108..................................................

1.1999

1.1994

32.6131

33.8854

35.6985

34.0752 220110..................................................

2.0011

1.1994

39.2167

40.7382

43.8401

41.3123 220111..................................................

1.2206

1.1994

33.6167

34.2498

35.6193

34.5167 220116..................................................

1.8714

1.1994

36.4149

38.8799

40.0952

38.4127 220119..................................................

1.1333

1.1994

30.9965

32.0863

33.7174

32.3365 220126..................................................

1.1806

1.1994

31.4882

32.6938

35.6250

33.2716 220133..................................................

***

*

29.4855

34.9182

*

32.1170 220135..................................................

1.3038

1.2672

36.0203

37.5189

38.7180

37.4435 220153..................................................

***

*

*

19.8085

17.9600

18.7803 220154..................................................

***

*

*

28.7898

*

28.7898 220162..................................................

1.5970

*

*

*

*

* 220163..................................................

1.6172

1.1338

34.4874

37.4968

39.4859

37.2285 220171..................................................

1.6935

1.1338

32.7414

35.9948

36.4545

35.0735 220174..................................................

1.1926

1.1338

30.0406

30.9503

32.9113

31.3266 220175..................................................

1.2681

*

*

*

34.1550

34.1550 220176..................................................

1.6474

1.1338

*

*

31.4195

31.4195 230002..................................................

1.3237

1.0113

32.9010

32.7578

33.9675

33.2532 230003..................................................

1.2416

0.9455

27.5824

28.4716

28.9871

28.3360 230004..................................................

1.7110

1.0227

29.3934

31.5136

33.4620

31.5262 230005..................................................

1.2402

0.9337

25.8768

27.7463

29.0625

27.5854 230013..................................................

1.3836

1.0052

24.6511

27.2075

28.6417

26.7586 230015..................................................

1.1593

0.9159

26.2782

27.2541

28.9588

27.5253 230017..................................................

1.6518

1.0910

31.8821

32.5396

36.8018

33.8177 230019..................................................

1.6077

1.0052

32.3401

34.3213

35.1415

33.9317 230020..................................................

1.7476

1.0113

28.5646

29.5324

29.9072

29.3527 230021..................................................

1.5495

1.0365

26.5659

28.6169

29.5397

28.2368 230022..................................................

1.2686

0.9652

25.6683

30.1195

25.7829

27.0325 230024..................................................

1.6538

1.0113

32.1483

32.5892

34.5253

33.1061 230029..................................................

1.6160

1.0052

32.3538

32.3845

33.1460

32.6277 230030..................................................

1.2847

0.8864

23.8082

25.1100

24.9719

24.6466 230031..................................................

1.3571

0.9972

29.7232

30.0120

30.8859

30.2337 230034..................................................

1.3764

0.8864

24.4845

24.4141

29.1079

25.8635 230035..................................................

1.1994

0.9305

24.8822

25.6715

25.7083

25.4572 230036..................................................

1.4140

0.9472

29.3754

29.9642

31.0922

30.1636 230037..................................................

1.3059

1.0113

28.9244

28.5311

28.8529

28.7691 230038..................................................

1.7649

0.9455

28.2012

29.1263

30.1019

29.1994 230040..................................................

1.1794

0.9305

25.5154

26.3190

27.2835

26.3819 230041..................................................

1.5803

0.9472

27.8853

27.9569

30.3060

28.7057 230046..................................................

1.9162

1.0444

31.6235

32.2924

33.5285

32.5197 230047..................................................

1.4494

1.0052

31.1771

31.7075

32.0225

31.6475 230053..................................................

1.6700

1.0113

32.5711

32.1566

33.5420

32.7704 230054..................................................

1.8803

0.9412

25.7591

26.3251

28.1223

26.7475 230055..................................................

1.2587

0.8864

27.4349

28.4787

28.1872

28.0393 230058..................................................

1.1167

0.8864

25.9291

27.3156

27.9625

27.0813 230059..................................................

1.5346

0.9455

27.9091

28.5875

28.3586

28.2947 230060..................................................

1.2934

0.8864

28.2874

27.0288

28.7744

28.0391 230065..................................................

***

*

32.6255

*

*

32.6255 230066..................................................

1.3058

1.0227

30.6184

30.2104

32.3459

31.0702 230069..................................................

1.1826

1.0810

30.2663

31.3406

31.9653

31.2223 230070..................................................

1.6502

0.9034

25.6778

26.8315

28.0349

26.8663 230071..................................................

0.9448

1.0052

28.3064

29.6728

28.2055

28.7253 230072..................................................

1.3622

0.9455

26.2838

27.4742

28.8006

27.5408 230075..................................................

1.3557

1.0086

28.2540

30.9525

32.1146

30.4322 230077..................................................

1.8799

1.0810

29.8538

30.5567

31.0097

30.4726 230078..................................................

1.1903

0.8864

25.6809

25.7232

27.0050

26.0991 230080..................................................

1.2607

0.9472

24.1573

24.5432

25.6193

24.7905 230081..................................................

1.2326

0.8864

24.7374

26.4337

27.8091

26.3288 230085..................................................

1.2326

1.0910

23.4959

25.4289

27.6459

25.5347 230089..................................................

1.3435

1.0113

31.0522

32.8450

32.2293

31.9436

Page 23750

230092..................................................

1.3964

1.0113

28.6829

29.3442

30.5399

29.5449 230093..................................................

1.2159

0.8922

25.5804

27.4463

27.0555

26.7238 230095..................................................

1.2754

0.9472

22.8681

25.1854

25.9196

24.6699 230096..................................................

1.1779

1.0365

30.6024

31.7399

27.7873

29.8976 230097..................................................

1.6913

0.9305

28.2526

29.8962

31.5152

29.8782 230099..................................................

1.2173

1.0113

29.0221

29.3720

28.7386

29.0351 230100..................................................

1.1914

0.8864

24.1881

25.2118

25.6583

25.0492 230101..................................................

1.1683

0.8864

25.4839

28.4372

28.8595

27.6204 230104\5\...............................................

1.5934

1.0113

32.4634

32.4125

34.0171

32.9570 230B04\5\...............................................

***

*

*

*

34.0171

34.0171 230105..................................................

1.7842

0.9472

32.4583

30.5515

32.1103

31.7057 230106..................................................

1.2381

0.9455

25.3243

27.8584

30.0195

27.7687 230108..................................................

1.1549

0.8864

20.2539

24.4337

25.7463

23.4436 230110..................................................

1.2539

0.8864

27.0040

25.7196

27.0263

26.5809 230117..................................................

1.8415

1.0910

32.7994

33.0602

33.9148

33.2761 230118..................................................

1.0095

0.8864

23.6110

24.8890

24.8631

24.4400 230119..................................................

1.4381

1.0113

30.7488

31.9696

33.2026

32.0127 230121..................................................

1.2621

0.9652

26.4940

26.8361

27.7495

27.0478 230130..................................................

1.6817

1.0052

30.1608

31.2744

32.5589

31.3612 230132..................................................

1.5413

1.1258

32.3939

35.5304

38.2428

35.3551 230133..................................................

1.4288

0.8864

23.9442

25.0647

25.8516

24.9772 230135..................................................

1.3171

1.0113

25.9583

23.6005

31.5185

26.7530 230141..................................................

1.6173

1.1258

31.6152

33.2553

36.3094

33.7170 230142..................................................

1.2688

1.0113

27.8377

29.7417

29.9882

29.2232 230144..................................................

1.8275

1.0444

*

*

*

* 230146..................................................

1.3735

1.0113

26.8156

27.2621

29.0197

27.7279 230151..................................................

1.3314

1.0052

27.4546

29.8366

28.6704

28.6311 230156..................................................

1.5950

1.0444

32.3755

33.9034

34.7840

33.7042 230165..................................................

1.5974

1.0113

29.6376

31.4242

32.2831

31.1343 230167..................................................

1.6088

0.9899

29.8071

31.0657

32.8063

31.2488 230174..................................................

1.3451

0.9455

30.0563

29.7488

31.2452

30.3405 230176..................................................

1.3115

1.0113

28.1498

28.9798

29.2664

28.8186 230180..................................................

1.1167

0.8864

26.0707

24.9696

24.6000

25.1971 230184..................................................

***

*

34.6295

*

*

34.6295 230190..................................................

***

*

30.7875

33.8229

33.6707

32.7904 230193..................................................

1.3561

0.9972

25.1626

26.4728

28.4624

26.7218 230195..................................................

1.4319

1.0052

29.5656

30.9702

32.5528

31.0477 230197..................................................

1.6021

1.1258

32.0063

33.7128

34.8039

33.5209 230204..................................................

1.4349

1.0052

31.5615

32.2882

30.1956

31.3391 230207..................................................

1.2451

1.0052

25.4268

25.1983

26.8215

25.8117 230208..................................................

1.2210

0.9305

23.7523

24.3476

25.2472

24.4569 230212..................................................

1.0426

1.0444

31.9818

32.8567

33.4362

32.7601 230216..................................................

1.4778

0.9972

29.0147

29.2061

28.9567

29.0586 230217..................................................

1.4015

1.0086

30.1136

31.9732

33.0815

31.7828 230222..................................................

1.4250

0.9472

29.9341

30.6482

32.4389

30.9827 230223..................................................

1.3052

1.0052

28.6745

29.8430

31.9496

30.1361 230227..................................................

1.4799

1.0052

30.8218

33.6716

34.2728

32.7518 230230..................................................

1.4804

0.9899

29.8763

31.1712

31.4931

30.8595 230236..................................................

1.5428

0.9455

31.3110

30.8556

31.9088

31.3744 230239..................................................

1.3021

0.8864

21.0814

22.1579

23.5448

22.2557 230241..................................................

1.1943

0.9972

27.6106

28.5516

30.0233

28.7406 230244..................................................

1.4607

1.0113

29.6283

30.0405

32.1407

30.6177 230254..................................................

1.4847

1.0052

29.2653

29.5874

31.2379

30.0646 230257..................................................

0.9794

1.0052

29.6712

30.6372

30.0667

30.1067 230259..................................................

1.2691

1.0444

27.4217

27.5982

27.9557

27.6540 230264..................................................

2.0641

1.0052

22.7768

28.5416

29.2178

26.4132 230269..................................................

1.4701

1.0052

31.3226

31.3800

34.2667

32.3991 230270..................................................

1.3480

1.0113

28.5372

28.8173

29.2388

28.8712 230273..................................................

1.4692

1.0113

31.9862

31.5396

32.5706

32.0372 230275..................................................

0.5428

0.9034

23.8104

25.2133

22.3717

23.7470 230277..................................................

1.4612

1.0052

29.8372

31.4023

32.2518

31.1889 230279..................................................

0.5480

1.0810

27.2816

27.9726

26.8539

27.3521 230283..................................................

***

*

33.5531

*

*

33.5531 230294..................................................

***

*

31.6195

*

*

31.6195 230295..................................................

***

*

27.1298

*

*

27.1298 230296..................................................

***

*

*

34.2107

*

34.2107 230297..................................................

1.6971

1.0052

*

*

*

*

Page 23751

230298..................................................

0.7864

1.0052

*

*

*

* 230300..................................................

3.3739

1.0052

*

*

*

* 230301..................................................

1.0374

1.0052

*

*

*

* 240001..................................................

1.5531

1.0997

33.1499

34.7673

37.2179

35.0462 240002..................................................

1.8744

1.0519

31.6000

33.1051

34.6345

33.1529 240004..................................................

1.5878

1.0997

32.7010

32.5777

33.5085

32.9298 240006..................................................

1.2147

1.0982

31.0777

33.4777

32.8229

32.4953 240010..................................................

1.9657

1.0982

33.4668

32.7261

35.9102

34.0521 240014..................................................

1.0726

1.0997

29.8905

30.7519

33.4476

31.3959 240017..................................................

***

*

24.3596

*

*

24.3596 240018..................................................

1.2598

0.9925

28.1432

29.4995

30.5632

29.4372 240019..................................................

1.0353

1.0519

33.7546

32.7052

34.2538

33.5836 240020..................................................

1.1144

1.0997

31.3874

33.2449

34.5686

33.0762 240022..................................................

1.0632

0.9120

26.1920

27.3137

28.5889

27.3645 240030..................................................

1.3950

1.0638

26.5508

27.1312

27.6584

27.1136 240036..................................................

1.6415

1.0997

32.7028

34.2980

37.2177

34.8308 240038..................................................

1.4964

1.0997

31.9891

33.0554

34.7330

33.2508 240040..................................................

1.0575

1.0519

27.5074

28.9009

30.0238

28.8059 240043..................................................

1.2453

0.9120

23.3489

24.0708

25.7420

24.4201 240044..................................................

1.0841

0.9745

25.0988

26.8681

28.5689

26.7906 240047..................................................

1.5230

1.0519

28.6406

29.7835

35.6742

31.1184 240050..................................................

1.0910

1.0997

27.5553

30.9805

33.7946

30.9171 240052..................................................

1.2031

0.9120

28.7206

29.4617

31.0917

29.7873 240053..................................................

1.5039

1.0997

31.4324

33.1148

34.4186

33.0264 240056..................................................

1.3585

1.0997

33.1728

34.0845

35.8580

34.4096 240057..................................................

1.7902

1.0997

30.7703

33.4713

34.8349

33.0717 240059..................................................

1.0937

1.0997

31.0911

32.4803

32.5938

32.0866 240061..................................................

1.8510

1.0982

33.1799

32.0828

34.6008

33.3406 240063..................................................

1.5799

1.0997

33.7895

35.2877

36.9798

35.4057 240064..................................................

1.1730

1.0401

34.3757

27.2407

29.9902

30.4614 240066..................................................

1.5245

1.0997

35.3441

36.0705

39.6582

37.0745 240069..................................................

1.1972

1.0997

29.3718

30.9719

31.1660

30.5144 240071..................................................

1.1037

1.0997

28.6950

31.7754

32.5442

30.9915 240075..................................................

1.1903

1.0638

27.5039

29.1171

30.3218

29.0129 240076..................................................

1.0213

1.0997

30.6936

33.1439

33.7939

32.5944 240078..................................................

1.6519

1.0997

32.5785

34.6118

36.1976

34.5440 240080..................................................

1.9537

1.0997

32.5725

34.8064

36.5363

34.6282 240084..................................................

1.1356

1.0519

26.5975

27.0995

29.0260

27.5332 240088..................................................

1.2998

1.0638

28.0603

29.1387

30.7223

29.3333 240093..................................................

1.4599

1.0997

27.2928

29.1717

30.4718

29.0677 240100..................................................

1.3409

0.9120

30.8391

31.5774

30.9460

31.1194 240101..................................................

1.1984

0.9120

25.6963

26.8849

28.5492

27.1176 240104..................................................

1.2063

1.0997

31.6511

35.0736

35.8816

34.3219 240106..................................................

1.6106

1.0997

30.5927

32.8156

33.9953

32.4894 240115..................................................

1.4822

1.0997

32.0107

33.5288

36.2755

33.9354 240117..................................................

1.1647

0.9647

24.5750

27.6950

29.0889

27.1230 240128..................................................

***

*

23.3334

*

*

23.3334 240132..................................................

1.2651

1.0997

32.1233

34.6191

36.4224

34.2571 240141..................................................

1.1039

1.0997

31.4468

32.8689

34.2453

32.8961 240166..................................................

1.1593

0.9120

27.6987

26.5328

26.1726

26.6670 240187..................................................

1.2972

1.0997

27.8844

29.1582

30.9633

29.4012 240196..................................................

0.8466

1.0997

31.5965

34.3743

35.0319

33.6757 240206..................................................

0.9236

1.4448

*

*

*

* 240207..................................................

1.2383

1.0997

32.5589

34.6792

36.4537

34.6384 240210..................................................

1.2823

1.0997

32.7123

34.4184

36.5922

34.6233 240211..................................................

1.0511

0.9932

22.5430

17.4044

16.6144

18.6322 240213..................................................

1.4161

1.0997

33.8680

35.7818

37.4575

35.7765 250001..................................................

1.9650

0.8095

23.5222

23.7773

24.3386

23.8768 250002..................................................

0.9549

0.7883

23.4063

25.4201

25.0335

24.6387 250004..................................................

1.7720

0.8909

24.7907

25.8722

24.8072

25.1647 250006..................................................

1.1563

0.8909

24.4282

25.9199

27.0493

25.8303 250007..................................................

1.2323

0.8898

24.8929

27.7665

29.3457

27.3747 250009..................................................

1.2588

0.8361

23.0352

23.4866

24.9100

23.8155 250010..................................................

1.0456

0.7653

21.4322

21.8665

22.7976

22.0351 250012..................................................

0.9464

0.9329

21.5540

23.4837

26.4108

23.6996 250015..................................................

1.1829

0.7653

22.0067

22.2803

22.3674

22.2133 250017..................................................

1.0987

0.7653

22.7660

33.6840

25.7397

26.7933

Page 23752

250018..................................................

0.8867

0.7653

17.1276

17.9025

19.1099

18.0552 250019..................................................

1.5607

0.8898

25.7376

26.2199

27.7207

26.5559 250020..................................................

1.0028

0.7653

22.1851

23.7245

23.1510

23.0478 250023..................................................

0.8728

0.8156

18.0108

18.5067

19.5072

18.7146 250025..................................................

1.1390

0.7653

22.5621

23.1738

23.0544

22.9290 250027..................................................

0.9541

0.7653

24.4937

26.9922

32.5430

27.8433 250031..................................................

1.3451

0.8095

24.8139

25.9189

26.7496

25.8093 250034..................................................

1.5368

0.8909

26.1887

26.7996

27.9267

26.9950 250035..................................................

0.8649

0.7653

20.1622

19.1038

20.5237

19.9107 250036..................................................

1.0485

0.8030

20.3625

19.7951

22.5661

20.8304 250038..................................................

0.9523

0.8095

22.2571

26.9621

30.7941

25.9485 250040..................................................

1.4898

0.8156

24.5962

27.3366

26.2250

26.0460 250042..................................................

1.2547

0.8909

25.6807

26.1190

27.4593

26.4125 250043..................................................

0.9847

0.7653

18.8979

20.8841

21.1254

20.3156 250044..................................................

1.0363

0.7883

24.0508

24.9199

26.1725

25.0759 250048..................................................

1.6491

0.8095

25.2092

24.7659

27.6318

25.8347 250049..................................................

0.8715

0.7653

19.1044

20.4775

24.2222

21.0940 250050..................................................

1.3084

0.7653

20.8084

21.1657

22.4407

21.4799 250051..................................................

0.8661

0.7653

14.3741

13.9532

14.1652

14.1687 250057..................................................

1.1739

0.7653

22.7601

24.3654

22.9665

23.3314 250058..................................................

1.2366

0.7653

19.2502

18.9970

19.6711

19.3080 250059..................................................

0.9358

0.7653

23.8997

26.7491

25.5976

25.3587 250060..................................................

0.8110

0.7653

28.1431

25.4779

27.0347

26.8919 250061..................................................

0.8867

0.7653

17.8267

18.7413

25.1493

20.4689 250067..................................................

1.0949

0.7653

23.1193

25.2189

23.8020

24.0644 250069..................................................

1.4416

0.8280

22.6353

22.4194

23.4494

22.8355 250072..................................................

1.6783

0.8095

25.8399

25.5337

27.5770

26.3178 250077..................................................

0.9717

0.7653

18.3735

19.0416

19.6329

19.0451 250078..................................................

1.5855

0.8156

22.1243

22.8430

23.9580

22.9829 250079..................................................

0.8932

0.7653

45.5166

43.0845

46.0338

44.8458 250081..................................................

1.3682

0.8280

23.9995

25.6808

24.8259

24.8305 250082..................................................

1.4127

0.8150

23.0287

23.5399

25.6206

24.1469 250084..................................................

1.2526

0.7653

19.6492

19.1604

19.5676

19.4638 250085..................................................

1.0182

0.7653

22.5513

24.2915

24.6743

23.8551 250093..................................................

1.1850

0.7653

23.0984

23.9128

26.4337

24.4984 250094..................................................

1.6982

0.8156

24.1422

24.7718

25.4215

24.7893 250095..................................................

1.0314

0.7653

21.7488

23.6140

25.9001

23.7842 250096..................................................

1.2042

0.8095

24.9187

26.3743

27.7270

26.3759 250097..................................................

1.4899

0.8146

21.8139

22.0211

22.7899

22.2472 250099..................................................

1.2725

0.8095

21.1269

21.5656

27.5739

23.2182 250100..................................................

1.5271

0.8280

25.6846

27.0286

27.5468

26.7620 250102..................................................

1.5947

0.8095

24.6652

25.4050

25.5308

25.2035 250104..................................................

1.4396

0.8280

23.4303

24.4311

25.3986

24.4448 250112..................................................

0.9616

0.7653

24.3069

26.3357

27.4138

26.0536 250117..................................................

1.1581

0.8156

22.2450

23.7337

24.5692

23.5009 250120..................................................

***

*

24.6370

26.6522

*

25.6905 250122..................................................

1.1272

0.7653

27.2795

27.4424

23.4884

26.0511 250123..................................................

1.3504

0.8898

26.6221

27.9058

29.8280

28.1116 250124..................................................

0.8367

0.8095

20.4394

20.5667

21.9411

20.9862 250125..................................................

1.3788

0.8898

27.5158

26.7687

32.7395

28.5834 250126..................................................

1.0192

0.9329

24.4126

25.0019

25.2582

24.9087 250127..................................................

0.8041

1.4448

*

*

*

* 250128..................................................

0.9631

0.8099

17.7624

21.7882

23.5915

21.3639 250134..................................................

0.9291

0.8095

22.2167

21.0211

22.0830

21.7636 250136..................................................

1.0279

0.8095

22.9468

25.2241

27.1454

25.0260 250138..................................................

1.3091

0.8095

24.3018

25.2642

27.3114

25.5721 250141..................................................

1.4795

0.9329

28.5922

30.5112

33.4397

31.0006 250149..................................................

0.8769

0.7653

16.8796

17.2268

17.0956

17.0712 250151..................................................

0.5535

0.7653

18.8846

22.8238

*

19.4286 250152..................................................

0.8224

0.8095

26.9334

26.4559

28.5527

27.2309 250155..................................................

***

*

22.5728

*

*

22.5728 250156..................................................

***

*

*

16.8659

*

16.8659 250157..................................................

***

*

*

29.6398

*

29.6398 250162..................................................

1.0520

0.8912

*

*

*

* 260001..................................................

1.6886

0.9704

27.9230

29.5271

31.1839

29.5270 260004..................................................

0.9098

0.8470

20.3217

21.3629

24.1888

22.1072 260005..................................................

1.5296

0.8986

27.7855

27.9477

31.1215

28.9388

Page 23753

260006..................................................

1.4493

0.8470

30.3440

27.3754

33.7767

30.5981 260009..................................................

1.2153

0.9444

24.2360

25.7546

26.6670

25.5689 260011..................................................

1.5894

0.9038

25.6387

27.5762

31.2590

28.1581 260015..................................................

1.0293

0.8470

24.6139

25.0640

25.0244

24.8950 260017..................................................

1.3008

0.8736

23.5713

25.0461

26.2612

24.9757 260020..................................................

1.7335

0.8986

27.4730

29.3080

30.9576

29.2687 260021..................................................

1.3073

0.8986

29.3646

32.6735

19.4693

25.9620 260022..................................................

1.3246

0.8738

23.3393

24.8713

25.9379

24.7192 260023..................................................

1.3719

0.8986

24.3192

25.4314

25.5884

25.1233 260024..................................................

1.1889

0.8470

19.4952

19.2199

20.7131

19.8199 260025..................................................

1.3981

0.8986

22.2451

24.0358

24.5032

23.6143 260027..................................................

1.6154

0.9444

26.3590

29.3811

31.0217

28.7832 260032..................................................

1.8506

0.8986

25.6763

27.4857

28.7163

27.3241 260034..................................................

1.0142

0.9444

25.0573

27.1685

28.7725

27.0780 260040..................................................

1.7140

0.8470

24.3938

25.9074

27.2449

25.8128 260047..................................................

1.4348

0.8470

25.4978

26.6343

27.2646

26.4797 260048..................................................

1.1808

0.9444

27.6117

28.1515

29.6955

28.5297 260050..................................................

1.1398

1.0267

25.0506

26.2346

27.8050

26.4419 260052..................................................

1.3065

0.8986

26.0052

27.6360

29.6982

27.7827 260057..................................................

1.0872

0.9444

20.9639

21.5925

23.8167

22.1481 260059..................................................

1.2943

0.8547

22.6922

22.3885

24.9630

23.3714 260061..................................................

1.1720

0.8470

22.4766

22.8589

23.6708

22.9805 260062..................................................

1.2709

0.9444

28.1661

28.4975

29.6135

28.7754 260064..................................................

1.3641

0.8470

22.2395

23.3498

21.4934

22.3902 260065..................................................

1.7935

0.8470

27.1014

29.3564

27.9224

28.1492 260068..................................................

1.7301

0.8470

26.0295

27.3475

28.1227

27.1642 260070..................................................

0.9682

0.8470

24.6331

21.9701

25.2991

24.0399 260074..................................................

1.2162

0.8470

25.6218

28.0468

28.6203

27.4572 260077..................................................

1.6229

0.8986

26.7466

27.6624

28.7183

27.7262 260078..................................................

1.2711

0.8470

20.1983

21.1539

23.1780

21.5534 260080..................................................

1.0066

0.8470

17.9107

18.6070

18.6804

18.3878 260081..................................................

1.4925

0.8986

28.1182

29.1890

32.3581

29.9070 260085..................................................

1.5513

0.9444

26.6718

28.0306

29.6492

28.1046 260091..................................................

1.4867

0.8986

28.0537

28.5473

30.1154

28.9182 260094..................................................

1.6133

0.8470

24.1473

23.8654

25.1476

24.3842 260095..................................................

1.3868

0.9444

24.2698

27.6196

29.9069

27.0422 260096..................................................

1.5240

0.9444

29.7312

30.7267

32.9353

31.1666 260097..................................................

1.1896

0.8770

25.0624

25.5634

27.3117

26.0306 260102..................................................

0.9841

0.9444

27.2145

26.7624

30.7667

28.2426 260104..................................................

1.5825

0.8986

28.6247

28.0235

29.6366

28.7794 260105..................................................

1.8539

0.8986

29.8848

29.4766

32.4075

30.5702 260107..................................................

***

*

25.8177

27.9710

29.7754

27.7676 260108..................................................

1.8291

0.8986

26.6374

27.0758

28.5633

27.4377 260110..................................................

1.6476

0.8470

24.7656

26.6030

28.0368

26.5197 260113..................................................

1.1410

0.8470

21.2072

21.8884

23.0810

22.0233 260115..................................................

1.2609

0.8986

23.1396

24.6389

25.5643

24.4735 260116..................................................

1.0435

0.8470

21.3503

20.7479

22.5593

21.5340 260119..................................................

1.2922

0.8470

27.9769

31.5490

31.4981

30.2546 260137..................................................

1.7457

0.9704

24.3273

27.6592

31.4059

27.8364 260138..................................................

1.8944

0.9444

30.4410

30.6284

31.7554

30.9538 260141..................................................

1.8592

0.8470

24.1555

25.5663

26.6672

25.5210 260142..................................................

1.0838

0.8470

21.5923

21.7609

22.8201

22.0857 260147..................................................

0.9526

0.8470

21.4235

22.1928

22.9670

22.1968 260159..................................................

***

*

22.6276

23.9515

24.3018

23.5847 260160..................................................

1.0612

0.8470

23.8257

25.5096

26.6702

25.4076 260162..................................................

1.4383

0.8986

27.0236

28.4660

30.5739

28.7100 260163..................................................

1.2130

0.8557

21.6408

21.5566

23.8630

22.3617 260166..................................................

1.2356

0.9444

29.1225

28.5858

29.5234

29.0824 260175..................................................

1.1172

0.9444

25.1817

24.6064

25.7060

25.1720 260176..................................................

1.7557

0.8986

29.3034

31.1056

30.6112

30.3581 260177..................................................

1.2272

0.9444

27.0185

28.7942

29.0786

28.3077 260178..................................................

1.9689

0.8470

25.4782

27.1201

26.9886

26.5981 260179..................................................

1.5286

0.8986

26.6069

28.3234

29.6937

28.2012 260180..................................................

1.5853

0.8986

28.2931

29.3820

30.7313

29.4593 260183..................................................

1.6733

0.8986

27.5577

29.2684

31.4894

29.4549 260186..................................................

1.4640

0.8470

26.9797

28.8610

29.1853

28.3616 260190..................................................

1.2175

0.9444

27.9137

30.5343

30.8981

29.7909

Page 23754

260191..................................................

1.4412

0.8986

24.6973

26.3244

27.8627

26.3553 260193..................................................

1.2305

0.9444

26.8922

28.1060

29.5416

28.1851 260195..................................................

1.2498

0.8470

22.6870

24.0411

25.0275

23.9191 260198..................................................

***

*

28.0021

27.2555

27.9073

27.7138 260200..................................................

1.2908

0.8986

28.2453

27.4784

30.3290

28.7369 260207..................................................

1.1540

0.8470

22.6109

22.9579

23.6383

23.1705 260209..................................................

1.1532

0.9038

25.0098

25.0749

26.4196

25.5826 260210..................................................

1.3929

0.8986

26.8745

30.5975

36.4040

30.6935 260211..................................................

1.4262

0.9444

40.9821

35.9113

37.1525

38.3586 260213..................................................

***

*

*

34.8953

*

34.8953 260214..................................................

1.2306

0.9444

*

*

31.0153

31.0153 260216..................................................

1.3065

0.9444

*

*

*

* 260218..................................................

0.8126

*

*

*

*

* 260219..................................................

1.3191

0.8986

*

*

*

* 260220..................................................

2.3259

*

*

*

*

* 270002..................................................

1.1469

0.8640

24.0534

25.2907

28.3363

25.9060 270003..................................................

1.2563

0.8679

28.8700

29.1938

28.0533

28.6560 270004..................................................

1.6239

0.9045

26.1319

26.6779

28.5851

27.1552 270011..................................................

1.0779

*

22.7061

24.4696

*

23.5588 270012..................................................

1.5992

0.8679

25.2914

26.5854

28.0655

26.6761 270014..................................................

1.8067

0.8992

25.8231

27.4811

28.2567

27.1793 270017..................................................

1.3001

0.8909

26.5404

27.4150

29.3524

27.7689 270023..................................................

1.5599

0.8909

25.5682

26.3076

28.1878

26.6584 270032..................................................

1.0422

0.8640

20.3469

20.4330

21.6349

20.8153 270049..................................................

1.7681

0.9045

27.1634

28.6880

29.8869

28.6461 270051..................................................

1.5064

0.8909

26.5621

24.9371

29.3917

26.9486 270057..................................................

1.2964

0.8640

25.5811

27.1838

28.3612

27.1309 270074..................................................

0.8884

1.4448

*

*

*

* 270081..................................................

1.0022

*

19.5612

20.0438

*

19.8033 270086..................................................

1.2443

0.8679

21.0808

20.7976

21.8997

21.2340 270087..................................................

1.3324

0.8640

25.9772

24.8022

24.9177

25.2095 280003..................................................

1.7687

0.9620

30.6124

30.1057

32.3760

30.9970 280009..................................................

1.8349

0.9336

27.0705

29.3634

28.1542

28.1942 280013..................................................

1.7183

0.9400

27.0250

27.9523

30.3102

28.4716 280020..................................................

1.6559

0.9620

27.3284

32.3896

29.4807

29.7217 280023..................................................

1.3206

0.9336

26.7980

29.5132

30.0701

28.7818 280030..................................................

1.9392

0.9400

29.5102

30.6991

31.8740

30.6841 280032..................................................

1.2928

0.9336

24.3995

24.7539

25.6529

24.9364 280040..................................................

1.5775

0.9400

28.7207

29.5276

30.7378

29.6445 280060..................................................

1.6610

0.9400

27.7496

30.3049

30.8594

29.5587 280061..................................................

1.4476

0.9223

26.0208

26.4824

28.9580

27.1706 280065..................................................

1.2542

0.9611

28.0581

28.0132

29.5456

28.5374 280077..................................................

1.3602

0.8841

27.0860

28.2206

29.9204

28.4615 280081..................................................

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0.9400

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31.1212

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29.5979 280105..................................................

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0.9400

27.8599

29.8488

30.0457

29.2896 280111..................................................

1.1718

0.8761

24.5617

27.4853

28.3536

26.8743 280119..................................................

0.8951

1.4448

*

*

*

* 280123..................................................

0.9698

0.8884

15.4047

22.2185

20.2745

18.6147 280125..................................................

1.5858

0.8761

22.1345

23.2900

24.7453

23.4399 280127..................................................

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0.9620

29.3684

25.6806

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26.9797 280128..................................................

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0.9620

28.5422

28.8734

27.1001

28.1534 280129..................................................

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0.9400

*

27.8793

27.9490

27.9189 280130..................................................

1.3820

0.9400

*

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29.9161 290001..................................................

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1.0476

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33.3287

34.9942 290002..................................................

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17.3876

23.9348

22.7349

20.8853 290003..................................................

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30.5242 290009..................................................

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34.1940 290012..................................................

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27.6277

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25.9788 290021..................................................

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35.4886 290022..................................................

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36.9258 290042..................................................

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*

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*

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*

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*

*

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1.1666

*

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1.1666

*

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1.0476

*

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30.0551 290051..................................................

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1.0027

*

*

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0.9824

*

*

*

* 290053..................................................

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1.1666

*

*

*

* 300001..................................................

1.4434

1.0807

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31.0102

30.0651 300003..................................................

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33.0771

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33.0547

31.6597 300014..................................................

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1.0807

29.7667

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30.7717

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1.0807

29.9560

31.6699

33.4139

31.6768 300018..................................................

1.3172

1.0807

29.4270

31.7891

31.5012

30.9778 300019..................................................

1.2444

1.0807

27.5672

28.2287

28.3103

28.0672 300020..................................................

1.1991

1.0807

30.8491

30.9783

32.4635

31.4527 300023..................................................

1.4459

1.0807

31.0040

31.2726

32.3183

31.5692 300029..................................................

1.8204

1.0807

29.8117

31.4429

32.0012

31.1343 300034..................................................

1.8504

1.0807

30.7676

31.6880

33.5519

32.0214 310001..................................................

1.7571

1.2878

41.7460

39.3391

41.4917

40.8275 310002..................................................

1.7914

1.2693

37.9183

37.8652

37.9453

37.9105 310003..................................................

1.1900

1.2878

36.2346

39.0785

40.1509

38.5759 310005..................................................

1.3414

1.1440

32.1319

33.6311

34.7634

33.5607 310006..................................................

1.4339

1.2878

28.4771

28.7321

30.4276

29.2523 310008..................................................

1.3390

1.2878

32.6788

33.3172

34.3243

33.4553 310009..................................................

1.3656

1.2693

33.6940

33.6165

35.4592

34.2954 310010..................................................

1.2858

1.1313

33.9552

33.7009

36.0797

34.6164 310011..................................................

1.2607

1.1599

31.2907

34.3497

37.4820

34.3008 310012..................................................

1.5959

1.2878

38.3590

39.8568

41.9596

40.0664 310013..................................................

***

*

31.0447

35.6260

32.9465

33.1378 310014..................................................

1.8164

1.1221

30.0793

32.9016

36.5996

33.3018 310015..................................................

1.9106

1.2693

36.8818

39.2928

40.8200

39.0289 310016..................................................

1.3313

1.2878

35.6155

38.2740

41.0326

38.2707 310017..................................................

1.3644

1.2693

32.2434

35.7308

35.9780

34.6067 310018..................................................

1.1472

1.2693

30.3234

32.9704

32.6937

31.9526 310019..................................................

1.5510

1.2878

30.3518

30.6369

31.8909

30.9689 310020..................................................

1.5807

1.2878

33.5516

37.3372

38.4230

37.3143 310021..................................................

1.6495

1.1316

32.1929

31.6562

32.2042

32.0219 310022..................................................

1.3231

1.1221

30.4043

31.1951

32.8059

31.4436 310024..................................................

1.3886

1.1440

33.3415

33.8622

36.6897

34.6507 310025..................................................

1.4248

1.2878

34.3687

32.2630

32.1469

32.9318 310026..................................................

1.3243

1.2878

29.1588

30.1392

30.1294

29.8053 310027..................................................

1.4636

1.1440

29.7793

31.5967

34.6445

31.9780 310028..................................................

1.1907

1.1440

32.2977

33.9911

34.8312

33.7159 310029..................................................

1.7792

1.1221

32.9246

33.6695

35.2057

33.9510 310031..................................................

2.8606

1.1221

37.0668

39.3783

39.5882

38.6577 310032..................................................

1.3218

1.1221

30.7865

33.0258

35.2379

33.0201 310034..................................................

1.4121

1.1221

31.7012

32.7523

36.8586

33.7114 310037..................................................

1.4765

1.2878

38.5415

38.2865

40.4608

39.0092 310038..................................................

1.8931

1.2693

35.9190

36.3344

39.8671

37.3872 310039..................................................

1.2417

1.2693

31.4278

33.2100

32.6403

32.4242 310040..................................................

1.2573

1.2878

33.8535

37.7945

41.2219

37.4721 310041..................................................

1.3358

1.1221

32.8390

33.9799

35.1979

33.9784 310042..................................................

***

*

34.4986

*

*

34.4986 310044..................................................

1.3493

1.1313

31.9678

33.7614

33.5843

33.0824 310045..................................................

1.6491

1.2878

36.7862

38.4424

39.2064

38.1273 310047..................................................

1.3458

1.1666

34.1520

37.3695

37.7198

36.4657 310048..................................................

1.3736

1.1316

32.9681

33.9506

34.5223

33.8353 310050..................................................

1.2457

1.2693

29.1732

32.3686

37.9191

32.9302 310051..................................................

1.4905

1.1440

35.0121

38.1174

39.7645

37.6891 310052..................................................

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32.5778

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32.3544 310058..................................................

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30.4080

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29.4040 310060..................................................

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27.7048 310061..................................................

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31.6648

39.0538

33.5561

34.7375 310063..................................................

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1.1440

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38.1450

34.4537 310064..................................................

1.5372

1.1666

35.7607

38.6310

39.4132

38.0057 310069..................................................

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1.1221

31.7642

34.4669

35.1354

33.8309 310070..................................................

1.4555

1.2693

34.3225

36.3279

36.9963

35.8869 310073..................................................

1.7821

1.1221

32.6733

34.2858

36.9226

34.6721 310074..................................................

1.4656

1.2878

40.3494

39.6196

39.0709

39.6558 310075..................................................

1.4250

1.1221

31.5226

32.5338

33.5226

32.5111 310076..................................................

1.6465

1.2693

38.0643

37.5163

38.1641

37.9202 310077..................................................

***

*

34.6085

*

*

34.6085 310078..................................................

***

*

30.5761

*

*

30.5761 310081..................................................

1.2620

1.1221

30.1561

31.0699

31.7950

31.0154 310083..................................................

1.3189

1.2693

30.3580

31.9151

28.3385

30.1096 310084..................................................

1.2659

1.1221

33.5941

32.6051

34.9604

33.7173 310086..................................................

1.2615

1.1221

29.5566

29.8794

30.9445

30.1377 310088..................................................

1.1243

1.1666

29.9929

30.3552

31.2420

30.5505 310090..................................................

1.2372

1.1440

32.8191

33.4615

33.9146

33.3953 310091..................................................

1.1327

1.1221

29.3969

31.9762

35.2892

32.2224 310092..................................................

1.4052

1.1313

29.7958

32.7054

32.8408

31.7803 310093..................................................

1.2201

1.2693

29.1288

30.2860

32.3840

30.5687 310096..................................................

1.9372

1.2693

34.1524

35.0707

34.2007

34.4697 310105..................................................

1.1572

1.2878

30.1069

32.5672

32.0252

31.5545 310108..................................................

1.4030

1.2693

33.0172

34.5866

36.2821

34.6390 310110..................................................

1.3096

1.1313

33.2246

33.4809

35.6793

34.1565 310111..................................................

1.2536

1.1221

31.8393

34.8284

36.0727

34.2677 310112..................................................

1.3277

1.1221

31.2372

32.2676

34.5315

32.6218 310113..................................................

1.2425

1.1221

31.0436

33.6771

35.0222

33.3347 310115..................................................

1.3224

1.1221

29.5320

31.9208

32.1173

31.2475 310116..................................................

1.2972

1.2878

29.2748

29.8144

27.5857

28.8828 310118..................................................

1.3587

1.2878

31.1803

31.2296

32.8252

31.7711 310119..................................................

1.8782

1.2693

43.1238

41.5702

41.2971

41.9830 310120..................................................

1.0851

1.1440

29.2535

33.3861

35.1643

32.4707 310122..................................................

***

*

*

41.9029

*

41.9029 310123..................................................

***

*

*

37.1022

*

37.1022 310124..................................................

***

*

*

41.8827

*

41.8827 310125..................................................

***

*

*

36.2186

*

36.2186 310126..................................................

***

*

*

*

34.3166

34.3166 320001..................................................

1.6823

0.9499

29.6182

30.0077

31.4174

30.3597 320002..................................................

1.5341

1.0587

32.0477

33.1342

34.1580

33.1619 320003..................................................

1.1298

1.0207

27.6222

31.4473

31.5768

30.3534 320004..................................................

1.3299

0.8858

24.7803

26.2073

28.2392

26.4283 320005..................................................

1.4214

0.9295

24.7543

28.7893

25.2152

26.1577 320006..................................................

1.2584

0.9295

26.9080

28.0964

28.5156

27.8949 320009..................................................

1.5798

0.9499

32.0116

27.8084

31.3279

30.3184 320011..................................................

1.1519

0.9300

25.6693

27.9522

28.9931

27.5536 320013..................................................

1.1126

1.0207

22.8283

30.5865

31.2869

27.7697 320014..................................................

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0.8858

27.2806

28.7089

30.4781

28.8685 320016..................................................

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0.8858

25.0835

27.1492

26.6374

26.3150 320017..................................................

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0.9499

31.6357

33.3496

30.5759

31.7120 320018..................................................

1.5461

0.8882

26.5109

25.9248

28.3438

26.9103 320019..................................................

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0.9499

27.8067

35.0217

28.6731

30.2204 320021..................................................

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0.9499

26.9918

28.8504

30.4499

28.7977 320022..................................................

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0.8858

23.9595

25.3707

27.5132

25.6817 320030..................................................

1.0361

0.8858

21.0378

24.4497

25.5246

23.7752 320033..................................................

1.2183

1.0207

31.7114

30.1471

30.1829

30.6567 320037..................................................

1.2261

0.9499

24.9657

25.2876

27.8969

26.0664 320038..................................................

1.2596

0.8858

21.7022

32.7192

31.6504

29.0042 320057..................................................

0.9342

1.4430

*

*

*

* 320058..................................................

0.7891

1.4430

*

*

*

* 320059..................................................

0.9914

1.4430

*

*

*

* 320060..................................................

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1.4430

*

*

*

* 320061..................................................

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*

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*

* 320062..................................................

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*

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Page 23757

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23.9141 320070..................................................

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1.4430

*

*

*

* 320074..................................................

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28.4396

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29.1304 320079..................................................

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24.2897

21.5109 320085..................................................

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27.4100

28.4513

27.9647 320086..................................................

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0.8858

*

*

*

* 320087..................................................

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1.0587

*

*

*

* 330002..................................................

1.5701

1.3043

30.9600

32.1956

34.7252

32.6020 330003..................................................

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0.8833

24.4326

25.2223

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25.5129 330004..................................................

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1.0709

28.0594

30.2236

30.3204

29.4839 330005..................................................

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0.9593

30.3200

31.5030

33.2828

31.7049 330006..................................................

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1.3043

33.6284

34.2001

36.3279

34.6900 330008..................................................

1.1757

0.9593

23.4429

25.2005

26.2131

24.9414 330009..................................................

1.3652

1.3043

36.2820

38.9166

41.3767

38.8011 330010..................................................

1.0125

0.8375

20.7476

19.7098

20.5800

20.3266 330011..................................................

1.3772

0.8721

25.1308

27.4747

26.8258

26.4851 330013..................................................

1.9475

0.8833

26.4578

26.8382

28.8015

27.3879 330014..................................................

1.3374

1.3043

42.1759

45.7619

46.3155

44.6761 330016..................................................

***

*

22.0493

23.0769

*

22.5738 330019..................................................

1.3063

1.3043

38.5368

39.7429

44.5627

40.8880 330023..................................................

1.5312

1.2855

35.9428

36.4736

37.5106

36.6960 330024..................................................

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1.3043

42.7691

43.2342

44.8034

43.6032 330025..................................................

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0.9593

21.2565

23.2424

24.2691

22.9268 330027..................................................

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1.2855

42.8000

45.1920

45.9531

44.5412 330028..................................................

1.5319

1.3043

36.6498

36.2901

38.0116

36.9910 330029..................................................

0.5241

0.9593

23.2039

24.0679

22.9321

23.3384 330030..................................................

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0.8911

24.6175

25.3454

25.5081

25.1586 330033..................................................

1.2323

0.8531

24.5510

24.8022

25.0205

24.7863 330036..................................................

1.2126

1.3043

29.1884

30.3757

30.4633

30.0049 330037..................................................

1.2293

0.8911

22.3689

21.9246

23.4904

22.5870 330041..................................................

1.3098

1.3043

37.4883

36.9934

37.1640

37.2203 330043..................................................

1.4593

1.2729

39.1643

38.8060

40.6059

39.5013 330044..................................................

1.3446

0.8721

26.5669

28.2293

28.2619

27.6916 330045..................................................

1.4086

1.2729

38.1269

40.0326

41.6537

39.9715 330046..................................................

1.3696

1.3043

50.3152

47.4975

52.2364

49.9699 330047..................................................

1.2132

0.8375

24.3932

24.9934

26.1791

25.2159 330049..................................................

1.4907

1.2694

29.8350

34.8585

34.9720

33.3441 330053..................................................

1.0857

0.8911

20.6272

21.8383

20.1297

20.8283 330055..................................................

1.5415

1.3043

41.5934

42.2007

44.2313

42.7264 330056..................................................

1.3947

1.3043

36.0136

38.8910

39.9628

38.2393 330057..................................................

1.6802

0.8833

26.4989

27.7121

30.1910

28.1436 330058..................................................

1.2665

0.8911

22.2524

22.6852

23.6285

22.8634 330059..................................................

1.5527

1.3043

41.7343

44.9162

45.3660

44.0375 330061..................................................

1.1594

1.3043

36.0587

37.8828

37.8620

37.2887 330064..................................................

1.2603

1.3043

38.0437

38.2332

41.5714

39.3164 330065..................................................

1.0618

0.9593

25.3043

24.4004

26.2272

25.3188 330066..................................................

1.2729

0.8833

29.1780

25.8174

27.2069

27.4291 330067..................................................

1.3961

1.2694

27.8900

29.2571

30.7516

29.2920 330072..................................................

1.3012

1.3043

37.8505

39.6996

41.4567

39.5848 330073..................................................

1.1090

0.8911

22.5592

23.4020

25.1380

23.7034 330074..................................................

1.1944

0.8911

22.6629

23.4576

23.1004

23.0807 330075..................................................

1.1190

0.9865

23.1592

24.2552

23.7516

23.7241 330078..................................................

1.4677

0.9593

25.8073

27.2870

27.6659

26.9471 330079..................................................

1.3733

0.8308

24.6054

24.9941

27.9464

25.8287 330080..................................................

1.1760

1.3043

39.1417

38.9405

40.2059

39.4431 330084..................................................

1.0851

0.8308

22.5573

25.6880

27.3430

25.1537 330085..................................................

1.1551

0.9471

25.3285

26.6235

27.1697

26.3813 330086..................................................

1.3189

1.3043

32.7675

35.5269

40.9743

36.5723 330088..................................................

1.0110

1.2729

34.0789

35.3871

35.9962

35.1584 330090..................................................

1.4588

0.9101

25.5351

26.8730

27.7287

26.7363 330091..................................................

1.3843

0.9593

25.9378

27.0040

28.3015

27.0881 330094..................................................

1.2631

0.9901

25.7116

26.9148

28.6203

27.1128

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1.1987

0.8308

22.7189

24.2422

24.7885

23.9177 330100..................................................

1.1185

1.3043

38.3333

39.6244

37.8618

38.6066 330101..................................................

1.8970

1.3043

40.1929

43.7944

45.5381

43.2279 330102..................................................

1.4096

0.9593

25.3879

26.6887

27.2523

26.4449 330103..................................................

1.2008

0.8351

22.8242

24.5585

25.4907

24.2904 330104..................................................

1.3423

1.3043

33.7537

35.1076

36.5857

35.1622 330106..................................................

1.6914

1.2855

43.8210

46.3657

48.2871

46.1844 330107..................................................

1.2407

1.2729

34.9047

35.7384

38.0246

36.2529 330108..................................................

1.1289

0.8347

23.2919

23.9368

25.3011

24.1893 330111..................................................

0.9674

0.9593

20.3473

40.4349

23.2125

25.3142 330115..................................................

1.1888

0.9865

25.2373

23.8235

24.3889

24.4744 330119..................................................

1.7304

1.3043

39.0528

42.2901

41.2326

40.8420 330125..................................................

1.7378

0.8911

27.2920

28.0584

29.4802

28.3192 330126..................................................

1.3038

1.2855

35.2257

36.5689

37.7797

36.5514 330127..................................................

1.3108

1.3043

45.3680

45.2993

45.2542

45.3069 330128..................................................

1.2304

1.3043

39.5197

41.7790

43.3424

41.5728 330132..................................................

1.1001

0.8439

21.0479

21.7648

22.1446

21.6691 330133..................................................

1.3704

1.3043

39.3837

38.5228

39.9011

39.2582 330135..................................................

1.2101

1.1586

27.9132

32.0525

33.2291

31.0896 330136..................................................

1.5320

0.9471

25.8531

26.6680

25.4193

25.9628 330140..................................................

1.7962

0.9865

27.6183

29.3461

31.1320

29.4083 330141..................................................

1.3202

1.2729

39.4701

39.3741

39.1699

39.3348 330144..................................................

0.9865

0.8362

22.9561

23.3874

24.9303

23.7658 330151..................................................

1.2083

0.8362

21.7665

19.7959

21.6335

21.0260 330152..................................................

1.3015

1.3043

37.6721

38.2079

39.5722

38.4999 330153..................................................

1.7175

0.8833

26.4386

28.4446

28.9924

27.9865 330154..................................................

1.6921

*

*

*

*

* 330157..................................................

1.3796

0.9471

26.5686

27.1432

29.7604

27.7881 330158..................................................

1.6713

1.3043

38.2033

41.7010

39.5913

39.8276 330159..................................................

1.3553

0.9865

28.2774

31.7835

33.8472

31.2089 330160..................................................

1.5503

1.3043

36.6208

37.1915

39.1048

37.6457 330162..................................................

1.3383

1.3043

34.9460

37.6226

38.7613

37.1390 330163..................................................

1.1132

0.9593

27.1933

28.3910

28.6229

28.0754 330164..................................................

1.4898

0.8911

27.7217

27.8746

29.8437

28.5199 330166..................................................

1.0613

0.8308

20.4680

20.7121

22.8498

21.3014 330167..................................................

1.6290

1.2855

36.7653

39.1251

39.1824

38.3281 330169..................................................

1.3998

1.3043

45.3774

46.4939

47.5367

46.4021 330171..................................................

***

*

30.4005

35.1577

*

32.5880 330175..................................................

1.1285

0.8568

23.8509

24.1005

26.7868

24.8937 330177..................................................

0.9936

0.8308

20.6338

22.9834

23.4294

22.3276 330180..................................................

1.1924

0.8833

24.3761

25.4170

26.8643

25.5779 330181..................................................

1.3033

1.2855

41.4104

43.0977

46.2154

43.5483 330182..................................................

2.2878

1.2855

40.9014

41.3033

42.7924

41.6641 330184..................................................

1.3645

1.3043

35.8102

39.0437

39.7213

38.2058 330185..................................................

1.2668

1.2729

36.3155

38.4002

39.6695

38.1531 330188..................................................

1.2402

0.9593

25.1153

27.5988

29.7302

27.4385 330189..................................................

1.2886

0.8833

22.3484

22.4383

25.8116

23.5448 330191..................................................

1.2850

0.8833

25.5656

26.4328

28.2938

26.8175 330193..................................................

1.4383

1.3043

39.9327

39.8910

40.0256

39.9494 330194..................................................

1.7941

1.3043

45.5639

46.8880

49.8845

47.4698 330195..................................................

1.7054

1.3043

39.7802

41.7885

43.3185

41.6774 330196..................................................

1.2884

1.3043

36.7178

38.2525

38.6925

37.9124 330197..................................................

1.1174

0.8308

26.8921

25.9872

26.5516

26.4718 330198..................................................

1.3922

1.2855

33.4930

34.8985

35.8688

34.8129 330199..................................................

1.1949

1.3043

38.6407

40.3948

39.4065

39.4834 330201..................................................

1.8000

1.3043

37.2064

42.6707

46.5096

42.1336 330202..................................................

1.4107

1.3043

37.4150

37.4158

38.7609

37.8756 330203..................................................

1.4153

0.9865

32.1207

34.0499

34.6499

33.6383 330204..................................................

1.4550

1.3043

39.6393

41.9953

39.5313

40.4252 330205..................................................

1.2337

1.1586

31.9510

33.9418

35.3766

33.7848 330208..................................................

1.1951

1.3043

32.1256

33.5287

37.1706

34.2436 330209..................................................

***

*

30.2038

*

*

30.2038 330211..................................................

1.0836

0.8308

24.4470

25.8752

24.9417

25.1105 330213..................................................

1.0678

0.8308

24.4049

27.4890

28.5365

26.7727 330214..................................................

1.8791

1.3043

41.8719

42.1339

43.2434

42.4360 330215..................................................

1.2792

0.8721

23.7361

23.9583

26.3964

24.6837 330218..................................................

1.0910

0.9865

26.9638

26.9982

28.4109

27.4690

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330219..................................................

1.7127

0.9593

29.8889

32.5658

33.2132

31.8655 330221..................................................

1.3708

1.3043

39.2080

40.0514

42.5461

40.6770 330222..................................................

1.2774

0.8833

25.8507

27.7198

28.7835

27.5072 330223..................................................

0.9707

0.8308

23.3669

26.1264

27.1959

25.6000 330224..................................................

1.3100

1.0709

27.9231

29.1738

30.4765

29.2021 330225..................................................

1.2228

1.2855

32.3585

35.7651

32.9013

33.6812 330226..................................................

1.4002

0.8911

24.5646

24.8471

26.3674

25.2746 330229..................................................

1.2244

0.8420

21.9356

23.0577

23.9230

22.9668 330230..................................................

1.0278

1.3043

37.1298

38.6569

39.3870

38.3808 330231..................................................

1.1135

1.3043

40.6697

44.9422

48.9002

44.9236 330232..................................................

1.2072

0.8833

26.3313

27.4639

27.9601

27.2541 330233..................................................

1.5357

1.3043

47.3497

52.7070

40.8517

46.1530 330234..................................................

2.3425

1.3043

48.2306

49.3219

49.8754

49.1340 330235..................................................

1.1520

0.9471

27.7031

29.4346

30.8007

29.3076 330236..................................................

1.5494

1.3043

40.2386

42.8981

42.6166

41.9558 330238..................................................

1.2738

0.8911

21.7435

21.8386

23.3946

22.3482 330239..................................................

1.2402

0.8420

22.3854

23.1885

24.6380

23.4006 330240..................................................

1.4609

1.3043

43.5753

40.5001

41.6117

41.8580 330241..................................................

1.8409

0.9865

30.2304

32.7683

32.9148

32.0133 330242..................................................

1.3112

1.3043

37.4870

36.9015

38.7839

37.7206 330245..................................................

1.7745

0.8721

26.1811

27.4326

28.6678

27.4605 330246..................................................

1.3715

1.2729

37.1611

35.7416

35.9559

36.2356 330247..................................................

1.1834

1.3043

35.4980

39.0219

41.3428

38.4848 330249..................................................

1.3392

0.9865

25.3246

24.6091

26.9847

25.6366 330250..................................................

1.3845

0.9216

27.1606

29.0080

29.6168

28.6244 330259..................................................

1.5072

1.2855

35.1514

36.4788

39.0189

36.8295 330261..................................................

1.2365

1.3043

33.7834

40.2579

38.0192

37.2335 330263..................................................

1.0140

0.8308

23.8738

24.1333

24.2125

24.0872 330264..................................................

1.3203

1.1586

30.4701

31.0557

32.1770

31.4635 330265..................................................

1.2419

0.8911

21.6477

23.9081

22.7426

22.7616 330267..................................................

1.3921

1.3043

32.8541

34.9885

35.3884

34.4218 330268..................................................

0.9313

0.8308

25.3567

23.8793

23.9129

24.3479 330270..................................................

2.0758

1.3043

57.3596

55.2136

52.3126

54.6691 330273..................................................

1.3499

1.3043

37.0157

35.9298

39.7849

37.6016 330276..................................................

1.1594

0.8344

24.3300

26.0935

27.0432

25.8320 330277..................................................

1.2068

0.9101

26.4535

30.9053

30.8138

29.1290 330279..................................................

1.6224

0.9593

27.4539

29.6385

31.2369

29.4467 330285..................................................

1.9771

0.8911

30.1928

31.1235

31.9305

31.0944 330286..................................................

1.3514

1.2729

35.5895

37.6040

38.8533

37.3699 330290..................................................

1.6233

1.3043

39.4690

40.6933

39.8010

39.9779 330304..................................................

1.3053

1.3043

36.2845

37.3537

39.4605

37.8134 330306..................................................

1.4567

1.3043

36.3552

38.7713

39.0391

38.0888 330307..................................................

1.3412

0.9561

29.2529

29.5885

30.8103

29.9028 330314..................................................

***

*

26.2719

28.1788

22.6868

26.0606 330316..................................................

1.2398

1.3043

34.8567

37.1766

37.9320

36.6690 330331..................................................

1.2869

1.2855

39.8402

41.2694

44.1690

41.7977 330332..................................................

1.3105

1.2855

35.1646

37.0111

38.6906

36.9311 330338..................................................

***

*

37.7497

*

*

37.7497 330339..................................................

0.7634

0.8833

23.5786

24.3066

25.0041

24.2976 330340..................................................

1.2284

1.2729

37.9000

37.4161

38.4698

37.9265 330350..................................................

1.5260

1.3043

41.1339

44.4617

44.2368

43.3333 330353..................................................

1.2443

1.3043

45.9692

45.0977

46.0175

45.7015 330354..................................................

2.1246

*

*

*

*

* 330357..................................................

1.2886

1.3043

38.2286

40.3850

40.2097

39.5419 330372..................................................

1.2901

1.2855

36.1840

35.1297

37.0288

36.1053 330385..................................................

1.0504

1.3043

48.6175

49.0859

47.3989

48.3826 330386..................................................

1.3408

1.1461

29.9366

33.3216

32.9974

32.1005 330389..................................................

1.7338

1.3043

37.1862

39.6871

37.5883

38.1257 330390..................................................

1.2394

1.3043

36.3842

35.5562

38.7634

36.9285 330393..................................................

1.7385

1.2729

38.0619

39.2186

38.9295

38.7593 330394..................................................

1.6520

0.8721

27.3388

28.4597

28.8056

28.2126 330395..................................................

1.4204

1.3043

36.3921

37.5791

50.1276

40.5815 330396..................................................

1.3480

1.3043

37.4998

39.4904

39.1940

38.7397 330397..................................................

1.4094

1.3043

37.5682

41.4448

41.1659

39.9850 330399..................................................

1.1317

1.3043

34.7394

36.7626

39.8000

37.1071 330401..................................................

1.3519

1.2729

37.8559

40.4485

41.7804

40.0688 330403..................................................

0.9101

0.8911

25.5163

25.2937

28.7267

26.3688

Page 23760

330404..................................................

0.9366

1.3043

*

*

36.1044

36.1044 330405..................................................

0.9452

1.3043

*

*

35.2698

35.2698 330406..................................................

0.9450

0.8833

*

*

28.2727

28.2727 330407..................................................

0.9449

0.8833

*

*

*

* 340001..................................................

1.4870

0.9570

28.3988

29.5709

29.9082

29.3235 340002..................................................

1.7858

0.9192

28.4860

29.6622

30.7384

29.6332 340003..................................................

1.2344

0.8632

24.1602

26.0888

26.6393

25.6927 340004..................................................

1.4318

0.9096

26.6404

27.5283

27.9184

27.3734 340008..................................................

1.2672

0.9567

26.7443

27.7206

29.0639

27.8645 340010..................................................

1.3315

0.9557

27.2105

28.7544

29.5207

28.5197 340011..................................................

1.1738

0.8632

19.7441

22.0047

22.5138

21.4242 340012..................................................

1.2246

0.8632

23.2288

24.7576

24.9253

24.3215 340013..................................................

1.2360

0.9307

23.9492

26.3607

26.9137

25.7232 340014..................................................

1.6086

0.8984

27.4888

27.8384

29.5330

28.3119 340015..................................................

1.3956

0.9570

28.0585

28.3928

30.0958

28.8519 340016..................................................

1.3330

0.8632

25.6454

27.2365

27.9629

26.9654 340017..................................................

1.2759

0.9192

25.7780

27.5672

28.4845

27.2551 340020..................................................

1.1889

0.8788

26.4465

27.5473

28.3440

27.4399 340021..................................................

1.3379

0.9570

29.4864

29.3835

31.3610

30.1011 340023..................................................

1.3629

0.9307

26.4225

26.2716

27.6909

26.8311 340024..................................................

1.1349

0.8809

23.6638

26.4001

26.8984

25.6597 340025..................................................

1.2988

0.9192

23.5881

24.0101

25.2827

24.3044 340027..................................................

1.2181

0.9174

25.5973

26.3840

26.6506

26.2232 340028..................................................

1.5011

0.9923

28.0323

30.7591

31.9846

30.2233 340030..................................................

1.9766

0.9693

29.6630

30.4591

31.1985

30.4842 340032..................................................

1.4553

0.9570

26.5958

28.7636

29.2058

28.2291 340035..................................................

1.0979

0.8632

23.9669

24.6262

26.0827

24.8874 340036..................................................

1.3100

0.9685

27.2691

27.3860

29.0626

27.9422 340037..................................................

1.1218

0.8794

25.6262

29.0618

30.5346

28.5630 340038..................................................

1.2380

0.8885

22.4829

24.2111

26.2582

24.3742 340039..................................................

1.2806

0.9570

27.4457

27.8228

29.5042

28.2768 340040..................................................

1.9081

0.9346

27.6626

28.7434

30.1256

28.8796 340041..................................................

1.3315

0.8946

24.3595

26.8314

27.1270

26.1141 340042..................................................

1.2353

0.8632

25.0110

25.6349

27.0573

25.9214 340047..................................................

1.8051

0.8984

27.4022

28.4968

28.7600

28.2338 340049..................................................

1.7851

0.9693

30.6791

29.6826

31.5524

30.6567 340050..................................................

1.2008

0.9567

26.0365

27.5274

29.2266

27.6025 340051..................................................

1.1886

0.8794

23.9612

24.4561

25.4961

24.6507 340053..................................................

1.4900

0.9570

27.8577

28.9355

30.8320

29.2316 340055..................................................

1.2129

0.8946

26.0647

26.5752

29.0098

27.1555 340060..................................................

1.0621

0.9141

22.9097

25.1791

26.8366

24.9813 340061..................................................

1.7496

0.9693

27.0089

29.8574

31.2885

29.4140 340064..................................................

1.1205

0.8632

23.4233

23.9701

25.0796

24.1848 340068..................................................

1.2915

0.8632

22.6814

23.6757

24.7388

23.6999 340069..................................................

1.8414

0.9693

29.3439

31.4951

32.2147

31.0749 340070..................................................

1.2531

0.8984

25.3226

26.6546

27.7660

26.6186 340071..................................................

1.0621

0.9557

26.3921

27.9748

29.7321

28.0710 340072..................................................

1.1433

*

25.2493

24.1350

*

24.6895 340073..................................................

1.6527

0.9693

30.9849

31.6803

33.2859

32.0279 340075..................................................

1.2349

0.8946

25.1551

25.1438

26.8298

25.7432 340084..................................................

1.1236

0.9570

21.1363

23.1300

25.6868

23.2795 340085..................................................

1.1506

0.8882

26.5164

27.9572

29.1072

27.8491 340087..................................................

1.2341

0.8632

22.4287

25.4730

23.8343

23.9111 340090..................................................

1.3071

0.9685

26.4031

26.7428

28.3594

27.2234 340091..................................................

1.6022

0.9096

27.1285

28.8044

30.4345

28.8160 340096..................................................

1.2333

0.8882

24.9036

26.5438

26.5795

26.0408 340097..................................................

1.2431

0.8632

26.2228

29.8005

27.9788

27.9546 340098..................................................

1.4670

0.9570

28.2493

29.7180

31.3896

29.8226 340099..................................................

1.2912

0.8632

21.8564

23.9702

26.0062

24.0248 340104..................................................

0.7848

0.8794

16.1204

17.0165

19.9477

17.8305 340106..................................................

1.1406

0.8632

26.0892

26.1340

24.5134

25.5139 340107..................................................

1.1991

0.9068

24.1762

26.5626

27.3548

26.0750 340109..................................................

1.2448

0.8868

25.4464

26.6383

26.6462

26.2343 340113..................................................

1.9457

0.9570

28.5587

30.3841

32.3765

30.4662 340114..................................................

1.5304

0.9693

28.3222

28.1311

30.1188

28.8788 340115..................................................

1.6260

0.9693

26.7592

27.2781

28.0955

27.3861 340116..................................................

1.7476

0.8946

27.5881

29.3698

29.9425

28.9452

Page 23761

340119..................................................

1.2861

0.9570

25.6226

29.4470

27.2924

27.4283 340120..................................................

1.0708

0.8632

25.9134

25.5399

26.1449

25.8647 340121..................................................

1.0930

0.9087

23.1343

23.8854

25.1565

24.0798 340123..................................................

1.2779

0.9141

26.0637

28.5669

28.7125

27.7861 340124..................................................

***

*

22.2988

23.5480

25.7275

23.7126 340126..................................................

1.3283

0.9557

26.9866

28.2247

30.6880

28.6662 340127..................................................

1.1942

0.9693

26.4746

28.2161

28.8647

27.8604 340129..................................................

1.3110

0.9570

25.7976

26.7606

31.7833

27.9613 340130..................................................

1.3497

0.9570

26.1717

28.1594

29.5278

27.9862 340131..................................................

1.4690

0.9174

27.4750

28.8542

29.6545

28.6874 340132..................................................

1.2127

0.8632

23.5856

24.6162

25.3247

24.5295 340133..................................................

1.0197

0.8940

23.4678

24.8579

26.8831

25.1020 340137..................................................

***

*

22.1741

28.9672

27.0855

25.1884 340138..................................................

0.9092

0.9693

*

*

*

* 340141..................................................

1.6729

0.9087

29.3878

29.3171

29.3351

29.3465 340142..................................................

1.2123

0.8632

26.6886

27.7555

28.2393

27.5936 340143..................................................

1.5447

0.8946

28.0082

27.9777

29.3839

28.4856 340144..................................................

1.2183

0.9570

26.1865

27.0150

27.6523

26.9370 340145..................................................

1.2148

0.9570

25.8459

26.7482

28.0628

26.9029 340147..................................................

1.3027

0.9557

26.9162

28.2626

29.6936

28.3096 340148..................................................

1.5007

0.8984

25.3660

25.8325

27.9119

26.4048 340151..................................................

1.2153

0.8684

22.7736

23.2158

24.5768

23.5273 340153..................................................

1.9232

0.9570

27.6509

28.5979

29.8260

28.7235 340155..................................................

1.4750

0.9693

30.3443

30.9501

31.7547

31.0367 340156..................................................

0.8722

1.4446

*

*

*

* 340158..................................................

1.1294

0.9087

27.7816

27.6526

29.4088

28.3011 340159..................................................

1.2146

0.9693

24.2588

25.3108

28.1688

25.9712 340160..................................................

1.3520

0.8632

21.7923

23.4631

24.2003

23.1718 340166..................................................

1.3505

0.9570

27.1132

28.5395

29.9101

28.5234 340168..................................................

0.4196

0.9087

*

*

*

* 340171..................................................

1.1184

0.9570

27.8539

27.4701

31.1928

28.9088 340173..................................................

1.3301

0.9693

28.3502

30.2815

30.9813

29.9351 340177..................................................

***

*

26.7155

*

*

26.7155 340179..................................................

***

*

34.1895

*

*

34.1895 340182..................................................

***

*

27.8071

*

*

27.8071 340183..................................................

1.1992

0.9570

*

*

30.1224

30.1224 350002..................................................

1.8113

0.7336

22.4307

23.5869

23.6039

23.2267 350003..................................................

1.2133

0.7336

23.9639

24.9975

24.5802

24.5236 350006..................................................

1.5637

0.7336

21.2726

22.4626

23.4334

22.3834 350009..................................................

1.0718

0.8212

23.8681

24.5737

23.9783

24.1447 350010..................................................

1.0699

*

20.1290

20.4198

*

20.2749 350011..................................................

1.9136

0.8212

23.8400

24.1135

26.0184

24.6622 350014..................................................

0.9542

*

19.1684

17.5837

*

18.3437 350015..................................................

1.5991

0.7336

20.9046

21.3342

22.9107

21.7900 350017..................................................

1.2273

0.7336

22.4359

21.6187

24.0965

22.7331 350019..................................................

1.6984

0.7709

23.2018

24.9615

24.9880

24.4055 350030..................................................

0.9524

0.7336

20.2722

22.5976

23.1013

22.0048 350063..................................................

0.9136

1.4365

*

*

*

* 350064..................................................

0.7388

1.4365

*

*

*

* 350070..................................................

1.7656

0.8212

25.2365

26.2454

26.2850

25.9334 360001..................................................

1.4815

0.9581

25.8669

28.8623

30.1018

28.2801 360002..................................................

1.2851

0.8723

24.5155

25.4859

25.2198

25.0794 360003..................................................

1.7681

0.9581

28.9672

30.7812

31.8948

30.5710 360006..................................................

1.8125

0.9869

30.1363

30.9806

31.8259

31.0038 360008..................................................

1.3172

0.8759

26.2632

27.5683

28.0182

27.2862 360009..................................................

1.5509

0.9299

25.0007

27.0618

28.2407

26.7836 360010..................................................

1.2398

0.8784

23.7825

24.7352

25.5935

24.7214 360011..................................................

1.2808

0.9657

27.6036

31.5587

29.9864

29.6800 360012..................................................

1.3492

0.9869

30.1416

31.0526

31.9806

31.0579 360013..................................................

1.0853

0.9299

27.0893

29.8412

30.2383

29.0666 360014..................................................

1.1225

0.9657

27.1017

27.0743

28.1800

27.4862 360016..................................................

1.4873

0.9581

27.8031

29.6298

30.2164

29.2161 360017..................................................

1.6193

0.9869

29.8525

31.7081

33.2491

31.6157 360019..................................................

1.3267

0.9266

26.9178

27.2997

28.3226

27.5252 360020..................................................

1.5825

0.9266

23.6400

25.6328

27.6681

25.6284 360025..................................................

1.4547

0.9267

27.4533

27.1546

28.4754

27.6992 360026..................................................

1.3750

0.9321

25.5379

25.2945

27.5409

26.1280

Page 23762

360027..................................................

1.5168

0.9266

27.4454

28.2923

29.6304

28.4671 360029..................................................

1.1810

0.9267

24.3216

26.4208

27.8825

26.2449 360032..................................................

1.2265

0.8582

25.0034

25.9916

27.2621

26.0956 360035..................................................

1.6390

0.9869

30.0172

31.3181

31.2432

30.8528 360036..................................................

1.1944

0.9266

27.8343

29.3514

29.9390

29.0664 360037..................................................

1.5004

0.9266

29.0046

30.0446

30.6535

29.8835 360038..................................................

1.5826

0.9581

25.4274

31.0611

31.3759

29.1457 360039..................................................

1.4590

0.9657

23.9783

24.7873

25.8206

24.8982 360040..................................................

1.2069

0.8969

24.8569

25.5337

26.7437

25.7182 360041..................................................

1.4496

0.9266

26.1522

26.6755

28.4427

27.1150 360044..................................................

1.1770

0.8709

21.5619

24.3840

24.7681

23.5345 360046..................................................

1.2150

0.9581

25.4673

26.2417

28.2956

26.6958 360048..................................................

1.8237

0.9267

29.3415

29.4378

30.0370

29.6170 360049..................................................

***

*

26.2222

*

*

26.2222 360051..................................................

1.6897

0.9321

26.8501

28.1167

29.4411

28.1381 360052..................................................

1.5471

0.9321

26.2066

26.8806

28.4711

27.2049 360054..................................................

1.3413

0.8759

22.9359

24.8248

23.6593

23.7903 360055..................................................

1.4007

0.8931

27.3941

30.0143

31.4776

29.5863 360056..................................................

1.5488

0.9581

26.5318

30.3677

31.1802

29.4451 360058..................................................

1.1206

0.8582

23.8119

24.5003

25.9278

24.7681 360059..................................................

1.4695

0.9266

29.3624

30.6173

30.6279

30.2152 360062..................................................

1.5597

0.9869

31.7422

32.8893

32.8990

32.5514 360064..................................................

1.5123

0.8931

25.2336

27.7795

28.6078

27.1789 360065..................................................

1.2709

0.9266

28.0405

29.7155

31.5056

29.7621 360066..................................................

1.4332

0.9299

27.1436

29.7605

30.9636

29.2899 360068..................................................

1.8584

0.9267

26.2065

26.6933

28.6320

27.1929 360070..................................................

1.6693

0.8845

27.2389

27.8891

28.8717

27.9936 360071..................................................

1.1466

0.8617

23.4619

26.4081

25.7940

25.2133 360072..................................................

1.5262

0.9869

25.9589

27.2286

28.3666

27.2276 360074..................................................

1.2813

0.9267

25.8959

27.5328

27.9970

27.1581 360075..................................................

1.2013

0.9266

26.8925

26.1657

28.3916

27.1857 360076..................................................

1.5143

0.9581

28.1013

29.0148

29.2102

28.7968 360077..................................................

1.5018

0.9266

28.4449

28.0133

28.3010

28.2547 360078..................................................

1.2814

0.9266

25.7885

27.4689

27.3636

26.8573 360079..................................................

1.7270

0.9321

27.2437

30.1230

31.3114

29.5585 360080..................................................

1.1032

0.8582

21.4526

22.7020

21.8797

22.0297 360081..................................................

1.3032

0.9267

29.8366

29.5312

31.4274

30.2589 360082..................................................

1.3735

0.9266

29.2561

28.7925

30.5823

29.5279 360084..................................................

1.6319

0.8845

27.3917

28.5402

29.2435

28.4167 360085..................................................

2.0543

0.9869

31.5800

32.8502

33.1267

32.5905 360086..................................................

1.6514

0.9321

25.4218

27.3124

28.3559

27.0242 360087..................................................

1.4326

0.9266

29.6579

28.4185

28.6324

28.8850 360089..................................................

1.1327

0.8582

25.3465

25.5608

28.0769

26.2935 360090..................................................

1.4661

0.9267

29.0199

30.7530

29.2643

29.6802 360091..................................................

1.3415

0.9266

25.8657

27.6809

28.1671

27.2522 360092..................................................

1.2566

0.9869

25.4954

25.4055

28.0797

26.3112 360095..................................................

1.4803

0.9267

26.4635

29.3787

30.1514

28.6022 360096..................................................

1.1353

0.8582

25.9275

26.8653

27.9493

26.9250 360098..................................................

1.4304

0.9266

25.5973

26.6382

26.5824

26.3001 360100..................................................

1.3412

0.8845

25.4523

23.6167

25.8131

24.9650 360101..................................................

1.4779

0.9266

27.6030

29.7817

30.6609

29.3460 360107..................................................

1.1819

0.9267

24.6095

26.0534

26.8168

25.8586 360109..................................................

1.0429

0.8582

26.3131

30.1382

30.4624

28.9111 360112..................................................

1.8522

0.9267

30.5715

31.1356

32.4383

31.4039 360113..................................................

1.2805

0.9581

26.6556

30.2871

30.3893

29.0672 360115..................................................

1.3320

0.9266

25.9841

26.1821

26.8438

26.3395 360116..................................................

1.2122

0.9581

25.1717

26.4968

26.8619

26.2113 360118..................................................

1.4755

0.9295

27.3884

28.5643

29.9812

28.5726 360121..................................................

1.2872

0.9267

27.4442

28.3835

31.6755

29.0943 360123..................................................

1.4063

0.9266

27.1920

28.0334

28.5418

27.9298 360125..................................................

1.2052

0.8582

24.1388

25.9067

27.1761

25.6993 360130..................................................

1.5015

0.9266

25.6570

26.3986

28.1792

26.7600 360131..................................................

1.3679

0.8845

25.3719

26.6635

27.3408

26.4479 360132..................................................

1.3742

0.9581

27.7724

29.4070

29.8386

28.9945 360133..................................................

1.5965

0.9321

29.8684

31.7521

33.1791

31.6376 360134..................................................

1.7642

0.9581

27.7339

28.5141

29.9175

28.7663 360137..................................................

1.7064

0.9266

26.1250

27.6894

30.3093

28.0256

Page 23763

360141..................................................

1.6073

0.8931

29.7937

31.1778

31.9380

30.9580 360143..................................................

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28.3057

26.9394

28.0681

27.7625 360144..................................................

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0.9266

28.2473

28.9177

29.6531

28.9566 360145..................................................

1.6504

0.9266

27.1908

28.1835

29.3247

28.2623 360147..................................................

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0.8582

25.5854

27.5548

29.2356

27.4482 360148..................................................

1.1785

0.8582

26.0837

26.3399

25.7446

26.0498 360150..................................................

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25.1217

28.2561

27.8825

27.0949 360151..................................................

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0.8845

25.3780

26.5636

26.9664

26.3114 360152..................................................

1.5125

0.9869

29.9425

31.5377

33.3560

31.6190 360153..................................................

0.9954

0.8582

19.8499

20.2147

21.8404

20.6626 360155..................................................

1.4645

0.9266

26.9127

28.9521

28.8915

28.2820 360156..................................................

1.1512

0.8701

24.3281

25.0833

26.2253

25.2574 360159..................................................

1.3312

0.9657

29.1529

28.6174

29.0171

28.9284 360161..................................................

1.3364

0.8931

25.4433

27.0875

27.7406

26.7559 360163..................................................

1.8747

0.9581

28.9742

30.0724

31.2057

30.0774 360170..................................................

1.1878

0.9869

28.5474

29.5954

30.0025

29.4160 360172..................................................

1.3762

0.9266

27.5669

28.8283

30.2315

28.8817 360174..................................................

1.2862

0.9321

26.8586

28.3143

28.3749

27.8656 360175..................................................

1.2487

0.9657

28.1531

28.3054

29.7479

28.7375 360179..................................................

1.5492

0.9581

30.0311

29.8299

31.3518

30.4088 360180..................................................

2.3387

0.9266

29.6633

31.4342

32.0205

31.0895 360185..................................................

1.2624

0.8582

25.6800

26.1080

26.4201

26.0786 360187..................................................

1.4967

0.9321

24.9353

25.7600

27.3727

26.0387 360189..................................................

1.1420

0.9869

26.3756

27.5097

28.2736

27.4040 360192..................................................

1.3279

0.9266

26.4616

27.5991

29.1980

27.8031 360195..................................................

1.0799

0.9266

25.0922

27.6155

27.2619

26.6349 360197..................................................

1.1347

0.9657

28.7580

28.9207

28.5250

28.7314 360203..................................................

1.1898

0.8582

24.4433

25.3692

27.7551

25.8598 360210..................................................

1.2170

0.9869

28.2976

29.6476

31.8161

29.9477 360211..................................................

1.6076

0.8582

25.7053

26.5459

27.2721

26.4875 360212..................................................

1.3076

0.9266

25.6080

26.6976

28.5868

26.9659 360218..................................................

1.2246

0.9869

29.8662

30.0101

31.0690

30.3264 360230..................................................

1.5275

0.9266

28.8018

30.0661

30.5975

29.8409 360234..................................................

1.4185

0.9581

25.9360

31.0656

30.7904

29.2950 360236..................................................

1.3057

0.9581

25.6728

29.5321

29.9348

28.6891 360239..................................................

1.3536

0.9321

27.2939

30.7728

31.7919

29.9651 360241..................................................

***

*

23.0662

25.7290

25.8138

24.8236 360242..................................................

1.9535

*

*

*

*

* 360245..................................................

0.6344

0.9266

20.6504

20.3426

20.4587

20.4760 360247..................................................

0.4196

0.9869

19.3677

*

*

19.3677 360253..................................................

2.2617

0.9581

33.2371

34.3347

34.6849

34.0994 360259..................................................

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0.9267

25.9878

27.2902

28.0868

27.1587 360261..................................................

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0.9118

22.3614

25.6332

26.6241

24.8458 360262..................................................

1.2975

0.9267

28.6995

30.1559

31.5616

30.2316 360263..................................................

1.9432

0.9299

25.1652

25.4864

28.1657

26.3875 360264..................................................

***

*

36.0754

*

*

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***

*

36.6265

*

*

36.6265 360266..................................................

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0.9869

*

31.7565

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30.6488 360267..................................................

***

*

*

34.0936

*

34.0936 360268..................................................

***

*

*

34.0526

*

34.0526 360269..................................................

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0.9581

*

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25.2427 360270..................................................

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0.8582

*

*

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28.8661 360271..................................................

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*

*

*

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*

*

*

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38.0986 360273..................................................

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*

*

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37.6617 360274..................................................

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0.9321

*

*

*

* 360276..................................................

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0.8931

*

*

*

* 370001..................................................

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27.8930

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0.8016

21.4543

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0.8686

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0.8112

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11.7942

13.0963

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14.5180 370078..................................................

1.5381

0.8652

27.8611

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30.4817

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0.8686

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30.5423

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0.8686

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0.8179

16.8252

16.6752

24.5386

19.7622 370170..................................................

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1.4446

*

*

*

* 370171..................................................

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1.4446

*

*

*

* 370172..................................................

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1.4704

*

*

*

* 370173..................................................

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*

*

*

* 370174..................................................

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1.4446

*

*

*

* 370176..................................................

1.3084

0.8652

24.7655

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25.4759 370178..................................................

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15.8654 370180..................................................

1.1405

1.4446

*

*

*

* 370183..................................................

0.9683

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30.3849

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34.6942

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27.6367

19.0638

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*

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25.8260

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27.5894 370217..................................................

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26.8677

*

*

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0.8652

*

30.3445

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26.4612 370219..................................................

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*

*

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41.4373 370220..................................................

2.3081

0.8686

*

*

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21.3140 370222..................................................

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0.8686

*

*

26.9158

26.9158 370223..................................................

0.8701

0.8686

*

*

24.0138

24.0138 370226..................................................

1.4674

0.8016

*

*

*

* 370227..................................................

0.9326

0.8652

*

*

*

* 370228..................................................

1.2387

0.8652

*

*

*

* 380001..................................................

1.2850

1.1204

29.5842

32.0770

33.8473

31.8553 380002..................................................

1.2143

1.0298

30.3385

31.5246

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1.1204

32.4016

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34.5647 380010..................................................

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*

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*

*

34.4208 380014..................................................

1.8838

1.1076

33.6078

33.1928

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37.0024

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1.1157

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30.6606 380033..................................................

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*

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*

*

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***

*

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*

*

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*

*

45.3849

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*

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*

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*

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*

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*

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0.8389

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***

*

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0.9799

26.7358

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1.0992

33.3185

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*

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*

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1.1285

0.8342

23.2039

24.3372

24.3181

23.9420 390086..................................................

1.5931

0.8342

23.5141

25.0992

24.7444

24.4724 390090..................................................

1.9186

0.8579

27.3528

27.0122

30.1231

28.1610 390091..................................................

1.1759

0.8559

21.7010

23.3562

23.2108

22.7618 390093..................................................

1.1913

0.8559

22.6082

22.6023

23.8837

23.0312 390095..................................................

1.1678

0.8342

22.6150

24.6290

25.3848

24.2111 390096..................................................

1.6015

1.0788

28.8258

28.6055

30.3896

29.2646 390097..................................................

1.2500

1.0992

26.1741

27.9858

28.1266

27.3784 390100..................................................

1.6431

0.9799

30.0132

30.0234

32.5896

30.9302 390101..................................................

1.2844

0.9666

23.1497

24.8377

27.3460

25.1596 390102..................................................

1.4773

0.8579

24.8369

24.4589

25.5321

24.9493 390103..................................................

***

*

20.5741

20.4446

*

20.5090 390104..................................................

1.1021

0.8342

19.2326

19.6630

20.4543

19.7621 390107..................................................

1.5861

0.8579

24.1159

24.6565

25.6775

24.8676 390108..................................................

1.1988

1.0992

27.8171

28.5928

34.3038

30.1995 390110..................................................

1.5950

0.8579

27.7311

25.3407

25.7142

26.1477 390111..................................................

2.1581

1.0992

34.2990

34.8756

38.6429

35.9670 390112..................................................

1.3266

0.8342

20.2380

21.5439

18.4179

19.9664 390113..................................................

1.3312

0.8559

23.3686

24.2593

24.8661

24.1707 390114..................................................

1.6377

0.8579

26.9620

27.9184

28.5319

27.8260 390115..................................................

1.4264

1.0992

29.6905

30.8063

32.5023

31.0518

Page 23767

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1.0992

32.2513

33.2562

33.9272

33.1578 390117..................................................

1.1784

0.8344

20.7821

21.5038

22.2319

21.5356 390118..................................................

1.1738

0.8342

20.5614

21.8917

23.6529

22.0851 390119..................................................

1.2800

0.8342

23.0928

24.3245

25.3896

24.2630 390121..................................................

***

*

25.4826

*

*

25.4826 390122..................................................

1.1069

0.8395

23.1866

23.3220

24.6425

23.7140 390123..................................................

1.1993

1.0992

32.4528

34.0062

35.1219

33.8960 390125..................................................

1.2499

0.8364

22.4033

22.8816

24.0182

23.1230 390127..................................................

1.3561

1.0992

31.9091

33.6557

33.1200

32.8957 390128..................................................

1.2331

0.8579

24.1628

24.1390

25.1844

24.5037 390130..................................................

1.1985

0.8342

23.0592

23.2504

30.3208

25.3350 390131..................................................

1.3570

0.8579

23.0577

23.5783

27.7127

24.8832 390132..................................................

1.4504

1.0992

29.6396

31.1168

30.0723

30.2692 390133..................................................

1.7609

0.9675

31.1083

32.9812

33.0697

32.4255 390136..................................................

***

*

23.9813

*

*

23.9813 390137..................................................

1.4546

0.8342

24.2878

26.1457

26.9140

25.8031 390138..................................................

1.1966

0.9185

25.3410

27.4231

27.7549

26.8681 390139..................................................

1.3522

1.0992

34.1447

34.0836

36.4969

34.9221 390142..................................................

1.5286

1.0992

33.8224

34.5773

33.3491

33.9107 390145..................................................

1.5880

0.8579

24.6672

25.6980

26.9194

25.7780 390146..................................................

1.1823

0.8364

22.6752

25.1805

23.9869

23.9695 390147..................................................

1.3781

0.8579

26.8522

28.6606

29.0974

28.1881 390150..................................................

1.1119

0.8579

22.8228

22.7668

22.6473

22.7481 390151..................................................

1.3436

1.1006

29.9254

31.4067

31.8952

31.1171 390153..................................................

1.3705

1.0992

32.8234

33.2427

36.0259

34.1045 390154..................................................

1.2171

0.8342

22.8391

23.3559

23.9776

23.4008 390156..................................................

1.3593

1.0992

32.2688

32.8999

33.7034

32.9631 390157..................................................

1.3257

0.8579

21.5923

22.1112

23.0975

22.2734 390160..................................................

1.3326

0.8579

24.0208

22.9696

25.2027

24.0528 390162..................................................

1.5041

1.1449

35.5057

34.5809

35.1818

35.0918 390163..................................................

1.2454

0.8559

23.2055

22.8341

24.8747

23.6452 390164..................................................

2.1300

0.8579

26.3087

27.1950

29.7760

27.7684 390166..................................................

***

*

20.9272

23.3255

28.2160

23.9468 390168..................................................

1.4758

0.8579

26.1365

26.9816

27.3654

26.8304 390169..................................................

1.4118

0.8342

26.5514

26.2643

26.6049

26.4723 390173..................................................

1.2178

0.8342

23.9927

25.6455

27.6024

25.7719 390174..................................................

1.6824

1.0992

34.2069

34.8999

34.9029

34.6825 390176..................................................

1.1316

0.8579

23.9779

24.1247

12.3126

18.1769 390178..................................................

1.3247

0.8930

22.6006

23.1452

23.9151

23.2190 390179..................................................

1.4264

1.0992

28.0688

30.1219

31.5474

29.9836 390180..................................................

1.3926

1.0992

34.9832

35.5291

38.2969

36.3036 390181..................................................

***

*

25.9871

26.6021

27.8820

26.8191 390183..................................................

1.1452

0.8342

27.0122

27.8358

28.2196

27.6769 390184..................................................

1.0915

0.8579

22.7451

23.9736

23.9958

23.5369 390185..................................................

1.2586

0.9675

25.4256

27.1119

25.5306

25.9878 390189..................................................

1.1436

0.8342

22.6796

23.6215

23.4893

23.2864 390192..................................................

1.0388

0.8342

20.5459

23.6171

23.7948

22.6673 390194..................................................

1.2037

0.9675

27.5890

26.3152

23.7351

25.7636 390195..................................................

1.6565

1.0992

34.2980

34.5594

37.2471

35.3797 390196..................................................

1.6460

*

*

*

*

* 390197..................................................

1.4171

0.9675

26.8270

27.2455

28.1394

27.4100 390198..................................................

1.1294

0.8708

20.5979

20.4350

21.0850

20.7061 390199..................................................

1.1366

0.8342

22.3224

23.0046

24.5461

23.3008 390201..................................................

1.3518

0.9512

27.0054

27.3542

28.5649

27.6588 390203..................................................

1.5297

1.0992

29.4930

29.1370

30.7209

29.8038 390204..................................................

1.2911

1.0992

29.5251

30.7346

32.0218

30.7952 390211..................................................

1.2835

0.8930

25.1689

26.5052

27.7862

26.4993 390217..................................................

1.2278

0.8579

23.5879

24.1886

26.2690

24.6769 390219..................................................

1.3577

0.8579

25.4886

26.1196

26.3253

25.9698 390220..................................................

1.0888

1.0992

28.9128

30.7435

32.0869

30.6085 390222..................................................

1.2691

1.0992

30.9464

31.7361

32.3724

31.7085 390223..................................................

1.9836

1.0992

30.2523

34.3280

37.4105

33.8814 390225..................................................

1.1877

0.9799

27.5803

27.2555

26.3628

26.9591 390226..................................................

1.7135

1.0992

32.6658

32.6508

35.4653

33.6044 390228..................................................

1.3609

0.8579

23.9845

24.2242

25.5103

24.5893 390231..................................................

1.4014

1.0992

30.9339

32.8353

35.2285

33.0470 390233..................................................

1.3823

0.9666

25.6904

27.2597

28.3647

27.1364

Page 23768

390236..................................................

0.9818

0.8345

22.1144

23.1290

24.5566

23.2393 390237..................................................

1.5868

0.8342

27.4944

28.4337

29.0645

28.3719 390246..................................................

1.1777

*

25.1956

26.0179

*

25.6189 390256..................................................

1.9774

0.9185

28.0617

28.8970

28.5871

28.5302 390258..................................................

1.4533

1.0992

30.4142

31.7164

32.0531

31.4303 390263..................................................

1.5092

0.9675

28.5864

29.9850

31.7255

30.1997 390265..................................................

1.5374

0.8579

24.0675

25.0166

27.7776

25.6284 390266..................................................

1.1912

0.8930

20.8789

22.2228

23.0128

22.0423 390267..................................................

1.2760

0.8579

24.2428

24.8309

25.7553

24.9521 390268..................................................

1.4064

0.8810

25.6643

26.7342

28.4188

27.0040 390270..................................................

1.6183

0.8342

24.9510

26.5010

27.0286

26.2567 390272..................................................

0.6051

1.0992

*

*

32.9893

32.9893 390278..................................................

0.6005

1.0992

26.6664

28.6323

28.8290

28.0560 390285..................................................

1.4914

1.0992

36.7163

37.6669

38.4678

37.6177 390286..................................................

1.2124

1.0992

29.5281

31.3393

31.7320

30.8704 390287..................................................

***

*

39.3176

42.2401

*

40.3959 390288..................................................

***

*

30.9701

*

*

30.9701 390289..................................................

***

*

30.7583

*

*

30.7583 390290..................................................

1.8004

1.0992

38.3776

41.1426

47.7624

42.2989 390302..................................................

0.8675

1.0992

*

*

*

* 390303..................................................

***

*

27.5580

*

*

27.5580 390304..................................................

1.2958

1.0992

30.4832

32.1633

33.4111

32.1082 390305..................................................

***

*

*

29.3217

*

29.3217 390306..................................................

***

*

*

40.3789

*

40.3789 390307..................................................

2.0387

0.8930

*

24.5393

22.9455

23.6860 390308..................................................

***

*

*

36.1737

*

36.1737 390309..................................................

***

*

*

37.8924

*

37.8924 390310..................................................

***

*

*

44.3991

*

44.3991 390311..................................................

***

*

*

*

49.8990

49.8990 390312..................................................

1.2883

1.0992

*

*

51.3342

51.3342 390313..................................................

1.1642

0.9204

*

*

*

* 390314..................................................

1.9344

0.9675

*

*

*

* 390315..................................................

1.6395

0.8579

*

*

*

* 390316..................................................

1.6856

0.9518

*

*

*

* 390318..................................................

0.8280

0.9675

*

*

*

* 400001..................................................

1.3295

0.4404

13.9386

14.9151

15.4246

14.7738 400002..................................................

1.9377

0.4122

15.3833

12.9440

12.9793

13.6878 400003..................................................

1.3791

0.4122

13.9258

15.7906

14.6853

14.8161 400004..................................................

1.2115

0.4404

12.0923

12.5928

13.5193

12.7362 400005..................................................

1.2533

0.4404

10.3505

11.1152

11.7582

11.0789 400006..................................................

1.1625

0.4404

8.1841

8.1381

*

8.1610 400007..................................................

1.1605

0.4404

11.8203

12.0743

10.4935

11.4512 400009..................................................

0.9834

0.3137

9.3834

9.5114

10.1204

9.6757 400010..................................................

0.9051

0.3311

9.8132

10.7993

10.4202

10.3256 400011..................................................

1.1055

0.4404

9.6641

8.5503

9.4065

9.2136 400012..................................................

1.4864

0.4404

12.3362

10.1156

*

11.0797 400013..................................................

1.3650

0.4404

11.1414

11.4222

12.3068

11.6476 400014..................................................

1.3749

0.3896

10.5286

9.9395

12.3295

10.8952 400015..................................................

1.4718

0.4404

13.7043

22.2017

21.9216

18.9475 400016..................................................

1.4676

0.4404

16.6472

16.1931

17.9101

16.9079 400017..................................................

0.8958

0.4404

10.3123

9.9185

10.0587

10.0981 400018..................................................

1.1103

0.4404

11.9184

12.3942

13.1567

12.5002 400019..................................................

1.5158

0.4404

12.8380

14.7133

15.2358

14.0763 400021..................................................

1.3614

0.4648

14.4549

13.9217

14.9779

14.4495 400022..................................................

1.4439

0.4122

14.9089

15.3625

15.2119

15.1640 400024..................................................

0.8933

0.3896

10.8439

12.6226

13.7214

12.2509 400026..................................................

1.1373

0.3137

9.9262

7.1179

8.9063

8.4875 400028..................................................

1.1913

0.4122

11.3260

10.6711

9.6940

10.5465 400032..................................................

1.1451

0.4404

10.3736

10.7141

10.7841

10.6281 400044..................................................

1.4861

0.4122

14.6420

11.3551

12.1404

12.5283 400048..................................................

1.3035

0.3137

9.6416

9.6860

10.5172

9.9689 400061..................................................

2.2573

0.4404

18.1303

18.0093

17.4499

17.8500 400079..................................................

1.2280

0.3311

9.5296

10.4599

10.6123

10.2200 400087..................................................

1.3360

0.4404

11.0377

11.4162

12.0032

11.4590 400098..................................................

1.3491

0.4404

13.8034

13.7878

12.8752

13.4675 400102..................................................

1.1900

0.4404

10.5879

12.1761

12.1258

11.5565 400103..................................................

1.9297

0.3896

10.6971

11.7488

11.3309

11.2618

Page 23769

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1.2190

0.4404

11.4322

12.8404

12.6932

12.3296 400105..................................................

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0.4404

15.6626

16.9029

17.0458

16.5427 400106..................................................

1.1085

0.4404

13.4097

12.9272

14.8543

13.7089 400109..................................................

1.4302

0.4404

14.4386

14.8208

14.5707

14.6114 400110..................................................

1.2156

0.3358

11.1812

9.9278

10.8210

10.6067 400111..................................................

1.2130

0.3311

14.1718

10.2141

10.7888

11.5139 400112..................................................

1.2446

0.4404

10.1512

13.5177

11.2302

11.5795 400113..................................................

1.1764

0.4122

10.5305

10.9503

11.5947

11.0441 400114..................................................

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0.4404

10.1379

10.8913

11.6870

10.9257 400115..................................................

1.0815

0.4404

12.0713

9.6200

10.6805

10.8173 400117..................................................

1.1347

0.4404

9.5929

11.6258

12.1537

11.0019 400118..................................................

1.2649

0.4404

12.8692

12.7861

12.6196

12.7539 400120..................................................

1.3351

0.4404

13.4069

14.0817

14.5200

14.0199 400121..................................................

1.1129

0.4404

9.7427

9.1826

9.9712

9.6244 400122..................................................

1.8905

0.4404

8.9478

9.5814

10.0960

9.5553 400123..................................................

1.2353

0.3896

12.8317

12.5609

13.8597

13.0762 400124..................................................

2.6860

0.4404

17.2139

17.9140

19.1698

18.1028 400125..................................................

1.2073

0.4067

11.9787

13.5394

13.1075

12.8846 400126..................................................

1.2894

0.4648

14.1062

16.5726

*

15.3043 400127..................................................

2.0911

0.4404

17.8303

20.7775

*

19.5304 400128..................................................

1.0184

0.4404

*

12.3520

*

12.3520 410001..................................................

1.3144

1.1338

29.0877

30.0315

30.5848

29.9101 410004..................................................

1.3107

1.1338

29.4953

31.3023

35.2360

31.9950 410005..................................................

1.2724

1.1338

28.1141

31.4387

34.5807

31.2615 410006..................................................

1.3911

1.0669

30.1855

32.8456

33.5403

32.1894 410007..................................................

1.6113

1.1338

33.2896

32.0730

34.2549

33.1928 410008..................................................

1.3225

1.0669

30.9505

32.5889

33.5128

32.3511 410009..................................................

1.2374

1.0669

31.7300

32.8422

34.3405

32.9948 410010..................................................

1.1305

1.1338

32.0704

32.7379

34.8380

33.2523 410011..................................................

1.4882

1.1338

33.8781

30.1941

36.7639

33.5131 410012..................................................

1.5728

1.1338

33.6072

37.0299

35.5818

35.4055 410013..................................................

1.2045

1.1587

35.8075

41.0010

40.1823

38.9884 420002..................................................

1.5630

0.9561

29.5592

30.5111

31.2220

30.4468 420004..................................................

1.9671

0.9231

28.1455

28.9250

30.2325

29.1286 420005..................................................

1.1610

0.8609

25.0420

24.6968

26.5027

25.3750 420006..................................................

***

*

26.3293

27.7764

29.1383

27.7486 420007..................................................

1.6315

0.9294

26.8165

29.0901

28.9533

28.2944 420009..................................................

1.4114

0.9294

27.0147

29.9378

28.6625

28.5279 420010..................................................

1.1406

0.8609

25.1452

25.5710

26.5503

25.7612 420011..................................................

1.1778

0.9605

22.1787

25.5130

25.9543

24.5702 420015..................................................

1.3156

0.9605

24.1685

26.3499

27.4912

26.0287 420016..................................................

0.9672

0.8609

21.6266

22.5681

23.4313

22.5462 420018..................................................

1.8307

0.8984

25.6687

27.5563

29.0897

27.4853 420019..................................................

1.0990

0.8767

22.5489

25.4954

25.8113

24.4094 420020..................................................

1.3500

0.9231

28.4344

27.5000

29.2372

28.3934 420023..................................................

1.7169

0.9605

27.4589

28.9321

30.4471

28.9941 420026..................................................

1.8642

0.8984

27.8986

28.0647

29.5039

28.4725 420027..................................................

1.5767

0.9294

26.4472

28.5621

31.3772

28.7401 420030..................................................

1.3204

0.9231

27.8435

28.4433

30.3403

28.8720 420033..................................................

1.1839

0.9605

30.4162

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32.4244

31.3429 420036..................................................

1.2480

0.9557

23.8742

24.6505

26.3463

24.9665 420037..................................................

1.3390

0.9605

29.8321

30.9556

32.7083

31.1311 420038..................................................

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0.9605

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28.2220

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25.5724

24.4361 420054..................................................

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25.6779

25.6444

26.7888

26.0196 420055..................................................

1.0931

0.8609

24.0965

25.1738

25.3132

24.8604 420056..................................................

1.3487

0.8609

27.7250

28.4512

29.7763

28.7570 420057..................................................

1.2036

0.8609

24.9313

26.2489

25.6602

25.6193 420062..................................................

1.1026

0.9557

26.7467

25.9569

27.2249

26.6400 420064..................................................

1.2630

0.8683

24.3540

24.6507

25.0602

24.6890 420065..................................................

1.4161

0.9231

25.5483

26.8118

28.1872

26.8671 420066..................................................

0.9980

0.8609

25.1062

25.0932

*

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Page 23770

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25.6857

27.7315

28.0296

27.1430 420069..................................................

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0.8609

22.3445

23.7494

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0.8984

24.7899

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0.9294

25.2862

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0.8609

17.8019

21.6587

20.7707

19.9748 420073..................................................

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0.8984

25.5204

26.1120

28.2651

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0.9605

29.5135

30.9001

32.0165

30.8100 420079..................................................

1.5040

0.9231

27.5439

28.6374

30.5954

28.9420 420080..................................................

1.4321

0.8827

28.6060

31.5670

32.8693

30.8888 420082..................................................

1.5113

0.9597

31.2671

33.9874

34.8836

33.3515 420083..................................................

1.4528

0.9294

26.4932

28.9007

29.6565

28.4194 420085..................................................

1.5909

0.9074

27.8386

29.1127

29.9059

28.9688 420086..................................................

1.4584

0.8984

28.0485

27.9523

29.6321

28.5671 420087..................................................

1.8044

0.9231

25.4697

26.8409

28.4609

26.9052 420089..................................................

1.3777

0.9231

28.1855

29.5862

31.7347

29.8346 420091..................................................

1.4537

0.8609

26.0592

27.2520

27.9042

27.0840 420093..................................................

***

*

28.0765

33.0474

*

30.2237 420098..................................................

1.2041

0.8609

30.7532

27.1939

27.6701

28.2065 420099..................................................

***

*

*

30.3089

*

30.3089 420100..................................................

***

*

*

*

29.2958

29.2958 420101..................................................

1.2049

0.8609

*

*

33.1975

33.1975 420102..................................................

1.4677

0.9605

*

*

*

* 430005..................................................

1.3356

0.8428

22.4111

23.8694

25.4368

23.9203 430008..................................................

1.1161

0.8963

24.4277

26.0873

27.2262

25.9003 430012..................................................

1.3044

0.9262

24.0326

25.2030

27.0179

25.4023 430013..................................................

1.2029

0.9262

25.9828

27.0427

28.4945

27.1837 430014..................................................

1.4127

0.8428

26.8752

27.9288

28.9278

27.9157 430015..................................................

1.1983

0.8428

23.6296

26.5787

28.0396

26.1008 430016..................................................

1.5975

0.9379

28.9376

32.8765

31.1313

30.9581 430027..................................................

1.7417

0.9379

26.6044

27.5759

29.2595

27.8481 430048..................................................

1.2671

0.8557

24.1969

25.1715

25.6411

25.0133 430060..................................................

0.9444

0.8428

13.2618

*

*

13.2618 430064..................................................

0.9859

0.8428

18.3125

16.4916

17.7325

17.4427 430077..................................................

1.7222

0.9618

25.8572

27.2116

31.1926

28.0482 430081..................................................

0.9388

1.4448

*

*

*

* 430082..................................................

0.8463

1.4448

*

*

*

* 430083..................................................

0.8496

1.4448

*

*

*

* 430084..................................................

0.9068

1.4448

*

*

*

* 430085..................................................

0.8878

1.4448

*

*

*

* 430089..................................................

1.8588

0.8783

22.3335

23.2467

24.9033

23.5426 430090..................................................

1.6017

0.9379

26.4862

29.0197

32.7369

29.5038 430091..................................................

2.2308

0.9502

25.1105

24.7274

26.7238

25.5162 430092..................................................

1.8871

0.8428

21.6478

21.9197

23.2508

22.2946 430093..................................................

1.3555

0.9502

27.5326

26.0232

24.7398

26.0952 430094..................................................

1.7381

0.8557

22.9091

23.2894

23.6605

23.3062 430095..................................................

2.4765

0.9379

31.3409

32.2326

32.5850

32.0536 430096..................................................

1.9114

0.8428

21.6713

24.6041

24.9608

23.8070 440001..................................................

1.1662

0.7999

21.2398

21.5755

25.4844

22.7818 440002..................................................

1.7208

0.8886

25.7434

26.3802

26.9121

26.3584 440003..................................................

1.3386

0.9445

28.4862

28.3557

26.0107

27.4326 440006..................................................

1.4409

0.9445

29.7146

31.5533

31.7373

31.0128 440007..................................................

0.9815

0.8176

19.9754

18.8273

22.7570

20.4815 440008..................................................

0.9673

0.8339

23.2126

27.3732

26.8850

25.9985 440009..................................................

1.1674

0.7957

23.9279

23.8148

24.4410

24.0653 440010..................................................

0.9494

0.7957

19.3669

19.6231

20.2498

19.7446 440011..................................................

1.3656

0.7957

23.6154

23.6698

24.8292

24.0419 440012..................................................

1.5047

0.7964

24.0169

23.7871

24.9243

24.2664 440015..................................................

1.8290

0.7957

25.0430

26.0601

27.1580

26.0995 440016..................................................

1.0436

0.8101

23.0350

24.5812

25.2515

24.2770 440017..................................................

1.7685

0.7964

25.0588

24.6707

26.1800

25.3213 440018..................................................

1.1100

0.7999

23.2107

25.0780

24.5898

24.3284 440019..................................................

1.6911

0.7957

25.3592

25.2230

26.2435

25.5920 440020..................................................

1.0903

0.8614

24.0995

24.7785

27.5620

25.4792 440024..................................................

1.1324

0.8717

23.9745

24.7705

26.2519

25.0623 440025..................................................

1.1246

0.8611

22.5407

22.6571

24.0274

23.0928 440026..................................................

***

*

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Page 23771

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22.8053 440031..................................................

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25.3762 440035..................................................

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26.2451

27.9203

26.6992 440039..................................................

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0.9445

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30.0895 440040..................................................

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21.1282

20.9641 440046..................................................

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0.9445

27.9539

29.7377

30.7314

29.5270 440047..................................................

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0.8295

21.7892

22.8323

25.2156

23.3140 440048..................................................

1.8071

0.9305

29.4789

29.3187

30.6710

29.8250 440049..................................................

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0.9305

26.4772

28.8742

29.8603

28.4462 440050..................................................

1.2834

0.7964

24.4616

24.9694

26.3815

25.3086 440051..................................................

0.9337

0.8039

23.9253

23.4866

23.6554

23.6741 440052..................................................

1.0032

0.7957

22.8016

22.6128

24.4075

23.2437 440053..................................................

1.2712

0.9445

27.1197

27.8180

30.3887

28.4325 440054..................................................

1.0962

0.7957

23.5137

23.7931

21.9638

23.0467 440056..................................................

1.2127

0.7957

22.7820

23.2313

24.0623

23.3523 440057..................................................

1.1032

0.7978

16.6346

17.2176

19.3540

17.6957 440058..................................................

1.2003

0.7957

24.3522

26.0706

29.1174

26.6028 440059..................................................

1.4855

0.9252

28.3565

27.9467

29.4514

28.5989 440060..................................................

1.1325

0.8339

24.1024

25.0795

26.5869

25.2908 440061..................................................

1.1295

0.7957

23.9678

23.7360

25.4125

24.3711 440063..................................................

1.6197

0.7999

24.2566

23.9644

26.0741

24.7976 440064..................................................

0.9999

0.8857

23.7176

26.1246

26.7947

25.5515 440065..................................................

1.2421

0.9445

24.6169

25.8536

25.6096

25.3745 440067..................................................

1.1905

0.7957

24.4772

24.6553

26.0852

25.0966 440068..................................................

1.1835

0.8717

24.8146

26.1071

27.9066

26.2722 440070..................................................

1.0014

0.8066

20.0938

21.9166

23.2223

21.7288 440072..................................................

1.0393

0.8886

23.9563

25.7089

26.1643

25.2966 440073..................................................

1.4453

0.9252

26.3570

27.6154

27.5114

27.1567 440081..................................................

1.1673

0.8009

20.7125

20.7688

21.9671

21.1573 440082..................................................

1.9913

0.9445

30.6115

32.2479

32.8913

31.8790 440083..................................................

0.9577

0.7957

25.6099

23.6356

25.7074

24.9682 440084..................................................

1.1762

0.7982

18.6043

18.8699

19.8938

19.1297 440091..................................................

1.7581

0.8857

26.5687

28.1989

28.9678

27.9314 440102..................................................

1.0796

0.7957

20.7363

21.6762

22.1103

21.5215 440104..................................................

1.7788

0.8857

26.5741

27.9756

28.0888

27.5200 440105..................................................

0.9119

0.7999

22.9372

22.7962

23.7139

23.1599 440109..................................................

1.0139

0.8027

20.8924

21.4629

22.5885

21.7090 440110..................................................

1.1221

0.7957

20.9179

22.5929

23.6262

22.5559 440111..................................................

1.2820

0.9445

29.0975

28.8453

29.7446

29.2213 440115..................................................

0.9684

0.8295

23.1409

23.7107

24.9776

23.9354 440120..................................................

1.4947

0.7957

25.7161

24.7572

26.0604

25.5176 440125..................................................

1.6557

0.7957

22.8097

23.6328

24.0920

23.4915 440130..................................................

1.1217

0.7957

23.9955

25.1262

26.3188

25.1413 440131..................................................

1.1784

0.9305

25.6666

26.9649

28.3153

26.9308 440132..................................................

1.2291

0.7957

23.9410

24.0708

29.3371

25.7508 440133..................................................

1.7069

0.9445

29.2829

29.6093

32.5699

30.4215 440135..................................................

0.6898

0.7957

28.1925

27.7037

27.2084

27.7046 440137..................................................

1.0639

0.8695

22.2538

22.9547

24.6130

23.2371 440141..................................................

0.9917

0.7957

24.2406

24.9917

24.8736

24.6802 440144..................................................

1.2549

0.9252

23.9241

25.2293

26.3207

25.2055 440147..................................................

***

*

33.1756

34.8199

36.6955

34.8975 440148..................................................

1.1236

0.9252

23.9810

22.6188

28.0703

24.8107 440150..................................................

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0.9445

28.1012

29.4381

30.5491

29.3876 440151..................................................

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0.9252

27.1729

28.2203

28.6580

27.9977 440152..................................................

2.0008

0.9305

27.1877

28.4612

29.0563

28.2859 440153..................................................

1.0509

0.7964

23.6473

24.9388

23.3772

23.9591 440156..................................................

1.6421

0.8857

27.7309

28.5645

30.5139

28.9635 440159..................................................

1.4818

0.9305

26.9098

25.8289

27.2779

26.6811 440161..................................................

1.9267

0.9445

28.7074

29.9894

31.0647

29.9300 440162..................................................

***

*

27.6837

24.8705

24.6410

25.6902 440166..................................................

***

*

35.3064

*

*

35.3064 440168..................................................

1.0456

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25.7687 440189..................................................

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0.8452

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28.8974

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0.9252

27.3917

29.6272

30.6519

29.2789 440193..................................................

1.3104

0.9445

24.3622

25.2124

25.9713

25.1845 440194..................................................

1.2925

0.9445

29.4706

30.8593

32.3002

30.9187 440197..................................................

1.3992

0.9445

29.4275

30.1184

31.4294

30.3064 440200..................................................

0.9829

0.9445

21.1860

23.8654

23.8295

22.9591 440203..................................................

***

*

23.7451

17.9041

*

20.6007 440217..................................................

1.3768

0.9305

28.8641

29.8888

31.6636

30.1328 440218..................................................

2.0116

0.9445

23.7257

18.7275

36.9244

25.9465 440222..................................................

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28.4664

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29.3485 440225..................................................

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28.3176

27.3318 440227..................................................

1.2974

0.9445

*

30.7785

31.9097

31.3743 440228..................................................

1.5738

0.9305

*

28.3687

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29.0087 450002..................................................

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0.8867

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24.5017 450010..................................................

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30.1022

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25.4450

25.5346

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25.3821 450024..................................................

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0.8867

26.9113

28.2047

27.3787

27.5109 450028..................................................

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0.9226

29.1438

29.5792

29.5668

29.4314 450029..................................................

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0.8816

25.0602

26.9361

28.6442

26.7635 450031..................................................

1.4439

0.9852

29.0824

30.3542

29.2123

29.5392 450032..................................................

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0.8407

21.5084

25.5785

26.3146

24.2723 450033..................................................

1.5969

0.9226

29.2468

27.8680

29.7653

28.9230 450034..................................................

1.5308

0.8595

26.5313

27.6929

29.6291

28.1119 450035..................................................

1.5326

0.9925

28.0668

28.8049

30.3345

29.0806 450037..................................................

1.5845

0.8666

26.6207

28.3403

28.2594

27.7345 450039..................................................

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0.9852

26.7503

28.2081

29.8132

28.2727 450040..................................................

1.7553

0.8712

25.4734

26.8412

28.5453

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0.8703

26.6382

26.5429

27.6115

26.9555 450044..................................................

1.6959

0.9852

31.0381

29.4293

32.9897

31.1698 450046..................................................

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0.8494

24.8947

25.5903

27.2425

25.9770 450047..................................................

0.8561

0.9226

21.8824

23.8457

24.9663

23.5090 450051..................................................

1.9250

0.9852

28.8829

29.9038

30.3953

29.7565 450052..................................................

0.9850

0.8153

22.6448

23.0007

24.3959

23.3480 450054..................................................

1.7911

0.8855

27.5399

26.5599

30.2202

28.0403 450055..................................................

1.0449

0.8153

22.9245

23.6382

24.1423

23.5765 450056..................................................

1.6824

0.9521

28.3092

31.4971

32.0873

30.6432 450058..................................................

1.5743

0.8949

26.6926

26.9918

27.7297

27.1586 450059..................................................

1.2980

0.9024

26.8325

27.3856

28.5629

27.5865 450064..................................................

1.5113

0.9852

26.8355

28.2786

29.0474

28.0416 450068..................................................

2.0486

0.9925

29.5876

30.5001

32.0346

30.7379 450072..................................................

1.2155

0.9925

25.8619

27.1081

28.0902

27.0430 450073..................................................

0.8877

0.8153

26.9446

26.1567

22.2326

25.0645 450076..................................................

1.6904

*

*

*

*

* 450078..................................................

0.8999

0.8153

21.4716

20.0758

20.7809

20.7567 450079..................................................

1.6789

0.9852

30.2420

30.5968

36.8906

32.4452 450080..................................................

1.2493

0.8666

27.9191

26.2439

26.8091

27.0298 450082..................................................

1.1597

0.8153

23.9025

24.2018

25.5648

24.5569 450083..................................................

1.7529

0.8901

27.4955

32.6462

30.2031

29.9862

Page 23773

450085..................................................

1.0822

0.8153

24.3637

25.6440

26.3606

25.4425 450087..................................................

1.3998

0.9852

30.0095

31.2668

32.6536

31.3363 450090..................................................

1.2615

0.8803

21.3837

21.8839

22.7815

22.0412 450092..................................................

1.2126

0.8153

24.9917

26.2781

28.2267

26.4935 450096..................................................

***

*

26.5103

28.1902

*

27.3122 450097..................................................

1.4580

0.9925

29.0142

29.8734

31.9758

30.2412 450099..................................................

1.3019

0.8883

31.3495

31.7829

29.8469

30.9845 450101..................................................

1.6171

0.8703

25.4409

26.7457

28.4201

26.8726 450102..................................................

1.7083

0.8901

25.6318

26.4161

27.3343

26.4779 450104..................................................

1.1855

0.8949

24.6169

28.8063

27.7838

26.9841 450107..................................................

1.5806

0.8867

27.6064

27.8177

29.0310

28.1649 450108..................................................

1.1922

0.8949

21.6557

19.3245

22.4281

21.1092 450119..................................................

1.3181

0.9118

27.8027

31.1026

34.4129

30.7679 450121..................................................

***

*

29.1296

27.7472

*

28.4439 450123..................................................

1.3318

0.8595

24.9674

26.2469

24.0420

24.9404 450124..................................................

1.7511

0.9521

28.2571

30.9140

31.9772

30.4250 450126..................................................

1.3989

0.9925

29.3768

30.5540

32.0348

30.6758 450128..................................................

1.2318

0.9118

25.1122

26.3296

28.3156

26.5694 450130..................................................

1.1977

0.8949

24.3295

24.3842

26.9201

25.2414 450131..................................................

***

*

25.9494

*

*

25.9494 450132..................................................

1.6322

0.9425

30.1620

31.9981

31.1340

31.0941 450133..................................................

1.5320

0.9283

28.4647

30.0648

30.9597

29.8077 450135..................................................

1.6395

0.9852

27.8983

30.1385

30.7885

29.6276 450137..................................................

1.6679

0.9852

31.4950

31.9644

35.7749

33.2271 450143..................................................

1.0277

0.9521

23.4592

23.6834

24.4333

23.8654 450144..................................................

1.0083

0.8712

26.2881

29.2987

31.1551

28.7443 450147..................................................

1.4564

0.8153

24.3562

24.7221

26.3019

25.1662 450148..................................................

1.2241

0.9852

27.0894

29.6777

30.0530

28.8673 450151..................................................

***

*

23.9558

26.2011

22.8759

24.2772 450152..................................................

1.2565

0.8855

23.3428

23.1056

24.3424

23.6074 450154..................................................

1.3302

0.8153

21.7237

22.9357

24.2578

22.9598 450155..................................................

1.1251

0.8153

21.7604

24.8052

24.8768

23.6641 450162..................................................

1.3269

0.8712

33.3285

32.9317

33.7803

33.3236 450163..................................................

1.0627

0.8207

24.1267

24.7857

27.0963

25.3188 450165..................................................

1.1447

0.8949

28.6490

29.1839

30.2222

29.3460 450176..................................................

1.4003

0.9118

23.1284

24.4338

25.8569

24.4742 450177..................................................

1.0905

0.8153

23.7624

24.4064

26.0891

24.7683 450178..................................................

0.9986

0.9283

27.8405

27.1184

28.5998

27.8381 450184..................................................

1.5684

0.9925

28.5399

29.5940

30.9705

29.6894 450187..................................................

1.2150

0.9925

28.3243

27.7374

29.2737

28.4472 450188..................................................

0.9254

0.8153

23.0595

23.2280

24.6816

23.6817 450191..................................................

1.1258

0.9521

26.5863

28.3937

31.1321

28.6333 450192..................................................

1.1180

0.8424

24.1186

26.4722

26.9874

25.8921 450193..................................................

2.0321

0.9925

34.4545

36.4793

37.1873

36.0649 450194..................................................

1.2632

0.8366

22.9605

24.3531

30.4368

25.7167 450196..................................................

1.4595

0.9852

24.0161

23.4577

25.4820

24.2962 450200..................................................

1.6042

0.8195

23.5012

25.6413

27.9825

25.4502 450201..................................................

0.9730

0.8153

23.2510

23.2800

22.5445

22.9956 450203..................................................

1.2116

0.9684

26.5237

27.8795

28.0968

27.5107 450209..................................................

1.8278

0.8997

27.5668

30.6146

31.9858

29.9981 450210..................................................

1.0215

0.8304

21.8722

22.5736

22.9049

22.4486 450211..................................................

1.3455

0.8666

28.4581

28.3770

28.8471

28.5692 450213..................................................

1.7959

0.8949

25.9169

26.8566

28.0289

26.9446 450214..................................................

1.2281

0.9925

27.4357

27.9913

28.2247

27.8829 450219..................................................

0.9660

0.8153

21.9207

23.9636

24.7267

23.5184 450221..................................................

1.1119

0.8153

19.3793

21.3721

20.7113

20.5035 450222..................................................

1.6824

0.9925

30.0314

30.3801

31.9231

30.7843 450224..................................................

1.3283

0.8901

26.8302

28.4382

28.7921

28.0121 450229..................................................

1.6525

0.8408

24.4450

25.1370

26.8016

25.3958 450231..................................................

1.6726

0.8997

27.1674

26.9783

27.0533

27.0671 450234..................................................

1.0198

0.8153

20.6889

20.4659

21.6802

21.1358 450235..................................................

1.0077

0.8153

23.5212

21.8967

23.8005

23.0639 450236..................................................

1.1319

0.8542

23.5426

22.9622

24.5926

23.6934 450237..................................................

1.6540

0.8949

25.7939

30.5885

31.2172

28.9557 450239..................................................

0.9770

0.8855

21.2586

19.1359

18.4232

19.4675 450241..................................................

1.0252

0.8153

20.8732

21.3641

28.4948

23.5112 450243..................................................

1.0024

0.8153

15.4510

17.2966

19.0176

17.2995

Page 23774

450253..................................................

0.9321

0.9925

24.2435

24.1056

22.9919

23.7733 450270..................................................

1.2113

0.8424

15.2190

19.8180

12.9994

15.5383 450271..................................................

1.2778

0.9684

22.7035

24.1269

23.9525

23.6286 450272..................................................

1.2096

0.9521

26.2576

27.0521

29.0903

27.4843 450280..................................................

1.4612

0.9852

29.9730

31.6575

34.9324

32.1866 450283..................................................

1.0893

0.9852

22.7938

24.1754

28.2079

24.8171 450289..................................................

1.4524

0.9925

32.2645

32.6533

32.6122

32.5225 450292..................................................

1.2808

0.9852

26.3242

26.8110

29.0226

27.3779 450293..................................................

0.8910

0.8153

23.6413

24.0827

24.1552

23.9551 450296..................................................

1.0439

0.9925

30.4324

31.5596

33.4528

31.7845 450299..................................................

1.5997

0.9193

27.5797

28.4171

29.4576

28.5044 450306..................................................

0.9802

0.8408

21.4558

22.9486

22.6822

22.3403 450315..................................................

2.4335

0.9852

37.1721

*

31.4204

33.9617 450324..................................................

1.5212

0.9852

25.1633

26.6093

27.9889

26.5490 450330..................................................

1.2552

0.9925

26.0771

27.1100

27.7403

26.9930 450340..................................................

1.4092

0.8600

25.0344

25.6791

30.5228

26.9242 450346..................................................

1.4343

0.8595

23.6072

23.8720

24.8416

24.1224 450347..................................................

1.2208

0.9925

28.7667

30.7825

28.5780

29.3911 450348..................................................

1.0018

0.8153

21.6787

21.0484

22.6822

21.8120 450351..................................................

1.2791

0.9684

26.5388

29.2560

29.9580

28.5841 450352..................................................

1.1062

0.9852

26.2281

27.2983

27.6466

27.0615 450353..................................................

***

*

27.0248

27.9576

*

27.5079 450358..................................................

1.9716

0.9925

31.4926

32.5922

33.9078

32.6875 450369..................................................

0.9268

0.8153

19.9148

22.8525

24.1950

22.2632 450370..................................................

1.2579

0.8388

25.5834

26.3235

29.0806

27.0009 450372..................................................

1.4550

0.9852

30.8886

29.5022

30.9328

30.4453 450373..................................................

0.9144

0.8153

24.8286

27.0726

27.4243

26.4835 450378..................................................

1.3092

0.9925

30.3883

32.2278

33.0566

31.9025 450379..................................................

1.4002

0.9852

33.7521

35.3807

35.0613

34.7094 450388..................................................

1.7004

0.8949

27.4328

27.8155

29.5360

28.2774 450389..................................................

1.1714

0.9852

25.6732

26.9638

26.8481

26.4861 450393..................................................

0.7662

0.9852

21.9347

*

39.0250

28.4483 450395..................................................

1.0730

0.9925

27.5189

26.7743

28.4265

27.6022 450399..................................................

0.8925

0.8153

20.3528

22.1731

20.6300

21.0332 450400..................................................

1.0684

0.8153

23.6358

26.2871

29.5008

26.1110 450403..................................................

1.3192

0.9852

29.0359

29.8643

31.7040

30.2580 450411..................................................

1.0061

0.8153

20.9372

21.5746

21.7875

21.4276 450418..................................................

***

*

28.4362

*

*

28.4362 450419..................................................

1.3124

0.9852

31.9966

34.2427

34.9949

33.8163 450422..................................................

1.2786

0.9852

34.4331

31.3454

32.4640

32.6976 450424..................................................

1.3562

0.9925

28.2463

30.7228

29.8269

29.5962 450431..................................................

1.6067

0.9521

26.3263

27.3926

28.5263

27.4173 450438..................................................

1.1486

0.8388

27.8659

26.5223

27.7728

27.3852 450446..................................................

0.7131

0.9925

17.0691

17.2871

15.4631

16.6064 450447..................................................

1.3552

0.9852

25.4200

26.5238

28.3710

26.7880 450451..................................................

1.0753

0.8689

24.6201

26.5477

25.8824

25.6945 450460..................................................

0.9426

0.8206

22.4227

24.9870

25.2172

24.1531 450462..................................................

1.7253

0.9852

29.6069

30.1466

30.6488

30.1364 450465..................................................

1.1257

0.9925

26.2759

27.0835

28.1840

27.2041 450469..................................................

1.4624

0.9852

26.3262

26.3445

31.1333

27.8724 450475..................................................

1.1940

0.8666

23.0942

24.5176

24.7023

24.0834 450484..................................................

1.4990

0.8666

26.7242

28.3913

27.7774

27.6347 450488..................................................

1.1180

0.8666

22.3981

23.7985

24.9095

23.7092 450489..................................................

0.9839

0.8153

23.4806

25.2680

26.9542

25.1940 450497..................................................

0.9966

0.8528

22.0918

23.1860

23.0703

22.7799 450498..................................................

0.9829

0.8153

18.6563

20.2475

20.6876

19.8494 450508..................................................

1.4530

0.8666

28.4471

27.2850

29.1501

28.3018 450514..................................................

***

*

26.3704

27.3043

26.4002

26.6921 450518..................................................

1.4419

0.8595

28.1755

29.1322

27.5863

28.1826 450530..................................................

1.2667

0.9925

29.1349

29.9720

30.7727

29.9520 450537..................................................

1.5128

0.9852

27.7757

28.7448

30.9146

29.1361 450539..................................................

1.2202

0.8220

23.1829

24.2151

25.0188

24.1139 450547..................................................

0.9744

0.9852

23.7820

34.3349

25.4122

27.1653 450558..................................................

1.7678

0.8408

26.9407

28.0655

28.7729

27.9448 450563..................................................

1.5299

0.9852

30.8332

32.0507

32.6847

31.9164 450565..................................................

1.3270

0.9684

26.7942

28.1741

27.4760

27.4805 450571..................................................

1.6222

0.8600

25.2108

27.4605

26.5303

26.3740

Page 23775

450573..................................................

1.0770

0.8279

22.0797

22.1492

24.6744

22.9817 450578..................................................

0.9673

0.8153

22.5167

25.0498

25.2476

24.2617 450580..................................................

1.0515

0.8153

22.3886

23.9004

25.9872

23.9915 450584..................................................

1.0829

0.8153

20.5257

22.5204

23.6045

22.1623 450586..................................................

1.0201

0.8153

18.9107

20.6699

18.3294

19.3042 450587..................................................

1.2259

0.8153

23.1202

25.0174

25.9358

24.6518 450591..................................................

1.1895

0.9925

25.7031

27.1744

27.9847

26.9265 450596..................................................

1.1854

0.9684

27.4011

29.8462

31.6577

29.6788 450597..................................................

0.9963

0.8153

24.7853

24.2586

24.8439

24.6216 450604..................................................

1.3397

0.8153

24.4743

25.9133

29.1526

26.5819 450605..................................................

0.9810

0.8494

20.9276

23.9332

14.8030

19.8571 450610..................................................

1.5974

0.9925

27.7317

28.3713

30.5957

28.8793 450615..................................................

0.9986

0.8185

21.8442

24.1902

22.6324

22.8680 450617..................................................

1.5826

0.9925

28.0225

28.8323

30.2898

29.0536 450620..................................................

0.9635

0.8153

18.6183

20.3723

21.2530

20.0799 450630..................................................

1.5054

0.9925

29.1462

29.8431

31.7991

30.2292 450634..................................................

1.6203

0.9852

28.7312

30.3274

31.7983

30.2933 450638..................................................

1.5993

0.9925

30.6572

32.4911

33.3208

32.0988 450639..................................................

1.4598

0.9852

30.4019

32.6255

34.3727

32.4471 450641..................................................

0.9799

0.8528

19.4389

20.2483

21.7288

20.4546 450643..................................................

1.3367

0.8816

22.7355

24.4999

27.2517

24.7934 450644..................................................

1.5467

0.9925

29.7918

30.7815

31.6848

30.7914 450646..................................................

1.4527

0.8867

25.6313

26.8060

27.4611

26.6291 450647..................................................

1.8764

0.9852

30.6924

32.4236

34.0988

32.4013 450651..................................................

1.5358

0.9852

30.4484

31.9261

33.6467

32.0226 450653..................................................

1.1592

0.8153

25.2144

26.1756

26.5346

25.9882 450654..................................................

0.9049

0.8153

21.5002

22.5447

25.0736

23.0141 450656..................................................

1.4220

0.8666

25.5050

28.1493

29.7276

27.7366 450658..................................................

0.9793

0.8153

22.2293

24.7856

22.7086

23.2037 450659..................................................

1.4021

0.9925

31.5024

34.2380

34.2632

33.2709 450661..................................................

1.4614

0.9425

30.2610

30.0751

29.2361

29.8375 450662..................................................

1.6460

0.9226

29.0535

29.0532

30.9608

29.6825 450668..................................................

1.5414

0.8867

28.8635

30.6114

30.2059

29.8659 450669..................................................

1.2189

0.9852

27.9796

30.2374

32.1221

30.1382 450670..................................................

1.4361

0.9925

25.9638

26.4266

26.2942

26.2315 450672..................................................

1.8349

0.9852

30.1191

31.8420

33.0834

31.7654 450674..................................................

0.9478

0.9925

28.7101

29.8971

31.9284

30.1847 450675..................................................

1.4578

0.9852

28.9005

30.9562

32.6351

30.8652 450677..................................................

1.3166

0.9852

25.9555

27.2760

27.1594

26.8126 450678..................................................

1.4170

0.9852

31.1563

33.3386

33.5496

32.6557 450683..................................................

1.2015

0.9852

27.4925

21.1737

24.8430

24.2908 450684..................................................

1.2814

0.9925

29.3025

30.2139

31.2746

30.2639 450686..................................................

1.6149

0.8712

24.2331

25.8530

26.4851

25.5754 450688..................................................

1.2727

0.9852

26.8599

26.9897

29.4376

27.7076 450690..................................................

1.3408

0.8901

26.5528

26.1743

30.0569

27.4939 450694..................................................

1.1759

0.8153

23.9961

24.0031

27.0859

24.8819 450697..................................................

1.4748

0.8949

24.8667

26.4132

28.2983

26.4744 450698..................................................

0.9175

0.8280

20.0955

21.5742

23.3052

21.6138 450702..................................................

1.6153

0.8666

26.8384

26.3696

27.1300

26.7835 450709..................................................

1.4034

0.9925

26.8146

27.1077

31.3218

28.4257 450711..................................................

1.4823

0.9118

26.7472

27.5622

28.1016

27.5198 450713..................................................

1.5563

0.9521

28.8285

29.4980

30.4912

29.6225 450715..................................................

1.3146

0.9852

17.3991

17.0235

*

17.2098 450716..................................................

1.4070

0.9925

32.3960

33.7096

33.9898

33.3800 450718..................................................

1.4669

0.9521

27.3215

28.1560

29.7584

28.4466 450723..................................................

1.4494

0.9852

28.5103

30.1704

31.0456

29.9614 450730..................................................

1.3722

0.9852

31.3324

32.7293

32.8896

32.3004 450742..................................................

1.1754

0.9852

27.2023

30.0583

30.4185

29.2913 450743..................................................

1.4478

0.9852

28.3362

28.4736

29.5077

28.8191 450746..................................................

0.8780

0.8153

20.6343

22.7873

23.3483

22.2429 450747..................................................

1.1965

0.8901

23.8314

25.8175

28.3918

25.8472 450749..................................................

0.9371

0.8153

20.0487

22.1562

23.9271

21.9555 450751..................................................

***

*

18.7456

21.4223

*

20.1469 450754..................................................

0.9429

0.8153

22.1819

24.7797

22.8559

23.2191 450755..................................................

0.9660

0.8429

19.8988

22.2006

24.7427

22.1319 450758..................................................

***

*

28.7342

28.2803

28.3285

28.4884 450760..................................................

1.0061

0.8867

24.7489

25.1637

23.7138

24.5602

Page 23776

450766..................................................

2.0334

0.9852

30.8004

30.2341

31.2061

30.7524 450770..................................................

1.1706

0.9521

24.1647

24.3244

23.6084

24.0129 450771..................................................

1.7003

0.9852

30.7105

32.0500

32.4987

31.7652 450774..................................................

1.7600

0.9925

27.2080

25.7436

27.5052

26.8202 450775..................................................

1.3943

0.9925

28.1428

29.8230

31.6636

29.9048 450779..................................................

1.2842

0.9852

29.9674

31.8403

32.0748

31.3351 450780..................................................

2.5251

0.8949

26.7611

27.0084

28.5545

27.4508 450788..................................................

1.5291

0.8494

26.2840

28.3759

29.7646

28.1299 450795..................................................

1.1739

0.9925

25.2007

32.9803

43.8548

34.0292 450796..................................................

1.8173

0.8997

36.4073

37.6274

39.4710

37.9807 450797..................................................

1.2450

0.9925

24.8950

24.8598

26.0293

25.2371 450801..................................................

1.4989

0.8195

24.6328

23.6072

25.6368

24.6370 450803..................................................

1.2105

0.9925

28.9235

29.0106

28.7024

28.8861 450804..................................................

2.0345

0.9925

27.8775

29.1282

31.1869

29.4370 450808..................................................

1.8935

0.9521

21.9793

23.0312

29.6456

24.9240 450809..................................................

1.6551

0.9521

26.4223

27.3080

29.4671

27.7555 450811..................................................

1.7218

0.9118

27.2584

31.2208

31.7219

29.8931 450813..................................................

1.1338

0.8949

20.1710

22.9289

26.5793

23.2366 450820..................................................

1.4186

0.9925

31.4666

33.9030

34.7415

33.5465 450822..................................................

1.3260

0.9852

32.2968

32.2145

34.4032

32.9996 450824..................................................

2.6758

0.9521

31.2375

33.3653

31.8377

32.1641 450825..................................................

1.4768

0.9118

20.6457

25.1521

25.7993

23.7848 450827..................................................

1.4405

0.9175

23.7554

24.1984

24.3655

24.1145 450828..................................................

1.3774

0.8153

24.4740

24.8236

26.9546

25.5737 450829..................................................

***

*

20.6016

19.5842

*

20.0933 450830..................................................

1.0119

0.9283

28.5902

27.8005

28.4004

28.2670 450831..................................................

0.9180

0.9925

23.3880

23.9467

24.4124

23.8672 450832..................................................

1.3167

0.9925

26.5229

27.3290

28.1375

27.3874 450833..................................................

1.1878

0.9852

27.0133

27.9649

29.0241

28.0113 450834..................................................

1.6180

0.9193

20.9607

27.4844

26.7240

24.5166 450838..................................................

1.0772

0.8279

19.5754

18.9620

19.2941

19.2971 450839..................................................

0.9688

0.8153

25.8222

27.2199

27.5319

26.8415 450840..................................................

1.2996

0.9852

30.1743

32.2538

32.4135

31.6992 450841..................................................

1.9116

0.9226

20.9410

20.9424

24.4366

22.2249 450844..................................................

1.3797

0.9925

30.7887

33.7978

33.0727

32.7243 450845..................................................

1.8834

0.8867

29.4933

29.9265

28.5011

29.2842 450847..................................................

1.2564

0.9925

28.5548

29.7356

30.7409

29.7031 450848..................................................

1.2904

0.9925

29.5355

30.5546

31.1455

30.4213 450850..................................................

1.5769

0.9562

21.9266

31.9606

27.2645

26.5516 450851..................................................

2.3662

0.9852

32.6950

35.1102

32.8357

33.5034 450853..................................................

1.7353

0.9852

36.1169

37.1043

38.3572

37.3449 450854..................................................

***

*

27.1868

*

*

27.1868 450855..................................................

1.6258

0.9226

30.8855

32.6916

30.7321

31.4205 450856..................................................

2.0970

0.8949

39.0865

37.7362

35.4977

37.3569 450857..................................................

***

*

30.4632

*

*

30.4632 450860..................................................

1.8529

0.9925

24.0171

29.1075

33.3360

29.3070 450861..................................................

***

*

34.9290

*

*

34.9290 450862..................................................

1.5594

0.9925

31.2224

31.8095

33.7932

32.2128 450863..................................................

***

*

24.8825

*

*

24.8825 450864..................................................

2.1890

0.8901

23.3765

24.5049

25.3514

24.5415 450865..................................................

1.1032

0.9521

29.1763

29.9559

31.9179

30.4451 450866..................................................

***

*

15.2959

*

*

15.2959 450867..................................................

1.1589

0.9521

28.2289

29.5879

31.4926

29.7806 450868..................................................

1.7418

0.9425

27.9579

25.3486

27.7398

27.0759 450869..................................................

2.1455

0.9118

22.6253

26.1616

28.7406

27.5500 450870..................................................

***

*

37.4364

*

*

37.4364 450871..................................................

1.8768

0.9521

*

28.9150

32.3967

30.6337 450872..................................................

1.3756

0.9852

*

27.2833

31.7321

29.8421 450873..................................................

***

*

*

14.8821

*

14.8821 450874..................................................

1.6738

0.9852

*

34.6083

35.6817

35.2071 450875..................................................

1.7360

0.8997

*

23.2763

23.2949

23.2862 450876..................................................

1.9264

0.8712

*

28.4343

30.3498

29.4575 450877..................................................

1.4979

0.8867

*

26.1867

29.2330

27.6968 450878..................................................

2.5641

0.8949

*

31.6750

33.6233

32.6691 450879..................................................

1.3352

0.8816

*

35.5672

36.4836

36.0727 450880..................................................

1.5477

0.9852

*

35.9572

32.6680

34.0899 450881..................................................

***

*

*

24.5464

*

24.5464

Continued on page 23777

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

]

pp. 23777-23826

Medicare Program; Proposed Changes to the Hospital Inpatient

Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed

Changes to Disclosure of Physician Ownership in Hospitals and Physician

Self-Referral Rules; Proposed Collection of Information Regardi[Page 23777]

Continued from page 23776

Page 23777

450882..................................................

***

*

*

26.6910

*

26.6910 450883..................................................

2.4793

0.9852

*

35.2646

37.1500

36.2387 450884..................................................

1.0281

0.8715

*

27.8213

23.5791

25.5501 450885..................................................

1.4517

0.9852

*

34.1148

36.0926

35.1477 450886..................................................

1.5017

0.9852

*

*

30.1552

30.1552 450887..................................................

***

*

*

*

25.5574

25.5574 450888..................................................

1.7096

0.9708

*

*

28.5970

28.5970 450889..................................................

1.5530

0.9852

*

*

35.6125

35.6125 450890..................................................

1.8266

0.9852

*

*

32.1973

32.1973 450891..................................................

1.4143

0.9852

*

*

39.0842

39.0842 450892..................................................

***

*

*

*

39.5303

39.5303 450893..................................................

1.3909

0.9852

*

*

36.2633

36.2633 450894..................................................

1.7932

0.9852

*

*

25.9422

25.9422 450895..................................................

***

*

*

18.4142

*

18.4142 460001..................................................

1.8307

0.9075

28.7150

30.0040

*

29.3648 460003..................................................

1.5382

0.9271

31.4135

32.3427

29.6430

31.1480 460004..................................................

1.7729

0.9271

28.2040

29.6342

29.8751

29.2534 460005..................................................

1.5237

0.9271

25.0239

26.0731

29.4163

26.8371 460006..................................................

1.4480

0.9271

27.1392

28.3678

28.9633

28.1485 460007..................................................

1.3341

0.9228

27.1308

28.0035

29.1171

28.1204 460008..................................................

1.3382

0.9271

29.5907

31.5485

27.6886

29.5829 460009..................................................

1.9760

0.9271

27.2885

28.3836

29.4687

28.4457 460010..................................................

2.0995

0.9271

29.0063

30.4606

30.9793

30.1575 460011..................................................

1.3236

0.8395

24.4402

24.9677

26.5474

25.3370 460013..................................................

1.3909

0.9075

27.7381

29.2731

29.7232

28.9118 460014..................................................

1.1488

0.9271

28.2647

29.5963

30.6427

29.4780 460015..................................................

1.3542

0.8827

27.2506

29.1318

28.7993

28.4031 460017..................................................

1.5067

0.8778

24.3030

26.1589

28.7101

26.4243 460018..................................................

0.8937

0.8395

22.0517

22.8028

22.0916

22.3156 460019..................................................

1.1962

0.8395

24.3756

23.2202

25.1607

24.2508 460020..................................................

0.9177

*

18.5159

*

*

18.5159 460021..................................................

1.7949

1.1388

28.0291

29.5761

29.7373

29.2069 460023..................................................

1.2032

0.9075

26.9512

28.5884

28.9445

28.1975 460026..................................................

1.0634

0.9052

26.9295

27.9487

29.2757

28.0634 460030..................................................

1.1657

0.8395

23.5942

24.4218

26.8971

24.9667 460033..................................................

0.8711

0.8395

25.3422

26.6606

27.9090

26.6490 460035..................................................

0.9610

0.8395

20.6322

21.9115

23.8672

22.1202 460039..................................................

1.0970

0.8827

29.5651

30.4912

30.0656

30.0667 460041..................................................

1.3694

0.9271

26.4640

26.3807

26.7342

26.5286 460042..................................................

1.4973

0.9271

24.9454

26.8389

36.2868

28.7517 460043..................................................

0.9867

0.9075

28.2008

28.6668

29.5636

28.8137 460044..................................................

1.3270

0.9271

27.4928

28.7023

29.5056

28.5642 460047..................................................

1.6851

0.9271

28.2336

29.9990

30.9988

29.7618 460049..................................................

1.9801

0.9271

26.6702

28.4884

28.6251

27.9963 460051..................................................

1.4090

0.9271

27.0160

27.8841

28.1118

27.6918 460052..................................................

1.6516

0.9075

26.1629

27.1995

28.7433

27.4110 460054..................................................

1.6931

0.8827

24.9926

25.7870

26.3926

25.7328 460055..................................................

1.4742

0.9075

*

*

*

* 470001..................................................

1.2668

0.9297

28.3017

29.7540

32.2867

30.1248 470003..................................................

1.8776

0.9275

28.1137

30.1973

30.0513

29.4645 470005..................................................

1.3533

0.9275

30.7872

33.1981

33.9946

32.7064 470011..................................................

1.1581

0.9275

28.1330

29.6269

30.8723

29.5547 470012..................................................

1.2088

0.9275

26.0225

27.0751

29.8242

27.6835 470024..................................................

1.1462

0.9275

27.0394

26.6351

27.3091

26.9932 490001..................................................

1.0923

0.8061

23.2174

24.0368

24.6876

23.9910 490002..................................................

1.0162

0.8061

20.8609

21.7092

24.0666

22.0939 490004..................................................

1.2931

0.9449

27.1676

27.5890

28.8643

27.8908 490005..................................................

1.5720

1.0669

29.8215

30.5349

31.4889

30.6457 490007..................................................

2.0360

0.8869

27.6572

29.3098

30.7391

29.2722 490009..................................................

1.9926

0.9728

30.4722

28.4642

31.4238

30.0808 490011..................................................

1.5707

0.8869

26.4766

27.4764

28.8762

27.6271 490012..................................................

1.0101

0.8061

21.0605

22.9922

21.8319

21.9360 490013..................................................

1.3744

0.9694

24.7521

25.5560

27.3086

25.8824 490017..................................................

1.5021

0.8869

25.8216

27.5902

29.6761

27.7176 490018..................................................

1.3622

0.9449

26.2510

27.2644

27.8664

27.1379 490019..................................................

1.1503

1.0669

25.9885

25.8264

29.8874

27.1451 490020..................................................

1.2876

0.9203

27.3142

29.3468

30.5993

29.0707

Page 23778

490021..................................................

1.4622

0.8646

25.7938

27.0641

28.1233

26.9966 490022..................................................

1.4112

1.0669

32.2676

30.1203

31.7964

31.3740 490023..................................................

1.3297

1.0669

30.3416

30.9920

32.6291

31.3336 490024..................................................

1.6994

0.8889

26.1125

27.9689

29.0379

27.6964 490027..................................................

1.1143

0.8061

24.0288

23.0017

24.3832

23.7446 490032..................................................

1.9515

0.9203

25.2654

28.5897

28.0097

27.3514 490033..................................................

1.0967

1.0669

31.2922

31.8282

30.9894

31.3730 490037..................................................

1.2781

0.8061

24.7711

25.2859

26.2942

25.4675 490038..................................................

1.2238

0.8061

21.8509

22.6504

24.0844

22.8205 490040..................................................

1.5127

1.1017

32.6564

34.1841

35.6796

34.1603 490041..................................................

1.5635

0.8869

26.0897

27.1613

29.1224

27.4587 490042..................................................

1.3157

0.8750

24.4650

25.7333

26.6055

25.6256 490043..................................................

1.3375

1.1017

33.7096

35.8872

36.5934

35.4348 490044..................................................

1.4493

0.8869

23.3527

23.3793

24.1751

23.6463 490045..................................................

1.3427

1.0669

32.0937

30.3772

32.8751

31.7663 490046..................................................

1.5416

0.8869

26.6517

27.9604

29.3861

28.0339 490048..................................................

1.4333

0.8646

26.2828

27.0620

28.0302

27.1308 490050..................................................

1.5231

1.0669

31.3885

32.2993

31.1346

31.5946 490052..................................................

1.6678

0.8869

23.5973

25.0046

25.1956

24.5749 490053..................................................

1.1871

0.8061

23.3315

23.8004

24.6193

23.9160 490057..................................................

1.6362

0.8869

26.6898

27.4918

29.0678

27.7786 490059..................................................

1.6585

0.9203

27.3611

30.8669

32.1008

30.0791 490060..................................................

1.0194

0.8061

23.6113

24.3192

25.7752

24.5807 490063..................................................

1.8759

1.1017

31.3619

31.6069

34.1154

32.3880 490066..................................................

1.3873

0.8869

27.8250

29.5917

31.4281

29.7032 490067..................................................

1.2870

0.9203

24.9021

25.9497

26.7787

25.8584 490069..................................................

1.5365

0.9203

27.3181

29.1527

30.1463

28.8658 490071..................................................

1.4069

0.9203

29.7186

31.7061

33.7101

31.7115 490073..................................................

***

*

33.1829

34.5774

46.4178

36.1085 490075..................................................

1.3188

0.8483

25.2022

25.7323

27.3411

26.0795 490077..................................................

1.4181

0.9728

26.6806

28.1506

31.0002

28.6185 490079..................................................

1.2674

0.8985

25.3103

25.2340

24.2052

24.9039 490084..................................................

1.1427

0.8248

24.9007

25.7657

26.3132

25.6727 490088..................................................

1.0983

0.8646

24.1471

25.0619

26.0270

25.0928 490089..................................................

1.1018

0.8889

24.9438

25.9902

27.4562

26.1612 490090..................................................

1.0545

0.8061

25.1157

25.5418

27.0746

25.9182 490092..................................................

1.0775

0.8061

23.3439

25.7405

27.5268

25.4745 490093..................................................

1.5429

0.8869

25.6531

26.7886

28.7103

27.0735 490094..................................................

0.9727

0.9203

28.2165

28.9155

29.7975

28.9991 490097..................................................

1.0690

0.9203

26.5322

27.1470

27.4607

27.0696 490098..................................................

1.2889

0.8061

23.2782

25.1625

26.7140

25.0883 490101..................................................

1.4144

1.1017

31.2377

32.3695

32.9490

32.2107 490104..................................................

0.7712

0.9203

*

17.0548

19.0055

18.0437 490105..................................................

0.8355

0.8061

25.5329

26.3827

*

25.9379 490106..................................................

0.7733

0.8061

23.8334

25.7352

26.2318

25.2383 490107..................................................

1.4215

1.1017

32.2672

33.5430

35.0239

33.6804 490108..................................................

1.0546

0.8646

22.9076

23.3204

25.1884

23.8173 490109..................................................

0.9060

0.8869

22.7854

24.2296

21.6710

22.7835 490110..................................................

1.3576

0.8307

24.2887

24.9861

26.3071

25.2068 490111..................................................

1.1082

0.8061

22.1476

22.7336

26.4282

23.6179 490112..................................................

1.7315

0.9203

27.1932

29.0816

31.2526

29.1894 490113..................................................

1.2911

1.0669

31.8177

32.4547

34.7813

33.0718 490114..................................................

1.1439

0.8061

22.5255

22.1387

23.0526

22.5829 490115..................................................

1.2011

0.8061

22.4058

23.5718

23.2109

23.0488 490116..................................................

1.1712

0.8061

24.2258

24.3853

25.0343

24.5470 490117..................................................

1.1002

0.8061

19.6398

18.1138

20.3031

19.3436 490118..................................................

1.6337

0.9203

27.6749

29.0569

31.2383

29.3451 490119..................................................

1.3013

0.8869

26.5756

27.8866

29.5203

28.0191 490120..................................................

1.4551

0.8869

25.8795

25.9610

27.1973

26.3518 490122..................................................

1.5919

1.1017

32.0743

33.3719

35.2212

33.5744 490123..................................................

1.1435

0.8061

24.3490

24.2254

24.5997

24.3927 490126..................................................

1.1732

0.8061

23.6690

24.0908

25.3282

24.3545 490127..................................................

1.1178

0.8061

21.3735

23.5161

23.1390

22.6004 490130..................................................

1.2203

0.8869

23.9982

25.3352

25.9771

25.1170 490134..................................................

0.8323

0.8061

*

33.2405

31.1474

32.1153 490135..................................................

0.7518

0.8889

*

25.9998

27.2771

26.6418 490136..................................................

1.4451

0.9203

*

*

31.2889

31.2889

Page 23779

490138..................................................

1.9348

0.8646

*

*

*

* 500001..................................................

1.6024

1.1562

31.1605

33.0901

37.5297

33.7723 500002..................................................

1.3750

1.0164

27.6400

29.1448

30.1855

29.0190 500003..................................................

1.3968

1.1377

30.6939

32.1262

32.7960

31.8089 500005..................................................

1.8014

1.1562

33.5117

35.0997

36.0900

34.9342 500007..................................................

1.3520

1.1377

29.2869

30.5263

31.0289

30.3229 500008..................................................

1.9737

1.1562

32.6052

33.5666

34.7787

33.6731 500011..................................................

1.3817

1.1562

31.4514

32.6223

38.3960

33.9417 500012..................................................

1.7799

1.0164

30.0509

33.8101

33.1661

32.2294 500014..................................................

1.6593

1.1562

36.1380

36.5833

37.2677

36.6858 500015..................................................

1.4000

1.1562

34.5877

37.5724

40.8644

37.5957 500016..................................................

1.6703

1.1377

31.4905

32.9177

34.2801

32.9164 500019..................................................

1.2524

1.0295

30.5594

31.6242

33.8866

32.0653 500021..................................................

1.3071

1.1377

30.7927

32.4702

33.5572

32.3511 500024..................................................

1.7453

1.1462

32.6171

36.1647

37.4510

35.4266 500025..................................................

1.9117

1.1562

37.7952

40.6369

44.7077

41.0323 500026..................................................

1.4550

1.1562

32.8369

34.5881

35.5055

34.3334 500027..................................................

1.4942

1.1562

34.6164

39.2906

42.4941

38.7477 500030..................................................

1.6959

1.1395

32.4426

34.9174

36.7964

34.7347 500031..................................................

1.2671

1.1297

32.8833

33.2391

34.1649

33.4481 500033..................................................

1.2468

1.0164

30.6292

31.8891

32.6732

31.7837 500036..................................................

1.3290

1.0164

28.7096

30.5938

31.9136

30.4918 500037..................................................

1.0577

1.0164

28.1056

31.2654

29.1752

29.5198 500039..................................................

1.5629

1.1377

32.2245

33.5606

34.5710

33.5071 500041..................................................

1.4344

1.1186

30.3627

34.2017

36.9240

33.8434 500044..................................................

1.8913

1.0514

29.0214

31.0936

32.0719

30.6373 500049..................................................

1.3698

1.0164

27.7170

29.8189

30.8120

29.5153 500050..................................................

1.5082

1.1186

32.6751

33.7713

35.7229

34.0820 500051..................................................

1.7917

1.1562

32.5764

34.7610

36.4745

34.6036 500052..................................................

1.4632

1.1562

*

*

*

* 500053..................................................

1.2557

1.0164

28.2901

30.2811

28.5649

29.0318 500054..................................................

1.9737

1.0514

31.6595

32.5105

34.8088

32.9758 500058..................................................

1.6843

1.0164

30.7487

30.7034

32.6820

31.4274 500060..................................................

1.3541

1.1562

37.4869

38.7682

40.3002

38.8996 500064..................................................

1.8909

1.1562

31.6112

32.3581

34.7906

32.9459 500072..................................................

1.2605

1.0576

31.2000

32.5269

33.1128

32.3268 500077..................................................

1.4765

1.0514

31.6153

33.2223

34.3082

33.0354 500079..................................................

1.3733

1.1377

31.3280

32.5809

34.2468

32.6847 500084..................................................

1.2608

1.1562

30.2411

32.7883

33.3057

32.1164 500088..................................................

1.4739

1.1562

35.3770

36.7953

38.5166

36.8898 500108..................................................

1.6172

1.1377

31.8483

34.3872

35.8890

34.0321 500119..................................................

1.3809

1.0514

29.7028

31.2233

31.7102

30.8549 500124..................................................

1.4071

1.1562

32.3505

34.4790

36.3296

34.3958 500129..................................................

1.5755

1.1377

32.1102

34.4447

37.3169

34.6824 500134..................................................

0.5967

1.1562

27.2428

28.1374

28.9744

28.2246 500139..................................................

1.4903

1.1462

33.9739

34.6412

37.5682

35.2949 500141..................................................

1.2645

1.1562

31.3308

33.7532

34.2350

33.1511 500143..................................................

0.5889

1.1462

23.6766

25.3099

26.3882

25.1082 500148..................................................

1.2204

1.0164

26.4206

37.7830

24.6331

30.3555 500150..................................................

1.2775

1.1186

*

*

34.7828

34.7828 510001..................................................

1.9319

0.8569

25.2973

25.8693

26.7901

26.0184 510002..................................................

1.2681

0.8732

23.8921

23.7270

24.8834

24.1721 510006..................................................

1.3528

0.8631

24.9627

24.8777

26.6403

25.4772 510007..................................................

1.6750

0.9107

24.7264

27.1149

28.5769

26.8115 510008..................................................

1.3363

0.9253

26.3554

27.5241

27.4687

27.1395 510012..................................................

0.9584

0.7759

18.8984

20.8455

22.9026

20.8292 510013..................................................

1.1635

0.7635

22.7882

22.8779

22.9605

22.8737 510018..................................................

1.0730

0.8398

22.4597

23.1043

23.7726

23.1223 510022..................................................

1.8098

0.8398

26.9511

26.8328

27.6095

27.1376 510023..................................................

1.2565

0.8011

20.6435

21.0940

23.1446

21.6346 510024..................................................

1.7530

0.8569

25.5634

26.6621

31.1308

27.8371 510026..................................................

0.9848

0.7635

17.9908

19.2025

17.8264

18.3206 510029..................................................

1.2995

0.8398

22.7104

24.0872

25.3908

24.0179 510030..................................................

1.1499

0.7635

24.3936

24.2007

25.5580

24.7270 510031..................................................

1.4626

0.8398

23.2624

24.0237

26.7854

24.6110 510033..................................................

1.5988

0.8028

22.6189

24.0796

24.2824

23.6905 510038..................................................

1.0704

0.7635

20.6565

20.9180

21.7526

21.1101

Page 23780

510039..................................................

1.3740

0.7635

19.8751

20.4719

21.3807

20.5901 510046..................................................

1.3781

0.7795

22.1712

22.2935

24.7175

23.0443 510047..................................................

1.2053

0.8569

27.1214

27.6859

28.8777

27.9077 510048..................................................

1.1872

0.7635

18.8576

22.7930

23.6384

21.5406 510050..................................................

1.5377

0.8569

21.0772

21.9009

23.5780

22.1906 510053..................................................

1.0938

0.7635

22.3318

21.5338

22.6278

22.1640 510055..................................................

1.5578

0.9107

28.4615

29.4111

30.7366

29.5844 510058..................................................

1.3382

0.8028

23.9015

25.3248

24.8750

24.7020 510059..................................................

***

*

22.1435

20.8847

21.9025

21.6378 510062..................................................

1.2241

0.8398

26.2296

26.7066

27.7962

26.9089 510067..................................................

1.0951

0.7635

25.0437

25.2130

25.2231

25.1585 510070..................................................

1.2034

0.8398

23.5639

23.9742

25.4968

24.3383 510071..................................................

1.2818

0.7795

23.4508

23.2954

23.4542

23.4003 510072..................................................

1.0733

0.7635

20.5146

19.4370

20.2379

20.0443 510077..................................................

1.0382

0.8748

24.5010

25.9515

27.1603

25.8349 510082..................................................

1.1006

0.7635

19.9081

20.3279

21.1654

20.4929 510085..................................................

1.2021

0.8398

26.3877

26.2617

26.8122

26.4911 510086..................................................

1.0879

0.7635

19.8735

19.2606

20.1963

19.7687 510090..................................................

***

*

*

*

39.0764

39.0764 520002..................................................

1.3026

0.9823

27.7705

29.0501

31.9053

29.6240 520004..................................................

1.4018

0.9796

27.6530

28.9857

30.9192

29.2469 520008..................................................

1.5695

1.0182

30.7553

33.8057

33.6749

32.7716 520009..................................................

1.6546

0.9511

27.4044

28.8591

29.6272

28.6360 520011..................................................

1.2826

0.9511

26.6268

28.0224

29.5006

28.0213 520013..................................................

1.4977

1.0976

29.0018

30.1834

32.1701

30.5206 520017..................................................

1.1201

0.9599

28.4699

29.3278

31.0517

29.6386 520019..................................................

1.3503

0.9511

28.6971

29.8640

30.2175

29.6442 520021..................................................

1.3207

1.0315

28.4182

29.1129

29.7788

29.1139 520027..................................................

1.4430

1.0182

31.4284

32.4137

33.5809

32.5077 520028..................................................

1.3966

1.1014

26.7260

28.0813

29.4683

28.3047 520030..................................................

1.6874

0.9823

29.4678

30.5724

31.6785

30.5738 520033..................................................

1.2248

0.9511

28.0662

29.0236

30.2616

29.1742 520034..................................................

1.2622

0.9511

26.1094

26.8886

28.1800

27.0611 520035..................................................

1.3586

0.9587

27.3276

28.1048

29.4053

28.2938 520037..................................................

1.7405

0.9823

30.1799

32.2144

31.6795

31.3757 520038..................................................

1.2048

1.0182

29.3134

29.6339

30.5249

29.8341 520040..................................................

***

*

29.1262

31.2038

35.9633

32.0420 520041..................................................

1.0813

1.1232

23.5495

25.3764

26.1572

25.0721 520044..................................................

1.3626

0.9587

27.3685

28.2382

28.6601

28.1191 520045..................................................

1.5915

0.9511

27.3336

29.2556

30.0840

28.8905 520048..................................................

1.5102

0.9511

26.8080

29.1870

30.1468

28.5889 520049..................................................

2.0434

0.9511

26.9851

28.0936

29.4223

28.1983 520051..................................................

1.5346

1.0182

31.9949

31.5974

32.4111

32.0738 520057..................................................

1.1885

0.9704

27.7528

29.1158

31.3292

29.4114 520059..................................................

1.3571

1.0026

29.5801

30.4491

31.1783

30.4093 520060..................................................

***

*

24.8638

*

*

24.8638 520062..................................................

1.3331

1.0182

28.8510

32.8584

32.6992

31.5738 520063..................................................

1.1678

1.0182

29.0993

30.3391

31.5185

30.3770 520064..................................................

1.5219

1.0182

30.3225

31.5723

33.1248

31.5779 520066..................................................

1.4182

0.9824

29.2088

31.0644

31.6673

30.6304 520070..................................................

1.6950

0.9599

27.6771

28.2059

30.0451

28.7359 520071..................................................

1.2135

1.0026

30.0262

30.6930

31.5435

30.8053 520075..................................................

1.6946

0.9511

29.2920

30.1582

32.2755

30.5484 520076..................................................

1.2239

1.1014

27.3335

27.4423

26.8932

27.2252 520078..................................................

1.4666

1.0182

29.9837

31.6606

32.0179

31.1768 520083..................................................

1.7215

1.1232

30.8826

32.7728

34.7200

32.8276 520087..................................................

1.7126

0.9796

28.5810

30.5659

31.9747

30.3890 520088..................................................

1.3463

0.9523

30.7450

30.6657

30.7462

30.7187 520089..................................................

1.5744

1.1232

33.8793

33.4098

34.9331

34.0808 520091..................................................

1.2752

0.9511

25.4593

27.3442

28.7166

27.1741 520095..................................................

1.2282

0.9704

30.4216

32.0381

33.2399

31.9187 520096..................................................

1.3683

1.0026

27.8896

29.5985

28.5204

28.6435 520097..................................................

1.3252

0.9511

29.1479

29.9998

31.0204

30.0765 520098..................................................

2.0129

1.1232

32.5785

36.5776

38.0962

35.8078 520100..................................................

1.3329

0.9824

29.3243

29.9458

31.7748

30.3552 520102..................................................

1.1961

1.0026

29.1680

30.7990

31.5735

30.5379 520103..................................................

1.5575

1.0182

30.3165

32.6269

34.5620

32.5629

Page 23781

520107..................................................

1.3439

0.9523

28.9878

29.4178

30.0343

29.4887 520109..................................................

1.0451

0.9511

24.7228

25.0697

25.9723

25.2667 520113..................................................

1.2659

0.9511

31.4708

33.3475

33.3023

32.7086 520116..................................................

1.2564

1.0026

27.9688

30.2156

31.6687

29.9794 520132..................................................

***

*

25.0006

27.3431

*

26.0481 520136..................................................

1.6351

1.0182

30.6522

32.1479

32.3480

31.6992 520138..................................................

1.8898

1.0182

30.8016

31.6581

32.5653

31.6762 520139..................................................

1.3351

1.0182

28.8870

30.4903

31.7060

30.3322 520140..................................................

***

*

31.0043

31.1315

*

31.0699 520152..................................................

***

*

29.7308

*

*

29.7308 520160..................................................

1.7768

0.9511

27.9548

29.5582

30.3037

29.2715 520170..................................................

1.4785

1.0182

30.4309

31.4710

31.7586

31.2272 520173..................................................

1.0888

*

29.2429

31.0599

*

30.1478 520177..................................................

1.5992

1.0182

31.4555

32.5714

33.1218

32.4064 520189..................................................

1.1684

1.0315

28.0014

29.0295

29.2212

28.7600 520193..................................................

1.7185

0.9511

27.8113

29.2007

29.4715

28.8651 520194..................................................

1.5801

1.0182

30.1668

31.4379

30.9993

30.8959 520195..................................................

0.6565

1.0182

36.3116

36.2900

41.6044

37.9667 520196..................................................

1.7736

0.9599

36.9266

31.1175

31.6125

32.7571 520197..................................................

***

*

*

30.1917

*

30.1917 520198..................................................

1.3572

0.9511

*

28.5975

29.9781

29.2918 520199..................................................

2.0438

1.0182

*

36.5699

37.0103

36.7943 520202..................................................

1.6509

0.9823

*

*

*

* 520203..................................................

2.9989

1.1232

*

*

*

* 530002..................................................

1.1984

0.9223

28.3063

29.2069

29.2407

28.9305 530006..................................................

1.2359

0.9223

27.2421

29.2104

30.3704

28.9041 530008..................................................

1.1650

0.9223

24.0090

26.5180

30.5992

27.0161 530009..................................................

0.9602

0.9223

24.6719

26.0490

27.0529

25.9191 530010..................................................

1.2145

0.9223

25.9852

27.4121

28.5518

27.3468 530011..................................................

1.1265

0.9223

27.8772

27.8613

31.1309

28.8654 530012..................................................

1.7040

0.9618

26.9582

28.7524

30.6085

28.7888 530014..................................................

1.5582

0.9611

26.7156

28.5469

29.6709

28.4442 530015..................................................

1.1779

0.9327

29.8310

29.8306

33.4886

31.0902 530017..................................................

0.9134

0.9223

29.8503

31.1105

25.8172

28.8536 530025..................................................

1.2876

0.9223

24.4392

29.4346

28.8951

27.4712 530032..................................................

1.0528

0.9223

23.9004

24.6580

25.4254

24.6844

\1\ Based on salaries adjusted for occupational mix, according to the calculation in section III.D.2. of the preamble to this proposed rule.

\2\ The case-mix index is based on the billed DRGs in the FY 2007 MedPAR file. It is not transfer adjusted.

\3\ Provider 140010 is part of a multicampus provider (MCH) that is comprised of campuses that are located in two different CBSAs. The provider number with a ``B'' in the 4th position, 140B10, indicates the portion of the wage and hours of the MCH that is allocated to CBSA 29404; provider number 140010 indicates the portion of wages and hours of the MCH that is allocated to CBSA 16974.

\4\ Provider 220074 is part of a multicampus provider (MCH) that is comprised of campuses that are located in two different CBSAs. The provider number with a ``B'' in the 4th position, 220B74, indicates the portion of the wage and hours of the MCH that is allocated to CBSA 14484; provider number 220074 indicates the portion of wages and hours of the MCH that is allocated to CBSA 39300.

\5\ Provider 230104 is part of a multicampus provider (MCH) that is comprised of campuses that are located in two different CBSAs. The provider number with a ``B'' in the 4th position, 230B04, indicates the portion of the wage and hours of the MCH that is allocated to CBSA 47644; provider number 230104 indicates the portion of wages and hours of the MCH that is allocated to CBSA 19804.

*Denotes wage data not available for the provider for that year.

**Based on the sum of the salaries and hours computed for Federal FYs 2007, 2008, and 2009.

***Denotes MedPAR data not available for the provider for FY 2007.

Table 3A.--FY 2009 and 3-Year* Average Hourly Wage for Urban Areas by

CBSA

*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009

FY 2009

CBSA code

Urban area

average hourly 3-Year average wage

hourly wage

10180........... Abilene, TX...........

27.1004

25.7723 10380........... Aguadilla-Isabela-San

10.6709

10.7622

Sebasti[aacute]n, PR. 10420........... Akron, OH.............

28.3319

26.9292 10500........... Albany, GA............

28.2617

27.2184 10580........... Albany-Schenectady-

28.4655

27.2227

Troy, NY. 10740........... Albuquerque, NM.......

30.6500

29.7201 10780........... Alexandria, LA........

26.1655

24.7913 10900........... Allentown-Bethlehem-

31.2097

30.7425

Easton, PA-NJ. 11020........... Altoona, PA...........

26.7060

25.9824

Page 23782

11100........... Amarillo, TX..........

29.0008

28.2619 11180........... Ames, IA..............

30.4757

30.0901 11260........... Anchorage, AK.........

38.0798

36.6236 11300........... Anderson, IN..........

28.7750

27.5948 11340........... Anderson, SC..........

31.3772

28.7401 11460........... Ann Arbor, MI.........

33.6572

32.6579 11500........... Anniston-Oxford, AL...

25.8029

24.6804 11540........... Appleton, WI..........

30.0406

29.0241 11700........... Asheville, NC.........

29.6273

28.5517 12020........... Athens-Clarke County,

30.9008

29.8591

GA. 12060........... Atlanta-Sandy Springs-

31.4502

30.3269

Marietta, GA. 12100........... Atlantic City-

38.0743

36.7794

Hammonton, NJ. 12220........... Auburn-Opelika, AL....

24.3605

24.4407 12260........... Augusta-Richmond

30.9498

29.7603

County, GA-SC. 12420........... Austin-Round Rock, TX.

30.6888

29.3079 12540........... Bakersfield, CA.......

36.5786

34.6045 12580........... Baltimore-Towson, MD..

32.1655

30.9372 12620........... Bangor, ME............

32.5961

30.6397 12700........... Barnstable Town, MA...

40.8356

39.1326 12940........... Baton Rouge, LA.......

26.2494

25.0384 12980........... Battle Creek, MI......

32.3508

30.7409 13020........... Bay City, MI..........

30.3060

28.7057 13140........... Beaumont-Port Arthur,

27.7045

26.7778

TX. 13380........... Bellingham, WA........

36.7964

34.7347 13460........... Bend, OR..............

35.6036

33.2554 13644........... Bethesda-Frederick-

33.9508

32.8571

Gaithersburg, MD. 13740........... Billings, MT..........

29.1465

27.7805 13780........... Binghamton, NY........

28.1030

27.6136 13820........... Birmingham-Hoover, AL.

28.3138

27.3821 13900........... Bismarck, ND..........

23.2350

22.4949 13980........... Blacksburg-

26.1759

25.2599

Christiansburg-

Radford, VA. 14020........... Bloomington, IN.......

30.3742

28.6837 14060........... Bloomington-Normal, IL

30.6807

29.0683 14260........... Boise City-Nampa, ID..

29.9365

29.1371 14484........... Boston-Quincy, MA.....

38.6504

36.7387 14500........... Boulder, CO...........

32.3079

31.3052 14540........... Bowling Green, KY.....

26.8895

25.3106 14600........... Bradenton-Sarasota-

31.5095

30.2345

Venice, FL. 14740........... Bremerton-Silverdale,

34.5710

33.5071

WA. 14860........... Bridgeport-Stamford-

42.0944

39.8678

Norwalk, CT. 15180........... Brownsville-Harlingen,

29.7382

29.0319

TX. 15260........... Brunswick, GA.........

32.6731

31.3350 15380........... Buffalo-Niagara Falls,

30.9123

29.5833

NY. 15500........... Burlington, NC........

27.7660

26.6186 15540........... Burlington-South

29.6973

29.1460

Burlington, VT. 15764........... Cambridge-Newton-

35.6990

34.3809

Framingham, MA. 15804........... Camden, NJ............

34.1250

32.6476 15940........... Canton-Massillon, OH..

28.5297

27.6782 15980........... Cape Coral-Fort Myers,

30.6869

29.4302

FL. 16180........... Carson City, NV.......

32.3122

30.2124 16220........... Casper, WY............

30.6085

28.7888 16300........... Cedar Rapids, IA......

28.3050

27.0341 16580........... Champaign-Urbana, IL..

30.1432

29.1751 16620........... Charleston, WV........

27.1192

26.3071 16700........... Charleston-North

29.7955

28.4097

Charleston-

Summerville, SC. 16740........... Charlotte-Gastonia-

30.8456

29.4515

Concord, NC-SC. 16820........... Charlottesville, VA...

31.3517

29.8273 16860........... Chattanooga, TN-GA....

28.6158

27.6439 16940........... Cheyenne, WY..........

29.6709

28.4442 16974........... Chicago-Naperville-

33.3033

32.5973

Joliet, IL. 17020........... Chico, CA.............

35.0695

34.2761 17140........... Cincinnati-Middletown,

30.9027

29.7285

OH-KY-IN. 17300........... Clarksville, TN-KY....

26.7544

25.7478 17420........... Cleveland, TN.........

26.2909

25.3790 17460........... Cleveland-Elyria-

29.8896

28.9336

Mentor, OH. 17660........... Coeur d'Alene, ID.....

29.5998

28.7256 17780........... College Station-Bryan,

29.6321

28.1756

TX. 17820........... Colorado Springs, CO..

31.4793

29.6470 17860........... Columbia, MO..........

27.2133

26.2863

Page 23783

17900........... Columbia, SC..........

28.9948

27.6672 17980........... Columbus, GA-AL.......

29.2007

27.4844 18020........... Columbus, IN..........

31.7711

29.8902 18140........... Columbus, OH..........

31.8334

30.9635 18580........... Corpus Christi, TX....

27.3797

26.2260 18700........... Corvallis, OR.........

35.7074

34.1739 19060........... Cumberland, MD-WV.....

24.2686

24.3744 19124........... Dallas-Plano-Irving,

31.7539

30.5827

TX. 19140........... Dalton, GA............

27.3868

26.8521 19180........... Danville, IL..........

31.2955

29.5310 19260........... Danville, VA..........

27.3411

26.0795 19340........... Davenport-Moline-Rock

27.2010

26.8964

Island, IA-IL. 19380........... Dayton, OH............

30.0672

28.7100 19460........... Decatur, AL...........

24.8584

24.2893 19500........... Decatur, IL...........

26.3336

25.3091 19660........... Deltona-Daytona Beach-

28.4632

27.8441

Ormond Beach, FL. 19740........... Denver-Aurora, CO.....

34.1438

32.7970 19780........... Des Moines-West Des

30.6173

28.7458

Moines, IA. 19804........... Detroit-Livonia-

32.3846

31.4605

Dearborn, MI. 20020........... Dothan, AL............

24.8722

23.3546 20100........... Dover, DE.............

34.3823

32.3013 20220........... Dubuque, IA...........

26.5562

26.9190 20260........... Duluth, MN-WI.........

33.8981

31.7842 20500........... Durham, NC............

31.2419

30.0944 20740........... Eau Claire, WI........

30.9902

29.6325 20764........... Edison-New Brunswick,

36.1487

34.5118

NJ. 20940........... El Centro, CA.........

29.1074

28.1129 21060........... Elizabethtown, KY.....

27.2829

26.5352 21140........... Elkhart-Goshen, IN....

30.6988

29.4323 21300........... Elmira, NY............

26.8991

25.8564 21340........... El Paso, TX...........

28.5812

28.1095 21500........... Erie, PA..............

28.0896

26.9188 21660........... Eugene-Springfield, OR

35.9675

34.2186 21780........... Evansville, IN-KY.....

27.4904

26.7119 21820........... Fairbanks, AK.........

36.1891

34.2975 21940........... Fajardo, PR...........

13.1075

12.8846 22020........... Fargo, ND-MN..........

26.0887

24.9864 22140........... Farmington, NM........

25.2152

26.1577 22180........... Fayetteville, NC......

31.9846

30.2233 22220........... Fayetteville-

29.4256

27.9239

Springdale-Rogers, AR-

MO. 22380........... Flagstaff, AZ.........

37.5481

35.8798 22420........... Flint, MI.............

36.2781

34.1503 22500........... Florence, SC..........

27.3900

26.5639 22520........... Florence-Muscle

25.2619

24.0763

Shoals, AL. 22540........... Fond du Lac, WI.......

30.7462

30.7188 22660........... Fort Collins-Loveland,

30.8219

29.2764

CO. 22744........... Fort Lauderdale-

31.6349

30.8485

Pompano Beach-

Deerfield Beach, FL. 22900........... Fort Smith, AR-OK.....

25.2751

24.4937 23020........... Fort Walton Beach-

28.1059

26.8450

Crestview-Destin, FL. 23060........... Fort Wayne, IN........

28.8955

28.1729 23104........... Fort Worth-Arlington,

31.2137

29.8330

TX. 23420........... Fresno, CA............

35.7716

34.2816 23460........... Gadsden, AL...........

25.7517

24.9688 23540........... Gainesville, FL.......

30.4476

29.0940 23580........... Gainesville, GA.......

30.0367

28.8932 23844........... Gary, IN..............

30.0576

28.8628 24020........... Glens Falls, NY.......

28.2938

26.8175 24140........... Goldsboro, NC.........

29.5207

28.5197 24220........... Grand Forks, ND-MN....

24.9880

24.4055 24300........... Grand Junction, CO....

31.2200

29.9879 24340........... Grand Rapids-Wyoming,

29.9037

29.1399

MI. 24500........... Great Falls, MT.......

27.9340

26.5446 24540........... Greeley, CO...........

32.4200

30.9988 24580........... Green Bay, WI.........

30.6825

29.5078 24660........... Greensboro-High Point,

29.4639

28.1363

NC. 24780........... Greenville, NC........

30.1256

28.8796 24860........... Greenville-Mauldin-

31.0004

29.7649

Easley, SC. 25020........... Guayama, PR...........

10.1106

09.6176 25060........... Gulfport-Biloxi, MS...

28.6731

27.0856

Page 23784

25180........... Hagerstown-

29.8828

28.7638

Martinsburg, MD-WV. 25260........... Hanford-Corcoran, CA..

35.7293

33.4052 25420........... Harrisburg-Carlisle,

29.4620

28.6481

PA. 25500........... Harrisonburg, VA......

28.8643

27.8908 25540........... Hartford-West Hartford-

36.0188

34.1981

East Hartford, CT. 25620........... Hattiesburg, MS.......

24.2839

23.4139 25860........... Hickory-Lenoir-

28.8353

27.7789

Morganton, NC. 25980........... \1\ Hinesville-Fort

Stewart, GA. 26100........... Holland-Grand Haven,

29.3296

28.2605

MI. 26180........... Honolulu, HI..........

37.4061

34.9722 26300........... Hot Springs, AR.......

29.4741

27.9457 26380........... Houma-Bayou Cane-

25.3740

24.7942

Thibodaux, LA. 26420........... Houston-Sugar Land-

31.9906

30.9869

Baytown, TX. 26580........... Huntington-Ashland, WV-

29.4107

27.7644

KY-OH. 26620........... Huntsville, AL........

28.9607

27.8624 26820........... Idaho Falls, ID.......

29.3359

28.2699 26900........... Indianapolis-Carmel,

31.6890

30.3105

IN. 26980........... Iowa City, IA.........

30.2168

29.3116 27060........... Ithaca, NY............

30.8103

29.9028 27100........... Jackson, MI...........

30.5399

29.5811 27140........... Jackson, MS...........

25.9122

24.9687 27180........... Jackson, TN...........

27.3080

26.6865 27260........... Jacksonville, FL......

29.3541

28.3904 27340........... Jacksonville, NC......

27.0573

25.9214 27500........... Janesville, WI........

31.7184

30.5036 27620........... Jefferson City, MO....

29.1505

27.2519 27740........... Johnson City, TN......

25.8452

24.5939 27780........... Johnstown, PA.........

25.9505

24.9881 27860........... Jonesboro, AR.........

26.0204

24.6491 27900........... Joplin, MO............

31.3014

28.6510 28020........... Kalamazoo-Portage, MI.

35.1589

33.2912 28100........... Kankakee-Bradley, IL..

38.7329

33.0300 28140........... Kansas City, MO-KS....

30.4624

29.0579 28420........... Kennewick-Pasco-

31.3630

30.6561

Richland, WA. 28660........... Killeen-Temple-Fort

28.5417

26.9557

Hood, TX. 28700........... Kingsport-Bristol-

25.3719

24.5154

Bristol, TN-VA. 28740........... Kingston, NY..........

30.3965

29.3492 28940........... Knoxville, TN.........

25.4214

24.8943 29020........... Kokomo, IN............

29.8433

29.2845 29100........... La Crosse, WI-MN......

31.6291

30.0294 29140........... Lafayette, IN.........

28.8946

27.2885 29180........... Lafayette, LA.........

27.2063

25.9638 29340........... Lake Charles, LA......

24.4720

24.0434 29404........... Lake County-Kenosha

33.4390

32.6639

County, IL-WI. 29420........... Lake Havasu City-

31.6370

29.6383

Kingman, AZ. 29460........... Lakeland-Winter Haven,

28.1459

27.5004

FL. 29540........... Lancaster, PA.........

31.0576

30.0449 29620........... Lansing-East Lansing,

31.9010

30.9914

MI. 29700........... Laredo, TX............

28.4147

26.3095 29740........... Las Cruces, NM........

28.3851

27.2925 29820........... Las Vegas-Paradise, NV

37.5945

35.4889 29940........... Lawrence, KS..........

26.8014

25.6444 30020........... Lawton, OK............

27.8148

26.3376 30140........... Lebanon, PA...........

29.0022

26.8307 30300........... Lewiston, ID-WA.......

29.8774

29.0074 30340........... Lewiston-Auburn, ME...

30.0517

28.7720 30460........... Lexington-Fayette, KY.

28.8431

27.8163 30620........... Lima, OH..............

29.9606

28.3617 30700........... Lincoln, NE...........

31.0009

30.3915 30780........... Little Rock-North

28.2114

28.2530

Little Rock-Conway,

AR. 30860........... Logan, UT-ID..........

28.3537

27.8958 30980........... Longview, TX..........

27.3041

26.9355 31020........... Longview, WA..........

36.9240

33.8434 31084........... Los Angeles-Long Beach-

38.9626

36.6108

Glendale, CA. 31140........... Louisville-Jefferson

29.7925

28.3269

County, KY-IN. 31180........... Lubbock, TX...........

28.0803

26.7835 31340........... Lynchburg, VA.........

27.7933

26.6660 31420........... Macon, GA.............

31.6291

30.3409 31460........... Madera, CA............

26.7719

26.0576

Page 23785

31540........... Madison, WI...........

36.2618

34.3945 31700........... Manchester-Nashua, NH.

33.0542

31.4821 31900........... Mansfield, OH.........

29.9812

28.5726 32420........... Mayag[uuml]ez, PR.....

12.5555

11.7170 32580........... McAllen-Edinburg-

29.3886

27.9884

Mission, TX. 32780........... Medford, OR...........

33.0786

32.3223 32820........... Memphis, TN-MS-AR.....

30.0626

28.8798 32900........... Merced, CA............

39.1381

36.7035 33124........... Miami-Miami Beach-

31.8599

30.6911

Kendall, FL. 33140........... Michigan City-La

29.1570

27.7380

Porte, IN. 33260........... Midland, TX...........

30.8197

29.6993 33340........... Milwaukee-Waukesha-

32.8741

31.8085

West Allis, WI. 33460........... Minneapolis-St. Paul-

35.4391

33.7580

Bloomington, MN-WI. 33540........... Missoula, MT..........

28.2291

26.9683 33660........... Mobile, AL............

25.1640

24.3569 33700........... Modesto, CA...........

39.1156

36.9865 33740........... Monroe, LA............

25.6673

24.6843 33780........... Monroe, MI............

28.7386

29.0350 33860........... Montgomery, AL........

26.3999

25.1056 34060........... Morgantown, WV........

27.8745

26.4870 34100........... Morristown, TN........

23.5598

23.4073 34580........... Mount Vernon-

32.2055

31.3429

Anacortes, WA. 34620........... Muncie, IN............

26.7339

25.4260 34740........... Muskegon-Norton

32.9571

31.3172

Shores, MI. 34820........... Myrtle Beach-North

28.0263

27.0772

Myrtle Beach-Conway,

SC. 34900........... Napa, CA..............

45.2771

42.3405 34940........... Naples-Marco Island,

31.7163

30.5323

FL. 34980........... Nashville-Davidson-

30.5185

29.8356

Murfreesboro-

Franklin, TN. 35004........... Nassau-Suffolk, NY....

41.0210

39.8184 35084........... Newark-Union, NJ-PA...

37.3360

36.1271 35300........... New Haven-Milford, CT.

38.1842

37.0168 35380........... New Orleans-Metairie-

29.4715

27.1340

Kenner, LA. 35644........... New York-White Plains-

42.0303

40.8866

Wayne, NY-NJ. 35660........... Niles-Benton Harbor,

29.3085

28.0264

MI. 35980........... Norwich-New London, CT

36.8468

36.0398 36084........... Oakland-Fremont-

49.9560

47.7941

Hayward, CA. 36100........... Ocala, FL.............

27.4049

26.5357 36140........... Ocean City, NJ........

37.4820

34.3008 36220........... Odessa, TX............

30.3782

30.3247 36260........... Ogden-Clearfield, UT..

29.7855

28.2615 36420........... Oklahoma City, OK.....

27.9928

27.1135 36500........... Olympia, WA...........

37.0153

34.9710 36540........... Omaha-Council Bluffs,

30.2913

29.2081

NE-IA. 36740........... Orlando-Kissimmee, FL.

29.6766

28.9783 36780........... Oshkosh-Neenah, WI....

30.0761

28.8544 36980........... Owensboro, KY.........

28.2413

27.1328 37100........... Oxnard-Thousand Oaks-

36.9286

35.1055

Ventura, CA. 37340........... Palm Bay-Melbourne-

30.3622

29.2690

Titusville, FL. 37380........... \2\ Palm Coast, FL....

28.3179

27.7197 37460........... Panama City-Lynn

27.4719

25.9842

Haven, FL. 37620........... Parkersburg-Marietta-

25.9281

25.2122

Vienna, WV-OH. 37700........... Pascagoula, MS........

25.8776

25.5012 37764........... Peabody, MA...........

34.6216

32.8179 37860........... Pensacola-Ferry Pass-

26.1506

24.9081

Brent, FL. 37900........... Peoria, IL............

29.1439

28.4392 37964........... Philadelphia, PA......

35.4610

33.9583 38060........... Phoenix-Mesa-

33.0972

31.5810

Scottsdale, AZ. 38220........... Pine Bluff, AR........

26.6629

25.9270 38300........... Pittsburgh, PA........

27.6753

26.3759 38340........... Pittsfield, MA........

33.6590

31.7762 38540........... Pocatello, ID.........

29.3360

28.3737 38660........... Ponce, PR.............

13.2835

13.4725 38860........... Portland-South

31.9890

30.7480

Portland-Biddeford,

ME. 38900........... Portland-Vancouver-

36.1216

34.7569

Beaverton, OR-WA. 38940........... Port St. Lucie, FL....

31.9898

30.8026 39100........... Poughkeepsie-Newburgh-

35.2679

33.9878

Middletown, NY. 39140........... Prescott, AZ..........

32.8634

30.9614 39300........... Providence-New Bedford-

34.3817

33.0490

Fall River, RI-MA. 39340........... Provo-Orem, UT........

29.1600

28.8274

Page 23786

39380........... Pueblo, CO............

27.8188

26.8684 39460........... Punta Gorda, FL.......

29.9874

29.4798 39540........... Racine, WI............

28.8930

28.8892 39580........... Raleigh-Cary, NC......

31.2156

30.0484 39660........... Rapid City, SD........

30.6204

27.7643 39740........... Reading, PA...........

30.0875

29.3819 39820........... Redding, CA...........

41.6249

39.4241 39900........... Reno-Sparks, NV.......

33.7604

34.6330 40060........... Richmond, VA..........

29.6609

28.3807 40140........... Riverside-San

36.2653

34.0181

Bernardino-Ontario,

CA. 40220........... Roanoke, VA...........

28.6468

27.4630 40340........... Rochester, MN.........

35.3899

33.7865 40380........... Rochester, NY.........

28.7144

27.8099 40420........... Rockford, IL..........

31.7824

30.6686 40484........... Rockingham County-

31.9359

31.0988

Strafford County, NH. 40580........... Rocky Mount, NC.......

29.2288

27.8751 40660........... Rome, GA..............

31.2559

29.9017 40900........... Sacramento-Arden-

41.9426

40.3835

Arcade-Roseville, CA. 40980........... Saginaw-Saginaw

29.1128

28.2485

Township North, MI. 41060........... St. Cloud, MN.........

37.2177

34.8308 41100........... St. George, UT........

29.7373

29.2069 41140........... St. Joseph, MO-KS.....

33.7767

30.5981 41180........... St. Louis, MO-IL......

28.9842

27.8523 41420........... Salem, OR.............

34.3369

32.4058 41500........... Salinas, CA...........

47.9744

45.4050 41540........... Salisbury, MD.........

29.6266

27.8982 41620........... Salt Lake City, UT....

29.8767

29.1422 41660........... San Angelo, TX........

27.7212

26.5502 41700........... San Antonio, TX.......

28.8457

27.6665 41740........... San Diego-Carlsbad-San

36.2686

34.6834

Marcos, CA. 41780........... Sandusky, OH..........

28.4754

27.6992 41884........... San Francisco-San

48.5597

46.7826

Mateo-Redwood City,

CA. 41900........... San Germ[aacute]n-Cabo

14.9779

14.5348

Rojo, PR. 41940........... San Jose-Sunnyvale-

51.2569

48.2592

Santa Clara, CA. 41980........... San Juan-Caguas-

14.1930

13.8050

Guaynabo, PR. 42020........... San Luis Obispo-Paso

38.5623

36.3112

Robles, CA. 42044........... Santa Ana-Anaheim-

38.1247

35.9846

Irvine, CA. 42060........... Santa Barbara-Santa

37.7124

35.1162

Maria-Goleta, CA. 42100........... Santa Cruz-

51.5525

48.3881

Watsonville, CA. 42140........... Santa Fe, NM..........

34.1580

33.1619 42220........... Santa Rosa-Petaluma,

49.2189

45.6081

CA. 42340........... Savannah, GA..........

28.8176

27.8424 42540........... Scranton-Wilkes-Barre,

26.5201

25.6648

PA. 42644........... Seattle-Bellevue-

37.3352

35.3387

Everett, WA. 42680........... Sebastian-Vero Beach,

30.7417

30.0442

FL. 43100........... Sheboygan, WI.........

29.1159

28.0863 43300........... Sherman-Denison, TX...

29.9470

27.3065 43340........... Shreveport-Bossier

27.5578

26.7863

City, LA. 43580........... Sioux City, IA-NE-SD..

28.3024

27.7781 43620........... Sioux Falls, SD.......

30.2235

29.2197 43780........... South Bend-Mishawaka,

31.0993

30.1358

IN-MI. 43900........... Spartanburg, SC.......

29.1025

28.3525 44060........... Spokane, WA...........

33.9523

32.3332 44100........... Springfield, IL.......

29.4330

27.9091 44140........... Springfield, MA.......

33.3312

31.8950 44180........... Springfield, MO.......

27.3178

26.6919 44220........... Springfield, OH.......

27.8315

26.5028 44300........... State College, PA.....

28.4188

27.0040 44700........... Stockton, CA..........

38.6087

36.4711 44940........... Sumter, SC............

27.6406

26.7218 45060........... Syracuse, NY..........

31.7909

30.5763 45104........... Tacoma, WA............

35.9647

33.8969 45220........... Tallahassee, FL.......

29.0061

27.8746 45300........... Tampa-St. Petersburg-

28.9032

28.1723

Clearwater, FL. 45460........... Terre Haute, IN.......

29.4437

27.6736 45500........... Texarkana, TX-

26.4165

24.8363

Texarkana, AR. 45780........... Toledo, OH............

29.8934

28.9126 45820........... Topeka, KS............

28.5929

27.0599 45940........... Trenton-Ewing, NJ.....

34.3697

33.3207

Page 23787

46060........... Tucson, AZ............

30.4264

29.2232 46140........... Tulsa, OK.............

27.8831

26.3265 46220........... Tuscaloosa, AL........

28.0199

26.8295 46340........... Tyler, TX.............

28.6912

27.8517 46540........... Utica-Rome, NY........

28.1040

27.1057 46660........... Valdosta, GA..........

26.3052

25.6427 46700........... Vallejo-Fairfield, CA.

45.6926

44.8127 47020........... Victoria, TX..........

25.6787

25.2869 47220........... Vineland-Millville-

35.2379

33.0201

Bridgeton, NJ. 47260........... Virginia Beach-Norfolk-

28.5838

27.2923

Newport News, VA-NC. 47300........... Visalia-Porterville,

33.2020

31.5996

CA. 47380........... Waco, TX..............

28.0515

26.9091 47580........... Warner Robins, GA.....

30.5824

28.8902 47644........... Warren-Troy-Farmington

32.1363

31.0932

Hills, MI. 47894........... Washington-Arlington-

34.3840

33.3639

Alexandria, DC-VA-MD-

WV. 47940........... Waterloo-Cedar Falls,

28.0510

26.9028

IA. 48140........... Wausau, WI............

31.6785

30.5738 48260........... Weirton-Steubenville,

25.8721

24.7386

WV-OH. 48300........... Wenatchee, WA.........

30.3614

31.9688 48424........... West Palm Beach-Boca

31.1027

29.7030

Raton-Boynton Beach,

FL. 48540........... Wheeling, WV-OH.......

22.6472

21.8074 48620........... Wichita, KS...........

28.9395

27.7964 48660........... Wichita Falls, TX.....

29.5744

26.8201 48700........... Williamsport, PA......

25.8784

24.8306 48864........... Wilmington, DE-MD-NJ..

34.0940

32.8588 48900........... Wilmington, NC........

29.1370

29.0123 49020........... Winchester, VA-WV.....

31.4889

30.6457 49180........... Winston-Salem, NC.....

29.0508

28.2246 49340........... Worcester, MA.........

35.2688

34.2006 49420........... Yakima, WA............

32.0317

30.9552 49500........... Yauco, PR.............

10.8210

10.6067 49620........... York-Hanover, PA......

31.1804

29.5691 49660........... Youngstown-Warren-

28.8065

27.5854

Boardman, OH-PA. 49700........... Yuba City, CA.........

34.7445

32.8688 49740........... Yuma, AZ..............

31.9135

30.1305

\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 FY 2008. To calculate the 3-year average hourly wage for this new area, we included the hospitals' data from their previous geographic location for FY 2006 and FY 2007.

Table 3B.--FY 2009 and 3-Year* Average Hourly Wage for Rural Areas by

CBSA

*Based on the sum of the salaries and hours computed for Federal FYs 2007, 2008, and 2009

FY 2009

CBSA code

Nonurban area

average hourly 3-Year average wage

hourly wage

01.............. Alabama...............

24.6411

23.6242 02.............. Alaska................

38.4008

35.4138 03.............. Arizona...............

28.5407

27.4573 04.............. Arkansas..............

24.6204

23.3335 05.............. California............

38.6569

35.9246 06.............. Colorado..............

30.0754

28.7842 07.............. Connecticut...........

36.4301

35.6330 08.............. Delaware..............

32.6029

30.8226 10.............. Florida...............

27.8797

26.8062 11.............. Georgia...............

25.2642

24.2873 12.............. Hawaii................

36.0283

33.6508 13.............. Idaho.................

24.4380

24.1641 14.............. Illinois..............

27.1642

25.9705 15.............. Indiana...............

27.3432

26.4475 16.............. Iowa..................

28.1850

26.6791 17.............. Kansas................

25.9806

24.8089 18.............. Kentucky..............

25.2536

24.2249 19.............. Louisiana.............

24.7667

23.6881 20.............. Maine.................

27.7429

26.2711 21.............. Maryland..............

28.3407

27.4609 22.............. Massachusetts......... .............. .............. 23.............. Michigan..............

28.5656

27.6632

Page 23788

24.............. Minnesota.............

29.3894

28.3126 25.............. Mississippi...........

24.6569

23.9273 26.............. Missouri..............

26.3804

25.2174 27.............. Montana...............

27.8425

26.4700 28.............. Nebraska..............

28.0119

26.9486 29.............. Nevada................

31.6580

29.6483 30.............. New Hampshire.........

33.2526

32.8237 31.............. New Jersey \1\........ .............. .............. 32.............. New Mexico............

28.5810

27.1089 33.............. New York..............

26.7717

25.8110 34.............. North Carolina........

27.8184

26.7060 35.............. North Dakota..........

23.7299

22.7358 36.............. Ohio..................

27.6801

26.8138 37.............. Oklahoma..............

25.8341

24.3148 38.............. Oregon................

33.1220

30.9016 39.............. Pennsylvania..........

26.9119

25.8178 40.............. Puerto Rico \1\....... .............. .............. 41.............. Rhode Island \1\...... .............. .............. 42.............. South Carolina........

27.7889

26.8744 43.............. South Dakota..........

27.1581

25.8858 44.............. Tennessee.............

25.6634

24.6486 45.............. Texas.................

26.2796

25.3601 46.............. Utah..................

27.0526

25.6723 47.............. Vermont...............

32.0308

30.2935 49.............. Virginia..............

25.9700

24.9967 50.............. Washington............

32.6127

31.5030 51.............. West Virginia.........

24.6596

23.6988 52.............. Wisconsin.............

30.7058

29.7224 53.............. Wyoming...............

29.7219

28.3175

\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 and by State--FY 2009

Constituent counties are listed in Table 4E.

Wage

CBSA Code

Urban area

State

index

GAF

10180.............. Abilene, TX...... TX........

0.8408

0.8880 10380.............. Aguadilla-Isabela- PR........

0.3311

0.4691

San

Sebasti[aacute]n

, PR. 10420.............. Akron, OH........ OH........

0.8784

0.9150 10500.............. Albany, GA....... GA........

0.8770

0.9140 10580.............. Albany-

NY........

0.8833

0.9185

Schenectady-

Troy, NY. 10740.............. Albuquerque, NM.. NM........

0.9499

0.9654 10780.............. Alexandria, LA... LA........

0.8127

0.8676 10900.............. Allentown-

NJ........

1.1221

1.0821

Bethlehem-

Easton, PA-NJ. 10900.............. Allentown-

PA........

0.9675

0.9776

Bethlehem-

Easton, PA-NJ. 11020.............. Altoona, PA...... PA........

0.8342

0.8833 11100.............. Amarillo, TX..... TX........

0.8997

0.9302 11180.............. Ames, IA......... IA........

0.9417

0.9597 11260.............. Anchorage, AK.... AK........

1.1884

1.1255 11300.............. Anderson, IN..... IN........

0.8923

0.9249 11340.............. Anderson, SC..... SC........

0.9721

0.9808 11460.............. Ann Arbor, MI.... MI........

1.0444

1.0302 11500.............. Anniston-Oxford, AL........

0.8007

0.8588

AL. 11540.............. Appleton, WI..... WI........

0.9511

0.9662 11700.............. Asheville, NC.... NC........

0.9192

0.9439 12020.............. Athens-Clarke

GA........

0.9589

0.9717

County, GA. 12060.............. Atlanta-Sandy

GA........

0.9760

0.9835

Springs-

Marietta, GA. 12100.............. Atlantic City-

NJ........

1.1666

1.1113

Hammonton, NJ. 12220.............. Auburn-Opelika,

AL........

0.7647

0.8322

AL. 12260.............. Augusta-Richmond GA........

0.9604

0.9727

County, GA-SC. 12260.............. Augusta-Richmond SC........

0.9589

0.9717

County, GA-SC. 12420.............. Austin-Round

TX........

0.9521

0.9669

Rock, TX. 12540.............. Bakersfield, CA.. CA........

1.1822

1.1214 12580.............. Baltimore-Towson, MD........

0.9981

0.9987

MD. 12620.............. Bangor, ME....... ME........

1.0115

1.0079

Page 23789

12700.............. Barnstable Town, MA........

1.2672

1.1761

MA. 12940.............. Baton Rouge, LA.. LA........

0.8142

0.8687 12980.............. Battle Creek, MI. MI........

1.0039

1.0027 13020.............. Bay City, MI..... MI........

0.9472

0.9635 13140.............. Beaumont-Port

TX........

0.8595

0.9015

Arthur, TX. 13380.............. Bellingham, WA... WA........

1.1395

1.0935 13460.............. Bend, OR......... OR........

1.1043

1.0703 13644.............. Bethesda-

MD........

1.1018

1.0686

Frederick-

Gaithersburg, MD. 13740.............. Billings, MT..... MT........

0.9045

0.9336 13780.............. Binghamton, NY... NY........

0.8721

0.9105 13820.............. Birmingham-

AL........

0.8786

0.9152

Hoover, AL. 13900.............. Bismarck, ND..... ND........

0.7336

0.8088 13980.............. Blacksburg-

VA........

0.8122

0.8672

Christiansburg-

Radford, VA. 14020.............. Bloomington, IN.. IN........

0.9419

0.9598 14060.............. Bloomington-

IL........

0.9520

0.9669

Normal, IL. 14260.............. Boise City-Nampa, ID........

0.9290

0.9508

ID. 14484.............. Boston-Quincy, MA MA........

1.1994

1.1326 14500.............. Boulder, CO...... CO........

0.9994

0.9996 14540.............. Bowling Green, KY KY........

0.8344

0.8834 14600.............. Bradenton-

FL........

0.9757

0.9833

Sarasota-Venice,

FL. 14740.............. Bremerton-

WA........

1.0706

1.0478

Silverdale, WA. 14860.............. Bridgeport-

CT........

1.2591

1.1709

Stamford-

Norwalk, CT. 15180.............. Brownsville-

TX........

0.9226

0.9463

Harlingen, TX. 15260.............. Brunswick, GA.... GA........

1.0139

1.0095 15380.............. Buffalo-Niagara

NY........

0.9593

0.9719

Falls, NY. 15500.............. Burlington, NC... NC........

0.8632

0.9042 15540.............. Burlington-South VT........

0.9275

0.9498

Burlington, VT. 15764.............. Cambridge-Newton- MA........

1.1078

1.0726

Framingham, MA. 15804.............. Camden, NJ....... NJ........

1.1221

1.0821 15940.............. Canton-Massillon, OH........

0.8845

0.9194

OH. 15980.............. Cape Coral-Fort

FL........

0.9502

0.9656

Myers, FL. 16180.............. Carson City, NV.. NV........

1.0027

1.0018 16220.............. Casper, WY....... WY........

0.9618

0.9737 16300.............. Cedar Rapids, IA. IA........

0.8746

0.9123 16580.............. Champaign-Urbana, IL........

0.9353

0.9552

IL. 16620.............. Charleston, WV... WV........

0.8398

0.8873 16700.............. Charleston-North SC........

0.9231

0.9467

Charleston-

Summerville, SC. 16740.............. Charlotte-

NC........

0.9570

0.9704

Gastonia-

Concord, NC-SC. 16740.............. Charlotte-

SC........

0.9557

0.9694

Gastonia-

Concord, NC-SC. 16820.............. Charlottesville, VA........

0.9728

0.9813

VA. 16860.............. Chattanooga, TN- GA........

0.8880

0.9219

GA. 16860.............. Chattanooga, TN- TN........

0.8857

0.9202

GA. 16940.............. Cheyenne, WY..... WY........

0.9223

0.9461 16974.............. Chicago-

IL........

1.0334

1.0228

Naperville-

Joliet, IL. 17020.............. Chico, CA........ CA........

1.1822

1.1214 17140.............. Cincinnati-

IN........

0.9583

0.9713

Middletown, OH-

KY-IN. 17140.............. Cincinnati-

KY........

0.9590

0.9717

Middletown, OH-

KY-IN. 17140.............. Cincinnati-

OH........

0.9581

0.9711

Middletown, OH-

KY-IN. 17300.............. Clarksville, TN- KY........

0.8302

0.8804

KY. 17300.............. Clarksville, TN- TN........

0.8280

0.8788

KY. 17420.............. Cleveland, TN.... TN........

0.8137

0.8683 17460.............. Cleveland-Elyria- OH........

0.9266

0.9491

Mentor, OH. 17660.............. Coeur d'Alene, ID ID........

0.9185

0.9434 17780.............. College Station- TX........

0.9193

0.9440

Bryan, TX. 17820.............. Colorado Springs, CO........

0.9738

0.9820

CO. 17860.............. Columbia, MO..... MO........

0.8470

0.8925 17900.............. Columbia, SC..... SC........

0.8984

0.9293 17980.............. Columbus, GA-AL.. AL........

0.9061

0.9347 17980.............. Columbus, GA-AL.. GA........

0.9061

0.9347 18020.............. Columbus, IN..... IN........

0.9852

0.9898 18140.............. Columbus, OH..... OH........

0.9869

0.9910 18580.............. Corpus Christi,

TX........

0.8494

0.8942

TX. 18700.............. Corvallis, OR.... OR........

1.1076

1.0725 19060.............. Cumberland, MD-WV MD........

0.8795

0.9158 19060.............. Cumberland, MD-WV WV........

0.7635

0.8313 19124.............. Dallas-Plano-

TX........

0.9852

0.9898

Irving, TX. 19140.............. Dalton, GA....... GA........

0.8499

0.8946 19180.............. Danville, IL..... IL........

0.9711

0.9801 19260.............. Danville, VA..... VA........

0.8483

0.8935

Page 23790

19340.............. Davenport-Moline- IL........

0.8606

0.9023

Rock Island, IA-

IL. 19340.............. Davenport-Moline- IA........

0.8709

0.9097

Rock Island, IA-

IL. 19380.............. Dayton, OH....... OH........

0.9321

0.9530 19460.............. Decatur, AL...... AL........

0.7714

0.8372 19500.............. Decatur, IL...... IL........

0.8428

0.8895 19660.............. Deltona-Daytona

FL........

0.8814

0.9172

Beach-Ormond

Beach, FL. 19740.............. Denver-Aurora, CO CO........

1.0561

1.0381 19780.............. Des Moines-West

IA........

0.9460

0.9627

Des Moines, IA. 19804.............. Detroit-Livonia- MI........

1.0052

1.0036

Dearborn, MI. 20020.............. Dothan, AL....... AL........

0.7718

0.8375 20100.............. Dover, DE........ DE........

1.0669

1.0453 20220.............. Dubuque, IA...... IA........

0.8709

0.9097 20260.............. Duluth, MN-WI.... MN........

1.0519

1.0353 20260.............. Duluth, MN-WI.... WI........

1.0499

1.0339 20500.............. Durham, NC....... NC........

0.9693

0.9789 20740.............. Eau Claire, WI... WI........

0.9599

0.9724 20764.............. Edison-New

NJ........

1.1221

1.0821

Brunswick, NJ. 20940.............. El Centro, CA.... CA........

1.1822

1.1214 21060.............. Elizabethtown, KY KY........

0.8466

0.8922 21140.............. Elkhart-Goshen,

IN........

0.9547

0.9688

IN. 21300.............. Elmira, NY....... NY........

0.8347

0.8836 21340.............. El Paso, TX...... TX........

0.8867

0.9210 21500.............. Erie, PA......... PA........

0.8708

0.9096 21660.............. Eugene-

OR........

1.1157

1.0779

Springfield, OR. 21780.............. Evansville, IN-KY IN........

0.8525

0.8965 21780.............. Evansville, IN-KY KY........

0.8531

0.8969 21820.............. Fairbanks, AK.... AK........

1.1884

1.1255 21940.............. Fajardo, PR...... PR........

0.4067

0.5400 22020.............. Fargo, ND-MN..... MN........

0.9120

0.9389 22020.............. Fargo, ND-MN..... ND........

0.8212

0.8738 22140.............. Farmington, NM... NM........

0.8858

0.9203 22180.............. Fayetteville, NC. NC........

0.9923

0.9947 22220.............. Fayetteville-

AR........

0.9131

0.9396

Springdale-

Rogers, AR-MO. 22220.............. Fayetteville-

MO........

0.9123

0.9391

Springdale-

Rogers, AR-MO. 22380.............. Flagstaff, AZ.... AZ........

1.1652

1.1104 22420.............. Flint, MI........ MI........

1.1258

1.0845 22500.............. Florence, SC..... SC........

0.8609

0.9025 22520.............. Florence-Muscle

AL........

0.7883

0.8497

Shoals, AL. 22540.............. Fond du Lac, WI.. WI........

0.9523

0.9671 22660.............. Fort Collins-

CO........

0.9581

0.9711

Loveland, CO. 22744.............. Fort Lauderdale- FL........

1.0025

1.0017

Pompano Beach-

Deerfield Beach,

FL. 22900.............. Fort Smith, AR-OK AR........

0.7843

0.8467 22900.............. Fort Smith, AR-OK OK........

0.8016

0.8595 23020.............. Fort Walton Beach- FL........

0.8703

0.9093

Crestview-

Destin, FL. 23060.............. Fort Wayne, IN... IN........

0.9004

0.9307 23104.............. Fort Worth-

TX........

0.9684

0.9783

Arlington, TX. 23420.............. Fresno, CA....... CA........

1.1822

1.1214 23460.............. Gadsden, AL...... AL........

0.7991

0.8576 23540.............. Gainesville, FL.. FL........

0.9427

0.9604 23580.............. Gainesville, GA.. GA........

0.9321

0.9530 23844.............. Gary, IN......... IN........

0.9320

0.9529 24020.............. Glens Falls, NY.. NY........

0.8780

0.9148 24140.............. Goldsboro, NC.... NC........

0.9159

0.9416 24220.............. Grand Forks, ND- MN........

0.9120

0.9389

MN. 24220.............. Grand Forks, ND- ND........

0.7709

0.8368

MN. 24300.............. Grand Junction,

CO........

0.9925

0.9949

CO. 24340.............. Grand Rapids-

MI........

0.9305

0.9519

Wyoming, MI. 24500.............. Great Falls, MT.. MT........

0.8679

0.9075 24540.............. Greeley, CO...... CO........

1.0028

1.0019 24580.............. Green Bay, WI.... WI........

0.9511

0.9662 24660.............. Greensboro-High

NC........

0.9141

0.9403

Point, NC. 24780.............. Greenville, NC... NC........

0.9346

0.9547 24860.............. Greenville-

SC........

0.9605

0.9728

Mauldin-Easley,

SC. 25020.............. Guayama, PR...... PR........

0.3137

0.4521 25060.............. Gulfport-Biloxi, MS........

0.8898

0.9232

MS. 25180.............. Hagerstown-

MD........

0.9273

0.9496

Martinsburg, MD-

WV. 25180.............. Hagerstown-

WV........

0.9253

0.9482

Martinsburg, MD-

WV. 25260.............. Hanford-Corcoran, CA........

1.1822

1.1214

CA. 25420.............. Harrisburg-

PA........

0.9185

0.9434

Carlisle, PA.

Page 23791

25500.............. Harrisonburg, VA. VA........

0.8956

0.9273 25540.............. Hartford-West

CT........

1.1897

1.1263

Hartford-East

Hartford, CT. 25620.............. Hattiesburg, MS.. MS........

0.7653

0.8326 25860.............. Hickory-Lenoir-

NC........

0.8946

0.9266

Morganton, NC. 26100.............. Holland-Grand

MI........

0.9101

0.9375

Haven, MI. 26180.............. Honolulu, HI..... HI........

1.1608

1.1075 26300.............. Hot Springs, AR.. AR........

0.9146

0.9407 26380.............. Houma-Bayou Cane- LA........

0.7870

0.8487

Thibodaux, LA. 26420.............. Houston-Sugar

TX........

0.9925

0.9949

Land-Baytown, TX. 26580.............. Huntington-

KY........

0.9127

0.9394

Ashland, WV-KY-

OH. 26580.............. Huntington-

OH........

0.9118

0.9387

Ashland, WV-KY-

OH. 26580.............. Huntington-

WV........

0.9107

0.9380

Ashland, WV-KY-

OH. 26620.............. Huntsville, AL... AL........

0.8987

0.9295 26820.............. Idaho Falls, ID.. ID........

0.9327

0.9534 26900.............. Indianapolis-

IN........

0.9827

0.9881

Carmel, IN. 26980.............. Iowa City, IA.... IA........

0.9337

0.9541 27060.............. Ithaca, NY....... NY........

0.9561

0.9697 27100.............. Jackson, MI...... MI........

0.9477

0.9639 27140.............. Jackson, MS...... MS........

0.8095

0.8653 27180.............. Jackson, TN...... TN........

0.8452

0.8912 27260.............. Jacksonville, FL. FL........

0.9092

0.9369 27340.............. Jacksonville, NC. NC........

0.8632

0.9042 27500.............. Janesville, WI... WI........

0.9824

0.9879 27620.............. Jefferson City,

MO........

0.9038

0.9331

MO. 27740.............. Johnson City, TN. TN........

0.7999

0.8582 27780.............. Johnstown, PA.... PA........

0.8342

0.8833 27860.............. Jonesboro, AR.... AR........

0.8291

0.8796 27900.............. Joplin, MO....... MO........

0.9704

0.9796 28020.............. Kalamazoo-

MI........

1.0910

1.0615

Portage, MI. 28100.............. Kankakee-Bradley, IL........

1.2018

1.1341

IL. 28140.............. Kansas City, MO- KS........

0.9453

0.9622

KS. 28140.............. Kansas City, MO- MO........

0.9444

0.9616

KS. 28420.............. Kennewick-Pasco- WA........

1.0164

1.0112

Richland, WA. 28660.............. Killeen-Temple-

TX........

0.8855

0.9201

Fort Hood, TX. 28700.............. Kingsport-Bristol- TN........

0.7957

0.8551

Bristol, TN-VA. 28700.............. Kingsport-Bristol- VA........

0.8061

0.8628

Bristol, TN-VA. 28740.............. Kingston, NY..... NY........

0.9433

0.9608 28940.............. Knoxville, TN.... TN........

0.7957

0.8551 29020.............. Kokomo, IN....... IN........

0.9254

0.9483 29100.............. La Crosse, WI-MN. MN........

0.9815

0.9873 29100.............. La Crosse, WI-MN. WI........

0.9796

0.9860 29140.............. Lafayette, IN.... IN........

0.8960

0.9276 29180.............. Lafayette, LA.... LA........

0.8438

0.8902 29340.............. Lake Charles, LA. LA........

0.7682

0.8348 29404.............. Lake County-

IL........

1.0376

1.0256

Kenosha County,

IL-WI. 29404.............. Lake County-

WI........

1.0357

1.0243

Kenosha County,

IL-WI. 29420.............. Lake Havasu City- AZ........

0.9817

0.9874

Kingman, AZ. 29460.............. Lakeland-Winter

FL........

0.8715

0.9101

Haven, FL. 29540.............. Lancaster, PA.... PA........

0.9799

0.9862 29620.............. Lansing-East

MI........

0.9899

0.9931

Lansing, MI. 29700.............. Laredo, TX....... TX........

0.8816

0.9173 29740.............. Las Cruces, NM... NM........

0.8858

0.9203 29820.............. Las Vegas-

NV........

1.1666

1.1113

Paradise, NV. 29940.............. Lawrence, KS..... KS........

0.8317

0.8814 30020.............. Lawton, OK....... OK........

0.8630

0.9040 30140.............. Lebanon, PA...... PA........

0.8991

0.9298 30300.............. Lewiston, ID-WA.. ID........

0.9271

0.9495 30300.............. Lewiston, ID-WA.. WA........

1.0164

1.0112 30340.............. Lewiston-Auburn, ME........

0.9326

0.9533

ME. 30460.............. Lexington-

KY........

0.8950

0.9268

Fayette, KY. 30620.............. Lima, OH......... OH........

0.9299

0.9514 30700.............. Lincoln, NE...... NE........

0.9620

0.9738 30780.............. Little Rock-North AR........

0.8754

0.9129

Little Rock-

Conway, AR. 30860.............. Logan, UT-ID..... ID........

0.8827

0.9181 30860.............. Logan, UT-ID..... UT........

0.8827

0.9181 30980.............. Longview, TX..... TX........

0.8666

0.9066 31020.............. Longview, WA..... WA........

1.1434

1.0961 31084.............. Los Angeles-Long CA........

1.1916

1.1275

Beach-Glendale,

CA. 31140.............. Louisville-

IN........

0.9238

0.9472

Jefferson

County, KY-IN.

Page 23792

31140.............. Louisville-

KY........

0.9245

0.9477

Jefferson

County, KY-IN. 31180.............. Lubbock, TX...... TX........

0.8712

0.9099 31340.............. Lynchburg, VA.... VA........

0.8646

0.9052 31420.............. Macon, GA........ GA........

0.9815

0.9873 31460.............. Madera, CA....... CA........

1.1822

1.1214 31540.............. Madison, WI...... WI........

1.1232

1.0828 31700.............. Manchester-

NH........

1.0807

1.0546

Nashua, NH. 31900.............. Mansfield, OH.... OH........

0.9295

0.9512 32420.............. Mayag[uuml]ez, PR PR........

0.3896

0.5244 32580.............. McAllen-Edinburg- TX........

0.9118

0.9387

Mission, TX. 32780.............. Medford, OR...... OR........

1.0298

1.0203 32820.............. Memphis, TN-MS-AR AR........

0.9329

0.9535 32820.............. Memphis, TN-MS-AR MS........

0.9329

0.9535 32820.............. Memphis, TN-MS-AR TN........

0.9305

0.9519 32900.............. Merced, CA....... CA........

1.1969

1.1310 33124.............. Miami-Miami Beach- FL........

0.9865

0.9907

Kendall, FL. 33140.............. Michigan City-La IN........

0.9041

0.9333

Porte, IN. 33260.............. Midland, TX...... TX........

0.9562

0.9698 33340.............. Milwaukee-

WI........

1.0182

1.0124

Waukesha-West

Allis, WI. 33460.............. Minneapolis-St.

MN........

1.0997

1.0672

Paul-

Bloomington, MN-

WI. 33460.............. Minneapolis-St.

WI........

1.0976

1.0659

Paul-

Bloomington, MN-

WI. 33540.............. Missoula, MT..... MT........

0.8909

0.9239 33660.............. Mobile, AL....... AL........

0.7809

0.8442 33700.............. Modesto, CA...... CA........

1.1963

1.1306 33740.............. Monroe, LA....... LA........

0.7961

0.8554 33780.............. Monroe, MI....... MI........

0.8918

0.9246 33860.............. Montgomery, AL... AL........

0.8192

0.8723 34060.............. Morgantown, WV... WV........

0.8631

0.9041 34100.............. Morristown, TN... TN........

0.7957

0.8551 34580.............. Mount Vernon-

WA........

1.0164

1.0112

Anacortes, WA. 34620.............. Muncie, IN....... IN........

0.8479

0.8932 34740.............. Muskegon-Norton

MI........

1.0227

1.0155

Shores, MI. 34820.............. Myrtle Beach-

SC........

0.8683

0.9078

North Myrtle

Beach-Conway, SC. 34900.............. Napa, CA......... CA........

1.3847

1.2497 34940.............. Naples-Marco

FL........

0.9820

0.9876

Island, FL. 34980.............. Nashville-

TN........

0.9445

0.9617

Davidson-

Murfreesboro-

Franklin, TN. 35004.............. Nassau-Suffolk,

NY........

1.2729

1.1797

NY. 35084.............. Newark-Union, NJ- NJ........

1.1440

1.0965

PA. 35084.............. Newark-Union, NJ- PA........

1.1574

1.1053

PA. 35300.............. New Haven-

CT........

1.1897

1.1263

Milford, CT. 35380.............. New Orleans-

LA........

0.9140

0.9403

Metairie-Kenner,

LA. 35644.............. New York-White

NJ........

1.2878

1.1891

Plains-Wayne, NY-

NJ. 35644.............. New York-White

NY........

1.3043

1.1995

Plains-Wayne, NY-

NJ. 35660.............. Niles-Benton

MI........

0.9095

0.9371

Harbor, MI. 35980.............. Norwich-New

CT........

1.1897

1.1263

London, CT. 36084.............. Oakland-Fremont- CA........

1.5278

1.3367

Hayward, CA. 36100.............. Ocala, FL........ FL........

0.8633

0.9042 36140.............. Ocean City, NJ... NJ........

1.1484

1.0994 36220.............. Odessa, TX....... TX........

0.9425

0.9603 36260.............. Ogden-Clearfield, UT........

0.9243

0.9475

UT. 36420.............. Oklahoma City, OK OK........

0.8686

0.9080 36500.............. Olympia, WA...... WA........

1.1462

1.0979 36540.............. Omaha-Council

IA........

0.9360

0.9557

Bluffs, NE-IA. 36540.............. Omaha-Council

NE........

0.9400

0.9585

Bluffs, NE-IA. 36740.............. Orlando-

FL........

0.9189

0.9437

Kissimmee, FL. 36780.............. Oshkosh-Neenah,

WI........

0.9511

0.9662

WI. 36980.............. Owensboro, KY.... KY........

0.8764

0.9136 37100.............. Oxnard-Thousand

CA........

1.1822

1.1214

Oaks-Ventura, CA. 37340.............. Palm Bay-

FL........

0.9401

0.9586

Melbourne-

Titusville, FL. 37380.............. Palm Coast, FL... FL........

0.8769

0.9140 37460.............. Panama City-Lynn FL........

0.8633

0.9042

Haven, FL. 37620.............. Parkersburg-

OH........

0.8582

0.9006

Marietta-Vienna,

WV-OH. 37620.............. Parkersburg-

WV........

0.8028

0.8603

Marietta-Vienna,

WV-OH. 37700.............. Pascagoula, MS... MS........

0.8030

0.8605 37764.............. Peabody, MA...... MA........

1.0744

1.0504 37860.............. Pensacola-Ferry

FL........

0.8633

0.9042

Pass-Brent, FL. 37900.............. Peoria, IL....... IL........

0.9043

0.9334 37964.............. Philadelphia, PA. PA........

1.0992

1.0669 38060.............. Phoenix-Mesa-

AZ........

1.0271

1.0185

Scottsdale, AZ.

Page 23793

38220.............. Pine Bluff, AR... AR........

0.8274

0.8783 38300.............. Pittsburgh, PA... PA........

0.8579

0.9004 38340.............. Pittsfield, MA... MA........

1.0445

1.0303 38540.............. Pocatello, ID.... ID........

0.9103

0.9377 38660.............. Ponce, PR........ PR........

0.4122

0.5450 38860.............. Portland-South

ME........

0.9927

0.9950

Portland-

Biddeford, ME. 38900.............. Portland-

OR........

1.1204

1.0810

Vancouver-

Beaverton, OR-WA. 38900.............. Portland-

WA........

1.1186

1.0798

Vancouver-

Beaverton, OR-WA. 38940.............. Port St. Lucie,

FL........

0.9905

0.9935

FL. 39100.............. Poughkeepsie-

NY........

1.0944

1.0637

Newburgh-

Middletown, NY. 39140.............. Prescott, AZ..... AZ........

1.0198

1.0135 39300.............. Providence-New

MA........

1.0669

1.0453

Bedford-Fall

River, RI-MA. 39300.............. Providence-New

RI........

1.0669

1.0453

Bedford-Fall

River, RI-MA. 39340.............. Provo-Orem, UT... UT........

0.9052

0.9341 39380.............. Pueblo, CO....... CO........

0.9303

0.9517 39460.............. Punta Gorda, FL.. FL........

0.9286

0.9505 39540.............. Racine, WI....... WI........

0.9511

0.9662 39580.............. Raleigh-Cary, NC. NC........

0.9685

0.9783 39660.............. Rapid City, SD... SD........

0.9502

0.9656 39740.............. Reading, PA...... PA........

0.9327

0.9534 39820.............. Redding, CA...... CA........

1.2730

1.1797 39900.............. Reno-Sparks, NV.. NV........

1.0476

1.0324 40060.............. Richmond, VA..... VA........

0.9203

0.9447 40140.............. Riverside-San

CA........

1.1822

1.1214

Bernardino-

Ontario, CA. 40220.............. Roanoke, VA...... VA........

0.8889

0.9225 40340.............. Rochester, MN.... MN........

1.0982

1.0662 40380.............. Rochester, NY.... NY........

0.8911

0.9241 40420.............. Rockford, IL..... IL........

0.9862

0.9905 40484.............. Rockingham County- NH........

1.0807

1.0546

Strafford

County, NH. 40580.............. Rocky Mount, NC.. NC........

0.9068

0.9352 40660.............. Rome, GA......... GA........

0.9699

0.9793 40900.............. Sacramento--Arden- CA........

1.2827

1.1859

Arcade--Rosevill e, CA. 40980.............. Saginaw-Saginaw

MI........

0.9034

0.9328

Township North,

MI. 41060.............. St. Cloud, MN.... MN........

1.1549

1.1036 41100.............. St. George, UT... UT........

0.9228

0.9465 41140.............. St. Joseph, MO-KS KS........

1.0481

1.0327 41140.............. St. Joseph, MO-KS MO........

1.0472

1.0321 41180.............. St. Louis, MO-IL. IL........

0.8993

0.9299 41180.............. St. Louis, MO-IL. MO........

0.8986

0.9294 41420.............. Salem, OR........ OR........

1.0650

1.0441 41500.............. Salinas, CA...... CA........

1.4671

1.3001 41540.............. Salisbury, MD.... MD........

0.9194

0.9441 41620.............. Salt Lake City,

UT........

0.9271

0.9495

UT. 41660.............. San Angelo, TX... TX........

0.8600

0.9019 41700.............. San Antonio, TX.. TX........

0.8949

0.9268 41740.............. San Diego-

CA........

1.1822

1.1214

Carlsbad-San

Marcos, CA. 41780.............. Sandusky, OH..... OH........

0.8828

0.9182 41884.............. San Francisco-San CA........

1.4879

1.3127

Mateo-Redwood

City, CA. 41900.............. San Germ[aacute]n- PR........

0.4648

0.5918

Cabo Rojo, PR. 41940.............. San Jose-

CA........

1.5758

1.3654

Sunnyvale-Santa

Clara, CA. 41980.............. San Juan-Caguas- PR........

0.4404

0.5703

Guaynabo, PR. 42020.............. San Luis Obispo- CA........

1.1822

1.1214

Paso Robles, CA. 42044.............. Santa Ana-Anaheim- CA........

1.1822

1.1214

Irvine, CA. 42060.............. Santa Barbara-

CA........

1.1822

1.1214

Santa Maria-

Goleta, CA. 42100.............. Santa Cruz-

CA........

1.5766

1.3658

Watsonville, CA. 42140.............. Santa Fe, NM..... NM........

1.0587

1.0398 42220.............. Santa Rosa-

CA........

1.5052

1.3232

Petaluma, CA. 42340.............. Savannah, GA..... GA........

0.8943

0.9264 42540.............. Scranton--Wilkes- PA........

0.8342

0.8833

Barre, PA. 42644.............. Seattle-Bellevue- WA........

1.1562

1.1045

Everett, WA. 42680.............. Sebastian-Vero

FL........

0.9519

0.9668

Beach, FL. 43100.............. Sheboygan, WI.... WI........

0.9511

0.9662 43300.............. Sherman-Denison, TX........

0.9291

0.9509

TX. 43340.............. Shreveport-

LA........

0.8547

0.8981

Bossier City, LA. 43580.............. Sioux City, IA-NE- IA........

0.8745

0.9123

SD. 43580.............. Sioux City, IA-NE- NE........

0.8783

0.9150

SD. 43580.............. Sioux City, IA-NE- SD........

0.8783

0.9150

SD. 43620.............. Sioux Falls, SD.. SD........

0.9379

0.9570 43780.............. South Bend-

IN........

0.9644

0.9755

Mishawaka, IN-MI.

Page 23794

43780.............. South Bend-

MI........

0.9651

0.9760

Mishawaka, IN-MI. 43900.............. Spartanburg, SC.. SC........

0.9017

0.9316 44060.............. Spokane, WA...... WA........

1.0514

1.0349 44100.............. Springfield, IL.. IL........

0.9133

0.9398 44140.............. Springfield, MA.. MA........

1.0343

1.0234 44180.............. Springfield, MO.. MO........

0.8470

0.8925 44220.............. Springfield, OH.. OH........

0.8629

0.9040 44300.............. State College, PA PA........

0.8810

0.9169 44700.............. Stockton, CA..... CA........

1.1822

1.1214 44940.............. Sumter, SC....... SC........

0.8609

0.9025 45060.............. Syracuse, NY..... NY........

0.9865

0.9907 45104.............. Tacoma, WA....... WA........

1.1137

1.0765 45220.............. Tallahassee, FL.. FL........

0.8981

0.9290 45300.............. Tampa-St.

FL........

0.8993

0.9299

Petersburg-

Clearwater, FL. 45460.............. Terre Haute, IN.. IN........

0.9130

0.9396 45500.............. Texarkana, TX-

AR........

0.8197

0.8727

Texarkana, AR. 45500.............. Texarkana, TX-

TX........

0.8195

0.8726

Texarkana, AR. 45780.............. Toledo, OH....... OH........

0.9267

0.9492 45820.............. Topeka, KS....... KS........

0.8873

0.9214 45940.............. Trenton-Ewing, NJ NJ........

1.1221

1.0821 46060.............. Tucson, AZ....... AZ........

0.9442

0.9614 46140.............. Tulsa, OK........ OK........

0.8652

0.9056 46220.............. Tuscaloosa, AL... AL........

0.8695

0.9087 46340.............. Tyler, TX........ TX........

0.8901

0.9234 46540.............. Utica-Rome, NY... NY........

0.8721

0.9105 46660.............. Valdosta, GA..... GA........

0.8163

0.8702 46700.............. Vallejo-

CA........

1.3974

1.2575

Fairfield, CA. 47020.............. Victoria, TX..... TX........

0.8153

0.8695 47220.............. Vineland-

NJ........

1.1221

1.0821

Millville-

Bridgeton, NJ. 47260.............. Virginia Beach-

NC........

0.8868

0.9210

Norfolk-Newport

News, VA. 47260.............. Virginia Beach-

VA........

0.8869

0.9211

Norfolk-Newport

News, VA. 47300.............. Visalia-

CA........

1.1822

1.1214

Porterville, CA. 47380.............. Waco, TX......... TX........

0.8703

0.9093 47580.............. Warner Robins, GA GA........

0.9490

0.9648 47644.............. Warren-Troy-

MI........

0.9972

0.9981

Farmington-

Hills, MI. 47894.............. Washington-

DC........

1.0670

1.0454

Arlington-

Alexandria, DC-

VA-MD-WV. 47894.............. Washington-

MD........

1.0670

1.0454

Arlington-

Alexandria DC-VA-

MD-WV. 47894.............. Washington-

VA........

1.0669

1.0453

Arlington-

Alexandria DC-VA-

MD-WV. 47894.............. Washington-

WV........

1.0647

1.0439

Arlington-

Alexandria DC-VA-

MD-WV. 47940.............. Waterloo-Cedar

IA........

0.9248

0.9479

Falls, IA. 48140.............. Wausau, WI....... WI........

0.9823

0.9878 48260.............. Weirton-

OH........

0.8582

0.9006

Steubenville, WV-

OH. 48260.............. Weirton-

WV........

0.8011

0.8591

Steubenville, WV-

OH. 48300.............. Wenatchee, WA.... WA........

1.0164

1.0112 48424.............. West Palm Beach- FL........

0.9631

0.9746

Boca Raton-

Boynton Beach,

FL. 48540.............. Wheeling, WV-OH.. OH........

0.8582

0.9006 48540.............. Wheeling, WV-OH.. WV........

0.7635

0.8313 48620.............. Wichita, KS...... KS........

0.8980

0.9290 48660.............. Wichita Falls, TX TX........

0.9175

0.9427 48700.............. Williamsport, PA. PA........

0.8342

0.8833 48864.............. Wilmington, DE-MD- DE........

1.0645

1.0437

NJ. 48864.............. Wilmington, DE-MD- MD........

1.0645

1.0437

NJ. 48864.............. Wilmington, DE-MD- NJ........

1.1221

1.0821

NJ. 48900.............. Wilmington, NC... NC........

0.9087

0.9365 49020.............. Winchester, VA-WV VA........

0.9771

0.9843 49020.............. Winchester, VA-WV WV........

0.9751

0.9829 49180.............. Winston-Salem, NC NC........

0.9096

0.9372 49340.............. Worcester, MA.... MA........

1.0945

1.0638 49420.............. Yakima, WA....... WA........

1.0164

1.0112 49500.............. Yauco, PR........ PR........

0.3358

0.4737 49620.............. York-Hanover, PA. PA........

0.9666

0.9770 49660.............. Youngstown-Warren- OH........

0.8931

0.9255

Boardman, OH-PA. 49660.............. Youngstown-Warren- PA........

0.8930

0.9254

Boardman, OH-PA. 49700.............. Yuba City, CA.... CA........

1.1822

1.1214 49740.............. Yuma, AZ......... AZ........

0.9903

0.9933

Page 23795

Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for

Rural Areas by CBSA and by State--FY 2009

CBSA code

Rural area

State

Wage index

GAF

01........... Alabama........ AL......

0.7647

0.8322 02........... Alaska......... AK......

1.1884

1.1255 03........... Arizona........ AZ......

0.8857

0.9202 04........... Arkansas....... AR......

0.7641

0.8317 05........... California..... CA......

1.1822

1.1214 06........... Colorado....... CO......

0.9303

0.9517 07........... Connecticut.... CT......

1.1897

1.1263 08........... Delaware....... DE......

1.0252

1.0172 10........... Florida........ FL......

0.8633

0.9042 11........... Georgia........ GA......

0.7840

0.8465 12........... Hawaii......... HI......

1.1219

1.0820 13........... Idaho.......... ID......

0.7597

0.8284 14........... Illinois....... IL......

0.8428

0.8895 15........... Indiana........ IN......

0.8479

0.8932 16........... Iowa........... IA......

0.8709

0.9097 17........... Kansas......... KS......

0.8086

0.8646 18........... Kentucky....... KY......

0.7837

0.8463 19........... Louisiana...... LA......

0.7682

0.8348 20........... Maine.......... ME......

0.8609

0.9025 21........... Maryland....... MD......

0.8795

0.9158 22........... Massachusetts.. MA......

1.0199

1.0136 23........... Michigan....... MI......

0.8864

0.9207 24........... Minnesota...... MN......

0.9120

0.9389 25........... Mississippi.... MS......

0.7653

0.8326 26........... Missouri....... MO......

0.8470

0.8925 27........... Montana........ MT......

0.8640

0.9047 28........... Nebraska....... NE......

0.8761

0.9134 29........... Nevada......... NV......

0.9824

0.9879 30........... New Hampshire.. NH......

1.0807

1.0546 31........... New Jersey \1\. NJ......

1.1221

1.0821 32........... New Mexico..... NM......

0.8858

0.9203 33........... New York....... NY......

0.8308

0.8808 34........... North Carolina. NC......

0.8632

0.9042 35........... North Dakota... ND......

0.7336

0.8088 36........... Ohio........... OH......

0.8582

0.9006 37........... Oklahoma....... OK......

0.8016

0.8595 38........... Oregon......... OR......

1.0298

1.0203 39........... Pennsylvania... PA......

0.8342

0.8833 40........... Puerto Rico \1\ PR...... .............. .............. 41........... Rhode Island

RI...... .............. ..............

\1\. 42........... South Carolina. SC......

0.8609

0.9025 43........... South Dakota... SD......

0.8428

0.8895 44........... Tennessee...... TN......

0.7957

0.8551 45........... Texas.......... TX......

0.8153

0.8695 46........... Utah........... UT......

0.8395

0.8871 47........... Vermont........ VT......

0.9275

0.9498 49........... Virginia....... VA......

0.8061

0.8628 50........... Washington..... WA......

1.0164

1.0112 51........... West Virginia.. WV......

0.7635

0.8313 52........... Wisconsin...... WI......

0.9511

0.9662 53........... Wyoming........ WY......

0.9223

0.9461

\1\ All counties in the State or Territory are classified as urban. The

New Jersey floor is imputed as specified in Sec. 412.64(h)(4) and discussed in the FY 2005 IPPS final rule (69 FR 49109) and in section

III.B.2 of the preamble of this proposed rule.

Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA and by State--FY 2009

CBSA code

Area

State

Wage index

GAF

10420.................... Akron, OH....................... OH.................

0.8784

0.9150 10500.................... Albany, GA...................... AL.................

0.8397

0.8872 10500.................... Albany, GA...................... GA.................

0.8397

0.8872 10580.................... Albany-Schenectady-Troy, NY..... NY.................

0.8833

0.9185 10740.................... Albuquerque, NM................. NM.................

0.9295

0.9512 10780.................... Alexandria, LA.................. LA.................

0.8127

0.8676 10900.................... Allentown-Bethlehem-Easton, PA- PA.................

0.9675

0.9776

NJ. 11100.................... Amarillo, TX.................... KS.................

0.8885

0.9222 11100.................... Amarillo, TX.................... TX.................

0.8883

0.9221

Page 23796

11180.................... Ames, IA........................ IA.................

0.8881

0.9219 11260.................... Anchorage, AK................... AK.................

1.1884

1.1255 11460.................... Ann Arbor, MI................... MI.................

1.0113

1.0077 12060.................... Atlanta-Sandy Springs-Marietta, AL.................

0.9760

0.9835

GA. 12060.................... Atlanta-Sandy Springs-Marietta, GA.................

0.9760

0.9835

GA. 12420.................... Austin-Round Rock, TX........... TX.................

0.9521

0.9669 12620.................... Bangor, ME...................... ME.................

1.0115

1.0079 12940.................... Baton Rouge, LA................. MS.................

0.8146

0.8690 13020.................... Bay City, MI.................... MI.................

0.9472

0.9635 13644.................... Bethesda-Frederick-Gaithersburg, DC.................

1.1018

1.0686

MD. 13644.................... Bethesda-Frederick-Gaithersburg, PA.................

1.1006

1.0678

MD. 13644.................... Bethesda-Frederick-Gaithersburg, VA.................

1.1017

1.0686

MD. 13780.................... Binghamton, NY.................. PA.................

0.8560

0.8990 13820.................... Birmingham-Hoover, AL........... AL.................

0.8786

0.9152 13900.................... Bismarck, ND.................... ND.................

0.7336

0.8088 13980.................... Blacksburg-Christiansburg-

WV.................

0.7795

0.8432

Radford, VA. 14020.................... Bloomington, IN................. IN.................

0.8791

0.9155 14260.................... Boise City-Nampa, ID............ ID.................

0.9100

0.9375 14260.................... Boise City-Nampa, ID............ NV.................

0.9824

0.9879 14484.................... Boston-Quincy, MA............... MA.................

1.1338

1.0898 14484.................... Boston-Quincy, MA............... RI.................

1.1338

1.0898 14600.................... Bradenton-Sarasota-Venice, FL... FL.................

0.9648

0.9758 14740.................... Bremerton-Silverdale, WA........ WA.................

1.0576

1.0391 14860.................... Bridgeport-Stamford-Norwalk, CT. NY.................

1.2694

1.1775 15380.................... Buffalo-Niagara Falls, NY....... NY.................

0.9593

0.9719 15540.................... Burlington-South Burlington, VT. NY.................

0.9216

0.9456 15764.................... Cambridge-Newton-Framingham, MA. NH.................

1.0807

1.0546 16180.................... Carson City, NV................. NV.................

0.9837

0.9888 16220.................... Casper, WY...................... SD.................

0.9618

0.9737 16580.................... Champaign-Urbana, IL............ IL.................

0.8840

0.9190 16620.................... Charleston, WV.................. WV.................

0.8398

0.8873 16700.................... Charleston-North Charleston-

SC.................

0.9231

0.9467

Summerville, SC. 16740.................... Charlotte-Gastonia-Concord, NC- NC.................

0.9570

0.9704

SC. 16740.................... Charlotte-Gastonia-Concord, NC- SC.................

0.9557

0.9694

SC. 16820.................... Charlottesville, VA............. VA.................

0.9449

0.9619 16860.................... Chattanooga, TN-GA.............. AL.................

0.8740

0.9119 16860.................... Chattanooga, TN-GA.............. GA.................

0.8740

0.9119 16860.................... Chattanooga, TN-GA.............. TN.................

0.8717

0.9103 16974.................... Chicago-Naperville-Joliet, IL... IL.................

1.0334

1.0228 16974.................... Chicago-Naperville-Joliet, IL... IN.................

1.0328

1.0223 16974.................... Chicago-Naperville-Joliet, IL... WI.................

1.0315

1.0215 17140.................... Cincinnati-Middletown, OH-KY-IN. IN.................

0.9583

0.9713 17140.................... Cincinnati-Middletown, OH-KY-IN. OH.................

0.9581

0.9711 17300.................... Clarksville, TN-KY.............. KY.................

0.8302

0.8804 17460.................... Cleveland-Elyria-Mentor, OH..... OH.................

0.9266

0.9491 17660.................... Coeur d'Alene, ID............... MT.................

0.8992

0.9298 17820.................... Colorado Springs, CO............ CO.................

0.9738

0.9820 17860.................... Columbia, MO.................... MO.................

0.8470

0.8925 17900.................... Columbia, SC.................... SC.................

0.8984

0.9293 17980.................... Columbus, GA-AL................. AL.................

0.8495

0.8943 17980.................... Columbus, GA-AL................. GA.................

0.8495

0.8943 18140.................... Columbus, OH.................... OH.................

0.9657

0.9764 18700.................... Corvallis, OR................... OR.................

1.0572

1.0388 19124.................... Dallas-Plano-Irving, TX......... TX.................

0.9852

0.9898 19340.................... Davenport-Moline-Rock Island, IA- IL.................

0.8606

0.9023

IL. 19340.................... Davenport-Moline-Rock Island, IA- IA.................

0.8709

0.9097

IL. 19380.................... Dayton, OH...................... OH.................

0.9321

0.9530 19740.................... Denver-Aurora, CO............... CO.................

1.0409

1.0278 19804.................... Detroit-Livonia-Dearborn, MI.... MI.................

1.0052

1.0036 20100.................... Dover, DE....................... DE.................

1.0304

1.0207 20260.................... Duluth, MN-WI................... MN.................

1.0401

1.0273 20500.................... Durham, NC...................... NC.................

0.9693

0.9789 20500.................... Durham, NC...................... VA.................

0.9694

0.9789 20764.................... Edison-New Brunswick, NJ........ NJ.................

1.1221

1.0821 21060.................... Elizabethtown, KY............... KY.................

0.8230

0.8751 21140.................... Elkhart-Goshen, IN.............. IN.................

0.9547

0.9688 21500.................... Erie, PA........................ NY.................

0.8420

0.8889 21660.................... Eugene-Springfield, OR.......... OR.................

1.1157

1.0779 21780.................... Evansville, IN-KY............... IN.................

0.8479

0.8932 21780.................... Evansville, IN-KY............... KY.................

0.8131

0.8679

Page 23797

22020.................... Fargo, ND-MN.................... ND.................

0.8212

0.8738 22020.................... Fargo, ND-MN.................... SD.................

0.8428

0.8895 22180.................... Fayetteville, NC................ NC.................

0.9567

0.9701 22220.................... Fayetteville-Springdale-Rogers, AR.................

0.8952

0.9270

AR-MO. 22220.................... Fayetteville-Springdale-Rogers, OK.................

0.8950

0.9268

AR-MO. 22380.................... Flagstaff, AZ................... AZ.................

1.1305

1.0876 22420.................... Flint, MI....................... MI.................

1.0810

1.0548 22520.................... Florence-Muscle Shoals, AL...... AL.................

0.7883

0.8497 22520.................... Florence-Muscle Shoals, AL...... MS.................

0.7883

0.8497 22540.................... Fond du Lac, WI................. WI.................

0.9523

0.9671 22660.................... Fort Collins-Loveland, CO....... CO.................

0.9581

0.9711 22744.................... Ft Lauderdale-Pompano Beach-

FL.................

1.0025

1.0017

Deerfield Beach, FL. 23020.................... Fort Walton Beach-Crestview-

FL.................

0.8633

0.9042

Destin, FL. 23060.................... Fort Wayne, IN.................. IN.................

0.9004

0.9307 23104.................... Fort Worth-Arlington, TX........ TX.................

0.9684

0.9783 23540.................... Gainesville, FL................. FL.................

0.9427

0.9604 23844.................... Gary, IN........................ IN.................

0.9320

0.9529 24300.................... Grand Junction, CO.............. CO.................

0.9925

0.9949 24340.................... Grand Rapids-Wyoming, MI........ MI.................

0.9305

0.9519 24500.................... Great Falls, MT................. MT.................

0.8679

0.9075 24540.................... Greeley, CO..................... NE.................

0.9611

0.9732 24540.................... Greeley, CO..................... WY.................

0.9611

0.9732 24580.................... Green Bay, WI................... MI.................

0.9412

0.9594 24580.................... Green Bay, WI................... WI.................

0.9511

0.9662 24660.................... Greensboro-High Point, NC....... NC.................

0.8984

0.9293 24660.................... Greensboro-High Point, NC....... VA.................

0.8985

0.9293 24780.................... Greenville, NC.................. NC.................

0.9174

0.9427 24860.................... Greenville-Mauldin-Easley, SC... NC.................

0.9307

0.9520 24860.................... Greenville-Mauldin-Easley, SC... SC.................

0.9294

0.9511 25060.................... Gulfport-Biloxi, MS............. MS.................

0.8156

0.8697 25420.................... Harrisburg-Carlisle, PA......... PA.................

0.9185

0.9434 25540.................... Hartford-West Hartford-East

CT.................

1.1897

1.1263

Hartford, CT. 25540.................... Hartford-West Hartford-East

MA.................

1.0972

1.0656

Hartford, CT. 25860.................... Hickory-Lenoir-Morganton, NC.... NC.................

0.8794

0.9158 26180.................... Honolulu, HI.................... HI.................

1.1608

1.1075 26420.................... Houston-Sugar Land-Baytown, TX.. TX.................

0.9925

0.9949 26580.................... Huntington-Ashland, WV-KY-OH.... KY.................

0.8767

0.9138 26580.................... Huntington-Ashland, WV-KY-OH.... OH.................

0.8759

0.9133 26580.................... Huntington-Ashland, WV-KY-OH.... WV.................

0.8748

0.9125 26620.................... Huntsville, AL.................. AL.................

0.8636

0.9045 26620.................... Huntsville, AL.................. TN.................

0.8614

0.9029 26820.................... Idaho Falls, ID................. ID.................

0.9327

0.9534 26820.................... Idaho Falls, ID................. WY.................

0.9327

0.9534 26900.................... Indianapolis-Carmel, IN......... IN.................

0.9707

0.9798 26980.................... Iowa City, IA................... IA.................

0.9107

0.9380 27060.................... Ithaca, NY...................... NY.................

0.9101

0.9375 27140.................... Jackson, MS..................... MS.................

0.8095

0.8653 27180.................... Jackson, TN..................... MS.................

0.8361

0.8846 27180.................... Jackson, TN..................... TN.................

0.8339

0.8830 27260.................... Jacksonville, FL................ FL.................

0.9092

0.9369 27260.................... Jacksonville, FL................ GA.................

0.9112

0.9383 27620.................... Jefferson City, MO.............. MO.................

0.8736

0.9116 27780.................... Johnstown, PA................... PA.................

0.8342

0.8833 27860.................... Jonesboro, AR................... AR.................

0.8291

0.8796 27860.................... Jonesboro, AR................... MO.................

0.8470

0.8925 27900.................... Joplin, MO...................... KS.................

0.9351

0.9551 27900.................... Joplin, MO...................... OK.................

0.9349

0.9549 28020.................... Kalamazoo-Portage, MI........... MI.................

1.0365

1.0249 28140.................... Kansas City, MO-KS.............. MO.................

0.9444

0.9616 28420.................... Kennewick-Pasco-Richland, WA.... ID.................

0.9560

0.9697 28420.................... Kennewick-Pasco-Richland, WA.... WA.................

1.0164

1.0112 28700.................... Kingsport-Bristol-Bristol, TN-VA KY.................

0.7919

0.8523 28700.................... Kingsport-Bristol-Bristol, TN-VA TN.................

0.7957

0.8551 28940.................... Knoxville, TN................... KY.................

0.7889

0.8501 28940.................... Knoxville, TN................... TN.................

0.7957

0.8551 29180.................... Lafayette, LA................... LA.................

0.8438

0.8902 29460.................... Lakeland-Winter Haven, FL....... FL.................

0.8715

0.9101 29540.................... Lancaster, PA................... PA.................

0.9799

0.9862 29620.................... Lansing-East Lansing, MI........ MI.................

0.9652

0.9760 29820.................... Las Vegas-Paradise, NV.......... AZ.................

1.1388

1.0931

Page 23798

29820.................... Las Vegas-Paradise, NV.......... UT.................

1.1388

1.0931 30460.................... Lexington-Fayette, KY........... KY.................

0.8756

0.9130 30620.................... Lima, OH........................ OH.................

0.9299

0.9514 30700.................... Lincoln, NE..................... NE.................

0.9336

0.9540 30780.................... Little Rock-North Little Rock-

AR.................

0.8650

0.9055

Conway, AR. 30860.................... Logan, UT-ID.................... UT.................

0.8827

0.9181 30980.................... Longview, TX.................... TX.................

0.8666

0.9066 31084.................... Los Angeles-Long Beach-Glendale, CA.................

1.1822

1.1214

CA. 31140.................... Louisville-Jefferson County, KY- KY.................

0.9123

0.9391

IN. 31340.................... Lynchburg, VA................... VA.................

0.8646

0.9052 31420.................... Macon, GA....................... GA.................

0.9618

0.9737 31540.................... Madison, WI..................... WI.................

1.1014

1.0684 31700.................... Manchester-Nashua, NH........... NH.................

1.0807

1.0546 32780.................... Medford, OR..................... OR.................

1.0298

1.0203 32820.................... Memphis, TN-MS-AR............... AR.................

0.8909

0.9239 32820.................... Memphis, TN-MS-AR............... MS.................

0.8909

0.9239 32820.................... Memphis, TN-MS-AR............... TN.................

0.8886

0.9223 33124.................... Miami-Miami Beach-Kendall, FL... FL.................

0.9865

0.9907 33340.................... Milwaukee-Waukesha-West Allis,

WI.................

1.0026

1.0018

WI. 33460.................... Minneapolis-St. Paul-

MN.................

1.0997

1.0672

Bloomington, MN-WI. 33460.................... Minneapolis-St. Paul-

WI.................

1.0976

1.0659

Bloomington, MN-WI. 33540.................... Missoula, MT.................... MT.................

0.8909

0.9239 33700.................... Modesto, CA..................... CA.................

1.1963

1.1306 33740.................... Monroe, LA...................... AR.................

0.7789

0.8427 33740.................... Monroe, LA...................... LA.................

0.7785

0.8424 33860.................... Montgomery, AL.................. AL.................

0.8192

0.8723 34060.................... Morgantown, WV.................. WV.................

0.8631

0.9041 34740.................... Muskegon-Norton Shores, MI...... MI.................

0.9455

0.9623 34820.................... Myrtle Beach-North Myrtle Beach- NC.................

0.8632

0.9042

Conway, SC. 34820.................... Myrtle Beach-North Myrtle Beach- SC.................

0.8609

0.9025

Conway, SC. 34980.................... Nashville-Davidson-Murfreesboro- KY.................

0.9276

0.9498

Franklin, TN. 34980.................... Nashville-Davidson-Murfreesboro- TN.................

0.9252

0.9482

Franklin, TN. 35004.................... Nassau-Suffolk, NY.............. CT.................

1.2038

1.1354 35084.................... Newark-Union, NJ-PA............. NJ.................

1.1316

1.0884 35084.................... Newark-Union, NJ-PA............. NY.................

1.1461

1.0979 35084.................... Newark-Union, NJ-PA............. PA.................

1.1449

1.0971 35300.................... New Haven-Milford, CT........... CT.................

1.1897

1.1263 35380.................... New Orleans-Metairie-Kenner, LA. LA.................

0.9140

0.9403 35644.................... New York-White Plains-Wayne, NY- CT.................

1.2391

1.1581

NJ. 35644.................... New York-White Plains-Wayne, NY- NJ.................

1.2693

1.1774

NJ. 35644.................... New York-White Plains-Wayne, NY- NY.................

1.2855

1.1877

NJ. 35980.................... Norwich-New London, CT.......... RI.................

1.1587

1.1061 36084.................... Oakland-Fremont-Hayward, CA..... CA.................

1.5278

1.3367 36140.................... Ocean City, NJ.................. DE.................

1.0909

1.0614 36220.................... Odessa, TX...................... NM.................

0.9273

0.9496 36220.................... Odessa, TX...................... TX.................

0.9283

0.9503 36420.................... Oklahoma City, OK............... OK.................

0.8686

0.9080 36500.................... Olympia, WA..................... WA.................

1.1297

1.0871 36740.................... Orlando-Kissimmee, FL........... FL.................

0.9073

0.9356 37460.................... Panama City-Lynn Haven, FL...... AL.................

0.8322

0.8818 37700.................... Pascagoula, MS.................. AL.................

0.8030

0.8605 37764.................... Peabody, MA..................... NH.................

1.0807

1.0546 37860.................... Pensacola-Ferry Pass-Brent, FL.. AL.................

0.8115

0.8667 37900.................... Peoria, IL...................... IL.................

0.9043

0.9334 37964.................... Philadelphia, PA................ DE.................

1.0799

1.0540 37964.................... Philadelphia, PA................ NJ.................

1.1221

1.0821 37964.................... Philadelphia, PA................ PA.................

1.0788

1.0533 38220.................... Pine Bluff, AR.................. MS.................

0.8150

0.8693 38300.................... Pittsburgh, PA.................. OH.................

0.8582

0.9006 38300.................... Pittsburgh, PA.................. PA.................

0.8579

0.9004 38300.................... Pittsburgh, PA.................. WV.................

0.8569

0.8996 38340.................... Pittsfield, MA.................. NY.................

0.9901

0.9932 38340.................... Pittsfield, MA.................. VT.................

0.9275

0.9498 38860.................... Portland-South Portland-

ME.................

0.9644

0.9755

Biddeford, ME. 38900.................... Portland-Vancouver-Beaverton, OR- OR.................

1.1204

1.0810

WA. 38900.................... Portland-Vancouver-Beaverton, OR- WA.................

1.1186

1.0798

WA. 38940.................... Port St. Lucie, FL.............. FL.................

0.9741

0.9822 39100.................... Poughkeepsie-Newburgh-

NY.................

1.0709

1.0480

Middletown, NY. 39140.................... Prescott, AZ.................... AZ.................

1.0011

1.0008 39340.................... Provo-Orem, UT.................. UT.................

0.9052

0.9341

Page 23799

39580.................... Raleigh-Cary, NC................ NC.................

0.9557

0.9694 39740.................... Reading, PA..................... PA.................

0.9204

0.9448 39820.................... Redding, CA..................... CA.................

1.2730

1.1797 39900.................... Reno-Sparks, NV................. NV.................

1.0476

1.0324 40060.................... Richmond, VA.................... VA.................

0.9203

0.9447 40140.................... Riverside-San Bernardino-

AZ.................

1.1254

1.0843

Ontario, CA. 40220.................... Roanoke, VA..................... VA.................

0.8750

0.9126 40220.................... Roanoke, VA..................... WV.................

0.8732

0.9113 40380.................... Rochester, NY................... NY.................

0.8911

0.9241 40420.................... Rockford, IL.................... IL.................

0.9756

0.9832 40484.................... Rockingham County-Strafford

ME.................

1.0007

1.0005

County, NH. 40660.................... Rome, GA........................ AL.................

0.9524

0.9672 40900.................... Sacramento--Arden-Arcade--

CA.................

1.2710

1.1785

Roseville, CA. 40980.................... Saginaw-Saginaw Township North, MI.................

0.8864

0.9207

MI. 41060.................... St. Cloud, MN................... MN.................

1.0638

1.0433 41100.................... St. George, UT.................. UT.................

0.9228

0.9465 41140.................... St. Joseph, MO-KS............... MO.................

1.0267

1.0182 41180.................... St. Louis, MO-IL................ IL.................

0.8993

0.9299 41180.................... St. Louis, MO-IL................ MO.................

0.8986

0.9294 41620.................... Salt Lake City, UT.............. UT.................

0.9271

0.9495 41700.................... San Antonio, TX................. TX.................

0.8949

0.9268 41884.................... San Francisco-San Mateo-Redwood CA.................

1.4879

1.3127

City, CA. 41940.................... San Jose-Sunnyvale-Santa Clara, CA.................

1.5758

1.3654

CA. 42044.................... Santa Ana-Anaheim-Irvine, CA.... CA.................

1.1822

1.1214 42100.................... Santa Cruz-Watsonville, CA...... CA.................

1.5766

1.3658 42140.................... Santa Fe, NM.................... NM.................

1.0207

1.0141 42220.................... Santa Rosa-Petaluma, CA......... CA.................

1.4497

1.2896 42340.................... Savannah, GA.................... GA.................

0.8841

0.9191 42340.................... Savannah, GA.................... SC.................

0.8827

0.9181 42644.................... Seattle-Bellevue-Everett, WA.... WA.................

1.1377

1.0924 43300.................... Sherman-Denison, TX............. OK.................

0.9291

0.9509 43340.................... Shreveport-Bossier City, LA..... LA.................

0.8547

0.8981 43580.................... Sioux City, IA-NE-SD............ NE.................

0.8761

0.9134 43620.................... Sioux Falls, SD................. SD.................

0.9262

0.9489 43780.................... South Bend-Mishawaka, IN-MI..... IN.................

0.9353

0.9552 43900.................... Spartanburg, SC................. SC.................

0.9017

0.9316 44060.................... Spokane, WA..................... ID.................

1.0315

1.0215 44180.................... Springfield, MO................. AR.................

0.8477

0.8930 44180.................... Springfield, MO................. MO.................

0.8470

0.8925 44940.................... Sumter, SC...................... SC.................

0.8609

0.9025 45060.................... Syracuse, NY.................... NY.................

0.9471

0.9635 45220.................... Tallahassee, FL................. GA.................

0.8397

0.8872 45300.................... Tampa-St. Petersburg-Clearwater, FL.................

0.8993

0.9299

FL. 45500.................... Texarkana, TX-Texarkana, AR..... AR.................

0.8093

0.8651 45780.................... Toledo, OH...................... OH.................

0.9267

0.9492 45820.................... Topeka, KS...................... KS.................

0.8720

0.9105 46140.................... Tulsa, OK....................... OK.................

0.8652

0.9056 46220.................... Tuscaloosa, AL.................. MS.................

0.8280

0.8788 46340.................... Tyler, TX....................... TX.................

0.8901

0.9234 46700.................... Vallejo-Fairfield, CA........... CA.................

1.3974

1.2575 47260.................... Virginia Beach-Norfolk-Newport

NC.................

0.8868

0.9210

News, VA. 47644.................... Warren-Troy-Farmington-Hills, MI MI.................

0.9972

0.9981 47894.................... Washington-Arlington-Alexandria, VA.................

1.0669

1.0453

DC-VA. 47940.................... Waterloo-Cedar Falls, IA........ IA.................

0.9248

0.9479 48140.................... Wausau, WI...................... WI.................

0.9823

0.9878 48620.................... Wichita, KS..................... KS.................

0.8785

0.9151 48620.................... Wichita, KS..................... OK.................

0.8784

0.9150 48700.................... Williamsport, PA................ PA.................

0.8342

0.8833 48864.................... Wilmington, DE-MD-NJ............ DE.................

1.0645

1.0437 48864.................... Wilmington, DE-MD-NJ............ NJ.................

1.1221

1.0821 48900.................... Wilmington, NC.................. SC.................

0.9074

0.9356 49180.................... Winston-Salem, NC............... NC.................

0.9096

0.9372 49340.................... Worcester, MA................... NH.................

1.0807

1.0546 49660.................... Youngstown-Warren-Boardman, OH- OH.................

0.8582

0.9006

PA. 49660.................... Youngstown-Warren-Boardman, OH- PA.................

0.8559

0.8989

PA. 04....................... Arkansas........................ LA.................

0.7682

0.8348 05....................... California...................... CA.................

1.1822

1.1214 10....................... Florida......................... FL.................

0.8633

0.9042 14....................... Illinois........................ IL.................

0.8428

0.8895 14....................... Illinois........................ KY.................

0.8320

0.8817

Page 23800

14....................... Illinois........................ MO.................

0.8470

0.8925 16....................... Iowa............................ MO.................

0.8738

0.9118 17....................... Kansas.......................... KS.................

0.8086

0.8646 22....................... Massachusetts................... MA.................

1.0199

1.0136 23....................... Michigan........................ MI.................

0.8864

0.9207 25....................... Mississippi..................... MS.................

0.7653

0.8326 26....................... Missouri........................ MO.................

0.8470

0.8925 30....................... New Hampshire................... VT.................

0.9297

0.9513 33....................... New York........................ NY.................

0.8308

0.8808 34....................... North Carolina.................. TN.................

0.8611

0.9027 36....................... Ohio............................ OH.................

0.8582

0.9006 37....................... Oklahoma........................ OK.................

0.8016

0.8595 38....................... Oregon.......................... OR.................

1.0298

1.0203 39....................... Pennsylvania.................... NY.................

0.8351

0.8839 39....................... Pennsylvania.................... PA.................

0.8342

0.8833 44....................... Tennessee....................... KY.................

0.7978

0.8567 44....................... Tennessee....................... TN.................

0.7957

0.8551 45....................... Texas........................... TX.................

0.8153

0.8695 49....................... Virginia........................ KY.................

0.8062

0.8628 49....................... Virginia........................ VA.................

0.8061

0.8628 50....................... Washington...................... WA.................

1.0164

1.0112 53....................... Wyoming......................... NE.................

0.9223

0.9461

Table 4D-1.--Rural Floor Budget Neutrality Factors--FY 2009

Rural floor budget

State

neutrality ajustment factor

Alabama.................................................

1.00000

Alaska..................................................

0.99734

Arizona.................................................

1.00000

Arkansas................................................

1.00000

California..............................................

0.98552

Colorado................................................

0.99683

Connecticut.............................................

0.96390

Delaware................................................

1.00000

Washington, DC..........................................

1.00000

Florida.................................................

0.99781

Georgia.................................................

1.00000

Hawaii..................................................

1.00000

Idaho...................................................

1.00000

Illinois................................................

0.99993

Indiana.................................................

0.99928

Iowa....................................................

0.99572

Kansas..................................................

1.00000

Kentucky................................................

1.00000

Louisiana...............................................

0.99945

Maine...................................................

1.00000

Maryland................................................ ..............

Massachusetts...........................................

1.00000

Michigan................................................

1.00000

Minnesota...............................................

1.00000

Mississippi.............................................

1.00000

Missouri................................................

0.99910

Montana.................................................

1.00000

Nebraska................................................

1.00000

Nevada..................................................

1.00000

New Hampshire...........................................

0.97787

New Jersey..............................................

0.98738

New Mexico..............................................

0.99875

New York................................................

1.00000

North Carolina..........................................

0.99983

North Dakota............................................

0.99424

Ohio....................................................

0.99906

Oklahoma................................................

0.99983

Oregon..................................................

0.99955

Pennsylvania............................................

0.99895

Puerto Rico.............................................

1.00000

Rhode Island............................................

1.00000

South Carolina..........................................

0.99840

South Dakota............................................

1.00000

Tennessee...............................................

0.99741

Texas...................................................

0.99980

Utah....................................................

1.00000

Vermont.................................................

0.90100

Virginia................................................

0.99991

Washington..............................................

0.99791

West Virginia...........................................

0.99782

Wisconsin...............................................

0.99809

Wyoming.................................................

1.00000

* Maryland hospitals, under section 1814(b)(3) of the Act, are waived from the IPPS ratesetting. Therefore, the rural floor budget neutrality adjustment does not apply.

** The rural floor budget neutrality factor for New Jersey is based on an imputed floor (see Table 4B).

Table 4D-2.--Urban Areas With Hospitals Receiving the Statewide Rural Floor or Imputed Floor Wage Index--FY 2009

*Only hospitals that are geographically located in the specified State receive the State's rural or imputed floor wage index.

Rural or imputed floor

CBSA code

Urban area

State *

wage index

10900................................ Allentown-Bethlehem-

NJ.....................

1.1221

Easton, PA-NJ. 11020................................ Altoona, PA............ PA.....................

0.8342 11260................................ Anchorage, AK.......... AK.....................

1.1884 11540................................ Appleton, WI........... WI.....................

0.9511 12220................................ Auburn-Opelika, AL..... AL.....................

0.7647 12540................................ Bakersfield, CA........ CA.....................

1.1822 13900................................ Bismarck, ND........... ND.....................

0.7336 15500................................ Burlington, NC......... NC.....................

0.8632

Page 23801

15540................................ Burlington-South

VT.....................

0.9275

Burlington, VT. 15804................................ Camden, NJ............. NJ.....................

1.1221 16940................................ Cheyenne, WY........... WY.....................

0.9223 17020................................ Chico, CA.............. CA.....................

1.1822 17860................................ Columbia, MO........... MO.....................

0.8470 19060................................ Cumberland, MD-WV...... MD.....................

0.8795 19060................................ Cumberland, MD-WV...... WV.....................

0.7635 19340................................ Davenport-Moline-Rock

IA.....................

0.8709

Island, IA-IL. 19500................................ Decatur, IL............ IL.....................

0.8428 20220................................ Dubuque, IA............ IA.....................

0.8709 20764................................ Edison-New Brunswick,

NJ.....................

1.1221

NJ. 20940................................ El Centro, CA.......... CA.....................

1.1822 21820................................ Fairbanks, AK.......... AK.....................

1.1884 22020................................ Fargo, ND-MN........... MN.....................

0.9120 22140................................ Farmington, NM......... NM.....................

0.8858 22500................................ Florence, SC........... SC.....................

0.8609 22900................................ Fort Smith, AR-OK...... OK.....................

0.8016 23420................................ Fresno, CA............. CA.....................

1.1822 24220................................ Grand Forks, ND-MN..... MN.....................

0.9120 24580................................ Green Bay, WI.......... WI.....................

0.9511 25260................................ Hanford-Corcoran, CA... CA.....................

1.1822 25540................................ Hartford-West Hartford- CT.....................

1.1897

East Hartford, CT. 25620................................ Hattiesburg, MS........ MS.....................

0.7653 27340................................ Jacksonville, NC....... NC.....................

0.8632 27780................................ Johnstown, PA.......... PA.....................

0.8342 28420................................ Kennewick-Pasco-

WA.....................

1.0164

Richland, WA. 28700................................ Kingsport-Bristol-

TN.....................

0.7957

Bristol, TN-VA. 28700................................ Kingsport-Bristol-

VA.....................

0.8061

Bristol, TN-VA. 28940................................ Knoxville, TN.......... TN.....................

0.7957 29340................................ Lake Charles, LA....... LA.....................

0.7682 29740................................ Las Cruces, NM......... NM.....................

0.8858 30300................................ Lewiston, ID-WA........ WA.....................

1.0164 31460................................ Madera, CA............. CA.....................

1.1822 31700................................ Manchester-Nashua, NH.. NH.....................

1.0807 32780................................ Medford, OR............ OR.....................

1.0298 34100................................ Morristown, TN......... TN.....................

0.7957 34580................................ Mount Vernon-Anacortes, WA.....................

1.0164

WA. 34620................................ Muncie, IN............. IN.....................

0.8479 35300................................ New Haven-Milford, CT.. CT.....................

1.1897 35980................................ Norwich-New London, CT. CT.....................

1.1897 36100................................ Ocala, FL.............. FL.....................

0.8633 36780................................ Oshkosh-Neenah, WI..... WI.....................

0.9511 37100................................ Oxnard-Thousand Oaks-

CA.....................

1.1822

Ventura, CA. 37460................................ Panama City-Lynn Haven, FL.....................

0.8633

FL. 37620................................ Parkersburg-Marietta-

OH.....................

0.8582

Vienna, WV-OH. 37860................................ Pensacola-Ferry Pass-

FL.....................

0.8633

Brent, FL. 39380................................ Pueblo, CO............. CO.....................

0.9303 39540................................ Racine, WI............. WI.....................

0.9511 40140................................ Riverside-San

CA.....................

1.1822

Bernardino-Ontario, CA. 40484................................ Rockingham County-

NH.....................

1.0807

Strafford County, NH. 41740................................ San Diego-Carlsbad-San CA.....................

1.1822

Marcos, CA. 42020................................ San Luis Obispo-Paso

CA.....................

1.1822

Robles, CA. 42044................................ Santa Ana-Anaheim-

CA.....................

1.1822

Irvine, CA. 42060................................ Santa Barbara-Santa

CA.....................

1.1822

Maria-Goleta, CA. 42540................................ Scranton-Wilkes-Barre, PA.....................

0.8342

PA. 43100................................ Sheboygan, WI.......... WI.....................

0.9511 44180................................ Springfield, MO........ MO.....................

0.8470 44700................................ Stockton, CA........... CA.....................

1.1822 44940................................ Sumter, SC............. SC.....................

0.8609 45940................................ Trenton-Ewing, NJ...... NJ.....................

1.1221 47020................................ Victoria, TX........... TX.....................

0.8153 47220................................ Vineland-Millville-

NJ.....................

1.1221

Bridgeton, NJ. 47300................................ Visalia-Porterville, CA CA.....................

1.1822 48260................................ Weirton-Steubenville,

OH.....................

0.8582

WV-OH. 48300................................ Wenatchee, WA.......... WA.....................

1.0164 48540................................ Wheeling, WV-OH........ OH.....................

0.8582 48540................................ Wheeling, WV-OH........ WV.....................

0.7635 48700................................ Williamsport, PA....... PA.....................

0.8342 48864................................ Wilmington, DE-MD-NJ... NJ.....................

1.1221

Page 23802

49420................................ Yakima, WA............. WA.....................

1.0164 49700................................ Yuba City, CA.......... CA.....................

1.1822

Table 4E.--Urban CBSAs and Constituent Counties--FY 2009

Urban area (constituent

CBSA code

counties)

10180..................................... Abilene, TX

Callahan County, TX

Jones County, TX

Taylor County, TX 10380..................................... Aguadilla-Isabela-San

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

Portage County, OH

Summit County, OH 10500..................................... Albany, GA

Baker County, GA

Dougherty County, GA

Lee County, GA

Terrell County, GA

Worth County, GA 10580..................................... Albany-Schenectady-Troy, NY

Albany County, NY

Rensselaer County, NY

Saratoga County, NY

Schenectady County, NY

Schoharie County, NY 10740..................................... Albuquerque, NM

Bernalillo County, NM

Sandoval County, NM

Torrance County, NM

Valencia County, NM 10780..................................... Alexandria, LA

Grant Parish, LA

Rapides Parish, LA 10900..................................... Allentown-Bethlehem-Easton,

PA-NJ

Warren County, NJ

Carbon County, PA

Lehigh County, PA

Northampton County, PA 11020..................................... Altoona, PA

Blair County, PA 11100..................................... Amarillo, TX

Armstrong County, TX

Carson County, TX

Potter County, TX

Randall County, TX 11180..................................... Ames, IA

Story County, IA 11260..................................... Anchorage, AK

Anchorage Municipality, AK

Matanuska-SusitnaBorough,

AK 11300..................................... Anderson, IN

Madison County, IN 11340..................................... Anderson, SC

Anderson County, SC 11460..................................... Ann Arbor, MI

Washtenaw County, MI 11500..................................... Anniston-Oxford, AL

Calhoun County, AL 11540..................................... Appleton, WI

Calumet County, WI

Outagamie County, WI 11700..................................... Asheville, NC

Buncombe County, NC

Haywood County, NC

Henderson County, NC

Madison County, NC 12020..................................... Athens-Clarke County, GA

Clarke County, GA

Madison County, GA

Oconee County, GA

Oglethorpe County, GA 12060..................................... \1\ Atlanta-Sandy Springs-

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-Hammonton, NJ

Atlantic County, NJ

Hammonton County, NJ 12220..................................... Auburn-Opelika, AL

Lee County, AL 12260..................................... Augusta-Richmond County, GA-

SC

Burke County, GA

Columbia County, GA

McDuffie County, GA

Richmond County, GA

Aiken County, SC

Edgefield County, SC 12420..................................... \1\ Austin-Round Rock, TX

Bastrop County, TX

Caldwell County, TX

Hays County, TX

Travis County, TX

Williamson County, TX 12540..................................... Bakersfield, CA

Kern County, CA 12580..................................... \1\ Baltimore-Towson, MD

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

Penobscot County, ME 12700..................................... Barnstable Town, MA

Barnstable County, MA 12940..................................... Baton Rouge, LA

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

Calhoun County, MI 13020..................................... Bay City, MI

Bay County, MI 13140..................................... Beaumont-Port Arthur, TX

Hardin County, TX

Jefferson County, TX

Orange County, TX 13380..................................... Bellingham, WA

Whatcom County, WA 13460..................................... Bend, OR

Deschutes County, OR 13644..................................... \1\ Bethesda-Frederick-

Gaithersburg, MD

Frederick County, MD

Montgomery County, MD 13740..................................... Billings, MT

Carbon County, MT

Yellowstone County, MT 13780..................................... Binghamton, NY

Broome County, NY

Tioga County, NY 13820..................................... \1\ Birmingham-Hoover, AL

Bibb County, AL

Blount County, AL

Page 23803

Chilton County, AL

Jefferson County, AL

St. Clair County, AL

Shelby County, AL

Walker County, AL 13900..................................... Bismarck, ND

Burleigh County, ND

Morton County, ND 13980..................................... Blacksburg-Christiansburg-

Radford, VA

Giles County, VA

Montgomery County, VA

Pulaski County, VA

Radford City, VA 14020..................................... Bloomington, IN

Greene County, IN

Monroe County, IN

Owen County, IN 14060..................................... Bloomington-Normal, IL

McLean County, IL 14260..................................... Boise City-Nampa, ID

Ada County, ID

Boise County, ID

Canyon County, ID

Gem County, ID

Owyhee County, ID 14484..................................... \1\ Boston-Quincy, MA

Norfolk County, MA

Plymouth County, MA

Suffolk County, MA 14500..................................... Boulder, CO

Boulder County, CO 14540..................................... Bowling Green, KY

Edmonson County, KY

Warren County, KY 14600..................................... Bradenton-Sarasota-Venice,

FL

Bradenton County, FL

Manatee County, FL

Sarasota County, FL 14740..................................... Bremerton-Silverdale, WA

Kitsap County, WA 14860..................................... Bridgeport-Stamford-Norwalk,

CT

Fairfield County, CT 15180..................................... Brownsville-Harlingen, TX

Cameron County, TX 15260..................................... Brunswick, GA

Brantley County, GA

Glynn County, GA

McIntosh County, GA 15380..................................... \1\ Buffalo-Niagara Falls,

NY

Erie County, NY

Niagara County, NY 15500..................................... Burlington, NC

Alamance County, NC 15540..................................... Burlington-South Burlington,

VT

Chittenden County, VT

Franklin County, VT

Grand Isle County, VT 15764..................................... \1\ Cambridge-Newton-

Framingham, MA

Middlesex County, MA 15804..................................... \1\ Camden, NJ

Burlington County, NJ

Camden County, NJ

Gloucester County, NJ 15940..................................... Canton-Massillon, OH

Carroll County, OH

Stark County, OH 15980..................................... Cape Coral-Fort Myers, FL

Lee County, FL 16180..................................... Carson City, NV

Carson City, NV 16220..................................... Casper, WY

Natrona County, WY 16300..................................... Cedar Rapids, IA

Benton County, IA

Jones County, IA

Linn County, IA 16580..................................... Champaign-Urbana, IL

Champaign County, IL

Ford County, IL

Piatt County, IL 16620..................................... Charleston, WV

Boone County, WV

Clay County, WV

Kanawha County, WV

Lincoln County, WV

Putnam County, WV 16700..................................... Charleston-North Charleston-

Summerville, SC

Berkeley County, SC

Charleston County, SC

Dorchester County, SC

Summerville County, SC 16740..................................... \1\ Charlotte-Gastonia-

Concord, NC-SC

Anson County, NC

Cabarrus County, NC

Gaston County, NC

Mecklenburg County, NC

Union County, NC

York County, SC 16820..................................... Charlottesville, VA

Albemarle County, VA

Fluvanna County, VA

Greene County, VA

Nelson County, VA

Charlottesville City, VA 16860..................................... Chattanooga, TN-GA

Catoosa County, GA

Dade County, GA

Walker County, GA

Hamilton County, TN

Marion County, TN

Sequatchie County, TN 16940..................................... Cheyenne, WY

Laramie County, WY 16974..................................... \1\ Chicago-Naperville-

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..................................... Chico, CA

Butte County, CA 17140..................................... \1\ Cincinnati-Middletown,

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

Christian County, KY

Trigg County, KY

Montgomery County, TN

Stewart County, TN 17420..................................... Cleveland, TN

Bradley County, TN

Polk County, TN 17460..................................... \1\ Cleveland-Elyria-Mentor,

OH

Cuyahoga County, OH

Geauga County, OH

Lake County, OH

Lorain County, OH

Medina County, OH 17660..................................... Coeur d'Alene, ID

Kootenai County, ID 17780..................................... College Station-Bryan, TX

Brazos County, TX

Burleson County, TX

Robertson County, TX 17820..................................... Colorado Springs, CO

El Paso County, CO

Teller County, CO 17860..................................... Columbia, MO

Boone County, MO

Howard County, MO 17900..................................... Columbia, SC

Calhoun County, SC

Fairfield County, SC

Kershaw County, SC

Lexington County, SC

Richland County, SC

Saluda County, SC 17980..................................... Columbus, GA-AL

Russell County, AL

Chattahoochee County, GA

Harris County, GA

Marion County, GA

Muscogee County, GA 18020..................................... Columbus, IN

Bartholomew County, IN 18140..................................... \1\ Columbus, OH

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

Aransas County, TX

Nueces County, TX

San Patricio County, TX 18700..................................... Corvallis, OR

Benton County, OR 19060..................................... Cumberland, MD-WV

Allegany County, MD

Mineral County, WV 19124..................................... \1\ Dallas-Plano-Irving, TX

Collin County, TX

Page 23804

Dallas County, TX

Delta County, TX

Denton County, TX

Ellis County, TX

Hunt County, TX

Kaufman County, TX

Rockwall County, TX 19140..................................... Dalton, GA

Murray County, GA

Whitfield County, GA 19180..................................... Danville, IL

Vermilion County, IL 19260..................................... Danville, VA

Pittsylvania County, VA

Danville City, VA 19340..................................... Davenport-Moline-Rock

Island, IA-IL

Henry County, IL

Mercer County, IL

Rock Island County, IL

Scott County, IA 19380..................................... Dayton, OH

Greene County, OH

Miami County, OH

Montgomery County, OH

Preble County, OH 19460..................................... Decatur, AL

Lawrence County, AL

Morgan County, AL 19500..................................... Decatur, IL

Macon County, IL 19660..................................... Deltona-Daytona Beach-Ormond

Beach, FL

Volusia County, FL 19740..................................... \1\ Denver-Aurora, CO

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,

IA

Dallas County, IA

Guthrie County, IA

Madison County, IA

Polk County, IA

Warren County, IA 19804..................................... \1\ Detroit-Livonia-

Dearborn, MI

Wayne County, MI 20020..................................... Dothan, AL

Geneva County, AL

Henry County, AL

Houston County, AL 20100..................................... Dover, DE

Kent County, DE 20220..................................... Dubuque, IA

Dubuque County, IA 20260..................................... Duluth, MN-WI

Carlton County, MN

St. Louis County, MN

Douglas County, WI 20500..................................... Durham, NC

Chatham County, NC

Durham County, NC

Orange County, NC

Person County, NC 20740..................................... Eau Claire, WI

Chippewa County, WI

Eau Claire County, WI 20764..................................... \1\ Edison-New Brunswick, NJ

Middlesex County, NJ

Monmouth County, NJ

New Brunswick County, NJ

Ocean County, NJ

Somerset County, NJ 20940..................................... El Centro, CA

Imperial County, CA 21060..................................... Elizabethtown, KY

Hardin County, KY

Larue County, KY 21140..................................... Elkhart-Goshen, IN

Elkhart County, IN 21300..................................... Elmira, NY

Chemung County, NY 21340..................................... El Paso, TX

El Paso County, TX 21500..................................... Erie, PA

Erie County, PA 21660..................................... Eugene-Springfield, OR

Lane County, OR 21780..................................... Evansville, IN-KY

Gibson County, IN

Posey County, IN

Vanderburgh County, IN

Warrick County, IN

Henderson County, KY

Webster County, KY 21820..................................... Fairbanks, AK

Fairbanks North Star

Borough, AK 21940..................................... Fajardo, PR

Ceiba Municipio, PR

Fajardo Municipio, PR

Luquillo Municipio, PR 22020..................................... Fargo, ND-MN

Clay County, MN

Cass County, ND 22140..................................... Farmington, NM

San Juan County, NM 22180..................................... Fayetteville, NC

Cumberland County, NC

Hoke County, NC 22220..................................... Fayetteville-Springdale-

Rogers, AR-MO

Benton County, AR

Madison County, AR

Washington County, AR

McDonald County, MO 22380..................................... Flagstaff, AZ

Coconino County, AZ 22420..................................... Flint, MI

Genesee County, MI 22500..................................... Florence, SC

Darlington County, SC

Florence County, SC 22520..................................... Florence-Muscle Shoals, AL

Colbert County, AL

Lauderdale County, AL 22540..................................... Fond du Lac, WI

Fond du Lac County, WI 22660..................................... Fort Collins-Loveland, CO

Larimer County, CO 22744..................................... \1\ Fort Lauderdale-Pompano

Beach-Deerfield Beach, FL

Broward County, FL 22900..................................... Fort Smith, AR-OK

Crawford County, AR

Franklin County, AR

Sebastian County, AR

Le Flore County, OK

Sequoyah County, OK 23020..................................... Fort Walton Beach-Crestview-

Destin, FL

Okaloosa County, FL 23060..................................... Fort Wayne, IN

Allen County, IN

Wells County, IN

Whitley County, IN 23104..................................... \1\ Fort Worth-Arlington, TX

Johnson County, TX

Parker County, TX

Tarrant County, TX

Wise County, TX 23420..................................... Fresno, CA

Fresno County, CA 23460..................................... Gadsden, AL

Etowah County, AL 23540..................................... Gainesville, FL

Alachua County, FL

Gilchrist County, FL 23580..................................... Gainesville, GA

Hall County, GA 23844..................................... Gary, IN

Jasper County, IN

Lake County, IN

Newton County, IN

Porter County, IN 24020..................................... Glens Falls, NY

Warren County, NY

Washington County, NY 24140..................................... Goldsboro, NC

Wayne County, NC 24220..................................... Grand Forks, ND-MN

Polk County, MN

Grand Forks County, ND 24300..................................... Grand Junction, CO

Mesa County, CO 24340..................................... Grand Rapids-Wyoming, MI

Barry County, MI

Ionia County, MI

Kent County, MI

Newaygo County, MI 24500..................................... Great Falls, MT

Cascade County, MT 24540..................................... Greeley, CO

Weld County, CO 24580..................................... Green Bay, WI

Brown County, WI

Kewaunee County, WI

Oconto County, WI 24660..................................... Greensboro-High Point, NC

Guilford County, NC

Randolph County, NC

Rockingham County, NC 24780..................................... Greenville, NC

Greene County, NC

Pitt County, NC 24860..................................... Greenville-Mauldin-Easley,

SC

Greenville County, SC

Laurens County, SC

Pickens County, SC

Page 23805

25020..................................... Guayama, PR

Arroyo Municipio, PR

Guayama Municipio, PR

Patillas Municipio, PR 25060..................................... Gulfport-Biloxi, MS

Hancock County, MS

Harrison County, MS

Stone County, MS 25180..................................... Hagerstown-Martinsburg, MD-

WV

Washington County, MD

Berkeley County, WV

Morgan County, WV 25260..................................... Hanford-Corcoran, CA

Kings County, CA 25420..................................... Harrisburg-Carlisle, PA

Cumberland County, PA

Dauphin County, PA

Perry County, PA 25500..................................... Harrisonburg, VA

Rockingham County, VA

Harrisonburg City, VA 25540..................................... \1\ Hartford-West Hartford-

East Hartford, CT

Hartford County, CT

Middlesex County, CT

Tolland County, CT 25620..................................... Hattiesburg, MS

Forrest County, MS

Lamar County, MS

Perry County, MS 25860..................................... Hickory-Lenoir-Morganton, NC

Alexander County, NC

Burke County, NC

Caldwell County, NC

Catawba County, NC 25980..................................... Hinesville-Fort Stewart, GA

Liberty County, GA

Long County, GA 26100..................................... Holland-Grand Haven, MI

Ottawa County, MI 26180..................................... Honolulu, HI

Honolulu County, HI 26300..................................... Hot Springs, AR

Garland County, AR 26380..................................... Houma-Bayou Cane-Thibodaux,

LA

Lafourche Parish, LA

Terrebonne Parish, LA 26420..................................... \1\ Houston-Sugar Land-

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-OH

Boyd County, KY

Greenup County, KY

Lawrence County, OH

Cabell County, WV

Wayne County, WV 26620..................................... Huntsville, AL

Limestone County, AL

Madison County, AL 26820..................................... Idaho Falls, ID

Bonneville County, ID

Jefferson County, ID 26900..................................... \1\ Indianapolis-Carmel, IN

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

Johnson County, IA

Washington County, IA 27060..................................... Ithaca, NY

Tompkins County, NY 27100..................................... Jackson, MI

Jackson County, MI 27140..................................... Jackson, MS

Copiah County, MS

Hinds County, MS

Madison County, MS

Rankin County, MS

Simpson County, MS 27180..................................... Jackson, TN

Chester County, TN

Madison County, TN 27260..................................... \1\ Jacksonville, FL

Baker County, FL

Clay County, FL

Duval County, FL

Nassau County, FL

St. Johns County, FL 27340..................................... Jacksonville, NC

Onslow County, NC 27500..................................... Janesville, WI

Rock County, WI 27620..................................... Jefferson City, MO

Callaway County, MO

Cole County, MO

Moniteau County, MO

Osage County, MO 27740..................................... Johnson City, TN

Carter County, TN

Unicoi County, TN

Washington County, TN 27780..................................... Johnstown, PA

Cambria County, PA 27860..................................... Jonesboro, AR

Craighead County, AR

Poinsett County, AR 27900..................................... Joplin, MO

Jasper County, MO

Newton County, MO 28020..................................... Kalamazoo-Portage, MI

Kalamazoo County, MI

Van Buren County, MI 28100..................................... Kankakee-Bradley, IL

Kankakee County, IL 28140..................................... \1\ Kansas City, MO-KS

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..................................... Kennewick-Pasco-Richland, WA

Benton County, WA

Franklin County, WA 28660..................................... Killeen-Temple-Fort Hood, TX

Bell County, TX

Coryell County, TX

Lampasas County, TX 28700..................................... Kingsport-Bristol-Bristol,

TN-VA

Hawkins County, TN

Sullivan County, TN

Bristol City, VA

Scott County, VA

Washington County, VA 28740..................................... Kingston, NY

Ulster County, NY 28940..................................... Knoxville, TN

Anderson County, TN

Blount County, TN

Knox County, TN

Loudon County, TN

Union County, TN 29020..................................... Kokomo, IN

Howard County, IN

Tipton County, IN 29100..................................... La Crosse, WI-MN

Houston County, MN

La Crosse County, WI 29140..................................... Lafayette, IN

Benton County, IN

Carroll County, IN

Tippecanoe County, IN 29180..................................... Lafayette, LA

Lafayette Parish, LA

St. Martin Parish, LA 29340..................................... Lake Charles, LA

Calcasieu Parish, LA

Cameron Parish, LA 29404..................................... Lake County-Kenosha County,

IL-WI

Lake County, IL

Kenosha County, WI 29420..................................... Lake Havasu City-Kingman, AZ

Mohave County, AZ 29460..................................... Lakeland-Winter Haven, FL

Polk County, FL

Winter Haven County, FL 29540..................................... Lancaster, PA

Lancaster County, PA 29620..................................... Lansing-East Lansing, MI

Clinton County, MI

Eaton County, MI

Ingham County, MI 29700..................................... Laredo, TX

Webb County, TX 29740..................................... Las Cruces, NM

Dona Ana County, NM 29820..................................... \1\ Las Vegas-Paradise, NV

Clark County, NV 29940..................................... Lawrence, KS

Page 23806

Douglas County, KS 30020..................................... Lawton, OK

Comanche County, OK 30140..................................... Lebanon, PA

Lebanon County, PA 30300..................................... Lewiston, ID-WA

Nez Perce County, ID

Asotin County, WA 30340..................................... Lewiston-Auburn, ME

Androscoggin County, ME 30460..................................... Lexington-Fayette, KY

Bourbon County, KY

Clark County, KY

Fayette County, KY

Jessamine County, KY

Scott County, KY

Woodford County, KY 30620..................................... Lima, OH

Allen County, OH 30700..................................... Lincoln, NE

Lancaster County, NE

Seward County, NE 30780..................................... Little Rock-North Little

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

Franklin County, ID

Cache County, UT 30980..................................... Longview, TX

Gregg County, TX

Rusk County, TX

Upshur County, TX 31020..................................... Longview, WA

Cowlitz County, WA 31084..................................... \1\ Los Angeles-Long Beach-

Glendale, CA

Los Angeles County, CA 31140..................................... \1\ Louisville-Jefferson

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

Crosby County, TX

Lubbock County, TX 31340..................................... Lynchburg, VA

Amherst County, VA

Appomattox County, VA

Bedford County, VA

Campbell County, VA

Bedford City, VA

Lynchburg City, VA 31420..................................... Macon, GA

Bibb County, GA

Crawford County, GA

Jones County, GA

Monroe County, GA

Twiggs County, GA 31460..................................... Madera, CA

Madera County, CA 31540..................................... Madison, WI

Columbia County, WI

Dane County, WI

Iowa County, WI 31700..................................... Manchester-Nashua, NH

Hillsborough County, NH 31900..................................... Mansfield, OH

Richland County, OH 32420..................................... Mayag[uuml]ez, PR

Hormigueros Municipio, PR

Mayag[uuml]ez Municipio, PR 32580..................................... McAllen-Edinburg-Mission, TX

Hidalgo County, TX 32780..................................... Medford, OR

Jackson County, OR 32820..................................... \1\ Memphis, TN-MS-AR

Crittenden County, AR

DeSoto County, MS

Marshall County, MS

Tate County, MS

Tunica County, MS

Fayette County, TN

Shelby County, TN

Tipton County, TN 32900..................................... Merced, CA

Merced County, CA 33124..................................... \1\ Miami-Miami Beach-

Kendall, FL

Miami-Dade County, FL 33140..................................... Michigan City-La Porte, IN

LaPorte County, IN 33260..................................... Midland, TX

Midland County, TX 33340..................................... \1\ Milwaukee-Waukesha-West

Allis, WI

Milwaukee County, WI

Ozaukee County, WI

Washington County, WI

Waukesha County, WI 33460..................................... \1\ Minneapolis-St. Paul-

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

Missoula County, MT 33660..................................... Mobile, AL

Mobile County, AL 33700..................................... Modesto, CA

Stanislaus County, CA 33740..................................... Monroe, LA

Ouachita Parish, LA

Union Parish, LA 33780..................................... Monroe, MI

Monroe County, MI 33860..................................... Montgomery, AL

Autauga County, AL

Elmore County, AL

Lowndes County, AL

Montgomery County, AL 34060..................................... Morgantown, WV

Monongalia County, WV

Preston County, WV 34100..................................... Morristown, TN

Grainger County, TN

Hamblen County, TN

Jefferson County, TN 34580..................................... Mount Vernon-Anacortes, WA

Skagit County, WA 34620..................................... Muncie, IN

Delaware County, IN 34740..................................... Muskegon-Norton Shores, MI

Muskegon County, MI 34820..................................... Myrtle Beach-North Myrtle

Beach-Conway, SC

Horry County, SC 34900..................................... Napa, CA

Napa County, CA 34940..................................... Naples-Marco Island, FL

Collier County, FL 34980..................................... \1\ Nashville-Davidson-

Murfreesboro-Franklin, TN

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

Nassau County, NY

Suffolk County, NY 35084..................................... \1\ Newark-Union, NJ-PA

Essex County, NJ

Hunterdon County, NJ

Morris County, NJ

Sussex County, NJ

Union County, NJ

Pike County, PA 35300..................................... New Haven-Milford, CT

New Haven County, CT 35380..................................... \1\ New Orleans-Metairie-

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-

Wayne, NY-NJ

Bergen County, NJ

Hudson County, NJ

Passaic County, NJ

Bronx County, NY

Kings County, NY

Page 23807

New York County, NY

Putnam County, NY

Queens County, NY

Richmond County, NY

Rockland County, NY

Westchester County, NY 35660..................................... Niles-Benton Harbor, MI

Berrien County, MI 35980..................................... Norwich-New London, CT

New London County, CT 36084..................................... \1\ Oakland-Fremont-Hayward,

CA

Alameda County, CA

Contra Costa County, CA 36100..................................... Ocala, FL

Marion County, FL 36140..................................... Ocean City, NJ

Cape May County, NJ 36220..................................... Odessa, TX

Ector County, TX 36260..................................... Ogden-Clearfield, UT

Davis County, UT

Morgan County, UT

Weber County, UT 36420..................................... \1\ Oklahoma City, OK

Canadian County, OK

Cleveland County, OK

Grady County, OK

Lincoln County, OK

Logan County, OK

McClain County, OK

Oklahoma County, OK 36500..................................... Olympia, WA

Thurston County, WA 36540..................................... Omaha-Council Bluffs, NE-IA

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

Lake County, FL

Orange County, FL

Osceola County, FL

Seminole County, FL 36780..................................... Oshkosh-Neenah, WI

Winnebago County, WI 36980..................................... Owensboro, KY

Daviess County, KY

Hancock County, KY

McLean County, KY 37100..................................... Oxnard-Thousand Oaks-

Ventura, CA

Ventura County, CA 37340..................................... Palm Bay-Melbourne-

Titusville, FL

Brevard County, FL 37380..................................... Palm Coast, FL

Flager County, FL 37460..................................... Panama City-Lynn Haven, FL

Bay County, FL 37620..................................... Parkersburg-Marietta-Vienna,

WV-OH

Washington County, OH

Pleasants County, WV

Wirt County, WV

Wood County, WV 37700..................................... Pascagoula, MS

George County, MS

Jackson County, MS 37764..................................... Peabody, MA

Essex County, MA 37860..................................... Pensacola-Ferry Pass-Brent,

FL

Escambia County, FL

Santa Rosa County, FL 37900..................................... Peoria, IL

Marshall County, IL

Peoria County, IL

Stark County, IL

Tazewell County, IL

Woodford County, IL 37964..................................... \1\ Philadelphia, PA

Bucks County, PA

Chester County, PA

Delaware County, PA

Montgomery County, PA

Philadelphia County, PA 38060..................................... \1\ Phoenix-Mesa-Scottsdale,

AZ

Maricopa County, AZ

Pinal County, AZ 38220..................................... Pine Bluff, AR

Cleveland County, AR

Jefferson County, AR

Lincoln County, AR 38300..................................... \1\ Pittsburgh, PA

Allegheny County, PA

Armstrong County, PA

Beaver County, PA

Butler County, PA

Fayette County, PA

Washington County, PA

Westmoreland County, PA 38340..................................... Pittsfield, MA

Berkshire County, MA 38540..................................... Pocatello, ID

Bannock County, ID

Power County, ID 38660..................................... Ponce, PR

Juana D[iacute]az

Municipio, PR

Ponce Municipio, PR

Villalba Municipio, PR 38860..................................... Portland-South Portland-

Biddeford, ME

Cumberland County, ME

Sagadahoc County, ME

York County, ME 38900..................................... \1\ Portland-Vancouver-

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

Martin County, FL

St. Lucie County, FL 39100..................................... Poughkeepsie-Newburgh-

Middletown, NY

Dutchess County, NY

Orange County, NY 39140..................................... Prescott, AZ

Yavapai County, AZ 39300..................................... \1\ Providence-New Bedford-

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

Juab County, UT

Utah County, UT 39380..................................... Pueblo, CO

Pueblo County, CO 39460..................................... Punta Gorda, FL

Charlotte County, FL 39540..................................... Racine, WI

Racine County, WI 39580..................................... Raleigh-Cary, NC

Franklin County, NC

Johnston County, NC

Wake County, NC 39660..................................... Rapid City, SD

Meade County, SD

Pennington County, SD 39740..................................... Reading, PA

Berks County, PA 39820..................................... Redding, CA

Shasta County, CA 39900..................................... Reno-Sparks, NV

Storey County, NV

Washoe County, NV 40060..................................... \1\ Richmond, VA

Amelia County, VA

Caroline County, VA

Charles City County, VA

Chesterfield County, VA

Cumberland County, VA

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\ Riverside-San Bernardino-

Ontario, CA

Riverside County, CA

San Bernardino County, CA 40220..................................... Roanoke, VA

Botetourt County, VA

Craig County, VA

Franklin County, VA

Roanoke County, VA

Roanoke City, VA

Salem City, VA 40340..................................... Rochester, MN

Dodge County, MN

Olmsted County, MN

Wabasha County, MN 40380..................................... \1\ Rochester, NY

Livingston County, NY

Monroe County, NY

Ontario County, NY

Page 23808

Orleans County, NY

Wayne County, NY 40420..................................... Rockford, IL

Boone County, IL

Winnebago County, IL 40484..................................... Rockingham County-Strafford

County, NH

Rockingham County, NH

Strafford County, NH 40580..................................... Rocky Mount, NC

Edgecombe County, NC

Nash County, NC 40660..................................... Rome, GA

Floyd County, GA 40900..................................... \1\ Sacramento--Arden-

Arcade--Roseville, CA

El Dorado County, CA

Placer County, CA

Sacramento County, CA

Yolo County, CA 40980..................................... Saginaw-Saginaw Township

North, MI

Saginaw County, MI 41060..................................... St. Cloud, MN

Benton County, MN

Stearns County, MN 41100..................................... St. George, UT

Washington County, UT 41140..................................... St. Joseph, MO-KS

Doniphan County, KS

Andrew County, MO

Buchanan County, MO

DeKalb County, MO 41180..................................... \1\ St. Louis, MO-IL

Bond County, IL

Calhoun County, IL

Clinton County, IL

Jersey County, IL

Macoupin County, IL

Madison County, IL

Monroe County, IL

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

Marion County, OR

Polk County, OR 41500..................................... Salinas, CA

Monterey County, CA 41540..................................... Salisbury, MD

Somerset County, MD

Wicomico County, MD 41620..................................... Salt Lake City, UT

Salt Lake County, UT

Summit County, UT

Tooele County, UT 41660..................................... San Angelo, TX

Irion County, TX

Tom Green County, TX 41700..................................... \1\ San Antonio, TX

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\ San Diego-Carlsbad-San

Marcos, CA

San Diego County, CA 41780..................................... Sandusky, OH

Erie County, OH 41884..................................... \1\ San Francisco-San Mateo-

Redwood City, CA

Marin County, CA

San Francisco County, CA

San Mateo County, CA 41900..................................... San Germ[aacute]n-Cabo Rojo,

PR

Cabo Rojo Municipio, PR

Lajas Municipio, PR

Sabana Grande Municipio, PR

San Germ[aacute]n

Municipio, PR 41940..................................... \1\ San Jose-Sunnyvale-Santa

Clara, CA

San Benito County, CA

Santa Clara County, CA 41980..................................... \1\ San Juan-Caguas-

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

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 Robles,

CA

San Luis Obispo County, CA 42044..................................... \1\ Santa Ana-Anaheim-

Irvine, CA

Orange County, CA 42060..................................... Santa Barbara-Santa Maria-

Goleta, CA

Santa Barbara County, CA 42100..................................... Santa Cruz-Watsonville, CA

Santa Cruz County, CA 42140..................................... Santa Fe, NM

Santa Fe County, NM 42220..................................... Santa Rosa-Petaluma, CA

Sonoma County, CA 42340..................................... Savannah, GA

Bryan County, GA

Chatham County, GA

Effingham County, GA 42540..................................... Scranton--Wilkes-Barre, PA

Lackawanna County, PA

Luzerne County, PA

Wyoming County, PA 42644..................................... \1\ Seattle-Bellevue-

Everett, WA

King County, WA

Snohomish County, WA 42680..................................... Sebastian-Vero Beach, FL

Indian River County, FL 43100..................................... Sheboygan, WI

Sheboygan County, WI 43300..................................... Sherman-Denison, TX

Grayson County, TX 43340..................................... Shreveport-Bossier City, LA

Bossier Parish, LA

Caddo Parish, LA

De Soto Parish, LA 43580..................................... Sioux City, IA-NE-SD

Woodbury County, IA

Dakota County, NE

Dixon County, NE

Union County, SD 43620..................................... Sioux Falls, SD

Lincoln County, SD

McCook County, SD

Minnehaha County, SD

Turner County, SD 43780..................................... South Bend-Mishawaka, IN-MI

St. Joseph County, IN

Cass County, MI 43900..................................... Spartanburg, SC

Spartanburg County, SC 44060..................................... Spokane, WA

Spokane County, WA 44100..................................... Springfield, IL

Menard County, IL

Sangamon County, IL 44140..................................... Springfield, MA

Franklin County, MA

Hampden County, MA

Hampshire County, MA 44180..................................... Springfield, MO

Christian County, MO

Dallas County, MO

Greene County, MO

Polk County, MO

Webster County, MO 44220..................................... Springfield, OH

Clark County, OH 44300..................................... State College, PA

Centre County, PA

Page 23809

44700..................................... Stockton, CA

San Joaquin County, CA 44940..................................... Sumter, SC

Sumter County, SC 45060..................................... Syracuse, NY

Madison County, NY

Onondaga County, NY

Oswego County, NY 45104..................................... Tacoma, WA

Pierce County, WA 45220..................................... Tallahassee, FL

Gadsden County, FL

Jefferson County, FL

Leon County, FL

Wakulla County, FL 45300..................................... \1\ Tampa-St. Petersburg-

Clearwater, FL

Hernando County, FL

Hillsborough County, FL

Pasco County, FL

Pinellas County, FL 45460..................................... Terre Haute, IN

Clay County, IN

Sullivan County, IN

Vermillion County, IN

Vigo County, IN 45500..................................... Texarkana, TX-Texarkana, AR

Miller County, AR

Bowie County, TX 45780..................................... Toledo, OH

Fulton County, OH

Lucas County, OH

Ottawa County, OH

Wood County, OH 45820..................................... Topeka, KS

Jackson County, KS

Jefferson County, KS

Osage County, KS

Shawnee County, KS

Wabaunsee County, KS 45940..................................... Trenton-Ewing, NJ

Mercer County, NJ 46060..................................... Tucson, AZ

Pima County, AZ 46140..................................... Tulsa, OK

Creek County, OK

Okmulgee County, OK

Osage County, OK

Pawnee County, OK

Rogers County, OK

Tulsa County, OK

Wagoner County, OK 46220..................................... Tuscaloosa, AL

Greene County, AL

Hale County, AL

Tuscaloosa County, AL 46340..................................... Tyler, TX

Smith County, TX 46540..................................... Utica-Rome, NY

Herkimer County, NY

Oneida County, NY 46660..................................... Valdosta, GA

Brooks County, GA

Echols County, GA

Lanier County, GA

Lowndes County, GA 46700..................................... Vallejo-Fairfield, CA

Solano County, CA 47020..................................... Victoria, TX

Calhoun County, TX

Goliad County, TX

Victoria County, TX 47220..................................... Vineland-Millville-

Bridgeton, NJ

Cumberland County, NJ 47260..................................... \1\ Virginia Beach-Norfolk-

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..................................... Visalia-Porterville, CA

Tulare County, CA 47380..................................... Waco, TX

McLennan County, TX 47580..................................... Warner Robins, GA

Houston County, GA 47644..................................... \1\ Warren-Troy-Farmington

Hills, MI

Lapeer County, MI

Livingston County, MI

Macomb County, MI

Oakland County, MI

St. Clair County, MI 47894..................................... \1\ Washington-Arlington-

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

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

Black Hawk County, IA

Bremer County, IA

Grundy County, IA 48140..................................... Wausau, WI

Marathon County, WI 48260..................................... Weirton-Steubenville, WV-OH

Jefferson County, OH

Brooke County, WV

Hancock County, WV 48300..................................... Wenatchee, WA

Chelan County, WA

Douglas County, WA 48424..................................... \1\ West Palm Beach-Boca

Raton-Boynton Beach, FL

Palm Beach County, FL 48540..................................... Wheeling, WV-OH

Belmont County, OH

Marshall County, WV

Ohio County, WV 48620..................................... Wichita, KS

Butler County, KS

Harvey County, KS

Sedgwick County, KS

Sumner County, KS 48660..................................... Wichita Falls, TX

Archer County, TX

Clay County, TX

Wichita County, TX 48700..................................... Williamsport, PA

Lycoming County, PA 48864..................................... Wilmington, DE-MD-NJ

New Castle County, DE

Cecil County, MD

Salem County, NJ 48900..................................... Wilmington, NC

Brunswick County, NC

New Hanover County, NC

Pender County, NC 49020..................................... Winchester, VA-WV

Frederick County, VA

Winchester City, VA

Hampshire County, WV 49180..................................... Winston-Salem, NC

Davie County, NC

Forsyth County, NC

Stokes County, NC

Yadkin County, NC 49340..................................... Worcester, MA

Worcester County, MA 49420..................................... Yakima, WA

Yakima County, WA 49500..................................... Yauco, PR

Gu[aacute]nica Municipio,

PR

Guayanilla Municipio, PR

Pe[ntilde]uelas Municipio,

PR

Yauco Municipio, PR 49620..................................... York-Hanover, PA

York County, PA 49660..................................... Youngstown-Warren-Boardman,

OH-PA

Mahoning County, OH

Trumbull County, OH

Mercer County, PA 49700..................................... Yuba City, CA

Sutter County, CA

Yuba County, CA 49740..................................... Yuma, AZ

Yuma County, AZ

\1\ Large urban area.

Page 23810

Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA--FY 2009

Note: The rural floor budget neutrality adjustment is not applicable to the Puerto Rico-specific wage index.

Wage index--

CBSA code

Area

Wage index

GAF

reclassified

GAF--reclassified hospitals

hospitals

10380.............. Aguadilla-Isabela-San

0.7845

0.8469 ................... .................

Sebasti[aacute]n, PR. 21940.............. Fajardo, PR..............

0.9572

0.9705 ................... ................. 25020.............. Guayama, PR..............

0.7472

0.8191 ................... ................. 32420.............. Mayag[uuml]ez, PR........

0.9236

0.9470 ................... ................. 38660.............. Ponce, PR................

0.9757

0.9833 ................... ................. 41900.............. San Germ[aacute]n-Cabo

1.0864

1.0584 ................... .................

Rojo, PR. 41980.............. San Juan-Caguas-Guaynabo,

1.0348

1.0237 ................... .................

PR. 49500.............. Yauco, PR................

0.7969

0.8560 ................... .................

The following list represents all hospitals that are eligible to have their wage index increased by the out-migration adjustment listed in this table. Hospitals cannot receive the out-migration adjustment if they are reclassified under section 1886(d)(10) of the

Act or redesignated under section 1886(d)(8)(B) 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)(B) of the Act wish to retain their reclassification/ redesignation status and waive the application of the out-migration adjustment. 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)(B) of the Act will be deemed to have waived the out-migration adjustment, unless they explicitly notify CMS that they elected 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, Attn.: Wage Index Adjustment

Waivers, Division of Acute Care, Room C4-08-06, 7500 Security

Boulevard, Baltimore, MD 21244-1850.

Table 4J.--Out-Migration Adjustment--FY 2009

Reclassified for FY

Out-migration

Qualifying county

Provider No.

2009

adjustment

name

County code

010005............................ *.....................

0.0296 MARSHALL............

01470 010008............................ ......................

0.0174 CRENSHAW............

01200 010009............................ *.....................

0.0092 MORGAN..............

01510 010010............................ *.....................

0.0296 MARSHALL............

01470 010012............................ *.....................

0.0186 DE KALB.............

01240 010015............................ ......................

0.0046 CLARKE..............

01120 010021............................ ......................

0.0030 DALE................

01220 010022............................ *.....................

0.1128 CHEROKEE............

01090 010025............................ *.....................

0.0235 CHAMBERS............

01080 010027............................ ......................

0.0015 COFFEE..............

01150 010029............................ *.....................

0.0289 LEE.................

01400 010032............................ ......................

0.0325 RANDOLPH............

01550 010035............................ *.....................

0.0254 CULLMAN.............

01210 010038............................ ......................

0.0047 CALHOUN.............

01070 010040............................ ......................

0.0061 ETOWAH..............

01270 010045............................ ......................

0.0222 FAYETTE.............

01280 010046............................ ......................

0.0061 ETOWAH..............

01270 010047............................ ......................

0.0127 BUTLER..............

01060 010049............................ ......................

0.0015 COFFEE..............

01150 010052............................ *.....................

0.0103 TALLAPOOSA..........

01610 010054............................ *.....................

0.0092 MORGAN..............

01510 010059............................ *.....................

0.0069 LAWRENCE............

01390 010061............................ *.....................

0.0542 JACKSON.............

01350 010065............................ *.....................

0.0103 TALLAPOOSA..........

01610 010078............................ ......................

0.0047 CALHOUN.............

01070 010083............................ *.....................

0.0134 BALDWIN.............

01010 010085............................ *.....................

0.0092 MORGAN..............

01510 010091............................ ......................

0.0046 CLARKE..............

01120 010100............................ *.....................

0.0134 BALDWIN.............

01010 010101............................ *.....................

0.0211 TALLADEGA...........

01600 010109............................ ......................

0.0451 PICKENS.............

01530 010110............................ ......................

0.0215 BULLOCK.............

01050 010125............................ ......................

0.0476 WINSTON.............

01660 010128............................ ......................

0.0046 CLARKE..............

01120 010129............................ ......................

0.0134 BALDWIN.............

01010 010138............................ ......................

0.0066 SUMTER..............

01590 010143............................ *.....................

0.0254 CULLMAN.............

01210 010146............................ ......................

0.0047 CALHOUN.............

01070

Page 23811

010150............................ *.....................

0.0127 BUTLER..............

01060 010158............................ *.....................

0.0023 FRANKLIN............

01290 010164............................ *.....................

0.0211 TALLADEGA...........

01600 030067............................ ......................

0.0298 LAPAZ...............

03055 040014............................ *.....................

0.0199 WHITE...............

04720 040019............................ *.....................

0.0258 ST. FRANCIS.........

04610 040039............................ *.....................

0.0172 GREENE..............

04270 040047............................ ......................

0.0117 RANDOLPH............

04600 040067............................ ......................

0.0007 COLUMBIA............

04130 040071............................ *.....................

0.0149 JEFFERSON...........

04340 040076............................ *.....................

0.1000 HOT SPRING..........

04290 040081............................ ......................

0.0357 PIKE................

04540 050002............................ ......................

0.0010 ALAMEDA.............

05000 050007............................ ......................

0.0146 SAN MATEO...........

05510 050008............................ ......................

0.0026 SAN FRANCISCO.......

05480 050009............................ *.....................

0.0180 NAPA................

05380 050013............................ *.....................

0.0180 NAPA................

05380 050014............................ *.....................

0.0139 AMADOR..............

05020 050016............................ ......................

0.0103 SAN LUIS OBISPO.....

05500 050042............................ *.....................

0.0162 TEHAMA..............

05620 050043............................ ......................

0.0010 ALAMEDA.............

05000 050047............................ ......................

0.0026 SAN FRANCISCO.......

05480 050055............................ ......................

0.0026 SAN FRANCISCO.......

05480 050069............................ *.....................

0.0020 ORANGE..............

05400 050070............................ ......................

0.0146 SAN MATEO...........

05510 050073............................ *.....................

0.0171 SOLANO..............

05580 050075............................ ......................

0.0010 ALAMEDA.............

05000 050076............................ *.....................

0.0026 SAN FRANCISCO.......

05480 050084............................ ......................

0.0132 SAN JOAQUIN.........

05490 050089............................ *.....................

0.0017 SAN BERNARDINO......

05460 050090............................ *.....................

0.0058 SONOMA..............

05590 050099............................ *.....................

0.0017 SAN BERNARDINO......

05460 050101............................ *.....................

0.0171 SOLANO..............

05580 050113............................ ......................

0.0146 SAN MATEO...........

05510 050118............................ *.....................

0.0132 SAN JOAQUIN.........

05490 050122............................ ......................

0.0132 SAN JOAQUIN.........

05490 050129............................ *.....................

0.0017 SAN BERNARDINO......

05460 050133............................ *.....................

0.0178 YUBA................

05680 050136............................ *.....................

0.0058 SONOMA..............

05590 050140............................ *.....................

0.0017 SAN BERNARDINO......

05460 050150............................ *.....................

0.0342 NEVADA..............

05390 050152............................ ......................

0.0026 SAN FRANCISCO.......

05480 050167............................ ......................

0.0132 SAN JOAQUIN.........

05490 050168............................ *.....................

0.0020 ORANGE..............

05400 050173............................ *.....................

0.0020 ORANGE..............

05400 050174............................ *.....................

0.0058 SONOMA..............

05590 050193............................ *.....................

0.0020 ORANGE..............

05400 050194............................ *.....................

0.0052 SANTA CRUZ..........

05540 050195............................ ......................

0.0010 ALAMEDA.............

05000 050197............................ *.....................

0.0146 SAN MATEO...........

05510 050211............................ ......................

0.0010 ALAMEDA.............

05000 050224............................ *.....................

0.0020 ORANGE..............

05400 050226............................ *.....................

0.0020 ORANGE..............

05400 050228............................ ......................

0.0026 SAN FRANCISCO.......

05480 050230............................ *.....................

0.0020 ORANGE..............

05400 050232............................ ......................

0.0103 SAN LUIS OBISPO.....

05500 050242............................ *.....................

0.0052 SANTA CRUZ..........

05540 050245............................ *.....................

0.0017 SAN BERNARDINO......

05460 050264............................ ......................

0.0010 ALAMEDA.............

05000 050272............................ *.....................

0.0017 SAN BERNARDINO......

05460 050279............................ *.....................

0.0017 SAN BERNARDINO......

05460 050283............................ ......................

0.0010 ALAMEDA.............

05000 050289............................ ......................

0.0146 SAN MATEO...........

05510 050291............................ *.....................

0.0058 SONOMA..............

05590 050298............................ ......................

0.0017 SAN BERNARDINO......

05460 050300............................ *.....................

0.0017 SAN BERNARDINO......

05460 050305............................ ......................

0.0010 ALAMEDA.............

05000 050313............................ ......................

0.0132 SAN JOAQUIN.........

05490 050320............................ ......................

0.0010 ALAMEDA.............

05000 050325............................ ......................

0.0033 TUOLUMNE............

05650 050327............................ *.....................

0.0017 SAN BERNARDINO......

05460

Page 23812

050335............................ *.....................

0.0033 TUOLUMNE............

05650 050336............................ ......................

0.0132 SAN JOAQUIN.........

05490 050348............................ *.....................

0.0020 ORANGE..............

05400 050366............................ ......................

0.0015 CALAVERAS...........

05040 050367............................ *.....................

0.0171 SOLANO..............

05580 050385............................ *.....................

0.0058 SONOMA..............

05590 050407............................ ......................

0.0026 SAN FRANCISCO.......

05480 050426............................ *.....................

0.0020 ORANGE..............

05400 050444............................ ......................

0.0233 MERCED..............

05340 050454............................ ......................

0.0026 SAN FRANCISCO.......

05480 050457............................ ......................

0.0026 SAN FRANCISCO.......

05480 050476............................ *.....................

0.0278 LAKE................

05160 050488............................ ......................

0.0010 ALAMEDA.............

05000 050494............................ *.....................

0.0342 NEVADA..............

05390 050506............................ ......................

0.0103 SAN LUIS OBISPO.....

05500 050512............................ ......................

0.0010 ALAMEDA.............

05000 050517............................ *.....................

0.0017 SAN BERNARDINO......

05460 050526............................ *.....................

0.0020 ORANGE..............

05400 050528............................ *.....................

0.0233 MERCED..............

05340 050541............................ *.....................

0.0146 SAN MATEO...........

05510 050543............................ *.....................

0.0020 ORANGE..............

05400 050547............................ *.....................

0.0058 SONOMA..............

05590 050548............................ *.....................

0.0020 ORANGE..............

05400 050551............................ *.....................

0.0020 ORANGE..............

05400 050567............................ *.....................

0.0020 ORANGE..............

05400 050570............................ *.....................

0.0020 ORANGE..............

05400 050580............................ *.....................

0.0020 ORANGE..............

05400 050584............................ ......................

0.0017 SAN BERNARDINO......

05460 050586............................ *.....................

0.0017 SAN BERNARDINO......

05460 050589............................ *.....................

0.0020 ORANGE..............

05400 050603............................ *.....................

0.0020 ORANGE..............

05400 050609............................ *.....................

0.0020 ORANGE..............

05400 050618............................ *.....................

0.0017 SAN BERNARDINO......

05460 050633............................ ......................

0.0103 SAN LUIS OBISPO.....

05500 050667............................ *.....................

0.0180 NAPA................

05380 050668............................ ......................

0.0026 SAN FRANCISCO.......

05480 050678............................ *.....................

0.0020 ORANGE..............

05400 050680............................ *.....................

0.0171 SOLANO..............

05580 050690............................ *.....................

0.0058 SONOMA..............

05590 050693............................ *.....................

0.0020 ORANGE..............

05400 050714............................ ......................

0.0052 SANTA CRUZ..........

05540 050720............................ *.....................

0.0020 ORANGE..............

05400 050744............................ *.....................

0.0020 ORANGE..............

05400 050745............................ *.....................

0.0020 ORANGE..............

05400 050746............................ *.....................

0.0020 ORANGE..............

05400 050747............................ *.....................

0.0020 ORANGE..............

05400 050748............................ ......................

0.0132 SAN JOAQUIN.........

05490 050754............................ ......................

0.0146 SAN MATEO...........

05510 050758............................ *.....................

0.0017 SAN BERNARDINO......

05460 060001............................ ......................

0.0042 WELD................

06610 060003............................ *.....................

0.0069 BOULDER.............

06060 060010............................ ......................

0.0153 LARIMER.............

06340 060027............................ *.....................

0.0069 BOULDER.............

06060 060030............................ ......................

0.0153 LARIMER.............

06340 060103............................ *.....................

0.0069 BOULDER.............

06060 060116............................ *.....................

0.0069 BOULDER.............

06060 060119............................ ......................

0.0153 LARIMER.............

06340 070006............................ *.....................

0.0045 FAIRFIELD...........

07000 070010............................ *.....................

0.0045 FAIRFIELD...........

07000 070018............................ *.....................

0.0045 FAIRFIELD...........

07000 070028............................ *.....................

0.0045 FAIRFIELD...........

07000 070033............................ *.....................

0.0045 FAIRFIELD...........

07000 070034............................ *.....................

0.0045 FAIRFIELD...........

07000 080001............................ *.....................

0.0063 NEW CASTLE..........

08010 080003............................ *.....................

0.0063 NEW CASTLE..........

08010 100014............................ *.....................

0.0047 VOLUSIA.............

10630 100017............................ *.....................

0.0047 VOLUSIA.............

10630 100045............................ *.....................

0.0047 VOLUSIA.............

10630 100047............................ *.....................

0.0028 CHARLOTTE...........

10070 100068............................ *.....................

0.0047 VOLUSIA.............

10630 100072............................ *.....................

0.0047 VOLUSIA.............

10630

Page 23813

100077............................ *.....................

0.0028 CHARLOTTE...........

10070 100081............................ *.....................

0.0022 WALTON..............

10650 100102............................ ......................

0.0125 COLUMBIA............

10110 100118............................ *.....................

0.0177 FLAGLER.............

10170 100156............................ *.....................

0.0125 COLUMBIA............

10110 100232............................ *.....................

0.0054 PUTNAM..............

10530 100236............................ *.....................

0.0028 CHARLOTTE...........

10070 100252............................ *.....................

0.0151 OKEECHOBEE..........

10460 100290............................ ......................

0.0582 SUMTER..............

10590 100292............................ *.....................

0.0022 WALTON..............

10650 110023............................ *.....................

0.0416 GORDON..............

11500 110029............................ *.....................

0.0052 HALL................

11550 110040............................ *.....................

0.1455 JACKSON.............

11610 110041............................ *.....................

0.0623 HABERSHAM...........

11540 110100............................ ......................

0.0790 JEFFERSON...........

11620 110101............................ ......................

0.0067 COOK................

11311 110142............................ ......................

0.0185 EVANS...............

11441 110146............................ *.....................

0.0805 CAMDEN..............

11170 110150............................ *.....................

0.0227 BALDWIN.............

11030 110187............................ *.....................

0.0643 LUMPKIN.............

11701 110189............................ *.....................

0.0066 FANNIN..............

11450 110190............................ ......................

0.0241 MACON...............

11710 110205............................ ......................

0.0507 GILMER..............

11471 130003............................ *.....................

0.0235 NEZ PERCE...........

13340 130024............................ ......................

0.0675 BONNER..............

13080 130049............................ *.....................

0.0319 KOOTENAI............

13270 130066............................ ......................

0.0319 KOOTENAI............

13270 130067............................ *.....................

0.0725 BINGHAM.............

13050 140001............................ ......................

0.0369 FULTON..............

14370 140026............................ ......................

0.0315 LA SALLE............

14580 140043............................ *.....................

0.0056 WHITESIDE...........

14988 140058............................ *.....................

0.0126 MORGAN..............

14770 140110............................ *.....................

0.0315 LA SALLE............

14580 140116............................ ......................

0.0007 MC HENRY............

14640 140160............................ *.....................

0.0332 STEPHENSON..........

14970 140161............................ ......................

0.0168 LIVINGSTON..........

14610 140167............................ *.....................

0.0632 IROQUOIS............

14460 140176............................ ......................

0.0007 MC HENRY............

14640 140234............................ ......................

0.0315 LA SALLE............

14580 150006............................ *.....................

0.0113 LA PORTE............

15450 150015............................ *.....................

0.0113 LA PORTE............

15450 150022............................ ......................

0.0158 MONTGOMERY..........

15530 150030............................ *.....................

0.0192 HENRY...............

15320 150072............................ ......................

0.0105 CASS................

15080 150076............................ *.....................

0.0215 MARSHALL............

15490 150088............................ *.....................

0.0111 MADISON.............

15470 150091............................ *.....................

0.0050 HUNTINGTON..........

15340 150102............................ *.....................

0.0108 STARKE..............

15740 150113............................ *.....................

0.0111 MADISON.............

15470 150133............................ *.....................

0.0193 KOSCIUSKO...........

15420 150146............................ *.....................

0.0319 NOBLE...............

15560 160013............................ ......................

0.0179 MUSCATINE...........

16690 160030............................ ......................

0.0040 STORY...............

16840 160032............................ ......................

0.0235 JASPER..............

16490 160080............................ *.....................

0.0066 CLINTON.............

16220 170137............................ *.....................

0.0336 DOUGLAS.............

17220 170150............................ ......................

0.0166 COWLEY..............

17170 180012............................ *.....................

0.0080 HARDIN..............

18460 180017............................ *.....................

0.0035 BARREN..............

18040 180049............................ *.....................

0.0488 MADISON.............

18750 180064............................ ......................

0.0314 MONTGOMERY..........

18860 180066............................ *.....................

0.0439 LOGAN...............

18700 180070............................ ......................

0.0240 GRAYSON.............

18420 180079............................ ......................

0.0259 HARRISON............

18480 190003............................ *.....................

0.0085 IBERIA..............

19220 190015............................ *.....................

0.0243 TANGIPAHOA..........

19520 190017............................ *.....................

0.0187 ST. LANDRY..........

19480 190034............................ ......................

0.0189 VERMILION...........

19560 190044............................ ......................

0.0261 ACADIA..............

19000 190050............................ ......................

0.0044 BEAUREGARD..........

19050 190053............................ ......................

0.0101 JEFFERSON DAVIS.....

19260

Page 23814

190054............................ ......................

0.0085 IBERIA..............

19220 190078............................ ......................

0.0187 ST. LANDRY..........

19480 190086............................ *.....................

0.0061 LINCOLN.............

19300 190088............................ *.....................

0.0387 WEBSTER.............

19590 190099............................ ......................

0.0189 AVOYELLES...........

19040 190106............................ *.....................

0.0102 ALLEN...............

19010 190116............................ ......................

0.0085 MOREHOUSE...........

19330 190133............................ ......................

0.0102 ALLEN...............

19010 190140............................ ......................

0.0035 FRANKLIN............

19200 190144............................ *.....................

0.0387 WEBSTER.............

19590 190145............................ ......................

0.0090 LA SALLE............

19290 190184............................ *.....................

0.0161 CALDWELL............

19100 190190............................ ......................

0.0161 CALDWELL............

19100 190191............................ *.....................

0.0187 ST. LANDRY..........

19480 190246............................ ......................

0.0161 CALDWELL............

19100 190257............................ *.....................

0.0061 LINCOLN.............

19300 190277............................ ......................

0.0387 WEBSTER.............

19590 200024............................ *.....................

0.0094 ANDROSCOGGIN........

20000 200032............................ ......................

0.0466 OXFORD..............

20080 200034............................ *.....................

0.0094 ANDROSCOGGIN........

20000 200050............................ *.....................

0.0227 HANCOCK.............

20040 210001............................ ......................

0.0187 WASHINGTON..........

21210 210023............................ ......................

0.0079 ANNE ARUNDEL........

21010 210028............................ ......................

0.0512 ST. MARYS...........

21180 210043............................ ......................

0.0079 ANNE ARUNDEL........

21010 210061............................ ......................

0.0188 WORCESTER...........

21230 220001............................ *.....................

0.0067 WORCESTER...........

22170 220002............................ *.....................

0.0271 MIDDLESEX...........

22090 220010............................ *.....................

0.0355 ESSEX...............

22040 220011............................ *.....................

0.0271 MIDDLESEX...........

22090 220019............................ *.....................

0.0067 WORCESTER...........

22170 220025............................ *.....................

0.0067 WORCESTER...........

22170 220029............................ *.....................

0.0355 ESSEX...............

22040 220033............................ *.....................

0.0355 ESSEX...............

22040 220035............................ *.....................

0.0355 ESSEX...............

22040 220049............................ *.....................

0.0271 MIDDLESEX...........

22090 220058............................ *.....................

0.0067 WORCESTER...........

22170 220062............................ *.....................

0.0067 WORCESTER...........

22170 220063............................ *.....................

0.0271 MIDDLESEX...........

22090 220070............................ *.....................

0.0271 MIDDLESEX...........

22090 220080............................ *.....................

0.0355 ESSEX...............

22040 220082............................ *.....................

0.0271 MIDDLESEX...........

22090 220084............................ *.....................

0.0271 MIDDLESEX...........

22090 220090............................ *.....................

0.0067 WORCESTER...........

22170 220095............................ *.....................

0.0067 WORCESTER...........

22170 220098............................ *.....................

0.0271 MIDDLESEX...........

22090 220101............................ *.....................

0.0271 MIDDLESEX...........

22090 220105............................ *.....................

0.0271 MIDDLESEX...........

22090 220163............................ *.....................

0.0067 WORCESTER...........

22170 220171............................ *.....................

0.0271 MIDDLESEX...........

22090 220174............................ *.....................

0.0355 ESSEX...............

22040 220176............................ *.....................

0.0067 WORCESTER...........

22170 230003............................ *.....................

0.0220 OTTAWA..............

23690 230005............................ ......................

0.0473 LENAWEE.............

23450 230013............................ *.....................

0.0025 OAKLAND.............

23620 230015............................ ......................

0.0295 ST. JOSEPH..........

23740 230019............................ *.....................

0.0025 OAKLAND.............

23620 230021............................ *.....................

0.0101 BERRIEN.............

23100 230022............................ *.....................

0.0212 BRANCH..............

23110 230029............................ *.....................

0.0025 OAKLAND.............

23620 230035............................ *.....................

0.0095 MONTCALM............

23580 230037............................ *.....................

0.0210 HILLSDALE...........

23290 230047............................ *.....................

0.0021 MACOMB..............

23490 230069............................ *.....................

0.0210 LIVINGSTON..........

23460 230071............................ *.....................

0.0025 OAKLAND.............

23620 230072............................ *.....................

0.0220 OTTAWA..............

23690 230075............................ ......................

0.0047 CALHOUN.............

23120 230078............................ *.....................

0.0101 BERRIEN.............

23100 230092............................ *.....................

0.0223 JACKSON.............

23370 230093............................ ......................

0.0058 MECOSTA.............

23530 230096............................ *.....................

0.0295 ST. JOSEPH..........

23740

Page 23815

230099............................ *.....................

0.0231 MONROE..............

23570 230121............................ *.....................

0.0678 SHIAWASSEE..........

23770 230130............................ *.....................

0.0025 OAKLAND.............

23620 230151............................ *.....................

0.0025 OAKLAND.............

23620 230174............................ *.....................

0.0220 OTTAWA..............

23690 230195............................ *.....................

0.0021 MACOMB..............

23490 230204............................ *.....................

0.0021 MACOMB..............

23490 230207............................ *.....................

0.0025 OAKLAND.............

23620 230208............................ *.....................

0.0095 MONTCALM............

23580 230217............................ ......................

0.0047 CALHOUN.............

23120 230222............................ *.....................

0.0035 MIDLAND.............

23550 230223............................ *.....................

0.0025 OAKLAND.............

23620 230227............................ *.....................

0.0021 MACOMB..............

23490 230254............................ *.....................

0.0025 OAKLAND.............

23620 230257............................ *.....................

0.0021 MACOMB..............

23490 230264............................ *.....................

0.0021 MACOMB..............

23490 230269............................ *.....................

0.0025 OAKLAND.............

23620 230277............................ *.....................

0.0025 OAKLAND.............

23620 230279............................ *.....................

0.0210 LIVINGSTON..........

23460 230301............................ *.....................

0.0025 OAKLAND.............

23620 240018............................ ......................

0.0805 GOODHUE.............

24240 240044............................ ......................

0.0625 WINONA..............

24840 240064............................ *.....................

0.0134 ITASCA..............

24300 240069............................ *.....................

0.0267 STEELE..............

24730 240071............................ *.....................

0.0385 RICE................

24650 240117............................ ......................

0.0527 MOWER...............

24490 240211............................ ......................

0.0812 PINE................

24570 250023............................ *.....................

0.0541 PEARL RIVER.........

25540 250040............................ *.....................

0.0021 JACKSON.............

25290 250117............................ *.....................

0.0541 PEARL RIVER.........

25540 250128............................ ......................

0.0446 PANOLA..............

25530 250162............................ ......................

0.0014 HANCOCK.............

25220 260059............................ ......................

0.0077 LACLEDE.............

26520 260064............................ *.....................

0.0089 AUDRAIN.............

26030 260097............................ ......................

0.0300 JOHNSON.............

26500 260116............................ *.....................

0.0087 ST. FRANCOIS........

26930 260163............................ ......................

0.0087 ST. FRANCOIS........

26930 280077............................ ......................

0.0080 DODGE...............

28260 280123............................ ......................

0.0123 GAGE................

28330 290002............................ *.....................

0.0277 LYON................

29090 300011............................ *.....................

0.0069 HILLSBOROUGH........

30050 300012............................ *.....................

0.0069 HILLSBOROUGH........

30050 300017............................ *.....................

0.0102 ROCKINGHAM..........

30070 300020............................ *.....................

0.0069 HILLSBOROUGH........

30050 300023............................ *.....................

0.0102 ROCKINGHAM..........

30070 300029............................ *.....................

0.0102 ROCKINGHAM..........

30070 300034............................ *.....................

0.0069 HILLSBOROUGH........

30050 310002............................ *.....................

0.0268 ESSEX...............

31200 310009............................ *.....................

0.0268 ESSEX...............

31200 310010............................ ......................

0.0092 MERCER..............

31260 310011............................ ......................

0.0115 CAPE MAY............

31180 310015............................ *.....................

0.0203 MORRIS..............

31300 310017............................ *.....................

0.0203 MORRIS..............

31300 310018............................ *.....................

0.0268 ESSEX...............

31200 310021............................ *.....................

0.0092 MERCER..............

31260 310031............................ *.....................

0.0153 BURLINGTON..........

31150 310038............................ *.....................

0.0209 MIDDLESEX...........

31270 310039............................ *.....................

0.0209 MIDDLESEX...........

31270 310044............................ ......................

0.0092 MERCER..............

31260 310050............................ *.....................

0.0203 MORRIS..............

31300 310054............................ *.....................

0.0268 ESSEX...............

31200 310057............................ *.....................

0.0153 BURLINGTON..........

31150 310061............................ *.....................

0.0153 BURLINGTON..........

31150 310069............................ *.....................

0.0096 SALEM...............

31340 310070............................ *.....................

0.0209 MIDDLESEX...........

31270 310076............................ *.....................

0.0268 ESSEX...............

31200 310083............................ *.....................

0.0268 ESSEX...............

31200 310091............................ *.....................

0.0096 SALEM...............

31340 310092............................ ......................

0.0092 MERCER..............

31260 310093............................ *.....................

0.0268 ESSEX...............

31200 310096............................ *.....................

0.0268 ESSEX...............

31200

Page 23816

310108............................ *.....................

0.0209 MIDDLESEX...........

31270 310110............................ ......................

0.0092 MERCER..............

31260 310119............................ *.....................

0.0268 ESSEX...............

31200 320003............................ *.....................

0.0629 SAN MIGUEL..........

32230 320011............................ ......................

0.0442 RIO ARRIBA..........

32190 320018............................ ......................

0.0024 DONA ANA............

32060 320085............................ ......................

0.0024 DONA ANA............

32060 330004............................ *.....................

0.0633 ULSTER..............

33740 330008............................ *.....................

0.0126 WYOMING.............

33900 330010............................ ......................

0.0067 MONTGOMERY..........

33380 330027............................ *.....................

0.0123 NASSAU..............

33400 330033............................ ......................

0.0223 CHENANGO............

33080 330047............................ ......................

0.0067 MONTGOMERY..........

33380 330073............................ *.....................

0.0151 GENESEE.............

33290 330094............................ *.....................

0.0503 COLUMBIA............

33200 330103............................ *.....................

0.0131 CATTARAUGUS.........

33040 330106............................ *.....................

0.0123 NASSAU..............

33400 330126............................ *.....................

0.0642 ORANGE..............

33540 330132............................ ......................

0.0131 CATTARAUGUS.........

33040 330135............................ ......................

0.0642 ORANGE..............

33540 330144............................ ......................

0.0054 STEUBEN.............

33690 330151............................ ......................

0.0054 STEUBEN.............

33690 330167............................ *.....................

0.0123 NASSAU..............

33400 330175............................ ......................

0.0260 CORTLAND............

33210 330181............................ *.....................

0.0123 NASSAU..............

33400 330182............................ *.....................

0.0123 NASSAU..............

33400 330191............................ *.....................

0.0017 WARREN..............

33750 330198............................ *.....................

0.0123 NASSAU..............

33400 330205............................ ......................

0.0642 ORANGE..............

33540 330224............................ *.....................

0.0633 ULSTER..............

33740 330225............................ *.....................

0.0123 NASSAU..............

33400 330235............................ *.....................

0.0306 CAYUGA..............

33050 330259............................ *.....................

0.0123 NASSAU..............

33400 330264............................ ......................

0.0642 ORANGE..............

33540 330276............................ ......................

0.0036 FULTON..............

33280 330277............................ *.....................

0.0054 STEUBEN.............

33690 330331............................ *.....................

0.0123 NASSAU..............

33400 330332............................ *.....................

0.0123 NASSAU..............

33400 330372............................ *.....................

0.0123 NASSAU..............

33400 330386............................ *.....................

0.0745 SULLIVAN............

33710 340020............................ ......................

0.0156 LEE.................

34520 340021............................ *.....................

0.0162 CLEVELAND...........

34220 340024............................ ......................

0.0177 SAMPSON.............

34810 340027............................ *.....................

0.0128 LENOIR..............

34530 340037............................ ......................

0.0162 CLEVELAND...........

34220 340038............................ ......................

0.0253 BEAUFORT............

34060 340039............................ *.....................

0.0101 IREDELL.............

34480 340068............................ *.....................

0.0087 COLUMBUS............

34230 340069............................ *.....................

0.0015 WAKE................

34910 340070............................ *.....................

0.0395 ALAMANCE............

34000 340071............................ *.....................

0.0226 HARNETT.............

34420 340073............................ *.....................

0.0015 WAKE................

34910 340085............................ ......................

0.0250 DAVIDSON............

34280 340096............................ ......................

0.0250 DAVIDSON............

34280 340104............................ ......................

0.0162 CLEVELAND...........

34220 340114............................ *.....................

0.0015 WAKE................

34910 340126............................ *.....................

0.0100 WILSON..............

34970 340129............................ *.....................

0.0101 IREDELL.............

34480 340133............................ ......................

0.0308 MARTIN..............

34580 340138............................ *.....................

0.0015 WAKE................

34910 340144............................ *.....................

0.0101 IREDELL.............

34480 340145............................ *.....................

0.0336 LINCOLN.............

34540 340151............................ ......................

0.0052 HALIFAX.............

34410 340173............................ *.....................

0.0015 WAKE................

34910 360002............................ ......................

0.0141 ASHLAND.............

36020 360010............................ *.....................

0.0074 TUSCARAWAS..........

36800 360013............................ *.....................

0.0135 SHELBY..............

36760 360025............................ *.....................

0.0077 ERIE................

36220 360036............................ *.....................

0.0126 WAYNE...............

36860 360040............................ ......................

0.0387 KNOX................

36430 360044............................ ......................

0.0127 DARKE...............

36190

Page 23817

360065............................ *.....................

0.0075 HURON...............

36400 360071............................ ......................

0.0035 VAN WERT............

36820 360086............................ *.....................

0.0186 CLARK...............

36110 360096............................ *.....................

0.0071 COLUMBIANA..........

36140 360107............................ *.....................

0.0119 SANDUSKY............

36730 360125............................ *.....................

0.0133 ASHTABULA...........

36030 360156............................ ......................

0.0119 SANDUSKY............

36730 360175............................ *.....................

0.0183 CLINTON.............

36130 360185............................ *.....................

0.0071 COLUMBIANA..........

36140 360187............................ *.....................

0.0186 CLARK...............

36110 360245............................ *.....................

0.0133 ASHTABULA...........

36030 370014............................ *.....................

0.0361 BRYAN...............

37060 370015............................ *.....................

0.0366 MAYES...............

37480 370023............................ ......................

0.0090 STEPHENS............

37680 370065............................ ......................

0.0096 CRAIG...............

37170 370072............................ ......................

0.0258 LATIMER.............

37380 370083............................ ......................

0.0051 PUSHMATAHA..........

37630 370100............................ ......................

0.0100 CHOCTAW.............

37110 370149............................ *.....................

0.0302 POTTAWATOMIE........

37620 370156............................ ......................

0.0121 GARVIN..............

37240 370169............................ ......................

0.0163 MCINTOSH............

37450 370172............................ ......................

0.0258 LATIMER.............

37380 370214............................ ......................

0.0121 GARVIN..............

37240 380022............................ *.....................

0.0067 LINN................

38210 380029............................ ......................

0.0075 MARION..............

38230 380051............................ *.....................

0.0075 MARION..............

38230 380056............................ ......................

0.0075 MARION..............

38230 390008............................ ......................

0.0060 LAWRENCE............

39450 390016............................ *.....................

0.0060 LAWRENCE............

39450 390030............................ ......................

0.0284 SCHUYLKILL..........

39650 390031............................ *.....................

0.0284 SCHUYLKILL..........

39650 390044............................ *.....................

0.0191 BERKS...............

39110 390052............................ ......................

0.0047 CLEARFIELD..........

39230 390056............................ ......................

0.0036 HUNTINGDON..........

39380 390065............................ *.....................

0.0532 ADAMS...............

39000 390066............................ *.....................

0.0372 LEBANON.............

39460 390079............................ *.....................

0.0003 BRADFORD............

39130 390086............................ *.....................

0.0047 CLEARFIELD..........

39230 390096............................ *.....................

0.0191 BERKS...............

39110 390110............................ *.....................

0.0003 CAMBRIA.............

39160 390113............................ *.....................

0.0053 CRAWFORD............

39260 390117............................ ......................

0.0002 BEDFORD.............

39100 390122............................ ......................

0.0053 CRAWFORD............

39260 390125............................ ......................

0.0022 WAYNE...............

39760 390130............................ *.....................

0.0003 CAMBRIA.............

39160 390138............................ *.....................

0.0218 FRANKLIN............

39350 390146............................ ......................

0.0022 WARREN..............

39740 390150............................ *.....................

0.0031 GREENE..............

39370 390151............................ *.....................

0.0218 FRANKLIN............

39350 390162............................ *.....................

0.0200 NORTHAMPTON.........

39590 390183............................ *.....................

0.0284 SCHUYLKILL..........

39650 390201............................ ......................

0.1170 MONROE..............

39550 390236............................ ......................

0.0003 BRADFORD............

39130 390313............................ *.....................

0.0284 SCHUYLKILL..........

39650 390316............................ ......................

0.0191 BERKS...............

39110 420002............................ ......................

0.0004 YORK................

42450 420007............................ *.....................

0.0027 SPARTANBURG.........

42410 420009............................ *.....................

0.0113 OCONEE..............

42360 420019............................ ......................

0.0158 CHESTER.............

42110 420020............................ *.....................

0.0007 GEORGETOWN..........

42210 420027............................ *.....................

0.0108 ANDERSON............

42030 420030............................ *.....................

0.0069 COLLETON............

42140 420036............................ *.....................

0.0064 LANCASTER...........

42280 420039............................ *.....................

0.0153 UNION...............

42430 420043............................ ......................

0.0157 CHEROKEE............

42100 420053............................ ......................

0.0035 NEWBERRY............

42350 420054............................ ......................

0.0003 MARLBORO............

42340 420062............................ *.....................

0.0109 CHESTERFIELD........

42120 420068............................ *.....................

0.0027 ORANGEBURG..........

42370 420069............................ *.....................

0.0052 CLARENDON...........

42130 420070............................ *.....................

0.0052 SUMTER..............

42420

Page 23818

420082............................ ......................

0.0008 AIKEN...............

42010 420083............................ *.....................

0.0027 SPARTANBURG.........

42410 420098............................ *.....................

0.0007 GEORGETOWN..........

42210 430008............................ ......................

0.0535 BROOKINGS...........

43050 430048............................ ......................

0.0129 LAWRENCE............

43400 430094............................ ......................

0.0129 LAWRENCE............

43400 440007............................ ......................

0.0219 COFFEE..............

44150 440008............................ *.....................

0.0449 HENDERSON...........

44380 440012............................ ......................

0.0007 SULLIVAN............

44810 440016............................ ......................

0.0144 CARROLL.............

44080 440017............................ ......................

0.0007 SULLIVAN............

44810 440024............................ *.....................

0.0230 BRADLEY.............

44050 440025............................ *.....................

0.0007 GREENE..............

44290 440030............................ ......................

0.0056 HAMBLEN.............

44310 440031............................ ......................

0.0019 ROANE...............

44720 440033............................ ......................

0.0027 CAMPBELL............

44060 440035............................ *.....................

0.0301 MONTGOMERY..........

44620 440047............................ ......................

0.0338 GIBSON..............

44260 440050............................ ......................

0.0007 GREENE..............

44290 440051............................ ......................

0.0082 MC NAIRY............

44540 440057............................ ......................

0.0021 CLAIBORNE...........

44120 440060............................ *.....................

0.0338 GIBSON..............

44260 440067............................ *.....................

0.0056 HAMBLEN.............

44310 440070............................ ......................

0.0109 DECATUR.............

44190 440081............................ ......................

0.0052 SEVIER..............

44770 440084............................ ......................

0.0025 MONROE..............

44610 440109............................ ......................

0.0070 HARDIN..............

44350 440115............................ ......................

0.0338 GIBSON..............

44260 440137............................ ......................

0.0738 BEDFORD.............

44010 440144............................ *.....................

0.0219 COFFEE..............

44150 440148............................ *.....................

0.0296 DE KALB.............

44200 440153............................ ......................

0.0007 COCKE...............

44140 440174............................ ......................

0.0312 HAYWOOD.............

44370 440176............................ ......................

0.0007 SULLIVAN............

44810 440180............................ ......................

0.0027 CAMPBELL............

44060 440181............................ ......................

0.0365 HARDEMAN............

44340 440182............................ ......................

0.0144 CARROLL.............

44080 440185............................ *.....................

0.0230 BRADLEY.............

44050 450032............................ ......................

0.0254 HARRISON............

45620 450039............................ *.....................

0.0024 TARRANT.............

45910 450052............................ *.....................

0.0276 BOSQUE..............

45160 450059............................ ......................

0.0075 COMAL...............

45320 450064............................ *.....................

0.0024 TARRANT.............

45910 450087............................ *.....................

0.0024 TARRANT.............

45910 450090............................ ......................

0.0650 COOKE...............

45340 450099............................ *.....................

0.0145 GRAY................

45563 450135............................ *.....................

0.0024 TARRANT.............

45910 450137............................ *.....................

0.0024 TARRANT.............

45910 450144............................ ......................

0.0559 ANDREWS.............

45010 450163............................ ......................

0.0054 KLEBERG.............

45743 450192............................ ......................

0.0271 HILL................

45651 450194............................ ......................

0.0213 CHEROKEE............

45281 450210............................ ......................

0.0151 PANOLA..............

45842 450224............................ *.....................

0.0195 WOOD................

45974 450236............................ ......................

0.0389 HOPKINS.............

45654 450270............................ ......................

0.0271 HILL................

45651 450283............................ *.....................

0.0653 VAN ZANDT...........

45947 450324............................ *.....................

0.0132 GRAYSON.............

45564 450347............................ *.....................

0.0370 WALKER..............

45949 450348............................ *.....................

0.0059 FALLS...............

45500 450370............................ ......................

0.0235 COLORADO............

45312 450389............................ *.....................

0.0618 HENDERSON...........

45640 450393............................ *.....................

0.0132 GRAYSON.............

45564 450395............................ *.....................

0.0441 POLK................

45850 450419............................ *.....................

0.0024 TARRANT.............

45910 450438............................ ......................

0.0235 COLORADO............

45312 450451............................ ......................

0.0536 SOMERVELL...........

45893 450460............................ ......................

0.0053 TYLER...............

45942 450469............................ *.....................

0.0132 GRAYSON.............

45564 450497............................ ......................

0.0375 MONTAGUE............

45800 450539............................ ......................

0.0067 HALE................

45582

Page 23819

450547............................ *.....................

0.0195 WOOD................

45974 450563............................ *.....................

0.0024 TARRANT.............

45910 450565............................ *.....................

0.0486 PALO PINTO..........

45841 450573............................ ......................

0.0126 JASPER..............

45690 450596............................ *.....................

0.0743 HOOD................

45653 450615............................ ......................

0.0032 CASS................

45260 450639............................ *.....................

0.0024 TARRANT.............

45910 450641............................ ......................

0.0375 MONTAGUE............

45800 450672............................ *.....................

0.0024 TARRANT.............

45910 450675............................ *.....................

0.0024 TARRANT.............

45910 450677............................ *.....................

0.0024 TARRANT.............

45910 450698............................ ......................

0.0127 LAMB................

45751 450747............................ *.....................

0.0126 ANDERSON............

45000 450755............................ ......................

0.0276 HOCKLEY.............

45652 450770............................ *.....................

0.0182 MILAM...............

45795 450779............................ *.....................

0.0024 TARRANT.............

45910 450813............................ *.....................

0.0126 ANDERSON............

45000 450838............................ ......................

0.0126 JASPER..............

45690 450872............................ *.....................

0.0024 TARRANT.............

45910 450880............................ *.....................

0.0024 TARRANT.............

45910 450884............................ ......................

0.0049 UPSHUR..............

45943 450886............................ *.....................

0.0024 TARRANT.............

45910 450888............................ ......................

0.0024 TARRANT.............

45910 460001............................ ......................

0.0023 UTAH................

46240 460013............................ ......................

0.0023 UTAH................

46240 460017............................ ......................

0.0383 BOX ELDER...........

46010 460023............................ ......................

0.0023 UTAH................

46240 460039............................ *.....................

0.0383 BOX ELDER...........

46010 460043............................ ......................

0.0023 UTAH................

46240 460052............................ ......................

0.0023 UTAH................

46240 460055............................ ......................

0.0023 UTAH................

46240 490019............................ *.....................

0.1088 CULPEPER............

49230 490084............................ ......................

0.0187 ESSEX...............

49280 490110............................ ......................

0.0185 MONTGOMERY..........

49600 500003............................ *.....................

0.0166 SKAGIT..............

50280 500007............................ *.....................

0.0166 SKAGIT..............

50280 500019............................ ......................

0.0131 LEWIS...............

50200 500039............................ *.....................

0.0094 KITSAP..............

50170 500041............................ *.....................

0.0020 COWLITZ.............

50070 510012............................ ......................

0.0124 MASON...............

51260 510018............................ *.....................

0.0188 JACKSON.............

51170 510047............................ *.....................

0.0269 MARION..............

51240 510077............................ *.....................

0.0021 MINGO...............

51290 520028............................ *.....................

0.0286 GREEN...............

52220 520035............................ ......................

0.0076 SHEBOYGAN...........

52580 520044............................ ......................

0.0076 SHEBOYGAN...........

52580 520057............................ ......................

0.0193 SAUK................

52550 520059............................ *.....................

0.0195 RACINE..............

52500 520071............................ *.....................

0.0161 JEFFERSON...........

52270 520076............................ *.....................

0.0146 DODGE...............

52130 520095............................ ......................

0.0193 SAUK................

52550 520096............................ *.....................

0.0195 RACINE..............

52500 520102............................ *.....................

0.0242 WALWORTH............

52630 520116............................ *.....................

0.0161 JEFFERSON...........

52270 670015............................ ......................

0.0024 TARRANT.............

45910 670023............................ ......................

0.0024 TARRANT.............

45910

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

FY 2009 proposed

FY 2009 proposed

MS-DRG

rule post-acute rule special pay

MDC

Type

MS-DRG title

Weights

Geometric

Arithmetic

DRG

DRG

mean LOS

mean LOS

001................ No................ No................

PRE SURG.............. Heart transplant or

23.4061

29.1

40.2 implant of heart assist system w MCC. 002................ No................ No................

PRE SURG.............. Heart transplant or

12.8956

18.4

24.7 implant of heart assist system w/o MCC.

Page 23820

003................ Yes............... No................

PRE SURG.............. ECMO or trach w MV 96+

18.3635

32.5

39.6 hrs or PDX exc face, mouth & neck w maj O.R. 004................ Yes............... No................

PRE SURG.............. Trach w MV 96+ hrs or PDX

11.1684

23.5

28.8 exc face, mouth & neck w/ o maj O.R.. 005................ No................ No................

PRE SURG.............. Liver transplant w MCC or

10.7436

15.9

21.2 intestinal transplant. 006................ No................ No................

PRE SURG.............. Liver transplant w/o MCC.

4.8292

8.9

10.2 007................ No................ No................

PRE SURG.............. Lung transplant..........

9.7325

15.9

19.7 008................ No................ No................

PRE SURG.............. Simultaneous pancreas/

4.8917

10.1

11.9 kidney transplant. 009................ No................ No................

PRE SURG.............. Bone marrow transplant...

6.6398

18.2

21.9 010................ No................ No................

PRE SURG.............. Pancreas transplant......

3.7508

9.1

10.8 011................ No................ No................

PRE SURG.............. Tracheostomy for

4.8900

13.1

16.7 face,mouth & neck diagnoses w MCC. 012................ No................ No................

PRE SURG.............. Tracheostomy for

3.0563

8.9

10.7 face,mouth & neck diagnoses w CC. 013................ No................ No................

PRE SURG.............. Tracheostomy for

1.9057

5.9

6.9 face,mouth & neck diagnoses w/o CC/MCC. 020................ No................ No................

01 SURG.............. Intracranial vascular

8.3276

14.8

18.4 procedures w PDX hemorrhage w MCC. 021................ No................ No................

01 SURG.............. Intracranial vascular

6.3534

13.7

15.4 procedures w PDX hemorrhage w CC. 022................ No................ No................

01 SURG.............. Intracranial vascular

4.2072

7.6

9.4 procedures w PDX hemorrhage w/o CC/MCC. 023................ No................ No................

01 SURG.............. Cranio w major dev impl/

5.0763

8.9

12.7 acute complex CNS PDX w

MCC or chemo implant. 024................ No................ No................

01 SURG.............. Cranio w major dev impl/

3.4757

6.3

9.0 acute complex CNS PDX w/ o MCC. 025................ Yes............... No................

01 SURG.............. Craniotomy & endovascular

5.0324

9.9

13.0 intracranial procedures w MCC. 026................ Yes............... No................

01 SURG.............. Craniotomy & endovascular

3.0107

6.5

8.2 intracranial procedures w CC. 027................ Yes............... No................

01 SURG.............. Craniotomy & endovascular

2.1083

3.5

4.5 intracranial procedures w/o CC/MCC. 028................ Yes............... Yes...............

01 SURG.............. Spinal procedures w MCC..

5.1853

10.7

14.3 029................ Yes............... Yes...............

01 SURG.............. Spinal procedures w CC or

2.7949

5.1

7.1 spinal neurostimulators. 030................ Yes............... Yes...............

01 SURG.............. Spinal procedures w/o CC/

1.5395

2.8

3.7

MCC. 031................ Yes............... No................

01 SURG.............. Ventricular shunt

4.3899

9.4

13.1 procedures w MCC. 032................ Yes............... No................

01 SURG.............. Ventricular shunt

1.9471

4.0

6.0 procedures w CC. 033................ Yes............... No................

01 SURG.............. Ventricular shunt

1.3334

2.3

3.0 procedures w/o CC/MCC. 034................ No................ No................

01 SURG.............. Carotid artery stent

3.2182

4.6

7.2 procedure w MCC. 035................ No................ No................

01 SURG.............. Carotid artery stent

2.0258

2.1

3.3 procedure w CC. 036................ No................ No................

01 SURG.............. Carotid artery stent

1.5706

1.3

1.6 procedure w/o CC/MCC. 037................ No................ No................

01 SURG.............. Extracranial procedures w

3.0208

5.9

8.5

MCC. 038................ No................ No................

01 SURG.............. Extracranial procedures w

1.5585

2.5

3.8

CC. 039................ No................ No................

01 SURG.............. Extracranial procedures w/

1.0057

1.5

1.8 o CC/MCC. 040................ Yes............... Yes...............

01 SURG.............. Periph/cranial nerve &

3.9691

9.7

13.3 other nerv syst proc w

MCC. 041................ Yes............... Yes...............

01 SURG.............. Periph/cranial nerve &

2.1517

5.3

7.2 other nerv syst proc w

CC or periph neurostim. 042................ Yes............... Yes...............

01 SURG.............. Periph/cranial nerve &

1.6771

2.5

3.6 other nerv syst proc w/o

CC/MCC. 052................ No................ No................

01 MED............... Spinal disorders &

1.6271

4.9

6.7 injuries w CC/MCC. 053................ No................ No................

01 MED............... Spinal disorders &

0.8617

3.2

4.0 injuries w/o CC/MCC. 054................ Yes............... No................

01 MED............... Nervous system neoplasms

1.5844

5.2

7.0 w MCC. 055................ Yes............... No................

01 MED............... Nervous system neoplasms

1.0781

3.8

5.1 w/o MCC. 056................ Yes............... No................

01 MED............... Degenerative nervous

1.6311

5.7

7.8 system disorders w MCC. 057................ Yes............... No................

01 MED............... Degenerative nervous

0.8755

3.9

5.0 system disorders w/o MCC.

Page 23821

058................ No................ No................

01 MED............... Multiple sclerosis &

1.5373

5.7

7.6 cerebellar ataxia w MCC. 059................ No................ No................

01 MED............... Multiple sclerosis &

0.9404

4.2

5.1 cerebellar ataxia w CC. 060................ No................ No................

01 MED............... Multiple sclerosis &

0.6978

3.4

4.0 cerebellar ataxia w/o CC/

MCC. 061................ No................ No................

01 MED............... Acute ischemic stroke w

2.8759

6.8

8.9 use of thrombolytic agent w MCC. 062................ No................ No................

01 MED............... Acute ischemic stroke w

1.9505

5.3

6.3 use of thrombolytic agent w CC. 063................ No................ No................

01 MED............... Acute ischemic stroke w

1.5168

3.9

4.5 use of thrombolytic agent w/o CC/MCC. 064................ Yes............... No................

01 MED............... Intracranial hemorrhage

1.8446

5.5

7.5 or cerebral infarction w

MCC. 065................ Yes............... No................

01 MED............... Intracranial hemorrhage

1.1748

4.3

5.2 or cerebral infarction w

CC. 066................ Yes............... No................

01 MED............... Intracranial hemorrhage

0.8426

3.1

3.7 or cerebral infarction w/ o CC/MCC. 067................ No................ No................

01 MED............... Nonspecific cva &

1.3899

4.4

5.8 precerebral occlusion w/ o infarct w MCC. 068................ No................ No................

01 MED............... Nonspecific cva &

0.8449

2.7

3.4 precerebral occlusion w/ o infarct w/o MCC. 069................ No................ No................

01 MED............... Transient ischemia.......

0.7143

2.4

3.0 070................ Yes............... No................

01 MED............... Nonspecific

1.8241

6.0

7.9 cerebrovascular disorders w MCC. 071................ Yes............... No................

01 MED............... Nonspecific

1.1307

4.4

5.6 cerebrovascular disorders w CC. 072................ Yes............... No................

01 MED............... Nonspecific

0.7629

2.8

3.5 cerebrovascular disorders w/o CC/MCC. 073................ No................ No................

01 MED............... Cranial & peripheral

1.3037

4.7

6.2 nerve disorders w MCC. 074................ No................ No................

01 MED............... Cranial & peripheral

0.8406

3.4

4.3 nerve disorders w/o MCC. 075................ No................ No................

01 MED............... Viral meningitis w CC/MCC

1.6738

5.7

7.3 076................ No................ No................

01 MED............... Viral meningitis w/o CC/

0.8544

3.4

4.1

MCC. 077................ No................ No................

01 MED............... Hypertensive

1.6225

5.2

6.7 encephalopathy w MCC. 078................ No................ No................

01 MED............... Hypertensive

1.0050

3.6

4.4 encephalopathy w CC. 079................ No................ No................

01 MED............... Hypertensive

0.7377

2.8

3.4 encephalopathy w/o CC/

MCC. 080................ No................ No................

01 MED............... Nontraumatic stupor &

1.1007

3.8

5.1 coma w MCC. 081................ No................ No................

01 MED............... Nontraumatic stupor &

0.7094

2.7

3.5 coma w/o MCC. 082................ No................ No................

01 MED............... Traumatic stupor & coma,

2.0177

3.7

6.4 coma >1 hr w MCC. 083................ No................ No................

01 MED............... Traumatic stupor & coma,

1.3027

3.7

5.0 coma >1 hr w CC. 084................ No................ No................

01 MED............... Traumatic stupor & coma,

0.8720

2.4

3.1 coma >1 hr w/o CC/MCC. 085................ Yes............... No................

01 MED............... Traumatic stupor & coma,

2.0942

5.5

7.6 coma 1 hr w

MCC. 83................ 82................ Traumatic stupor &

12

0.6327

21.6

18.0 coma, coma >1 hr w

CC. 84................ 82................ Traumatic stupor &

3

0.6327

21.6

18.0 coma, coma >1 hr w/ o CC/MCC. 85................ 85................ Traumatic stupor &

78

0.8652

26.1

21.8 coma, coma The effects of the annual reclassification of diagnoses and procedures, full implementation of the MS-DRG system and 100 percent cost-based DRG relative weights,

The effects of the changes in hospitals' wage index values reflecting wage data from hospitals' cost reporting periods beginning during FY 2005, compared to the FY 2004 wage data.

The effects of the recalibration of the DRG relative weights as required by section 1886(d)(4)(C) of the Act, including the wage and recalibration budget neutrality factors.

The effects of geographic reclassifications by the

MGCRB that will be effective in FY 2009.

The effects of the proposal to apply the rural floor budget neutrality adjustment at the State level, redistributing payments within the State, rather than adjusting payments to hospitals in other States.

The effects of the proposal to apply the imputed rural floor budget neutrality adjustment to the wage index at the State- level, rather than applying it to the standardized amount at the national level.

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 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 the proposed FY 2009 policies relative to payments based on FY 2008 policies.

To illustrate the impacts of the proposed FY 2009 changes, our analysis begins with a FY 2008 baseline simulation model using: the proposed FY 2009 update of 3.0 percent; the FY 2008 DRG GROUPER

(Version 25.0); the most current CBSA designations for hospitals based on OMB's MSA definitions; the FY 2008 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, 186 providers did not receive the full market basket rate-of-increase for FY 2008 because they failed the quality data submission process. For purposes of the simulations shown below, we modeled the proposed payment changes for FY 2009 using a reduced update for these 186 hospitals. However, we do not have enough information to determine which hospitals will not receive the full market basket rate-of-increase for FY 2009 at this time.

Each policy change, statutorily or otherwise, is then added incrementally to

Page 23908

this baseline, finally arriving at an FY 2009 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 2008 to FY 2009. 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 2009 using the most recently forecasted hospital market basket increase for FY 2009 of 3.0 percent. (Hospitals that fail to comply with the quality data submission requirements to receive the full update will receive an update reduced by 2.0 percentage points to 1.0 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 3.0 percent.

A second significant factor that affects the proposed changes in hospitals' payments per case from FY 2008 to FY 2009 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 2008 that are no longer reclassified in FY 2009.

Conversely, payments may increase for hospitals not reclassified in

FY 2008 that are reclassified in FY 2009. 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 2008 will be 4.8 percent of total

DRG payments. When the FY 2008 final rule was published, we projected FY 2008 outlier payments would be 5.1 percent of total DRG plus outlier payments; the average standardized amounts were offset correspondingly. The effects of the lower than expected outlier payments during FY 2009 (as discussed in the Addendum to this proposed rule) are reflected in the analyses below comparing our current estimates of FY 2008 payments per case to estimated FY 2009 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 2009. 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 3,528 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 2,542 hospitals located in urban areas included in our analysis. Among these, there are 1,402 hospitals located in large urban areas

(populations over 1 million), and 1,140 hospitals in other urban areas (populations of 1 million or fewer). In addition, there are 986 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 2009 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 2,584, 1,424, 1,160 and 944, 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 2,485 nonteaching hospitals in our analysis, 805 teaching hospitals with fewer than 100 residents, and 238 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).

There were 197 RRCs, 355 SCHs, 156 MDHs, 102 hospitals that are both

SCHs and RRCs, and 12 hospitals that are both an MDH and an RRC.

The next series of 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 2005 Medicare cost reports.

The next two groupings concern the geographic reclassification status of hospitals. The first grouping displays all urban hospitals that were reclassified by the MGCRB for FY 2009. The second grouping shows the MGCRB rural reclassifications. The final category shows the impact of the proposed policy changes on the 20 cardiac specialty hospitals in our analysis.

Table I.--Impact Analysis of Proposed Changes for FY 2009

Application of proposed rural floor

All

All

Proposed

Proposed

and imputed

proposed proposed

FY 2009

FY 2009

rural

Proposed

FY 2009

FY 2009

Number of cost based Proposed

DRG, rel.

FY 2009 MGCRB

floor,

FY 2009 changes w/ changes w/ hospitals

DRG

FY 2009 wts. and Reclassifications including

out-

CMI

CMI

\1\

Weights & wage data wage index

\5\

proposed migration adjustment adjustment

MS-DRG

\3\

changes

within adjustment prior to

and changes

\4\

state

\7\

estimated estimated

\2\

budget

CMI growth CMI growth neutrality

\8\

\9\

\6\

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

All Hospitals.......................

3,528

0.1

-0.1

0

0

0

0

2.3

4.1

By Geographic Location:

Urban hospitals.................

2,542

0.2

-0.1

0.1

-0.2

0

0

2.4

4.2

Large urban areas...............

1,402

0.5

-0.1

0.3

-0.4

-0.1

0

2.6

4.4

Other urban areas...............

1,140

0

0

-0.1

-0.1

0.1

0

2.2

3.9

Rural hospitals.................

986

-1

0

-1.1

2.1

-0.1

0.1

1.5

3.3

Bed Size (Urban): 0-99 beds......................

643

-0.7

-0.1

-0.8

-0.4

0.1

0

1.6

3.4 100-199 beds....................

829

0.1

0

0

-0.1

0.1

0

2.2

4 200-299 beds....................

483

0.2

0

0.2

-0.2

-0.1

0

2.4

4.2 300-499 beds....................

411

0.3

0

0.3

-0.2

0

0

2.6

4.3 500 or more beds................

176

0.5

-0.3

0.1

-0.3

0

0

2.5

4.3

Bed Size (Rural): 0-49 beds.......................

338

-2.3

0.1

-2.3

0.6

0

0.2

0.7

2.5 50-99 beds......................

373

-1.2

0

-1.3

1.1

-0.1

0.2

1.2

3 100-149 beds....................

166

-0.9

0.1

-0.8

2.5

0

0.1

1.5

3.3 150-199 beds....................

67

-0.6

-0.1

-0.8

3

-0.1

0

2

3.8

Page 23909

200 or more beds................

42

-0.3

-0.1

-0.4

3.2

-0.1

0

2.1

3.9

Urban by Region:

New England.....................

121

0

0

-0.1

0.5

0.1

0

1.2

3

Middle Atlantic.................

348

0

-0.5

-0.5

0.1

0

0

1.2

3

South Atlantic..................

385

0.4

-0.3

0.1

-0.4

0

0

2.7

4.4

East North Central..............

394

0.5

-0.5

-0.1

-0.4

0

0

2.4

4.1

East South Central..............

163

-0.1

-0.2

-0.2

-0.2

0

0

2.4

4.2

West North Central..............

157

-0.1

0.2

0.1

-0.7

0

0

2.8

4.5

West South Central..............

371

0.4

0

0.3

-0.6

0

0

2.9

4.7

Mountain........................

157

0.3

0.1

0.5

-0.2

0

0

3.2

5

Pacific.........................

393

0.4

0.9

1.2

-0.2

0

0

3.4

5.2

Puerto Rico.....................

53

-0.2

-0.7

-0.9

-0.7

0

0

1.4

3.2

Rural by Region:

New England.....................

23

-0.8

-0.4

-1.3

2.4

-0.9

0

0.6

2.3

Middle Atlantic.................

70

-0.9

-0.1

-1.1

2

0

0.1

1.3

3.1

South Atlantic..................

172

-0.6

-0.1

-0.7

2.2

0

0.1

1.9

3.7

East North Central..............

121

-0.9

-0.3

-1.3

1.6

0

0.1

1.4

3.2

East South Central..............

176

-1.3

-0.1

-1.4

2.7

0

0.1

1.6

3.4

West North Central..............

113

-0.9

0.1

-0.8

1.7

0

0.1

1.6

3.4

West South Central..............

200

-1.7

0.5

-1.3

2.5

0

0.1

1.3

3.1

Mountain........................

75

-0.9

0

-1

0.5

0

0.1

1.2

3.1

Pacific.........................

36

-0.7

0.6

-0.2

1.8

-0.3

0

1.8

3.6

By Payment Classification:

Urban hospitals.................

2,584

0.2

-0.1

0.1

-0.2

0

0

2.4

4.2

Large urban areas...............

1,424

0.4

-0.1

0.3

-0.4

-0.1

0

2.6

4.4

Other urban areas...............

1,160

0

0

-0.1

0

0.1

0

2.2

3.9

Rural areas.....................

944

-1

0

-1.1

2

-0.1

0.1

1.5

3.3

Teaching Status:

Nonteaching.....................

2,485

-0.2

0

-0.2

0.3

0

0

2.2

4

Fewer than 100 residents........

805

0.2

0

0.1

-0.2

0

0

2.4

4.2 100 or more residents...........

238

0.5

-0.3

0.2

-0.3

0

0

2.5

4.2

Urban DSH:

Non-DSH.........................

838

-0.3

-0.2

-0.4

-0.1

0

0

1.8

3.6 100 or more beds................

1,534

0.4

-0.1

0.3

-0.3

0

0

2.6

4.3

Less than 100 beds..............

354

-0.7

0

-0.8

0

0

0

1.6

3.4

Rural DSH:

SCH.............................

389

-1.5

0

-1.5

0.4

0

0.1

1.5

3.3

RRC.............................

206

-0.6

0

-0.6

3.4

-0.1

0

1.9

3.7 100 or more beds................

39

-0.8

0

-0.9

1.3

0

0.4

1.3

3.1

Less than 100 beds..............

168

-1.7

0

-1.8

1.3

0

0.3

0.6

2.4

Urban teaching and DSH:

Both teaching and DSH...........

811

0.4

-0.1

0.3

-0.4

0

0

2.5

4.3

Teaching and no DSH.............

172

-0.1

-0.2

-0.3

0

0

0

1.8

3.6

No teaching and DSH.............

1,077

0.2

0

0.2

0

0.1

0

2.5

4.3

No teaching and no DSH..........

524

-0.2

-0.2

-0.4

-0.3

0

0

1.9

3.7

Special Hospital Types:

RRC.............................

197

-0.4

-0.1

-0.4

3.2

0

0

2.3

4.1

SCH.............................

355

-1.3

0.1

-1.3

0.4

0

0.1

1.2

3

MDH.............................

156

-1.8

0.1

-1.8

0.5

0

0.2

2

3.8

SCH and RRC.....................

102

-0.5

0.1

-0.5

1.7

0

0

2.2

4.1

MDH and RRC.....................

12

-1.3

0.1

-1.3

0.9

-0.3

0

1

2.8

Type of Ownership:

Voluntary.......................

2,027

0.1

-0.1

0

0

0

0

2.3

4

Proprietary.....................

827

0

0

-0.1

0

-0.1

0

2.4

4.1

Government......................

587

0.1

-0.1

0

0.1

0.1

0

2.6

4.4

Medicare Utilization as a Percent of

Inpatient Days: 0-25...........................

255

0.8

-0.1

0.7

-0.4

-0.2

0

3.2

4.9 25-50...........................

1,350

0.3

0

0.3

-0.3

0

0

2.7

4.4 50-65...........................

1,431

-0.1

-0.2

-0.3

0.4

0.1

0

1.9

3.7

Over 65.........................

392

-0.8

-0.2

-1

0.5

0

0.1

1.2

3

FY 2009 Reclassifications by the

Medicare Geographic Classification

Review Board:

All Reclassified Hospitals......

805

0

0

0

2

-0.1

0

2.1

3.8

Non-Reclassified Hospitals......

2,723

0.2

-0.1

0

-0.7

0

0

2.4

4.2

Urban Hospitals Reclassified....

445

0.2

0

0.2

1.5

-0.2

0

2.1

3.9

Urban Nonreclassified, FY 2009..

2,075

0.3

-0.1

0.1

-0.7

0.1

0

2.5

4.3

All Rural Hospitals Reclassified

360

-0.7

0

-0.7

3.3

-0

0

1.8

3.7

Full Year FY 2009..............

Rural Nonreclassified Hospitals

565

-1.5

-0

-1.6

-0.4

-0.1

0.3

1

2.8

Full Year FY 2009..............

Page 23910

All Section 401 Reclassified

29

-1.3

-0.2

-1.6

0.6

0

0

1.6

3.5

Hospitals......................

Other Reclassified Hospitals

61

-1

-0.2

-1.3

3.2

-0.2

0.1

1

2.8

(Section 1886(d)(8)(B))........

Specialty Hospitals

Cardiac specialty Hospitals.....

20

-2.2

-0.1

-2.4

-0.7

0.1

0

0

1.8

\1\ Because data necessary to classify some hospitals by category were missing, the total number of hospitals in each category may not equal the national total. Discharge data are from FY 2007, and hospital cost report data are from reporting periods beginning in FY 2006 and FY 2005.

\2\ This column displays the payment impact of the changes to the V26 GROUPER and the recalibration of the DRG weights based on FY 2007 MedPAR data in accordance with section 1886(d)(4)(C)(iii) of the Act.

\3\ This column displays the payment impact of updating the wage index data to the FY 2005 cost report data.

\4\ This column displays the combined payment impact of the changes in column 2 and column 3 and the budget neutrality factors for DRG and wage index changes in accordance with section 1886(d)(4)(C)(iii) of the Act and section 1886(d)(3)(E) of the Act.

\5\ Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate the FY 2009 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2008. Reclassification for prior years has no bearing on the payment impacts shown here. This column reflects the geographic budget neutrality factor of 0.992333.

\6\ This column displays the effects of the rural floor and the imputed rural floor, including the proposal to apply the budget neutrality adjustment within State.

\7\ This column displays the impact 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.

\8\ This column shows changes in payments from FY 2008 to FY 2009, including the proposed FY 2009 -0.9 percent documentation and coding adjustment, but not the projected 1.8 percent increase in case-mix expected to occur in FY 2009 due to improvements in documentation and coding. It incorporates all of the changes displayed in Columns 4, 5, 6, 7 (the changes displayed in Columns 2 and 3 are included in Column 4). It also reflects the impact of the

FY 2009 update, and changes in hospitals' reclassification status in FY 2009 compared to FY 2008.

\9\ This column shows changes in payments from FY 2008 to FY 2009 including the proposed FY 2009 -0.9 percent documentation and coding adjustment and the projected 1.8 percent increase in case-mix expected to occur in FY 2009 due to improvements in documentation and coding. It incorporates all of the changes displayed in Columns 4, 5, 6, 7, 8 (the changes displayed in Columns 2 and 3 are included in Column 4). It also reflects the impact of the

FY 2008 update, and changes in hospitals' reclassification status in FY 2009 compared to FY 2008. The sum of these impacts may be different from the percentage changes shown here due to rounding and interactive effects.

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

In Column 2 of Table I, we present the effects of the DRG reclassifications, 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, the FY2009

DRG relative weights will be 100 percent cost-based and 100 percent

MS-DRGs, thus completing our three year transition to cost-based relative weights and our two year transition to MS-DRGs. For FY 2009, the MS-DRGs are calculated using the FY2007 MedPAR data grouped to the Version 26.0 (FY2009) DRGs. 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. In previous years, this column would also reflect the effects of the recalibration budget neutrality factor that is applied to the hospital-specific rates and the Puerto

Rico-specific standardized amount. However, for this proposed rule, we show the effects of the recalibration budget neutrality factor of 0.998700 in column 4. We note that, consistent with section 1886(d)(4)(C)(iii) of the Act, we are applying a budget neutrality factor to the national standardized amounts to ensure that the overall payment impact of the DRG changes (combined with the wage index changes) is budget neutral. This proposed wage and recalibration budget neutrality factor of 0.99525 is applied to payments in Column 4 and not Column 2.

The proposed changes to the relative weights and DRGs shown in column 2 are prior to any offset for budget neutrality. The ``All

Hospitals'' line indicates that proposed changes in this column will increase payments by 0.1 percent. However, as stated earlier, the proposed changes shown in this column are combined with revisions to the wage index, and the budget neutrality adjustments made for these changes are shown in column 4. Thus, the impact after accounting only for budget neutrality for proposed changes to the DRG relative weights and classification is somewhat lower than the figures shown in this column (approximately 0.1 percent).

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 wage index for FY 2009 is based on data submitted for hospital cost reporting periods beginning on or after October 1, 2004 and before October 1, 2005. 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 2008 wage index, based on FY 2004 wage data and having a 100-percent occupational mix adjustment applied, to a model using the FY 2009 pre-reclassification wage index, also having a 100-percent occupational mix adjustment applied, based on FY 2005 wage data

(while holding other payment parameters such as use of the version 26.0 DRG grouper constant). The wage data collected on the FY 2005 cost report include overhead costs for contract labor that were not collected on FY 2004 and earlier cost reports. The impacts below incorporate the effects of the FY 2005 wage data collected on hospital cost reports, including additional overhead costs for contract labor compared to the wage data from FY 2004 cost reports that were used to calculate the FY 2008 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 before application of the wage and

DRG recalibration budget neutrality adjustment shown in column 4.

Thus, the figures in this column are approximately 0.1 below what they otherwise would be if they also illustrated a budget neutrality adjustment solely for changes to the wage index. Among the regions, the largest increase is in the urban Pacific region, which experiences a 0.9 percent increase before applying an adjustment for budget neutrality. The largest decline from updating the wage data is seen in Puerto Rico (0.7 percent decrease).

In looking at the wage data itself, the national average hourly wage increased 4.2 percent compared to FY 2008. Therefore, the only manner in which to maintain or exceed

Page 23911

the previous year's wage index was to match or exceed the national 4.2 percent increase in average hourly wage. Of the 3,457 hospitals with wage data for both FYs 2008 and 2009, 1,707, or 49.4 percent, experienced an average hourly wage increase of 4.2 percent or more.

The following chart compares the shifts in wage index values for hospitals for FY 2009 relative to FY 2008. Among urban hospitals, 32 will experience an increase of more than 5 percent and less than 10 percent and 5 will experience an increase of more than 10 percent.

Among rural hospitals, none will experience an increase of more than 5 percent and less than 10 percent, and none will experience an increase of more than 10 percent. However, 972 rural hospitals will experience increases or decreases of less than 5 percent, while 2,420 urban hospitals will experience increases or decreases of less than 5 percent. Eighteen urban hospitals will experience decreases in their wage index values of more than 5 percent and less than 10 percent. Ten 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. These figures reflect changes in the wage index which is an adjustment to either 69.7 percent or 62 percent of a hospital's standardized amount depending upon whether its wage index is greater than 1.0 or less than or equal to 1.0. Therefore, these figures are illustrating a somewhat larger change in the wage index than would occur to the hospital's total payment.

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.................

5

0

Increase more than 5 percent and less than 10

32

0 percent......................................

Increase or decrease less than 5 percent......

2,420

972

Decrease more than 5 percent and less than 10

18

0 percent......................................

Decrease more than 10 percent.................

10

0

E. Combined Effects of Proposed MS-DRG and Wage Index Changes

(Column 4)

Section 1886(d)(4)(C)(iii) of the Act requires that changes to

MS-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 2008 and FY 2009 using the FY 2007 Medicare utilization data after applying the changes to the DRG relative weights and the wage index.

We computed a wage and MS-DRG recalibration budget neutrality factor of 0.999525 (which is applied to the national standardized amounts) and a recalibration budget neutrality factor 0.998700

(which is applied to the hospital-specific rates and the Puerto

Rico-specific standardized amount). The 0.0 percent impact for all hospitals demonstrates that the proposed MS-DRG and wage changes, in combination with the budget neutrality factor, are budget neutral.

In Table I, the combined overall impacts of the effects of both the

MS-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 changes in Columns 2 and 3 and the budget neutrality factors discussed previously.

We estimate that the combined impact of the proposed changes to the relative weights and DRGs and the updated wage data with budget neutrality applied will increase payments to hospitals located in large urban areas (populations over 1 million) by approximately 0.3.

These proposed changes would generally increase payments to hospitals in all urban areas (0.1 percent) and large teaching hospitals (0.2 percent). Rural hospitals will generally experience a decrease in payments (-1.1 percent). Among the rural hospital categories, rural hospitals with less than 50 beds will experience the greatest decline in payment (-2.3 percent) primarily due to the changes to MS-DRGs and the relative cost weights.

F. Effects of MGCRB Reclassifications (Column 5)

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 5 reflect the per case payment impact of moving from this baseline to a simulation incorporating the MGCRB decisions for FY 2009 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. Hospitals may appeal denials of MGCRB decisions to the CMS Administrator. Further, hospitals have 45 days from publication of the IPPS rule in the Federal Register to decide whether to withdraw or terminate an approved geographic reclassification for the following year. This column reflects all

MGCRB decisions, Administrator appeals and decisions of hospitals for FY 2009 geographic reclassifications.

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 0.992333 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 2.1 percent.

G. Effects of the Proposed Rural Floor and Imputed Rural Floor,

Including the Proposed Application of Budget Neutrality at the

State Level (Column 6)

As discussed in section III.B. of the preamble of this FY 2009 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. In FY 2008, we changed how we applied budget neutrality to the rural floor. Rather than applying a budget neutrality adjustment to the standardized amount, a uniform budget neutrality adjustment is applied to the wage index. For FY 2009, we are proposing to apply the rural floor budget neutrality adjustment at the State level, which would redistribute payments within the

State rather than across all other providers within the Nation.

Furthermore, 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. In the

FY 2008 IPPS final rule with comment period (72 FR 47321), we finalized our rule to extend the imputed rural floor for 1 additional year. In this proposed rule, we are proposing to extend the imputed rural floor for an additional 3 years through FY 2011.

Furthermore, consistent with our proposal to apply the rural floor budget neutrality adjustment at the State level, we are proposing to apply the imputed rural floor budget neutrality adjustment to the wage index at the State level.

Column 6 shows the projected impact of the rural floor and the imputed rural floor, including the proposed application of the budget neutrality adjustment at the State level. The column compares the post-reclassification FY 2009 wage index of providers before the rural floor adjustment and the post-reclassification FY 2009 wage index of providers with the rural floor and

Page 23912

imputed rural floor adjustment. Only urban hospitals can benefit from the rural floor provision. Because the provision is budget neutral, in prior years, all other hospitals (that is, all rural hospitals and those urban hospitals to which the adjustment is not made) had experienced a decrease in payments due to the budget neutrality adjustment applied nationally. However, under this proposal, States that have no hospitals receiving a rural floor wage index would no longer have a negative budget neutrality adjustment applied to their wage indices. Conversely, all hospitals in States with hospitals receiving a rural floor would have their wage indices downwardly adjusted to achieve budget neutrality within the State.

We project that, in aggregate, 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 because the rural floor adjustment applies to urban hospitals. Rural New England hospitals can expect the greatest decrease in payment by 0.9 percent because hospitals in Vermont will receive a rural floor budget neutrality adjustment of 0.901 or a reduction of approximately 10 percent, and hospitals in Connecticut will receive a rural floor budget neutrality adjustment of 0.9639 or a reduction of approximately 4 percent. New Jersey, which is the only State that benefits from the imputed rural floor, is expected to receive a rural floor budget neutrality adjustment of 0.987838 or a reduction of approximately 1.2 percent.

The table that appears in section III B.2.b. of the preamble of this proposed rule shows how payments would change, at the State level, if we moved from our current policy of applying rural floor budget neutrality at the national level to our proposed policy to apply the rural floor budget neutrality within the State. The table shows that, under our current policy of applying budget neutrality at the national level, States that do not have any hospitals receiving the rural floor wage index would expect a decrease in payments because, in order to maintain budget neutrality nationally, these hospitals have to pay for the hospitals in other States that do receive a rural floor. For example, States such as Arizona, New

York, and Rhode Island, which do not have hospitals receiving a rural floor, would expect to lose 0.2 percent in payments under a national rural floor budget neutrality adjustment. However, under our proposed policy to apply rural floor budget neutrality within each State, States that do not have hospitals receiving a floor would see an increase in payments (compared with our current policy of applying budget neutrality at the national level) because they would no longer have their wage indexes adjusted to maintain budget neutrality. However, all hospitals in States with hospitals receiving a rural floor would expect a decrease in their payments in order to achieve budget neutrality within their States (that is, the wage indices for hospitals in that State would be decreased in order to make the additional payments to hospitals in that State receiving the rural floor). Therefore, compared with our current policy of applying budget neutrality at the national level, States such as

Arizona, New York, and Rhode Island could expect payment increases of 0.3 percent under a rural floor budget neutrality applied at the

State level, while States such as California and Connecticut, which have several hospitals that benefit from the rural floor, could expect decreases in payments by 0.8 percent and 2.2 percent, respectively.

H. Effects of the Proposed Wage Index Adjustment for Out-Migration

(Column 7)

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 2009 relative to 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 $20 million.

I. Effects of All Proposed Changes With CMI Adjustment Prior to

Estimated Growth (Column 8)

Column 8 compares our estimate of payments per case between FY 2008 and FY 2009 with all changes reflected in this proposed rule for FY 2009, including a -0.9 percent documentation and coding adjustment to the FY 2009 national standardized amounts to account for anticipated improvements in documentation and coding that are expected to increase case-mix. We generally apply an adjustment to the DRGs to ensure budget neutrality assuming constant utilization.

However, in the FY 2008 IPPS final rule with comment period, we indicated that we believe that the adoption of MS-DRGs would lead to increases in case-mix as a result of improved documentation and coding. In the FY 2008 IPPS final rule with comment period, we had finalized a policy to apply a documentation and coding adjustment to the standardized amount of -1.2 percent for FY 2008, -1.8 percent for FY 2009, and -1.8 percent for FY 2010 to offset the expected increase in case-mix and achieve budget neutrality. However, in compliance with section 7 of Pub. L. 110-90, we reduced the documentation and coding adjustment to -0.6 percent for FY 2008. In accordance with section 7 of Pub. L. 110-90, for FY 2009, we are applying a documentation and coding adjustment of -0.9 percent to the FY 2009 national standardized amounts (in addition to the -0.6 percent adjustment made for FY 2008). We are not proposing to apply the documentation and coding adjustment to the FY 2009 hospital- specific rates and the FY 2009 Puerto Rico-specific standardized amount. However, we continue to believe that case-mix growth of an additional 1.8 percent compared to FY 2008 is likely to occur across all hospitals as a result of improvements in documentation and coding.

Column 8 illustrates the total payment change for FY 2009 compared to FY 2008, taking into account the -0.9 percent FY 2009 documentation and coding adjustment but not the projected 1.8 percent case-mix increase itself. Therefore, this column illustrates a total payment change that is less than what is anticipated to occur.

J. Effects of All Proposed Changes With CMI Adjustment and

Estimated Growth (Column 9)

Column 9 compares our estimate of payments per case between FY 2008 and FY 2009, incorporating all changes reflected in this proposed rule for FY 2009 (including statutory changes). This column includes the FY 2009 documentation and coding adjustment of -0.9 percent and the projected 1.8 percent increase in case-mix from improved documentation and coding (with the 1.8 percent case-mix increase assumed to occur equally across all hospitals).

Column 9 reflects the impact of all FY 2009 changes relative to

FY 2008, including those shown in Columns 2 through 7. The average increase for all hospitals is approximately 4.1 percent. This increase includes the effects of the 3.0 percent market basket update. It also reflects the 0.3 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 2008 (4.8 percent), as described in the introduction to this Appendix and the Addendum to this proposed rule. As a result, payments are projected to be 0.3 percentage points lower in FY 2008 than originally estimated, resulting in a 0.3 percentage point greater increase for FY 2009 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. 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 9 may not equal the product of the percentage changes described above.

The overall change in payments per case for hospitals in FY 2009 is proposed to increase by 4.1 percent. Hospitals in urban areas will experience an estimated 4.2 percent increase in payments per case compared to FY 2008. Hospitals in large urban areas will experience an estimated 4.4 percent increase and hospitals in other urban areas will experience an estimated 3.9 percent increase in payments per case in FY 2008. Hospital payments per case in rural areas are estimated to increase 3.3 percent. The increases that are larger than the national average for larger urban areas and smaller than the national average for other urban and rural areas are largely attributed to the differential impact of adopting MS-DRGs.

Page 23913

Among urban census divisions, the largest estimated payment increases will be 5.2 percent in the Pacific region (generally attributed to MS-DRGs and wage data) and 5.0 percent in the Mountain region (mostly due to MS-DRGs). The smallest urban increase is estimated at 3.0 percent in the Middle Atlantic and New England regions.

Among the rural regions in Column 9, the providers in the New

England region experience the smallest increase in payments (2.3 percent) primarily due to the State-specific rural floor budget neutrality adjustment. The South Atlantic and Pacific regions will have the highest increases among rural regions, with 3.7 percent and 3.6 percent estimated increases, respectively. Again, increases in rural areas are generally less than the national average due to the adoption of MS-DRGs.

Among special categories of rural hospitals in Column 9, the SCH and RRC providers will receive an estimated increase in payments of 4.1 percent, and the MDH and RRCs will experience an estimated increase in payments by 2.8 percent.

Urban hospitals reclassified for FY 2009 are anticipated to receive an increase of 3.9 percent, while urban hospitals that are not reclassified for FY 2009 are expected to receive an increase of 4.3 percent. Rural hospitals reclassifying for FY 2009 are anticipated to receive a 3.7 percent payment increase and rural hospitals that are not reclassifying are estimated to receive a payment increase of 2.8 percent.

K. Effects of Policy on Payment Adjustments for Low-Volume Hospitals

For FY 2009, we are continuing to apply the volume adjustment criteria we specified in the FY 2005 IPPS final rule (69 FR 49099).

We expect that three providers will receive the low-volume adjustment for FY 2009. We estimate the impact of these providers receiving the additional 25-percent payment increase to be approximately $2,300.

L. Impact Analysis of Table II

Table II presents the projected impact of the proposed changes for FY 2009 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 2008 with the proposed average estimated payments per case for FY 2009, 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 proposed percentage changes in average payments from Column 9 of Table I.

Table II.--Impact Analysis of Proposed Changes for FY 2009 Operating Prospective Payment System

Payments per case

Average

Average FY proposed FY All proposed

Number of

2008

2009

FY 2009 hospitals payment per payment per

changes case \1\

case \1\

(1)

(2)

(3)

(4)

All hospitals..............................................

3,528

$9,144

$9,519

4.1

By Geographic Location:

Urban hospitals........................................

2,542

9,571

9,972

4.2

Large urban areas (populations over 1 million).........

1,402

10,045

10,484

4.4

Other urban areas (populations of 1 million or fewer)..

1,140

9,000

9,355

3.9

Rural hospitals........................................

986

6,683

6,905

3.3

Bed Size (Urban): 0-99 beds..............................................

643

7,283

7,533

3.4 100-199 beds...........................................

829

8,103

8,428

4 200-299 beds...........................................

483

8,985

9,363

4.2 300-499 beds...........................................

411

10,046

10,482

4.3 500 or more beds.......................................

176

11,875

12,382

4.3

Bed Size (Rural): 0-49 beds..............................................

338

5,509

5,644

2.5 50-99 beds.............................................

373

6,097

6,279

3 100-149 beds...........................................

166

6,660

6,884

3.4 150-199 beds...........................................

67

7,467

7,752

3.8 200 or more beds.......................................

42

8,361

8,686

3.9

Urban by Region:

New England............................................

121

9,935

10,230

3

Middle Atlantic........................................

348

10,440

10,752

3

South Atlantic.........................................

385

9,025

9,427

4.5

East North Central.....................................

394

9,065

9,440

4.1

East South Central.....................................

163

8,681

9,044

4.2

West North Central.....................................

157

9,140

9,555

4.5

West South Central.....................................

371

9,043

9,466

4.7

Mountain...............................................

157

9,571

10,051

5

Pacific................................................

393

11,614

12,219

5.2

Puerto Rico............................................

53

4,706

4,857

3.2

Rural by Region:

New England............................................

23

9,051

9,263

2.3

Middle Atlantic........................................

70

6,912

7,124

3.1

South Atlantic.........................................

172

6,529

6,773

3.7

East North Central.....................................

121

6,872

7,093

3.2

East South Central.....................................

176

6,263

6,474

3.4

West North Central.....................................

113

6,886

7,119

3.4

West South Central.....................................

200

6,088

6,276

3.1

Mountain...............................................

75

6,802

7,010

3.1

Pacific................................................

36

8,162

8,455

3.6

By Payment Classification:

Urban hospitals........................................

2,584

9,549

9,948

4.2

Large urban areas (populations over 1 million).........

1,424

10,026

10,464

4.4

Other urban areas (populations of 1 million or fewer)..

1,160

8,975

9,328

3.9

Page 23914

Rural areas............................................

944

6,716

6,941

3.3

Teaching Status:

Non-teaching...........................................

2,485

7,716

8,023

4

Fewer than 100 Residents...............................

805

9,193

9,577

4.2 100 or more Residents..................................

238

13,392

13,951

4.2

Urban DSH:

Non-DSH................................................

838

8,118

8,409

3.6 100 or more beds.......................................

1,534

10,062

10,498

4.3

Less than 100 beds.....................................

354

6,792

7,022

3.4

Rural DSH:

SCH....................................................

389

6,093

6,293

3.3

RRC....................................................

206

7,465

7,740

3.7 100 or more beds.......................................

39

6,110

6,299

3.1

Less than 100 beds.....................................

168

5,451

5,580

2.4

Urban teaching and DSH:

Both teaching and DSH..................................

811

10,986

11,457

4.3

Teaching and no DSH....................................

172

8,885

9,201

3.6

No teaching and DSH....................................

1,077

8,283

8,644

4.4

No teaching and no DSH.................................

524

7,796

8,083

3.7

Rural Hospital Types:

RRC....................................................

197

7,783

8,100

4.1

SCH....................................................

355

6,564

6,764

3

MDH....................................................

156

5,757

5,975

3.8

SCH and RRC............................................

102

7,901

8,223

4.1

MDH and RRC............................................

12

7,303

7,510

2.8

Type of Ownership:

Voluntary..............................................

2,027

9,252

9,625

4

Proprietary............................................

827

8,424

8,772

4.1

Government.............................................

587

9,440

9,853

4.4

Medicare Utilization as a Percent of Inpatient Days: 0-25...................................................

255

13,112

13,751

4.9 25-50..................................................

1,350

10,344

10,801

4.4 50-65..................................................

1,431

7,950

8,245

3.7

Over 65................................................

392

7,033

7,245

3

Hospitals Reclassified by the Medicare Geographic

Classification Review Board:

FY 2009 Reclassifications:

All Reclassified Hospitals FY 2009.....................

805

8,803

9,141

3.8

All Non-Reclassified Hospitals FY 2009.................

2,723

9,264

9,651

4.2

Urban Reclassified Hospitals FY 2009:..................

445

9,547

9,921

3.9

Urban Non-reclassified Hospitals FY 2009:..............

2,075

9,586

9,994

4.3

Rural Reclassified Hospitals FY 2009:..................

360

7,240

7,505

3.7

Rural Nonreclassified Hospitals FY 2009:...............

565

5,870

6,033

2.8

All Section 401 Reclassified Hospitals:................

29

7,555

7,816

3.5

Other Reclassified Hospitals (Section 1886(d)(8)(B))...

61

6,534

6,716

2.8

Specialty Hospitals:

Cardiac Specialty Hospitals............................

20

10,894

11,085

1.8

\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 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 HACs, Including Infections

In section II.F. of the preamble of this proposed rule, we discuss our implementation of section 5001(c) of Pub. L. 109-171, which requires the Secretary to identify conditions that (1) are high cost, high volume, or both, (2) result in the assignment of a case to a MS-DRG that has a higher payment when present as a secondary diagnosis, and (3) 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 MS-DRG reclassifications and recalibration. Therefore, we do our budget neutrality calculations as though the payment provision

Page 23915

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.

We note that the provision will only apply when one or more of the selected conditions are the only secondary diagnosis or diagnoses present on the claim that will lead to higher payment.

Therefore, if at least one 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. Medicare beneficiaries will generally have multiple secondary diagnoses during a hospital stay, such that beneficiaries having one MCC or CC will frequently have additional conditions that also will generate higher payment.

Therefore, in only a small percentage of the cases will the beneficiary have only one secondary diagnosis that would lead to higher payment.

The section 5001(c) payment provision will go into effect on

October 1, 2008. Our savings estimate for the next 5 fiscal years from this provision has changed from our savings estimate published in the FY 2008 IPPS final rule with comment period because of the potential addition to the list of selected HACs for FY 2009 of the nine conditions considered in section II.F. of this proposed rule.

We had estimated a savings of $20 million per year from this provision for the eight conditions we originally selected in the FY 2008 IPPS final rule with comment period (72 FR 48168). We now estimate that this provision will save $50 million per year for the first 3 years beginning October 1, 2008. Beginning in FY 2012, we estimate a savings of $60 million per year as a result of this provision. Our savings estimates for the next 5 fiscal years are shown below:

Savings

Year

(in millions)

FY 2009.....................................................

$50

FY 2010.....................................................

50

FY 2011.....................................................

50

FY 2012.....................................................

60

FY 2013.....................................................

60

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

Weights for LTCHs

In section II.I. of the preamble to this proposed rule, we discuss the proposed MS-LTC-DRGs (proposed Version 26.0 of the

GROUPER) and development of the proposed relative weights for use under the LTCH PPS for FY 2009. We also discuss that when we adopted the new severity adjusted MS-LTC-DRG patient classification system under the LTCH PPS in the FY 2008 IPPS final rule with comment, we implemented a 2-year transition, in which the MS-LTC-DRG relative weights for FY 2009 would be based completely on the MS-LTC-DRG patient classification system (and no longer based in part on the former LTC-DRG patient classification system). Consistent with the requirement at Sec. 412.517 established in the RY 2008 LTCH PPS final rule (72 FR 26880 through 26884), the proposed annual update to the classification and relative weights under the LTCH PPS for RY 2009 was 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 MS-LTC-DRG classification and relative weight changes. To achieve budget neutrality under Sec. 412.517, in determining the proposed FY 2009

MS-LTC-DRG relative weights, we applied a factor of 1.038266 in the first step of the budget neutrality process (normalization), and we applied a budget neutrality factor of 0.9965 after normalization

(see section II.I.4. (step 7) of the preamble of this proposed rule). These proposed factors that were applied to maintain budget neutrality were based on the most recent available LTCH claims data

(FY 2007 MedPAR files) for the 387 LTCHs in our database. Consistent with the budget neutrality requirement under Sec. 412.517, we estimate that with the proposed changes to the MS-LTC-DRG classifications and relative weights for FY 2009, there would be no change in aggregate LTCH PPS payments. In applying the budget neutrality adjustment described above, we assumed constant utilization.

C. Effects of Proposed Policy Change Relating to New Medical

Service and Technology Add-On Payments

In section II.J. of the preamble to this proposed rule, we discuss proposed add-on payments for new medical services and technologies. As explained in that section, add-on payments for new technology under section 1886(d)(5)(K) of the Act are not required to be budget neutral. As discussed in section II.J.4. of this proposed rule, we have yet to determine whether any of the four applications we received will meet the criteria for new technology add-on payments for FY 2009. Consequently, it is premature to estimate the potential payment impact in FY 2009 of any potential new technology add-on payments for FY 2009. There are no technologies receiving new technology add-on payment in FY 2008.

Therefore, at this time, we estimate that Medicare's new technology add-on payments would remain unchanged in FY 2009 compared to FY 2008. If any of the four applicants are found to be eligible for new technology add-on payments for FY 2009 in the final rule, we would discuss the estimated payment impact for FY 2009 in that final rule.

D. Effects of Proposed Policy Regarding Postacute Care Transfers to

Home Health Services

In section IV.A. of the preamble to this proposed rule, we noted that, under current regulations, the postacute care transfer policy applies to acute care discharges for which home health care (for a related condition) begins within 3 days of the discharge from an acute care hospital where the patient was discharged from the hospital prior to the geometric mean length of stay for a

``qualified'' MS-DRG. In that section, we discussed the reasons why we believe that the 3-day timeframe is no longer an appropriate threshold under the postacute care transfer policy. We discussed our rationale for extending the timeframe from within 3 days to within 7 days. Accordingly, we proposed to revise the timeframe in our regulations to within 7 days of discharge to home under a written plan for the provision of home health services, effective with discharges occurring on or after October 1, 2008.

To estimate the impact of this proposal, we used acute care hospital claims from the FY 2005 MedPAR file and searched for claims with a discharge destination code of ``01'' (Discharged to Home or

Self-Care (Routine Discharge)) or ``06'' (Discharged/Transferred to

Home under Care of Organized Home Health Service Organization in

Anticipation of Covered Skilled Care). We then matched the acute care hospital MedPAR claims with HHA final action claims for 2005, using beneficiary identification numbers. We then compared the hospital discharge date with the home health admission date and determined a distribution by the difference in these two dates. We found that, for those patients for whom home health services began within 60 days of hospital discharge, in 6.7 percent of the cases, the services began on days 4 through day 7 after the acute care hospital discharge. We estimate that applying the proposed change to the hospital postacute care transfer policy would reduce Medicare payments to acute care inpatient hospitals by approximately $330 million over 5 years. For FY 2009, we estimate that Medicare payments would be reduced by approximately $50 million.

E. Effects of Proposed Requirements for Hospital Reporting of

Quality Data for Annual Hospital Payment Update

In section IV.B. 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 2009 and FY 2010. There are an estimated 186 hospitals in this analysis that may not receive the full market basket update for FY 2009. Most of these hospitals are either small rural or small urban hospitals. However, at this time, information is not available to determine the hospitals that do not meet the requirements for the full hospital market increase for FY 2009.

We also note that, for the FY 2009 payment update, hospitals must pass our validation requirement of a minimum of 80 percent reliability, based upon our chart-audit validation process, for the four quarters of data from FY 2007. These data were due to the QIO

Clinical Warehouse by May 15, 2007 (fourth quarter CY 2006 discharges), August 15, 2007 (first quarter CY 2007 discharges),

November 15, 2007 (second quarter CY 2007 discharges), and February 15, 2008 (third quarter CY 2007 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 proposing to provide additional validation criteria to ensure that the quality data being sent to CMS are accurate. The requirement of 5 charts per

Page 23916

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 $597,600 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.

F. Effects of Proposed Policy Change to Methodology for Computing

Core Staffing Factors for Volume Decrease Adjustment for SCHs and

MDHs

In section IV.D. of the preamble of this proposed rule, we discuss a change to the methodology we would use to compute the average nursing staff factors (nursing hours per patient days) for the volume decrease adjustment for SCHs and MDHs. If certain requirements are met, this adjustment may be made if the hospital's total discharges decrease by more than 5 percent from one cost reporting period to the next. We do not believe this proposed change would have any significant impact on Medicare payments to these hospitals.

G. Effects of Proposed Clarification of Policy for Collection of

Risk Adjustment Data From MA Organizations

In section IV.H. of the preamble of this proposed rule, we discuss our proposed revision of our regulations to clarify that CMS has the authority to require MA organizations to submit encounter data for each item and service provided to an MA plan enrollee. The proposed revision also would clarify that CMS will determine the formats for submitting encounter data, which may be more abbreviated than those used for the Medicare fee-for-service claims data submission process. At this time, we have not yet determined an approach for submission of the encounter data. Therefore, we are not in a position to determine the extent to which the cost impact of submitting encounter data would differ from the current costs to MA organizations of submitting risk adjustment data.

H. Effects of Proposed Policy Changes Relating to Hospital

Emergency Services Under EMTALA

In section IV.I. of the preamble of this proposed rule, we are proposing to clarify our policy regarding the applicability of

EMTALA to hospital inpatients. We are proposing to amend the regulations to state that when an individual covered by EMTALA was admitted as an inpatient and remains unstabilized with an emergency medical condition, a receiving hospital with specialized capabilities has an EMTALA obligation to accept that individual, assuming that the transfer of the individual is an appropriate transfer and the participating hospital with specialized capabilities has the capacity to treat the individual. In addition, we are proposing two changes relating to the requirements for on- call physicians in hospital emergency departments. We are proposing to delete the provision relating to maintaining a list of on-call physicians from the regulations referring to EMTALA at Sec. 489.24(j)(1) because a provision addressing the on-call physician list is already included in the regulations relating to provider agreements at Sec. 489.20(r)(2). We are proposing to incorporate the language of Sec. 489.24(j)(1) as replacement language for the existing Sec. 489.20(r)(2) and amend the regulatory language to make it more consistent with the statutory language found at section 1866(a)(1)(I)(iii) of the Act, which refers to hospital CoPs and the requirement to maintain an on-call list. These proposed changes would make the regulations consistent with the statutory basis for maintaining an on-call list. In addition, we are proposing to amend our regulations to provide that hospitals may comply with the on- call list requirement by participating in a formal community call plan so long as the plan includes a number of elements that are specified in the preamble to the proposed rule. Lastly, we are proposing to make a technical change to the regulations to conform them to the statutory language found in the Pandemic and All-Hazards

Preparedness Act. These proposals do not include any substantive new requirements. Although hospitals choosing to participate in a community call arrangement will be required to devise a formal community call plan, such a plan would increase a hospital's flexibility in meeting its on-call requirements. We are estimating no impact on Medicare expenditures and no significant impact on hospitals with emergency departments.

I. Effects of Implementation of Rural Community Hospital

Demonstration Program

In section IV.K. 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.'' There are currently nine hospitals participating in the demonstration. We are currently conducting a solicitation for up to six additional hospitals to participate in the demonstration program.

As discussed in section IV.K. 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 2009 that would be made to each participating hospital under the demonstration would be approximately $2,134,123.

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. As an estimate for the 15 hospitals that may participate, the total annual impact of the demonstration program for FY 2009 is projected to be $32,011,849.

(In the final rule, we should know the exact number of hospitals participating in the demonstration program and would revise our estimates accordingly.) The adjustment factor to the Federal rate used in calculating Medicare inpatient prospective payments as a result of the demonstration is 0.999903.

J. Effects of Proposed Policy Changes Relating to Payments to

Hospitals-Within-Hospitals

In section VI.F. of the preamble of this proposed rule, we discuss our proposed policy change to allow a HwH that cannot meet the criteria in regulations for a separate governing body solely because it is a State hospital occupying space with another State hospital or located on the same campus as another State hospital and both hospitals are under the same governing authority, or the governing authority of a third entity that controls both State hospitals, to nevertheless qualify for an exclusion from the IPPS if the hospital meets other applicable criteria for HwHs in the regulations and the specified proposed criteria in this proposed rule. We are only aware of one hospital that would be allowed qualify for exclusion from the IPPS under the proposed criteria and to expand its bed size under the proposed provisions. Because any expansion would occur at some point in the future, we are unable to quantify the impact of this proposed change.

K. Effects of Proposed Policy Changes Relating to Requirements for

Disclosure of Physician Ownership in Hospitals

In section VII. of the preamble of this proposed rule, we discuss our proposals concerning (1) the definition of a physician- owned hospital; (2) the requirement that physician-owned hospitals disclose the ownership to patients; and (3) the requirement that all hospitals and CAHs must furnish written notice to their patients at the beginning of their hospital stay or outpatient visit if a physician is not present in the hospital 24 hours per day, 7 days per week, and that the notice must indicate how the hospital will meet the medical needs of any patient who develops an emergency medical condition at a time when there is no physician present in the hospital. The definition and the above requirements were implemented in the FY 2008 IPPS final rule with comment period (72

FR 47387 and 47391).

In this proposed rule, we are proposing to revise the definition of a physician-owned hospital at Sec. 489.3 to include hospitals that have an ownership or investment interests by a physician and/or by an immediate family member of a physician. (The existing definition refers to an ownership or investment interest by a physician only, and not to an ownership or investment interest by an immediate family member.) We are also proposing to except from the definition of physician-owned hospital those hospitals that do not have at least one physician owner/investor or immediate family member

Page 23917

owner/investor who refers patients to the hospital. We believe that the proposed changes to the definition of physician-owned hospital would result in no more than a de minimis increase in the number of hospitals that are subject to the disclosure requirements applicable to physician-owned hospitals. We believe that there would be very few hospitals that would now meet the definition of physician-owned hospital, if we adopt our proposal to include immediate family members within the group of owners or investors that cause a hospital to be considered physician-owned, that did not already meet the definition. That is, we believe there are very few hospitals for which an immediate family member of a physician, but not the physician himself or herself, or any other physician, has an ownership or investment interest. Moreover, to the extent that such hospitals exist, that is, hospitals that have no physician owner/ investors but which have owners/investors who are immediate family members of one or more physicians, such hospitals would not be subject to the disclosure requirement if we adopt our proposed exception to the definition of a physician-owned hospital for those hospitals that do not have at least one referring physician whose immediate family member is an owner/investor. Also, if we adopt this proposed exception to the definition of physician-owned hospital, the number of hospitals that now are subject to the disclosure requirement may be reduced slightly as we understand that there are some hospitals that have no referring physician owner/investors but rather have physician owner/investors who have retired from the practice of medicine. Thus, if both our proposed changes to the definition of physician-owned hospital are adopted, the net result may be no change, or a minimal increase or decrease in the number of hospitals that are subject to the disclosure requirement. Finally, if our proposal to change the definition of physician-owned hospital is adopted to encompass immediate family members, some hospitals that already meet the definition based on the presence of physician owner/investors may have to amend their list of physician owner/ investors to add immediate family members, which we believe would be a minimal burden.

We are proposing to clarify that the list of the hospital's owners or investors who are physicians or immediate family members of physicians must be provided to the patient at the time the request for the list is made by or on behalf of the patient. We note that hospitals are already currently required to furnish the list of physician owners or investors and, thus, we believe that the impact of stipulating a timeframe for furnishing the list is negligible.

We are proposing to require all hospitals to require that all physician owners who also are members of the hospital's medical staff to agree, as a condition of continued medical staff membership or admitting privileges, to disclose, in writing, to all patients they refer to the hospital any ownership or investment interest that is held by themselves or by an immediate family member (as defined in Sec. 411.351). Disclosure would be required at the time the referral is made. Both hospitals and physicians would participate in the disclosure process. We believe this proposal would have a small effect on physician-owned hospitals to the extent that it may require them to change their bylaws or make similar changes.

We do not anticipate that our proposals in section VII. of the preamble of this proposed rule would have a significant economic impact on a substantial number of physicians, other health care providers and suppliers, or the Medicare or Medicaid programs and their beneficiaries. Specifically, we believe that this proposed rule would affect mostly hospitals, physicians, and beneficiaries.

The proposed changes concerning both the definition of a physician- owned hospital and the disclosure of physician ownership in hospitals are consistent with the physician self-referral statute and regulations as well as the current practices of most hospitals.

Thus, our proposed requirement that the list of physician owners be provided to the patient at the time the request for the list is made by or on behalf of the patient would present a negligible economic impact on the hospital. Similarly, the cost borne by individual physicians to implement these provisions would be limited to a one- time cost associated with developing a disclosure notice that would be shared with patients at the time the referral is made in addition to the negligible time associated with providing the list to the patient and maintaining a copy of the notice in the patient's medical record.

We are also proposing to provide authority for CMS to terminate the Medicare provider agreement of any hospital that fails to furnish the required written notice that a physician is not available 24 hours per day, 7 days per 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 there is no physician present in the hospital. We believe that the cost borne by hospitals to implement this proposal would be limited to a one-time cost associated with completing minor revisions to the hospital's policies and procedures to comply with the requirements of its

Medicare provider agreement. Most hospitals have standard procedures to satisfy CMS by correcting deficiencies (such as the failure to furnish notice of physician ownership in the hospital to patients) before action is taken by CMS to terminate the Medicare provider agreement.

Overall, we believe that beneficiaries would be positively impacted by these provisions. Specifically, disclosure of physician ownership or investment interests equips patients to make informed decisions about where they elect to receive care. Our proposals make no significant changes that have the potential to impede patient access to health care facilities and services. In fact, we believe that our proposals would help minimize anti-competitive behavior that can affect the decision as to where a beneficiary receives health care services and possibly the quality of the services furnished.

L. Effects of Proposed Changes Relating to Physician Self-Referral

Provisions

In section VIII. of the preamble of this proposed rule, we discuss our proposals pertaining to physician self-referral provisions, including: stand in the shoes, period of disallowance, and reporting of financial relationships between hospitals and physicians. We do not anticipate that our proposals would have a significant impact on physicians, other health care providers and suppliers, or the Medicare or Medicaid programs and their beneficiaries.

With respect to the proposals to modify the physician ``stand in the shoes'' provisions, we do not anticipate that entities that include one or more physician organizations would find it necessary to restructure their organizational relationships. We believe that if either of our alternative approaches is adopted, compliance with the ``stand in the shoes'' provisions would be made easier by simplifying the required analysis of arrangements in which a physician organization is interposed between the referring physician and the entity furnishing DHS. In addition to our proposals concerning the physician ``stand in the shoes'' provisions, we are making an entity ``stand in the shoes'' proposal, whereby an entity that furnishes DHS would be deemed to stand in the shoes of an organization in which it has a 100-percent ownership interest and would be deemed to have the same compensation arrangements with the same parties and on the same terms as does the organization that it owns. We believe that the entity stand in the shoes proposal may result in more financial relationships between entities and physicians being subject to the physician self-referral provisions, but we are unable to quantify at this time the possible increase or determine the effect of the proposal on the referral patterns or organization structures of DHS entities and their wholly-owned organizations. Rather, we welcome public comments on these issues.

Our proposal pertaining to the period of disallowance is a codification of what we believe is existing law and reflects what we believe most entities furnishing DHS are already following.

Therefore, we do not anticipate a significant economic impact on the industry.

M. Effects of Proposed Changes Relating to Reporting of Financial

Relationships Between Hospitals and Physicians

As discussed in section IX. of the preamble to this proposed rule, we are proposing to require that 500 hospitals furnish information concerning their financial relationships with their physicians. The financial relationships include ownership and investment interests and compensation arrangements. We are proposing that this information be submitted in a collection of information instrument that CMS has developed--the ``DFRR,'' which is included in Appendix C to this proposed rule. We are unable to quantify the number of physicians who have ownership and investment interests and compensation arrangements with hospitals. Even if we assume that the 500 hospitals have a substantial number of financial relationships with physicians, we believe that, in general, the economic impact on these hospitals would not be substantial. Because we are proposing that the DFRR be completed by hospitals and that the

Page 23918

physician information requested in the DFRR will be on file at the hospital, we believe there should be negligible, if any, impact upon physicians or other health care providers or suppliers.

Specifically, we believe that the cost to complete the DFRR for each hospital would be approximately $1,550, and the total cost burden for the industry would be approximately $775,000.

We expect that this proposed rule may result in savings to the

Medicare program by minimizing anti-competitive business arrangements as well as financial incentives that encourage overutilization. In addition, to the extent that we determine that any arrangements are noncompliant with the physician self-referral statute and regulations, there may be monies returned to the

Medicare Trust Fund. We cannot gauge with any certainty the extent of these savings to the Medicare program at this time. Finally, we do not anticipate any financial burden on beneficiaries or impact on beneficiary access to medically necessary services because the completion of the DFRR would be conducted by hospitals.

VIII. Effects 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.

The basic methodology for determining a capital PPS payment is set forth at Sec. 412.312. The basic methodology for calculating capital IPPS payments in FY 2009 would be 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).

We note that, in accordance with Sec. 412.322(c), the IME adjustment factor for FY 2009 is equal to half of the current adjustment, as discussed in section V.B.2. of the preamble of this proposed rule. 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 2007 update of the FY 2007 MedPAR file and the December 2007 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 2007 update of the most recently available hospital cost report data (FYs 2005 and 2006) to categorize hospitals. Our analysis has several qualifications. We use the best data available and make assumptions about case-mix and beneficiary enrollment as described below. In addition, as discussed in section III. of the Addendum to this proposed rule, as we established for FY 2008, we are proposing to adjust the national capital rate to account for improvements in documentation and coding under the MS-DRGs in FY 2009. (As discussed in section III.A.6. of the Addendum to this proposed rule, we are not proposing to adjust the Puerto Rico specific capital rate to account for improvements in documentation and coding under the MS-DRGs in FY 2009.) 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 2007 update of the FY 2007 MedPAR file, we simulated payments under the capital PPS for FY 2008 and FY 2009 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 (which are reduced by 50 percent in FY 2009 in accordance with Sec. 412.322(c), as discussed in section V.B.2. of the preamble of this proposed rule), disproportionate share, and outliers, if applicable. 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 2008 and 2009. (We note that this does not reflect the expected growth in case-mix due to improvement in documentation and coding under the MS-DRGs, as discussed below.)

We estimate that the Medicare discharges will be 13.2 million in FY 2008 and 13.3 million in FY 2009 for an approximately 0.4 percent increase from FY 2008 to FY 2009.

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 VIII. of the preamble and section III.A.2.1. of the Addendum to this proposed rule, the proposed FY-2009 update is 0.7 percent.

In addition to the proposed FY 2009 update factor, the proposed FY 2009 capital Federal rate was calculated based on a proposed GAF/DRG budget neutrality factor of 1.0007, a proposed outlier adjustment factor of 0.9427, and a proposed exceptions adjustment factor of 0.9998.

For FY 2009, as discussed in section III.A. of the

Addendum to this proposed rule, the proposed FY 2009 national capital rate was further adjusted by a factor to account for anticipated improvements in documentation and coding that are expected to increase case-mix under the MS-DRGs. In the FY 2008 IPPS final rule with comment period (72 FR 47186), we established adjustments to the IPPS rates based on the Office of the Actuary projected case-mix growth resulting from improved documentation and coding of 1.2 percent for FY 2008, 1.8 percent for FY 2009, and 1.8 percent for FY 2010. However, we reduced the documentation and coding adjustment to -0.6 percent for FY 2008, and for FY 2009, we are proposing to apply an adjustment of 0.9 percent, consistent with section 7 of Pub. L. 110-90. As noted above and as discussed in section III.A.6. of the Addendum to this proposed rule, we are not proposing to adjust the Puerto Rico-specific capital rate to account for improvements in documentation and coding under the MS-DRGs in FY 2009.

B. Results

We used the actuarial model described above to estimate the potential impact of our proposed changes for FY 2009 on total capital payments per case, using a universe of 3,528 hospitals. As described above, the individual hospital payment parameters are taken from the best available data, including the December 2007 update of the FY 2007 MedPAR file, the December 2007 update to the

PSF, and the most recent cost report data from the December 2007 update of HCRIS. In Table III, we present a comparison of total payments per case for FY 2008 compared to proposed FY 2009 based on the proposed FY 2009 payment policies. Column 2 shows estimates of payments per case under our model for FY 2008. Column 3 shows estimates of payments per case under our model for FY 2009. Column 4 shows the total percentage change in payments from FY 2008 to FY 2009. The change represented in Column 4 includes the proposed 0.7 percent update to the capital Federal rate, other changes in the adjustments to the capital Federal rate (for example, the 50 percent reduction to the teaching adjustment for FY

Page 23919

2009), and the additional 0.9 percent reduction to the national capital rate to account for improvements in documentation and coding

(or other changes in coding that do not reflect real changes in case-mix) for implementation of the MS-DRGs. Consistent with the impact analysis for the proposed policy changes under the IPPS for operating costs in section VI. of this Appendix, for purposes of this impact analysis, we also assume a 1.8 percent increase in case- mix growth for FY 2009, as determined by the Office of the Actuary, because we believe the adoption of the MS-DRG will result in case- mix growth due to documentation and coding changes that do not reflect real changes in patient severity of illness. 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 in FY 2009 can be expected to remain about the same as capital payments per case in FY 2008. The proposed capital rate for

FY 2009 would decrease 1.14 percent as compared to the FY 2008 capital rate, and the proposed changes to the GAFs are expected to result in a slight decrease (0.3 percent) in capital payments. In addition, the 50 percent reduction to the teaching adjustment in FY 2009 will also result in a decrease in capital payments from FY 2008 as compared to FY 2009. Countering these factors is the projected case-mix growth as a result of improved documentation and coding

(discussed above) as well as an estimated increase in outlier payments in FY 2008 as compared to FY 2009. The net result of these changes is an estimated 0.0 percent change in capital payments per discharge from FY 2008 to FY 2009 for all hospitals (as shown below in Table III).

The results of our comparisons by geographic location and by region are consistent with the results we expected with the decrease to the teaching adjustment in FY 2009 (Sec. 412.522(c)). The geographic comparison shows that all urban hospitals are expected to experience no change in capital IPPS payments per case in FY 2009 as compared to FY 2008, while hospitals in large urban areas are expected to experience a slight decrease (0.3 percent) in capital

IPPS payments per case in FY 2009 as compared to FY 2008. Capital

IPPS payments per case for rural hospitals are expected to increase 0.5 percent. These differences in payments per case by geographic location are mostly due to the decrease in the teaching adjustment.

Because teaching hospitals generally tend to be located in urban or large urban areas, we would expect that the 50 percent decrease in the teaching adjustment for FY 2009 would have a more significant impact on hospitals in those areas than those hospitals located in rural areas.

Most regions are estimated to experience an increase in total capital payments per case from FY 2008 to FY 2009. These increases vary by region and range from a 1.9 percent increase in the Pacific urban and West South Central urban regions to a 0.1 percent increase in the East North Central urban region. Two urban regions are projected to experience a relatively larger decrease in capital payments, with the difference mostly due to proposed changes in the

GAFs and the 50 percent reduction in the teaching adjustment for FY 2009: -2.7 percent in the Middle Atlantic urban region and -3.6 percent in the New England urban region. The East North Central urban region is also expected to experience a decrease of 0.1 percent in capital payments in FY 2009 as compared to FY 2008, mostly due to proposed changes in the GAFs. There are two rural regions that expected to experience a decrease in total capital payments per case: A -4.5 percent decrease in the New England rural region and a -1.0 percent decrease in the Middle Atlantic rural region. Again, for these two rural regions, the projected decrease in capital payments is mostly due to proposed changes in the GAF, as well as a smaller than average increase in changes payments due to the adoption of the MS-DRGs.

By type of ownership, voluntary and government hospitals are estimated to experience a decrease of 0.2 percent and 0.8 percent, respectively. The projected decrease in capital payments per case is primarily due to the 50 percent teaching adjustment reduction for FY 2009. Proprietary hospitals are estimated to experience an increase in capital payments per case of 1.6 percent. This estimated increase in capital payments is mostly due to a smaller than average decrease in payments resulting from the 50 percent teaching adjustment reduction for FY 2009.

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 2009. Reclassification for wage index purposes also affects the GAFs because that factor is constructed from the hospital wage index.

To present the effects of the hospitals being reclassified for

FY 2009, we show the average capital payments per case for reclassified hospitals for FY 2008. Urban reclassified hospitals are expected to have the largest decrease in capital payments of 0.4 percent, while rural reclassified hospitals are expected to have the largest increase in capital payments of 1.0 percent. Urban nonreclassified hospitals are not expected to experience any change in capital payment from FY 2008 to FY 2009, while rural nonreclassified hospitals are expected to experience a slight decrease in capital payments of 0.3 percent. The projected changes in capital payments for rural hospitals are mainly due to the proposed changes to the GAF (including the proposal to apply the rural floor budget neutrality at a State level). The projected changes in capital payments for urban hospitals are mainly due to the 50 percent reduction in the teaching adjustment in FY 2009.

Table III.--Comparison of Total Capital Payments Per Case

FY 2008 payments compared to FY 2009 payments

Average FY Average FY

Number of

2008

2009 hospitals payments/ payments/

Change case

case

By Geographic Location:

All hospitals...........................................

3,528

757

757

0.0

Large urban areas (populations over 1 million)..........

1,402

834

831

-0.3

Other urban areas (populations of 1 million or fewer)...

1,140

752

754

0.3

Rural areas.............................................

986

528

531

0.5

Urban hospitals.........................................

2,542

796

796

0.0 0-99 beds...........................................

643

632

642

1.6 100-199 beds........................................

829

684

692

1.1 200-299 beds........................................

483

752

758

0.8 300-499 beds........................................

411

829

827

-0.3 500 or more beds....................................

176

973

957

-1.7

Rural hospitals.........................................

986

528

531

0.5 0-49 beds...........................................

338

429

427

-0.5 50-99 beds..........................................

373

485

487

0.4 100-149 beds........................................

166

532

537

1.0 150-199 beds........................................

67

586

595

1.4 200 or more beds....................................

42

652

652

0.0

By Region:

Page 23920

Urban by Region.........................................

2,542

796

796

0.0

New England.........................................

121

835

805

-3.6

Middle Atlantic.....................................

348

858

835

-2.7

South Atlantic......................................

385

755

763

1.1

East North Central..................................

394

777

770

-0.9

East South Central..................................

163

719

727

1.2

West North Central..................................

157

777

779

0.2

West South Central..................................

371

747

761

1.9

Mountain............................................

157

807

822

1.8

Pacific.............................................

393

925

943

1.9

Puerto Rico.........................................

53

367

368

0.3

Rural by Region.........................................

986

528

531

0.5

New England.........................................

23

706

675

-4.5

Middle Atlantic.....................................

70

543

537

-1.0

South Atlantic......................................

172

516

524

1.5

East North Central..................................

121

555

555

0.1

East South Central..................................

176

480

484

0.9

West North Central..................................

113

560

567

1.1

West South Central..................................

200

479

483

0.8

Mountain............................................

75

533

539

1.2

Pacific.............................................

36

650

660

1.6

By Payment Classification:

All hospitals...........................................

3,528

757

757

0.0

Large urban areas (populations over 1 million)..........

1,424

832

830

-0.3

Other urban areas (populations of 1 million or fewer)...

1,160

750

752

0.3

Rural areas.............................................

944

528

531

0.6

Teaching Status:

Non-teaching........................................

2,484

643

657

2.1

Fewer than 100 Residents............................

805

765

769

0.5 100 or more Residents...............................

238

1,085

1,037

-4.4

Urban DSH: 100 or more beds................................

1,534

823

820

-0.3

Less than 100 beds..............................

354

567

573

1.2

Rural DSH:

Sole Community (SCH/EACH).......................

389

467

469

0.4

Referral Center (RRC/EACH)......................

206

584

589

0.8

Other Rural: 100 or more beds............................

39

489

493

0.8

Less than 100 beds..........................

168

438

438

0.1

Urban teaching and DSH:

Both teaching and DSH...............................

811

896

881

-1.6

Teaching and no DSH.................................

172

784

777

-0.8

No teaching and DSH.................................

1,077

683

700

2.5

No teaching and no DSH..............................

524

702

716

2.0

Rural Hospital Types:

Non special status hospitals

2,459

800

799

-0.1

RRC/EACH............................................

63

700

714

2.0

SCH/EACH............................................

36

654

659

0.8

Medicare-dependent hospitals (MDH)..................

11

457

456

-0.2

SCH, RRC and EACH...................................

15

751

776

3.4

Hospitals Reclassified by the Medicare Geographic

Classification Review Board:

FY 2009 Reclassifications:

All Urban Reclassified..............................

445

802

799

-0.4

All Urban Non-Reclassified..........................

2,075

796

796

0.0

All Rural Reclassified..............................

360

573

579

1.0

All Rural Non-Reclassified..........................

565

459

458

-0.3

Other Reclassified Hospitals (Section 1886(d)(8)(B))

54

535

538

0.5

Type of Ownership:

Voluntary...........................................

2,027

770

769

-0.2

Proprietary.........................................

827

699

710

1.6

Government..........................................

587

752

746

-0.8

Medicare Utilization as a Percent of Inpatient Days: 0-25................................................

255

998

971

-2.8 25-50...............................................

1,350

847

843

-0.5 50-65...............................................

1,431

671

677

0.9

Over 65.............................................

392

598

601

0.5

Page 23921

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, and presents rationale for our decisions and, where relevant, alternatives that were considered.

X. Overall Conclusion

The changes we are proposing in this proposed rule will 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 2009. Table I of section VI. of this Appendix demonstrates the estimated distributional impact of the IPPS budget neutrality requirements for proposed MS-DRG and wage index changes, and for the wage index reclassifications under the MGCRB. Table I also shows an overall increase of 4.1 percent in operating payments.

We estimate operating payments to increase by $3.96 billion. This accounts for the projected savings associated with the postacute care transfer policy proposal and the HACs policy, which each have an estimated savings of $50 million. In addition, this estimate includes the hospital reporting of quality data program costs ($2.39 million) and all proposed operating payment policies as described in section VII. of this Appendix. Capital payments are estimated to increase by 0.0 percent per case, as shown in Table III of section

VIII. of this Appendix. Therefore, we project that the increase in capital payments in FY 2009 compared to FY 2008 is negligible ($6 million). The proposed operating and capital payments should result in a net increase of $3.967 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 to providers as a result of the proposed changes to the IPPS presented in this proposed rule. All expenditures are classified as transfers to Medicare providers.

Table IV.--Accounting Statement: Classification of Estimated

Expenditures From FY 2008 to FY 2009

Category

Transfers

Annualized Monetized Transfers......... $3.967 Billion.

From Whom to Whom...................... Federal Government to IPPS

Medicare Providers.

Total.............................. $3.967 Billion.

XII. Executive Order 12866

In accordance with the provisions of Executive Order 12866, the

Office of Management and Budget reviewed this proposed rule.

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

I. Background

Section 1886(e)(4)(A) of the Act requires that the Secretary, taking into consideration the recommendations of the MedPAC, recommend update factors for inpatient hospital services for each fiscal year that take into account the amounts necessary for the efficient and effective delivery of medically appropriate and necessary care and high quality care. Under section 1886(e)(5)(B) of the Act, we are required to publish update factors recommended by the Secretary in the proposed and final IPPS rules, respectively.

Accordingly, this Appendix provides the recommendations for the update factors for the IPPS national standardized amount, the Puerto

Rico-specific standardized amount, the hospital-specific rates for

SCHs and MDHs, and the rate-of-increase limits for hospitals and hospital units excluded from the IPPS, as well as LTCHS, IPFs, and

IRFs. We also discuss our response to MedPAC's recommended update factors for inpatient hospital services.

II. Inpatient Hospital Update for FY 2009

Section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001(a) of Pub. L. 109-171, sets the FY 2009 percentage increase in the operating cost standardized amount equal to the rate-of-increase in the hospital market basket for IPPS hospitals in all areas, subject to the hospital submitting quality information under rules established by the Secretary in accordance with 1886(b)(3)(B)(viii) of the Act. For hospitals that do not provide these data, the update is equal to the market basket percentage increase less 2.0 percentage points. Consistent with current law, based on Global

Insight, Inc.'s first quarter 2008 forecast of the FY 2009 market basket increase, we are estimating that the FY 2009 update to the standardized amount will be 3.0 percent (that is, the current estimate of the market basket rate-of-increase) for hospitals in all areas, provided the hospital submits quality data in accordance with our rules. For hospitals that do not submit quality data, we are estimating that the update to the standardized amount will be 1.0 percent (that is, the current estimate of the market basket rate-of- increase minus 2.0 percentage points).

Section 1886(d)(9)(C)(1) of the Act is the basis for determining the percentage increase to the Puerto Rico-specific standardized amount. For FY 2009, we are applying the full rate-of-increase in the hospital market basket for IPPS hospitals to the Puerto Rico- specific standardized amount. Therefore, the update to the Puerto

Rico-specific standardized amount is estimated to be 3.0 percent.

Section 1886(b)(3)(B)(iv) of the Act sets the FY 2009 percentage increase in the hospital-specific rates applicable to SCHs and MDHs equal to the rate set forth in section 1886(b)(3)(B)(i) of the Act

(that is, the same update factor as for all other hospitals subject to the IPPS, or the rate-of-increase in the market basket).

Therefore, the update to the hospital-specific rates applicable to

SCHs and MDHs is estimated to be 3.0 or 1.0 percent, depending upon whether the hospital submits quality data.

Section 1886(b)(3)(B)(ii) of the Act is used for purposes of determining the percentage increase in the rate-of-increase limits for children's and cancer hospitals. Section 1886(b)(3)(B)(ii) of the Act sets the percentage increase in the rate-of-increase limits equal to the market basket percentage increase. 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.

Section 1886(j)(3)(C) of the Act addresses the increase factor for the Federal prospective payment rate of IRFs. Section 123 of Pub. L. 106-113, as amended by section 307(b) of Pub. L. 106-554, provides the statutory authority for updating payment rates under the LTCH

PPS. As discussed below, for cost reporting periods beginning on or after October 1, 2006, LTCHs that are not defined as new under Sec. 412.23(e)(4), and that had not elected to be paid under 100 percent of the Federal rate are paid 100 percent of the adjusted Federal PPS rate. Therefore, because no portion of LTCHs' prospective payments will be based on reasonable cost concepts for cost reporting periods beginning on or after October 1, 2006, we are not proposing a rate- of-increase percentage to the reasonable cost portion for FY 2009 for LTCHs to be used under Sec. 413.40. In addition, section 124 of

Pub. L. 106-113 provides the statutory authority for updating all aspects of the payment rates for IPFs. Under this broad authority,

IPFs that are not defined as new under Sec. 412.426(c) are paid under a blended methodology for cost reporting periods beginning on or after January 1, 2005, and before January 1, 2008. For cost reporting periods beginning on or after January 1, 2008, existing

IPFs are paid based on 100 percent of the Federal per diem rate.

Therefore, because no portion of the existing IPFs prospective payments will be based on reasonable cost concepts for cost reporting periods beginning on or after

Page 23922

January 1, 2008, we are not proposing a rate-of-increase percentage to the reasonable cost portion for FY 2009 for IPFs to be used under

Sec. 412.426(c). New IPFs are paid based on 100 percent of the

Federal per diem payment amount.

Currently, children's hospitals, cancer hospitals, and RNHCIs are the remaining three types of hospitals still reimbursed under the reasonable cost methodology. We are providing our current estimate of the FY 2009 IPPS operating market basket percentage increase (3.0 percent) to update the target limits for children's hospitals, cancer hospitals, and RNHCIs.

Effective for cost reporting periods beginning on or after

October 1, 2002, LTCHs have been paid under the LTCH PPS.

Additionally, for cost reporting periods beginning on or after

October 1, 2006, no portion of a LTCH's PPS payments can be based on reasonable cost concepts. Consequently, there is no need to propose to update the target limit under Sec. 413.40 effective October 1, 2008, for LTCHs.

In the RY 2009 LTCH PPS proposed rule (73 FR 5361 through 5362), we proposed an update of 2.6 percent to the LTCH PPS Federal rate for RY 2009, which is based on a proposed market basket increase of 3.5 percent and a proposed adjustment of 0.9 percent to account for the increase in case-mix in a prior year that resulted from changes in coding practices rather than an increase in patient severity. The proposed market basket of 3.5 percent used in determining this proposed update factor is based on our proposal in the LTCH proposed rule to extend the LTCH RY 2009 by 3 months (a total of 15 months instead of 12 months) through September 30, 2009. (A full discussion of the reasons for this proposed extension of RY 2009 can be found in the RY 2009 LTCH PPS proposed rule (73 FR 5351 through 5353).)

However, if we were not proposing to extend the 2009 LTCH PPS rate year by 3 months, we would have proposed a market basket update of 3.1 percent for a 12-month RY 2009 offset by the proposed adjustment of 0.9 percent to account for the increase in case-mix in a prior year that resulted from changes in coding practices rather than an increase in patient severity.

Effective for cost reporting periods beginning on or after

January 1, 2005, IPFs are paid under the IPF PPS. IPF PPS payments are based on a Federal per diem rate that is derived from 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. For cost reporting periods beginning on or after January 1, 2005, and before January 1, 2008, existing IPFs (those not defined as ``new'' under Sec. 412.426(c)) are paid based on a blend of the reasonable cost-based PPS payments and the Federal per diem base rate. For cost reporting periods beginning on or after January 1, 2008, existing IPFs are paid based on 100 percent of the Federal per diem rate. Consequently, there is no need to propose to update the target limit under Sec. 412.426(c) effective October 1, 2008, for IPFs.

IRFs are paid under the IRF PPS for cost reporting periods beginning on or after January 1, 2002. For cost reporting periods beginning on or after October 1, 2002 (FY 2003), and thereafter, the

Federal prospective payments to IRFs are based on 100 percent of the adjusted Federal IRF prospective payment amount, updated annually

(69 FR 45721). Section 1886(j)(3)(C) of the Act, as amended by section 115 of Pub. L. 110-173 sets the FY 2009 IRF PPS update factor equal to 0 percent. Thus, we are not applying an update

(market basket) to the IRF PPS rates for FY 2009.

III. Secretary's Recommendation

MedPAC is recommending an inpatient hospital update equal to the market basket rate of increase for FY 2009. MedPAC's rationale for this update recommendation is described in more detail below. Based on the FY 2009 President's Budget, we are recommending an update to the standardized amount of 0 percent. We are recommending that this same update factor apply to SCHs and MDHs.

Section 1886(d)(9)(C)(1) of the Act is the basis for determining the percentage increase to the Puerto Rico-specific standardized amount. For FY 2009, we are applying the full rate-of-increase in the hospital market basket for IPPS hospitals to the Puerto Rico- specific standardized amount. Therefore, the update to the Puerto

Rico-specific standardized amount is estimated to be 3.0 percent.

In addition to making a recommendation for IPPS hospitals, in accordance with section 1886(e)(4)(A) of the Act, we are also recommending update factors for all other types of hospitals.

Consistent with the President's Budget, we are recommending an update based on the IPPS market basket increase for children's hospitals, cancer hospitals, and RNHCIs of 0 percent. As mentioned above, for cost reporting periods beginning on or after January 1, 2008, existing IPFs are paid based on 100 percent of the Federal per diem rate (and are no longer paid a blend of the reasonable cost- based PPS payments and the Federal per diem base rate).

Consequently, we are no longer recommending an update factor for the portion of the payment that is based on reasonable costs. Consistent with the President's Budget, based on Global Insight, Inc.'s first quarter 2008 forecast of the RPL market basket increase, we are recommending an update to the IPF PPS Federal rate for RY 2009 of 3.2 percent for the Federal per diem payment amount.

In the RY 2009 LTCH PPS proposed rule (73 FR 5361 through 5362), we proposed an update of 2.6 percent to the LTCH PPS Federal rate for RY 2009, which is based on a proposed market basket increase of 3.5 percent and a proposed adjustment of 0.9 percent to account for the increase in case-mix in a prior year that resulted from changes in coding practices rather than an increase in patient severity. The proposed market basket of 3.5 percent used in determining this proposed update factor is based on our proposal in the LTCH proposed rule to extend the LTCH RY 2009 by 3 months (a total of 15 months instead of 12 months) through September 30, 2009. (A full discussion on the reasons for this proposed extension of RY 2009 can be found in the RY 2009 LTCH PPS proposed rule (73 FR 5351 through 5353).)

However, if we were not proposing to extend the 2009 LTCH PPS rate year by 3 months, we would have proposed a market basket update for a 12 month RY 2009 of 3.1 percent in determining the proposed update factor for RY 2009 offset by the proposed adjustment of 0.9 percent to account for the increase in case-mix in a prior year that resulted from changes in coding practices rather than an increase in patient severity.

Finally, consistent with the President's FY 2009 Budget, we are recommending a zero percent update to the IRF PPS Federal rate for

FY 2009. This recommendation is consistent with the zero percent increase factor specified in section 1886(j)(3)(C) of the Act, as amended by section 115 of Pub. L. 110-173.

IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating

Payments in Traditional Medicare

In its March 2008 Report to Congress, MedPAC assessed the adequacy of current payments and costs, and the relationship between payments and an appropriate cost base, utilizing an established methodology used by MedPAC in the past several years.

MedPAC recommended an update to the hospital inpatient rates equal to the increase in the hospital market basket in FY 2009, concurrent with implementation of a quality incentive program.

Similar to last year, MedPAC also recommended that CMS put pressure on hospitals to control their costs rather than accommodate the current rate of cost growth, which is, in part, caused by a lack of pressure from private payers.

MedPAC noted that indicators of payment adequacy are almost uniformly positive. MedPAC expects Medicare margins to remain low in 2008. At the same time though, MedPAC's analysis finds that hospitals with low non-Medicare profit margins have below average standardized costs and most of these facilities have positive overall Medicare margins.

Response: Similar to our response last year, we agree with

MedPAC that hospitals should control costs rather than accommodate the current rate of growth. An update equal to less than the market basket will motivate hospitals to control their costs, consistent with MedPAC's recommendation. As MedPAC noted, the lack of financial pressure at certain hospitals can lead to higher costs and in turn bring down the overall Medicare margin for the industry.

As discussed in section II of the preamble of this proposed rule, CMS implemented the MS-DRGs in FY 2008 to better account for severity of illness under the IPPS, and is basing the DRG weights on costs rather than charges. We continue to believe that these refinements will better match Medicare payment of the cost of care and provide incentives for hospitals to be more efficient in controlling costs.

We note that, because the operating and capital prospective payment systems remain separate, we are proposing to continue to use separate updates for operating and capital payments. The proposed update to the

Page 23923

capital rate is discussed in section III of the Addendum to this proposed rule.

Appendix C--Disclosure of Financial Relationship Report (DFRR) Form

Disclosure of Financial Relationship Report (DFRR)

Requirement

Completion of the Disclosure of Financial Relationship Report

(DFRR or Report) is required under section 1877(f) of the Social

Security Act. The Report must be completed, certified by the appropriate officer of the hospital, and received by CMS within 60 days of the date that appears on the cover letter or e-mail transmission. Pursuant to 42 CFR 411.361(f), failure to timely submit the requested information concerning an entity's ownership, investment, and compensation arrangements may result in civil monetary penalties of up to $10,000 for each day beyond the deadline established for disclosure.

Please be advised that the results from the DFRR may be shared with other Federal agencies and with Congressional committees, as permitted or mandated by law. We intend to protect from public disclosure, to the fullest extent permitted by Exemptions 4 and 6 of the Freedom of Information Act, 5 U.S.C. 552(b)(4) and (6), any confidential business information and any individual-specific information collected. We note that CMS is prevented by the Trade

Secrets Act, 18 U.S.C. 1905, from releasing confidential business information, except as authorized by law.

Information collected from each hospital will be analyzed separately to determine whether the financial relationships are in compliance with the physician self-referral laws and implementing regulations. At this time, we do not plan to aggregate data.

Exception to Mandatory Reporting

An entity that furnishes 20 or fewer Part A and/or Part B services during a calendar year is excepted from this reporting requirement pursuant to 42 CFR 411.361(b). If you believe that the hospital qualifies for this exception:

The Chief Executive Officer, Chief Financial Officer, or a comparable officer of the Hospital must certify in writing that the hospital furnishes 20 or fewer Part A and/or Part B services during a calendar year.

The certification statement must read as follows: ``I,

(insert name), hereby certify that, to the best of my knowledge and belief, (insert name of Hospital) furnishes 20 or fewer Part A and/ or Part B services during a calendar year. Therefore the hospital is relying on the exception in 42 CFR 411.361(b) and will not be reporting financial relationship data concerning the facility.'' The certification statement must be signed and dated, and include the title of the signatory.

If the hospital or entity qualifies for the exception at 42 CFR 411.361(b), please mail the original and one copy of the signed certification statement to: Physician Self-Referral, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Mailstop

C4-25-02, Baltimore, Maryland 21244-1850. In addition, we request, but do not require, that you e-mail a PDF or other electronically scanned version of the document to HOSPITALDISCLOSURE@cms.hhs.gov.

In the subject line, please include the title ``Exception to

Disclosure Report.''

General Instructions for DFRR

The requested disclosures on Worksheets 1 through 6 pertain only to hospitals with physician ownership or investment.

For purposes of this Report, ownership is synonymous with investment.

For any question pertaining to the financial relationship between a physician and the Hospital or entity or individual, ``physician'' shall include each immediate family member of the physician, as defined in 42 CFR 411.351.

The terms, ``physician-owner'' and ``physician- investor'' are used interchangeably throughout this report.

Please provide the physician's last name, first name, and Medicare National Provider Identifier (NPI). Only for those physicians who have not yet received an NPI, may the physician's

Unique Physician Identification Number (UPIN) be submitted instead.

We will not accept a hospital created identifier (for example,

Physician 1, Physician 2, etc.).

Where supporting documentation or an explanation is requested, please include the name of the physician-owner or physician-investor, and his/her NPI.

Supplemental documents should be provided only when specifically requested on a worksheet. Supporting documentation should be organized and clearly labeled to reference the relevant worksheet. Please include only information that responds to the question asked; extraneous information should not be included. For example, if only a few pages of a large document are responsive to a question, please only submit those relevant pages.

If a particular question does not apply to the hospital, please type ``N/A.''

If sufficient rows are not provided, please save the

Excel spreadsheet, insert the necessary number of additional rows, and print a copy of the revised Excel spreadsheet.

Upon completion of the entire DFRR, please verify all information presented (including the totals for the respective fields or columns) and return an original and one copy to: Physician

Self-Referral, Centers for Medicare & Medicaid Services, 7500

Security Boulevard, Mailstop C4-25-02, Baltimore, Maryland 21244- 1850. CMS also requests, but does not require, that a PDF or other electronically scanned version of the DFRR and accompanying documentation be sent to HOSPITALDISCLOSURE@cms.hhs.gov.

Please enter all date fields in the following format:

MM/DD/YY. For example, ``March 31, 2006'' must be entered as follows: 03/31/06.

Report Contents

The attached report consists of the following spreadsheets:

Cover Sheet--(Certification Page)

Worksheet 1--Hospital Characteristics

Worksheet 2--Direct Ownership in Hospital

Worksheet 3--Indirect Ownership in Hospital

Worksheet 4--Payments Made to Hospital by Direct Owners

Worksheet 5--Payments Made to Hospital by Indirect

Owners

Worksheet 6--Investment Reconciliation

Worksheet 7--Compensation Arrangements--Rentals,

Personal Service Arrangements, and Recruitment (See 42 CFR 411.357)

Worksheet 8--Other Types of Compensation Arrangements

(See 42 CFR 411.357)

Key Terms 1. Additional Purchases: Stocks purchased after initial or starting investment. Report the total cost and number of additional shares of stock purchased. 2. Assessments: Any cost or fee required and paid by any investor of the hospital. These fees usually do not involve any basis or change in the owner's investment in the facility. 3. Back-up Guarantee: Physician-owner's risk of loss or liability related to the ownership of his or her stock is guaranteed by another entity. If the borrower has problems in repayment, the payment is guaranteed by a third party. 4. Basis of Stock/Shares: The cost of the stock at the end of the cost reporting period(s) ending in 2006. 5. Capital Calls: Each investor is asked/required to put additional capital in the company. Depending on the structure of the call, if no additional shares are issued, the basis (cost) of the investor's stock will increase, or if additional shares are issued, the number of the investor's shares will increase. 6. Compilation of Financial Statements: A compilation presents information in the form of financial statements that are the representation of management without expressing assurances. 7. Direct Ownership or Investment Interest: Direct ownership or investment interest is defined at 42 CFR 411.354(a)(2). 8. Disproportionate Guarantee by Physician Investor: Physician investor's risk of loss or liability related to the ownership of his/her stock is guaranteed by the corporate investor in a disproportionate percentage to the percentage of stock owned by that physician investor (i.e.: Physician investor owns 40% of the stock of a hospital, but assumes risk of loss or liability equal to 20%.) 9. Fair Market Value: Fair market value is defined at 42 CFR 411.351. 10. Hospital: Hospital is synonymous with operating entity (that is, the corporation or legal entity through which the hospital operates). 11. Immediate family member: An immediate family member means:

Husband or wife; birth or adoptive parent, child, or sibling; stepparent, stepchild, stepbrother, or stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister- in-law; grandparent or grandchild; and spouse of a grandparent or grandchild. 42 CFR 411.351. 12. Indirect Ownership or Investment Interest: An indirect ownership or investment interest is defined at 42 CFR 411.354(b)(5).

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13. Internally prepared: Internally prepared financial statements are prepared by employees of the hospital, and are used mostly to monitor the hospital's performance. 14. Loan Guarantees: A situation when the borrower's liability is collateralized by a third party. 15. NPI: Medicare National Provider Identifier. 16. Other Capital Assessments: Report only if shares of stock are involved. Fees assessed should not be reported. 17. Relinquishments or Sales: For each share of stock that is sold during the cost reporting period(s) in 2006, report the dollar amount of the sale and the number of shares sold. 18. Reporting Period: The reporting period refers to any cost reporting period(s) ending in 2006. 19. Return of Capital Dividends: A distribution that is not paid out of the earnings and profits of the company. This distribution reduces the basis of the stock. 20. Review of Financial Statements: A review of financial statements is an engagement that results in an accountant's opinion that expresses less assurance than that of a certified audit, but more than a compilation. Typically this involves limited auditing, testing, analytical procedures, and/or inquiries. 21. Stock/share: These terms are used interchangeably throughout the worksheets. 22. Stock Dividends: Stock dividends are distributions made by a corporation of its own stock.

Worksheet 1--Hospital Characteristics

Please include month, date, and year for the beginning and end of your cost reporting period(s).

Worksheet 2--Direct Ownership in Hospital

Identify the class of stock (if applicable) and list all owners of that class within the same grouping on the Worksheet.

If the direct owner is the physician, enter ``Self'' in

Column B.

If the direct owner is not the physician, please write the individual's name in Column A and in Column B indicate his/her relationship to the physician and give the physician's name.

The basis of the stock/shares is the cost of the stock at the end of the cost reporting period(s) ending in 2006. This amount should equal Worksheet 6, Column B, Line 18.

One hundred percent of ownership should be identified for each individual class of stock.

Worksheet 3--Indirect Ownership in Hospital

Report only indirect ownership interests of physicians and immediate family members on this Worksheet.

In Column A, identify each entity with ownership in the hospital and identify the type of entity in Column B. The entity's percentage of direct ownership should be listed in Column C.

List each investor-owner of the group entity in Column

D. Indicate if the investor-owner is a physician. If the investor- owner is an immediate family member, please indicate the relationship to, and name of the physician to whom the investor- owner is related.

Column E should indicate each investor-owner's percentage ownership in the entity at the end of the cost reporting period(s) in 2006, with the number of shares owned (if applicable) listed in Column F. Each type of share owned (if applicable) should be listed individually with the type of stock labeled in Column G.

To calculate the percent of indirect ownership in

Column H for each investor-owner of the entity, multiply the percentage in Column C by the percentage in Column E.

Worksheet 4--Payments Made to Hospital by Direct Owners

Report only payments to the hospital by direct physician-owners and immediate family member owners on this

Worksheet.

Complete one line for each payment made by a physician- owner related to his or her investment interest, including, but not limited to: Initial investments, assessments, capital calls, and loan guarantees. If necessary, please insert additional lines.

In Column B, indicate ``Self'' if the physician is the direct owner. If the direct owner is not the physician, please list the direct owner's name in Column A and in Column B, indicate the immediate family member's relationship to the physician and give the physician's name.

Do not group payments under one physician name, but rather use a separate line for each type of payment made by a physician.

Worksheet 5--Payments Made to Hospital by Indirect Owners

Report only payments made by indirect physician-owners and immediate family member owners on this Worksheet.

Complete one line for each payment made by an entity related to an investment interest, including, but not limited to:

Initial investments, assessments, capital calls, and loan guarantees. If necessary, please insert additional lines.

List the name of the indirect ownership entity in

Column A. In Column B, list the names of individuals that compose that entity, placing only one person per line and indicating his or her status, i.e. ``Self'' for physician, or ``IFM'' for immediate family member.

For immediate family members, enter the relationship to and name of, the physician family member in Column C.

Do not group payments under one entity name, but rather use a separate line for each type of payment made by an entity.

Worksheet 6--Investment Reconciliation

Please complete a separate Worksheet for each physician-owner or immediate family member owner.

Please provide the owner's Social Security Number (SSN) or NPI as appropriate.

If a physician owns more than one class of stock/ equity, a separate worksheet must be completed for each class of stock/equity.

Line 10, Column A--The begin date must be the start of the cost reporting period(s) that end(s) in 2006. That is, for a cost reporting period of July 1, 2005 to June 30, 2006, the begin date is 07/01/05.

Line 10, Columns B, C, and D must reflect the physician-owner's total investment for the class of stock/equity described, as of the beginning of the period being evaluated (all cost period(s) ending in 2006).

Lines 11 through 17, Columns B, C, and D must reflect any and all changes to the physician-owner's stock/equity during the period being evaluated, so that line 18 reflects the owner's total investment at the end of the period.

Line 17 must reflect all other capital assessments that occurred during the cost reporting period(s) ending in 2006.

Line 18, Column A--The end date must be the end date of the cost reporting period(s) that end(s) in 2006. That is, for a cost reporting period of July 1, 2005 to June 30, 2006, the end date is 06/30/06.

Line 18, Column B--The amount entered here should be equal to the amount listed on Worksheet 2, Column C for each class of stock for each physician owner.

Worksheet 7--Compensation Arrangements--Rentals, Personal Service

Arrangements, and Recruitment (See 42 CFR 411.357)

For all physicians who had one or more of the compensation arrangements listed in columns A through D list the physician's complete name in the first column, the physician's NPI, and insert either a Y or N as to whether the physician is an owner/ investor of the hospital. In addition, please insert the applicable number of compensation arrangements in each respective column.

For those compensation arrangements listed in columns A through D, include not just those that you believe fit within an exception in 42 CFR 411.357, but those that are implicated by the referenced exception.

The information requested in columns A and B must include compensation arrangements that occur in either direction

(i.e., rentals to/from physicians).

Please indicate in the appropriate column the number of compensation arrangements that pertain to the physician for the reporting period(s) ending in 2006.

Note that each Column A-D that is filled in with a number requires the submission of supporting documentation for each compensation arrangement. With the exception of uniform personal service arrangements, please submit a copy of the written agreement(s) that were in effect during the reporting period(s) ending in 2006.

Personal Service Arrangements (PSA--Column C)

cir

For each physician listed, please indicate the number of

PSAs in effect for the cost reporting period(s) ending in 2006.

cir

In the next column indicate if the physician used a uniform PSA prepared by the hospital. We consider a PSA to be uniform if all of the elements present in the arrangements are materially the same. Only one copy of the uniform PSA should be included in the supplemental materials. The

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one copy will satisfy the supporting documentation requirement for all physicians who entered into a uniform PSA with the hospital.

cir

Indicate whether or not the hospital has a signed copy of this agreement on file for this physician in the next sub-column with a Y or N.

cir

If the physician had a non-uniform PSA in effect for the cost reporting period(s) ending in 2006, please indicate this on the

Worksheet and provide a copy of the PSA with the supplemental materials for this Worksheet.

Worksheet 8--Other Types of Compensation Arrangements (See 42 CFR 411.357)

This Worksheet addresses other compensation arrangements exceptions that are found at 42 CFR 411.357.

Please note that you may be required to furnish an explanation or additional documentation depending on the answer to each question.

Submit only the information that is necessary to answer the question by removing extraneous documentation where possible.

Questions

Questions regarding these instructions may be directed to: DFRR-

Questions@cms.hhs.gov.

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