Previous Article 66 FR 148 pgs. 39828-40102 - Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Rates and Costs of Graduate Medical Education: Fiscal Year 2002 Rates; Provisions of the Balanced Budget Refinement Act of 1999; and Provisions of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000
Type: RULEVolume: 66Number: 148Pages: 39828 - 40102
Docket number: [CMS 1131-F, CMS 1158-F, and CMS 1178-F]
FR document: [FR Doc. 01-18868 Filed 7-31-01; 8:45 am]
Agency: Health and Human Services Department
Sub Agency: Centers for Medicare Medicaid Services
Official PDF Version: PDF Version
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare Medicaid Services
42 CFR Parts 405, 410, 412, 413, 482, 485, and 486
[CMS 1131-F, CMS 1158-F, and CMS 1178-F]
RINs 0938-AK20; 0938-AK73; and 0938-AK74
Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Rates and Costs of Graduate Medical Education: Fiscal Year 2002 Rates; Provisions of the Balanced Budget Refinement Act of 1999; and Provisions of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000
AGENCY:
Centers for Medicare Medicaid Services (CMS), HHS.
ACTION:
Final rules.
SUMMARY:
We are revising the Medicare hospital inpatient prospective payment systems for operating and capital costs to: implement applicable statutory requirements, including a number of provisions of the Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act of 2000 (Public Law 106-554); and implement changes arising from our continuing experience with these systems. In addition, in the Addendum to this final rule, we describe changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs. These changes apply to discharges occurring on or after October 1, 2001. We also set forth the rate-of-increase limits as well as policy changes for hospitals and hospital units excluded from the prospective payment systems.
We are making changes to the policies governing payments to hospitals for the direct costs of graduate medical education and critical access hospitals.
Lastly, we are responding to public comments received on the following two related interim final rules that we published in the Federal Register and finalizing those interim rules:
• An August 1, 2000 interim final rule with comment period (65 FR 47026, HCFA-1131-IFC) that implemented, or conformed the regulations to, certain statutory provisions relating to Medicare payments to hospitals for inpatient services that were contained in the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (Public Law 106-113), and that were effective during FY 2000. These provisions related to reclassification of hospitals from urban to rural status, reclassification of certain hospitals for purposes of payment during fiscal year 2000, critical access hospitals, payments to hospitals excluded from the prospective payment system, and payments for indirect and direct graduate medical education costs.
• A June 13, 2001 interim final rule with comment period (66 FR 32172, HCFA-1178-IFC) that implemented, or conformed the regulations to, certain statutory provisions relating to Medicare payments to hospitals for inpatient services that were contained in Public Law 106-554, and that were effective prior to passage of Public Law 106-554 on December 21, 2000; on April 1, 2001; or on July 1, 2001. Many of the provisions of Public Law 106-554 modified changes to the Social Security Act made by Public Law 106-113 or the Balanced Budget Act of 1997 (Public Law 105-33), or both.
EFFECTIVE DATE:
The provisions of this final rule are effective October 1, 2001. This rule is a major rule as defined in 5 U.S.C. 804(2). Pursuant to 5 U.S.C. 801(a)(1)(A), we are submitting a report to Congress on this rule on August 1, 2001.
FOR FURTHER INFORMATION CONTACT:
Stephen Phillips, (410) 786-4548, Operating Prospective Payment, Diagnosis-Related Groups (DRGs), Wage Index, Hospital Geographic Reclassifications, Sole Community Hospitals, Disproportionate Share Hospitals, and Medicare-Dependent, Small Rural Hospitals Issues; Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded Hospitals, Graduate Medical Education and Critical Access Hospitals Issues.
SUPPLEMENTARY INFORMATION:
Availability of Copies and Electronic Access
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I. Background
A. Summary
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. Under these prospective payment systems, Medicare payment for hospital inpatient operating and capital-related costs is made at predetermined, specific rates for each hospital discharge. Discharges are classified according to a list of diagnosis-related groups (DRGs). Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG.
Under section 1886(d)(1)(B) of the Act in effect without consideration of the amendments made by Public Law 105-33, Public Law 106-113, and Public Law 106-554, certain specialty hospitals are excluded from the hospital inpatient prospective payment system: psychiatric hospitals and units, rehabilitation hospitals and units, children's hospitals, long-term care hospitals, and cancer hospitals. For these hospitals and units, Medicare payment for operating costs is based on reasonable costs subject to a hospital-specific annual limit, until the payment provisions of Public Laws 105-33, 106-113, and 106-554 that are applicable to three classes of these hospitals are implemented, as discussed below.
Various sections of Public Laws 105-33, 106-113, and 106-554 provide for the transition of rehabilitation hospitals and units, psychiatric hospitals and units, and long-term care hospitals from being paid on an excluded hospital basis to being paid on an individual prospective payment system basis. These provisions are as follows:
• Rehabilitation Hospitals and Units. Section 1886(j) of the Act, as added by section 4421 of Public Law 105-33 and amended by section 125 of Public Law 106-113 and section 305 of Public Law 106-554, authorizes the implementation of a prospective payment system for inpatient hospital services furnished by rehabilitation hospitals and units. Section 4421 of Public Law 105-33 amended the Act by adding section 1886(j). Section 1886(j) of the Act provides for a fully implemented prospective payment system for inpatient rehabilitation hospitals and rehabilitation units, effective for cost reporting periods beginning during or after October 2002, with payment provisions during a transitional period based on target amounts specified in section 1886(b) of the Act. Section 125 of Public Law 106-113 amended section 1886(j) of the Act to require the Secretary to use a discharge as the payment unit for inpatient rehabilitation services under the prospective payment system and to establish classes of patient discharges by functional-related groups. Section 305 of Public Law 106-554 further amended section 1886(j) of the Act to allow hospitals to elect to be paid the full Federal prospective payment rather than the transitional period payments specified in the Act. A final rule implementing the prospective payment system for inpatient rehabilitation hospitals will be published in the Federal Register shortly.
• Psychiatric Hospitals and Units. Sections 124(a) and (c) of Public Law 106-113 provide for the development of a per diem prospective payment system for payment for inpatient hospital services of psychiatric hospitals and units under the Medicare program, effective for cost reporting periods beginning on or after October 1, 2002. This system must include an adequate patient classification system that reflects the differences in patient resource use and costs among these hospitals and must maintain budget neutrality. We are in the process of developing a proposed rule, to be followed by a final rule, to implement the prospective payment system for psychiatric hospitals and units, effective for October 1, 2002.
• Long-Term Care Hospitals. Sections 123(a) and (c) of Public Law 106-113 provide for the development of a per discharge prospective payment system for payment for inpatient hospital services furnished by long-term care hospitals under the Medicare program, effective for cost reporting periods beginning on or after October 1, 2002. Section 307(b)(1) of Public Law 106-554 provides that payments under the long-term care prospective payment system will be made on a prospective payment basis rather than a cost basis. The long-term care hospital prospective payment system must include a patient classification system that reflects the differences in patient resource use and costs, and must maintain budget neutrality. We are planning to develop a proposed rule, to be followed by a final rule, to implement the prospective payment system for long-term care hospitals, effective for October 1, 2002. Section 307 of Public Law 106-554 provides that if the Secretary is unable to develop a prospective payment system for long-term care hospitals that can be implemented by October 1, 2002, the Secretary must implement a prospective payment system that bases payment under the system using the existing acute hospital DRGs, modified where feasible to account for resource use of long-term care hospital patients using the most recently available hospital discharge data for long-term care services.
Under sections 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 on a reasonable cost basis. Reasonable cost is determined under the provisions of section 1861(v)(1)(A) of the Act and existing regulations under Parts 413 and 415.
Under section 1886(a)(4) of the Act, costs of approved educational activities are excluded from the operating costs of inpatient hospital services. Hospitals with approved graduate medical education (GME) programs are paid for the direct costs of GME in accordance with section 1886(h) of the Act; the amount of payment for direct GME costs for a cost reporting period is based on the hospital's number of residents in that period and the hospital's costs per resident in a base year.
The regulations governing the acute care hospital inpatient prospective payment system are located in 42 CFR part 412. The regulations governing excluded hospitals and hospital units are located in Parts 412 and 413. The regulations governing GME payments are located in Part 413. The regulations governing CAHs are located in Parts 413 and 485.
This final rule implements amendments enacted by Public Law 106-554 relating to updates to FY 2002 payments for hospital inpatient services, hospitals' geographic reclassifications and wage indexes, GME costs, the payment adjustment for disproportionate share hospitals (DSHs), the indirect medical education (IME) adjustment for teaching hospitals, and CAHs. It also implements other changes affecting DRG classifications and relative weights, annual updates to the data used to calculate the wage index, sole community hospitals (SCHs), payments under the inpatient capital prospective payment system, and policies related to hospitals and units excluded from the prospective payment system. These changes are addressed in sections II., III., IV., and VI. of this preamble.
Section 533 of Public Law 106-554 requires the Secretary to establish a mechanism to recognize the costs of new medical services and technologies by October 1, 2001. We proposed a mechanism in the May 4, 2001 proposed rule. We received 61 comments on our proposed criteria to qualify for this special payment and on the proposed mechanism to pay for qualifying new technologies. Due to this large number of comments, we will publish a separate final rule to respond to comments received on our proposal, and to establish a mechanism, by October 1, 2001.
Although we intend to establish the mechanism by October 1, 2001, we will not make additional payments under the mechanism for cases involving new technology during FY 2002 because it is not feasible. This is due to the timing of the enactment of Public Law 106-554 on December 21, 2000, the requirement that we establish the mechanism through notice and an opportunity for public comment, and the requirement that the payments be implemented in a budget neutral manner. That is, it was not feasible to establish the criteria by which new technologies would qualify through a proposed rule with opportunity for public comment as part of the May 4, 2001 proposed rule, finalize those criteria in response to public comments, allow technologies to qualify under those criteria, and implement payments for any qualified technologies in a budget neutral manner. This is because making the special payments in a budget neutral manner requires an adjustment to the standardized amounts (which must be published in final by August 1 each year).
Representatives of new technologies seeking to qualify for special payments under this provision for FY 2003 should proceed with their application by contacting us at the telephone numbers listed in the "For Further Information Contact" section of this preamble. As indicated previously, a final rule containing the specific qualifying criteria and payment mechanism will be published shortly.
This final rule also responds to public comments on, and finalizes implementation of, provisions of Public Law 106-113 that relate to Medicare payments to hospitals for FY 2001 that were addressed in a separate interim final rule with comment period (HCFA-1131-IFC), published in the Federal Register on August 1, 2000 (65 FR 47026).
Lastly, this final rule responds to public comments on, and finalizes implementation of, other provisions of Public Law 106-554 that relate to Medicare payments to hospitals effective prior to October 1, 2001 (that is, for FY 2001 or for the period between April l, 2001 and September 30, 2001) that were addressed in a separate interim final rule with comment period (HCFA-1178-IFC), published in the Federal Register on June 13, 2001 (66 FR 32172).
In summary, this final rule responds to public comments on, and finalizes, three documents published in the Federal Register: The August 1, 2000 interim final rule with comment period, the May 4, 2001 proposed rule (HCFA-1158-P), and the June 13, 2001 interim final rule with comment period, as discussed below.
The charts below specify the effective dates of the various provisions of Public Law 106-113 and Public Law 106-554.
| Section No. | Title | Effective date |
|---|---|---|
| 111 | Indirect Medical Education Adjustment Formula | 10/01/1999. |
| 121 | Wage Adjustment to Caps on Target Amounts for Excluded Hospitals and Units | 10/01/1999. |
| 152(a) | Reclassified Hospitals in Certain Designated Counties | 10/01/1999. |
| 153 | Calculation of Wage Index for Hattiesburg, Mississippi | 10/01/1999. |
| 154 | Calculation of Wage Index for Allentown-Bethlehem-Easton, Pennsylvania MSA | 10/01/1999. |
| 312 | Initial Residency Period for Child Neurology Residency Programs | 7/01/2000, for residency programs that began before, on, or after 11/29/1999. |
| 401(a) | Reclassification of Certain Urban Hospitals to Rural | 01/01/2000. |
| 401(b)(2) | Application of Reclassifications under Section 401(a) to Critical Access Hospitals | 01/01/2000. |
| 403(a) | Length of Stay Restrictions on Inpatient Stays in Critical Access Hospitals | 11/29/1999. |
| 403(b) | Qualifications of For-Profit Hospitals for Critical Access Hospital Status | 11/29/1999. |
| 403(c) | Qualification of Closed Hospitals or Hospitals Downsized to Health Clinics for Critical Access Hospital Designation | 11/29/1999 for hospitals that closed after 11/29/1989; 11/29/1999 for hospitals that downsized to health clinics. |
| 403(e) | Elimination of Medicare Part B Deductible and Coinsurance for Clinical Diagnostic Laboratory Tests Furnished in Critical Access Hospitals | 11/29/1999. |
| 403(f) | Provisions on Swing-Beds in Critical Access Hospitals | 11/29/1999. |
| 404 | Extension of Medicare-Dependent, Small Rural Hospital Program | 10/01/2002 through 9/30/2006. |
| 407(a) | Residents on Approved Leaves of Absence-GME and IME | 11/29/1999. |
| 407(b) | Expansion of Number of Unweighted Residents in Rural Hospitals-GME and IME | 04/01/2000. |
| 407(c) | Urban Hospitals with Rural Training Tracks or Integrated Rural Tracks-GME and IME | 04/01/2000. |
| 407(d) | Residents Training at Certain Veterans Hospitals-GME and IME | 10/01/1997 |
| 408(a) | Swing Beds for Skilled Nursing Facility Level of Care Patients | 07/01/1998 through the end of the facility's third cost reporting period after this date. |
| 408(b) | Elimination of Constraints on Length of Stay in Swing Beds in Rural Hospitals | 07/01/1998 through the end of the facility's third cost reporting period after this date. |
| 541 | Additional Payments to Hospitals for Approved Nursing and Allied Health Education to Reflect Utilization of Medicare+Choice Enrollees | 01/01/2000. |
| Section No. | Title | Effective date |
|---|---|---|
| 201 | Clarification of No Beneficiary Cost-Sharing for Clinical Diagnostic Laboratory Tests Furnished by Critical Access Hospitals | 11/29/1999. |
| 202 | Assistance with Fee Schedule Payment for Professional Services under All-Inclusive Rate | 07/01/2001. |
| 211 | Threshold for Disproportionate Share Hospitals | 04/01/2001. |
| 212 | Option to Base Eligibility for Medicare-Dependent, Small Rural Hospital Program on Discharges during Two of the Three Most Recently Audited Cost Reporting Periods | 04/01/2001. |
| 213 | Extension of Option to use Rebased Target Amounts to All Sole Community Hospitals | 10/01/2000. |
| 301 | Revision of Acute Care Hospital Payment Update for 2001 | 04/01/2001. |
| 302 | Additional Modification in Transition for Indirect Medical Education Adjustment | 04/01/2001. |
| 303 | Decrease in Reductions for Disproportionate Share Hospitals | 04/01/2001. |
| 304(a) | Three-Year Wage Index Reclassifications; Use of 3 Years of Wage Data for Evaluating Reclassifications | 10/01/2001. |
| 304(b) | Statewide Wage Index for Reclassifications | 10/01/2001 for reclassification beginning 10/01/2002. |
| 304(c) | Collection of Occupational Case Mix Data | 09/30/2003 for application 10/1/2004. |
| 306 | Payment for Inpatient Services of Psychiatric Hospitals | 10/01/2000. |
| 307 | Payment for Inpatient Services of Long-Term Care Hospitals | 10/01/2000. |
| 511 | Increase in Floor for Payments for Direct Costs of Graduate Medical Education | 10/01/2001. |
| 512 | Change in Distribution Formula for Medicare+Choice-Related Nursing and Allied Health Education Costs | 01/01/2001. |
| 541 | Increase in Reimbursement for Bad Debt | 10/01/2000. |
B. Summary of the Provisions of the May 4, 2001 Proposed Rule
On May 4, 2001, we published a proposed rule in the Federal Register (66 FR 22646) that set forth proposed changes to the Medicare hospital inpatient prospective payment system for operating and capital-related costs for FY 2002. We set forth proposed changes to the amounts and factors used in determining the rates for these costs. In addition, we proposed changes relating to payments for GME costs and payments to excluded hospitals and units, SCHs, and CAHs.
The following is a summary of the major changes that we proposed and the issues we addressed in the May 4, 2001 proposed rule:
1. Changes to the DRG Reclassifications and Recalibrations of Relative Weights
As required by section 1886(d)(4)(C) of the Act, we proposed annual adjustments to the DRG classifications and relative weights. Based on analyses of Medicare claims data, we proposed to establish a number of new DRGs and make changes to the designation of diagnosis and procedure codes under other existing DRGs for FY 2002.
We also addressed the provisions of section 533 of Public Law 106-544 regarding development of a mechanism for increased payment for new medical services and technologies and the required report to Congress on expeditiously introducing new medical services and technology into the DRGs.
2. Changes to the Hospital Wage Index
We proposed to use wage data taken from hospitals' FY 1998 cost reports in the calculation of the FY 2002 wage index. We also proposed to implement the third year of the phaseout of wage costs related to GME or Part A certified registered nurse anesthetists (CRNA) from the FY 2002 wage index calculation.
We proposed several changes to the wage index methodology that would apply in calculating the FY 2003 wage index, and addressed new procedures for requesting wage data corrections and a modification of the process and timetable for updating the wage index.
• We also discussed the collection of hospital occupational mix data as required by section 304(c) of Public Law 106-554.
• In addition, we discussed revisions to the wage index based on hospital redesignations and reclassifications for purposes of the wage index, including changes to reflect the provisions of sections 304(a) and (b) of Public Law 106-554 relating to 3-year wage index reclassifications by the MGCRB, the use of 3 years of wage data for evaluating reclassification requests for FYs 2003 and later, and the application of a statewide wage index for reclassifications beginning in FY 2003.
3. Other Decisions and Changes to the Prospective Payment System for Inpatient Operating and Graduate Medical Education Costs
We discussed several provisions of the regulations in 42 CFR parts 412 and 413 and set forth certain proposed changes concerning SCHs; rural referral centers; changes relating to the IME adjustment as a result of section 302 of Public Law 106-554; changes relating to the DSH adjustment as a result of section 303 of Public Law 106-554; the establishment of policies relating to the 3-year application of wage index reclassifications by the MGCRB, the use of 3 years of wage data in evaluating reclassification requests to the MGCRB for FYs 2003 and later, and the use of a statewide wage index for reclassifications beginning in FY 2003, as required by sections 304(a) and (b) of Public Law 106-554.
We discussed proposed requirements for qualifying for additional payments for new medical services and technology, as required by section 533(b) of Public Law 106-554.
Lastly, we proposed changes relating to payment for the direct costs of GME, including changes as a result of section 511 of Public Law 106-554.
4. Prospective Payment System for Capital-Related Costs
We proposed payment requirements for capital-related costs, including the special exceptions payment, beginning October 1, 2001.
5. Proposed Changes for Hospitals and Hospital Units Excluded from the Prospective Payment Systems
We discussed the following proposals concerning excluded hospitals and hospital units and CAHs:
• Limits on and adjustments to the proposed target amounts for FY 2002.
• Revision of the methodology for wage neutralizing the hospital-specific target amounts using preclassified wage data.
• Updated caps for new excluded hospitals and units as well as changes in the effective date of classifications of excluded hospitals and units.
• The prospective payment system for inpatient rehabilitation hospitals and units.
• Payments to CAHs, including exclusion from the payment window requirements; the availability of CRNA pass-through payments; payment for emergency room on-call physicians; treatment of ambulance services; the use of certain qualified practitioners for preanesthesia and postanesthesia evaluations; and clarification of location requirements for CAHs.
6. Determining Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits
In the Addendum to the proposed rule, we set forth proposed changes to the amounts and factors for determining the FY 2002 prospective payment rates for operating costs and capital-related costs. We also proposed threshold amounts for outlier cases. In addition, we proposed update factors for determining the rate-of-increase limits for cost reporting periods beginning in FY 2002 for hospitals and hospital units excluded from the prospective payment system.
7. Impact Analysis
In Appendix A, we set forth an analysis of the impact of the proposed changes on affected entities.
8. Capital Acquisition Model
In Appendix B of the proposed rule, we set forth the technical appendix on the proposed FY 2002 capital cost model.
9. Report to Congress on the Update Factor for Hospitals under the Prospective Payment System and Hospitals and Units Excluded From the Prospective Payment System
In Appendix C of the proposed rule, as required by section 1886(e)(3) of the Act, we set forth our report to Congress on our initial estimate of a recommended update factor for FY 2002 for payments to hospitals included in the prospective payment systems, and hospitals excluded from the prospective payment systems.
10. Recommendation of Update Factor for Hospital Inpatient Operating Costs
In Appendix D, as required by sections 1886(e)(4) and (e)(5) of the Act, we included our recommendation of the appropriate percentage change for FY 2002 for the following:
• Large urban area and other area average standardized amounts (and hospital-specific rates applicable to SCHs and Medicare-dependent, small rural hospitals) for hospital inpatient services paid for under the prospective payment system for operating costs.
• Target rate-of-increase limits to the allowable operating costs of hospital inpatient services furnished by hospitals and hospital units excluded from the prospective payment system.
11. Discussion of Medicare Payment Advisory Commission Recommendations
In the proposed rule, we discussed recommendations by the Medicare Payment Advisory Commission (MedPAC) concerning hospital inpatient payment policies and presented our responses to those recommendations. Under section 1805(b) of the Act, MedPAC is required to submit a report to Congress, not later than March 1 of each year, that reviews and makes recommendations on Medicare payment policies. We respond to those recommendations in section VII. of this preamble. For further information relating specifically to the MedPAC March 1 report or to obtain a copy of the report, contact MedPAC at (202) 653-7220 or visit MedPAC's website at: www.medpac.gov.
12. Public Comments Received in Response to the May 4, 2001 Proposed Rule
We received a total of 232 timely items of correspondence containing multiple comments on the proposed rule. Major issues addressed by the commenters included: additional payments for new medical services and technologies, geographic reclassifications of hospitals for purposes of the wage index, DRG reclassifications, payments for GME, and payments to CAHs.
Summaries of the public comments received and our responses to those comments are set forth below under the appropriate heading, with the exception of comments and responses pertaining to specific payments for new technologies under section 533 of Public Law 106-554. As described previously, this provision will be implemented through a separate final rule.
C. Summary of the Provisions of the August 1, 2000 Interim Final Rule with Comment Period
On August 1, 2000, we published in the Federal Register (65 FR 47026) an interim final rule with comment period that implemented, or conformed the regulations to, certain statutory provisions relating to Medicare payments to hospitals for inpatient services that were contained in Public Law 106-113, that were effective for FY 2000. The following is a summary of the policy changes we implemented as a result of Public Law 106-113:
1. Changes Relating to Payments for Operating Costs Under the Hospital Inpatient Prospective Payment System
• Reclassification of Certain Counties. We implemented the provisions of section 152(a) of Public Law 106-113 that reclassified hospitals in certain designated counties for purposes of making payments to affected hospitals under section 1886(d) of the Act for FY 2000. The counties affected by this provision are identified under section III. of this preamble.
• Wage Index. We implemented sections 153 and 154 of Public Law 106-113 that contain provisions affecting the wage indexes of specific Metropolitan Statistical Areas (MSA). Under section 153, the Hattiesburg, Mississippi FY 2000 wage index was calculated including wage data from Wesley Medical Center. Under section 154, the Allentown-Bethlehem-Easton, Pennsylvania MSA FY 2000 wage index was calculated including wage data for Lehigh Valley Hospital.
• Reclassification of Certain Urban Hospitals as Rural Hospitals. We implemented section 401 of Public Law 106-113 which directed the Secretary to treat certain hospitals located in urban areas as being located in rural areas of their State if the hospital meets statutory criteria and files an application with HCFA. This provision was effective on January 1, 2000.
• IME Adjustment. We implemented section 111 of Public Law 106-113 which provided for an additional payment to teaching hospitals equal to the additional amount the hospitals would have been paid for FY 2000 if the IME adjustment formula (which reflects the higher indirect operating costs associated with GME) for FY 2000 had remained the same as for FY 1999.
• Extension of the MDH Provision. We implemented section 404 of Public Law 106-113 which extended the MDH program and its current payment methodology for an additional 5 years, from FY 2002 through FY 2006.
2. Additional Changes Relating to Direct GME and IME
• Initial Residency Period for Child Neurology Residency Programs. We implemented section 312 of Public Law 106-113 which provides that in determining the number of residents for purposes of GME and IME payments, the period of board eligibility and the initial residency period for child neurology is the period of board eligibility for pediatrics plus 2 years. This provision is effective on or after July 1, 2000, for residency programs that began before, on, or after November 29, 1999.
• Residents on Approved Leaves of Absence. We implemented section 407(a) of Public Law 106-113 which provides that, for purposes of determining a hospital's full-time equivalent (FTE) cap for direct GME payments and the IME adjustment, a hospital may count an individual to the extent that the individual would have been counted as a primary care resident for purposes of the FTE cap but for the fact that the individual was on maternity or disability leave or a similar approved leave of absence. The provision relating to direct GME was effective with cost reporting periods beginning on or after November 29, 1999. The provision relating to the IME adjustment applied to discharges occurring in cost reporting periods beginning on or after November 29, 1999.
• Expansion of Number of Unweighted Residents in Rural Hospitals. We implemented section 407(b) of Public Law 106-113 which provides that a rural hospital's resident FTE count for direct GME and IME may not exceed 130 percent of the number of unweighted residents that the rural hospital counted in its most recent cost reporting period ending on or before December 31, 1996. The provision relating to direct GME applied to cost reporting periods beginning on or after April 1, 2000. The provision relating to the IME adjustment applied to discharges occurring on or after April 1, 2000.
• Urban Hospitals with Rural Training Tracks or Integrated Rural Tracks. We implemented section 407(c) of Public Law 106-113 which allows an urban hospital that establishes separately accredited approved medical residency training programs (or rural training tracks) in a rural area or has an accredited training program with an integrated rural track to receive an FTE cap adjustment for purposes of direct GME and IME. The provision was effective with cost reporting periods beginning on or after April 1, 2000, for direct GME, and with discharges occurring on or after April 1, 2000, for IME.
• Residents Training at Certain Veterans Affairs Hospitals. We implemented section 407(d) of PublicLaw 106-113 which provides that a non-Veterans Affairs (VA) hospital may receive a temporary adjustment to its FTE cap to reflect residents who were training at a VA hospital and were transferred on or after January 1, 1997, and before July 31, 1998, to the non-VA hospital because the program at the VA hospital would lose its accreditation by the Accreditation Council on Graduate Medical Education if the residents continued to train at the facility. This provision applies as if it was included in the enactment of Public Law 105-33, that is, for direct GME, with cost reporting periods beginning on or after October 1, 1997, and for IME, for discharges occurring on or after October 1, 1997. If a hospital is owed payments as a result of this provision, payments must be made immediately.
3. Payments for Nursing and Allied Health Education: Utilization of Medicare+Choice Enrollees
We implemented section 541 of Public Law 106-113 which provides an additional payment to hospitals that receive payments under section 1861(v) of the Act for approved nursing and allied health education programs associated with services to Medicare+Choice enrollees. This provision is effective for portions of cost reporting periods occurring on or after January 1, 2000.
4. Changes Relating to Hospitals and Hospital Units Excluded From the Prospective Payment System
We implemented section 121 of Public Law 106-113 which amended section 1886(b)(3)(H) of the Act to direct the Secretary to provide for an appropriate wage adjustment to the caps on the target amounts for psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals for cost reporting periods beginning on or after October 1, 1999.
5. Changes Relating to CAHs
We implemented-
• Section 401(b) of Public Law 106-113, which contained conforming changes to incorporate the reclassifications made by section 401(a) of Public Law 106-113 to the CAH statute (section 1820(c)(2)(B)(i) of the Act). This provision is effective beginning on January 1, 2000.
• Section 403(a) of Public Law 106-113, which deleted the 96-hour length of stay restriction on inpatient care in a CAH and authorized a period of stay that does not exceed, on an annual, average basis, 96 hours per patient. This provision is effective beginning on November 29, 1999.
• Section 403(b) of Public Law 106-113, which allows for-profit hospitals to qualify for CAH status. This provision is effective beginning on November 29, 1999.
• Section 403(c) of Public Law 106-113, which allows hospitals that have closed within 10 years prior to November 29, 1999, or hospitals that downsized to a health clinic or health center, to be designated as CAHs if they satisfy the established criteria for designation, other than the requirement for existing hospital status.
• Section 403(e) of Public Law 106-113, which eliminated the Medicare Part B deductible and coinsurance for clinical diagnostic laboratory tests furnished by a CAH on an outpatient basis. This provision is effective with respect to services furnished on or afterNovember 29, 1999.
• Section 403(f) of Public Law 106-113, entitled "Participation in Swing Bed Program," which amended sections 1883(a)(1) and (c) of the Act.
6. Changes Relating Hospital to Swing Bed Program
We implemented section 408(a) of Public Law 106-113 which eliminated the requirement for a hospital to obtain a certification of need to use acute care beds as swing beds for skilled nursing facility (SNF) level of care patients; and section 408(b) of Public Law 106-113 which eliminates constraints on the length of stay in swing beds for rural hospitals with 50 to 100 beds. These provisions were effective on the first day after the expiration of the transition period for prospective payments for covered SNF services under the Medicare program (that is, at the end of the transition period for the SNF prospective payments system that began with the facility's first cost reporting period beginning on or after July 1, 1998 and extend through the end of the facility's third cost reporting period after this date).
We received a total of eight timely items of correspondence containing multiple comments on the August 1, 2000 interim final rule with comment period. Summaries of the public comments received and our responses to those comments are set forth below under the appropriate section headings of this final rule.
D. Summary of the Provisions of the June 13, 2001 Interim Final Rule With Comment Period
On June 13, 2001, we published an interim final rule with comment period in the Federal Register (66 FR 32172) that implemented changes to the Act affecting Medicare payments to hospitals for inpatient services that were made by Public Law 106-554. Some of these changes were effective before the December 21, 2000 date of enactment of Public Law 106-554, on April 1, 2001, or on July 1, 2001. The changes, on which we requested public comment, are as follows:
1. Changes Relating to Payments for Operating Costs Under the Hospital Inpatient Prospective Payment System
• Treatment of Rural and Small Urban Disproportionate Share Hospitals (DSHs) . We implemented the provisions of section 211 of Public Law 106-554 which lowered thresholds by which certain classes of hospitals qualify for DSH payments, with respect to discharges occurring on or after April 1, 2001.
• Decrease in Reductions for DSH Payments . We implemented section 303 of Public Law 106-554 which modified the previous reduction in the DSH payment to be 2 percent in FY 2001 and 3 percent in FY 2002.
• Medicare-Dependent, Small Rural Hospitals (MDHs) . We implemented section 212 of Public Law 106-554 which provided an option to base eligibility for MDH status on discharges during two of the three most recently audited cost reporting periods, effective with cost reporting periods beginning on or after April 1, 2001.
• Revision of Prospective Payment System Standardized Amounts. We implemented section 301 of Public Law 106-554 which revised the update factor increase for the inpatient prospective payment rates for FY 2001.
• Indirect Medical Education Adjustment (IME). We implemented section 302 of Public Law 106-554 which provided that for the purposes of making the IME payment for discharges occurring on or after April 1, 2001 and before October 1, 2001, the adjustment will be determined as if the adjustment equaled a 6.75 percent increase in payment for every 10 percent increase in the resident-to-bed ratio, rather than a 6.25 percent increase.
• SCHs . We implemented section 213 of Public Law 106-554 which further extended the 1996 rebasing option, for hospital cost reporting periods beginning October 1, 2000, to all SCHs and provides that this extension is effective as if it had been included in section 405 of Public Law 106-113.
2. Payments for Nursing and Allied Health Education: Utilization of Medicare+Choice Enrollees
We implemented section 512 of Public Law 106-554 which revised the formula for determining the additional payment amounts to hospitals for Medicare+Choice nursing and allied health education costs to specifically account for each hospital's Medicare+Choice utilization.
3. Changes Relating to Payments for Capital-Related Costs Under the Hospital Inpatient Prospective Payment System
As a result of implementing section 301 of Public Law 106-554, which provided increased inpatient operating payment rates, we recalculated the unified outlier threshold for inpatient operating and inpatient capital-related costs. Therefore, we revised the capital outlier offset which also required us to revise the capital-related rates.
4. Changes Relating to Hospitals and Hospital Units Excluded From the Prospective Payment System
• Increase in the Incentive Payment for Excluded Psychiatric Hospitals and Units . We implemented section 306 of Public Law 106-554, which provided that for cost reporting periods beginning on or after October 1, 2000, for psychiatric hospitals and units, if the allowable net inpatient operating costs do not exceed the hospital's ceiling, payment is the lower of: (1) net inpatient operating costs plus 15 percent of the difference between inpatient operating costs and the ceiling; or, (2) net inpatient costs plus 3 percent of the ceiling.
• Increase in the Wage Adjusted 75th Percentile Cap on the Target Amounts for Long-Term Care Hospitals . We implemented section 307(a) of Public Law 106-554, which provided a 2-percent increase to the wage-adjusted 75th percentile cap on the target amount for long-term care hospitals, effective for cost reporting periods beginning during FY 2001.
• Increase in the Target Amounts for Long-Term Care Hospitals . We implemented section 307(a) Public Law 106-554, which provided a 25 percent increase to the target amounts for long-term care hospitals for cost reporting periods beginning in FY 2001, up to the cap on target amounts.
5. Changes Relating to CAHs
• Elimination of Coinsurance for Clinical Diagnostic Laboratory Tests Furnished by a CAH . We implemented section 201(a) of Public Law 106-554, which amended section 1834(g) of the Act to state that there will be no collection of coinsurance, deductible, copayments, or any other type of cost sharing from Medicare beneficiaries with respect to outpatient clinical diagnostic laboratory services furnished as outpatient CAH services and that those services will be paid for on a reasonable cost basis.
• Assistance with Fee Schedule Payment for Professional Services under All-Inclusive Rate . We implemented section 202 of Public Law 106-554, which amended section 1834(g)(2)(B) of the Act to provide that when a CAH elects to be paid for Medicare outpatient services under the reasonable costs for facility services plus fee schedule amounts for professional services method, Medicare will pay 115 percent of the amount it otherwise pays for the professional services.
• Condition of Participation with Hospital Requirements at the Time of Application for CAH Designation (§ 485.612) . We implemented a conforming change to correct § 485.612 to reflect that certain entities are not required to have a provider agreement prior to CAH designation.
6. Other Inpatient Costs
• Increase in Reimbursement for Bad Debts. We implemented section 541 of Public Law 106-554 which provided a 30 percent decrease of allowable hospital bad debt reimbursement for cost reporting periods beginning during FY 2001 and all subsequent fiscal years. This section modified section 4451 of Public Law 105-33 that reduced the total allowable bad debt reimbursement for hospitals by 45 percent.
We received a total of 13 timely pieces of correspondence containing comments on the June 13, 2001 interim final rule with comment period. A summary of these public comments and our responses to them are set forth under sections IV. and VI. of this final rule.
II. Changes to DRG Classifications and Relative Weights
A. Background
Under the prospective payment system, 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. Changes to the DRG classification system and the recalibration of the DRG weights for discharges occurring on or after October 1, 2001 are discussed below.
B. DRG Reclassification
1. General
Cases are classified into DRGs for payment under the prospective payment system based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay, as well as age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Medicare fiscal intermediaries enter the information into their claims processing systems and subject it to a series of automated screens called the Medicare Code Editor (MCE). These screens are designed to identify cases that require further review before classification into a DRG.
After screening through the MCE and any further development of the claims, cases are classified into the appropriate DRG by the Medicare GROUPER software program. The GROUPER program was developed as a means of classifying each case into a DRG on the basis of the diagnosis and procedure codes and demographic information (that is, sex, age, and discharge status). It is used both to classify past cases in order to measure relative hospital resource consumption to establish the DRG weights and to classify current cases for purposes of determining payment. The records for all Medicare hospital inpatient discharges are maintained in the Medicare Provider Analysis and Review (MedPAR) file. The data in this file are used to evaluate possible DRG classification changes and to recalibrate the DRG weights.
In version 18 of the GROUPER (used for FY 2001), cases are assigned to one of 499 DRGs (including one DRG (469) for a diagnosis that is invalid as a discharge diagnosis and one DRG (470) for ungroupable diagnoses) in 25 major diagnostic categories (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. However, some MDCs are not constructed on this basis because they involve multiple organ systems (for example, MDC 22 (Burns)).
In general, cases are assigned to an MDC, based on the principal diagnosis, before assignment to a DRG. However, there are six DRGs to which cases are directly assigned on the basis of procedure codes. These are the DRGs for heart, liver, bone marrow, and lung transplants (DRGs 103, 480, 481, and 495, respectively) and the two DRGs for tracheostomies (DRGs 482 and 483). Cases are assigned to these DRGs before classification to an MDC.
Within most MDCs, cases are then divided into surgical DRGs and medical DRGs. Surgical DRGs are based on a hierarchy that orders individual procedures or groups of procedures by resource intensity. Medical DRGs generally are differentiated on the basis of diagnosis and age. Some surgical and medical DRGs are further differentiated based on the presence or absence of complications or comorbidities (CC).
Generally, the GROUPER does not consider other procedures. That is, nonsurgical procedures or minor surgical procedures generally not performed in an operating room are not listed as operating room (OR) procedures in the GROUPER decision tables. However, there are a few non-OR procedures that do affect DRG assignment for certain principal diagnoses, such as extracorporeal shock wave lithotripsy for patients with a principal diagnosis of urinary stones.
We proposed numerous changes to the DRG classification system for FY 2002. The proposed changes, the public comments we received concerning them, and the final DRG changes are set forth below. Unless otherwise noted, the changes we are implementing will be effective in the revised GROUPER software (Version 19.0) to be implemented for discharges on or after October 1, 2001. Unless noted otherwise, we are relying on the data analysis in the proposed rule for the changes discussed here.
Chart 1 lists the changes we are making by adding new DRGs or removing old DRGs. Chart 2 summarizes the changes we are making with respect to the reassignment of procedure codes. Chart 3 presents the changes we are making to the titles of existing DRGs.
In Chart 2 of the proposed rule, several procedure codes were erroneously included in the "Removed from DRG" column of the chart (66 FR 22650). The 11 affected codes are 37.21, 37.22, 37.23, 37.26, 88.52, 88.53, 88.54, 88.55, 88.56, 88.57, and 88.58. Inclusion of these codes in this chart made it appear as if the codes were being deleted from DRG 104. In fact, they are being additionally assigned to DRG 514. We have corrected Chart 2 in this final rule.
| Diagnosis related groups (DRGs) | Added as new | Removed |
|---|---|---|
| Pre-MDC: | ||
| DRG 512 (Simultaneous Pancreas/Kidney Transplant) | X | |
| DRG 513 (Pancreas Transplants) | X | |
| MDC 5 (Diseases and Disorders of the Circulatory System): | ||
| DRG 112 (Percutaneous Cardiovascular Procedures) | X | |
| DRG 514 (Cardiac Defibrillator Implant with Cardiac Catheterization) | X | |
| DRG 515 (Cardiac Defibrillator Implant without Cardiac Catheterization) | X | |
| DRG 516 (Percutaneous Cardiovascular Procedures with Acute Myocardial Infarction (AMI)) | X | |
| DRG 517 (Percutaneous Cardiovascular Procedures without AMI, with Coronary Artery Stent Implant | X | |
| DRG 518 (Percutaneous Cardiovascular Procedures without AMI, without Coronary Artery Stent Implant | X | |
| MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue): | ||
| DRG 519 (Cervical Spinal Fusion with CC) | X | |
| DRG 520 (Cervical Spinal Fusion without CC) | X | |
| MDC 20 (Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders): | ||
| DRG 434 (Alcohol/Drug Abuse or Dependency, Detoxification or Other Symptomatic Treatment with CC) | X | |
| DRG 435 (Alcohol/Drug Abuse or Dependency, Detoxification or Other Symptomatic Treatment without CC) | X | |
| DRG 436 (Alcohol/Drug Dependence with Rehabilitation Therapy) | X | |
| DRG 437 (Alcohol/Drug Dependence, Combined Rehabilitation and Detoxification Therapy) | X | |
| DRG 521 (Alcohol/Drug Abuse or Dependence with CC) | X | |
| DRG 522 (Alcohol/Drug Abuse or Dependence without CC, with Rehabilitation Therapy) | X | |
| DRG 523 (Alcohol/Drug Abuse or Dependence without CC, without Rehabilitation Therapy) | X |
| Diagnosis/procedure codes | Removed from DRG | Reassigned to DRG |
|---|---|---|
| MDC 5 (Diseases and Disorders of the CirculatorySystem) | ||
| Principal Diagnosis Code: | ||
| 410.01Acute myocardial infarction of anterolateral wall, initial episode of care | 116 | 516. |
| 410.11Acute myocardial infarction of other anterior wall, initial episode of care | 116 | 516. |
| 410.21Acute myocardial infarction of inferolateral wall, initial episode of care | 116 | 516. |
| 410.31Acute myocardial infarction of inferoposterior wall, initial episode of care | 116 | 516. |
| 410.41Acute myocardial infarction of other inferior wall, initial episode of care | 116 | 516. |
| 410.51Acute myocardial infarction of other lateral wall, initial episode of care | 116 | 516. |
| 410.61True posterior wall infarction, initial episode of care | 116 | 516. |
| 410.71Subendocardial infarction, initial episode of care | 116 | 516. |
| 410.81Acute myocardial infarction of other specified sites, initial episode of care | 116 | 516. |
| 410.91Acute myocardial infarction of unspecified site, initial episode of care | 116 | 516 |
| Procedure Codes: | ||
| 37.94Implantation or replacement of automatic cardioverter/defibrillation, total system (AICD) | 104, 105 | 514, 515. |
| 37.95Implantation of automatic cardioverter/defibrillator lead(s) only | 104, 105 | 514, 515. |
| 37.96Implantation of automatic cardioverter/defibrillator pulse generator only | 104, 105 | 514, 515. |
| 37.97Raplacement of automatic cardioverter/defibrilator lead(s) only; | 104, 105 | 514, 515. |
| 37.98Replacement of automatic cardioverter/defibrillator pulse generator only | 104, 105 | 514, 515. |
| Operating Room Procedures: | ||
| 35.96Percutaneous valvuloplasty | 112, 116 | 516, 517, 518. |
| 36.01Single vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy without mention of thrombolytic agent | 112, 116 | 516, 517, 518. |
| 36.02Single vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy with mention of thrombolytic agent | 112, 116 | 516, 517, 518. |
| 36.05Multiple vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent | 112, 116 | 516, 517, 518. |
| 36.09Other removal of coronary artery obstruction | 112, 116 | 516, 517, 518. |
| 37.34Catheter ablation of lesion or tissues of heart | 112, 116 | 516, 517, 518. |
| 92.27Implantation or insertion of radioactive elements | non-OR in MDC-5 | 517 |
| Nonoperating Room Procedures: | ||
| 36.06Insertion of coronary artery stent(s) | 116 | 517. |
| 37.26 Cardiac electrophysiologic stimulation and recording studies | 112 | 514, 516, 517, 518. |
| 37.27Cardiac mapping | 112 | 516, 517, 518. |
| MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue) | ||
| Procedure Codes: | ||
| 81.02Other cervical fusion, anterior technique | 497, 498 | 519, 520. |
| 81.03Other cervical fusion, posterior technique | 497, 498 | 519, 520. |
| MDC 15 (Newborns and Other Neonates with Conditions Originating in the Perinatal Period) | ||
| Diagnosis Codes: | ||
| 770.7Chronic respiratory disease arising in the perinatal period | 387, 389 | 92, 93. |
| 773.0Hemolytic disease due to RH isoimmunization | 387, 389 | 390. |
| 773.1Hemolytic disease due to ABO isoimmunization | 387, 389 | 390. |
| Secondary Diagnosis Codes: | ||
| 478.1Other diseases of nasal cavity and sinuses | 390 | 391. |
| 520.6Disturbances in tooth eruption | 390 | 391. |
| 623.8Other specified noninflammatory disorders of vagina | 390 | 391. |
| 709.00Dyschromia, unspecified | 390 | 391. |
| 709.01Vitiglio | 390 | 391. |
| 709.09Dyschromia, Other | 390 | 391. |
| 744.1Accessory Auricle | 390 | 391. |
| 754.61Congenital pes planus | 390 | 391. |
| 757.33Congenital pigmentary anomalies of skin | 390 | 391. |
| 757.39Other specified anomaly of skin | 390 | 391. |
| 764.08"Light for dates" without mention of fetal malnutrition, 2,000-2,499 grams | 390 | 391. |
| 764.98Fetal growth retardation, unspecified, 2,000-2,499 grams | 390 | 391. |
| 772.6Cutaneous hemorrhage | 390 | 391. |
| 779.3Feeding problems in newborns | 390 | 391 |
| 794.15Abnormal and auditory function studies | 390 | 391. |
| 796.4Other abnormal clinical findings | 390 | 391. |
| V20.2Routine infant or child health check | 390 | 391. |
| V72.1Examination of ears and hearing | 390 | 391. |
| MDC | DRG No. | Current name | New name |
|---|---|---|---|
| MDC 5 | DRG 116 | Other Permanent Cardiac Pacemaker Implantation, or PTCA, with Coronary Artery Stent Implant | Other Cardiac Pacemaker Implantation. |
| MDC 8 | DRG 497 | Spinal Fusion with CC | Spinal Fusion except Cervical with CC. |
| MDC 8 | DRG 498 | Spinal Fusion without CC | Spinal Fusion except Cervical with CC. |
2. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Removal of Defibrillator Cases from DRGs 104 and 105
DRGs 104 (Cardiac Valve Other Major Cardiothoracic Procedures with Cardiac Catheterization) and 105 (Cardiac Valve Other Major Cardiothoracic Procedures without Cardiac Catheterization) include the replacement or open repair of one or more of the four heart valves. These valves may be diseased or damaged, resulting in either leakage or restriction of blood flow to the heart, compromising the ability of the heart to pump blood. This procedure requires the use of a heart-lung bypass machine, as the heart must be stilled and opened to repair or replace the valve.
Cardiac defibrillators are implanted to correct episodes of fibrillation (very fast heart rate) caused by malfunction of the conduction mechanism of the heart. Through implanted cardiac leads, the defibrillator mechanism senses changes in heart rhythm. When very fast heart rates occur, the defibrillator produces a burst of electric current through the leads to restore the normal heart rate. An implanted defibrillator constantly monitors heart rhythm. The implantation of this device does not require the use of a heart-lung bypass machine, and would be expected to be very different in terms of resource usage, although both procedures currently group to DRGs 104 and 105.
For the proposed rule, as part of our ongoing review of DRGs, we examined Medicare claims data on DRG 104 and DRG 105. We reviewed 100 percent of the FY 2000 MedPAR file containing hospital bills received through May 31, 2000, for discharges in FY 2000, and found that the average charges across all cases in DRG 104 were $84,060, while the average charges across all cases in DRG 105 were $66,348. Carving out code 37.94 (Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD]) from DRGs 104 and 105 increased those average charges to $91,366 for DRG 104 and $67,323 for DRG 105. We identified 11,021 defibrillator cases in DRG 104 (out of 25,112 total cases), with average charges of $74,719, and 2,434 defibrillator cases in DRG 105 (out of 20,094 total cases), with average charges of $59,267.
We performed additional review on cases containing code 37.95 (Implantation of automatic cardioverter/defibrillator lead(s) only) with code 37.96 (Implantation of automatic cardioverter/defibrillator pulse generator only) and on cases containing code 37.97 (Replacement of automatic cardioverter/defibrillator lead(s) only) with code 37.98 (Replacement of automatic cardioverter/defibrillator pulse generator only). This subgrouping contained only 56 patients. The average charges for the 18 patients in DRG 104 were $58,847. The average charges for the 38 patients in DRG 105 were $54,891.
In the proposed rule, because we believed the defibrillator cases are significantly different from other cases in DRGs 104 and 105, we proposed two new DRGs: DRG 514 (Cardiac Defibrillator Implant with Cardiac Catheterization) and DRG 515 (Cardiac Defibrillator Implant without Cardiac Catheterization).
We also proposed the removal of procedure codes 37.94, 37.95 and 37.96, and 37.97 and 37.98 from DRGs 104 and 105 to form the new DRGs 514 and 515.
We received 58 comments on this proposal.
Comment: Many commenters noted that implanted cardioverter defibrillators (ICDs) or AICDs are lifesaving devices that demonstrate state-of-the-art technology for the treatment of cardiac arrhythmias by continuously monitoring, analyzing, and, if needed, restoring a patient's normal heart rhythm.
One commenter described the technology. Similar to the size of a pacemaker, the ICD is placed under the skin of the upper chest. It has the capacity to continuously monitor and analyze a patient's heart rhythm. If the ICD detects an arrhythmia, it can terminate the abnormal rhythm with either a pacemaker function or the delivery of a low-energy electrical shock to restore normal heart rhythm.
Response: We agree that ICDs and AICDs are an important addition to the treatment of cardiac disease. The creation of DRGs 514 and 515 is not meant to effect a judgement call about the efficacy or importance of this treatment, but simply to attempt to improve the accuracy of payments within MDC 5, based on the actual charge data associated with these cases.
Comment: A vast majority of the commenters expressed concern that payments associated with defibrillators will decrease for FY 2002 as a result of this change, with some commenters noting that an ICD or AICD may cost the hospital between $22,000 and $25,000 per device. The commenters stated that if this is the case, there is a limited amount for the remainder of the hospital care (for example, operating room, supplies, nursing staff salary, and typically a 7-day stay in an intensive care unit). Most commenters called for additional analysis prior to implementation of DRGs 514 and 515.
Response: As we described in the proposed rule and above, DRGs 104 and 105 currently include many different procedures, with a range of costs associated with these different procedures. We proposed to change the assignment of cardiac defibrillators to new DRGs 514 and 515 to more accurately pay for the more expensive procedures remaining in DRGs 104 and 105, as well as to improve the payment accuracy for cardiac defibrillators. In fact, the relative weight of DRG 104 increases from FY 2001 to FY 2002 by 9.1 percent.
Comment: Many commenters argued that using hospital charges to determine DRG relative weights can give a distorted picture of the costs of a procedure. The commenters referred to an unspecified national database indicating that the average mark-up of charges over cost for ICDs is lower than the mark-up applied to other components of care. Other commenters referred to the March 2001 Report to Congress by the MedPAC, which, in the context of evaluating available data for setting accurate relative values, stated that hospitals' billed charges "give a distorted picture of relative costliness across DRGs because they reflect systematic differences among hospitals in the average mark-up of charges over costs" (page 11).
Several commenters stated that about 66 percent of hospitals are losing $5,000 or more per case for these procedures. These commenters did not understand why payment would be reduced even further in light of those losses.
Response: Hospital charges have been the basis for recalibrating the DRG relative weights since FY 1986 (see 50 FR 24372 and 50 FR 35652). To the extent that the mark-up of charges over costs varies from one particular device or procedure to another, the relative weights will be impacted. However, due to the relativity of the DRG weights, a low mark-up associated with one device or procedure will be offset by relatively higher mark-ups associated with another device or procedure, leading to higher relative weights, and thus higher payments, for the latter device or procedure. The prospective payment system is an average-based payment methodology, where hospitals are expected to offset any losses they may incur from any individual or group of cases with payment gains incurred from other cases.
Furthermore, hospital charges are determined by each hospital on an item-by-item basis. It is not possible to account for these individual management decisions in the process of developing a national payment system based on prospectively determined average payment rates.
As demonstrated in the impact analysis in Appendix A to this final rule, hospital payments would rise (prior to the budget neutrality adjustment) by 0.3 percent as a result of all of the DRG changes we are implementing in this final rule, including this change. In addition, we note that the latest analysis by MedPAC indicates the average hospital Medicare inpatient operating margin during FY 1999 (the latest year available) was 12.0 percent (Report to the Congress: Medicare Payment Policy, page 64). Therefore, we believe that hospitals will be able to adequately adjust to these payment changes in both the short and the long term.
Comment: One commenter noted that the adjustment to DRGs 104 and 105 as reflected in Table 5, "List of Diagnosis Related Groups (DRGs), Relative Weighting Factors, Geometric and Arithmetic Mean Length of Stay," in the Addendum of the proposed rule, does not reflect the resource consumption as discussed above. The commenter recommended that we increase the relative weights to reflect the resource consumption of DRGs 104 and 105.
Response: In this final rule, the relative weight for DRG 104 is 7.8411 for FY 2002, an increase of 9.1 percent from FY 2001. The relative weight for DRG 105 in this final rule is 5.6796 for FY 2002, a 0.4 percent increase from FY 2001. These percentage changes are very similar to the percent change in average charges in DRGs 104 and 105 after removing ICD and AICD charges, as described above. We note that the final relative weight values are based on 100 percent of FY 2000 discharges in the MedPAR database as of March 2001. The analysis using average charges described above was based on an earlier sample of cases; therefore, the percentage changes do not match exactly.
Comment: Other commenters noted that this change, and the resulting increase in payments for procedures remaining in DRGs 104 and 105, is a positive step to improving the payment for heart assist devices. However, the commenters were disappointed that we did not take the opportunity to make a similar revision for cases involving mechanical heart assist devices.
Response: As described above, removing the ICDs/AICDs from DRGs 104 and 105 will have the net effect of increasing the relative weights for both DRGs, so payment for the remaining cases will increase. We will continue to evaluate our options for improving the accuracy of our payments for heart assist technologies.
After carefully reviewing all of the comments submitted, we have decided to proceed with the creation of two new DRGs to capture cases involving the implantation of cardiac defibrillators. The new DRGs 514 and 515 include principal diagnosis codes and procedure codes as reflected in Chart 4 below:
| Diagnosis and procedure codes | Included in DRG 514 | Included in DRG 515 |
|---|---|---|
| Principal Diagnosis Codes: | ||
| All of the principal diagnosis codes assigned to MDC-5 | X | X |
| Principal or Secondary Procedure Code: | ||
| 37.94Implantation or replacement of automatic cardioverter/defibrillator, total system (AICD) | X | X |
| Combination Operating Procedure Codes: | ||
| 37.95Implantation of automatic cardioverter/defibrillator lead(s) only; | ||
| Plus | ||
| 37.96Implantation of automatic cardioverter/defibrillator pulse generator only; | X | X |
| Or | ||
| 37.97Replacement of automatic cardioverter/defibrillator lead(s) only; | ||
| Plus | ||
| 37.98Replacement of automatic cardioverter/defibrillator pulse generator only | X | X |
| Plus: One of the Following Nonoperating Room ProcedureCodes: | ||
| 37.21Right heart cardiac catheterization | X | |
| 37.22Left heart cardiac catheterization | X | |
| 37.23Combined right and left heart cardiac catheterization | X | |
| 37.26Cardiac electrophysiologic stimulation and recording studies | X | |
| 88.52Angiocardiography of right heart structures | X | |
| 88.53Angiocardiography of left heart structures | X | |
| 88.54Combined right and left heart angiocardiography | X | |
| 88.55Coronary arteriography using a single catheter | X | |
| 88.56Coronary arteriography using two catheters | X | |
| 88.57Other and unspecified coronary arteriography | X | |
| 88.58Negative-contrast cardiac roentgenography | X |
b. Percutaneous Cardiovascular Procedures
In the May 4 proposed rule, we indicated that we had reviewed other DRGs within MDC 5 in order to determine if there were also logic changes that could be made to these DRGs. The data were arrayed in a variety of ways displaying myriad permutations, resulting in the following proposed changes.
A percutaneous transluminal coronary angioplasty (PTCA) is an acute intervention intended to minimize cardiac damage by restarting circulation to the heart. Some patients with an acute myocardial infarction (AMI) are now treated by performing a PTCA during the hospitalization for the AMI. Currently, PTCAs with a coronary stent implant are assigned to DRG 116 (Other Permanent Cardiac Pacemaker Implantation, or PTCA with Coronary Artery Stent Implant), along with pacemaker implants. The remaining percutaneous cardiovascular procedures are assigned to DRG 112 (Percutaneous Cardiovascular Procedures).
The volume of percutaneous cardiovascular procedures has grown dramatically, with 186,669 cases identified in the FY 2000 MedPAR file containing hospital bills submitted through May 31, 2000. Because of the high volume, we decided to review the DRG for percutaneous cardiovascular procedures. As a first step in the evaluation, we combined the percutaneous cardiovascular procedures from DRGs 112 and 116. We then subdivided the combined percutaneous cardiovascular procedure group into two groups based on the principal diagnosis (Pdx) of AMI.
| Group | Count | Average charge |
|---|---|---|
| With Pdx of AMI | 50,442 | $31,722 |
| Without Pdx of AMI | 136,227 | 23,989 |
Each of these groups was further evaluated by subdividing them based on whether a coronary stent was implanted. The vast majority of patients with an AMI had a coronary stent implanted. Patients without an AMI were subdivided into two groups based on whether a coronary stent was implemented.
| Group | Count | Average charge |
|---|---|---|
| Without Pdx of AMI with stent | 111,441 | $24,745 |
| Without Pdx of AMI without stent | 24,786 | 20,589 |
In the proposed rule, based on this analysis, we proposed the removal of PTCAs with coronary artery stent from DRG 116, thus limiting DRG 116 to permanent cardiac pacemaker implantation. This removal would leave approximately 68,000 non-PTCA cases in DRG 116.
In conjunction with this evaluation, we considered a new technology, intravascular brachytherapy, that is being used to treat coronary in-stent stenosis. A gamma-radiation-impregnated tape is threaded through the affected vessel for a specified amount of dwell time, and then the tape is removed. Intravascular brachytherapy was approved by the Food and Drug Administration in November 2000.
Intravascular brachytherapy is assigned to procedure code 92.27 (Implantation or insert of radioactive elements). With the use of angioplasty, these cases are currently assigned to DRG 112 (Percutaneous Cardiovascular Procedures). Therefore, cases involving this new technology will be implicated by these changes.
Also in the proposed rule, we proposed to retitle DRG 116 "Other Cardiac Pacemaker Implantation," remove DRG 112, and create three new DRGs: DRG 516 (Percutaneous Cardiovascular Procedures with Acute Myocardial Infarction (AMI)); DRG 517 (Percutaneous Cardiovascular Procedures without AMI, with Coronary Artery Stent Implant); and DRG 518 (Percutaneous Cardiovascular Procedures without AMI, without Coronary Artery Stent Implant). In order to be assigned to new DRG 516, cases must contain one of the principal diagnoses plus the operating room procedures listed in Chart 5. Because DRG 516 contains acute myocardial infarction, which is hierarchically ordered before DRGs 517 and 518, any AMI cases also containing codes 92.27 or 36.06 (Insertion of coronary artery stents(s)) would automatically be assigned to DRG 516. We also proposed the assignment of patients with a percutaneous cardiovascular procedure and intravascular radiation treatment to new DRG 517. As more data become available, we will reassess the assignment of intravascular radiation treatment to DRG 517. New DRG 518 would contain the same operating room and nonoperating room procedures as new DRG 517, with the exception of codes 92.27 and 36.06. We received 10 comments on this proposal.
Comment: Several commenters supported the reclassification of percutaneous vascular procedures to DRGs within this MDC. Other commenters, however, stated the proposed changes would be inappropriate because they would reduce payment overall for percutaneous cardiovascular procedures. These commenters noted that new technologies associated with these procedures are, in fact, more costly rather than less costly. In addition, commenters expressed concern that payment for pacemakers under DRG 116 would be reduced from FY 2001 levels.
Response: Based on 100 percent of FY 2000 discharges on file through March 2001, we estimate the case-weighted average relative weight for DRGs 116, 516, 517 and 518 to be 2.2236, a 4.5 percent decline from the case-weighted average relative weight for DRGs 112 and 116 for FY 2001 (2.3280). As discussed above in relation to the new DRGs 514 and 515, the calculation of the relative weights reflects the charges submitted by hospitals for these cases.
Comment: Five commenters addressed only the inclusion of code 92.27 (Implantation or insertion of radioactive elements, also known as brachytherapy) in new DRG 517 in cases without presence of AMI (these cases would go to DRG 516 if AMI were present). Four of the five expressed appreciation for this change, citing its clinical appropriateness and increased payment, which is close to the additional facility costs for performing the procedure.
One commenter, while commending the decision to assign these cases to DRG 517, requested clarification about our decisionmaking process in assigning this technology to the same DRG as coronary stents. The commenter requested that we outline the specific criteria we applied or the process we followed to evaluate the adequacy of the external data submitted.
Response: Although we received external data from a manufacturer of this technology, they were not the basis for our decision, as we were unable to verify the data because the data were submitted too late in the process of preparing the FY 2002 proposed rule. When we proposed to restructure DRGs 112 and 116, our decision was based on the clinical coherence of the DRGs. Intravascular radiation treatment is an invasive procedure that requires an additional 35 to 45 minutes, and requires the services of both a radiation (nuclear) physicist and a radiation safety officer in the operating room, as well as specifically trained operating room personnel, such as an ultrasound specialist.
Comment: One commenter wrote that these changes fail to account for the use of GP IIB-IIIA inhibitors for cases with acute coronary syndromes. The commenter was concerned whether the DRG assignment for these cases under the proposed DRGs would be appropriate.
Response: The administration of GP IIB-IIIA inhibitors is through intravenous infusion, and is assigned to code 99.20 (Injection or infusion of platelet inhibitor). The GROUPER does not recognize code 99.20 as a procedure and, therefore, its presence does not affect DRG assignment. As described above, the DRG assignment for these cases under the newly configured DRGs 116, 516, 517, and 518 would be determined by the presence of AMI and the presence of other procedures that would cause the case to group to one of the other DRGs besides 518. Our analysis of FY 2000 MedPAR data indicates that, among cases with code 99.20 currently assigned to either DRGs 112 or 116 for FY 2000, the majority of these cases are currently assigned to DRG 116 (317,108 discharges compared to 52,945). Therefore, the majority of these cases involve procedures that do affect DRG assignment. We will continue to evaluate these cases, however, to determine whether further revisions would be appropriate.
Comment: One commenter indicated that codes 37.27 (Cardiac mapping) and 37.34 (Catheter ablation of lesion or tissues of heart) would now be grouped to new DRGs 516, 517, and 518. Because these procedures are not usually used on patients with AMI or patients who receive a stent, the commenter indicated the cases would most likely be grouped to DRG 518. The commenter believed that we were unaware that certain procedures, such as the two previously mentioned, have greater resource utilization than other percutaneous cardiovascular procedures that do not involve AMI or stents. The commenter asserted that this is an inadvertently inappropriate classification. The commenter recommended that CMS either create a separate DRG for cardiac mapping and ablation procedures, or else assign codes 37.27 and 37.34 to DRG 516 after retitling the DRG appropriately.
Response: These cases previously were assigned to either DRG 112 or 116, depending upon whether they involved the insertion of a stent or the implantation of a pacemaker. This GROUPER assignment logic did not change, although the presence or absence of AMI is now a factor as well. We believe this is an appropriate clinical categorization. However, we will consider this issue as we continue to evaluate these DRGs.
The principal diagnosis codes and operating room and nonoperating room procedure codes that are included in the new DRGs 516, 517, and 518 are reflected in Chart 5.
| Diagnosis and procedure codes | Included in DRG 516 | Included in DRG 517 | Included in DRG 518 |
|---|---|---|---|
| Principal Diagnosis Codes: | |||
| 410.01Acute myocardial infarction of anterolateral wall, initial episode of care | X | ||
| 410.11Acute myocardial infarction of other anterior wall, initial episode of care | X | ||
| 410.21Acute myocardial infarction of inferolateral wall, initial episode of care | X | ||
| 410.31Acute myocardial infarction of inferoposterior wall, initial episode of care | X | ||
| 410.41Acute myocardial infarction of other inferior wall, initial episode of care | X | ||
| 410.51Acute myocardial infarction of other lateral wall, initial episode of care | X | ||
| 410.61True posterior wall infarction, initial episode of care | X | ||
| 410.71Subendocardial infarction, initial episode of care | X | ||
| 410.81Acute myocardial infarction of other specified sites, initial episode of care | X | ||
| 410.91Acute myocardial infarction of unspecified site, initial episode of care | X | ||
| Plus: | |||
| Operating Room Procedures: | |||
| 35.96Percutaneous valvuloplasty | X | X | X |
| And | |||
| 36.01Single vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy without mention of thrombolytic agent | X | X | X |
| Or | |||
| 36.02Single vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy with mention of thrombolytic agent | X | X | X |
| Or | |||
| 36.05Multiple vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent | X | X | X |
| And | |||
| 36.09Other removal of coronary artery obstruction | X | X | X |
| And | |||
| 37.34Catheter ablation of lesion or tissues of heart | X | X | X |
| 92.27Implantation or insertion of radioactive elements | X | ||
| Or: | |||
| Nonoperating Room Procedures: | |||
| 36.06Insertion of coronary artery stent(s) | X | ||
| 37.26Cardiac electrophysiologic stimulation and recording studies | X | X | X |
| 37.27Cardiac mapping | X | X | X |
DRG 121 (Circulatory Disorders with AMI and Major Complication, Discharged Alive), DRG 122 (Circulatory Disorders with AMI without Major Complication, Discharged Alive), and DRG 123 (Circulatory Disorders with AMI, Expired) are not affected by these changes.
c. Removal of Heart Assist Systems
The ICD-9-CM Coordination and Maintenance Committee considered the nonoperative removal of heart assist systems at its November 17, 2000 meeting. A device called the intra-aortic balloon pump (IABP) is one of the most common types of ventricular assist systems. A balloon catheter is placed into the patient's descending thoracic aorta, and inflates and deflates with each heartbeat. This device is timed with the patient's own heart rhythm, and inflates and circulates blood to the heart and other organs. This allows the heart to rest and recover. The IABP may be used preoperatively, intraoperatively, or postoperatively. It supports the patient from a few hours to several days.
Code 37.64 (Removal of heart assist system) already exists, and it is considered by the GROUPER to be an operative procedure. However, the nonoperative removal of a heart assist system can be done at the patient's bedside, is noninvasive, and requires no anesthesia. Therefore, the Committee created code 97.44 (Nonoperative removal of heart assist system) for use with discharges beginning on or after October 1, 2001.
In the past, we have assigned new ICD-9-CM codes to the same DRG to which the predecessor code was assigned. In the proposed rule, we explained that if this practice were to be followed, we would have proposed that code 97.44 be assigned to MDC 5, DRGs 478 (Other Vascular Procedures with CC) and 479 (Other Vascular Procedures without CC). After hospital charge data became available, we would have considered moving it to other DRGs. However, in accordance with section 533(a) of Public Law 106-554, which requires a more expeditious technique of recognizing new medical services or technology for the hospital inpatient prospective payment system, we will reconsider this longstanding practice when possible. Therefore, as code 97.44 was designed to capture heart assist system removal that is clearly nonoperative, we did not propose to designate 97.44 as a code which the GROUPER recognizes as a procedure. The GROUPER will assign these cases to a medical DRG based on the principal diagnosis, or to a surgical DRG if a surgical procedure recognized by the GROUPER is performed. This assignment can be found in Table 6B, New Procedure Codes, in the Addendum to this rule.
We received no comments on this proposal. However, we did receive comments on another issue in MDC 5, relating to DRGs 110 and 111 (Major Cardiovascular Procedures with and without CC).
Comment: One commenter submitted a case study on stent technology, noting that Medicare payments in their facility were 31.4 percent lower than total costs. This commenter made no recommendations, but stated that often surgeons must use additional stent segments to repair aneurysms, increasing total costs by thousands of dollars.
Response: We do not have a clear understanding of the commenter's statement that often surgeons must use additional stent segments to repair aneurysms, thereby increasing total costs. We are unclear because the device presented to us for new ICD-9-CM code consideration was proposed as a single device, custom-fitted to the patient's needs. We will continue to monitor this technology and the new code (used for discharges on or after October 1, 2001).
Comment: One commenter noted that aortic endografts are assigned to DRGs 110 and 111, and the cost of the device alone is greater than the entire payment for DRG 111. The commenter noted that this is a straightforward issue, and recommended that these cases be assigned specifically to DRG 110.
Response: DRGs 110 and 111 are what we refer to as paired DRGs. Paired DRGs are exactly the same as each other with regard to the principal diagnosis and procedure codes in most cases. However, other aspects of the patient's case have a bearing on DRG assignment, such as the patient's age or the secondary diagnoses (which determine comorbidities or complications in appropriate DRGs). In this case, DRGs 110 and 111 are divided based on the presence or absence of secondary diagnosis codes. If there are no secondary diagnosis codes present, the case will be assigned to DRG 111. It has been our experience that patients not having secondary diagnoses are less expensive for the hospital to treat, thereby resulting in a lower weighted DRG assignment.
Hospitals should code their records completely, recording and submitting all relevant diagnosis and procedure codes having a bearing on the current admission. As noted previously, payment for each DRG is based on the average charges for cases assigned to that DRG as submitted to us by hospitals.
3. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue)
a. Refusions
We have received questions from correspondents regarding the appropriateness of the spinal fusion DRGs: DRG 496 (Combined Anterior/Posterior Spinal Fusion); DRG 497 (Spinal Fusion with CC); and DRG 498 (Spinal Fusion without CC). Several correspondents expressed concern about the inclusion of all refusions of the spine into one procedure code, 81.09 (Refusion of spine, any level or technique). The correspondents pointed out that because all refusions using any technique or level are in this one code, all of these cases are assigned to DRG 497 and DRG 498. They also pointed out that fusion cases involving both an anterior and posterior technique are assigned to DRG 496. Although cases with the refusion code that involve anterior and posterior techniques would appear to be more appropriately assigned to DRG 496, this is not the case.
We recognized this limitation in the refusion codes and further acknowledged that this limitation in the ICD-9-CM coding system creates DRG problems by preventing the assignment to DRG 496 even when both anterior and posterior techniques are used for refusion cases. Therefore, we referred the issue to the ICD-9-CM Coordination and Maintenance Committee and requested the Committee to consider code revisions for the refusions of the spine during its year 2000 public meetings.
After its deliberations, the Committee approved a series of new procedure codes for refusion of the spine that could lead to improvements within DRGs 497 and 498. These new codes, listed below, go into effect on October 1, 2001.
81.30Refusion of spine, not otherwise specified
81.31Refusion of atlas-axis spine
81.32Refusion of other cervical spine, anterior technique
81.33Refusion of other cervical spine, posterior technique
81.34Refusion of dorsal and dorsolumbar spine, anterior technique
81.35Refusion of dorsal and dorsolumbar spine, posterior technique
81.36Refusion of lumbar and lumbosacral spine, anterior technique
81.37Refusion of lumbar and lumbosacral spine, lateral transverse process technique
81.38Refusion of lumbar and lumbosacral spine, posterior technique
81.39Refusion of spine, not elsewhere classified
As previously stated, all refusions of the spine and corrections of the pseudarthrosis of the spine are assigned to code 81.09. Code 81.09, which is always assigned to DRG 497 or DRG 498, includes refusions at any level of the spine using any technique. With the creation of the new procedure codes listed above, it will be possible to determine the level of the spine at which the refusion is performed, as well as the technique used, and assign the case to a more appropriate DRG.
These new procedure codes should greatly improve our ability to determine the level and technique used in the refusion.
In the past, we have assigned new ICD-9-CM codes to the same DRG to which the predecessor code was assigned. In the proposed rule, we explained that if this practice were followed, these new codes would have been assigned to DRG 497 and 498 as they are currently. After data became available, we would have considered moving them to other DRGs. However, in accordance with section 533(a) of Public Law 106-554, which requires more expeditious methods of recognizing new medical services or technology under the inpatient hospital prospective payment system, we will reconsider this longstanding practice when possible. Since the new codes clearly allow us to identify cases where the technique was either anterior or posterior and these cases are clinically similar and, therefore, should be handled in the same fashion, we proposed to immediately assign these cases on the same basis as the fusion codes (81.00 through 81.09). We would not wait for actual claims data before making this change. These assignments are reflected in Chart 6 and also can be found in Table 6B, in section V. of the Addendum to this final rule.
Comment: One commenter supported the creation of the ICD-9-CM codes for refusions as well as their proposed DRG assignments.
Response: We appreciate the support of the commenter and are adopting the proposed DRG assignments for refusions of spine as final.
b. Fusion of Cervical Spine
In the proposed rule we discussed an inquiry concerning the spinal DRGs that focused on fusions of the cervical spine. The inquirer stated that there was a significant difference between inpatients who undergo anterior cervical spinal fusion and other types of spinal fusion in regard to treatment, recovery time, costs, and risk of complications. Anterior cervical spinal fusions are assigned to procedure code 81.02 (Other cervical fusion, anterior technique). The inquirer pointed out that anterior cervical fusions differ significantly from anterior techniques at other levels since the anatomic approach is far less invasive. Thoracic anterior techniques require working around the cardiac and respiratory systems in the chest cavity, while lumbar anterior techniques require working around bowel and digestive system and the abdominal muscles. The inquirer recommended that code 81.02 be removed from DRGs 497 and 498 and grouped separately.
We analyzed claims data from the FY 2000 MedPAR file containing hospital bills received through May 31, 2000, and confirmed that charges are lower for fusions of the cervical spine than fusions of the thoracic and lumbar spine. This was true for both anterior and posterior cervical fusions of the spine. Our medical consultants agree that the data and their clinical analysis support the creation of new DRGs for cervical fusions of the spine. We proposed to remove procedure codes 81.02 and 81.03 from the spinal fusion DRGs (currently, DRGs 497 and 498) and assign them to new DRGs for cervical spinal fusion with and without CC. We also proposed four groupings for fusion DRGs. The net effect of this change is an increase in the weights for DRGs 497 and 498, since the lower charges for the cervical fusions would be removed. The average standardized charge for all spinal fusions with CCs was $26,957. For all spinal fusions without CCs, the average charge was $16,492. The table below also shows average standardized charges for these types of cases before and after the revisions.
| Revised spinal fusion DRGs | Average charge before revisions | Average charge after revisions |
|---|---|---|
| DRG 497 Spinal Fusion Except Cervical with CC | $26,957 | $36,821 |
| DRG 498 Spinal Fusion Except Cervical without CC | 17,492 | 26,297 |
| DRG 519 Cervical Spinal Fusion with CC | 26,957 | |
| DRG 520 Cervical Spinal Fusion without CC | 16,492 |
Based on the groupings, we proposed the creation of two new DRGs: DRG 519 (Cervical Spinal Fusion with CC); and DRG 520 (Cervical Spinal Fusion without CC). The procedure codes that would be included in the DRGs 519 and 520 are reflected in Chart 6 below.
We also proposed to add the new ICD-9-CM procedure codes for refusion of the cervical spine (81.32 and 81.33) to the new cervical spine fusion DRGs because they are clinically similar.
In addition, we proposed to retitle DRG 497 "Spinal Fusion Except Cervical with CC" and DRG 498 "Spinal Fusion Except Cervical without CC." The retitled DRGs 497 and 498 would retain fusion codes 81.00, 81.01, and 81.04 through 81.08 and include the new refusion codes 81.30, 81.31, and 81.34 through 81.39, as reflected in Chart 6 below.
Comment: One commenter commended the creation of the new ICD-9-CM codes for spinal refusions and the development of the new DRGs for cervical fusions. This commenter, a manufacturer of devices used for spinal fusions, agreed that cervical fusions on average cost less than lumbar and thoracic fusions. Another commenter who supported the creation of the new DRGs mentioned that this classification would more appropriately reflect the resources used in the varying cases.
Two commenters asserted that DRGs 497 and 498 fail to take into account the cost variations when multi-level spinal fusions are performed. The commenters stated that the cost and complexity of a discharge varies substantially depending on the number of levels performed as part of a fusion procedure. Commenters recommended that new ICD-9-CM procedure codes be created for multi-level spine procedures to track and measure costs. The current ICD-9-CM codes do not differentiate between the number of levels that are fused. The commenter defined multi-level as three or more vertebral segments, either anterior or posterior, or both. In addition, the commenter recommended that these new multi-level fusion codes be assigned to the higher weighted DRG 496. The commenter recommended that DRG 496 be renamed "Multi-Level Spine Procedure Anterior and/or Posterior for Stabilization and/or Correction and/or Refusion."
Response: We agree that the current ICD-9-CM procedure codes do not differentiate between the number of levels fused. This proposal will be addressed by the ICD-9-CM Coordination and Maintenance Committee at its November 1, 2001 meeting. A potential problem with this recommendation will be the need to avoid overlapping codes. The current fusion codes are based on an axis of the level of the fusion (cervical or lumbar) and an additional axis of the approach (anterior, posterior, or lateral transverse). Devising a modified or additional scheme that utilizes an additional axis of the number of disks fused may be quite challenging. If this scheme requires the use of a set of codes from the new Chapter 17, we could quickly use up these currently empty codes. As far as the recommendation to include these new multi-level fusion codes in DRG 496, this issue will be deferred until after the coding issue is addressed. If new codes are created, they will be included in an upcoming proposed rule along with their proposed DRG assignment.
Since there was support for the proposed changes to the spinal DRGs, these will be implemented as final changes effective October 1, 2001.
c. Posterior Spinal Fusion
We received other correspondence regarding the currentDRG assignment for code 81.07, Lumbar and lumbosacral fusion, lateral transverse process technique. The correspondent stated that physicians consider code 81.07 to be a posterior procedure. The patient is placed prone on the operating table and the spine is exposed through a vertical midline incision. The correspondent pointed out that code 81.07 is not classified as a posterior procedure within DRG 496 (Combined Anterior/Posterior Spinal Fusion). Therefore, when 81.07 is reported with one of the anterior techniques fusion codes, it is not assigned to DRG 496. The correspondent recommended that code 81.07 be added to the list of posterior spinal fusion codes for use in determining assignment to DRG 496.
In the proposed rule, we indicated that we consulted with our clinical advisors and they agreed that this addition should be made. Since we proposed to handle the new refusion codes in the same manner as the fusion codes, we also proposed to assign DRG 496 when 81.37 is used with one of the anterior technique fusion or refusion codes. This would be similar to the manner in which code 81.07 is classified. For assignment to DRG 496, we would consider codes 81.02, 81.04, 81.06, 81.32, 81.34, and 81.36 to be anterior techniques and codes 81.03, 81.05, 81.07, 81.08, 81.33, 81.35, and 81.38 to be posterior techniques.
| Diagnosis and procedure codes | Existing DRG 496 | Assigned as anterior techniques | Assigned as posterior techniques | Retained in or Added to existing DRG 497 | Retained in or Added to existing DRG 498 | Included in DRG 519 included in DRG 520 |
|---|---|---|---|---|---|---|
| Principal or Secondary Procedure Codes: | ||||||
| 81.00Spinal fusion, not otherwise specified | X | X | ||||
| 81.01Atlas-axis fusion | X | X | ||||
| 81.02Other cervical fusion, anterior technique | X | X | X | |||
| 81.03Other cervical fusion, posterior technique | X | X | X | |||
| 81.04Lumbar and lumbosacral fusion, anterior technique | X | X | X | |||
| 81.05Lumbar and lumbosacral fusion, posterior technique | X | X | X | |||
| 81.06Lumbar and lumbosacral fusion, anterior technique | X | X | X | |||
| 81.07Lumbar and lumbosacral fusion, lateral transverse process technique | X | X | X | |||
| 81.08Lumbar and lumbosacral fusion, posterior technique | X | X | X | |||
| 81.30Refusion of spine, not otherwise specified | X | X | ||||
| 81.31Refusion of atlas-axis spine | X | X | ||||
| 81.32Refusion of other cervical spine, anterior technique | X | X | X | |||
| 81.33Refusion of other cervical spine, posterior technique | X | X | X | |||
| 81.34Refusion of dorsal and dorsolumbar spine, anterior technique | X | X | X | |||
| 81.35Refusion of dorsal and dorsolumbar spine, posterior technique | X | X | X | |||
| 81.36Refusion of lumbar and lumbosacral spine, anterior technique | X | X | X | |||
| 81.37Refusion of lumbar and lumbosacral spine, posterior technique | X | X | X | |||
| 81.38Refusion of lumbar and lumbosacral spine, posterior technique | X | X | X | |||
| 81.39Refusion of spine, not elsewhere classified | X | X |
There was no opposition expressed to the changes proposed for posterior spinal fusions; therefore, we are adopting the proposed changes as final.
d. Spinal Surgery
The California Division of Workers' Compensation notified us of a possible problem with the following spinal DRGs:
DRG 496 (Combined Anterior/Posterior Spinal Fusion)
DRG 497 (Spinal Fusion with CC)
DRG 498 (Spinal Fusion without CC)
DRG 499 (Back Neck Procedures except Spinal Fusion with CC)
DRG 500 (Back Neck Procedures except Spinal Fusion without CC)
The Division of Workers' Compensation uses the DRG categories developed by CMS to classify types of hospital care. However, instead of using CMS' weights for determining reimbursement for inpatient services, the Division sets a global fee for all inpatient medical services not otherwise exempted. This fee is established by multiplying the product of the DRG weight (or revised DRG weight for a small number of categories) and the health facility's composite factor by 1.20 to get the maximum amount for worker compensation admissions.
The Division of Workers' Compensation has received reports that the formula it uses for reimbursing cases may be providing inadequate reimbursement. California hospitals and orthopedists have reported that certain spinal surgery DRGs (DRGs 496 through 500) may involve different types of care and/or technologies than those in use at the time these groups were formulated. Health care providers in California report "recent increased use of the new implantation devices, hardware, and instrumentation, coupled with requirements for intensive hospital services accompanying use of new procedures, has led to inadequate reimbursement in these DRGs." As a short-term response to these concerns, the California Division of Workers' Compensation is exempting the costs of hardware and instrumentation from the global fee of the fee schedule for DRGs 496 through 500. The Division also requested that CMS examine these DRGs for any potential problem under the Medicare reimbursement system.
The ICD-9-CM coding system does not capture specific types of implantation devices, hardware, and instrumentation. Therefore, we were not able to verify the claim that these new devices have led to increased costs in specific cases. We believe that the adoption of a more detailed coding system, such as ICD-10-PCS, would supply greater amounts of detail on these items. However, in the short term, it is not possible to identify a specific problem that involves implantation devices, hardware, and instrumentation.
Comment: As previously stated, we received support for the proposed changes to the spinal fusion DRGs. As was also stated, one commenter pointed out that the current ICD-9-CM codes do not specify the number of levels fused, nor do they specify the types of devices used.
One commenter, who manufactures spinal fusion devices, commended the new ICD-9-CM codes for refusions and the new DRGs for cervical fusions. This commenter also requested new codes specifying the number of levels fused. The commenter stated that typically two devices are used per level and therefore, with increased levels, there would be an increase in the number of infusion devices. The commenter recommended new codes for multi-level spinal fusions, but did not recommend new codes that would specify particular types of devices.
Responses: This coding issue will be addressed at future meetings of the ICD-9-CM Coordination and Maintenance Committee. If new codes are created, their DRG assignment would be addressed in a subsequent proposed rule.
4. MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract)
We have received correspondence from a manufacturer of an implantable vascular device requesting that code 86.07 (Insertion of totally implantable vascular access device [VAD]) be assigned as an operative procedure in MDC 11, to DRG 315 (Other Kidney Urinary Tract O.R. Procedures). This request was inadvertently omitted from the May 4, 2001 proposed rule. Therefore, we are taking this opportunity to discuss possible designation of this procedure code as a code affecting DRG assignment in MDC 11.
Procedure code 86.07 describes the implantation of a VAD into the chest wall and blood vessels of a patient's upper body. Patients requiring this particular device have been diagnosed with renal (kidney) failure. Insertion of a VAD allows access to the patient's blood for dialysis purposes when other sites for hemodialysis have been exhausted. According to representatives from the manufacturer of one particular VAD used for hemodialysis, this device costs the hospitals $1,750, and is usually inserted in the outpatient setting as opposed to admission for insertion of the device.
The GROUPER program does not recognize code 86.07 as a procedure in other than MDC 9 (Disease and Disorders of the Skin, Subcutaneous Tissue and Breast), in DRGs 269 and 270 (Other Skin, Subcutaneous Tissue Breast Procedure, with and without CC). Therefore, its presence in any other MDC does not affect DRG assignment. Patients who are admitted with renal failure and who have a VAD inserted will be assigned to DRG 316 (Renal Failure), absent any other surgical procedures. DRG 316 is a medical DRG with a lower relative weight than cases in the surgical DRGs within the same MDC.
We extensively reviewed the MedPAR data. We found that code 86.07 appeared in 358 different DRGs. Of these 358 DRGs, 173 include additional procedures recognized by GROUPER and are therefore considered surgical, while 185 are medical. Because of the space limitations of the ICD-9-CM, code 86.07 is used to describe VAD devices used for other purposes than hemodialysis.
We looked specifically at the cases within DRGs 315 and 316 as shown in the two tables below:
| With code 86.07 | Without code 86.07 | |
|---|---|---|
| Number of Cases | 421 | 19,815. |
| Average Length of Stay | 12.5 days | 6.8 days. |
| Average Charges | $39,946 | $23,061. |
| With code 86.07 | Without code 86.07 | |
|---|---|---|
| Number of Cases | 1,020 | 19,815. |
| Average Length of Stay | 10.2 days | 6.6 days. |
| Average Charges | $27,730 | $15,045. |
Cases containing code 86.07 have higher average lengths of stay as well as higher average charges than cases not containing this code. We further examined the total number of reported procedures, as well as the range of average charges across both DRGs, for cases containing code 86.07. Both DRGs contain a significant number of additional procedures. The nature of these procedures varies widely, including such divergent procedures as X-rays and scans, injections, dental extraction, cardiac catheterization, aneurysm repair, and laparoscopic cholecystectomy. We also identified 24 cases in DRG 315 and 28 cases in DRG 316 with multiple insertions of the VAD. We believe those instances where the VAD is inserted as an inpatient procedure involve cases where other complications exist, leading to the higher average charges noted above. We are not assigning code 86.07 to DRG 315 as a surgical procedure, but will continue to consider possible alternative specifications of these DRGs.
Additionally, we take this opportunity to clarify correct coding practice. It has come to our attention that a brochure is being distributed with the product that advocates coding insertion of the Lifesite® Hemodialysis Access System using ICD-9-CM procedure code 86.07 in addition to code 39.93 (Insertion of vessel-to-vessel cannula). Inclusion of code 39.93 will force these cases into DRG 315, the higher weighted surgical DRG. Our data review showed 33 such cases of double coding. We would caution hospitals that the use of code 39.93, in the absence of the actual procedure, is erroneous. According to our vascular surgeon consultant, the LifeSite® Hemodialysis Access System as presented to us is not a vessel-to-vessel cannula. It is a device inserted into a vessel. Therefore, providers submitting code 39.93 without the actual procedure having been performed are at risk for review of fraudulent coding practice and DRG upcoding.
This same product brochure contains the name and telephone number of a nationally recognized coding specialist. The addition of this specialist's name and number was included without her knowledge or consent. We take this opportunity to reiterate that LifeSite® Hemodialysis Access System is correctly coded using 86.07 alone.
5. MDC 12 (Diseases and Disorders of the Male Reproductive System)
At its May 11, 2000 public meeting, the ICD-9-CM Coordination and Maintenance Committee considered a request from a manufacturer to create a unique code for the procedure Penile plethysmography with nerve stimulation in DRG 334 (Major Male Pelvic Procedures with CC). The penile plethysmography is a test that can be performed during a radical prostatectomy procedure. During the course of the procedure, the physician places a probe within an area where the prostatic nerves are thought to be located and is able to detect minor changes in penile tumescence or detumescence. This reaction tells the physician that the nerve bundles have been located, which may aid the physician in performing a nerve-sparing radical prostatectomy procedure with precision. The nerve bundles can also be restimulated at the conclusion of the procedure, providing immediate feedback as to whether erectile function will be restored after surgery.
After a presentation on the nerve identifying procedure and review of existing ICD-9-CM codes, the ICD-9-CM Coordination and Maintenance Committee determined that the existing code 89.58 (Plethysmogram) adequately describes this test.
Radical prostatectomies for patients with cancer of the prostate are grouped in either DRG 334 (Major Male Pelvic Procedures with CC) or DRG 335 (Major Male Pelvic Procedures without CC). We have received a request from a manufacturer of a nerve-identifying device to assign cases containing code 89.58 into DRG 334 only, not into DRG 335. DRG 334 results in higher payments to hospitals. For FY 2002, DRG 334 has a relative weight of 1.5177, and DRG 335 has a relative weight of 1.1047. The manufacturer requested that we designate code 89.58 as an operating room procedure code that would be recognized by the GROUPER software, and make that code applicable only to DRG 334. The manufacturer believed that this would serve to take any cases of nerve sparing out of the lower paying DRG 335, and would make the technology more attractive to hospitals. As paired DRGs 334 and 335 are currently structured, they differ only in whether or not a secondary diagnosis identified as a CC is recorded.
We examined those cases in DRG 334 to which the procedure code for prostatectomy was assigned. Of the total 7,241 cases in DRG 334 identified, 5,611 of these cases contained procedure code 60.5 (Radical prostatectomy). Only three of the prostatectomy cases included code 89.58. There are not a sufficient number of cases on which to base an assessment of the payment for this procedure. Therefore, we did not propose to modify the assignment of code 89.58.
We received one comment on this proposal.
Comment: The commenter argued that the analysis conducted on the procedure code assignment of 89.58 was incomplete, as it did not include evaluation of DRG 335 in the calculations. The commenter added that DRG also includes radical prostatectomies for patients with cancer of the prostate.
Response: We apologize for the omission. Our review of data on DRG 335 showed that the DRG contained 8,125 total cases. There were 8,117 cases that did not contain procedure code 89.58; these cases had average total charges of $12,808. There were 8 cases in this group containing code 89.58. These 8 cases had average total charges of $16,366. We found a subset of 7,050 cases containing procedure code 60.5; these cases had average total charges of $12,772. Within this subset, only 7 cases were reported containing codes 60.5 and 89.58. These 7 cases had average total charges of $16,593.
Even including these additional cases, we identified very few cases in our analysis. Therefore, we are adopting as final our original proposed decision not to modify the assignment of code 89.58 by assigning it exclusively to DRG 334 within MDC 12. However, we will continue to monitor this procedure to determine whether a change in DRG assignment is warranted in the future.
6. MDC 15 (Newborns and Other Neonates With Conditions Originating in the Perinatal Period)
DRG 390 (Neonate with Other Significant Problems) contains newborn or neonate cases with other significant problems not assigned to DRGs 385 through 389, DRG 391, or DRG 469. To be assigned to DRG 389 (Full Term Neonate with Major Problems), the neonate must have one of the principal or secondary diagnosis listed under this DRG. A neonate is assigned to DRG 390 when the neonate has a principal or secondary diagnosis of newborn or neonate with other significant problems that are not assigned to DRG 385 through 389, 391, or 469.
We have received correspondence suggesting a number of changes to be made to DRGs 398 and 391. These changes involve removing two codes from DRG 389 and adding 17 codes to DRG 391, as described below.
a. DRG 389 (Full Term Neonate with Major Problems)
The correspondent suggested removing the following codes from DRG 389 and assigning them to DRG 390:
773.0Hemolytic disease due to RH isoimmunization
773.1Hemolytic disease due to ABO isoimmunization
The correspondent stated that hemolytic disease due to RH isoimmunization or due to ABO isoimmunization should not be considered a major problem. The correspondent recommended that these two conditions be classified as significant problems instead and thus assigned to DRG 390.
Our medical consultants sought additional advice from the National Association of Children's Hospitals and Related Institutions (NACHRI). (CMS contracts with the 3M Health Information Systems to maintain the DRG system. The medical experts at 3M evaluate proposed DRG changes from a clinical perspective. These medical consultants assist CMS in evaluating alternative proposals.) NACHRI and our medical consultants agree that it is appropriate to remove codes 773.0 and 773.1 from DRG 389. Therefore, we proposed to remove 773.0 and 773.1 from DRG 389 so that neonates with these conditions are assigned to DRG 390.
Comment: Several commenters supported the proposed revisions for newborns within MDC 15. One commenter stated that the code assignments mentioned in the proposed rule are more appropriately classified based on their clinical attributes. Another commenter agreed with the proposed changes, but requested that an additional code be added to those being moved to DRG 391 (Normal Newborn). Specifically, the commenter requested that code 779.3, Feeding problems in newborns, be listed under DRG 391. Currently, when this code is listed as a secondary code, it results in the assignment of the neonate to DRG 390. The commenter stated that this condition and its resource consumption should not cause the neonate to be classified under DRG 390.
Response: We discussed this additional issue with our medical consultants and they agreed that code 779.3 should also be listed under DRG 391. They concurred that the addition of this code as a secondary diagnosis should not lead to the newborn being classified as having a significant problem. Therefore, code 779.3 will be included among the codes being moved to DRG 391 as of October 1, 2001.
Comment: One commenter suggested that codes 773.0 and 773.1 be removed from DRG 387 (Prematurity with major problems) in addition to DRG 389. The list of major problems in DRGs 389 and 387 mirror each other. The only difference is that DRG 387 includes premature newborns. The commenter asked us to consider codes 773.0 and 773.1 as significant problems for newborns and classify them into DRG 390, which would make them applicable for premature and full-term newborns.
Response: We agree with the commenter. We are removing codes 773.0 and 773.1 from DRG 389 as well as DRG 387. This removal will result in these cases being assigned to DRG 390 (Neonate with Other Significant Problems).
b. DRG 391 (Normal Newborn)
We also have received correspondence with recommendations for changes to DRG 391. The correspondent pointed out that the following secondary codes currently lead to the assignment of the neonate to DRG 390 (Neonate with Other Significant Problems). The correspondent believed that the conditions described by these codes should not cause the neonate to be classified under DRG 390 when reported as a secondary diagnosis. The correspondent recommended that these conditions be listed under DRG 391 (Normal Newborn).
478.1Other diseases of nasal cavity and sinuses
520.6Disturbances in tooth eruption
623.8Other specified noninflammatory disorders of vagina
709.00Dyschromia, unspecified
709.01Vitiglio
709.09Dyschromia, Other
744.1Accessory auricle
754.61Congenital pes planus
757.33Congenital pigmentary anomalies of skin
757.39Other specified anomaly of skin
764.08"Light for dates" without mention of fetal malnutrition, 2,000-2,499 grams
764.98Fetal growth retardation, unspecified, 2,000-2,499 grams
772.6Cutaneous hemorrhage
794.15Abnormal and auditory function studies
796.4Other abnormal clinical findings
V20.2Routine infant or child health check
V72.1Examination of ears and hearing
Our medical consultants also sought the advice of NACHRI on this recommendation. NACHRI reviewed the list of codes and agreed that none of these conditions should be considered to be a significant problem for a neonate. NACHRI concurred that neonates with these secondary diagnoses should be classified as normal newborns. Therefore, we proposed to add the codes listed above to DRG 391 and not classify them to DRG 390 when reported as a secondary diagnosis.
Comment: One commenter expressed concern that the weights assigned to five newborn DRGs (DRGs 385, 368, 387, 388, and 389) are undervalued. The commenter pointed out that legislation mandating Early Hearing Detection and Intervention (EHDI) has been passed in 35 States plus the District of Columbia. In these States, hearing screening must be performed prior to the newborn's discharge from the hospital unless prevented by medical complications. The cost per screening ranges from $15 to $30, which includes personnel, supplies, and equipment costs which are amortized over 3 years. The screening also includes costs for babies that require diagnostic evaluation.
The commenter requested that data from States that have not implemented EHDI programs be deleted from the Medicare supplemental database for, at a minimum, DRG 391 (Normal Newborn). The commenter stated that non-Medicare data used for developing the weights for the five newborn DRGs do not represent average costs if some of the 19 States that supply supplemental non-Medicare data are States that perform hearing screenings on less than 90 percent of newborns. The commenter further requested that we use data only from States that have EHDI programs that are operational at the 90 percent level. The commenter provided a list of States that meet these criteria.
Response: While we appreciate the commenter's furnishing us with information on the costs of providing services such as hearing screenings, it would be inappropriate for us to use this one service to determine whether or not to include a State's data because the State does not provide the service at a 90-percent level. The DRG weights are based on averages. As hospitals elect to include or exclude services, the weights will change over time. Therefore, we are not developing a criterion to exclude hospital data from States that do not have a 90-percent compliance level with EHDI.
Comment: One commenter noted that new procedure code 75.38, Fetal pulse osimetry, was classified as a nonoperative procedure code in Table 6B of the Addendum of the proposed rule. As a nonoperative procedure, it was not assigned to an MDC or to specific DRGs. The commenter requested that we assign code 75.38 to MDC 14 (Pregnancy, Childbirth and Puerperium), and the following DRGs:
DRG 370-(Caesarean Section with CC)
DRG 371-(Caesarean Section without CC)
DRG 372-(Vaginal Delivery with Complicating Diagnosis)
DRG 373-(Vaginal Delivery without CC)
The commenter believed it was critical that the clinical benefits and use of fetal pulse oximetry be closely tracked in order to monitor clinical outcomes and to recognize potential economic advantages. The commenter acknowledged that most labor and delivery patients are not Medicare beneficiaries. However, other third party payers benchmark hospital inpatient payment rates from Medicare DRGs. The commenter stated that if code 75.38 does not contribute or link to a DRG, it is often simply not coded. The commenter further stated that fetal oximetry is an exciting and significant emerging technology and that much knowledge can be gained by understanding its usage in the context of labor and delivery services.
Response: The commenter requested that 75.38 be assigned to the DRGs for deliveries (DRG 370 through 373). However, these DRGs are currently assigned based on the procedure codes for the specific type of delivery (caesarian or vaginal). Adding the procedure code 75.38 to these delivery DRGs would not affect the DRG assignment. The cases would still be assigned to the appropriate DRG based on the type of delivery, not whether the baby received fetal pulse oximetry. If the commenter is suggesting that the fetal pulse oximetry code, on its own, should lead to the DRG assignment, this option is not workable. Without knowing that the mother actually delivered, and the type of delivery, one would not be able to assign the case to one of the delivery DRGs. Once one knew through the procedure codes that the mother delivered, and the type of delivery, the addition of 75.38 would not add to the DRG assignment.
The commenter did not make an argument as to why 75.38 was incorrectly classified as a nonoperating room procedure. While we appreciate the commenter's desire that this new procedure code be used, assigning the code to existing DRGs is not consistent with the structure of DRGs. Procedure codes are only assigned to DRGs when they effect the DRG assignment logic. Therefore, we are not changing the operating room status of code 75.38, nor are we adding it to the delivery DRGs. Code 75.38 will be considered a nonoperative procedure.
c. Medicare Code Editor Changes
The Medicare Code Editor (MCE) is a front-end software program that detects and reports errors in the coding of claims data. The age conflict edit detects inconsistencies between a patient's age and any diagnosis on the patient's record. A subset of diagnoses is considered valid only for patients over the age of 14 years. These diagnoses are identified as "adult" diagnoses and range in age from 15 through 124 years. Therefore, any codes included on the Newborn Diagnoses edit are valid only for patients under age 14.
It has come to our attention that cases including the ICD-9-CM code 770.7, Chronic respiratory disease arising in the perinatal period, are being rejected. However, a condition such as bronchopulmonary dysplasia always originates in the perinatal period, so regardless of the patient's age, this condition is always coded as 770.7. The age at which the diagnosis was established or the age at continuing treatment does not affect the assignment of code 770.7.
Because correct coding is causing these claims to be rejected, in the May 4 proposed rule we proposed to remove code 770.7 from the Newborn Diagnoses edit in the MCE, as well as remove it from DRG 387 (Prematurity with Major Problems) and DRG 389 (Full Term Neonate with Major Problems). Clinical conditions in code 770.7, such as pulmonary fibrosis, would group to DRG 92 (Interstitial Lung Disease with CC) and DRG 93 (Interstitial Lung Disease without CC). Therefore, we proposed the addition of code 770.7 to DRGs 92 and 93, as they are most similar clinically. We indicated that we would monitor these cases in upcoming MedPAR data to ascertain that the cases consume similar resources.
We received no comments on these proposals, and are, therefore, adopting the change as final.
7. MDC 20 (Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders)
DRG 434 (Alcohol/Drug Abuse or Dependency, Detoxification or Other Symptomatic Treatment with CC) is assigned when the patient has a principal diagnosis of alcohol or drug abuse or dependence along with a secondary diagnosis classified as a CC. If these patients do not have a CC, they are assigned to DRG 435 (Alcohol/Drug Abuse or Dependency, detoxification or Other Symptomatic Treatment without CC). When the patients receive rehabilitation and detoxification therapy during the stay, they are assigned to DRG 437 (Alcohol/Drug Dependence, Combined Rehabilitation and Detoxification Therapy). If the patients receive only rehabilitation therapy, they are assigned to DRG 436 (Alcohol/Drug Dependence with Rehabilitation Therapy).
We have received inquiries as to why the relative weight for DRG 437, which includes both rehabilitation and detoxification (for FY 2001, the relative weight is .6606, with a geometric mean length of stay of 7.5) is lower than the FY 2001 relative weight for DRG 434, which includes only detoxification (.7256, with a geometric mean length of stay of 3.9). Likewise, the FY 2001 relative weight for DRG 436, which includes only rehabilitation (.7433), is higher than the FY 2001 relative weight for DRG 437, which includes combined rehabilitation and detoxification therapy (.6606). The inquirers indicated that those patients receiving the combination therapy would be expected to have a longer length of stay, require more services, and, therefore, be more costly to treat.
We analyzed data from the FY 2000 MedPAR file and did not find support for the inquirers' assertion that combination therapy is more costly to treat. The relative weights indicate that the presence of a CC in DRG 434 leads to a significantly higher weight than is found in DRG 435, which does not have a CC. Therefore, we analyzed the alcohol/drug DRGs and focused on eliminating the distinction between rehabilitation and rehabilitation with detoxification and assessing the impact of CCs. We combined data on DRGs 436 and 437 and then subdivided the data based on the presence or absence of a CC. The following table contains the results of the analysis.
| DRGS | With CC | Count | Charge | Length of stay | Without CC | Count | Charge | Length of stay |
|---|---|---|---|---|---|---|---|---|
| Detoxification Cases-DRG 434 and DRG 435 | 3,298 | $8,548 | 5.0 | 9,689 | $5,111 | 4.1 | ||
| All Rehabilitation Cases-DRG 436 and DRG 437 | 3,298 | 8,117 | 10.1 | 4,473 | 7,407 | 9.6 |
We found that, for both the detoxification and rehabilitation DRGs, the with-CC group has higher charges than the without-CC group. However, the with-CC groups still contain the anomaly that the detoxification DRG 434 has a slightly higher average charge than the combined rehabilitation DRGs 436 and 437. It appears that any significant medical problems as indicated by the presence of a CC dominate the cost incurred by hospitals for treating alcohol and drug abuse patients. For the without-CC groups, the detoxification DRG 435 has substantially lower average charges than the combined rehabilitation DRGs 436 and 437. Because the average charges of the with-CC for both the detoxification DRG 434 and combined rehabilitation DRGs 436 and 437 have similar average charges, we proposed to combine these two groups.
Based on the results of our analysis, we proposed to restructure MDC 20 as follows. We first identified those cases with a principal diagnosis within MDC 20 where the patient left against medical advice. These cases are found in DRG 433 (Alcohol/Drug Abuse or Dependence, Left Against Medical Advice (AMA)). We next identified all remaining cases with a principal diagnosis within MDC 20 where there was a CC. We assigned these cases to a new DRG, (Alcohol/Drug Abuse or Dependence with CC). The remaining cases (without CC and did not leave against medical advice) were then divided into two new DRGs based on whether or not the patient received rehabilitation (Alcohol/Drug Abuse or Dependence without CC, with Rehabilitation Therapy; and Alcohol/Drug Abuse or Dependence without CC, without Rehabilitation Therapy).
The following table illustrates the number of patients and average charges for each of the four proposed DRGs.
| DRG | Group title | Number of cases | Average charges |
|---|---|---|---|
| 433 | Alcohol/Drug Abuse or Dependence, Left Against Medical Advice | 3,509 | $3,855 |
| 521 | Alcohol/Drug Abuse or Dependence with CC | 18,235 | 8,470 |
| 522 | Alcohol/Drug Abuse or Dependence without CC, with Rehabilitation Therapy | 4,473 | 7,407 |
| 523 | Alcohol/Drug Abuse or Dependence without CC, without Rehabilitation Therapy | 9,689 | 5,111 |
This table illustrates that groups based first on the presence of CC and then on whether or not the patient receives rehabilitation therapy provide a much better explanation of differences in charges. Therefore, we proposed to retain DRG 433, make DRGs 434 through 437 invalid, and create new DRGs 521, 522, and 523 to include the diagnosis and procedure codes reflected in Chart 7 below.
| Diagnosis and procedure code | Included in Existing DRG 433 | Included in DRG 521 | Included in DRG 522 | Included in DRG 523 |
|---|---|---|---|---|
| Principal diagnosis: | ||||
| All principal diagnosis within existing MDC 20 involving cases in which patients left against medical advice (AMA) | X | |||
| All principal diagnoses within existing MDC 20 where there is a CC and where patient did not leave against medical advice (AMA) | X | |||
| All principal diagnoses within existing MDC 20 without CC and where patient did not leave against medical advice (AMA) | ||||
| All principal diagnoses in existing MDC 20 without CC involving cases where patients did not leave against medical advice (AMA) | X | |||
| Procedure Codes: | ||||
| 94.61Alcohol rehabilitation | X | |||
| 94.63Alcohol rehabilitation and detoxification | X | |||
| 94.64Drug rehabilitation | X | |||
| 94.66Drug rehabilitation and detoxification | X | |||
| 94.67Combined alcohol and drug rehabilitation | X | |||
| 94.69Combined alcohol and drug rehabilitation and detoxification | X |
Comment: One commenter was uncertain as to the intent of the reclassification of the DRGs to identify alcohol/drug use and alcohol/drug-induced organic mental disorders. The commenter expressed concern that the cases associated with alcohol/drug use would have a lower overall weight relative to the overall average weight of these cases in FY 2001. The commenter requested further information on the impact of this change in the final rule. Additionally, the commenter recommended that the title for DRG 521 be changed from "Alcohol/Drug Abuse or Dependence with CC" to "Alcohol/Drug Abuse with CC, with or without Rehabilitation Therapy."
Response: As described above, for FY 2001, cases receiving combined rehabilitation and detoxification (DRG 437) had a lower relative weight than patients receiving only detoxification (DRG 434) or rehabilitation (DRG 436). Since these relative weights are derived from actual claims data, we decided to review the issue to determine if other factors had any impact. It would be expected that those patients receiving the combination therapy would have a longer length of stay, require more services, and therefore be more costly to treat. This was not supported by the data.
The factor that seems to contribute the greatest to the costs of these cases is the presence of a CC. The presence of a CC had a greater impact on the average charges than did factors such as detoxification or rehabilitation. Once the importance of this factor was determined, the cases not leaving against medical advice (DRG 433) were split on whether or not a CC was present. Those with a CC were assigned to new DRG 521. The remaining cases were then split based on whether or not rehabilitation was provided.
As can be seen from the FY 2002 relative weights in the chart below, MDC 20 patients who have a CC are considerably more expensive to treat. They have the highest relative weight among this set of DRGs. The second highest weight is assigned to MDC 20 cases without CC who also received rehabilitation services.
| DRG title | Number of of cases | Final weights |
|---|---|---|
| DRG 433 Alcohol/Drug Abuse or Dependence, Left AMA | 5,522 | .2888 |
| DRG 521 Alcohol/Drug Abuse or Dependence with CC | 28,014 | .7355 |
| DRG 522 Alcohol/Drug Abuse or Dependence without CC, with Rehabilitation Therapy | 6,852 | .6249 |
| DRG 523 Alcohol/Drug Abuse or Dependence without CC, without Rehabilitation Therapy | 14,954 | .3997 |
As can be seen from this chart, the majority of patients are assigned to DRG 521, which has the highest relative weight among the MDC 20 DRGs. As is the case for all DRGs, the relative weights reflect hospitals' actual charges submitted for bills in the FY 2000 MedPAR file. Data support the new splits based first on the presence of a CC and then on the presence of rehabilitation therapy. Therefore, we are adopting the proposed DRG classification changes as final without change.
While we appreciate the comment on modifying the title for DRG 521, we believe that it does not add to the clarity of the DRG. All MDC 20 patients who have not left AMA but who have a CC are assigned to DRG 521. The presence or absence of a code for rehabilitation therapy does not effect the DRG assignment for these cases. Therefore, we are adopting the proposed title as final without change.
8. MDC 25 (Human Immunodeficiency Virus Infections)
Effective October 1, 2000, ICD-9-CM diagnosis codes 783.2 (Abnormal loss of weight) and 783.4 (Lack of expected normal physiological development) were made invalid (65 FR 47171). These two old diagnosis codes were expanded to five digits and the following new diagnosis codes were created:
783.21 Loss of weight
783.22 Underweight
783.40 Unspecified lack of normal physiological development
783.41 Failure to thrive
783.42 Delayed milestones
783.43 Short stature
These six revised codes were created in response to an industry request. Specifically, code 783.2 did not differentiate between whether the patient had lost weight recently or whether the patient was underweight. Code 783.4 was expanded to capture concepts such as failure to thrive, delayed milestones, and short stature. None of these concepts were captured in the old codes.
We listed these new codes in the August 1, 2000 final rule on the hospital inpatient prospective payment system in Table 6A-New Diagnosis Codes (65 FR 47169). At the time the final rule was published, all of these codes were assigned to DRGs 296 through 298. After the final rule was published, we received an inquiry as to why these new diagnosis codes were not included in MDC 25 as human immunodeficiency virus (HIV)-related conditions. The inquirer pointed out that the predecessor codes (783.2 and 783.4) were included in MDC 25 as HIV-related conditions and suggested that the new codes be added to MDC 25. These cases will be assigned to other MDCs if the patient does not have HIV.
In the proposed rule, we stated that we agreed that the expanded codes should have been placed in the MDC 25 as HIV-related conditions. The omission was an oversight. Therefore, we proposed to add diagnosis codes 783.21, 783.22, 783.40, 783.41, 783.42, and 783.43 as HIV-related conditions within MDC 25. When these six revised codes are reported with code 042 HIV, the patient will be classified within MDC 25.
Comment: One commenter supported the placement of codes 783.21, 783.22, 783.40, 783.41, 783.42, and 783.43, as HIV-related conditions within MDC 25.
Response: We appreciate the commenter's support and are adopting the proposed changes as final.
9. Surgical Hierarchies
Some inpatient stays entail multiple surgical procedures, each one of which, occurring by itself, could result in assignment of the case to a different DRG within the MDC to which the principal diagnosis is assigned. Therefore, it is necessary to have a decision rule by which these cases are assigned to a single DRG. The surgical hierarchy, an ordering of surgical classes from most resource intensive to least, performs that function. Its application ensures that cases involving multiple surgical procedures are assigned to the DRG associated with the most resource-intensive surgical class.
Because the relative resource intensity of surgical classes can shift as a function of DRG reclassification and recalibration, we reviewed the surgical hierarchy of each MDC, as we have for previous reclassifications, to determine if the ordering of classes coincided with the intensity of resource utilization, as measured by the same billing data used to compute the DRG relative weights.
A surgical class can be composed of one or more DRGs. For example, in MDC 11, the surgical class "kidney transplant" consists of a single DRG (DRG 302) and the class "kidney, ureter and major bladder procedures" consists of three DRGs (DRGs 303, 304, and 305). Consequently, in many cases, the surgical hierarchy has an impact on more than one DRG. The methodology for determining the most resource-intensive surgical class involves weighting each DRG for frequency to determine the average resources for each surgical class. For example, assume surgical class A includes DRGs 1 and 2 and surgical class B includes DRGs 3, 4, and 5. Assume also that the average charge of DRG 1 is higher than that of DRG 3, but the average charges of DRGs 4 and 5 are higher than the average charge of DRG 2. To determine whether surgical class A should be higher or lower than surgical class B in the surgical hierarchy, we would weight the average charge of each DRG by frequency (that is, by the number of cases in the DRG) to determine average resource consumption for the surgical class. The surgical classes would then be ordered from the class with the highest average resource utilization to that with the lowest, with the exception of "other OR procedures" as discussed below.
This methodology may occasionally result in a case involving multiple procedures being assigned to the lower-weighted DRG (in the highest, most resource-intensive surgical class) of the available alternatives. However, given that the logic underlying the surgical hierarchy provides that the GROUPER searches for the procedure in the most resource-intensive surgical class, this result is unavoidable.
We note that, notwithstanding the foregoing discussion, there are a few instances when a surgical class with a lower average relative weight is ordered above a surgical class with a higher average relative weight. For example, the "other OR procedures" surgical class is uniformly ordered last in the surgical hierarchy of each MDC in which it occurs, regardless of the fact that the relative weight for the DRG or DRGs in that surgical class may be higher than that for other surgical classes in the MDC. The "other OR procedures" class is a group of procedures that are least likely to be related to the diagnoses in the MDC but are occasionally performed on patients with these diagnoses. Therefore, these procedures should only be considered if no other procedure more closely related to the diagnoses in the MDC has been performed.
A second example occurs when the difference between the average weights for two surgical classes is very small. We have found that small differences generally do not warrant reordering of the hierarchy since, by virtue of the hierarchy change, the relative weights are likely to shift such that the higher-ordered surgical class has a lower average weight than the class ordered below it.
Based on the preliminary recalibration of the DRGs, we proposed the modification of the surgical hierarchy as set forth below. As we stated in the September 1, 1989 final rule (54 FR 36457), we are unable to test the effects of proposed revisions to the surgical hierarchy and to reflect these changes in the proposed relative weights due to the unavailability of the revised GROUPER software at the time the proposed rule is prepared. Rather, we simulate most major classification changes to approximate the placement of cases under the proposed reclassification and then determine the average charge for each DRG. These average charges then serve as our best estimate of relative resource use for each surgical class. We test the proposed surgical hierarchy changes after the revised GROUPER is received and reflect the final changes in the DRG relative weights in the final rule. Further, as discussed in section II.C. of this preamble, we anticipate that the final recalibrated weights will be somewhat different from those proposed, because they will be based on more complete data. Consequently, in the proposed rule we stated that further revision of the hierarchy, using the above principles, might be necessary in the final rule.
In the May 4 proposed rule, we proposed to revise the surgical hierarchy for the pre-MDC DRGs, MDC 5 (Diseases and Disorders of the Circulatory System), MDC 8 (Diseases and Disorders of the Musculoskeletal System Connective Tissue) and MDC 20 (Alcohol/Drug Use Alcohol/Drug Induced-Organic Mental Disorders) as follows:
• In the pre-MDC DRGs, we proposed to reorder Lung Transplant (DRG 495) above Bone Marrow Transplant (DRG 481). We also proposed to reorder Simultaneous Pancreas/Kidney Transplant (DRG 512) and Pancreas Transplant (DRG 513) above Lung Transplant (DRG 495).
• In MDC 5, we proposed to reorder Cardiac Defibrillator Implants (DRGs 514 and 515) above Other Cardiothoracic Procedures (DRG 108). We also proposed to reorder Percutaneous Cardiovascular Procedures (DRGs 516, 517, and 518) above Other Vascular Procedures (DRGs 478 and 479).
• In MDC 8, we proposed to reorder Cervical Spinal Fusion (DRGs 519 and 520) above Back Neck Procedures Except Spinal Fusion (DRGs 499 and 500).
• In MDC 20, we proposed to order as follows: Alcohol/Drug Abuse or Dependence, Left AMA (DRG 433) above Alcohol/Drug Abuse or Dependence With CC (DRG 521); Alcohol/Drug Abuse or Dependence With CC (DRG 521) above Alcohol/Drug Abuse or Dependence With Rehabilitation Therapy Without CC (DRG 522); and Alcohol/Drug Abuse or Dependence With Rehabilitation Therapy Without CC (DRG 522) above Alcohol/Drug Abuse or Dependence Without Rehabilitation Therapy Without CC (DRG 523).
Comment: One commenter expressed support for hierarchy proposals.
Response: We appreciate the commenter's support. Based on a test of the proposed revisions using the March 2001 update of the FY 2000 MedPAR file and the revised GROUPER software, we have found that the revisions are still supported by the data, and no additional changes are indicated. Therefore, we are adopting these proposed changes as final.
10. Refinement of Complications and Comorbidities (CC) List
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 a valid CC in combination with a particular principal diagnosis. Thus, we created the CC Exclusions List. We made these changes for the following reasons: (1) to preclude coding of CCs for closely related conditions; (2) to preclude duplicative coding 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. We developed this standard 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 standard list of CCs, either by adding new CCs or deleting CCs already on the list. We stated in the proposed rule that we did not propose to delete any of the diagnosis codes on the CC list at that time.
In the May 19, 1987 proposed notice (52 FR 18877) concerning changes to the DRG classification system, we explained that the excluded secondary diagnoses were established using the following five principles:
• Chronic and acute manifestations of the same condition should not be considered CCs for one another (as subsequently corrected in the September 1, 1987 final notice (52 FR 33154)).
• Specific and nonspecific (that is, not otherwise specified (NOS)) diagnosis codes for a condition should not be considered CCs for one another.
• Conditions that may not coexist, such as partial/total, unilateral/bilateral, obstructed/unobstructed, and benign/malignant, should not be considered CCs for one another.
• The same condition in anatomically proximal sites should not be considered CCs for one another.
• Closely related conditions should not be considered CCs for one another.
The creation of the CC Exclusions List was a major project involving hundreds of codes. The FY 1988 revisions were intended only as a first step toward refinement of the CC list in that the criteria used for eliminating certain diagnoses from consideration as CCs were intended to identify only the most obvious diagnoses that should not be considered complications or comorbidities of another diagnosis. For that reason, and in light of comments and questions on the CC list, we have continued to review the remaining CCs to identify additional exclusions and to remove diagnoses from the master list that have been shown not to meet the definition of a CC. (See the September 30, 1988 final rule (53 FR 38485) for the revision made for the discharges occurring in FY 1989; the September 1, 1989 final rule (54 FR 36552) for the FY 1990 revision; the September 4, 1990 final rule (55 FR 36126) for the FY 1991 revision; the August 30, 1991 final rule (56 FR 43209) for the FY 1992 revision; the September 1, 1992 final rule (57 FR 39753) for the FY 1993 revision; the September 1, 1993 final rule (58 FR 46278) for the FY 1994 revisions; the September 1, 1994 final rule (59 FR 45334) for the FY 1995 revisions; the September 1, 1995 final rule (60 FR 45782) for the FY 1996 revisions; the August 30, 1996 final rule (61 FR 46171) for the FY 1997 revisions; the August 29, 1997 final rule (62 FR 45966) for the FY 1998 revisions; the July 31, 1998 final rule (63 FR 40954) for the FY 1999 revisions, and the August 1, 2000 final rule (65 FR 47064) for the FY 2001 revisions.) In the July 30, 1999 final rule (64 FR 41490) we did not modify the CC Exclusions List for FY 2000 because we did not make any changes to the ICD-9-CM codes for FY 2000.
In this final rule, we are making a limited revision of the CC Exclusions List to take into account the changes that will be made in the ICD-9-CM diagnosis coding system effective October 1, 2001. (See section II.B.11. below, for a discussion of ICD-9-CM changes.) These changes are being made in accordance with the principles established when we created the CC Exclusions List in 1987.
Tables 6F and 6G in section V. of the Addendum to this final rule contain the revisions to the CC Exclusions List that will be effective for discharges occurring on or after October 1, 2001. Each table shows the principal diagnoses with changes to the excluded CCs. Each of these principal diagnoses is shown with an asterisk, and the additions or deletions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.
CCs that are added to the list are in Table 6G-Additions to the CC Exclusions List. Beginning with discharges on or after October 1, 2001, the indented diagnoses will not be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis.
CCs that are deleted from the list are in Table 6H-Deletions from the CC Exclusions List. Beginning with discharges on or after October 1, 2001, the indented diagnoses will be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis.
Copies of the original CC Exclusions List applicable to FY 1988 can be obtained from the National Technical Information Service (NTIS) of the Department of Commerce. It is available in hard copy for $133.00 plus shipping and handling. A request for the FY 1988 CC Exclusions List (which should include the identification accession number (PB) 88-133970) should be made to the following address: National Technical Information Service, United States Department of Commerce, 5285 Port Royal Road, Springfield, VA 22161; or by calling (800) 553-6847.
Users should be aware of the fact that all revisions to the CC Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, 1997, 1998, and 1999) and those in Tables 6F and 6G of this document must be incorporated into the list purchased from NTIS in order to obtain the CC Exclusions List applicable for discharges occurring on or after October 1, 2001. (Note: There was no CC Exclusions List in FY 2000 because we did not make changes to the ICD-9-CM codes for FY 2000.)
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 18.0, is available for $225.00, which includes $15.00 for shipping and handling. Version 19.0 of this manual, which includes the final FY 2002 DRG changes, will be available in October 2001 for $225.00. 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.
11. Review of Procedure Codes in DRGs 468, 476, and 477
Each year, we review cases assigned to DRG 468 (Extensive OR Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic OR Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive OR Procedure Unrelated to Principal Diagnosis) to determine whether it would be appropriate to change the procedures assigned among these DRGs.
DRGs 468, 476, and 477 are reserved for those cases in which none of the OR procedures performed 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. DRG 476 is assigned to those discharges in which one or more of the following prostatic procedures are performed and are unrelated to the principal diagnosis:
60.0Incision of prostate
60.12Open biopsy of prostate
60.15Biopsy of periprostatic tissue
60.18Other diagnostic procedures on prostate and periprostatic tissue
60.21Transurethral prostatectomy
60.29Other transurethral prostatectomy
60.61Local excision of lesion of prostate
60.69Prostatectomy NEC
60.81Incision of periprostatic tissue
60.82Excision of periprostatic tissue
60.93Repair of prostate
60.94Control of (postoperative) hemorrhage of prostate
60.95Transurethral balloon dilation of the prostatic urethra
60.99Other operations on prostate
All remaining OR procedures are assigned to DRGs 468 and 477, with DRG 477 assigned to those discharges in which the only procedures performed are nonextensive procedures that are unrelated to the principal diagnosis. The original list of the ICD-9-CM procedure codes for the procedures we consider nonextensive procedures, if performed with an unrelated principal diagnosis, was published in Table 6C in section IV. of the Addendum to the September 30, 1988 final rule (53 FR 38591). As part of the final rules published on September 4, 1990 (55 FR 36135), August 30, 1991 (56 FR 43212), September 1, 1992 (57 FR 23625), September 1, 1993 (58 FR 46279), September 1, 1994 (59 FR 45336), September 1, 1995 (60 FR 45783), August 30, 1996 (61 FR 46173), and August 29, 1997 (62 FR 45981), we moved several other procedures from DRG 468 to 477, and some procedures from DRG 477 to 468. No procedures were moved in FY 1999, as noted in the July 31, 1998 final rule (63 FR 40962); in FY 2000, as noted in the July 30, 1999 final rule (64 FR 41496); or in FY 2001, as noted in the August 1, 2000 final rule (65 FR 47064).
a. Moving Procedure Codes From DRGs 468 or 477 to MDCs
We annually conduct a review of procedures producing assignment to DRG 468 or 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 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.
Our medical consultants identified those procedures occurring in conjunction with certain principal diagnoses with sufficient frequency to justify adding them to one of the surgical DRGs for the MDC in which the diagnosis falls. Based on this year's review, we did not identify any necessary changes in procedures under DRG 477 and, therefore, we did not propose to move any procedures from DRG 477 to one of the surgical DRGs. However, our medical consultants have identified a number of procedure codes that should be removed from DRG 468 and put into more clinically coherent DRGs. The movements of these codes are specified in the charts below:
| Procedure code | Description | Included in DRG | Description |
|---|---|---|---|
| MDC 1-Diseases and Disorders of the Nervous System | |||
| 5495 | Peritoneal Incision | 7 | Peripheral and Cranial Nerve and Other Nervous System Procedures with CC. |
| 5495 | Peritoneal Incision | 8 | Peripheral and Cranial Nerve and Other Nervous System Procedures without CC. |
| MDC 3-Diseases and Disorders of the Ear | |||
| 3821 | Blood Vessel Biopsy | 63 | Other Ear, Nose, Mouth and Throat OR Procedure. |
| MDC 4-Diseases and Disorders of the Respiratory System | |||
| 3821 | Blood Vessel Biopsy | 76 | Other Respiratory System OR Procedures with CC. |
| 3821 | Blood Vessel Biopsy | 77 | Other Respiratory System OR Procedures with CC. |
| 3929 | Vascular Shunt Bypass NEC | 76 | Other Respiratory System OR Procedures with CC. |
| 3929 | Vascular Shunt Bypass NEC | 77 | Other Respiratory System OR Procedures with CC. |
| 3931 | Suture of Artery | 76 | Other Respiratory System OR Procedures with CC. |
| 3931 | Suture of Artery | 77 | Other Respiratory System OR Procedures with CC. |
| 5411 | Exploratory Laparotomy | 76 | Other Respiratory System OR Procedures with CC. |
| 5411 | Exploratory Laparotomy | 77 | Other Respiratory System OR Procedures with CC. |
| 7749 | Bone Biopsy NEC | 76 | Other Respiratory System OR Procedures with CC. |
| 7749 | Bone Biopsy NEC | 77 | Other Respiratory System OR Procedures with CC. |
| 8669 | Free Skin Graft NEC | 76 | Other Respiratory System OR Procedures with CC. |
| 8669 | Free Skin Graft NEC | 77 | Other Respiratory System OR Procedures with CC. |
| MDC 5-Diseases and Disorders of the Circulatory System | |||
| 3402 | Exploratory Thoracotomy | 120 | Other Circulatory System OR Procedures. |
| 3403 | Reopen Thoractomy Site | 120 | Other Circulatory System OR Procedures. |
| 3421 | Transpleura Thoracoscopy | 120 | Other Circulatory System OR Procedures. |
| 3422 | Mediastinoscopy | 120 | Other Circulatory System OR Procedures. |
| 3426 | Open Mediastinal Biopsy | 120 | Other Circulatory System OR Procedures. |
| 436 | Distal Gastrectomy | 120 | Other Circulatory System OR Procedures. |
| 437 | Partial Gastrectomy with Jejunal Anastomosis | 120 | Other Circulatory System OR Procedures. |
| 4389 | Partial Gastrectomy | 120 | Other Circulatory System OR Procedures. |
| 4399 | Total Gastrectomy | 120 | Other Circulatory System OR Procedures. |
| 4561 | Multiple Segment Small Bowel Excision | 120 | Other Circulatory System OR Procedures. |
| 4562 | Partial Small Bowel Resection NEC | 120 | Other Circulatory System OR Procedures. |
| 4572 | Cecectomy | 120 | Other Circulatory System OR Procedures. |
| 4573 | Right Hemicolectomy | 120 | Other Circulatory System OR Procedures. |
| 4574 | Transverse Colon Resection | 120 | Other Circulatory System OR Procedures. |
| 4575 | Left Hemicolectomy | 120 | Other Circulatory System OR Procedures. |
| 4579 | Partial Large Bowel Excision NEC | 120 | Other Circulatory System OR Procedures. |
| 458 | Total Intra-Abdominal Colectomy | 120 | Other Circulatory System OR Procedures. |
| 4593 | Small-to-Large Bowel NEC | 120 | Other Circulatory System OR Procedures. |
| 4603 | Large Bowel Exteriorization | 120 | Other Circulatory System OR Procedures. |
| 4613 | Permanent Colostomy | 120 | Other Circulatory System OR Procedures. |
| 4709 | Other Appendectomy | 120 | Other Circulatory System OR Procedures. |
| 4862 | Anterior Rectal Resection With Colostomy | 120 | Other Circulatory System OR Procedures. |
| 4863 | Anterior Rectal Resection NEC | 120 | Other Circulatory System OR Procedures. |
| 4869 | Rectal Resection | 120 | Other Circulatory System OR Procedures. |
| 5012 | Open Liver Biopsy | 120 | Other Circulatory System OR Procedures. |
| 540 | Abdominal Wall Incision | 120 | Other Circulatory System OR Procedures. |
| MDC 6-Diseases and Disorders of the Digestive System | |||
| 5122 | Cholecystectomy | 170 | Other Digestive System OR Procedures with CC. |
| 5122 | Cholecystectomy | 171 | Other Digestive System OR Procedures without CC. |
| 5123 | Laparoscopic Cholecystectomy | 170 | Other Digestive System OR Procedures with CC. |
| 5132 | GB-To-Intestine Anastomosis | 170 | Other Digestive System OR Procedures with CC. |
| 5136 | Choledochoenterostomy | 170 | Other Digestive System OR Procedures with CC. |
| 5136 | Choledochoenterostomy | 171 | Other Digestive System OR Procedures without CC. |
| 5137 | Hepatic Duct-GI Anastomosis | 170 | Other Digestive System OR Procedures with CC. |
| 5137 | Hepatic Duct-GI Anastomosis | 171 | Other Digestive System OR Procedures without CC. |
| 5159 | Bile Duct Incision NEC | 170 | Other Digestive System OR Procedures with CC. |
| 5159 | Bile Duct Incision NEC | 171 | Other Digestive System OR Procedures without CC. |
| MDC 7-Diseases and Disorders of the Hepatobiliary System and Pancreas | |||
| 540 | Abdominal Wall Incision | 201 | Other Heptobiliary and Pancreas Procedure. |
| MDC 8-Diseases and Disorders of the Musculoskeletal System and Connective Tissue | |||
| 3479 | Other Chest Wall Repair | 233 | Other Musculoskeletal System Connective Tissue OR Procedure with CC. |
| 3479 | Other Chest Wall Repair | 234 | Other Musculoskeletal System Connective Tissue OR Procedure with CC. |
| MDC 11-Diseases and Disorders of the Kideny and Urinary Tract | |||
| 540 | Abdominal Wall Incision | 315 | Other Kidney Urinary Tract OR Procedure. |
| 5451 | Laparoscopic Periton Adhesiolysis | 315 | Other Kidney Urinary Tract OR Procedure. |
| 5459 | Other Periton Adhesiolysis | 315 | Other Kidney Urinary Tract OR Procedure. |
b. Reassignment of Procedures among DRGs 468, 476, and 477
We also annually review the list of ICD-9-CM procedures that, when in combination with their principal diagnosis code, result in assignment to DRGs 468, 476, and 477, to ascertain if any of those procedures should be moved from one of these DRGs to another of these DRGs based on average charges and 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 our medical consultants were to find these shifts, we would propose moving 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. Based on our review this year, we did not propose to move any procedures from DRG 468 to DRGs 476 or 477, from DRG 476 to DRGs 468 or 477, or from DRG 477 to DRGs 468 or 476.
c. Adding Diagnosis Codes to MDCs
Based on our review this year, we did not propose to add any diagnosis codes to MDCs.
We received one comment in support of the proposed changes to the procedure codes in DRG 468, 476, and 477. In this final rule, we are adopting these proposed changes without further modification.
12. Changes to the ICD-9-CM Coding System
As described in section II.B.1. of this preamble, the ICD-9-CM is a coding system that is used for the reporting of diagnoses and procedures performed on a patient. In September 1985, the ICD-9-CM Coordination and Maintenance Committee was formed. This is a Federal interdepartmental committee, co-chaired by the National Center for Health Statistics (NCHS) 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 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) (formerly American Medical Record Association (AMRA)), the American Hospital Association (AHA), and various physician specialty groups as well as physicians, medical record administrators, health information management professionals, and other members of the public to contribute ideas on coding matters. After considering the opinions expressed at the public meetings and in writing, the Committee formulates recommendations, which then must be approved by the agencies.
The Committee presented proposals for coding changes for implementation in FY 2002 at public meetings held on May 11, 2000 and November 17, 2000, and finalized the coding changes after consideration of comments received at the meetings and in writing by January 08, 2001.
Copies of the Coordination and Maintenance Committee minutes of the 2000 meetings can be obtained from the CMS home page at: http://www.hcfa.gov/medicare/icd9cm.htm. Paper copies of these minutes are no longer available and the mailing list has been discontinued. We encourage commenters to address suggestions on coding issues involving diagnosis codes to: Donna Pickett, Co-Chairperson; ICD-9-CM Coordination and Maintenance Committee; NCHS; Room 1100; 6525 Belcrest Road; Hyattsville, 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, Purchasing Policy Group, Division of Acute Care; C4-07-07; 7500 Security Boulevard; Baltimore, MD 21244-1850. Comments may be sent by E-mail to: pbrooks@cms.hhs.gov.
The ICD-9-CM code changes that have been approved will become effective October 1, 2001. 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 section V. of the Addendum to this final 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 the proposed rule, we solicited comments only on the proposed DRG classification of these new codes.
Further, the Committee has approved the expansion of certain ICD-9-CM codes to require an additional digit for valid code assignment. Diagnosis codes that have been replaced by expanded codes 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, 2001. For codes that have been replaced by new or expanded codes, the corresponding new or expanded diagnosis codes are included in Table 6A (New Diagnosis Codes). New procedure codes are shown in Table 6B. Table 6C contains invalid diagnosis codes, and Table 6D contains invalid procedure codes. Revisions to diagnosis code titles are in Table 6E (Revised Diagnosis Code Titles), which also include the DRG assignments for these revised codes. Revisions to procedure code titles are in Table 6F (Revised Procedure Codes Titles).
In September 2000, the Department implemented a policy of paying for inpatient hospital stays for Medicare beneficiaries participating in clinical trials (HCFA Program Memorandum AB 00-89, September 19, 2000). Hospitals were encouraged to identify the patients involved by reporting an ICD-9-CM code. This would allow the examination of data on the patients involved in clinical trials. However, there was no clear ICD-9-CM diagnosis code for patients who took part in a clinical trial. There was a code for patients receiving an examination as part of the control group for clinical trials. This control group code was V70.7 (Examination for normal comparison or control in clinical research). Hospitals were instructed to use V70.5 (Health examination of defined subpopulations), for patients participating in a clinical trial.
This coding directive has created some confusion because of the title and description of the two codes. Hospitals also have requested that all clinical patients be captured under one code. They indicated that the use of one code would be especially useful because patients frequently do not know if they are part of the control group or are receiving new therapy.
To help alleviate the confusion, the ICD-9-CM Coordination and Maintenance Committee revised code V70.7. Effective October 1, 2001, the new title of code V70.7 is "Examination of patient in clinical trial." This revision will make it easier to capture data on Medicare beneficiaries who are participating in a clinical trial.
Comment: One commenter questioned the DRG assignment of 525.12 (Loss of teeth due to periodontal disease) listed in Table 6A of the Addendum of the proposed rule. Table 6A in the proposed rule listed the proposed DRG assignments within MDC 3 for this new code as DRGs 182, 183, and 184. The commenter stated that the DRG assignments within MDC 3 should actually be DRGs 185, 186, and 187, since these were the DRGs used for its predecessor code, 525.1. The commenter also pointed out that the other new codes within this category (525.10-525.19) were assigned to DRGs 185, 186, and 187.
Response: The commenter is correct. We are assigning code 525.12 to DRGs 185, 186, and 187 within MDC 3. This is consistent with the way the other codes in the new category were assigned. In this final rule, we are correcting Table 6A to show that 525.12 is assigned to DRGs 185, 186, and 187 within MDC 3.
13. Other Issues
a. Pancreas Transplant
Effective July 1, 1999, Medicare covers whole organ pancreas transplantation if the transplantation is performed simultaneously with or after a kidney transplant (procedure codes 55.69 (Other kidney transplantation), or diagnosis code V42.0 (Organ or tissue replaced by transplant, Kidney), along with 52.80 (Pancreatic transplant, not otherwise specified), or 52.82 (Homotransplant of pancreas)). A discussion of the history of these coverage decisions and codes can be found in the August 1, 2000 final rule on the prospective payment system for FY 2001 (65 FR 47067).
We discussed the appropriate DRG classification for these cases in both the July 30, 1999 final rule (64 FR 41497) and the August 1, 2000 final rule (65 FR 47067). Currently, cases can be assigned to one of two major DRGs depending on principal diagnosis. If a kidney transplant and a pancreas transplant are performed simultaneously on a patient with chronic renal failure secondary to diabetes with renal manifestations (diagnosis codes 250.40 through 250.43), the cases will be assigned to DRG 302 (Kidney Transplant). If a pancreas transplant is performed following a kidney transplant (during a different hospital admission) on a patient with chronic renal failure secondary to diabetes with renal manifestations, the case is assigned to DRG 468 (Extensive OR Procedure Unrelated to Principal Diagnosis). This is because pancreas transplant is not assigned to MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract), the MDC to which a principal diagnosis of chronic renal failure secondary to diabetes is assigned.
In the August 1, 2000 final rule, we noted that we would continue to monitor these transplant cases to determine the appropriateness of establishing a new DRG. For the May 4 proposed rule, using data in the FY 2000 MedPAR file (updated through May 31, 2000), we analyzed the cases for which procedure codes 52.80 and 52.82 were reported. (Our data showed that 15 of the cases were coded using 52.83 (Heterotransplant of pancreas), which is not a covered procedure under any circumstances.) We identified a total of 221 cases for this time period. The United Network for Organ Sharing (UNOS) reported it had identified 270 cases through September 2000.
These 221 MedPAR cases were distributed over 6 DRGs, with the majority (158 cases or 72 percent) assigned to DRG 302, and 23 cases (10 percent) assigned to DRG 468. The remaining 40 cases were distributed between 4 other DRGs, with the majority (25 cases) being assigned to DRG 292 (Other Endocrine, Nutritional and Metabolic OR Procedures with CC). Four cases were assigned to DRG 483 (Tracheostomy with Principal Diagnosis except Face, Mouth and Neck Diagnoses) in the Pre-MDC grouping, which took precedence over any other DRG assignment.
We arrayed the data based on the presence or absence of kidney transplant; that is, pancreas transplant codes with or without 55.69. The majority of cases (166 or 75 percent) had the combined kidney-pancreas transplant in one operative episode, with 55 (25 percent) of the cases having pancreas transplant subsequent to the kidney transplant. Differences in hospital charges were significantly higher for a pancreas transplant plus a kidney transplant ($138,809) than a pancreas transplant alone ($85,972), and both were higher than average standardized charges in DRG 302 ($64,760) or DRG 468 ($39,707), although it must be noted that these figures do reflect the resource intensive patients assigned to DRG 483. Those patients in DRG 483 had average standardized charges of $377,934.
Because these categories of patients do not fit into existing DRGs from either a clinical or resource perspective, in the May 4 proposed rule, we proposed to create two new DRGs that would reflect these patients' unique clinical profiles: DRG 512 (Simultaneous Pancreas/Kidney Transplant) and DRG 513 (Pancreas Transplants). Cases grouped to either DRGs 512 or 513 must have a principal or secondary diagnosis code and procedure code or combination of procedure codes as indicated in the chart below:
| Diagnosis and procedure codes | Included in DRG 512 | Included in DRG 513 |
|---|---|---|
| Principal or Secondary ICD-9-CM Diabetes Mellitus Code: | ||
| 250.00Diabetes mellitus without mention of complication, Type II or unspecified type, not as stated as uncontrolled | X | X |
| 250.01Diabetes mellitus without mention of complication, Type I, not stated as uncontrolled | X | X |
| 250.02Diabetes mellitus without mention of complication, Type II or unspecified type, uncontrolled | X | X |
| 250.03Diabetes mellitus without mention of complication, Type I, uncontrolled | X | X |
| 250.10Diabetes with ketoacidosis, Type II or Unspecified type, not stated as uncontrolled | X | X |
| 250.11Diabetes with ketoacidosis, Type I, not stated as uncontrolled | X | X |
| 250.12Diabetes with ketoacidosis, Type II or unspecified type, uncontrolled | X | X |
| 250.13Diabetes with ketoacidosis, Type I, controlled | X | X |
| 250.20Diabetes with hyperosmolarity, Type II or unspecified type, not stated as uncontrolled | X | X |
| 250.21Diabetes with hyperosmolarity, Type I, not stated as uncontrolled | X | X |
| 250.22Diabetes with hyperosmolarity, Type II or unspecified type, uncontrolled | X | X |
| 250.23Diabetes with hyperosmolarity, Type I, uncontrolled | X | X |
| 250.30Diabetes with other coma, Type II or unspecified type, not stated as uncontrolled | X | X |
| 250.31Diabetes with other coma, Type I, not stated as uncontrolled | X | X |
| 250.32Diabetes with other coma, Type II or unspecified type, uncontrolled | X | X |
| 250.33Diabetes with other coma, Type I, uncontrolled | X | X |
| 250.40Diabetes with renal manifestations, Type II or unspecified type, not stated as uncontrolled | X | X |
| 250.41Diabetes with renal manifestations, Type I, not stated as uncontrolled | X | X |
| 250.42Diabetes with renal manifestations, Type II or unspecified type, uncontrolled | X | X |
| 250.43Diabetes with renal manifestations, Type I, uncontrolled | X | X |
| 250.50Diabetes with ophthalmic manifestations, Type II or unspecified type, not stated as uncontrolled | X | X |
| 250.51Diabetes with ophthalmic manifestations, Type I, not stated as uncontrolled | X | X |
| 250.52Diabetes with ophthalmic manifestations, Type II or unspecified type, uncontrolled | X | X |
| 250.53Diabetes with ophthalmic manifestations, Type I, uncontrolled | X | X |
| 250.60Diabetes with neurological manifestations, Type II or unspecified type, not stated as uncontrolled | X | X |
| 250.61Diabetes with neurological manifestations, Type I, not stated as uncontrolled | X | X |
| 250.62Diabetes with neurological manifestations, Type II or unspecified type, uncontrolled | X | X |
| 250.63Diabetes with neurological manifestations, Type I uncontrolled | X | X |
| 250.70Diabetes with peripheral circulatory disorders, Type II or unspecified type, not stated as uncontrolled | X | X |
| 250.71Diabetes with peripheral circulatory disorders, Type I, not stated as uncontrolled | X | X |
| 250.72Diabetes with peripheral circulatory disorders, Type II or unspecified type, uncontrolled | X | X |
| 250.73Diabetes with peripheral circulatory disorders, Type I, uncontrolled | X | X |
| 250.80Diabetes with other specified manifestations, Type II or unspecified type, not stated as uncontrolled | X | X |
| 250.81Diabetes with other specified manifestations, Type I, not states as uncontrolled | X | X |
| 250.82Diabetes with other specified manifestations, Type II or unspecified type, uncontrolled | X | X |
| 250.83Diabetes with other specified manifestations, Type I, uncontrolled | X | X |
| 250.90Diabetes with unspecified complication, Type II or unspecified type, not states as uncontrolled | X | X |
| 250.91Diabetes with unspecified complication, Type I, not stated as uncontrolled | X | X |
| 250.92Diabetes with unspecified complication, Type II or unspecified type, uncontrolled | X | X |
| 250.93Diabetes with unspecified complication, Type I, uncontrolled | X | X |
| Principal or Secondary Diagnosis Code: | ||
| 585Chronic renal failure. | X | X |
| 403.01Hypertensive renal disease, malignant, with renal failure | X | X |
| 403.11Hypertensive renal disease, benign, with renal failure | X | X |
| 403.91Hypertensive renal disease, unspecified, with renal failure | X | X |
| 404.02Hypertensive heart renal disease, malignant, with renal failure | X | X |
| 404.03Hypertensive heart renal disease, malignant, with congestive heart failure and renal disease | X | X |
| 404.12Hypertensive heart renal disease, benign, with renal failure | X | X |
| 404.13Hypertensive heart renal disease, benign, with congestive heart failure and renal disease | X | X |
| 404.92Hypertensive heart renal disease, unspecified, with renal failure | X | X |
| 404.93Hypertensive heart renal disease, unspecified, with congestive heart failure and renal failure | X | X |
| V42.0Organ or tissue replaced by transplant, kidney | X | X |
| V43.89Organ or tissue replaced by other means, other (Kidney) | X | X |
| Procedure Code: | ||
| 52.80Pancreatic transplant, not otherwise specified | X | |
| 52.82Homotransplant of pancreas | X | |
| Combination Procedure Codes: | ||
| 52.80Pancreatic transplant, not otherwise specified, | ||
| Plus | ||
| 55.69Other kidney transplantation | X | |
| Or | ||
| 52.82Homotransplant of pancreas | ||
| Plus | ||
| 55.69Other kidney transplantation | X |
The logic for the DRG 512 accepts the pair of diagnosis codes in any position (principal/secondary or secondary/secondary). The pair of procedure codes must be present along with the two diagnosis codes. This DRG will be placed in the Pre-MDC GROUPER logic immediately following DRG 480 (Liver Transplant).
The logic for DRG 513 accepts the pair of diagnosis codes in any position (principal/secondary or secondary/secondary). Only one procedure code must be used along with the two diagnosis codes. This DRG will be placed in the Pre-MDC GROUPER logic immediately following new DRG 512 (Simultaneous Pancreas/Kidney Transplant).
We received two comments on this proposal. One commenter supported the creation of the two new DRGs; a summary of the other comment follows:
Comment: One commenter noted that, as pancreas transplants were approved by Medicare on July 1, 1999, a special billing procedure should be made available to hospitals to enable hospitals to bill for the transplant DRG back to the effective date of the covered service.
Response: DRGs 512 and 513 are effective for discharges occurring on or after October 1, 2001, for FY 2002. Discharges involving pancreas transplants occurring prior to that time are assigned to existing DRGs as described above. Therefore, there is no need for hospitals to resubmit their bills.
We are adopting the establishment of proposed DRGs 512 and 513 as final.
b. Intestinal Transplantation
Effective April 1, 2001, Medicare covers intestinal transplantation for the purpose of restoring intestinal function in patients with irreversible intestinal failure (Medicare Program Memorandum Transmittal No. AB-01-58, April 12, 2001). This procedure is covered only when performed for patients who have failed total parenteral nutrition (TPN) and only when performed in centers that meet approval criteria.
Intestinal failure is defined as the loss of absorptive capacity of the small bowel secondary to severe primary gastrointestinal disease or surgically induced short bowel syndrome. Intestinal failure prevents oral nutrition and may be associated with both mortality and profound morbidity.
If an intestinal transplantation alone is performed on a patient with an intestinal principal diagnosis, the case would be assigned to either DRG 148 (Major Small Large Bowel Procedures With CC) or DRG 149 (Major Small Large Bowel Procedures Without CC). If an intestinal transplantation and a liver transplantation are performed simultaneously, the case would be assigned to DRG 480 (Liver Transplant).
If an intestinal transplantation alone is performed on a patient with an intestinal principal diagnosis, the case would be assigned to either DRG 148 (Major Small Large Bowel Procedures with CC) or DRG 149 (Major Small Large Bowel Procedures Without CC). If an intestinal transplantation and a liver transplantation are performed simultaneously, the case would be assigned to DRG 480 (Liver Transplant).
If an intestinal transplantation and a pancreas transplantation are performed simultaneously, currently the case would be assigned to either DRG 148 or DRG 149. Effective October 1, 2001, the case would be assigned to DRG 513 (Pancreas Transplant). We proposed to make a conforming change to the regulations at § 412.2(e)(4) and § 486.302 to include intestines (and multivisceral organs) in the list of organs for which Medicare pays for the acquisition costs on a reasonable cost basis.
Effective October 1, 2000, procedure code 46.97 (Transplant of intestine) was created. For the proposed rule, we examined our Medicare claims data to determine whether it was appropriate to propose a new intestinal transplant DRG. We examined data in the FY 2000 MedPAR file containing bills submitted through May 31, 2000. Because procedure code 46.97 was not in place during this time we focused our examination on the previous code assignment for intestinal transplant, code 46.99 (Other operations on intestines), and facilities that are currently performing intestinal transplantation. We were able to identify only one case, with an average charge of approximately $10,738 as compared to the average standardized charges for DRGs 148 and 149, which are approximately $37,961, and $16,965, respectively. We will continue to monitor these cases to determine whether it may be appropriate in the future to establish a new DRG.
Comment: One commenter recommended performing data analysis next year to determine if a separate intestinal transplantation DRG should be created based on the fact that these procedures are being performed on a more frequent basis. Another commenter suggested that the preamble specifically state that while the acquisition costs for heart, liver, lung, and pancreas transplants continue to be paid on a reasonable cost basis, the acquisition costs for intestinal transplantation will be paid through the hospital inpatient prospective payment system DRG payment mechanism.
Response: It is our intent to continue to monitor these cases to determine whether it may be appropriate in the future to establish a new DRG.
To clarify the issue of acquisition costs, Medicare Program Memorandum Transmittal No. AB-01-58, released April 12, 2001, states that Medicare will not pay transplant facilities on a reasonable cost basis for organ acquisition for intestinal or multivisceral transplants. The DRG payment will be payment in full for hospital services related to this procedure. However, in this final rule, we are implementing a conforming change to the regulations at § 412.2(e)(4) and § 486.302, to include intestines (and multivisceral organs) in the list of organs for which Medicare pays for the acquisition costs on a reasonable cost basis. This change is effective with acquisition costs incurred on or after October 1, 2001. After that date, costs associated with the acquisition of intestines and multivisceral organs will be paid on a reasonable cost basis. Costs associated with intestines procured separately will be allocated to an intestine cost center and allocated on Worksheet D-6. Multivisceral organ transplantation includes organs in the digestive system (that is, stomach, duodenum, pancreas, liver, intestine, and colon). Multivisceral procurements, including an organ(s) as defined at § 486.302 as well as the intestine (small bowel), will be allocated to the intestinal acquisition cost center. Multivisceral procurements are procured en bloc and the entire cost of procuring all of the organs will be allocated to the intestinal acquisition cost center.
c. Payment for Blood Clotting Factor Administered to Hemophilia Inpatients
Comment: Although this issue was not addressed in the proposed rule, we received one comment requesting that the add-on payment for blood clotting factors administered to hemophilia inpatients include adequate reimbursement for hospitals that treat beneficiaries with acquired hemophilia.
Response: According to section 4452 of Public Law 105-33, which amended section 6011(d) of Public Law 101-239, prospective payment hospitals receive an additional payment for costs of administering blood clotting factor to Medicare hemophiliacs who are hospital inpatients.
Hemophilia, a bleeding disorder characterized by prolonged clotting time, is caused by a deficiency of a factor necessary for blood to clot. In the August 29, 1997 final rule implementing section 4452 of Public Law 105-33 (62 FR 46002), we stated that hemophilia was considered to encompass the following conditions: Factor VIII deficiency (classical hemophilia); Factor IX deficiency (also termed plasma thromboplastin component (PTC) or Christmas factor deficiency); and Von Willebrand's disease. The most common factors required by hemophiliacs to increase coagulation are Factor VIII and Factor IX; a small number of hemophiliacs have developed inhibitors to these factors and require special treatment. We did not receive any comments regarding this coverage until, most recently, the cases of acquired hemophilia, which affects a small subset of individuals (1 in 1 million), were brought to our attention.
We are revising our claims processing instructions to permit add-on payments for the following ICD-9-CM diagnosis codes associated with acquired hemophilia:
286.5Hemorrhagic disorder due to circulating anticoagulants
286.7Acquired coagulation factor deficiency.
C. Recalibration of DRG Weights
We proposed to use the same basic methodology for the FY 2002 recalibration as we did for FY 2001 (August 1, 2000 final rule (65 FR 47069)). That is, we would recalibrate the weights based on charge data for Medicare discharges. However, we proposed to use the most current charge information available, the FY 2000 MedPAR file. (For the FY 2001 recalibration, we used the FY 1999 MedPAR file.) The MedPAR file is based on fully coded diagnostic and procedure data for all Medicare inpatient hospital bills.
The final recalibrated DRG relative weights are constructed from FY 2000 MedPAR data (discharges occurring between October 1, 1999 and September 30, 2000), based on bills received by CMS through March 31, 2001, from all hospitals subject to the prospective payment system and short-term acute care hospitals in waiver States. The FY 2000 MedPAR file includes data for approximately 11,094,323 Medicare discharges.
The methodology used to calculate the DRG relative weights from the FY 2000 MedPAR file is as follows:
• To the extent possible, all the claims were regrouped using the DRG classification revisions discussed in section II.B. of this preamble.
• Charges were standardized to remove the effects of differences in area wage levels, indirect medical education and disproportionate share payments, and, for hospitals in Alaska and Hawaii, the applicable cost-of-living adjustment.
• The average standardized charge per DRG was calculated by summing the standardized charges for all cases in the DRG and dividing that amount by the number of cases classified in the DRG.
• We then eliminated statistical outliers, using the same criteria used in computing the current weights. That is, all cases that are outside of 3.0 standard deviations from the mean of the log distribution of both the charges per case and the charges per day for each DRG are eliminated.
• The average charge for each DRG was then recomputed (excluding the statistical outliers) and divided by the national average standardized charge per case to determine the relative weight. A transfer case is counted as a fraction of a case based on the ratio of its transfer payment under the per diem payment methodology to the full DRG payment for nontransfer cases. That is, transfer cases paid under the transfer methodology equal to half of what the case would receive as a nontransfer would be counted as 0.5 of a total case.
• We established the relative weight for heart and heart-lung, liver, and lung transplants (DRGs 103, 480, and 495) in a manner consistent with the methodology for all other DRGs except that the transplant cases that were used to establish the weights were limited to those Medicare-approved heart, heart-lung, liver, and lung transplant centers that have cases in the FY 1999 MedPAR file. (Medicare coverage for heart, heart-lung, liver, and lung transplants is limited to those facilities that have received approval from CMS as transplant centers.)
• Acquisition costs for kidney, heart, heart-lung, liver, lung, and pancreas transplants continue to be paid on a reasonable cost basis. Unlike other excluded costs, the acquisition costs are concentrated in specific DRGs: DRG 302 (Kidney Transplant); DRG 103 (Heart Transplant); DRG 480 (Liver Transplant); DRG 495 (Lung Transplant); and proposed new DRGs 512 (Simultaneous Pancreas/Kidney Transplant) and 513 (Pancreas Transplant). Because these costs are paid separately from the prospective payment rate, it is necessary to make an adjustment to prevent the relative weights for these DRGs from including the acquisition costs. Therefore, we subtracted the acquisition charges from the total charges on each transplant bill that showed acquisition charges before computing the average charge for the DRG and before eliminating statistical outliers.
When we recalibrated the DRG weights for previous years, we set a threshold of 10 cases as the minimum number of cases required to compute a reasonable weight. We use that same case threshold in recalibrating the DRG weights for FY 2002. Using the FY 2000 MedPAR data set, there are 37 DRGs that contain fewer than 10 cases. We computed the weights for these 37 low-volume DRGs by adjusting the FY 2001 weights of these DRGs by the percentage change in the average weight of the cases in the other DRGs.
The new weights are normalized by an adjustment factor (1.44556) so that the average case weight after recalibration is equal to the average case weight before recalibration. This adjustment is intended to ensure that recalibration by itself neither increases nor decreases total payments under the prospective payment system, and accounts for the gradual shift in cases toward higher-weighted DRGs over time.
We received no comments on DRG recalibration.
Section 1886(d)(4)(C)(iii) of the Act requires that, beginning with FY 1991, reclassification and recalibration changes be made in a manner that assures that the aggregate payments are neither greater than nor less than the aggregate payments that would have been made without the changes. Although normalization is intended to achieve this effect, equating the average case weight after recalibration to the average case weight before recalibration does not necessarily achieve budget neutrality with respect to aggregate payments to hospitals because payment to hospitals is affected by factors other than average case weight. Therefore, as we have done in past years and as discussed in section II.A.4.a. of the Addendum to the final rule, we make a budget neutrality adjustment to ensure that the requirement of section 1886(d)(4)(C)(iii) of the Act is met.
III. Changes to the Hospital Wage Index
A. Background
Section 1886(d)(3)(E) of the Act requires that, as part of the methodology for determining prospective payments to hospitals, the Secretary must adjust the standardized amounts "for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level." In accordance with the broad discretion conferred under the Act, we currently define hospital labor market areas based on the definitions of Metropolitan Statistical Areas (MSAs), Primary MSAs (PMSAs), and New England County Metropolitan Areas (NECMAs) issued by the Office of Management and Budget (OMB). The OMB also designates Consolidated MSAs (CMSAs). A CMSA is a metropolitan area with a population of one million or more, comprising two or more PMSAs (identified by their separate economic and social character). For purposes of the hospital wage index, we use the PMSAs rather than CMSAs since they allow a more precise breakdown of labor costs. If a metropolitan area is not designated as part of a PMSA, we use the applicable MSA. Rural areas are areas outside a designated MSA, PMSA, or NECMA. For purposes of the wage index, we combine all of the rural counties in a State to calculate a rural wage index for that State.
We note that, effective April 1, 1990, the term Metropolitan Area (MA) replaced the term MSA (which had been used since June 30, 1983) to describe the set of metropolitan areas consisting of MSAs, PMSAs, and CMSAs. The terminology was changed by OMB in the March 30, 1990 Federal Register to distinguish between the individual metropolitan areas known as MSAs and the set of all metropolitan areas (MSAs, PMSAs, and CMSAs) (55 FR 12154). For purposes of the prospective payment system, we will continue to refer to these areas as MSAs.
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 should measure, to the extent feasible, the earnings and paid hours of employment by occupational category, and must exclude the wages and wage-related costs incurred in furnishing skilled nursing services. As discussed below in section III.F. 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 the wage index.
B. FY 2002 Wage Index Update
The FY 2002 wage index values in section V of the Addendum to this final rule (effective for hospital discharges occurring on or after October 1, 2001 and before October 1, 2002) are based on the data collected from the Medicare cost reports submitted by hospitals for cost reporting periods beginning in FY 1998 (the FY 2001 wage index was based on FY 1997 wage data).
The final FY 2002 wage index includes the following categories of data associated with costs paid under the hospital inpatient prospective payment system (as well as outpatient costs), which were also included in the FY 2001 wage index:
• Salaries and hours from short-term, acute care hospitals.
• Home office costs and hours.
• Certain contract labor costs and hours.
• Wage-related costs.
Consistent with the wage index methodology for FY 2001, the wage index for FY 2002 also continues to exclude the direct and overhead salaries and hours for services not paid through the inpatient prospective payment system such as skilled nursing facility (SNF) services, home health services, or other subprovider components that are not subject to the prospective payment system.
We calculate a separate Puerto Rico-specific wage index and apply it to the Puerto Rico standardized amount. (See 62 FR 45984 and 46041.) This wage index is based solely on Puerto Rico's data. Finally, section 4410 of Public Law 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is not located in a rural area may not be less than the area wage index applicable to hospitals located in rural areas in that State.
C. FY 2002 Wage Index
Because the hospital wage index is used to adjust payments to hospitals under the prospective payment system, the wage index should, to the extent possible, reflect the wage costs associated with the areas of the hospital included under the hospital inpatient prospective payment system. In response to concerns within the hospital community related to the removal, from the wage index calculation, of costs related to graduate medical education (GME) (teaching physicians and residents) and certified registered nurse anesthetists (CRNAs), which are paid by Medicare separately from the prospective payment system, the AHA convened a workgroup to develop a consensus recommendation on this issue. The workgroup recommended that costs related to GME and CRNAs be phased out of the wage index calculation over a 5-year period. Based upon our analysis of hospitals' FY 1996 wage data, and consistent with the AHA workgroup's recommendation, we specified in the July 30, 1999 final rule (64 FR 41505) that we would phase-out these costs from the calculation of the wage index over a 5-year period, beginning in FY 2000. In keeping with the decision to phase-out costs related to GME and CRNAs, the final FY 2002 wage index is based on a blend of 40 percent of an average hourly wage including these costs, and 60 percent of an average hourly wage excluding these costs.
Beginning with the FY 1998 cost reports, we revised the Worksheet S-3, Part II so that hospitals can separately report teaching physician Part A costs on lines 4.01, 10.01, 12.01, and 18.01. Therefore, it is no longer necessary for us to conduct the special survey we used for the FY 2000 and FY 2001 wage indexes (64 FR 41505 and 65 FR 47071).
1. Health Insurance and Health-Related Costs
In the August 1, 2000 final rule, we clarified our definition of "purchased health insurance costs" and "self-insurance" for hospitals that provide health insurance to employees (65 FR 47073). For purposes of the wage index, purchased or self-funded health insurance plan costs include the hospitals' insurance premium costs, external administration costs, and the share of costs for services delivered to employees.
In response to a comment received concerning this issue, we stated that, for self-funded health insurance costs, personnel costs associated with hospital staff that deliver the services to the employees must continue to be excluded from wage-related costs if the costs are already included in the wage data as salaries on Worksheet S-3, Part II, Line 1. However, after further consideration of this policy, particularly with respect to concerns expressed by our fiscal intermediaries about the level of effort required during the wage index desk review process to ensure hospitals are appropriately identifying and excluding these costs, in the May 4, 2001 proposed rule we proposed a revision. Effective with the calculation of the FY 2003 wage index, for either purchased or self-funded health insurance, we proposed to allow personnel costs associated with hospital staff who deliver services to employees to be included as part of the wage-related costs. We believe the proposed revised policy will ensure that health insurance costs are consistently reported by hospitals. Health insurance costs would continue to be developed using generally accepted accounting principles.
In the August 1, 2000 final rule (65 FR 47073), we further clarified that health-related costs (including employee physical examinations, flu shots, and clinic visits, and other services that are not covered by employees' health insurance plans but are provided at no cost or at discounted rates to employees of the hospital) may be included as "other" wage-related costs if, among other criteria, the combined cost of all such health-related costs is greater than one percent of the hospital's total salaries (less excluded area salaries).
For purposes of calculating the FY 2003 wage index (which will be based on data for cost reporting periods beginning in FY 1999), we proposed to revise this policy to allow hospitals to include health-related costs as allowable core wage-related costs.
Comment: One commenter supported our proposal to include health-related costs as core wage-related costs. The commenter also agreed with our proposal to include all personnel costs associated with hospital staff who deliver health services to employees. However, the commenter expressed concern that the proposed changes would require burdensome and duplicative revisions to cost reports that have already been filed.
Response: We believe that these revised policies (to eliminate the distinction between purchased health insurance and self-funded health insurance, and to treat costs associated with health-related services that are not part of the employees' health insurance plan consistent with costs included in the plan) will ensure that these costs are treated consistently across hospitals and fiscal intermediaries.
In response to the commenter's concern that the policy will require revisions to previously submitted cost reports, we believe the changes are not significant, particularly in light of the volume of changes submitted every year by hospitals during the wage data review process (see discussion in section III.G. of this final rule). The cost report changes necessary to implement these policy changes involve including costs previously disallowed. In the case of personnel costs associated with hospital staff who deliver services to employees, these costs would have already been identified in order to be excluded from the wage data. With respect to health services provided outside the employees' health insurance plan, we acknowledge that some hospitals may not have tracked these costs because they did not qualify for inclusion as other wage-related costs. However, due to concerns expressed by fiscal intermediaries about the difficulty of identifying these costs separate from those that are part of the insurance plan, we believe there may be inconsistencies in the current data with regard to how these costs are treated. Therefore, we believe, in the interest of improving the consistency of the data, that we should begin to allow these costs as core wage-related costs effective with the FY 2003 wage index.
2. Costs of Contracted Pharmacy and Laboratory Services
Our policy concerning inclusion of contract labor costs for purposes of calculating the wage index has evolved over the years. We recognize the role of contract labor in meeting special personnel needs of many hospitals. In addition, improvements in the wage data have allowed us to more accurately identify contract labor costs and hours. As a result, effective with the FY 1994 wage index, we included the costs of direct patient care contract services in the wage index calculation. The FY 1999 wage index included the costs and hours of certain management contract services, and the FY 2000 wage index included the costs for contract physician Part A services. (The 1996 proposed rule (61 FR 27456) provided an in-depth background to the issues related to the inclusion of contract labor costs in the wage index calculation.)
We revised the 1998 cost report to collect the data associated with contract pharmacy, Worksheet S-3, Part II, Line 9.01, and contract laboratory, Worksheet S-3, Part II, Line 9.02. The cost reporting instructions for these line numbers followed that for all contract labor lines; that is, to include the amount paid for services furnished under contract for direct patient care, and not include cost for equipment, supplies, travel expenses, and other miscellaneous or overhead items (Medicare Provider Reimbursement Manual, Part 2, Cost Reporting Forms and Instructions, Chapter 36, Transmittal 6, pages 36-32). Effective with the FY 2002 wage index, which uses FY 1998 wage data, we are including in this final rule (as proposed in the May 4 proposed rule) the costs and hours of contract pharmacy and laboratory services.
Comment: Two commenters supported our proposed policy to include the costs and hours of contract pharmacy and laboratory as direct patient care contract labor in the FY 2002 wage index. However, both commenters recommended that clearer guidelines be provided to ensure consistency in interpretation by fiscal intermediaries and contract vendors.
Response: Beginning with the FY 2002 wage index, we are including the costs and hours of contract pharmacy and laboratory services in the calculation of the wage index. Further instructions for reporting contract pharmacy and laboratory costs will be included in Transmittal 8 of the cost report, due for release in early fall 2001.
3. Collection of Occupational Mix Data
Section 304(c) of Public Law 106-554 amended section 1886(d)(3)(E) of the Act to require that the Secretary must provide 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. The initial collection of these data must be completed by September 30, 2003, for application beginning October 1, 2004.
Currently, the wage data collected on the cost report reflect the sum of wages, hours, and wage-related costs for all hospital employees. There is no separate collection by occupational categories of employees, such as registered nurses or physical therapists. Total salaries and hours reflect management decisions made by hospitals in terms of how many employees within a certain occupation to employ to treat different types of patients. For example, a large academic medical center may tend to hire more high-cost specialized employees to treat its more acutely ill patient population. The argument is that the higher labor costs incurred to treat this patient population are reflected in the higher case mix of these hospitals, and therefore, reflecting these costs in the wage index is essentially counting them twice.
An occupational mix adjustment can be used to account for hospital management decisions about how many employees to hire in each occupational category. Occupational mix data measure the price the hospital must pay for employees within each category. A wage index that reflected only these market prices would remove the impact of management decisions about the mix of employees needed and, therefore, better capture geographic variations in the labor market.
We have examined this issue previously. In the May 27, 1994 Federal Register (59 FR 27724), we discussed the outcome of consideration of this issue by a hospital workgroup. At that time, the workgroup's consensus was that the data required to implement an occupational mix adjustment were not available and the likelihood of obtaining such data would be minimal. There seemed to be little support among hospital industry representatives for developing a system that would create additional reporting burdens with an unproven or minimal impact on the distribution of payments. Also, in the August 30, 1991 Federal Register (56 FR 43219), we stated our belief that the collection of these data would be costly and difficult.
In considering the format to collect occupational mix data, we looked to data currently being collected by the Bureau of Labor Statistics (BLS), which conducts an annual mail survey to produce estimates of employment and wages for specific occupations. This program, Occupational Employment Statistics (OES), collects data on wage and salary workers in nonfarm establishments in order to produce employment and wage estimates for over 700 occupations.
The OES survey collects wage data in 12 hourly rate intervals. Employers report the number of employees in an occupation per each wage range. To illustrate, the wage intervals used for the 1999 survey are as follows:
| Interval | Hourly wages | Annual wages |
|---|---|---|
| Range A | Under $6.75 | Under $14,040. |
| Range B | $6.75 to $8.49 | $14,040 to $17,659. |
| Range C | 8.50 to 10.74 | 17,660 to 22,359. |
| Range D | 10.75 to 13.49 | 22,360 to 28,079. |
| Range E | 13.50 to 16.99 | 28,080 to 35,359. |
| Range F | 17.00 to 21.49 | 35,360 to 44,719. |
| Range G | 21.50 to 27.24 | 44,720 to 56,679. |
| Range H | 27.25 to 34.49 | 56,680 to 71,759. |
| Range I | 34.50 to 43.74 | 71,760 to 90,999. |
| Range J | 43.75 to 55.49 | 91,000 to 115,439. |
| Range K | 55.50 to 69.99 | 115,440 to 145,599. |
| Range L | 70.00 and over | 145,600 and over. |
We noted that this table is for illustrative purposes, and that we may update the data ranges in our actual collection instrument.
Although we initially considered using the OES data, section 304(c) of Public Law 106-554 requires us to collect data from every short-term, acute care hospital. The OES data are a sample survey and, therefore, as currently conducted, are not consistent with the statutory requirement to include data from every hospital. Another issue with using OES data is that, for purposes of the Medicare wage index, the hospitals' data must be reviewed and verified by the fiscal intermediaries. The OES survey is a voluntary survey for most States.
Although we decided to pursue a separate data collection effort than OES, we proposed in the May 4, 2001 proposed rule to model our format after the one used by OES. In this way, hospitals participating in the OES survey would have no additional recordkeeping and reporting requirements beyond those of the OES survey.
The OES survey of the hospital industry is designed to capture all occupational categories within the industry. For purposes of adjusting the wage index for occupational mix, we do not believe it is necessary to collect data from such a comprehensive scope of categories. Furthermore, because the data must be audited, a comprehensive list of categories would be excessively burdensome.
In deciding which occupational categories to include, we reviewed the occupational categories collected by OES and identified those with at least 35,000 hospital employees. Our goal is to collect data from a sample of occupational categories that provides a valid measure of wage rates within a geographical area. In the May 4 proposed rule, using this threshold of at least 35,000 employees within a category nationally, we proposed to collect data on the number of employees by wage range as illustrated in the above table, for the occupational categories listed below. The following data, which was also listed in the proposed rule, are based on the 1998 OES survey. (These data are no longer available on the internet.)
| OES code | Category | Number of employees | Percent of total hospital employees | Mean hourly wage |
|---|---|---|---|---|
| 15008 | Medicine and Health Services Manager | 93,680 | 1.9 | $27.38 |
| 27302 | Social Workers, Medical and Psychiatric | 53,360 | 1.1 | 16.33 |
| 32102 | Physicians and Surgeons | 125,640 | 2.6 | 43.76 |
| 32308 | Physical Therapists | 39,840 | 0.8 | 26.14 |
| 32502 | Registered Nurses | 1,231,980 | 25.0 | 21.12 |
| 32505 | Licensed Practical Nurses | 206,360 | 4.2 | 13.39 |
| 32517 | Pharmacists | 46,860 | 1.0 | 28.62 |
| 32911, 32928, and 32931 | Clinical Technologists and Technicians | 122,380 | 2.50 | 11.69 |
| 51002, 55105, 55108, 55305, 55332, and 55347 | First-Line Supervisors and Clerical Workers | 445,730 | 9.5 | 11.39 |
| 65038, 67002, and 67005 | Food Preparation Workers and Housekeeping | 218,440 | 4.5 | 8.17 |
| 66008 | Nursing Aides, Orderlies, and Attendants | 301,240 | 6.2 | 8.67 |
We proposed that this list of occupational categories provides a good representation of the employee mix at most hospitals. It has since come to our attention that the occupational categories listed in the proposed rule have been replaced by Standard Occupational Category definitions.
Because we had not yet settled on the methodology to use the occupational mix data in the wage index, we discussed in the proposed rule one option to weight each hospital's wage index by its occupational mix index. This requires calculating a national occupational mix index and then breaking it down by MSA and by hospital, similar to how the wage index is broken down. In this way, the wage index would capture geographic differences in wage rates. The decision about how to apply the occupational mix index to the wage index depends on the quality of the data collected, since this effort will be the first time wage and hour data by occupation are collected in this audited manner.
Section 304(c) directs the Secretary to provide for the collection of these data by September 30, 2003, and to apply them in the wage index by October 1, 2004. Therefore, the data are to be incorporated in the FY 2005 wage index. Under our current timetable, the FY 2005 wage index will be based on wage data collected from hospitals' cost reporting periods beginning during FY 2001. In order to facilitate the fiscal intermediaries' review of these data, we believe the occupational mix data should coincide with the data otherwise used to calculate the cost report. Therefore, we will conduct a special survey of all short-term acute-care hospitals that are required to report wage data to collect these data coinciding with hospitals' FY 2001 cost reports.
Comment: Several commenters expressed interest in working with us to develop an appropriate data collection tool. They suggested that the data be relatively simple for hospitals to gather and submit, and should be collected on 100 percent of hospital employees. Another commenter recommended that, at least initially, only data on nursing categories would be sufficient since nurses are 35 percent of hospital employees and can be divided into a few easily distinguishable categories. Two commenters offered examples for how these data are collected in their area. Some commenters wanted these data incorporated in the cost report to limit the number of forms hospitals must complete and to improve the response rate.
Response: We agree that it would be beneficial to work with the industry to develop a workable data collection tool, especially given the importance of the wage index in adjusting hospital payments. We appreciate the comments on the option presented in the proposed rule and believe that these comments will help initiate further thought toward the development of an occupational mix survey that can be administered without excessive burden on hospitals, the fiscal intermediaries, or CMS.
Due to time constraints in meeting the statutory deadlines, our intention at this point is to attempt to develop a survey instrument for the initial collection of occupational mix data that can be used by hospitals during calendar year 2002. Therefore, prior to January 1, 2002, we plan to work with the hospital community to develop a survey instrument. We believe issues related to the sample size of the data collected and the appropriate occupational categories to collect can best be resolved through consultation with the industry. Therefore, we will be contacting those organizations that expressed an interest in consultation in their comments. Other interested parties are encouraged to contact us as well.
After developing a method that appropriately balances the need to collect accurate and reliable data with the need to collect data hospitals can be reasonably expected to have available, we will issue instructions as to the type of data to be collected, in advance of actually requiring hospitals to begin providing the data.
Comment: Some commenters asked us to further develop the planned use of the occupation information and then decide what information is required. They requested that we publish the projected economic effects of an occupational mix adjustment upon each hospital as soon as feasible, and demonstrate tangible benefits prior to requiring hospitals to collect data. One commenter offered a specific methodology that could be employed. Other commenters want the methodology phased-in over time to allow hospitals time to adjust to different payment levels.
Response: In the proposed rule, we stated that we had not yet settled on the actual methodology for using the occupational mix data in the calculation of the wage index. We indicated the decision as to how the data will be used is dependent on the quality of the data collected. That is still the case. Furthermore, as discussed above, we intend to develop an appropriate data collection instrument in consultation with the hospital community. Therefore, until decisions are made with regard to the specific data to be collected, we cannot specify how the data will be used. However, the selection of an appropriate methodology (including a possible phase-in) will be influenced by analysis of the impacts of the method on hospital payments.
Comment: Two commenters expressed concerns that adopting the occupational mix adjustment for the wage index will lower the average hourly wage of teaching hospitals because of their mix of highly skilled, higher paid employees to treat patients with more complex conditions. These commenters argued that implementation of the occupational mix adjustment should proceed only in conjunction with the adoption of severity-adjusted DRGs. These commenters wrote that the current DRG system does not adequately recognize patient severity and pay for the higher resource costs associated with complex patients, but teaching hospitals can recoup some of these losses because their higher employee skill mix is reflected in their average hourly wage.
Furthermore, one commenter countered the argument that the higher labor costs incurred to treat a more severely ill patient population are reflected in the higher case mix of these hospitals and, therefore, reflecting these costs in the wage index is essentially counting them twice. This commenter pointed out that, because the DRG weights are based on hospital charges that are standardized by, among other factors, the area wage index, the weights of tertiary care DRGs are lower than they would be if the average charge per case were not first standardized by the wage index. However, the commenter went on to state that it is preferable to account for skill mix in the wage index rather than the case-mix index.
Response: As we stated in the August 1, 2000 final rule (65 FR 47103), we agree that severity-adjusted DRGs have potential for reducing discrepancies between payments and costs for individual cases (60 FR 29246). We have stated that, prior to implementing severity-adjusted DRGs, we would need specific legislative authority to offset any significant anticipated increase in payments attributable to changes in coding practices caused by significant changes to the DRG classification system. Section 301 of Public Law 106-554 authorized the Secretary to adjust the average standardized amounts if he determines that DRG coding or classification changes are likely to result in a change in aggregate payments. Therefore, based on this authority, we are beginning to evaluate the potential for implementing severity-adjusted DRGs. Because we are at the initial stages of that effort, we cannot yet estimate when, or if, such implementation may occur. However, we agree with these commenters' points that significant changes to any of the adjustments under the prospective payment system must be considered in light of the effects such changes may have to other such adjustments.
Comment: One commenter interpreted our proposal to suggest that the fiscal year for which the data will be collected will be closed by the time the methodology and data requirements have been established.
Response: In the proposed rule, we indicated we would conduct a special survey to collect these data to coincide with hospitals' cost reports beginning during FY 2001. We do not intend to require hospitals to retroactively adjust their payroll records to collect these data. Therefore, given our intention to gather input from the industry prior to designing the survey instrument, it likely will not be possible to completely coincide the data collection period with hospitals' FY 2001 cost reports.
Although there may be some auditing benefits to having the data overlap, this type of data is not routinely collected through the cost reports, so that the auditing benefits of such overlap may be minimal. In addition, there may be a benefit to collecting occupational mix for a more recent period in terms of reflecting current trends, such as higher wages paid to nurses during a shortage.
Comment: Other commenters raised specific technical concerns about the occupational mix discussion in the proposed rule.
Response: Rather than respond individually at this time to technical issues associated with the occupational mix discussion in the proposed rule, we will address these issues through direct consultation with the industry, as described above.
D. Verification of Wage Data From the Medicare Cost Report
The data for the FY 2002 wage index were obtained from Worksheet S-3, Parts II and III of the FY 1998 Medicare cost reports. The data file used to construct the wage index includes FY 1998 data submitted to us as of July 2001. 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 to revise or verify data elements that resulted in specific edit failures. The unresolved data elements that were included in the calculation of the proposed FY 2002 wage index have been resolved and are reflected in the calculation of the final FY 2002 wage index. We note that, as part of this process to identify aberrant data and correct any errors prior to the calculation of the final FY 2002 wage index, we notified by letter those hospitals that were leading to large variations in the wage indexes of their labor market areas compared to the FY 2001 wage index. These hospitals were advised to review their data to identify the reason for the large increases or decreases and notify their fiscal intermediary of any necessary corrections.
Also, as part of our editing process, in the final wage index, we removed data for 30 hospitals that failed edits. For 24 of these hospitals, we were unable to obtain sufficient documentation to verify or revise the data because the hospitals are no longer participating in the Medicare program or are in bankruptcy status. Six hospitals had incomplete or inaccurate data resulting in exceptionally large, zero, or negative average hourly wages. Therefore, they were removed from the calculation. As a result, the final FY 2002 wage index is calculated based on FY 1998 wage data for 4,880 hospitals.
Comment: One commenter recommended that we incorporate additional fatal edits in the cost reporting systems to eliminate obvious errors on the Worksheet S-3 that result in incomplete or erroneous wage data that are difficult to correct 4 years later.
Response: We do not agree with the recommendation of the commenter. A separate desk review is performed for the wage index. The desk review, combined with the level two edits, is sufficient to provide fiscal intermediaries with information to identify discrepancies, such as zero or negative average hourly wage or missing hours, that can be resolved by the fiscal intermediary during the cost reporting process.
E. Computation of the FY 2002 Wage Index
We note a technical change to the FY 2002 calculation. For the FY 2001 wage index calculation, we initially proposed to subtract Line 13 of Worksheet S-3, Part III from total hours when determining the excluded hours ratio used to estimate the amount of overhead attributed to excluded areas (65 FR 26299). However, the formula resulted in large and inappropriate increases in the average hourly wages for some hospitals (65 FR 47074), particularly hospitals that have large overhead and excluded area costs. Therefore, for the final FY 2001 wage index calculation, we reverted to the FY 2000 excluded hours ratio formula, which did not subtract Line 13.
Subsequently, we analyzed how the application of this formula resulted in overstated average hourly wages for some hospitals and how we could improve the overall accuracy of the overhead allocation methodology. We became aware that the problem was not in the excluded hours ratio formula. Rather, our wage index calculation did not also remove the overhead wage-related costs associated with excluded areas, an amount that must be estimated before it can be subtracted from the calculation. The combined effect of applying the excluded hours ratio formula, which appropriately removes salaries of lower-wage, overhead employees, and not subtracting overhead wage-related costs associated with excluded areas, resulted in overstated salary costs and average hourly wages.
For the FY 2002 wage index calculation, we are applying the excluded hours ratio formula that subtracts Part III, Line 13 from total hours. Additionally, for the first time in the wage index calculation, we estimated and subtracted overhead wage-related costs allocated to excluded areas.
After we applied this new calculation, there were still a few hospitals that experienced large increases in their average hourly wages. The intermediaries verified that the hospitals' wage data were accurate, so we kept the data in the wage index calculation. These hospitals primarily function as SNFs, psychiatric hospitals, or rehabilitation hospitals that have few acute care beds. The hospitals' higher average hourly wages reflect the costs of the higher salaried employees that remain in the wage index calculation after we subtract the costs of excluded area and associated overhead employees.
The method used to compute the final FY 2002 wage index follows.
Step 1-As noted above, we based the FY 2002 wage index on wage data reported on the FY 1998 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, 1997 and before October 1, 1998. In addition, we included data from any hospital that had cost reporting periods beginning before October 1997 and reported a cost reporting period covering all of FY 1998. These data were 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 1998 data. We note that, if a hospital had more than one cost reporting period beginning during FY 1998 (for example, a hospital had two short cost reporting periods beginning on or after October 1, 1997 and before October 1, 1998), we included wage data from only one of the cost reporting periods, the longest, 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 latest period in the wage index calculation.
Step 2-Salaries-The method used to compute a hospital's average hourly wage is a blend of 40 percent of the hospital's average hourly wage including all GME and CRNA costs, and 60 percent of the hospital's average hourly wage after eliminating all GME and CRNA costs.
In calculating a hospital's average salaries plus wage-related costs, including all GME and CRNA costs, we subtracted from Line 1 (total salaries) the Part B salaries reported on Lines 3 and 5, home office salaries reported on Line 7, and excluded salaries reported on Lines 8 and 8.01 (that is, direct salaries attributable to skilled nursing facility services, home health services, and other subprovider components not subject to the inpatient prospective payment system). We also subtracted from Line 1 the salaries for which no hours were reported on Lines 2, 4, and 6. To determine total salaries plus wage-related costs, we added to the net hospital salaries the costs of contract labor for direct patient care, certain top management, pharmacy, laboratory, and physician Part A services (Lines 9, 9.01, 9.02, 10, and 10.01), home office salaries and wage-related costs reported by the hospital on Lines 11, 12, and 12.01, and nonexcluded area wage-related costs (Lines 13, 14, 16, 18, 18.01, and 20).
We note that contract labor and home office salaries for which no corresponding hours are reported were not included. In addition, wage-related costs for specific categories of employees (Lines 16, 18, 18.01, and 20) are excluded if no corresponding salaries are reported for those employees (Lines 2, 4, 4.01, and 6, respectively).
We then calculated a hospital's salaries plus wage-related costs by subtracting from total salaries the salaries plus wage-related costs for teaching physicians, Lines (4.01, 10.01, 12.01, and 18.01), Part A CRNAs (Lines 2 and 16), and residents (Lines 6 and 20).
Step 3-Hours-With the exception of wage-related costs, for which there are no associated hours, we computed 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 allocated overhead costs to areas of the hospital excluded from the wage index calculation. First, we determined 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 3, 5, 7, and Part III, Line 13 of Worksheet S-3). We then computed the amounts of overhead salaries and hours to be allocated to excluded areas by multiplying the above ratio by the total overhead salaries and hours reported on Line 13 of Worksheet S-3, Part III. Next, we computed the amounts of overhead wage-related costs to be allocated to excluded areas using three steps: (1) We determined the ratio of overhead hours (Part III, Line 13) to revised hours (Line 1 minus the sum of Lines 3, 5, and 7); (2) we computed overhead wage-related costs by multiplying the overhead hours ratio by wage-related costs reported on Part II, Lines 13, 14, 16, 18, 18.01, and 20; and (3) we multiplied the computed overhead wage-related costs by the above excluded area hours ratio. Finally, we subtracted 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. Using the above method for computing overhead salaries, wage-related costs, and hours to allocate to excluded areas, we also computed these costs excluding all costs associated with GME and CRNAs (Lines 2, 4.01, 6, 10.01, 12.01, and 18.01).
Step 5-For each hospital, we adjusted 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 estimated the percentage change in the employment cost index (ECI) for compensation for each 30-day increment from October 14, 1997 through April 15, 1999 for private industry hospital workers from the Bureau of Labor Statistics' 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. The factors used to adjust the hospital's data were based on the midpoint of the cost reporting period, as indicated below.
| After | Before | Adjustment factor |
|---|---|---|
| 10/14/97 | 11/15/97 | 1.03822 |
| 11/14/97 | 12/15/97 | 1.03561 |
| 12/14/97 | 01/15/98 | 1.03292 |
| 01/14/98 | 02/15/98 | 1.03048 |
| 02/14/98 | 03/15/98 | 1.02828 |
| 03/14/98 | 04/15/98 | 1.02621 |
| 04/14/98 | 05/15/98 | 1.02411 |
| 05/14/98 | 06/15/98 | 1.02200 |
| 06/14/98 | 07/15/98 | 1.01973 |
| 07/14/98 | 08/15/98 | 1.01714 |
| 08/14/98 | 09/15/98 | 1.01424 |
| 09/14/98 | 10/15/98 | 1.01137 |
| 10/14/98 | 11/15/98 | 1.00885 |
| 11/14/98 | 12/15/98 | 1.00669 |
| 12/14/98 | 01/15/99 | 1.00462 |
| 01/14/99 | 02/15/99 | 1.00239 |
| 02/14/99 | 03/15/99 | 1.00000 |
| 03/14/99 | 04/15/99 | 0.99746 |
For example, the midpoint of a cost reporting period beginning January 1, 1998 and ending December 31, 1998 is June 30, 1998. An adjustment factor of 1.01973 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 1998 and covered a period of less than 360 days or more than 370 days, we annualized the data to reflect a 1-year cost report. Annualization is accomplished by dividing the data by the number of days in the cost report and then multiplying the results by 365.
Step 6-Each hospital was assigned to its appropriate urban or rural labor market area before any reclassifications under section 1886(d)(8)(B) or section 1886(d)(10) of the Act. Within each urban or rural labor market area, we added the total adjusted salaries plus wage-related costs obtained in Step 5 (with and without GME and CRNA costs) for all hospitals in that area to determine the total adjusted salaries plus wage-related costs for the labor market area.
Step 7-We divided 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.
Because the FY 2002 wage index is based on a blend of average hourly wages, we then added 40 percent of the average hourly wage calculated without removing GME and CRNA costs, and 60 percent of the average hourly wage calculated with these costs excluded.
Step 8-We added the total adjusted salaries plus wage-related costs obtained in Step 5 for all hospitals in the nation and then divided the sum by the national sum of total hours from Step 4 to arrive at a national average hourly wage (using the same blending methodology described in Step 7). Using the data as described above, the national average hourly wage is $22.3096.
Step 9-For each urban or rural labor market area, we calculated the hospital wage index value by dividing the area average hourly wage obtained in Step 7 by the national average hourly wage computed in Step 8.
Step 10-Following the process set forth above, we developed a separate Puerto Rico-specific wage index for purposes of adjusting the Puerto Rico standardized amounts. (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 added the total adjusted salaries plus wage-related costs (as calculated in Step 5) for all hospitals in Puerto Rico and divided the sum by the total hours for Puerto Rico (as calculated in Step 4) to arrive at an overall average hourly wage of $10.7529 for Puerto Rico. For each labor market area in Puerto Rico, we calculated 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 Public Law 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 may not be less than the area wage index applicable to hospitals located in rural areas in that State. Furthermore, this wage index floor is to be implemented in such a manner as to ensure that aggregate prospective payment system payments are not greater or less than those that would have been made in the year if this section did not apply. For FY 2002, this change affects 217 hospitals in 40 MSAs. The MSAs affected by this provision are identified in Table 4A by a footnote.
F. Revisions to the Wage Index Based on Hospital Redesignation
Under section 1886(d)(8)(B) of the Act, hospitals in certain rural counties adjacent to one or more MSAs are considered to be located in one of the adjacent MSAs if certain standards are met. Under section 1886(d)(10) of the Act, the Medicare Geographic Classification Review Board (MGCRB) considers applications by hospitals for geographic reclassification for purposes of payment under the prospective payment system.
1. Provisions of Public Law 106-554
Section 304 of Public Law 106-554 made changes to several provisions of section 1886(d)(10) of the Act relating to hospital reclassifications and the wage index:
• Section 304(a) amended section 1886(d)(10)(D) of the Act by adding a clause (v) to provide that, beginning with FY 2001, an MGCRB decision on a hospital reclassification for purposes of the wage index is effective for 3 years, unless the hospital elects to terminate the reclassification. Section 304(a) also provides that the MGCRB must use the 3 most recent years' average hourly wage data in evaluating a hospital's reclassification application for FY 2003 and any succeeding fiscal year (section 1886(d)(10)(D)(vi) of the Act).
• Section 304(b) provides that, by October 1, 2001, 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. Section 304(b) further requires that if the Secretary applies a statewide wage index to a State, an application under section 1886(d)(10) of the Act by an individual hospital in that State would not be considered.
We address our policy proposals relating to implementation of these three provisions of sections 304(a) and (b) of Public Law 106-554 in section IV.G. of this final rule. The following discussion of the revisions to the wage index based on hospital redesignations reflects those policies.
2. Effects of Reclassification
The methodology for determining the wage index values for redesignated hospitals is applied jointly to the hospitals located in those rural counties that were deemed urban under section 1886(d)(8)(B) of the Act and those hospitals that were reclassified as a result of the MGCRB decisions under section 1886(d)(10) of the Act. Section 1886(d)(8)(C) of the Act provides that the application of the wage index to redesignated hospitals is dependent on the hypothetical impact that the wage data from these hospitals would have on the wage index value for the area to which they have been redesignated. Therefore, as provided in section 1886(d)(8)(C) of the Act, the wage index values were determined by considering the following:
• If including the wage data for the redesignated hospitals would reduce the wage index value for the area to which the hospitals are redesignated by 1 percentage point or less, the area wage index value determined exclusive of the wage data for the redesignated hospitals applies to the redesignated hospitals.
• If including the wage data for the redesignated hospitals reduces the wage index value for the area to which the hospitals are redesignated by more than 1 percentage point, the 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 area to which the hospitals are redesignated, both the area and the redesignated hospitals receive the combined wage index value.
• The wage index value for a redesignated urban or rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located.
• Rural areas whose wage index values would be reduced by excluding the wage data for hospitals that have been redesignated to another area continue to have their wage index values calculated as if no redesignation had occurred.
• Rural areas whose wage index values increase as a result of excluding the wage data for the hospitals that have been redesignated to another area have their wage index values calculated exclusive of the wage data of the redesignated hospitals.
• Currently, the wage index value for an urban area is calculated exclusive of the wage data for hospitals that have been reclassified to another area.
For the FY 2002 wage index, we include the wage data for a reclassified urban hospital in both the area to which it is reclassified and the MSA where the hospital is physically located. We believe this improves consistency and predictability in hospital reclassification and wage indexes, as well as alleviates the fluctuations in the wage indexes due to reclassifications. For example, hospitals applying to reclassify into another area will know which hospitals' data will be included in calculating the wage index, because even if some hospitals in the area are reclassified, their data will be included in the calculation of the wage index of the area where they are geographically located. Also, in some cases, excluding the data of hospitals reclassified to another MSA could have a large downward impact on the wage index of the MSA in which the hospital is physically located. The negative impact of removing the data of the reclassified hospitals from the wage index calculation could lead to large wage disparities between the reclassified hospitals and other hospitals in the MSA, as the remaining hospitals would receive reduced payments due to a lower wage index. Our approach is to promote consistency and simplify our rules with respect to how we construct the wage indexes of rural and urban areas. As noted above, in the case of rural hospitals redesignated to another area, the wage index of the rural area where the hospitals are geographically located is calculated by including the wage data of the redesignated hospitals (unless doing so would result in a lower wage index).
Finally, we note that the Medicare Payment Advisory Commission (MedPAC), in its March 2001 "Report to the Congress: Medicare Payment Policy," recommended this policy (p. 82). (Section VII. of this preamble includes a discussion of MedPAC's recommendations and our responses.) To illustrate the potential negative impact on hospitals in an area where reclassifications of some hospitals to another area results in a decline in the wage index after the reclassified hospitals are excluded from the wage index calculation, MedPAC points out that hospitals in several MSAs have organized to pay qualifying hospitals not to reclassify. Our policy change in this final rule removes this distorted incentive.
Comment: One commenter had some concerns about the reclassification of rural hospitals. This commenter had two points. The first point was that rural hospitals that seek reclassification to urban areas and end up "empty" because all the urban hospitals have successfully sought reclassification elsewhere continue to be disadvantaged because the rural hospitals continue to compete with the urban hospitals in that area, but those urban hospitals are receiving even higher payments, while the rural hospitals are not receiving the same payments. The commenter believed that the solution to this dilemma is to allow the rural hospitals that seek reclassification to an "empty" MSA to receive the same wage index as the urban hospitals that were able to reclassify out of that MSA, essentially reclassifying both the urban hospitals and the proximate rural hospitals to the same area. One other commenter made this same point about urban hospitals.
The commenter's second point was that, periodically, based on updated census data, new MSAs appear. Sometimes, a rural hospital seeking reclassification to the nearest MSA or rural area is disadvantaged when this occurs because reclassification to the new MSA does not afford the rural hospital the same advantages as reclassification to the MSA to which it formerly sought reclassification, but now is not the closest MSA. The commenter wrote that rural hospitals previously qualified for geographic reclassification to an MSA should retain the option to reclassify to that MSA despite the fact that a closer MSA is created.
Response: First, both rural and, for FY 2002, urban hospitals are advantaged by the fact that we hold all areas harmless when calculating the wage index for hospitals reclassifying into both MSAs and rural areas. While we understand the commenter's point about its competitors, we do not believe that this justifies a "piggyback" effect for reclassification purposes wherein either rural or urban hospitals that obtain reclassification into an empty MSA should then be reclassified again to an area to which these hospitals are not proximate. Since a hospital in this type of situation could not obtain reclassification on its own to the area to which the hospitals that have vacated the MSA have reclassified, we do not believe that it would be appropriate to reclassify them based on the reclassification of another hospital.
Second, a hospital that is not subject to the proximity criteria because it has a special status as either a rural referral center or a SCH already has an advantage over other reclassifying hospitals in that it can utilize a larger radius in seeking reclassification opportunities (under § 412.230(a)(3)). Rural referral centers and SCHs may also reclassify to any MSA to which they qualify under § 412.230(b). We believe these criteria provide adequate opportunity for rural referral centers and SCHs to reclassify.
Comment: Commenters generally supported our proposal to include the wage data for a reclassified urban hospital in both the area to which it is reclassified and the MSA where the hospital is physically located. The commenters expressed that this would provide more stability in the calculation of the wage index, allowing them to plan their budgets from year-to-year with more predictability.
We did not receive any negative comments on this proposal; however, we did receive one additional comment that encouraged us to extend the hold harmless provision to a further degree. This commenter believed that both rural and urban hospitals should benefit from the same hold-harmless policy. In other words, an urban hospital's wage data should be included in the area in which it is physically located if it benefits the area. However, The commenter further stated that, on the other hand, if it benefits the area to exclude that hospital's wage data in the event the hospital successfully seeks reclassification for the wage index to another area, then the hospital's data should be excluded. The commenter believed that some urban areas may be harmed by retaining the wage data of urban hospitals that are reclassifying out of those areas.
Response: We appreciate the commenters' support of our proposal to retain an urban hospital's wage data in the area in which it is physically located, even if that hospital successfully seeks reclassification to another area. As we proposed in the proposed rule, in this final rule we are calculating the wage index for urban areas effective for FY 2002 payments by including the wage data for a reclassified urban hospital in both the area to which it is reclassified and the MSA where the hospital is physically located.
In reference to the commenter who believed that we should apply the same hold-harmless policy to urban hospitals as we do to rural hospitals, we note that the rural hold-harmless policy (as described above) is dictated by section 1886(d)(8)(C)(iii) of the Act. We believe that hospitals continue to compete for services with the hospitals that are grouped with them in their respective MSAs. Therefore, it would be appropriate to continue to calculate the wage index for those areas as if those hospitals had not reclassified to another area. As a result, we intend to implement our policy to hold urban areas harmless to the extent that the wages of the hospitals that are physically located within urban areas will continue to be used in the compilation of the wage index whether or not these hospitals successfully seek reclassification elsewhere.
Comment: Several commenters expressed interest in utilizing the occupational mix data to apply for reclassification for the wage index. These commenters pointed out that, at one time, hospitals did have the option to use occupational mix data to seek reclassification for the wage index as those data were made available by the AHA. In addition to the other applicable criteria for reclassification, a hospital that applied for reclassification for the wage index using this criterion was required to show that its average hourly wage, based on occupational mix data, was 90 percent of the area to which it sought reclassification.
Response: Prior to requests for reclassification effective during FY 1999, a hospital could be reclassified for the wage index by showing that its average hourly wage weighted for occupational categories was at least 90 percent of the average hourly wage of the hospitals in the area to which it sought reclassification (in addition to the other applicable criteria for reclassification). Occupational mix data were available from the AHA; however, the AHA stopped collecting the data in 1993. Therefore, because there was no other suitable source of occupational mix data for hospitals to use, we eliminated the option for using this data effective with reclassification requests for FY 1999 (62 FR 45988).
Section 304(c) of Public Law 106-554 requires that the Secretary must provide 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. These data are to be collected by September 30, 2003. Section 304(c) also requires that the data are to be applied in the wage index by October 1, 2004. At that point, the data will be incorporated into a hospital's average hourly wages. Therefore, the occupational mix data will be reflected in hospital reclassifications for the wage index as it is incorporated into the wage index data. In addition, as soon as viable occupational mix data become available, we will consider providing hospitals with the opportunity to use it to support their reclassification requests.
The wage index values for FY 2002 are shown in Tables 4A, 4B, 4C, and 4F in the Addendum to this final rule. Hospitals that are redesignated should use the wage index values shown in Table 4C. Areas in Table 4C may have more than one wage index value because the wage index value for a redesignated urban or rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located. When the wage index value of the area to which a hospital is redesignated is lower than the wage index value for the rural areas of the State in which the hospital is located, the redesignated hospital receives the higher wage index value; that is, the wage index value for the rural areas of the State in which it is located, rather than the wage index value otherwise applicable to the redesignated hospitals.
As mentioned earlier, section 304(a) of Public Law 106-554 amended section 1886(d)(10)(D) of the Act by adding a new clause (v) to provide that a reclassification of a hospital by the MGCRB for purposes of the wage index is effective for 3 years (instead of 1 year) unless, under procedures established by the Secretary, the hospital elects to terminate the reclassification before the end of the 3-year period. Section 304(a) of Public Law 106-554 also amended section 1886(d)(10)(D) of the Act to specify that, for applications for reclassification for the wage index for FYs 2003 and later, the MGCRB must base any comparison of the average hourly wage of the hospital with the average hourly wage for hospitals in the area in which it is located and the area to which it seeks reclassification, using data from the most recently published hospital wage survey (as of the date of the hospital's application), as well as data from each of the two immediately preceding surveys. (Our policies in this final rule to incorporate the provisions of section 304(a) of Public Law 106-554 in the regulations are addressed in section IV.G. of this final rule).
Consistent with the section 304(a) amendment, Tables 3A and 3B list the 3-year average hourly wage for each labor market area before the redesignation of hospitals, based on FY 1996, 1997, and 1998 wage data. 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 final rule includes the adjusted average hourly wage for each hospital from the FY 1996 and FY 1997 cost reporting periods, as well as the FY 1998 period used to calculate the FY 2002 wage index. Table 2 also shows the 3-year average that the MGCRB will use to evaluate a hospital's application for reclassification for FY 2003 (unless that average hourly wage is later revised in accordance with § 412.63(w)(2)). The 3-year averages are calculated by dividing the sum of the dollars (adjusted to a common reporting period using the method described previously in this section) 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.
Applications for FY 2003 reclassifications are due to the MGCRB by September 4, 2001. (We note that, as of May 21, 2001, the new location and mailing address of the MGCRB and the Provider Reimbursement Review Board (PRRB) is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670. Also, please specify whether the mail is intended for the MGCRB or the PRRB.)
We indicated in the proposed rule that, at the time the proposed wage index was constructed, the MGCRB had completed its review of FY 2002 reclassification requests. The final FY 2002 wage index values incorporate all 643 hospitals redesignated for purposes of the wage index (hospitals redesignated under section 1886(d)(8)(B) or section 1886(d)(10) of the Act for FY 2002. Since publication of the May 4 proposed rule, the number of reclassifications has changed because some MGCRB decisions were still under review by the Administrator and because some hospitals decided to withdraw their requests for reclassification.
Changes to the wage index that resulted from withdrawals of requests for reclassification, wage index corrections, appeals, and the Administrator's review process have been incorporated into the wage index values published in this final rule. The 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 value for the area to which they are redesignated, or a wage index value that includes the data for both the hospitals already in the area and the redesignated hospitals. Further, the wage index value for the area from which the hospitals are redesignated may be affected.
Under § 412.273, hospitals that have been reclassified by the MGCRB were permitted to withdraw their applications within 45 days of the publication of the May 4, 2001 proposed rule. The request for withdrawal of an application for reclassification that would be effective in FY 2002 had to be received by the MGCRB by June 18, 2001. A hospital that requested to withdraw its application may not later request that the MGCRB decision be reinstated.
In addition, because the 3-year effect of the amendment made by section 304(a) of Public Law 106-554 is applicable to reclassifications for FY 2001 (which had already taken place prior to the date of enactment of Public Law 106-554) and because the application process for reclassification for FY 2002 had already been completed by the date of enactment, we are deeming hospitals that are reclassified for purposes of the wage index to one area for FY 2001 and are reclassified for purposes of the wage index or the standardized amount to another area for FY 2002 to be reclassified to the area for which they applied for FY 2002, unless they elected to receive the wage index reclassification they were granted for FY 2001. Consistent with our application withdrawal procedures under § 412.273, we allowed hospitals that wished to receive, for FY 2002, the reclassification they were granted for FY 2001, to withdraw their applications by June 18, 2001 also.
Comment: Two commenters requested us to continue publishing the case-mix index because it assists hospitals in monitoring possible referral center qualifying status and in preparing applications for reclassification to use another area's standardized amount. (We also received numerous telephone calls with this request.)
Response: Prior to this year, the case-mix index was published in Table 3C. This index shows the average DRG relative weight for discharges from a prior fiscal year. Due to the requirement to publish so much additional average hourly wage data in Tables 2, 3A, and 3B, we stopped publishing the case-mix index beginning with the May 4, 2001 proposed rule.
In light of public comments and in balancing the requirements for additional publication of average hourly wage data, we will resume publishing the case-mix index, but not in the Federal Register . Beginning with the publication date of this final rule, we will make the case-mix index for FY 2000 and future fiscal years available on the internet at: http://www.hcfa.gov/medicare/ippsmain.htm. We intend to update the case-mix index at this website to coincide with the publication of the annual proposed and final rules.
3. Statewide Wage Index
As stated earlier, section 304(b) of Public Law 106-554 requires the Secretary to establish, by October 1, 2001, a process (based on the voluntary process utilized by the Secretary under section 1848 of the Act) under which an appropriate statewide entity may apply to have all the geographic areas in the State treated as a single geographic area for purposes of computing and applying a single wage index, beginning in FY 2003. Section 304(b) further requires that, if the Secretary applies a statewide wage index to an area, an application by an individual hospital in that area would not be considered. We believe the reference to the voluntary process utilized by the Secretary under section 1848 of the Act refers to the process whereby we allow a State containing multiple physician fee schedule payment areas (and thus multiple geographic adjustment factors) to voluntarily convert to a single statewide payment area with a single geographic adjustment factor (see § 414.4(b), as discussed in the June 24, 1994 Federal Register (59 FR 32759).
Section IV.G. of this final rule contains our policy for implementing the provisions of section 304(b) in regulations. We are providing that hospitals that seek a statewide geographic reclassification under the amendments made by section 304(b) of Public Law 106-554 must apply to the MGCRB with the same deadlines as other hospitals. An approved application by the MGCRB will mean that the data of all the hospitals in the State will be used in computing and applying the wage index for that State. We are providing that the statewide wage index is applicable for 3 years from the date of approval or until all of the participating hospitals terminate their approved statewide wage index reclassification (effective with the next full fiscal year after their termination request), whichever occurs first.
4. Section 402 of Public Law 106-113
Beginning October 1, 1988, section 1886(d)(8)(B) of the Act required us to treat a hospital located in a rural county adjacent to one or more urban areas as being located in the MSA to which the greatest number of workers in the county commute, if the rural county would otherwise be considered part of an urban area under the standards published in the Federal Register on January 3, 1980 (45 FR 956) for designating MSAs (and for designating NECMAs), and if the commuting rates used in determining outlying counties (or, for New England, similar recognized areas) were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous MSAs (or NECMAs)). Hospitals that met the criteria using the January 3, 1980 version of these OMB standards were deemed urban for purposes of the standardized amounts and for purposes of assigning the wage index.
During FY 1994, we incorporated the revised MSA definitions based on 1990 census population data. As a result, some counties that previously were treated as an adjacent county under section 1886(d)(8)(B) of the Act officially became part of certain MSAs. However, as specified in the Act, we continued to utilize the January 3, 1980 standards. For FY 2000, there were 27 hospitals in 22 counties affected by this provision.
On March 30, 1990, OMB issued revised 1990 standards (55 FR 12154). There has been an increasing amount of interest by the hospital industry in using the 1990 standards as opposed to the 1980 standards to determine which hospitals qualify under the provisions set forth in section 1886(d)(8)(B) of the Act. Section 402 of Public Law 106-113 provides that, with respect to FYs 2001 and 2002, a hospital may elect to have the 1990 standards applied to it for purposes of section 1886(d)(8)(B) and that, beginning with FY 2003, hospitals will be required to use the standards published in the Federal Register by the Director of OMB based on the most recent decennial census.
We worked with staff of the Population Distribution Branch within the Population Division of the Census Bureau to compile a list of hospitals that meet the March 30, 1990 standards using 1990 census population data and information prepared for the Metropolitan Area Standards Review Project. The conditions that must be met for a hospital located in a rural county adjacent to one or more urban areas to be treated as being located in the urban area to which the greatest number of workers in the rural county commute are as follows:
• The rural county would otherwise be considered part of an MSA but for the fact that the rural county does not meet the standard established by OMB relating to the commuting rate of workers between the county and the central county or counties of any adjacent MSA.
• The county would meet the commuting standard if commuting to (and where applicable, from) the central county or central counties of all adjacent MSAs or NECMAs (rather than to just one) were considered.
A county meeting the above commuting standards must also meet the other standards established by OMB for inclusion in an MSA as an outlying county. In order to meet these requirements, the rural county must have a degree of "metropolitan character." "Metropolitan character" is established by meeting one of the following OMB standards, which were published in the Federal Register on March 30, 1990:
a. At least 50 percent of the employed workers residing in the county commute to the central county/counties, and either-
• The population density of the county is at least 25 persons per square mile; or
• At least 10 percent of the population, or at least 5,000 persons, lives in the qualifier urbanized area(s).
b. From 40 to 50 percent of the employed workers commute to the central county/counties, and either-
• The population density is at least 35 persons per square mile; or
• At least 10 percent of the population, or at least 5,000 persons, lives in the qualifier urbanized area(s).
c. From 25 to 40 percent of the employed workers commute to the central county/counties and either the population density of the county is at least 50 persons per square mile, or any two of the following conditions exist:
• Population density is at least 35 persons per square mile.
• At least 35 percent of the population is urban.
• At least 10 percent of the population, or at least 5,000 persons, lives in the qualifier urbanizer area(s).
d. From 15 to 25 percent of the employed workers commute to the central county/counties, the population density of the county is at least 50 persons per square mile, and any two of the following conditions also exist:
• Population density is at least 60 persons per square mile.
• At least 35 percent of the population is urban.
• Population growth between the last two decennial censuses is at least 20 percent.
• At least 10 percent of the population, or at least 5,000 persons, lives in the qualifier urbanized area(s).
Also accepted as meeting this commuting requirement under item d. are:
• The number of persons working in the county who live in the central county/counties is equal to at least 15 percent of the number of employed workers living in the county; or
• The sum of the number of workers commuting to and from the central county/counties is equal to at least 20 percent of the number of employed workers living in the county.
e. From 15 to 25 percent of the employed workers commute to the central county/counties, the population density of the county is less than 50 persons per square mile, and any two of the following conditions also exist:
• At least 35 percent of the population is urban.
• Population growth between the last two decennial censuses is at least 20 percent.
• At least 10 percent of the population, or at least 5,000 persons, lives in the qualifier urbanized area(s).
f. At least 2,500 of the population lives in a central city of the MSA located in the qualifier urbanized area(s).
When we apply the 1990 standards as opposed to 1980 standards, the number of qualifying counties increases from 22 to 31. On the basis of the evaluation of these data, effective for discharges occurring on or after October 1, 2001, hospitals listed in the first column of the following table are considered, for purposes of assigning the inpatient standardized amount and the wage index, to be located in the corresponding urban area in the second column:
| Rural county | MSA |
|---|---|
| Chilton, AL | Birmingham, AL |
| Marshall, AL | Huntsville, AL |
| Talladega, AL | Anniston, AL |
| Bradford, FL | Jacksonville, FL |
| Hendry, FL | West Palm Beach-Boca Raton, FL |
| Putnam, FL | Gainesville, FL |
| Jackson, GA | Athens, GA |
| Christian, IL | Springfield, IL |
| Macoupin, IL | St. Louis, MO-IL |
| Piatt, IL | Champaign-Urbana, IL |
| Brown, IN | Indianapolis, IN |
| Carroll, IN | Lafayette, IN |
| Henry, IN | Indianapolis, IN |
| Jefferson, KS | Topeka, KS |
| Barry, MI | Kalamazoo-Battle Creek, MI |
| Cass, MI | Benton Harbor, MI |
| Ionia, MI | Grand Rapids-Muskegon-Holland, MI |
| Shiawassee, MI | Flint, MI |
| Tuscola, MI | Saginaw-Bay City-Midland, MI |
| Caswell, NC | Greensboro-Winston Salem-High Point, NC |
| Greene, NC | Greenville, NC |
| Harnett, NC | Raleigh-Durham-Chapel Hill, NC |
| Wilson, NC | Rocky Mount, NC |
| Preble, OH | Dayton-Springfield, OH |
| Van Wert, OH | Lima, OH |
| Adams, PA | York, PA |
| Lawrence, PA | Pittsburgh, PA |
| Monroe, PA | Newark, NJ |
| Schuylkill, PA | Reading, PA |
| Jefferson, WI | Milwaukee-Waukesha, WI |
| Walworth, WI | Milwaukee-Waukesha, WI |
There are 14 counties that meet the qualifying criteria using 1990 standards that did not meet the criteria using the 1980 standards. These 14 counties are:
Chilton, AL
Talladega, AL
Bradford, FL
Hendry, FL
Putnam, FL
Jackson, GA
Piatt, IL
Brown, IN
Carroll, IN
Greene, NC
Wilson, NC
Adams, PA
Monroe, PA
Schuylkill, PA.
In addition, when we apply the 1980 standards for three of the counties, the MSA assigned is different from the MSA that would be assigned using the 1990 standards. These counties are as follows:
| Rural county | 1980 MSA designation | 1990 MSA designation |
|---|---|---|
| Ionia, MI | Lansing-East Lansing, MI | Grand Rapids-Muskegon-Holland, MI. |
| Caswell, NC | Danville, VA | Greensboro-Winston Salem-High Point, NC. |
| Harnett, NC | Fayetteville, NC | Raleigh-Durham-Chapel Hill, NC. |
Section 402 of Public Law 106-113 states that hospitals may elect to use either the January 3, 1980 standards or the March 30, 1990 standards for payments during FY 2001 and FY 2002. We are assuming hospitals will elect to go to the MSA resulting in the highest payment amount accounting for the applicable wage indexes and standardized amounts. Based on our analysis, we believe all hospitals in the designated rural counties would benefit by being included in the respective MSAs shown above. Therefore, we proposed to assign the FY 2002 standardized amount and wage index of each respective MSA to the affected hospitals. Hospitals electing not to use the 1990 standards would be required to notify their fiscal intermediary in writing of such election prior to September 1, 2001, in order to allow sufficient time to reflect this change in our payment systems.
We note that five rural counties no longer meet the qualifying criteria when we apply the revised OMB standards. These rural counties are as follows: Indian River, FL; Mason, IL; Owen, IN; Morrow, OH; and Lincoln, WV. For FY 2002, we continue to treat these hospitals as attached to an MSA on the basis of the 1980 standards. Beginning FY 2003, they must meet the 1990 standards to continue to be treated as such.
We stated in the August 1, 2000 final rule that implemented changes to the prospective payment system for FY 2001 that we were in the process of working with OMB to identify the hospitals that would be affected by section 402 of Public Law 106-113 (65 FR 47076). We further indicated we would revise payments to hospitals in the affected counties as soon as data were available. Now that the affected counties have been identified, hospitals in the 14 counties identified above will be offered the opportunity to elect this designation, as previously described. We will provide further information related to this election, including recalculated wage indexes, through a forthcoming program memorandum.
Finally, three hospitals located in counties affected by the revised OMB standards also have been reclassified by the MGCRB. The affected hospitals are listed below. If the hospitals did not wish to be reclassified for FY 2002 based on their new designation as described above, they had to follow the procedures described above for requesting that their application for reclassification be withdrawn.
| Provider No. | 1990 MSA Designation | FY 2002 reclassification, MSA |
|---|---|---|
| 34-0071 | Raleigh-Durham-Chapel Hill, NC | Fayetteville, NC. |
| 34-0124 | Raleigh-Durham-Chapel Hill, NC | Fayetteville, NC. |
| 34-0126 | Rocky Mount, NC | Raleigh-Durham-Chapel Hill, NC (wage index only). |
5. Provisions of the August 1, 2000 Interim Final Rule: Sections 152(a), 153, and 154a) of Public Law 106-113
In the August 1, 2000 interim final rule with comment period, we implemented sections 152(a), 153, and 154(a) of Public Law 106-113. These sections contained provisions under which hospitals in certain counties are deemed to be located in specified areas for purposes of payment under the hospital inpatient prospective payment system, for discharges occurring during FY 2000. For payment purposes, hospitals under section 152(a) are to be treated as though they were reclassified for purposes of both the standardized amount and the wage index. Sections 153 and 154(a) did not affect the standardized amount. In the interim final rule, we calculated FY 2000 wage indexes for hospitals in the affected counties. These wage indexes are listed below. No other hospitals' FY 2000 wage indexes were affected, including those hospitals in the areas to which these affected hospitals were reclassified, as well as nonreclassified hospitals located in the areas from which these hospitals were reclassified.
We also implemented section 152(a), which provided that, for purposes of making payments under section 1886(d) of the Act for FY 2000-
• To hospitals in Iredell County, North Carolina, Iredell County was deemed to be located in the Charlotte-Gastonia-Rock Hill, North Carolina-South Carolina MSA;
• To hospitals in Orange County, New York, Orange County was deemed to be located in the New York, New York MSA;
• To hospitals in Lake County, Indiana and Lee County, Illinois, Lake County and Lee County were deemed to be located in the Chicago, Illinois MSA;
• To hospitals in Hamilton-Middletown, Ohio, Hamilton-Middletown was deemed to be located in the Cincinnati, Ohio-Kentucky-Indiana MSA;
• To hospitals in Brazoria County, Texas, Brazoria County was deemed to be located in the Houston, Texas MSA;
• To hospitals in Chittenden County, Vermont, Chittenden County was deemed to be located in the Boston-Worcester-Lawrence-Lowell-Brockton, Massachusetts-New Hampshire MSA.
In accordance with section 153 of Public Law 106-113, for discharges occurring during FY 2000, the Hattiesburg, Mississippi MSA wage index was recalculated by including the wage data for Wesley Medical Center. In accordance with section 154(a), the Allentown-Bethlehem-Easton, Pennsylvania MSA FY 2000 wage index was recalculated by including the wage data for Lehigh Valley Hospital.
The following table shows the changes to the FY 2000 wage index values for the hospitals in the affected counties. Hospitals affected by section 152(a) of Public Law 106-113 were also considered reclassified for purposes of the standardized amount.
| County or MSA | New MSA (for wage index and standardized amount) | New wage index | New Georgraphic Adjustment Factor (GAF) |
|---|---|---|---|
| Iredell County, NC | 1520 | 0.9434 | 0.9609 |
| Orange County, NY | 5600 | 1.4342 | 1.2801 |
| Lake County, IN | 1600 | 1.0750 | 1.0508 |
| Lee County, IL | 1600 | 1.0750 | 1.0508 |
| Hamilton-Middletown, OH | 1640 | 0.9419 | 0.9598 |
| Brazoria County, TX | 3360 | 0.9388 | 0.9577 |
| Chittenden County, VT | 1123 | 1.1359 | 1.0912 |
| Hattiesburg, MS MSA | 3285 | 0.7634 | 0.8312 |
| Allentown-Bethlehem-Easton, PA MSA | 0240 | 1.0228 | 1.0156 |
G. Requests for Wage Data Corrections
In the May 4, 2000 proposed rule, we stated that, to allow hospitals time to construct the proposed FY 2002 hospital wage index, we would make available in May 2001 a final public data file containing the FY 1998 hospital wage data.
The final wage data file was released on May 4, 2001. As noted above in section III.D. of this preamble, this file included hospitals' cost report data obtained from Worksheet S-3, Parts II and III of their FY 1998 Medicare cost reports. In addition, Table 2 in the Addendum to this final rule contains each hospital's adjusted average hourly wage used to construct the wage index values for the past 3 years, including the FY 1998 data used to construct the final FY 2002 wage index.
Under revised procedures, hospitals were given an opportunity to correct any incorrectly reported FY 1998 wage data on their cost reports and submit complete detailed supporting documentation to their intermediaries by March 9, 2001. Wage data corrections had to be reviewed and verified by the intermediary and transmitted to HCFA on or before April 9, 2001. These deadlines were necessary to allow sufficient time to review and process the data so that the final wage index calculation could be completed for development of the final prospective payment rates in this final rule.
We created the process described above to resolve all substantive wage data correction disputes before we finalize the wage data for the FY 2002 payment rates. Accordingly, hospitals that did not meet the procedural deadlines set forth above were not afforded a later opportunity to submit wage data corrections or to dispute the intermediary'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 later challenge, before the Provider Reimbursement Review Board, HCFA's failure to make a requested data revision (See W. A. Foote Memorial Hospital v. Shalala, No. 99-CV-75202-DT (E.D. Mich. 2001)).
As stated above, the final wage data public use file was released on May 4, 2001. Hospitals had an opportunity to examine both Table 2 of the proposed rule and the May 4 final public use wage data file (which reflected revisions to the data used to calculate the values in Table 2) to verify the data HCFA was using to calculate the wage index. Hospitals had until June 4, 2001, to submit requests to correct errors in the final wage data due to data entry or tabulation errors by the intermediary or HCFA. The correction requests considered at that time were limited to errors in the entry or tabulation of the final wage data that the hospital could not have known about before the release of the final wage data public use file.
If, after reviewing the May 2001 final data file, a hospital believed that its wage data are incorrect due to a fiscal intermediary or HCFA error in the entry or tabulation of the final wage data, it was provided an opportunity to send a letter to both its fiscal intermediary and HCFA, outlining why the hospital believed an error exists and provide all supporting information, including dates. These requests had to be received by us and the intermediaries no later than June 4, 2001.
Changes to the hospital wage data were made in those very limited situations involving an error by the intermediary or HCFA that the hospital could not have known about before its review of the final wage data file. Specifically, neither the intermediary nor HCFA accepted the following types of requests at that stage of the process:
• Requests for wage data corrections that were submitted too late to be included in the data transmitted to HCFA on or before April 9, 2001.
• Requests for correction of errors that were not, but could have been, identified during the hospital's review of the February 2001 wage data file.
• Requests to revisit factual determinations or policy interpretations made by the intermediary or HCFA during the wage data correction process.
Verified corrections to the wage index received timely (that is, by June 4, 2001) are incorporated into the final wage index in this final rule, to be effective October 1, 2001.
Again, we believe the wage data correction process described above provides hospitals with sufficient opportunity to bring errors in their wage data to the intermediary's attention. Moreover, because hospitals had access to the final wage data by early May 2001, they had the opportunity to detect any data entry or tabulation errors made by the intermediary or HCFA before the development and publication of the FY 2002 wage index and its implementation on October 1, 2001. If hospitals availed themselves of this opportunity, the wage index implemented on October 1 should be accurate. Nevertheless, in the event that errors are identified after that date, we retain the right to make midyear changes to the wage index under very limited circumstances.
Specifically, in accordance with § 412.63(w)(2), we may make midyear corrections to the wage index only in those limited circumstances in which a hospital can show (1) that the intermediary or HCFA made an error in tabulating its data; and (2) that the hospital could not have known about the error, or did not have an opportunity to correct the error, before the beginning of FY 2002 (that is, by the June 4, 2001 deadline). As indicated earlier, since a hospital had the opportunity to verify its data, and the intermediary notified the hospital of any changes, we do not foresee any specific circumstances under which midyear corrections would be necessary. However, should a midyear correction be necessary, the wage index-change for the affected area will be effective prospectively from the date the correction is made.
H. Modification of the Process and Timetable for Updating the Wage Index
Although the wage data correction process described above has proven successful in the past for ensuring that the wage data used each year to calculate the wage indexes are generally reliable and accurate, we are concerned about the growing volume of wage data revisions initiated by hospitals during February and the first week of March. We first discussed this issue in the FY 1998 proposed rule (62 FR 29918). At that time, we noted that, in developing the FY 1997 wage index, the wage data were revised between the proposed and final rules for more than 13 percent of the hospitals (approximately 700 of 5,200). Last year, in developing the FY 2001 wage index, the wage data were revised between the proposed and final rules for more than 32 percent of the hospitals (1,605 of 4,950). This year, in developing the FY 2002 wage index, the wage data were revised between the proposed rule and the final rule for 30 percent of the hospitals (1,473 of 4,910).
In the May 4, 2001 proposed rule, we indicated that since hospitals are expected to submit complete and accurate cost report data, and intermediaries review and request hospitals to correct problematic wage data before the data are submitted to HCFA in mid-November, we believed there should be limited revisions at this stage of the process. We reminded the hospital community that the primary purpose of this file is to allow hospitals to verify that we have their correct data on file. However, according to information received from the intermediaries, these late revisions are frequently due to hospitals' lack of responsiveness in providing sufficient information to the intermediaries during the desk reviews (that is, during the intermediary's review of the hospital's cost report).
In the proposed rule, we proposed two changes to the wage index development process and timetable beginning with the FY 2003 wage index. We believed these changes would encourage earlier submissions of wage data revisions by hospitals and would allow intermediaries more time to address the heavy volume of revisions requested after the intermediaries have completed their desk reviews of these data. First, we proposed to release the preliminary wage data file by early January rather than early February. As with the current preliminary file, the January file would include desk reviewed wage data that intermediaries submitted to us by November of the previous year and any timely revisions we received from intermediaries prior to release of the January file. Hospitals would be allowed until early February to submit requests for wage data revisions to their intermediaries. Second, intermediaries would be allowed approximately 8 weeks from the hospitals' deadline for submitting revision requests (that is, until early March) to review and transmit revised wage data to us.
We believed that the proposed revised schedule would improve the quality of the wage index by allowing intermediaries more time to sufficiently review wage data revisions before the data are submitted to us. Further, we believed the proposed revised process would encourage hospitals to submit revisions earlier, so the proposed wage index, from which hospitals base geographic reclassification decisions, is more accurate.
The timetable for developing the annual update to the wage index is as follows (an asterisk indicates no change from prior years):
Mid-November *
All desk reviews for hospitals wage data are completed and revised data transmitted by the fiscal intermediaries to HCRIS.
Early December *
CMS compiles file of wage data, received by mid-November, and sends it to the fiscal intermediaries for verification.
Early January
Edited wage data are available for release to the public.
Early February
Deadline for hospitals to request wage data revisions and provide adequate documentation to support the request.
April/May *
Proposed rule published with 60-day comment period and 45-day withdrawal deadline for hospitals applying for geographic reclassification.
Early April *
Deadline for the fiscal intermediaries to submit all revisions resulting from the hospitals' requests for adjustments (as of early February) (and verification of data submitted as of early January).
Deadline for hospital's to request CMS's intervention in cases where the hospital disagrees with the fiscal intermediary's policy interpretations pertaining to the allowability of particular costs.
Late April *
Fiscal intermediaries will alert hospitals to the availability of the final wage data file for their review and inform hospitals of the June deadline for hospitals to submit correction requests for corrections to errors due to CMS or fiscal intermediary mishandling of the final wage data.
Early May *
Release of final wage data public use file on CMS web page and through public use files office.
Early June *
Deadline for hospitals to submit correction requests to both CMS and the fiscal intermediaries to correct errors due to CMS or fiscal intermediary mishandling of the final wage data.
August 1 *
Publication of the final rule.
October 1 *
Effective date of updated wage index.
Comment: One commenter agreed, in general, with the premise of the proposed revised schedule. The commenter recommended that we publish the preliminary wage data file in August, using data from the hospitals' as-filed cost reports before fiscal intermediaries begin the wage index desk reviews. Hospitals would then have until October 1 to submit requests, along with supporting documentation, to correct errors. The commenter's proposal would give fiscal intermediaries until November 30 to complete the desk review and transmit the wage index data to us. The commenter believed that implementation of the recommended schedule eliminates the fiscal intermediary's duplication of effort (that is, reviewing the data a second time when hospitals request changes after the desk review, and then resubmitting the data to us) that exists in the current process.
Response: We appreciate the commenter's general support for our proposal to revise the wage index schedule, and we will give the commenter's recommended process careful consideration in developing future updates to the wage index. Having received no other comments opposing our proposed schedule, we will implement that schedule, beginning with the FY 2003 wage index. We believe that our revised schedule is a logical step in the evolution of the wage index development process. We will monitor the effectiveness of the revised schedule.
IV. Other Decisions and Changes to the Prospective Payment System for Inpatient Operating Costs and Graduate Medical Education Costs
A. Sole Community Hospitals (SCHs) (§§ 412.63, 412.71, 412.72, 412.73, 412.75, 412.77, and 412.92)
For the benefit of the reader, in this final rule, we are discussing and clarifying many of the rules and policies governing SCHs because of the legislative changes that have occurred in recent years. It has been several years since the SCH criteria have been published in one location. Rather than continue to refer to various Federal Register documents and sections of the Code of Federal Regulations, we are publishing a detailed discussion of these policies, making further changes to incorporate the provisions of sections 213, 302, 303, 304, and 311 of Public Law 106-554, and clarifying other related policies.
Under the hospital inpatient prospective payment system, special payment protections are provided to an 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 (EACH), 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 at § 412.92. To be classified as an SCH, a hospital must either have been designated as an SCH prior to the beginning of the prospective payment system on October 1, 1983, and must be located more than 35 miles from other like hospitals, or the hospital must be located in a rural area and meet one of the following requirements:
• It is located more than 35 miles from other like hospitals.
• It is located between 25 and 35 miles from other like hospitals, and it-
-Serves at least 75 percent of all inpatients, or 75 percent of Medicare beneficiary inpatients, within a 35-mile radius or, if larger, within its service area; or
-Has fewer than 50 beds and would qualify on the basis of serving 75 percent of its area s inpatients except that some patients seek specialized care unavailable at the hospital.
• It is located between 15 and 25 miles from other like hospitals, and because of local topography or extreme weather conditions, the other like hospitals are inaccessible for at least 30 days in each of 2 out of 3 years.
• The travel time between the hospital and the nearest like hospital is at least 45 minutes because of distance, posted speed limits, and predictable weather conditions.
Effective with hospital cost reporting periods beginning on or after April 1, 1990, section 1886(d)(5)(D)(i) of the Act, as amended by section 6003(e) of Public Law 101-239, provides that SCHs are paid based on whichever of the following rates yields the greatest aggregate payment:
• 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.
Effective with hospital cost reporting periods beginning on or after October 1, 2000, section 1886(b)(3)(I)(i) of the Act, as added by section 405 of Public Law 106-113 and amended by section 213 of Public Law 106-554, provides for other options, in addition to the three bulleted options in the above paragraph, for determining which rate would yield the greatest aggregate payment. For discharges for FY 2001 through FY 2003, these additional optional rates are-
• A phase-in blended rate of the updated hospital-specific rate based on FY 1982 costs per discharge and an FY 1996 hospital-specific rate; or
• A phase-in blended rate of the updated hospital-specific rate based on FY 1987 costs per discharge and an FY 1996 hospital-specific rate.
For discharges beginning in FY 2004, the additional optional rate would be 100 percent of the FY 1996 hospital-specific rate.
For each cost reporting period, the fiscal intermediary determines which of the payment options will yield the highest rate of payment. Payments are automatically made at the highest rate using the best data available at the time the fiscal intermediary makes the determination. However, it may not be possible for the fiscal intermediary to determine in advance precisely which of the rates will yield the highest 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. The fiscal intermediary makes a final adjustment at the close of the cost reporting period to determine precisely which of the payment rates would yield the highest payment to the hospital.
If a hospital disagrees with the fiscal intermediary's determination regarding the final amount of program payment to which it is entitled, it has the right to appeal the fiscal intermediary's decision in accordance with the procedures set forth in Subpart R of Part 405, which concern provider payment determinations and appeals.
In calculating a hospital-specific rate for an SCH based on its FY 1996 cost reporting period, we will, to the extent possible, use the same methodology that we used to calculate the hospital-specific rate based on either the FY 1982 or FY 1987 cost reporting period. That methodology is set forth in §§ 412.71, 412.72, 412.73, 412.75 and 412.77.
• If a hospital has a cost reporting period ending in FY 1982, it will be paid a hospital-specific rate based on its FY 1982 costs; or a hospital-specific rate based on its FY 1987 costs; or a hospital-specific rate based on its FY 1996 costs (which, until FY 2004, would be a blend of the greater of the FY 1982 or FY 1987 costs and the FY 1996 costs); or it will be paid based on the Federal rate.
• If a hospital has no cost reporting period ending in FY 1982, it will be paid a hospital-specific rate based on its FY 1987 costs; or a hospital-specific rate based on its FY 1996 costs (which, until FY 2004, would be a blend of its FY 1987 costs and FY 1996 costs); or it will be paid based on the Federal rate.
• If a hospital has no cost reporting period ending in either FY 1982 or FY 1987, it will be paid based on its FY 1996 costs; or it will be paid based on the Federal rate.
• If a hospital has no cost reporting period ending in FY 1982, FY 1987, or FY 1996, it cannot be paid based on a hospital-specific rate; it will be paid based on the Federal rate.
• If a hospital was operating during any or all of FY 1982, FY 1987, or FY 1996, but, for some reason, the cost report records are no longer available, the hospital will be treated as if it had no cost report for the applicable period. Section 1886(b)(3)(C) of the Act specifies the available periods that may be used.
For each SCH, the fiscal intermediary will calculate a hospital-specific rate based on the hospital's FY 1982, FY 1987, or FY 1996 cost report as follows:
• Determine the hospital's total allowable Medicare inpatient operating cost, as stated on the cost report.
• Divide the total Medicare operating cost by the number of Medicare discharges (without adjusting for transfers) in the cost reporting period to determine the base period cost per case.
• In order to take into consideration the hospital's individual case-mix, the base year cost per case is divided by the hospital's case-mix index applicable to the cost reporting period. This step is necessary to adjust the hospital's base period cost for case mix. This is done to remove the effects of case mix from the base period costs per case. Payments using these base period costs are then adjusted to reflect the actual case mix during the payment year. A hospital's case mix is computed based on its Medicare patient discharges subject to DRG-based payment.
The fiscal intermediary will inform each SCH of its hospital-specific rate based on its applicable cost reporting period within 180 days after the start of its cost reporting period.
(The provisions of section 213 of Public Law 106-554 relating to the extension to all SCHs the option to rebase using their FY 1996 operating costs, for cost reporting periods beginning on or after October 1, 2000, were addressed in the June 13, 2001 interim final rule with comment period, and are finalized in this final rule.)
An SCH is also eligible for a payment adjustment if, for reasons beyond its control, it experiences a decline in volume of greater than 5 percent compared to its preceding cost reporting period. This adjustment is also available to hospitals that could qualify as SCHs but choose not to be paid as SCHs; that is, hospitals that qualify and successfully apply to be designated as SCHs but continue to receive payments based on the Federal rate. In addition, section 6003(c)(1) of Public Law 101-239 deleted the sunset date on the 5-percent volume decline adjustment, thus allowing SCHs to receive the adjustment indefinitely. The sunset provision was included under section 1886(d)(5)(C)(ii) of the Act. (Section 6003(c)(1) of Public Law 101-239 amended that provision and redesignated it as section 1886(d)(5)(D) of the Act.)
In the September 1, 1983, issue of the Federal Register (48 FR 39781), we stated that any hospital designated as an SCH would retain that status until it experienced a change in circumstances. Section 6003(e)(3) of Public Law 101-239 specifically stated that any hospital classified as an SCH as of the date of enactment of Public Law 101-239 (December 19, 1989), will retain its SCH status even if the hospital did not meet the criteria established under section 6003(e)(1) of that law. These hospitals are the "grandfathered" SCH hospitals. Therefore, we have continued to allow hospitals designated as SCHs prior to December 19, 1989, to be "grandfathered" under current criteria.
In the June 4, 1991 Federal Register , we stated that a hospital's special status as an SCH would not be retained in light of the hospital's geographic reclassification for purposes of the standardized amount. In the event the hospital's reclassification ceases, it must reapply for special status and must meet all of the applicable qualifying criteria in effect at the time it seeks requalification (56 FR 25482). However, in the event a "grandfathered" SCH was successfully reclassified, it would be reinstated as an SCH if its reclassification ceased.
Section 401(a) of Public Law 106-113 established that any subsection (d) hospital (section 1886(d) of the Act) located in an urban area may be redesignated as being located in a rural area if the hospital meets one of several criteria established by the legislation. One of these criteria is that the hospital could qualify as an SCH if the hospital were located in a rural area. Under this provision, an urban hospital that may have been "grandfathered" as an SCH could now qualify and receive payment as an SCH if it met the criteria of a rural SCH instead of as an urban SCH. Given this extension of SCH eligibility, we no longer believe it is necessary to extend special protection to "grandfathered" SCHs that successfully apply for geographic reclassification through the MGCRB for the standardized amount after their MGCRB reclassification ends. Therefore, a hospital that loses its SCH status through a change in circumstances, such as reclassification through the MGCRB for the standardized amount, will not be reinstated as a SCH unless it can meet all of the SCH qualifying criteria in effect at the time it seeks requalification. This circumstance falls under the provisions of §§ 412.92 (b)(3) and (b)(5), which state that an approved classification as an SCH remains in effect without need for reapproval unless there is a change in the circumstances under which the classification was approved. We believe that a successful reclassification by the MGCRB fits the definition of a change in circumstances.
Because some hospitals may not have understood the effect reclassification would have on their special status, in the May 4 proposed rule we permitted affected hospitals, under existing § 412.273(a), the option to withdraw their applications for reclassification for FY 2002, even if the MGCRB had issued a decision, by submitting a withdrawal request to the MGCRB within 45 days of publication of this proposed rule. Finally, just as a competing hospital that closes leaves an opportunity for an existing hospital to qualify as an SCH, a new hospital that opens in an area with an existing hospital designated as an SCH endangers the SCH status of the existing hospital.
As of October 1, 1997, no designations of hospitals as EACHs can be made. The EACHs designated by CMS before October 1, 1997, will continue to be paid as SCHs for as long as they comply with the terms, conditions, and limitations under which they were designated as EACHs.
Under § 412.92(b)(2), we define the effective dates for several situations in which a hospital gains or gives up SCH status. First, SCH status and the associated payment adjustment is effective 30 days after CMS's written notification to the SCH. Thus, 30 days after the issuance of CMS's notice of approval, the hospital is considered to be an SCH and the payment adjustment is applied to discharges occurring on or after that date.
Second, § 412.92(b)(4)(ii) defines the effective date when a hospital chooses to give up its SCH status. Our policy has always been that an SCH can elect to give up its SCH status at any time by submitting a written request to the appropriate CMS regional office through its fiscal intermediary. The change to fully national rates becomes effective no later than 30 days after the hospital submits its request. We believe that the "no later than 30 days" policy for the effective date for cancelling SCH status is in keeping with the prospective nature of the prospective payment system. In addition, the 30-day timeframe to give up SCH status provides the fiscal intermediaries with enough time to alter their automated payment systems prospectively, thus avoiding expensive and time-consuming reprocessing of claims. The variable timeframe of "no later than 30 days from the date of the hospital's request" also permits the regional office, the fiscal intermediary, and the hospital to select a mutually agreeable date, for example, at the end of a month, to facilitate the change in SCH status. We expect that hospitals will anticipate when they wish to give up SCH status and to submit their requests in sufficient time to permit the 30-day period for making the change.
In addition, § 412.92(b)(2)(ii) defines the effective date of SCH status in the situation where a final and nonappealable administrative or judicial decision reverses CMS's denial of SCH status to a hospital. In this situation, if the hospital's application was submitted on or after October 1, 1983, the effective date will be 30 days after the date of CMS's original written notification of denial.
Under § 412.92(b)(2)(iii), we define retroactive approval of SCH status. If a hospital is granted retroactive approval of SCH status by a final and nonappealable court order or an administrative decision under subpart R of part 405 of the regulations, and it wishes its SCH status terminated prior to the current date (that is, it wishes to be paid as an SCH for a time-limited period, all of which is in the past), it must submit written notice to the CMS regional office through its fiscal intermediary within 90 days of the court order or the administrative decision. This written notice must clearly state that, although SCH status was granted retroactively by the court order or by the administrative decision, the hospital wants this status terminated as of a specific date. If written notice is not received within 90 days of the court order or the administrative decision, SCH status will continue. Written requests to terminate SCH status that are received subsequent to the 90-day period will be effective no later than 30 days after the request is submitted, as discussed above.
Under § 412.92(c)(1), we define mileage. We believe that mileage should continue to be measured by the shortest route over improved roads maintained by any local, State, or Federal government entity for public use. We consider improved roads to include the paved surface up to the front entrance of the hospital because this portion of the distance is utilized by the public to access the hospital. This definition provides consistency with the interpretation of the MGCRB when considering hospital reclassification applications. The MGCRB measures the distance between the hospital and the county line of the area to which it seeks reclassification beginning with the paved area outside the front entrance of the hospital. This provides a consistent, national definition that is easily recognizable for each hospital. Finally, rounding of mileage is not permissible. This is also consistent with the MGCRB definition of mileage (56 FR 25483). In this final rule, we are revising the definition of "miles" under § 412.92(c)(1) to state that an improved road includes the paved surface up to the front entrance of the hospital.
Under § 412.92(c)(2), we define "like" hospital. We consider like hospitals to be those hospitals furnishing short-term acute care. That is, a hospital may not qualify for an SCH classification on the grounds that neighboring hospitals offer specialty services, thereby seeking to exclude close-by competitors as like hospitals, in order to meet the mileage criteria by measuring to a like hospital that is located further away. For example, we believe that competing hospitals within a given area may each have their own specialty services, while all the facilities continue to be considered short-term acute care hospitals. We note that under § 412.92(a)(1)(ii), a hospital with fewer than 50 beds may qualify for SCH status under a special provision if patients that it would normally serve are seeking care elsewhere due to the unavailability of specialty services. This means that, if a hospital can prove that the patients from its service area are seeking specialty services elsewhere (such as, among others, heart surgery, transplants, and burn care), rather than routine care, and, because of that fact, that it otherwise would have met the criteria of section § 412.92(a)(1)(i), it can qualify as an SCH.
We note that § 412.92(b)(1)(iii)(A) retains an outdated reference to "hospitals located within a 50 mile radius of the hospital." With the issuance of the September 1, 1989 Federal Register (54 FR 36481, 36482), the 50 mile radius was determined to be unreasonable and all references should have been changed to 35 miles in accordance with § 412.92(a)(1)(i). In this final rule. we are revising the reference to "a 50 mile radius" in § 412.92(b)(1)(iii)(A) to read "a 35 mile radius".
We note that the travel time and weather conditions criteria set forth in § 412.92(a)(3) were discussed in detail in the September 4, 1990 Federal Register (55 FR 36050 through 36055 and 36162 through 36163).
Under § 412.92(a)(1)(i) and (b)(1)(ii), we define the market area analysis criteria used to determine SCH status. In the May 4, 2001 proposed rule, we discussed several points concerning these requests for SCH status that we proposed to clarify.
First, a hospital seeking an SCH designation based on these criteria must make its initial request to the fiscal intermediary with all the appropriate documents as will be discussed below (§ 412.92(b)(1)(i)). The fiscal intermediary will make a recommendation on the request, based on receipt of all the appropriate documentation and its own investigation and analysis, and that recommendation will be forwarded to the CMS regional office for another level of review and final approval or disapproval. The fiscal intermediary would forward its recommendation to the CMS regional office located in the hospital's area as opposed to the fiscal intermediary's area, if there is a difference in these areas. As discussed above, an approval of the request for SCH status will be effective 30 days after CMS issues the approval letter. If a determination on the request requires the use of data that are available at CMS central office only, upon receipt of the fiscal intermediary's recommendation, the CMS regional office will forward the request and the fiscal intermediary's recommendation to the appropriate contact at CMS central office where the determination will be made.
Second, a hospital must provide patient origin data (the number of patients from each zip code from which the hospital draws inpatients) for all inpatient discharges to document the boundaries of its service area (§ 412.92(b)(1)(ii)(A)). Or, the hospital can request that CMS develop patient origin data to define its service area based on the number of patients from each zip code from which the hospital draws Medicare Part A inpatients (§ 412.92(b)(1)(iii)). Then, the lowest number of zip codes in descending percentage order of Medicare inpatients that meets the 75-percent threshold will be used to represent the hospital's service area. We note that hospitals cannot substitute zip codes elsewhere on the list in order to manipulate the service area. (See Howard Young Medical Center, Inc. v. Shalala , 207 F.3d 437 (7th Cir. 2000).)
Third, the hospital must provide patient origin data from all other hospitals located within a 35-mile radius of it or, if larger, within its service area, to document that no more than 25 percent of either all of the population or the Medicare beneficiaries residing in the hospital's service area and hospitalized for inpatient care were admitted to other like hospitals for care (§ 412.92(b)(1)(ii)(B)). Again, CMS central office can develop patient origin data for other hospitals within the requesting hospital's service area if the hospital is requesting SCH status based on an examination of Medicare Part A inpatient utilization. In either case, the requesting hospital is required to submit a comprehensive list of hospitals located within a 35-mile radius or, if larger, within its service area. This list will be checked by both the fiscal intermediary and CMS. Again, a requesting hospital cannot argue that a competing hospital should be excluded from the service area based on the existence of specialty services at that hospital if both hospitals are short-term acute care facilities. Distances between all reported hospitals will be checked by both the fiscal intermediary and CMS, through electronic geographic mapping services (such as Yahoo or Mapquest) or by physically driving the distance involved.
In addition, data will be analyzed based on the year for which the hospital requests SCH status. Subsequent hospital mergers or terminations will not be taken into consideration in processing the request. For example, if a hospital requests SCH status using data for FY 1999, and that data show that there is a competing hospital in existence that subsequently closed its doors in FY 2000, the data will be analyzed with the terminated hospital in existence, unless the hospital seeking SCH status applies using later data, such as FY 2001. This principle is consistent with how we analyze wage index data. If a terminated hospital has a viable cost report for the year of wage data that is being analyzed to produce the wage index, its data are included as part of the computation.
We received the following comments on our May 4, 2001 proposed rule and the June 13, 2001 interim final rule with comment period:
Comment: Several commenters were concerned with the following issues related to the qualifying criteria for sole community hospitals: (1) Utilizing TAC worksheets or other data sources in order to develop a base year alternative for a new SCH; (2) determining a service area; (3) recognition of hospital mergers and terminations that influence a hospital seeking SCH status; (4) including competing hospitals within a 35-mile radius of the requesting hospital as opposed to a 35-road-mile distance; (5) obtaining patient origin data from competing hospitals, (6) timeliness of SCH approvals; (7) SCH status for hospitals with fewer than 50 beds; (8) CAHs as like hospitals; (9) the effect of wage index reclassifications on a hospital's SCH status; and (10) the use of affidavits and other certifications in verifying time and distance when applying for SCH status.
Response: We would like to reiterate that in the proposed rule we were restating historical and current policy and criteria for SCHs. We were not proposing new SCH policies or criteria, or revisions to existing policies or criteria. Rather, we were striving to publish criteria that has been developed over the past several years in one location for the reader's benefit.
First, we appreciate the input concerning a hospital's access to alternative data when a cost report from a prior year may not be readily available. We will take this comment into consideration in working with the fiscal intermediaries in the future to adjust a SCH's payments.
Second, we believe that, using discharge data available on the MedPAR file, we can accurately determine a hospital's service area based on the zip codes that contain the highest number of discharges for that facility and rank those zip codes accordingly. Several commenters suggested that we use patient destination data that are available in some States and, also, that we not be concerned if these data were not available based on a hospital's cost reporting period. As in other aspects of the Medicare program, we must rely on data that are consistent, verifiable by the fiscal intermediaries, and nationally available so that no one hospital or group of hospitals receives a distinct advantage by using an alternative source of data that is not widely available. Therefore, we believe that it is appropriate to determine the hospital's service area based on Medicare discharges.
Third, if a hospital chooses to have a merger recognized in its request for SCH status, or, likewise, a hospital termination, then it is free to wait until its cost report data reflects these changes. Then, CMS will consider the data in light of these facts.
Fourth, we believe it is reasonable to examine a hospital's competitors within a 35-mile radius. Most competing hospitals will not be at the outer limit of the 35-mile radius, and, if these hospitals are not truly competitors, the discharge data will bear out that fact. Also, we examine a hospital's service area based on discharges within zip code areas, and, often, this will exceed a 35-mile radius. Therefore, we believe the 35-mile radius is reasonable.
Fifth, we realize that obtaining patient origin data from competing hospitals may be a difficult proposition, which is why CMS offers to provide this information for the requesting hospital in § 412.92(b)(1)(iii)(A). CMS' data are based on Medicare discharges.
Sixth, approvals of SCH status are effective prospectively. There are several ways in which a hospital may qualify as a SCH, and fiscal intermediaries are required to collect and examine detailed documentation which sometimes requires the assistance of our regional or central office staff. We appreciate the fact that hospitals are concerned that their applications be approved in a timely manner, and we will make every effort to work diligently with our contractors as well as our regional offices to achieve that goal.
Seventh, a commenter suggested that we should be more specific when defining the criteria under which a hospital with fewer than 50 beds could qualify as an SCH at § 412.92(a)(ii). We will take this into consideration as we develop further criteria in the future. In the meantime, we will continue to work closely with our fiscal intermediaries in approving a hospital's SCH status under this provision.
Eighth, we do not consider CAHs like hospitals to be SCHs. CAHs are generally smaller with a very limited length of stay, while SCHs operate as full-service acute-care hospitals.
Ninth, a hospital's status as an SCH is not affected by a wage index reclassification approved by the MGCRB. A hospital's SCH status is affected by an approval for a standardized amount reclassification only, as a reclassification for purposes of a hospital's base payment rate changes its status for all inpatient hospital prospective payment purposes except the wage index.
Finally, hospitals are encouraged to provide as much documentation as possible to assist the fiscal intermediary and CMS in evaluating requests for SCH status. The more complete the documentation, the quicker a decision can be rendered. If a hospital can provide affidavits or other verification of mileage, distances, competing hospital locations, etc., then it is encouraged to do so.
B. Rural Referral Centers (§ 412.96)
Under the authority of section 1886(d)(5)(C)(i) of the Act, the regulations at § 412.96 set forth the criteria a hospital must meet in order to receive special treatment under the prospective payment system as a rural referral center. For discharges occurring before October 1, 1994, rural referral centers received the benefit of payment based on the other urban amount rather than the rural standardized amount. Although the other urban and rural standardized amounts were the same for discharges beginning with that date, rural referral centers would continue to receive special treatment under both the disproportionate share hospital (DSH) payment adjustment and the criteria for geographic reclassification.
Section 401 of Public Law 106-113 amended section 1886(d)(8) of the Act by adding subparagraph (E), which creates a mechanism, separate and apart from the MGCRB, permitting an urban hospital to apply to the Secretary to be treated as being located in the rural area of the State in which the hospital is located. The statute directs the Secretary to treat a qualifying hospital as being located in the rural area for purposes of provisions under section 1886(d) of the Act. Congress clearly intended hospitals that become rural under section 1886(d)(8)(E) of the Act to receive some benefit as a result. In addition, one of the criteria under section 1886(d)(8)(E) of the Act is that the hospital would qualify as an SCH or a rural referral center if it were located in a rural area. An SCH would be eligible to be paid on the basis of the higher of its hospital-specific rate or the Federal rate. On the other hand, the only benefit under section 1886(d) of the Act for an urban hospital to become a rural referral center would be waiver of the proximity requirements that are otherwise applicable under the MGCRB process, as set forth in § 412.230(a)(3)(i).
In the August 1, 2000 final rule (65 FR 47089), we stated that we believed Congress contemplated that hospitals might seek to be reclassified as rural under section 1886(d)(8)(E) of the Act in order to become rural referral centers so that the hospitals would be exempt from the MGCRB proximity requirement and could be reclassified by the MGCRB to another urban area. Therefore, in that final rule we sought a policy approach that would appropriately address our concern that these urban to rural redesignations not be utilized inappropriately, and that would benefit hospitals seeking to reclassify under the MGCRB process by achieving rural referral center status. (We became aware of several specific hospitals that were rural referral centers for FY 1991, but subsequently lost their status when the county in which they were located became urban, and had expressed their wish to be redesignated as a rural referral center in order to be eligible to reclassify.) Accordingly, in light of section 1886(d)(8)(E) of the Act and the language in the accompanying Conference Report, effective as of October 1, 2000, hospitals located in what is now an urban area, if they were ever a rural referral center, were reinstated to rural referral center status.
In addition, as discussed in 62 FR 45999 and 63 FR 26317, under section 4202 of Public Law 105-33, a hospital that was classified as a rural referral center for FY 1991 is to be classified as a rural referral center for FY 1998 and later years so long as that hospital continued to be located in a rural area and did not voluntarily terminate its rural referral center status. Otherwise, a hospital seeking rural referral center status must satisfy applicable criteria. One of the criteria under which a hospital may qualify as a rural referral center is to have 275 or more beds available for use. A rural hospital that does not meet the bed size requirement can qualify as a rural referral center if the hospital meets two mandatory prerequisites (specifying a minimum case-mix index 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). With respect to the two mandatory prerequisites, a hospital may be classified as a rural referral center if its-
• Case-mix index is at least equal to the lower of the median case-mix index for urban hospitals in its census region, excluding hospitals with approved teaching programs, or the median case-mix index for all urban hospitals nationally; and
• 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.)
1. Case-Mix Index
Section 412.96(c)(1) provides that CMS will establish updated national and regional case-mix index values in each year's annual notice of prospective payment rates for purposes of determining rural referral center status. The methodology we use to determine the national and regional case-mix index values is set forth in regulations at § 412.96(c)(1)(ii). The proposed national case-mix index value for FY 2002 in the May 4 proposed rule included all urban hospitals nationwide, and the proposed regional values for FY 2002 were the median values of urban hospitals within each census region, excluding those with approved teaching programs (that is, those hospitals receiving indirect medical education payments as provided in § 412.105). Those values were based on discharges occurring during FY 2000 (October 1, 1999 through September 30, 2000) and included bills posted to CMS's records through December 2000. (The proposed rule language erroneously cited the period as FY 1999 (October 1, 1998 through September 30, 1999.)
We proposed that, in addition to meeting other criteria, hospitals with fewer than 275 beds, if they are to qualify for initial rural referral center status for cost reporting periods beginning on or after October 1, 2001, must have a case-mix index value for FY 2000 that is at least-
• 1.3286; or
• The median case-mix index value for urban hospitals (excluding hospitals with approved teaching programs as identified in § 412.105) calculated by CMS for the census region in which the hospital is located. (See the table set forth in the May 4, 2001 proposed rule at 66 FR 22687.)Based on the latest data available (FY 2000 bills received through March 31, 2001), in addition to meeting other criteria, hospitals with fewer than 275 beds, if they are to qualify for initial rural referral center status for cost reporting periods beginning on or after October 1, 2001, must have a case-mix index value for FY 2000 that is at least-
• 1.3289; or
• The median case-mix index value for urban hospitals (excluding hospitals with approved teaching programs as identified in § 412.105) calculated by CMS for the census region in which the hospital is located. The final median case-mix values by region are set forth in the following table:
| Region | Case-Mix Index Value |
|---|---|
| 1. New England (CT, ME, MA, NH, RI, VT) | 1.2381 |
| 2. Middle Atlantic (PA, NJ, NY) | 1.2319 |
| 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) | 1.3055 |
| 4. East North Central (IL, IN, MI, OH, WI) | 1.2588 |
| 5. East South Central (AL, KY, MS, TN) | 1.2530 |
| 6. West North Central (IA, KS, MN, MO, NE, ND, SD) | 1.1690 |
| 7. West South Central (AR, LA, OK, TX) | 1.2443 |
| 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) | 1.3275 |
| 9. Pacific (AK, CA, HI, OR, WA) | 1.2991 |
Hospitals seeking to qualify as rural referral centers or those wishing to know how their case-mix index value compares to the criteria should obtain hospital-specific case-mix values from their fiscal intermediaries. Data are available on the Provider Statistical and Reimbursement (PSR) System. In keeping with our policy on discharges, these case-mix index values are computed based on all Medicare patient discharges subject to DRG-based payment.
2. Discharges
Section 412.96(c)(2)(i) provides that CMS will set forth the national and regional numbers of discharges in each year's annual notice of prospective payment rates for purposes of determining rural referral center status. As specified in section 1886(d)(5)(C)(ii) of the Act, the national standard is set at 5,000 discharges. However, in the May 4 proposed rule, we proposed to update the regional standards based on discharges for urban hospitals' cost reporting periods that began during FY 2000 (that is, October 1, 1999 through September 30, 2000). (The proposed rule language erroneously cited the period as FY 1999 (October 1, 1998 through September 30, 1999.) That is the latest year for which we have complete discharge data available.
Therefore, we proposed that, in addition to meeting other criteria, a hospital, if it is to qualify for initial rural referral center status for cost reporting periods beginning on or after October 1, 2001, must have as the number of discharges for its cost reporting period that began during FY 2000 a figure that is at least-
• 5,000; or
• The median number of discharges for urban hospitals in the census region in which the hospital is located. (See the table set forth in the May 4, 2001 proposed rule at 66 FR 22687.)
Based on the latest discharge data available for FY 2000, the final median number of discharges for urban hospitals by census region areas are as follows:
| Region | Number of Discharges |
|---|---|
| 1. New England (CT, ME, MA, NH, RI, VT) | 7,064 |
| 2. Middle Atlantic (PA, NJ, NY) | 8,488 |
| 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA,WV) | 8,562 |
| 4. East North Central (IL, IN, MI, OH, WI) | 7,616 |
| 5. East South Central (AL, KY, MS, TN) | 6,276 |
| 6. West North Central (IA, KS, MN, MO, NE, ND, SD) | 5,210 |
| 7. West South Central (AR, LA, OK, TX) | 6,196 |
| 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) | 8,878 |
| 9. Pacific (AK, CA, HI, OR, WA) | 7,106 |
We reiterate that an osteopathic hospital, if it is to qualify for rural referral center status for cost reporting periods beginning on or after October 1, 2001, must have at least 3,000 discharges for its cost reporting period that began during FY 2000.
We did not receive any comments on the criteria for rural referral centers.
C. Indirect Medical Education (IME) Adjustment (§ 412.105)
1. IME Adjustment Factor Formula Multiplier (Section 111 of Public Law 106-113 and section 302 of Public Law 106-554 and § 412.105(d)(3)).
Section 1886(d)(5)(B) of the Act provides that prospective payment hospitals that have residents in an approved graduate medical education (GME) program receive an additional payment to reflect the higher indirect operating costs associated with GME. The regulations regarding the calculation of this additional payment, known as the indirect medical education (IME) adjustment, are located at § 412.105. The additional payment is based in part on the applicable IME adjustment factor. The IME adjustment factor is calculated using a hospital's ratio of residents to beds, which is represented as r, and a multiplier, which is represented as c, in the following equation: c × [(1 + r).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 302 of Public Law 106-554 amended section 1886(d)(5)(B) of the Act to modify the transition for the IME formula multiplier, or c, that was first established by Public Law 105-33 and revised by Public Law 106-113.
As discussed in the August 1, 2000 final rule and the June 13, 2001 interim final rule with comment period, section 111(a) of Public Law 106-113 revised the formula multiplier for discharges occurring during FY 2001 (established under Public Law 105-33 at 1.6) to 1.54. However, section 302(b) of Public Law 106-554 provides a special payment rule which states that, for discharges occurring on or after April 1, 2001 and before October 1, 2001, IME payments are to be made as if 'c' equaled 1.66, rather than 1.54. The multiplier of 1.54 for the first 6 months of FY 2001 represents a 6.25 percent increase in the level of the IME adjustment for every 10 percent increase in the resident-to-bed ratio, and the multiplier for the second 6 months of FY 2001 represents a 6.75 percent increase in the level of the IME adjustment for every 10 percent increase in the resident-to-bed ratio. This results in an aggregate 6.5 percent increase for every 10 percent increase in the resident-to-bed ratio for FY 2001. Section 547(a)(2) of Public Law 106-554 provides further clarification that these payment increases will not apply to discharges occurring after FY 2001 and will not be taken into account in calculating the payment amounts applicable for discharges occurring after FY 2001. In the June 13 interim final rule, we revised § 412.105(d)(3)(v) to reflect the additional payment provided for discharges occurring during FY 2001 under section 302(b) of Public Law 106-554.
As discussed in the May 4, 2001 proposed rule, section 302(a) of Public Law 106-554 provides that, for discharges occurring during FY 2002, the formula multiplier is 1.6. For discharges occurring during FY 2003 and thereafter, the formula multiplier is 1.35. As explained above, section 302(b) of Public Law 106-554 provides for a special payment rule which states that, for discharges occurring on or after April 1, 2001 and before October 1, 2001, IME payments are to be made as if "c" equaled 1.66 rather than 1.54. The multiplier of 1.6 for FY 2002 represents a 6.5 percent increase for every 10 percent increase in the resident-to-bed ratio. The multiplier for FY 2003 and thereafter (1.35) represents a 5.5-percent increase for every 10-percent increase in the resident-to-bed ratio. In the May 4 proposed rule, we proposed to revise § 412.105(d)(3)(vi) to reflect the change in the formula multiplier for FY 2002 to 1.6 as made by section 302(a) of Public Law 106-554 for discharges occurring during FY 2002. We also proposed to add § 412.105(d)(3)(vii) to incorporate the formula multiplier of 1.35 for discharges occurring on or after October 1, 2002.
We did not receive any comments on the IME formula provisions of the June 13 interim final rule with comment period or the proposed amendments under the May 4 proposed rule. Therefore, we are adopting both changes to § 412.105(d)(3) as final without change.
2. Resident-to-Bed Ratio Cap (§ 412.105(a)(1))
In the May 4, 2001 proposed rule, we indicated that it had come to our attention that there is some misunderstanding about § 412.105(a)(1) regarding the determination of the resident-to-bed ratio that is used in calculating the IME adjustment. Section 4621(b)(1) of Public Law 105-33 amended section 1886(d)(5)(B) of the Act by adding a new clause (vi) to provide that, effective for cost reporting periods beginning on or after October 1, 1997, the resident-to-bed ratio may not exceed the ratio calculated during the prior cost reporting period (after accounting for the cap on the hospital's number of full-time equivalent (FTE) residents). We implemented this policy in the August 29, 1997 final rule with comment period (62 FR 46003) and the May 12, 1998 final rule (63 FR 26323) under regulations at § 412.105(a)(1). Existing § 412.105(a)(1) specifies that "[e]xcept for the special circumstances for affiliated groups and new programs described in paragraphs (f)(1)(vi) and (f)(1)(vii) of this section, for a hospital's cost reporting periods beginning on or after October 1, 1997, this ratio may not exceed the ratio for the hospital's most recent prior cost reporting period." In the May 4 proposed rule, we proposed to clarify § 412.105(a)(1) to add a provision that this ratio may not exceed the ratio for the hospital's most recent prior cost reporting period after accounting for the cap on the number of FTE residents.
In general, the resident-to-bed ratio from the prior cost reporting period, which is to be used as the cap on the resident-to-bed ratio for the current payment cost reporting period, should only include an FTE count subject to the FTE cap on the number of allopathic and osteopathic residents, but is not subject to the rolling average. (An explanation of rolling average appears in section IV.H.3. of this preamble.)
The following illustrates the steps for determining the resident-to-bed ratio for the current payment year cost reporting period and the cap on the resident-to-bed ratio:
Current payment year cost reporting period resident-to-bed ratio:
Step 1. Determine the hospital's number of FTE residents in the current payment year cost reporting period.
Step 2. Compare the number of allopathic and osteopathic FTEs from step 1 to the hospital's FTE cap (§ 412.105(f)(1)(iv)). If the number of allopathic and osteopathic FTEs from step 1 exceeds the FTE cap, replace it with the number of FTEs in the FTE cap. Add any dental and podiatry FTEs from step 1 to the capped allopathic and osteopathic FTE count.
Step 3. Determine the 3-year rolling average of the FTE residents using the FTEs from the current payment year cost reporting period and the prior two cost reporting periods (subject to the FTE cap in each cost reporting period). (Include podiatry and dental residents, and exclude residents in new programs in accordance with § 412.105(f)(1)(iv) and revised (f)(1)(v). Residents in new programs are added to the quotient of the rolling average.)
Step 4. Determine the hospital's number of beds (see § 412.105(b)) in the current payment year cost reporting period.
Step 5. Determine the ratio of the number of FTEs from step 3 to the number of beds from step 4. The lower of this resident-to-bed ratio or the resident-to-bed ratio cap (calculated below) from the immediately preceding cost reporting period is used to calculate the hospital's IME adjustment factor for the current payment year cost reporting period.
Resident-to-bed ratio cap:
Step 1. Determine the hospital's number of FTE residents in its cost reporting period that immediately precedes the current payment year cost reporting period.
Step 2. Compare the number of allopathic and osteopathic FTEs from step 1 to the hospital's FTE cap. If the number of allopathic and osteopathic FTEs from step 1 exceeds the FTE cap, replace it with the number of FTEs in the FTE cap. Add any dental and podiatry FTEs from step 1 to the capped allopathic and osteopathic FTE count. (If there is an increase in the number of FTEs in the current payment year cost reporting period due to a new program or an affiliation agreement, these FTEs are added to FTEs in the preceding cost reporting period after applying the FTE cap.)
Step 3. Determine the hospital's number of beds (§ 412.105(b)) in its cost reporting period that immediately precedes the current payment year cost reporting period.
Step 4. Determine the ratio of the number of FTEs in step 2 to the number of beds in step 3. This ratio is the resident-to-bed ratio cap for the current payment year cost reporting period.
Step 5. Compare the resident-to-bed ratio cap in step 4 to the resident-to-bed ratio in the current payment year cost reporting period. The lower of the resident-to-bed ratio from the current payment year cost reporting period or the resident-to-bed ratio cap from the immediately preceding cost reporting period is used to calculate the hospital's IME adjustment factor for the current payment year cost reporting period.
We note that the resident-to-bed ratio cap is a cap on the resident-to-bed ratio calculated for all residents, including allopathic, osteopathic, dental, and podiatry residents (63 FR 26324, May 12, 1998). However, as described in existing § 412.105(a)(1), the resident-to-bed ratio cap may be adjusted to reflect an increase in the current cost reporting period's resident-to-bed ratio due to residents in a new GME program or an affiliation agreement. While an exception does not apply if the resident-to-bed ratio increases because of an increase in the number of podiatry or dentistry residents or because of a change in the number of beds, the ratio could increase after a one-year delay. An increase in the current cost reporting period's ratio (while subject to the FTE cap on the overall number of allopathic and osteopathic residents) thereby establishes a higher cap for the following cost reporting period.
The following is an example of the application of the cap on the resident-to-bed ratio:
Example-Part 1:
• Assume Hospital A has 50 FTEs in its cost reporting period ending September 30, 1996, thereby establishing an IME FTE resident cap of 50 FTEs.
• In its cost reporting period of October 1, 1996 to September 30, 1997 (the prior year), it has 50 FTEs and 200 beds, so that its resident-to-bed ratio for this period is 50/200 = .25.
• In the (current year) cost reporting period of October 1, 1997 to September 30, 1998 (the first cost reporting period in which the FTE resident cap, the resident-to-bed ratio cap, and the rolling average apply), Hospital A has 50 FTEs and 200 beds.
• Hospital A's FTEs do not exceed its FTE cap, so its current number of FTEs (50) is used to calculate the 2-year rolling average: (50 + 50)/2 = 50.
• The result of the rolling average is used as the numerator of the resident-to-bed ratio. Thus, the resident-to-bed ratio is 50/200 = .25.
• .25 is compared to the resident-to-bed ratio from the prior period of October 1, 1996 to September 30, 1997. Because the FTE resident cap and the rolling average were not yet effective in the period of October 1, 1996 to September 30, 1997, that period s resident-to-bed ratio does not have to be recalculated to account for the FTE resident cap. Accordingly, the resident-to-bed ratio cap for October 1, 1997 to September 30, 1998 is .25.
• Because the resident-to-bed ratio does not exceed the prior year ratio, Hospital A would use the resident-to-bed ratio of .25 to determine the IME adjustment in its cost reporting period of October 1, 1997 to September 30, 1998.
Example-Part 2:
• In the (current year) cost reporting period of October 1, 1998 to September 30, 1999, Hospital A adds 1 podiatric and 1 dental resident, so that it has a total of 52 FTEs and 200 beds. Since the FTE resident cap only includes allopathic and osteopathic residents, Hospital A has not exceeded its FTE resident cap with the addition of a podiatric and a dental resident.
• Accordingly, the (now) 3-year rolling average would be (52 + 50 + 50)/3 = 50.67.
• 50.67 is used in the numerator of the current payment year's resident-to-bed ratio, so that the resident-to-bed ratio is 50.67/200 = .253.
• .253 is compared to the resident-to-bed ratio from the prior year's cost reporting period of October 1, 1997 to September 30, 1998 that is recalculated to account for the FTE resident cap. Because Hospital A did not exceed its FTE resident cap of 50 FTEs in this period of October 1, 1997 to September 30, 1998, the recalculated resident-to-bed ratio would be 50/200 = .25.
• Compare the current year resident-to-bed ratio (.253) to the resident-to-bed ratio cap (.25); .253 does exceed .25.
• Therefore, the resident-to-bed ratio in the period of October 1, 1998 to September 30, 1999 is capped at .25, which is to be used in calculating Hospital A s IME adjustment for October 1, 1998 to September 30, 1999.
Example-Part 3:
• In the cost reporting period of October 1, 1999 to September 30, 2000, Hospital A adds 2 internal medicine residents so that it has a total of 54 FTEs and 200 beds. While podiatric and dental residents are not included in the FTE resident cap, internal medicine residents are included. Hospital A has exceeded its IME FTE resident cap of 50 by 2 FTEs. Thus, 2 FTEs are excluded from the FTE count.
• Accordingly, the rolling average would be (52 + 52 + 50)/3 = 51.33.
• 51.33 is used in the numerator of the resident-to-bed ratio, so that the resident-to-bed ratio is 51.33/200 = .257.
• .257 is compared to the resident-to-bed ratio from October 1, 1998 to September 30, 1999 that is recalculated to only account for the FTE resident cap. The recalculated resident-to-bed ratio would be 50 allopathic or osteopathic FTEs plus 1 podiatric and 1 dental resident, which is 52/200 = .26.
• .26 is the resident-to-bed ratio cap for October 1, 1999 to September 30, 2000. .257 does not exceed .26.
• Therefore, the resident-to-bed ratio in the period of October 1, 1998 to September 30, 1999 is .257, which is to be used in calculating this period s IME adjustment.
If a hospital starts a new GME program, the adjustment to the resident-to-bed ratio cap applies for the period of years equal to the minimum accredited length for each new program started. (For example, for a new internal medicine program, the period of years equals 3; for a new surgery program, the period of years equals 5.) Within these program years, the number of new FTE residents in the current cost reporting period is added to the FTE resident count used in the numerator of the resident-to-bed ratio from the previous cost reporting period. The lower of the resident-to-bed ratio from the current cost reporting period or the adjusted resident-to-bed ratio from the preceding cost reporting period is used to calculate the hospital's IME adjustment for the current cost reporting period. If a hospital subsequently continues to expand its program, the numerator of the resident-to-bed ratio from the preceding cost reporting period would not be adjusted to reflect these additional residents. However, an increase in the ratio of the current cost reporting period would establish a higher cap for the following cost reporting period.
We also proposed to add a provision that the exception for new programs described in § 412.105(f)(1)(vii) applies for the period of years equal to the minimum accredited length for each new program.
Similarly, if a hospital increases the number of FTE residents in the current cost reporting period because of an affiliation agreement, the number of additional FTEs is added to the FTE resident count used in the numerator of the resident-to-bed ratio from the previous cost reporting period. The lower of the resident-to-bed ratio from the current cost reporting period or the adjusted resident-to-bed ratio from the preceding cost reporting period is used to calculate the hospital's IME adjustment for the current cost reporting period.
Comment: Several commenters addressed our clarifications to the regulations at § 412.105(a)(1) regarding the cap on the resident-to-bed ratio. One commenter stated that the explanation in the proposed rule regarding the resident-to-bed ratio was thorough. Another commenter expressed appreciation for the inclusion of examples in the proposed rule's preamble. One commenter noted that, in the proposed rule under step 2 of the example of the calculation of the resident-to-bed ratio cap, we indicate that the lesser of the prior year FTEs or the FTE cap is used in the numerator of the resident-to-bed ratio. The commenter noted that we do not specify that, while the FTE cap only applies to allopathic and osteopathic FTEs, dentistry and podiatry FTEs should be included in the numerator of the resident-to-bed ratio. The commenter asked that we specify that the prior year podiatry and dentistry FTEs must be added to the FTE count used in the resident-to-bed ratio after the FTE cap has been applied.
Response: We agree with the commenter concerning the inclusion of dental and podiatry FTEs in step 2, and we have clarified the language in step 2 of the examples of both the current year resident-to-bed ratio and the resident-to-bed ratio cap calculation in the preamble of this final rule. Specifically, we state, "Compare the number of allopathic and osteopathic FTEs from step 1 to the hospital's FTE cap. If the number of allopathic and osteopathic FTEs from step 1 exceeds the FTE cap, replace it with the FTE cap. Add any dental or podiatry FTEs from step 1 to the capped allopathic and osteopathic FTE count." Furthermore, we are revising the proposed changes to the regulations text at § 412.105(a)(1) to state that ". . . this ratio may not exceed the ratio for the hospital's most recent prior cost reporting period after accounting for the cap on the number of allopathic and osteopathic residents as described in paragraph (f)(1)(iv) of this section, and adding to the capped numerator any dental and podiatric full-time equivalent residents. . . ."
Comment: One commenter noted that, in clarifying the regulations at § 412.105(a)(1) regarding the resident-to-bed ratio cap, we added that the exception to the resident-to-bed ratio cap ". . . for new programs . . . applies for the period of years equal to the minimum accredited length for that type of program " (emphasis added). The commenter asked how we would apply the exception to the resident-to-bed ratio cap in a situation where a hospital has started several new programs with varying minimum accredited lengths.
Response: The exception at proposed § 412.105(a)(1) for new programs allows a hospital to add a full complement of residents and complete the initial cycle of a program before residents in the new programs are included in the application of the resident-to-bed ratio cap. In a situation where a hospital has started several new programs under § 412.105(f)(1)(vii), we would apply the exception to the resident-to-bed ratio cap to each new program individually based on each program's minimum accredited length. For example, if a hospital simultaneously starts a new internal medicine program (which has a minimum accredited length of 3 years) and an anesthesiology program (which has a minimum accredited length of 4 years), the FTE residents in the new internal medicine program will be subject to the resident-to-bed ratio cap in the fourth program year of the internal medicine program, while the anesthesiology FTE residents would still be excluded from the resident-to-bed ratio cap in the fourth program year of the anesthesiology programs. However, in subsequent program years, the anesthesiology FTE residents would be subject to the resident-to-bed ratio cap, as well.
The rules regarding the exception from the rolling average calculation for IME are the same for direct GME. The proposed revised regulations at § 412.105(f)(1)(v) and § 413.86(g)(5) in the May 4, 2001 proposed rule state that FTE residents in a new program are excluded from the rolling average calculation for the period of years equal to the minimum accredited length for the type of program. In this final rule, we are revising the regulations regarding the exceptions to the resident-to-bed ratio cap and the rolling average calculation for both IME and direct GME to clarify that these exceptions apply to each new program individually for which the FTE cap may be adjusted based on each program's minimum accredited length (§ 412.105(a)(1), 412.105(f)(1)(v), and 413.86(g)(5)(v)).
Comment: One commenter asserted that, in the proposed rule, it is inconsistent to account for both the FTE cap and the rolling average count of residents in the current year resident-to-bed ratio, but account for only the FTE cap in the resident-to-bed ratio cap (which is the prior year's ratio). The commenter stated that their willingness to support the proposed rule depended on whether the residency program is increasing or decreasing its FTEs every year.
Response: Section 1886(d)(5)(B)(v)(I) of the Act, as amended by Public Law 105-33, states that the resident-to-bed ratio "may not exceed the ratio of the number of interns and residents, subject to the limit under clause (v), with respect to the hospital for its most recent cost reporting period to the hospital's available beds . . . during that cost reporting period . . ." (emphasis added). Clause (v) is the FTE cap requirement; the statute does not specify clause (vi)(II), which is the rolling average requirement, in relation to the resident-to-bed ratio cap. Accordingly, the implementing regulations require that the resident-to-bed ratio cap should only account for the cap on the number of FTEs.
In addition, we note that the commenter is mistaken in indicating that the rules regarding the determination of the resident-to-bed ratio and the resident-to-bed ratio cap are proposed rules. These rules have been in place based on the statute since the effective date of Public Law 105-33. We simply took the opportunity in the proposed rule published on May 4, 2001 to further clarify our existing policy because we realized that there was some confusion surrounding these rules.
Comment: One commenter noted that, since under the provisions of § 413.86(g)(6)(i), the FTE cap for new programs is established based on the number of residents in the third year of the first program's existence, it follows that the FTE cap on the residents in the new programs is effective in the fourth program year. The commenter asked if the application of the cap is delayed until the expiration of the minimum accredited length of the new programs.
Response: The application of the FTE adjusted caps for new programs under § 413.86(g)(6)(i) and (g)(6)(ii) are not delayed until the expiration of the minimum accredited length of the new programs. Only the application of the resident-to-bed ratio cap for IME and the rolling average for both IME and direct GME are dependent upon the minimum accredited length of each new program. The regulations at § 413.86(g)(6)(i) state that the cap for new programs will be adjusted based on "the product of the highest number of residents in any program year during the third year of the first program's existence for all new residency training programs and the number of years in which residents are expected to complete the program based on the minimum accredited length for the type of program" ( emphasis added ). In general, when a hospital qualifies for a cap adjustment under § 413.86(g)(6)(i), the hospital has three years from the time that a resident first begins training in the first new program to establish its FTE cap. The first day of the fourth program year, the FTE cap on that first program, and any other programs that may have been started within the initial three years of that first program, is permanently established and takes effect.
For example, if a hospital that qualifies for a cap adjustment under § 413.86(g)(6)(i) starts a newly accredited dermatology program on July 1, 2001, and then starts a newly accredited anesthesiology program on July 1, 2002, the cap for both programs, and for the hospital as a whole, will be adjusted as of July 1, 2004, the first day of the fourth program year of dermatology, which is the first program that the hospital started. The hospital's cap will be based on the sum of: (a) The product of the highest number of residents in either PGY1, PGY2, or PGY3 in the third year of the dermatology program and 4 years (the minimum accredited length of dermatology); and (b) the product of the highest number of residents in either PGY1 or PGY2 for the anesthesiology program and 4 years (the minimum accredited length for anesthesiology). Any programs begun after the first program's start date but before the fourth program year of the first program will not have a full 3 years before the hospital's cap is permanently adjusted.
The rules under § 413.86(g)(6)(ii) differ for hospitals that qualify for an FTE cap adjustment for new programs started on or after January 1, 1995 and on or before August 5, 1997. Section 413.86(g)(6)(ii) states that the FTE cap adjustment is "based on the product of the highest number of residents in any program year during the third year of the newly established program and the number of years in which residents are expected to complete the program based on the minimum accredited length for the type of program" (emphasis added). In contrast to hospitals that qualify for a cap adjustment under § 413.86(g)(6)(i), where the cap for the hospital takes effect for all programs in the fourth program year of the first program that was started by the hospital, hospitals that qualify for an FTE cap adjustment under § 413.86(g)(6)(ii) have a full 3 years to grow each new program, as long as those programs all started training residents or received accreditation between January 1, 1995 and on or before August 5, 1997. The adjustment to the cap for each of those new programs would be applied individually, beginning with the first day of the fourth program year of each new program. (We note that rural hospitals that qualify for a cap adjustment under § 413.86(g)(6)(iii) may receive an FTE cap adjustment in the same manner as hospitals that qualify for the cap adjustment under § 413.86(g)(6)(ii), except that rural hospitals may receive this adjustment for programs started after August 5, 1997).
For example, assume a hospital that qualifies for a cap adjustment under § 413.86(g)(6)(ii) started a newly accredited internal medicine program on July 1, 1996, and a newly accredited dermatology program on July 1, 1997. The adjustment to the hospital's FTE cap because of the internal medicine program was effective July 1, 1999 (the first day of the fourth program year of internal medicine), and the cap adjustment resulting from the dermatology program was effective July 1, 2000 (the first day of the fourth program year for dermatology). The hospital's ultimate FTE cap is the sum of the FTE cap based on FTEs in the hospital's most recent cost reporting period ending on or before December 31, 1996, and the cap adjustments for the internal medicine and dermatology programs. (We note that since the internal medicine program began in 1996, depending on the hospital's cost reporting period, a portion of those FTEs may have already been included in the hospital's FTE cap. That portion that was included in the FTE cap must be subtracted from the cap adjustment that was calculated for the internal medicine program to avoid any double counting of the FTEs). The hospital's adjusted cap will be based on the sum of: (a) the product of the highest number of internal medicine residents in either PGY1, PGY2, or PGY3 in the third year of the internal medicine program and three (the minimum accredited length of internal medicine); and (b) the product of the highest number of dermatology residents in either PGY1, PGY2, or PGY3 for the dermatology program and four (the minimum accredited length for dermatology).
In summary, we reiterate that the application of the FTE cap adjustments for new programs is not delayed until the program year in which the minimum accredited length of each program expires. This would even apply to a new program with a minimum accredited length that exceeds 3 years. The FTE cap adjustment takes effect on the first day of the fourth program year of the first new program that was started by hospitals qualifying for a cap adjustment under § 413.86(g)(6)(i). For hospitals qualifying for a cap adjustment under § 413.86(g)(6)(ii) and (g)(6)(iii), the cap adjustments take effect on the first day of the fourth program year of each new program. However, the application of the resident-to-bed ratio cap for IME and the rolling average for both IME and direct GME are dependent upon the minimum accredited length of each new program.
Comment: With regard to the counting of residents for IME payment purposes in nonhospital sites, one commenter stated that although time spent in nonhospital sites may be included in the IME FTE count effective for discharges occurring on or after October 1, 1997, the application of the 1996 FTE cap effectively disallows the current year's FTEs training in the nonhospital site, because the 1996 FTE cap was based on residents training only in the hospital. The commenter added that only those hospitals that are in a position to elect a Medicare affiliation agreement are able to "circumvent" the 1996 FTE limit; those that cannot are "penalized." The commenter further stated that the regulatory intent of allowing nonhospital training time to be counted is not fully met by having only certain hospitals able to affiliate. The commenter recommended that we should allow hospitals to recalculate the 1996 IME FTE cap to include those FTEs training in nonhospital sites, so that hospitals will effectively be able to count residents currently training in nonhospital sites for IME purposes.
Response: The commenter is addressing a provision in Public Law 105-33 that was implemented in regulations at § 412.105(f)(1)(ii)(C). We did not propose any substantive changes to this policy; we simply were correcting an oversight in the regulations text for IME. (Comments on regulations implementing this provision were addressed in the May 12, 1998 final rule (63 FR 26323) and the July 31, 1998 final rule (63 FR 40954).)
3. Conforming Changes (§ 412.105(f)(1)(ii)(C) and (f)(1)(v))
In the August 29, 1997 final rule with comment period (62 FR 46003), the May 12, 1998 final rule (63 FR 26323), and the July 31, 1998 final rule (63 FR 40986), to implement the provisions of Public Law 105-33, we set forth certain policies that affected payment for both direct and indirect GME. Some of these policies related to the FTE cap on allopathic and osteopathic residents, the rolling average, and payment for residents training in nonhospital settings. In the May 4 proposed rule, we indicated that when we amended the regulations under § 413.86 for direct GME, we inadvertently did not make certain conforming changes in § 412.105 for IME. We proposed to make the following conforming changes:
• To revise § 412.105(f)(1)(ii)(C) to specify that, effective for discharges occurring on or after October 1, 1997, the time residents spend training in a nonhospital setting in patient care activities under an approved medical residency training program may be counted towards the determination of full-time equivalency if the criteria set forth at § 413.86(f)(3) or § 413.86(f)(4), as applicable, are met.
• To revise § 412.105(f)(1)(v) to specify that residents in new residency programs are not included in the rolling average for a period of years equal to the minimum accredited length for the type of program.
In addition, we proposed to revise § 412.105(f)(1)(ix) to specify, for IME purposes, a temporary adjustment to a hospital's FTE cap to reflect residents added because of another hospital's closure of its medical residency program (to conform to the May 4, 2001 proposed change for GME discussed in section IV.H.5. of this preamble).
We did not receive any comments on these conforming changes and are adopting them as final.
D. Payments to Disproportionate Share Hospitals (DSH) (Sections 211 and 303 of Public Law 106-554 and § 412.106)
Effective for discharges beginning on or after May 1, 1986, hospitals that serve a disproportionate number of low-income patients (the DSH patient percentage as defined in section 1886(d)(5)(F) of the Act) receive additional payments through the DSH adjustment. Hospitals that meet the DSH patient percentage criteria are entitled to the DSH payment adjustment.
1. Qualifying Thresholds for DSHs
In the June 13, 2001 interim final rule with comment period, we discussed the provisions of section 1886(d)(5)(F)(v) of the Act, as it existed prior to enactment of Public Law 106-554 and under § 412.106(c) of the existing regulations, which provided that a hospital qualified for DSH if the hospital had a DSH patient percentage equal to:
• At least 15 percent for an urban hospital with 100 or more beds or a rural hospital with 500 or more beds;
• At least 40 percent for an urban hospital with fewer than 100 beds;
• At least 45 percent for a rural hospital with 100 beds or fewer, if it is not also classified as an SCH;
• At least 30 percent for a rural hospital with more than 100 beds and fewer than 500 beds or which is classified as an SCH; or
• The hospital has 100 or more beds, is located in an urban area, and receives more than 30 percent of its net inpatient revenues from State and local government sources for the care of indigent patients not eligible for Medicare or Medicaid.
Section 211(a) of Public Law 106-554 amended section 1886(d)(5)(F)(v) to provide that, beginning with discharges occurring on or after April 1, 2001, the qualifying threshold is reduced to 15 percent for all hospitals. Therefore, in the June 13 interim final rule, we revised § 412.106(c) to reflect the change in DSH qualifying threshold percentages.
Comment: Several commenters responded on the subject of the calculation of the DSH payment adjustment. These commenters were concerned about how to apply the threshold changes as of April 1, 2000. They were also concerned about counting days in the calculation when a stay crosses over two cost reporting periods. Finally, these commenters were concerned about counting section 1115 expansion waiver days in the DSH payment adjustment calculation.
Response: Section 211(a) of Public Law 106-554 amended section 1886(d)(5)(F) of the Act to change the qualifying thresholds for the DSH payment adjustment to 15 percent for all hospital types, effective with discharges occurring on or after April 1, 2001. This means that the legislation is effective with discharges occurring on or after April 1, 2001, but not before. Therefore, fiscal intermediaries are required to determine whether a hospital meets the thresholds in place either before or after April 1, 2001, by applying the DSH patient percentage in the formula to each separate period. Days are counted based on the date of discharge. In other words, a hospital stay would be counted in the cost reporting year during which the patient was discharged.
Finally, counting section 1115 expansion waiver days in the DSH payment adjustment calculation was discussed in the August 1, 2000 Federal Register (65 FR 47086). This policy became effective for discharges occurring on or after January 20, 2000. Therefore, it is possible that a hospital will qualify for DSH payments as of January 20, 2000, whereas it did not qualify before January 20, 2000, and it should be paid accordingly. In other words, a hospital in that situation would receive Medicare DSH payments beginning January 20, 2000.
2. Calculation of the DSH Payment Adjustment
Section 211(b) of Public Law 106-554 further amended section 1886(d)(5)(F) to revise the calculation of the DSH payment adjustment for hospitals affected by the revised thresholds as specified in section 211(a) of the Act. In the June 13 interim final rule with comment period, we discussed these adjustments, which are effective for discharges occurring on or after April 1, 2001, as follows:
• Urban hospitals with fewer than 100 beds and whose DSH patient percentage is equal to or greater than 15 percent and less than 19.3 percent receive the DSH payment adjustment determined using the following formula:
(DSH patient percentage - 15) (.65) + 2.5.
• Urban hospitals with fewer than 100 beds and whose DSH patient percentage is equal to or greater than 19.3 percent receive a flat add-on of 5.25 percent.
• Rural hospitals that are both rural referral centers and SCHs receive the DSH payment adjustment determined using the higher of the SCH adjustment or the rural referral center adjustment.
• Rural hospitals that are SCHs and are not rural referral centers and whose DSH patient percentage is equal to or greater than 15 percent and less than 19.3 percent receive the DSH payment adjustment determined using the following formula:
(DSH patient percentage - 15) (.65) + 2.5.
• Rural hospitals that are SCHs and are not rural referral centers and whose DSH patient percentage is equal to or greater than 19.3 percent and less than 30 percent receive a flat add-on of 5.25 percent.
• Rural hospitals that are SCHs and are not rural referral centers and whose DSH patient percentage is equal to or greater than 30 percent receive 10 percent.
• Rural referral centers whose DSH patient percentage is greater than or equal to 15 percent and less than 19.3 percent receive the DSH payment adjustment determined using the following formula:
(DSH patient percentage - 15) (.65) + 2.5.
• Rural referral centers whose DSH patient percentage is equal to or greater than 19.3 percent but less than 30 percent receive a flat add-on of 5.25 percent.
• Rural referral centers whose DSH patient percentage is equal to or greater than 30 percent receive the DSH payment adjustment determined using the following formula:
(DSH patient percentage-30) (.6) + 5.25.
• Rural hospitals with fewer than 500 beds and whose DSH patient percentage is equal to or greater than 15 percent and less than 19.3 percent receive the DSH payment adjustment using the following formula:
(DSH patient percentage-15) (.65) + 2.5.
• Rural hospitals with fewer than 500 beds and whose DSH patient percentage is equal to or greater than 19.3 percent receive a flat add-on of 5.25 percent.
If we calcqulate DSH patient percentages to the hundredth place (our current practice), these payment formulas result in an anomaly for some DSH patient percentages just below 19.3 percent (but greater than 19.2 percent). That is, as the percentage values approach 19.3, the DSH payment adjustment resulting from the formula exceeds 5.25 percent. This would result in a higher DSH payment adjustment for DSH patient percentages just below 19.3 than for percentages of 19.3 and above. We stated in the June 13 interim final rule that, because we believe it would be contrary to the Congress' intent for hospitals with a DSH patient percentage of less than 19.3 percent to receive a greater payment than those hospitals of the same class that have a DSH patient percentage of 19.3 or greater, we were implementing this provision so that, for DSH patient percentages below 19.3 for affected hospitals, the DSH payment adjustment will not exceed 5.25 percent.
In the June 13 interim final rule with comment period, we revised § 412.106(d) to reflect the changes in the disproportionate share adjustment.
3. Percentage Reduction to the DSH Payment Adjustment
Section 1886(d)(5)(F)(ix) of the Act, as amended by section 112 of Public Law 106-113, specifies a percentage reduction in the payments a hospital would otherwise receive under the DSH payment adjustment formula. Prior to enactment of section 303 of Public Law 106-554, the reduction percentages were as follows: 3 percent for FY 2001, 4 percent for FY 2002, and 0 percent for FY 2003 and each subsequent fiscal year.
Section 303 of Public Law 106-554 revised the amount of the percent reductions to 2 percent for discharges occurring in FY 2001, and to 3 percent for discharges occurring in FY 2002. The reduction continues to be 0 percent for FY 2003 and each subsequent fiscal year. Section 303 of Public Law 106-554 contains a special rule for FY 2001: For discharges occurring on or after October 1, 2000 and before April 1, 2001, the reduction is to be 3 percent, and for discharges occurring on or after April 1, 2001 and before October 1, 2001, the reduction is to be 1 percent. Changes made by section 303 with respect to FY 2001 discharges were implemented in the June 13, 2001 interim final rule with comment period.
We are adopting as final the revisions to § 412.106(e) to reflect the change in the percentages made by section 303 of Public Law 106-554 that were included in the May 4, 2001 proposed rule and in the June 13, 2001 interim final rule with comment period. We also are making a technical change in the heading of paragraph (e).
E. Medicare-Dependent, Small Rural Hospitals (Section 404 of Public Law 106-113 and section 212 of Public Law 106-554 and 42 CFR 412.90(j) and 412.108)
Section 6003(f) of the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) added section 1886(d)(5)(G) to the Act and created the category of Medicare-dependent, small rural hospital (MDH) that are eligible for a special payment adjustment under the hospital inpatient prospective payment system. Section 1886(d)(5)(G) of the Act define an MDH as any hospital that meets all of the following criteria:
• The hospital is located in a rural area.
• The hospital has 100 or fewer beds.
• The hospital is not classified as an SCH (as defined at § 412.92).
• In the hospital's cost reporting period that began during FY 1987, not less than 60 percent of its inpatient days or discharges were attributable to inpatients entitled to Medicare Part A benefits. If the cost reporting period is for less than 12 months, the hospital's most recent 12-month or longer cost reporting period before the short period is used.
(For a more detailed discussion, see the April 20, 1990 Federal Register (55 FR 15154)).
As provided by the law, MDHs were eligible for a special payment adjustment under the prospective payment system, effective for cost reporting periods beginning on or after April 1, 1990 and ending on or before March 31, 1993. Hospitals classified as MDHs were paid using the same methodology applicable to SCHs, that is, based on whichever of the following rates yielded the greatest aggregate payment for the cost reporting period:
• The national Federal rate applicable to the hospital.
• The updated hospital-specific rate using FY 1982 cost per discharge.
• The updated hospital-specific rate using FY 1987 cost per discharge.
Section 13501(e)(1) of the Omnibus Budget Reconciliation Act of 1993 (Public Law 103-66) extended the MDH provision through FY 1994 and provided that, after the hospital's first three 12-month cost reporting periods beginning on or after April 1, 1990, the additional payment to an MDH whose applicable hospital-specific rate exceeded the Federal rate was limited to 50 percent of the amount by which the hospital-specific rate exceeded the Federal rate.
Section 4204(a)(3) of Public Law 105-33 reinstated the MDH special payment for discharges occurring on or after October 1, 1997 and before October 1, 2001, but did not revise the qualifying criteria for these hospitals or the payment methodology.
Section 404(a) of Public Law 106-113 extended the MDH provision to discharges occurring on or after October 1, 2002 and before October 1, 2006. In the August 1, 2000 interim final rule with comment period, we revised §§ 412.90(j) and 412.108 to reflect the extension of the MDH program through FY 2006.
As specified in the June 13, 2001 interim final rule with comment period, section 212 of Public Law 106-554 provided that, effective with cost reporting periods beginning on or after April 1, 2001, hospitals have the option to base MDH eligibility on two of the three most recently audited cost reporting periods for which the Secretary has a settled cost report, rather than on the cost reporting period that began during FY 1987. According to section 212, the criteria for at least 60 percent Medicare utilization will be met if in at least "2 of the 3 most recently audited cost reporting periods for which the Secretary has a settled cost report", at least 60 percent of the hospital's inpatient days or discharges were attributable to individuals receiving Medicare Part A benefits.
Hospitals that qualify under this provision are subject to the other provisions already in place for MDHs, that is, the payment methodology as defined in § 412.108(c) and the volume decrease provision as defined in § 412.108(d).
A hospital must notify its fiscal intermediary to be considered for MDH status under this new provision. Any hospital that believes it meets the criteria to qualify as an MDH, based on at least two of its three most recently settled cost reports, must submit a written request to its intermediary. The hospital's request must be submitted within 180 days from the date of the notice of amount of program reimbursement for the cost reporting period in question. The intermediary will make its determination and notify the hospital within 180 days from the date it receives the hospital's request and all of the required documentation.
In the June 13 interim final rule with comment period, we revised § 412.108(a)(1)(iii) to reflect the additional option provided by section 212 of Public Law 106-554.
We received one comment on the proposed regulation change.
Comment: One commenter representing a state hospital association expressed concern regarding the MDH qualifying process outlined in the interim final rule. The commenter questioned the timing of the process, especially that the hospital would be required to apply within 180 days from the date of the notice of program reimbursement and that the fiscal intermediary would have up to 180 days in which to make its decision. The commenter believed that this would not allow hospitals to qualify by the first cost reporting period beginning on or after the April 1, 2001, effective date of the new provision. The commenter also believed that this process would result in a lengthy period of time, perhaps 2-4 years while the cost report settlement and this process plays out. The commenter also believed the determination of whether or not a hospital meets the requirements to become an MDH under this new provision should be handled in manner consistent with that already in place. That is, fiscal intermediaries should automatically determine, using the cost report information they have, whether or not any additional hospitals would now qualify as an MDH under this new criteria, rather than putting the burden on the hospitals to apply for MDH status. The commenter also stated that the fiscal intermediaries require instruction regarding the calculation of the payment rates in order to determine which would most benefit the MDHs. The commenter also believed that the impact analysis understates the number of newly eligible hospitals under the new MDH provision.
Response: We disagree with the commenter that the process for approval of new MDHs could take as long as 2 to 4 years. We do agree with this commenter that hospitals' requests for consideration under this provision need not be limited to requests submitted within 180 days of the issuance of a notice of amount of program reimbursement, and we are deleting this requirement from § 412.108(b). This will eliminate any unintended delay in the time when hospitals could request MDH status. Therefore, hospitals are free to request MDH status at any time. We also are revising the time provided for fiscal intermediaries to make their determination, from 180 days to 90 days. We believe this will provide sufficient time for review while being responsive to the commenter's concern that the process not be too lengthy. Similar to the approval period for SCHs as described above, MDH status and the associated payment adjustment are effective 30 days after written notification to the MDH.
We believe it is most appropriate, and consistent with procedures for SCH and rural referral center designation, to require hospitals to request consideration as a MDH, rather than placing this requirement with the fiscal intermediaries. We will further clarify the MDH policy and process, including the change noted above, through future Program Memoranda.
With respect to the commenter's concern that our impact analysis underestimates the number of newly eligible hospitals under the new provision, we noted in the June 13, 2001 interim final rule with comment period that our most recent data available were 1998, and we were, therefore, unable to estimate the impacts using more recent data. Therefore, the actual impact of this provision may be different as the fiscal intermediaries evaluated hospitals' requests using more recent data.
F. Reclassification of Certain Urban Hospitals as Rural Hospitals (Sections 401(a) and (b) of Public Law 106-113 and 42 CFR 412.63(b), 412.90(e), 412.102, and 412.103)
1. Permitting Reclassification of Certain Urban Hospitals as Rural Hospitals
Under Medicare law, the location of a hospital can affect its payment methodology as well as whether the facility qualifies for special treatment both for operating and for capital payments. Whether a facility is situated in an urban or a rural area will, for example, affect payments based on the wage index values and Federal standardized amounts specific to the area. Similarly, the percentage increase in payments made to hospitals that treat a disproportionate share of low-income patients is based, in part, on its urban/rural status, as are determinations regarding a hospital's qualification as an SCH, rural referral center, critical access hospital (CAH), or other special category of facility. Section 1886(d)(2)(D) of the Act defines an "urban area" as an area within a MSA as defined by the Office of Management and Budget. The same provision defines a "large urban area," with respect to any fiscal year, as an urban area that the Secretary determines (in the publications described in section 1886(e)(5) of the Act before the fiscal year) has a population of more than 1 million as determined based on the most recent available published Census Bureau data. Section 1886(d)(2)(D) of the Act further defines a "rural area" as an area that is outside of a "large" urban area or "other" urban area. Since FY 1995, the average standardized amount for hospitals located in rural areas and "other" urban areas has been equal, as provided for in section 1886(b)(3)(B)(i)(X) of the Act.
Several provisions of the Act provide procedures under which a hospital can apply for reclassification from one geographic area to another. Section 1886(d)(8)(B) of the Act, which provides that if certain conditions are met, the Secretary shall treat a hospital located in a rural county adjacent to one or more urban areas as being located in the urban area to which the greatest number of workers in the county commute. Also, section 1886(d)(10) of the Act established the MGCRB to permit hospitals that are disadvantaged by their geographic classification to obtain a more appropriate classification to the area with which they have the most economic interaction.
In the August 1, 2000 interim final rule with comment period (65 FR 47029), we implemented section 401(a) of Public Law 106-113. Section 401(a) of Public Law 106-113, which amended section 1886(d)(8) by adding a new paragraph (E), directs the Secretary to treat any subsection (d) hospital located in an urban area as being located in the rural area of the State in which the hospital is located if the hospital files an application (in the form and manner determined by the Secretary) and meets one of the following criteria:
• The hospital is located in a rural census tract of an MSA (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 FR 6725));
• The hospital is located in an area designated by any law or regulation of the State as a rural area (or is designated by the State as a rural hospital);
• The hospital would qualify as a rural referral center, or as an SCH if the hospital were located in a rural area; or
• The hospital meets any other criteria specified by the Secretary.
The statutory effective date of this provision is January 1, 2000.
In the August 1, 2000 interim final rule with comment period, we provided a detailed discussion of the development of the Goldsmith Modifications (65 FR 47029). The Goldsmith Modification evolved from an outreach grant program sponsored by the Office of Rural Health Policy of the Health Resources and Services Administration (HRSA) in order to establish an operational definition of rural populations lacking easy geographic access to health services. Using 1980 census data, Dr. Harold F. Goldsmith and his associates created a methodology for identification of rural census tracts that were located within a large metropolitan county of at least 1,225 miles but were so isolated from the metropolitan core by distance or physical features so as to be more rural than urban in character. We utilize data based on 1990 census data, reflecting the most recent Goldsmith modification.
We also included Appendix A of that interim final rule with comment period a listing of the identified urban counties with census tracts that may qualify as rural under the most recent Goldsmith Modification (January 1, 2000). The amendments made by section 401 of Public Law 106-113 enable a hospital located in one of the areas listed in Appendix A of the August 1, 2000 interim final rule with comment period to be treated as if it were situated in the rural area of the State in which it is located.
Additionally, section 401(a) of Public Law 106-113 includes hospitals "* * * located in an area designated by any law or regulation of such State as a rural area (or is designated by such State as a rural hospital)." Since the concept of State "designation" referred to in the parenthetical clause was not explicit enough to provide a clear-cut rule for purposes of implementation, we required that a hospital's designation as rural be in the form of either State law or regulation if it is the basis for a hospital's request for urban to rural reclassification. We believe this will help ensure that the provision is implemented consistently among States.
Finally, a hospital also may seek to qualify for reclassification premised on the fact that, had it been located in a rural area, it would have qualified as a rural referral center or as an SCH. The hospital would need to satisfy the criteria set forth in section 1886(d)(5)(C) of the Act (as implemented in regulations at § 412.96) as a rural referral center, or the criteria set forth in section 1886(d)(5)(D) of the Act (as implemented in regulations at § 412.92) as an SCH.
Although the statute authorizes the Secretary to specify further qualifying criteria for a section 401 reclassification, we did not believe that additional criteria were warranted at the time the August 1, 2002 interim final rule was published. However, we invited comment specifically on whether the criteria in the interim final rule are sufficient at this time, and if not, what additional criteria should be incorporated.
A hospital that is reclassified as rural under section 1886(d)(8)(E) of the Act, as added by section 401(a) of Public Law 106-113, is treated as rural for all purposes of payment under the Medicare inpatient hospital prospective payment system (section 1886(d) of the Act), including standardized amount (§§ 412.60 et seq. ), wage index (§ 412.63), and the DSH payment adjustment calculations (§ 412.106) as of the effective date of the reclassification.
Comment: One commenter addressed policies discussed in the August 1, 2000 interim final rule with comment period. Other commenters addressed our policy to not permit hospitals that are redesignated as rural under section 1886(d)(8)(E) of the Act to be eligible for subsequent reclassifications by the MGCRB.
Response: These policies were addressed in the May 5, 2000 proposed rule (65 FR 26308) and the August 1, 2000 final rule (65 FR 47087) implementing the updates and policy changes to the prospective payment system for FY 2001. We responded to comments on the May 5, 2000 proposed rule in the August 1, 2000 final rule. Because we addressed these concerns in that final rule, we are not readdressing those comments in this final rule.
Comment: An association of physicians commented that the interim final rule with comment period stated that a hospital that is reclassified as rural under this provision must be treated as rural for all purposes of payment under the Medicare inpatient hospital prospective payment system, including standardized amount, wage index, and the DSH payment adjustment. However, the commenter pointed out, graduate medical education is not listed. The commenter urged that these hospitals also be considered rural for purposes of graduate medical education.
Response: Section 1886(d)(8)(E) of the Act provides that affected hospitals are considered rural for purposes of section 1886(d). Therefore, these reclassifications affect payments to a hospital under the IME adjustment, which are made under section 1886(d)(5)(B) of the Act, but not payments for direct GME, which are made under section 1886(h) of the Act.
2. Conforming Changes under Section 401(b) of Public Law 106-113
Section 401(b) of Public Law 106-113 sets forth conforming statutory changes relating to urban to rural reclassifications under section 401(a) of Public Law 106-113:
• Section 401(b)(1) provided that if a hospital is being treated as being located in a rural area under section 1886(d)(8)(E) of the Act (for purposes of section 1886(d) of the Act), the hospital will also be treated under section 1833(t) of the Act as being located in a rural area. This provision was addressed in the final rule for the hospital inpatient prospective payment system published in the Federal Register on August 1, 2000 (65 FR 47087).
• Section 401(b)(2) amended section 1820(c)(2)(B)(i) of the Act by extending the reclassification provisions of section 401(a) to the CAH program. A hospital that otherwise would have fulfilled the requirements for designation as a CAH had it been located in a rural area is now eligible for consideration as a CAH if it is treated as being located in a rural area under section 1886(d)(8)(E) of the Act, as added by section 401(a) of Public Law 106-113. (A list of certain existing hospitals that were identified as being located in Goldsmith areas was included in Appendix B of the August 1, 2000 interim final rule with comment period.) A more detailed discussion of the effect on the CAH program of this provision, as well as additional amendments to section 1820(c)(2)(B)(i) of the Act included in Public Law 106-113, is provided in section VI.B. of this preamble.
3. Application Procedures
The statute provides that a hospital seeking reclassification from urban to rural under section 1886(d)(8)(E) of the Act must submit an application "in a form and manner determined by the Secretary." In the August 1, 2000 interim final rule with comment period, we set forth procedures and requirements for the application for rural reclassification, including application submittal requirements, the filing and effective dates for the application, the procedures for withdrawal of applications, and cancellation of rural reclassification; and the qualifications through the Goldsmith Modification Criteria, by State designation and qualifications as a rural referral center or as an SCH. (See 65 FR 47030 through 47031 for a full discussion of these procedures and requirements.) As of early July 2001, 19 hospitals had taken advantage of this provision.
4. Changes in the Regulations
In the August 1, 2000 interim final rule with comment period, we added a new § 412.103 to incorporate the provisions on the urban to rural reclassification options set forth in section 1886(d)(8)(E) of the Act, as added by section 401(a) of Public Law 106-113, and the application procedures for requesting reclassification.
A formula for transition payments to hospitals located in an area that has undergone geographic reclassification from urban to rural is set forth in section 1886(d)(8)(A) of the Act and implemented in regulations at §§ 412.90 and 412.102. In the interim final rule with comment period, we revised existing §§ 412.63(b)(1) and 412.90(e) and the title of § 412.102 to clarify the distinction between hospital reclassification from urban to rural and the geographic reclassification (or redesignation) of an urban area to rural.
In addition, we revised § 485.610 by redesignating paragraph (b)(4) as paragraph (b)(5) and adding a new paragraph (b)(4) to reflect the conforming provision of section 401(b)(2) of Public Law 106-113.
We did not receive any comments on these changes in the regulations in the interim final rule with comment period and, therefore, are adopting them as final.
G. Medicare Geographic Classification Review Board (MGCRB) (New § 412.235 and Existing §§ 412.256, 412.273, 412.274(b), and 412.276)
With the creation of the MGCRB, beginning in FY 1991, under section 1886(d)(10) of the Act, hospitals could request reclassification from one geographic location to another for the purpose of using the other area's standardized amount for inpatient operating costs or the wage index value, or both (September 6, 1990 interim final rule with comment period (55 FR 36754), June 4, 1991 final rule with comment period (56 FR 25458), and June 4, 1992 proposed rule (57 FR 23631)). Implementing regulations in Subpart L of Part 412 (§§ 412.230 et seq. ) set forth criteria and conditions for redesignations from rural to urban, rural to rural, or from an urban area to another urban area with special rules for SCHs and rural referral centers.
As discussed in section III.F. of this final rule, section 304 of Public Law 106-554 contained several provisions related to the wage index and reclassification decisions made by the MGCRB. In summary, section 304 first establishes that hospital reclassification decisions by the MGCRB for wage index purposes are effective for 3 years, beginning with reclassifications for FY 2001. Second, it provides that the MGCRB must use the 3 most recent years of average hourly wage data in evaluating a hospital's reclassification application for FY 2003 and subsequent years. Third, it provides that an appropriate statewide entity may apply to have all of the geographic areas in a State treated as a single geographic area for purposes of computing and applying the wage index, for reclassifications beginning in FY 2003. In the May 4, 2001 proposed rule, we presented a discussion of how we proposed to implement these three provisions. (Section III.F. of this preamble discusses the application of these policy changes to the development of the final FY 2002 and later wage indexes based on hospital reclassification under the provisions of section 304 of Public Law 106-554.)
1. Three-Year Reclassifications for Wage Index Purposes
Section 304(a) of Public Law 106-554 amended section 1886(d)(10)(D) of the Act by adding clause (v), which provides that, if a hospital is approved for reclassification by the MGCRB for purposes of the wage index, the reclassification is effective for 3 years. The amendment made by section 304(a) is effective for reclassifications for FY 2001 and subsequent years. In addition, the legislation specifies that the Secretary must establish a mechanism under which a hospital may elect to terminate such reclassification during the 3-year period.
Consistent with new section 1886(d)(10)(D)(v) of the Act, in the May 4 proposed rule, we proposed to revise § 412.274(b) to provide under new paragraph (b)(2) that any hospital that is reclassified for a particular fiscal year for purposes of receiving the wage index value of another area would receive that reclassification for 3 years beginning with discharges occurring on the first day (October 1) of the second Federal fiscal year in which a hospital files a complete application. This 3-year reclassification would remain in effect unless the hospital terminates the reclassification under revised procedures that we proposed to establish under new proposed § 412.273(b). The provision would apply to hospitals that are reclassified for purposes of the wage index only, as well as those that are reclassified for both the wage index and the standardized amount. However, in the latter case, only the wage index reclassification would be extended for 2 additional years beyond the 1 year provided for in the existing regulations (3 years total). Hospitals seeking reclassification for purposes of the standardized amount must continue to reapply to the MGCRB on an annual basis.
a. Special Rule for a Hospital that was Reclassified for FY 2001 and FY 2002 to Different Areas
Because the 3-year effect of the amendment made by section 304(a) of Public Law 106-554 is applicable to reclassifications for FY 2001 (which had already taken place prior to the date of enactment of section 304(a) (December 21, 2000)), and because the application process for reclassifications for FY 2002 had already been completed by the date of enactment, we are establishing special procedures for hospitals that are reclassified for purposes of the wage index to one area for FY 2001, and are reclassified for purposes of the wage index or the standardized amount to another area for FY 2002. We are deeming such a hospital to be reclassified to the area for which it applied for FY 2002, unless the hospital elects to receive the wage index reclassification it was granted for FY 2001. Consistent with our procedures for withdrawing an application for reclassification (§ 412.273), we allowed a hospital that wished to receive the reclassification it was granted for FY 2001 to withdraw its FY 2002 application by making a written request to the MGCRB within 45 days of the publication date of the proposed rule (that is, by June 18, 2001). Again, only the wage index reclassification is extended for 2 additional years (3 years total). Hospitals seeking reclassification for purposes of the standardized amount must continue to reapply to the MGCRB on an annual basis.
(We note that, effective May 21, 2001, the new location and mailing address of the MGCRB and the Provider Reimbursement Review Board (PRRB) is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670. Please specify whether the mail is intended for the MGCRB or the PRRB.)
b. Overlapping Reclassifications Are Not Permitted
Under the broad authority delegated to the Secretary by section 1886(d)(10) of the Act, in the May 4 proposed rule, we proposed that a hospital that is reclassified to an area for purposes of the wage index may not extend the 3-year effect of the reclassification under section 304(a) of Public Law 106-554 by subsequently applying for reclassification to the same area for purposes of the wage index for a fiscal year that would be within the 3-year period. For example, if a hospital is reclassified for purposes of the wage index to Area A for FY 2002, is approved to receive Area A's wage index for 3 years (FYs 2002, 2003, and 2004), and reapplies to be reclassified to Area A for FYs 2003, 2004, and 2005 (3 years) for purposes of the wage index, the hospital would not be permitted to receive Area A's wage index for FY 2005 as a result of the reapplication. Instead, we proposed that if the hospital wishes to extend the FY 2002 3-year reclassification for fiscal years beyond FY 2004, it would have to apply for reclassification for FY 2005.
We believe new section 1886(d)(10)(D)(v) of the Act replaces the current annual wage index reclassification cycle with a 3-year reclassification cycle. We believe this policy was intended to provide consistency and predictability in hospital reclassification and wage index data, as well as to alleviate the year-to-year fluctuations in the ability of some hospitals to qualify for reclassification. We do not believe it was intended to be used to extend reclassifications for which hospitals otherwise would not be eligible (by reapplying during the second year of a 3-year reclassification because a hospital fears it may not be eligible for reclassification after its current 3-year reclassification expires).
c. Withdrawals of Applications and Terminations of Approved Reclassifications
(1) General
Under § 412.273(a), a hospital, or group of hospitals, may withdraw its application for reclassification at any time before the MGCRB issues its decision or, if after the MGCRB issues its decision, within 45 days of publication of our annual notice of proposed rulemaking concerning changes to the inpatient hospital prospective payment system and proposed payment rates for the fiscal year for which the application was filed. In the May 4 proposed rule, we proposed that the withdrawal procedures and the applicable timeframes in the existing regulations would apply to hospitals that would receive 3-year reclassification for wage index purposes. For example, if a hospital applied for reclassification to Area A for purposes of the wage index for FY 2002, but wished to withdraw its application, it must have done so prior to the MGCRB issuing a decision on its application or, if the MGCRB issued such a decision, within 45 days of the publication date of the proposed rule (that is, by June 18, 2001). Such a withdrawal, if effective, means that the hospital would not be reclassified to Area A for purposes of the wage index for FY 2002 (and would not receive continued reclassification for FYs 2003 and 2004), unless the hospital subsequently cancels its withdrawal (as discussed below). In other words, a withdrawal, if accepted, prevents a reclassification from ever becoming effective.
On the other hand, a reclassification decision that is terminated upon the request of the hospital has partial effect. Section 1886(d)(10)(D)(v) of the Act, as added by section 304(a) of Public Law 106-554, provides that a reclassification for purposes of the wage index is effective for 3 years "except that the Secretary shall establish procedures under which a . . . hospital may elect to terminate such reclassification before the end of such period." Consistent with section 1886(d)(10)(D)(v) of the Act, we proposed to allow a hospital to terminate its approved 3-year reclassification for 1 or 2 years of the 3-year effective period (§ 412.273(b)). This is a separate action from a reclassification withdrawal, which occurs following the initial decision by the MGCRB. A termination would occur during subsequent years. For example, a hospital that has been reclassified for purposes of the wage index for FY 2001 is also reclassified for FYs 2002 and 2003 (3 years). Such a hospital could terminate its approved reclassification so that the reclassification is effective only for FY 2001, or only for FYs 2001 and 2002. Consistent with the prospective nature of reclassifications, we proposed to not permit a hospital to terminate its approved 3-year reclassification for part of a fiscal year. A termination would be effective for the next fiscal year. In order to terminate an approved 3-year reclassification, we would require the hospital to notify the MGCRB in writing within 45 days of the publication date of the annual proposed rule for changes to the inpatient hospital prospective payment system. A termination, unless subsequently cancelled (as discussed below), is effective for the balance of the 3-year period.
We established a special procedural rule for handling FY 2001 reclassifications. As noted above, the amendments made by section 304(a) of Public Law 106-554 are effective for reclassifications for FYs 2001 and beyond, and reclassification decisions for FY 2001 had already been implemented prior to the date of enactment of section 304(a). We deemed those hospitals that were reclassified for FY 2001 to be reclassified for FYs 2002 and 2003. Therefore, if a deemed hospital that was reclassified for purposes of the wage index for FY 2001 wished to terminate its reclassification for FY 2002 and FY 2003, the hospital had to notify the MGCRB in writing by June 18, 2001 (that is, within 45 days after the publication of the proposed rule).
(2) Cancellation of a Withdrawal of Application or a Termination of an Approved Reclassification
In the May 4 proposed rule, we proposed that if a hospital elects to withdraw its 3-year reclassification application after the MGCRB has issued its decision, it may cancel its withdrawal in a subsequent fiscal year and request the MGCRB to reinstate its reclassification for the remaining fiscal years of the 3-year reclassification period. (This proposal was consistent with our proposal that 3-year reclassification periods may not overlap, as discussed in section IV.G.1.b. of this preamble.) Alternatively, a hospital may apply for reclassification to a different area (that is, an area different from the one to which it was originally reclassified), and if successful, the reclassification effect would be for 3 years.
Similarly, and for the same reasons, we proposed that if a hospital elects to terminate its accepted 3-year reclassification prior to the second or third year of that reclassification, it may cancel that termination and have its original reclassification reinstated for the duration of the original 3-year period. Alternatively, a hospital could apply for reclassification to a different area after terminating a prior 3-year reclassification and receive a new 3-year period of reclassification.
Example 1:
Hospital A files an application and the MGCRB issues a decision to reclassify it to Area B for purposes of wage index for FY 2002 through FY 2004 (3 years). Within 45 days after the publication of the proposed rule, Hospital A withdraws its application. Within the time for applying for a FY 2003 reclassification, Hospital A cancels its withdrawal for classification to Area B. Its reclassification to Area B is reinstated, but only for FYs 2003 and 2004.
Example 2:
Hospital B files an application for reclassification for wage index purposes for FY 2002 through FY 2004 and the MGCRB issues a decision for reclassification to Area C. Within 45 days after publication of the proposed rule, Hospital B withdraws its application. Hospital B does not cancel its withdrawal of the application. Hospital B timely applies and is reclassified to Area D for 3 years, beginning with FY 2003. In this case, the reclassification to Area D would be for FYs 2003 through 2005.
Example 3:
Hospital C is reclassified to Area A for purposes of the wage index for FY 2002, and terminates its 3-year reclassification effective for FYs 2003 and 2004. Within the timeframe for applying for FY 2004 reclassification, Hospital C cancels its termination. Its reclassification to Area A would be reinstated for FY 2004 only.
Example 4:
Hospital D has the same circumstances as Hospital C in Example 3, except that instead of canceling its termination, Hospital D applies and is reclassified to Area B for FY 2004. In this case, the reclassification would be for FYs 2004 through 2006.
d. Special Rules for Group Reclassifications
Section 412.232 discusses situations where all hospitals in a rural county are seeking urban redesignation, and § 412.234 discusses criteria where all hospitals in an urban county are seeking redesignation to another urban county. In these cases, hospitals submit an application as a group, and all hospitals in the county must be a party to the application. The reclassification is effective both for purposes of the wage index and the standardized amount of the area to which the hospitals are reclassified.
Section 304(a) of Public Law 106-554 does not specifically address the group reclassification situations under §§ 412.232 and 412.234. However, we believe that, in the case of hospitals reclassified under these group reclassification procedures, it would be appropriate to extend the 3-year reclassification provision to these situations for the wage index only. In order to be reclassified for the standardized amount during the second and third years of a 3-year reclassification for the wage index, the hospitals located in these counties would have to reapply on an annual basis to the MGCRB either as a group or as individual hospitals and meet the criteria outlined in § 412.232, § 412.234, or § 412.230, as appropriate.
Hospitals that are part of a group reclassification would be able to terminate their 3-year wage index reclassifications in the same manner as described above. If one hospital within the group elects to terminate its 3-year wage index reclassification, the reclassification of other hospitals in the group would be unaffected. The same rules for withdrawing from a group reclassification that are in effect now would continue. That is, all of the hospitals that are party to a group reclassification application must consent for a withdrawal to be approved.
Under section 152(b) of Public Law 106-113, hospitals in certain counties were deemed to be located in specified areas for purposes of payment under the hospital inpatient prospective payment system, for discharges occurring on or after October 1, 2000. For payment purposes, these hospitals are to be treated as though they were reclassified for purposes of both the standardized amount and the wage index. Section 152(b) also requires that these reclassifications be treated for FY 2001 as though they are reclassification decisions by the MGCRB. For purposes of applying the 3-year extension of wage index reclassifications, we proposed to extend section 1886(d)(10)(D)(v) to hospitals reclassified under section 152(b) of Public Law 106-113. These hospitals also would have to apply for the standardized amount on an annual basis to the MGCRB.
e. Administrator Authority to Cancel Inappropriate Reclassification Decisions
In the proposed rule we indicated that, under the provisions of § 412.278(g), the Administrator has the authority to review an inappropriate reclassification decision made by the MGCRB, as discovered by either the hospital or CMS, including 3-year reclassifications in the second and third years. The statement that this authority extended to the second and third years of 3-year reclassification was in error. Under the statute and our regulations, reclassification decisions are unreviewable once they become final. This principle applies to 3-year reclassification decisions. Once such a decision becomes final, it is unreviewable thereafter.
Comment: Several commenters expressed concern that we proposed that a hospital that is reclassified to an area for purposes of the wage index may not extend the 3-year effect of the reclassification under section 304(a) of Public Law 106-554, by subsequently applying for reclassification to the same area for purposes of the wage index for a fiscal year that would be within the 3-year period. These commenters argued that there is nothing in the statutory language that prohibits hospitals that are already approved for 3-year reclassifications from reapplying within that 3-year period to extend their reclassifications into future years. These commenters also pointed out that extending their wage index reclassifications in this way allows them to make budgetary commitments further into the future and fosters a more stable operating environment for their hospitals.
Response: Under section 1886(d)(10) of the Act, the Secretary has broad authority to establish policies and criteria with respect to the evaluation and approval of applications for reclassification. As indicated in the proposed rule, we believe that new section 1886(d)(10)(D)(v) of the Act, as added by section 304(a) of Public Law 106-554, replaces the annual reclassification cycle with a 3-year reclassification cycle. We believe that, if a hospital is already reclassified to a given geographic area for a 3-year period, it is appropriate to avoid expending resources to evaluate an application for reclassification to that same area for the second and third years of the 3-year period. Thus, if a hospital is already reclassified for a given fiscal year, and submits an application for reclassification to the same area for the same year, that application will not be approved. We are adding language to § 412.230(a)(5)(v) in this final rule to specify that an application for reclassification will not be approved under these circumstances.
Comment: One commenter supported our proposal to reclassify a hospital based on its FY 2002 approval unless the hospital notified the MGCRB otherwise by June 18, 2001. This commenter questioned whether or not hospitals would have this same option in future years. In other words, if a hospital successfully sought reclassification to a different area for FY 2003 and then withdrew that reclassification, would that hospital have the option to fall back on the FY 2002 reclassification, or would it then not be reclassified.
Response: We appreciate the commenter's support of our proposal on this issue. This was specifically put in place because the new 3-year reclassification policy was not enacted until well after the reclassification process for FY 2002 was underway. Therefore, some hospitals may have sought reclassification to a different area or for a different purpose than they did for FY 2001, and the option to carry forward a FY 2001 wage index reclassification for 3 years may have changed their decisions.
This policy applies in future years as well. For example, a hospital that successfully seeks reclassification for the wage index for FY 2004 to Area A, then successfully seeks reclassification for FY 2005 for the wage index to Area B, has the option to withdraw its FY 2005 decision, thereby reinstating its FY 2004 decision. However, if the hospital successfully withdraws its FY 2005 decision, the hospital cannot return to its FY 2005 decision without reapplying at a later date.
Comment: Several commenters expressed uncertainty about the timing of the extension of the wage index reclassification for 3 years. Some hospitals had successfully applied for FY 2001 as well as FY 2002 to the same area for the wage index, and it was not clear to these hospitals whether their wage index reclassifications were effective through FY 2003 or through FY 2004.
Response: As noted above, section 304(a) provides for 3-year wage index reclassifications effective with FY 2001 reclassifications. In the case of hospitals reclassified to the same area for both FY 2001 and FY 2002, because hospitals had already submitted their FY 2002 applications prior to enactment of Public Law 106-554, and the MGCRB had already issued its decision on these applications prior to publication of the May 4 proposed rule, we will consider FY 2002 to be the first year of the 3-year reclassification for these hospitals. Therefore, the reclassification period will extend through FY 2004. If a hospital was approved for FY 2001 for a wage index reclassification, but was unsuccessful in seeking a wage index reclassification for FY 2002, then its wage index reclassification would be effective for FY 2001, FY 2002, and FY 2003, and the hospital would have to reapply to seek reclassification for FY 2004.
Comment: One commenter supported our proposal that a hospital could cancel its withdrawal of an approved reclassification for the wage index in a future year in order to reinstate its original MGCRB approval.
Response: We appreciate the commenter's support of our proposal that hospitals reclassified for the wage index that then withdraw that approval have the ability to cancel the withdrawal, in effect reinstating the hospital's original reclassification approval for the wage index. We provided this option so that a hospital that later discovers that the withdrawal of its approved wage index reclassification was disadvantageous would have the ability to reinstate its MGCRB approval for the wage index for the remaining years in the 3-year term. However, a hospital is eligible to revert to its most recent MGCRB approval only.
In addition, the same process applies to cancellations of a withdrawal or termination as applies to requests for withdrawals and terminations. A hospital must request a cancellation of its withdrawal or termination within the 45-day period after the proposed rule is published, and that cancellation will become effective for the following Federal fiscal year.
Comment: Several commenters supported our proposal to extend the 3-year reclassification provision for the wage index to those hospitals that were reclassified for FY 2001 under section 152(b) of Public Law 106-113. While these hospitals did not successfully apply for reclassification through the MGCRB, they were effectively "reclassified" by this legislation, and the commenters believed that it would be correct to extend the 3-year wage index reclassification to this group of hospitals.
Response: We appreciate the commenters' support of our proposal. Section 152(b) of Public Law 106-113 required that the assignment of these hospitals to alternative geographic areas should be treated as if they were decisions of the MGCRB. As a result, these hospitals will be reclassified for the wage index to their designated areas for FY 2002 and FY 2003. They will be required to apply for reclassification to the MGCRB for FY 2004 if they wish to retain this reclassification for subsequent years.
2. Three-Year Average Hourly Wages
Section 304(a) of Public Law 106-554 amended section 1886(d)(10)(D) of the Act by adding clause (vi) which provides that the MGCRB must use the average of the 3 most recent years of hourly wage data for the hospital when evaluating a hospital's request for reclassification. Specifically, the MGCRB must base its evaluation on an average of the average hourly wage for the most recent years for the hospital seeking reclassification and the area to which the hospital seeks to reclassify. This provision is effective for reclassifications for FY 2003 and subsequent years. (Section III.F. of this preamble discusses the development and application of the hospital's 3-year average hourly wage data (Table 2 in the Addendum to this final rule) that the MGCRB will use to evaluate hospitals' applications for reclassifications for FY 2003; and the MSA and statewide rural 3-year average hourly wage data (Tables 3A and 3B in the Addendum to this final rule) for hospital reclassification applications for FY 2003.)
In the May 4, 2001 proposed rule, we proposed to revise §§ 412.230(e)(2) and 412.232(d)(2) to incorporate the provisions of section 1886(d)(10)(D)(vi) of the Act as added by section 304(a) of Public Law 106-554. Specifically, we provided that, for redesignations effective beginning FY 2003, for hospital-specific data, the hospital must provide a 3-year average of its average hourly wages using data from our hospital wage survey used to construct the wage index in effect for prospective payment purposes. For data for other hospitals, we proposed to require hospitals to provide a 3-year average of the average hourly wage in the area in which the hospital is located and a 3-year average of the average hourly wage in the area to which the hospital seeks reclassification. The wage data would be taken from the CMS hospital wage survey used to construct the wage index for prospective payment purposes, as published in Tables 2, 3A, and 3B of this final rule (unless those data are subsequently changed by CMS). The 3-year averages are calculated by dividing the sum of the dollars (adjusted to a common reporting period using the method described in section III. of this final rule) across all 3 years, by the sum of the hours.
Comment: Several commenters responded positively to our proposal to use a 3-year average of the most recent 3 years of average hourly wages based on data from our hospital wage survey used to construct the wage index when evaluating a hospital's request for reclassification. Under the proposal, if data does not exist for all 3 years, the available data within the 3-year period will be used to construct the average.
While it was clear to these commenters that these data will be used to construct the average hourly wage for a hospital applying for reclassification, they noted it was not clear to them whether the 3-year average would also be used for the area in which that hospital is physically located as well as the area to which that hospital seeks reclassification.
Response: We appreciate the commenters' support of our proposal to calculate the 3-year average hourly wage based on the data available during the applicable 3-year period, even if a hospital does not have data in all 3 years.
As noted above, the MGCRB will evaluate applications using the 3-year average hourly wages for hospitals and geographic areas as published in Tables 2, 3A, and 3B of this final rule (unless those data are subsequently changed by CMS).
Comment: One commenter requested that in cases of a change in ownership, a hospital be permitted the option of excluding prior years' wage data submitted by a previous owner for the purpose of calculating the average of the average hourly wages in order to qualify for reclassification. As a result, the average of the average hourly wages would be based on current and prior year data submitted by the new owner only.
Response: We believe we should treat these cases in a manner consistent with how we treat hospitals whose ownership has changed for other Medicare payment purposes. That is, where a hospital has simply changed ownership and the new owners have acquired the assets and liabilities of the previous owners, all of the applicable wage data associated with that hospital are included in the calculation of its 3-year average hourly wage. On the other hand, in the case of a new hospital, where there is no legal obligation to the operations of a predecessor hospital, the wage data associated with the previous hospital's provider number would not be used in calculating the new hospital's 3-year average hourly wage.
3. Statewide Wage Index
As stated earlier, section 304(b) of Public Law 106-554 provides for a process under which an appropriate statewide entity may apply to have all the geographic areas in the State treated as a single geographic area for purposes of computing and applying the area wage index for reclassifications beginning in FY 2003.
Section 304 does not indicate the duration of the application of these statewide wage indexes. However, it should be noted that the statutory language does refer to these applications as reclassifications. In the May 4, 2001 proposed rule, we proposed that these statewide wage index applications be processed similar to MGCRB applications, with the same effective dates of the decisions and the withdrawal and termination process. Therefore, similar to wage index reclassification decisions under section 1886(d)(10)(D)(v) of the Act as added by section 304(a) of Public Law 106-554, the statewide wage index reclassification would be effective for a total of 3 years. The same deadlines and timetable applicable to MGCRB reclassification applications would apply for statewide wage index applications.
We proposed to establish a new § 412.235 to include the requirements for statewide wage indexes. We proposed to apply the following criteria to determine whether hospitals would be approved for a statewide geographic wage index reclassification (§ 412.235(a)):
• There must be unanimous support for a statewide wage index among hospitals in the State in which the statewide wage index would be applied. We would require a signed affidavit on behalf of all the hospitals in the State of this support as part of the application for reclassification.
• All hospitals in the State must apply through a signed single application for the statewide wage index in order for the application to be considered by the MGCRB. We believe this is necessary to ensure that every hospital in the State is included in the application, since the payment of every hospital would be affected by the statewide wage index.
• There must be unanimous support for the termination or withdrawal of a statewide wage index among hospitals in the State in which the statewide wage index would be applied. We would require a signed affidavit for this agreement.
• All hospitals in the State waive their rights to any wage index that they would otherwise receive absent the statewide wage index, including a wage index that any of the hospitals might have received through individual or group geographic reclassification under § 412.273(a).
An individual hospital within the State may receive a wage index that could be higher or lower under the statewide wage index reclassification in comparison to its wage index otherwise (§ 412.235(b)). Specifically, hospitals must be aware that there may be a reduction in the wage index as a result of participation on a statewide basis.
In addition, we proposed to consider statewide wage index applications under the same process we use for hospital reclassification applications, including the effective dates of the MGCRB decision and the withdrawal and termination process (§ 412.235(c)). We proposed that applications for the statewide wage index would be effective for 3 years beginning with discharges occurring on the first day (October 1) of the second Federal fiscal year following the Federal fiscal year in which the hospitals file a complete application unless all of the participating hospitals withdraw their application or terminate their approved statewide wage index reclassification earlier, as discussed below. Once approved by the MGCRB, an application for a statewide wage index can only be withdrawn or terminated as a result of a signed affidavit on behalf of all the hospitals in the State indicating their request that the statewide reclassification be withdrawn or terminated. A request for withdrawal or termination must be submitted within 45 days of the publication of the annual proposed rule for the inpatient hospital prospective payment system announcing the reclassification. New hospitals that open prior to the September 1 deadline for submitting an application for a statewide wage index, but after a group application has been submitted, would be required to agree to the statewide wage index in order for the group application to remain viable. New hospitals that open after the deadline for submitting an application would receive the statewide wage index. The agreement of new hospitals would also be required in order to withdraw or terminate a statewide wage index reclassification. The rules discussed under section IV.G.1.c. of this preamble for withdrawals of applications and terminations of approved 3-year wage index reclassification decisions would apply to decisions regarding statewide wage index reclassifications.
Comment: Several commenters believed that Washington, DC should be recognized as a State for purposes of this statewide wage index reclassification policy. However, they were concerned that, while such a recognition may benefit hospitals located in Washington, DC, it may not benefit hospitals that are currently located outside of Washington, DC but within the Washington, D.C.-MD-VA-WV MSA. As a result, while these commenters believed that Washington, DC should be recognized as a State for this purpose, they also requested guidance about how the remainder of the hospitals in the current MSA would be treated.
One commenter did not believe that Washington, DC should be considered a State for this purpose. However, this commenter also stated that, should we decide that Washington, DC could be considered a State for this purpose, we should configure the criteria such that none of the hospitals that are currently located in the Washington, D.C.-MD-VA-WV MSA would be harmed.
Response: Section 304(b) of Public Law 106-554 directs the Secretary to establish a process "under which an appropriate statewide entity may apply to have all the geographic areas in a State treated as a single geographic area for purposes of computing and applying the area wage index under section 1886(d)(3)(E) of [the Social Security] Act. * * *" Most States encompass multiple labor market areas (urban MSAs and rural areas) with differing wage indexes, and we believe that the intent of section 304(b) is to offer hospitals within a State the opportunity to eliminate the disparate wage indexes resulting from separate urban and rural labor market areas within the State. However, hospitals in Washington, DC are not subject to disparate wage indexes. Washington, DC is part of a larger labor market area where all the hospitals receive the wage index for that labor market area (subject to MGCRB reclassifications). Put another way, Washington, DC is already "treated as a single geographic area" for purposes of the hospital wage index.
If we treated Washington, DC as a separate distinct labor market area and applied the usual wage index methodology, Washington, DC hospitals might reap a significant windfall and the hospitals remaining in the MSA might be disadvantaged. Given the intended purpose of section 304(b), we believe that such results would be inappropriate. We believe that Congress did not intend for section 304(b) to address the type of situation presented by Washington, DC.
As indicated above, section 304(b) permits a State to be treated as a single geographic area "for purposes of computing and applying the area wage index under section 1886(d)(3)(E) of [the] Act." Section 304(b) does not specify how to compute and apply the wage index for statewide geographic areas. Under section 1886(d)(3)(E) of the Act, the Secretary has broad authority to develop and apply the methodology for determining the wage index for labor market areas, and section 304(b) did not limit the agency's authority. Thus, even if Washington, DC is a State for purposes of section 304(b), the Secretary has broad authority under section 1886(d)(3)(E) to determine the wage index for all affected hospitals. Given the purpose of section 304, and to avoid conferring an inappropriate and unintended windfall (or disadvantage) to hospitals, we are providing (pursuant to our broad authority under section 1886(d)(3)(E) of the Act) that, even if Washington, DC is a State for purposes of section 304(b) of Public Law 106-554, the wage index applicable to the Washington, DC "statewide" geographic area would be the same wage index that would apply to the Washington, DC-MD-VA-WV MSA as a whole (which would be calculated by including Washington, DC hospitals, in accordance with all applicable rules).
H. Payment for Direct Costs of Graduate Medical Education (§ 413.86)
1. Background
Under section 1886(h) of the Act, Medicare pays hospitals for the direct costs of graduate medical education (GME). The payments are based in part on the number of residents trained by the hospital. Section 1886(h) of the Act, as amended by section 4623 of Public Law 105-33, caps the number of residents that hospitals may count for direct GME.
Section 1886(h)(2) of the Act, as amended by section 9202 of the Consolidated Omnibus Reconciliation Act (COBRA) of 1985 (Public Law 99-272), and implemented in regulations at § 413.86(e), establishes a methodology for determining payments to hospitals for the costs of approved GME programs. Section 1886(h)(2) of the Act, as amended by COBRA, sets forth a payment methodology for the determination of a hospital-specific, base-period per resident amount (PRA) that is calculated by dividing a hospital's allowable costs of GME for a base period by its number of residents in the base period. The base period is, for most hospitals, the hospital's cost reporting period beginning in FY 1984 (that is, the period of October 1, 1983 through September 30, 1984). The PRA is multiplied by the number of FTE residents working in all areas of the hospital complex (or nonhospital sites, when applicable), and the hospital's Medicare share of total inpatient days to determine Medicare's direct GME payments. In addition, as specified in section 1886(h)(2)(D)(ii) of the Act, for cost reporting periods beginning on or after October 1, 1993, through September 30, 1995, each hospital's PRA for the previous cost reporting period is not updated for inflation for any FTE residents who are not either a primary care or an obstetrics and gynecology resident. As a result, hospitals with both primary care and obstetrics and gynecology residents and nonprimary care residents have two separate PRAs beginning in FY 1994: one for primary care and obstetrics and gynecology and one for nonprimary care.
Section 1886(h)(2) of the Act was further amended by section 311 of Public Law 106-113 to establish a methodology for the use of a national average PRA in computing direct GME payments for cost reporting periods beginning on or after October 1, 2000, and on or before September 30, 2005. Generally, section 1886(h)(2) of the Act establishes a "floor" and a "ceiling" based on a locality-adjusted, updated, weighted average PRA. Each hospital's PRA is compared to the floor and ceiling to determine whether its PRA should be revised. PRAs that are below the floor, that is, 70 percent of the locality-adjusted, updated, weighted average PRA, would be revised to equal 70 percent of the locality-adjusted, updated, weighted average PRA. PRAs that exceed the ceiling, that is, 140 percent of the locality-adjusted, updated, weighted average PRA, would, depending on the fiscal year, either be frozen and not increased for inflation, or increased by a reduced inflation factor. We implemented section 311 of Public Law 106-113 in the hospital inpatient prospective payment system final rule published on August 1, 2000 (65 FR 47090). In that final rule, we set forth the methodology for calculating the weighted average PRA and outlined the steps for determining whether a hospital's PRA would be revised.
2. Amendments Made by Section 511 of Public Law 106-554 (§ 413.86(e)(4)(ii)(C) and (e)(5)(iv))
Section 511 of Public Law 106-554 amended section 1886(h)(2)(D)(iii) of the Act by increasing the floor to 85 percent of the locality-adjusted national average PRA. In general, section 511 provides that, effective for cost reporting periods beginning on or after October 1, 2001, and before October 1, 2002, PRAs that are below 85 percent of the respective locality-adjusted national average PRA would be increased to equal 85 percent of that locality-adjusted national average PRA. Accordingly, we proposed to implement section 511 by revising § 413.86(e)(4)(ii)(C)( 1 ) to incorporate this change and by outlining the methodology for determining whether a hospital's PRA(s) will be adjusted in FY 2002 relative to the increased floor of the locality-adjusted national average PRA.
In the August 1, 2000 final rule (65 FR 47091 and 47092), as implemented at § 413.86(e)(4), we determined, in accordance with section 311 of Public Law 106-113, that the weighted average PRA for cost reporting periods ending during FY 1997 is $68,464. We described the procedures for updating the weighted average PRA of $68,464 for inflation to FY 2001 and for adjusting this average for the locality of each individual hospital. We then outlined the steps for comparing each hospital's PRA(s) to the locality-adjusted national average PRA to determine if, for cost reporting periods beginning on or after October 1, 2000, and before October 1, 2001, the PRAs should be revised to equal the 70-percent floor.
In accordance with section 511 of Public Law 106-554, in the May 4 proposed rule, we proposed that, for cost reporting periods beginning during FY 2002, the FY 2002 PRAs of hospitals that are below 85 percent of the respective locality-adjusted national average PRA for FY 2002 be increased to equal 85 percent of that locality-adjusted national average PRA. Specifically, to determine which PRAs (primary care and nonprimary care separately) for each hospital are below the 85-percent floor, each hospital's locality-adjusted national average PRA for FY 2002 is multiplied by 85 percent. This resulting number is then compared to each hospital's PRA that is updated for inflation to FY 2002. If the hospital's PRA would be less than 85 percent of the locality-adjusted national average PRA, the individual PRA is replaced with 85 percent of the locality-adjusted national average PRA for that cost reporting period, and in future years the new PRA would be updated for inflation by the Consumer Price Index for All Urban Consumers (CPI-U) as compiled by the Bureau of Labor Statistics.
There may be some hospitals with both primary care and nonprimary care PRAs that are below the floor, and both PRAs are, therefore, replaced with 85 percent of the locality-adjusted national average PRA. In these situations, the hospitals would receive a single PRA; a distinction between PRAs would no longer be made based on the different inflation adjustments (under § 413.86(e)(3)(ii)). On the other hand, hospitals may have primary care PRAs that are above the floor, and nonprimary care PRAs that are below the floor. In these situations, only the nonprimary care PRAs would be revised to equal 85 percent of the locality adjusted national average PRA, and the prior year primary care PRAs would be updated for inflation by the CPI-U. An example of application of this provision appeared in the preamble of the May 4, 2001 proposed rule (66 FR 33697).
We note that section 511 of Public Law 106-554 only affects hospitals with PRAs below the 85-percent floor, and does not affect hospitals with PRAs that are either between the floor and ceiling or exceed the ceiling. Thus, with the exception of the change in the floor as provided by section 511, the policy regarding the use of a national average PRA for making direct GME payments remains as implemented in the regulations at § 413.86(e)(4).
We proposed to amend § 413.86(e)(4)(ii)(C)( 1 ) to add the rules implementing section 1886(h)(2)(D)(iii) of the Act as amended by section 511 of Public Law 106-554.
We also proposed to amend § 413.86(e)(5) regarding the determination of base year PRAs for new teaching hospitals for cost reporting periods beginning during FYs 2001 through 2005. In the August 1, 2000 final rule, we made a conforming change to § 413.86(e)(5) to account for situations in which hospitals do not have a 1984 base year PRA and establish a PRA in a cost reporting period after the 1984 base year. Existing § 413.86(e)(5)(iv) specifies that the new base year PRAs of such hospitals are subject to the regulations regarding the floor and the ceiling of the locality-adjusted national average PRA. Although the determination of new base year PRAs is subject to the national average methodology, it is not necessary to include this provision in the regulations. Therefore, we proposed to remove § 413.86(e)(5)(iv).
In the proposed rule, we clarified that, for purposes of calculating a base year PRA for a new teaching hospital, when calculating the weighted mean value of PRAs of hospitals located in the same geographic area or the weighted mean value of the PRAs in the hospital's census region (as defined in § 412.62(f)(1)(i)), the PRAs used in the weighted average calculation must not be less than the floors for cost reporting periods beginning during FY 2001 or FY 2002, or if they exceed the ceiling, they must either be frozen for FYs 2001 and 2002 or updated with the CPI-U minus 2 percent for FYs 2003 through 2005. In addition, existing § 413.86(e)(5) provides that the PRA for a new teaching hospital is based on the lower of the hospital's actual costs incurred in connection with the GME program or the weighted mean value of PRAs. If a hospital's actual costs of the GME program during its cost reporting period beginning during FY 2001 or FY 2002 are less than the floors, the hospital's PRA would not be based on the actual costs. Instead, it would be equal to 70 percent in FY 2001, or 85 percent during FY 2002, of the locality-adjusted national average PRA. The floor applies to hospitals with existing PRAs in FYs 2001 and 2002, or to hospitals that are establishing new base year PRAs in FYs 2001 and 2002. We proposed to clarify that if a hospital establishes a new base year PRA in a cost reporting period beginning after FY 2002, its PRA would not be increased to equal the floor if it is less than the floor. Similarly, the ceiling applies to hospitals with existing PRAS in FYs 2001 through 2005, or to hospitals that are establishing new base year PRAs in FYs 2001 through 2005.
Comment: One commenter believed that the provision to increase the PRA floor to 85 percent of the locality-adjusted national average will address many concerns about the fairness of GME payments. One commenter asked if the provisions of the proposed rule to increase PRAs that are less than 85 percent of the locality-adjusted national average PRA to equal 85 percent of the locality-adjusted national average PRA would provide relief to hospitals who do not have base year PRAs established in the 1984 base year and could not increase their PRAs because the appeal period has elapsed.
Response: Section 511 of the Public Law 106-554 amended section 1886(h)(2)(D)(iii) of the Act by increasing the floor to 85 percent of the locality adjusted national average PRA. Effective for cost reporting periods beginning on or after October 1, 2001 and before October 1, 2002, any PRAs that are below 85 percent of the respective locality-adjusted national average PRA would be increased to equal 85 percent of that locality-adjusted national average PRA. Accordingly, hospitals with PRAs (primary care and/or nonprimary care) that are less than 85 percent of the respective locality-adjusted national average PRA for the hospital's cost reporting period beginning on or after October 1, 2001 and before October 1, 2002, will have those PRAs increased to equal 85 percent of that locality-adjusted national average PRA. This provision sets the floor on per resident amounts for cost reporting periods beginning during FY 2002, regardless of the base year used to establish the hospital's PRA.
Comment: One commenter requested that we clarify the references in the preamble stating that the national average PRA methodology is applicable for "cost reporting periods beginning on or after October 1, 2000 and on or before September 30, 2005." The commenter believed that the PRA changes authorized in the law were meant to be permanent, and therefore, did not understand the basis for the September 30, 2005 endpoint.
Response: The changes made to a hospital's PRA as a result of section 311 of Public Law 106-113 and section 511 of Public Law 106-554 are permanent. However, this new methodology for determining whether or not a hospital's PRA is revised, as described in the statute, is only effective for cost reporting periods beginning on or after October 1, 2000 and on or before September 30, 2005. For cost reporting periods beginning on or after October 1, 2005, a hospital's PRA, whether or not it was revised by the new methodology, is updated with the full CPI-U, using the procedures in place prior to October 1, 2000. If a hospital's PRAs are below the floors, they will be revised accordingly in FYs 2001 or 2002, or both. After FY 2002, that hospital's revised PRA will be updated for inflation as usual, that is, using the procedures in place for all PRAs prior to October 1, 2000. If a hospital's PRAs exceed the ceiling, the PRAs would be frozen in FYs 2001 and 2002, and updated with a reduced inflation factor in FYs 2003, 2004, and 2005. Thus, after September 30, 2005, although any changes made to a hospital's PRAs as a result of the new methodology would remain in place, the procedure for updating PRAs reverts back to the procedure in place prior to October 1, 2000, that is, updating for inflation with the full CPI-U.
Comment: One commenter requested that we publish in the final rule the CPI-U factors that must be used to update the 1997 national average PRA to the midpoint of a hospital's cost reporting period beginning in FY 2001.
Response: As the commenter requested, we are including below the CPI-U factors. For cost reporting periods beginning on or after October 1, 2000 and before October 1, 2001, the following update factors should be used when implementing section 311 of Public Law 106-113. Specific instructions for applying these factors can be found in the hospital inpatient prospective payment system final rule published on August 1, 2000 (65 FR 47091). (Refer to the bottom of the middle column and the right column on page 47091 for "Step 1: Update the weighted average PRA for inflation".)
| Update weighted average PRA from: | To midpoint of cost reporting period beginning: | Use update factor of: \*\ |
|---|---|---|
| October 1, 1996 | October 1, 2000 | 1.11200 |
| October 1, 1996 | November 1, 2000 | 1.11389 |
| October 1, 1996 | December 1, 2000 | 1.11579 |
| October 1, 1996 | January 1, 2001 | 1.11800 |
| October 1, 1996 | February 1, 2001 | 1.12053 |
| October 1, 1996 | March 1, 2001 | 1.12307 |
| October 1, 1996 | April 1, 2001 | 1.12465 |
| October 1, 1996 | May 1, 2001 | 1.12528 |
| October 1, 1996 | June 1, 2001 | 1.12591 |
| October 1, 1996 | July 1, 2001 | 1.12780 |
| October 1, 1996 | August 1, 2001 | 1.13097 |
| October 1, 1996 | September 1, 2001 | 1.13414 |
| * Source: Forecast by Standard and Poor's DRI; Historical Data through August 2000. | ||
3. Determining the 3-Year Rolling Average for Direct GME Payments (§ 413.86(g)(4) and (g)(5))
Section 1886(h)(4)(G)(iii) of the Act, as added by section 4623 of Public Law 106-33, provides that for the hospital's first cost reporting period beginning on or after October 1, 1997, the hospital's weighted FTE count for direct GME payment purposes equals the average of the weighted FTE count for that cost reporting period and the preceding cost reporting period. For cost reporting periods beginning on or after October 1, 1998, section 1886(h)(4)(G) of the Act requires that hospitals' direct medical education weighted FTE count for payment purposes equal the average of the actual weighted FTE count for the payment year cost reporting period and the preceding two cost reporting periods (rolling average). This provision phases in the associated reduction in payment over a 3-year period for hospitals that are reducing their number of residents.
In the August 29, 1997 final rule with comment period (62 FR 46004), we revised § 413.86(g)(5) accordingly, and outlined the methodology for determining a hospital's direct GME payment. Based on what we explained in the 1997 final rule, for cost reporting periods beginning on or after October 1, 1997, we would determine a hospital's direct GME payment as follows:
Step 1. Determine the average of the weighted FTE counts for the payment year cost reporting period and the prior two immediately preceding cost reporting periods (with exception of the hospital's first cost reporting period beginning on or after October 1, 1997, which will be based on the average of the weighted average for that cost reporting period and the immediately preceding cost reporting period).
Step 2. Determine the hospital's direct GME amount without regard to the FTE cap (before determining Medicare's share). That is, take the sum of (a) the product of the primary care PRA and the primary care weighted FTE count in the current payment year, and (b) the product of the nonprimary care PRA and the nonprimary care weighted FTE count in the current payment year.
Step 3. Divide the hospital's direct GME amount by the total number of FTE residents (including the effect of weighting factors) for the cost reporting period to determine the weighted average PRA (this amount reflects the FTE weighted average of the primary and nonprimary care PRAs) for the cost reporting period.
Step 4. Multiply the weighted average PRA for the cost reporting period by the 3-year average weighted count to determine the hospital's allowable direct GME costs. This product is then multiplied by the hospital's Medicare patient load for the cost reporting period to determine Medicare's direct GME payment to the hospital.
Steps 2 and 3 above describe the methodology for combining a hospital's primary care PRA and nonprimary care PRA to determine the hospital's single weighted average PRA for the payment year cost reporting period. (This step accounts for hospitals that were training residents in both primary care and nonprimary care residency programs in FYs 1994 and 1995, when, as described in § 413.86(e)(3)(ii), each hospital's PRA for the previous cost reporting period was not adjusted for any resident FTEs who were not either a primary care resident or an obstetrics and a gynecology resident. As a result, such hospitals have two PRAs for direct GME payment; one for primary care and obstetrics and gynecology residents, and one for all other, or nonprimary care, residents. Hospitals that train either only primary care (including obstetrics and gynecology) residents or only nonprimary care residents follow the methodology described above, with the exception of combining two PRAs. Step 4 then dictates that the resulting average PRA is multiplied by the 3-year rolling average, which, in turn, is multiplied by the hospital's Medicare patient load in the current year to determine Medicare's direct GME payment to the hospital for that cost reporting period.
In implementing this provision in the August 29, 1997 final rule with comment period, we believed that the methodology described above was appropriate because it was consistent with the methodology described under section 1886(h)(3)(B) of the Act. This section specifies that, in order to arrive at the average PRA, or "aggregate approved amount," the Secretary must multiply a hospital's PRA by the "weighted average number of [FTE] residents * * * in the hospital's approved medical residency training programs in that period " (emphasis added).
We also believed the methodology outlined above and in the August 29, 1997 rule was appropriate because it was consistent with the intent of the statute that, after October 1, 1997, direct GME payments should be based on a rolling average. Specifically, section 4623 of Public Law 106-33 provides that, "For cost reporting periods beginning on or after October 1, 1997 * * * the total number of full-time equivalent residents for determining a hospital's graduate medical education payment shall equal the average of the actual full-time equivalent resident counts for the cost reporting period and the preceding two cost reporting periods' (emphasis added). Thus, while the statute does not include a specific methodology for computing the direct GME payments, it clearly indicates that the payment should be based on a 3-year average of the weighted number of residents, not the weighted number of residents in the current payment year cost reporting period.
As stated above, Congress provided that the direct GME payments should be made based on a 3-year average of the weighted number of residents in order to phase in the associated reduction in payment over a 3-year period for hospitals that are reducing the number of residents they are training. However, in steps 2 and 3 above, when combining a hospital's primary care PRA and nonprimary care PRA, we weight the respective PRAs by current year residents. This introduces the number of residents that a hospital is training in the current cost reporting period into the payment formula. A payment formula that incorporates the number of current year residents "dilutes" the effect of the rolling average as related to direct GME payments. After further consideration, we believe that, consistent with the statute, the formula should be based on rolling average counts of residents. We proposed an alternative methodology which would replace the current methodology in which the direct GME payment would be the sum of (a) the product of the primary care PRA and the primary care and obstetrics and gynecology rolling average, and (b) the product of the nonprimary care PRA and the nonprimary care rolling average. (This sum would then be multiplied by the Medicare patient load.) The new methodology would only be used for determining direct GME payments because there is no distinction between primary care and nonprimary care residents for IME payment purposes.
The new methodology is effective for cost reporting periods beginning on or after October 1, 2001. The methodology for determining a hospital's direct GME payment is as follows:
Step 1. Determine that the hospital's total unweighted FTE counts in the payment year cost reporting period and the prior two immediately preceding cost reporting periods for all residents in allopathic and osteopathic medicine do not exceed the hospital's FTE cap for these residents in accordance with § 413.86(g)(4). If the hospital's total unweighted FTE count in a cost reporting period exceeds its cap, the hospital's weighted FTE count, for primary care and obstetrics and gynecology residents and nonprimary care residents, respectively, will be reduced in the same proportion that the number of these FTE residents for that cost reporting period exceeds the unweighted FTE count in the cap. The proportional reduction is calculated for primary care and obstetrics and gynecology residents and nonprimary care residents separately in the following manner:
(FTE cap/unweighted total FTEs in the cost reporting period) × (weighted primary care and obstetrics and gynecology FTEs in the cost reporting period)
plus
(FTE cap/unweighted total FTEs in the cost reporting period) × (weighted nonprimary care FTEs in the cost reporting period).
Add the two products to determine the hospital's reduced cap.
Step 2. Determine the 3-year average of the weighted FTE count for primary care and obstetrics and gynecology residents in the payment year cost reporting period and the two immediately preceding cost reporting periods. Determine the 3-year average of the weighted FTE count for nonprimary care residents in the payment year cost reporting period and the two immediately preceding cost reporting periods.
Step 3. Determine the product of the primary care PRA and the primary care and obstetrics and gynecology 3-year average from step 2. Determine the product of the nonprimary care PRA and the nonprimary care 3-year average from step 2.
Step 4. Sum the products of step 3.
Step 5. Multiply the sum from step 4 by the hospital's Medicare patient load for the cost reporting period to determine Medicare's direct GME payment to the hospital.
Existing § 413.86(g)(5) specifies that residents in new programs are excluded from the rolling average calculation for a period of years equal to the minimum accredited length for the type of program, and are added to the payment formula after applying the averaging rules. Accordingly, for hospitals that qualify for an adjustment to their FTE caps for residents training in new programs under § 413.86(g)(6), primary care and obstetrics and gynecology residents in new programs would be added to the quotient of the primary care and obstetrics and gynecology 3-year average, and nonprimary care residents in new programs would be added to the quotient of the nonprimary care 3-year average. The sums of the respective 3-year averages and new residents would then be multiplied by the respective PRAs.
The following example illustrates the determination of direct GME payment under the proposed rolling average methodology for an existing teaching hospital with no new programs:
Example:
Assume a hospital with a cost reporting period ending September 30, 1996 (beginning October 1, 1995) had 100 unweighted FTE residents and 90 weighted FTE residents. The hospital's FTE cap is 100 unweighted residents.
Step 1. In its cost reporting period beginning in FY 2000, it had 100 unweighted residents and 90 weighted residents (50 primary care and 40 nonprimary care).
• The hospital had 90 unweighted residents and 85 weighted residents (50 primary care and 35 nonprimary care) for its cost reporting period beginning in FY 2001.
• In its cost reporting period beginning in FY 2002, the hospital had 80 unweighted residents and 80 weighted residents (50 primary care and 30 nonprimary care).
Step 2. The 3-year average of weighted primary care and obstetrics and gynecology residents is (50 +50 + 50)/3 = 50. The 3-year average of weighted nonprimary care residents is (40 + 35 + 30)/3 = 35.
Step 3. Primary care: $80,000 PRA × 50 weighted primary care and obstetrics and gynecology FTEs = $4,000,000. Nonprimary care: $78,000 × 35 weighted nonprimary care FTEs = $2,730,000.
Step 4. $4,000,000 + $2,730,000 = $6,730,000.
Step 5. If the hospital's Medicare patient load for the payment cost reporting period is .20, Medicare's direct GME payment would be $6,730,000 × .20 = $1,346,000.
Whether the proposed methodology results in a payment difference for a hospital is dependent upon whether or not the number and mix (primary care and nonprimary care) of FTEs changes in a 3-year period. If the number and mix of FTEs does not change in a 3-year period, there would be no difference in a direct GME payment amount derived using the proposed methodology versus the existing methodology. For example, if a hospital has 90 weighted FTEs (50 primary care and 40 nonprimary care) in the current year and the 2 previous years (using the PRAs and the Medicare patient load from the example above), the payment amounts derived from the existing methodology and the proposed methodology would be equal.
If the number and mix of FTEs varies from year to year, there will be a difference in the results of the two methodologies. In some instances the existing methodology would result in a higher payment, and in other instances the proposed methodology would result in a higher payment. In the example above, the hospital has reduced its number of weighted residents by 5 FTEs in FYs 2001 and 2002. Calculating this hospital's direct GME payment amount using the existing methodology (using the PRAs and the Medicare patient load from the example) would result in a payment of $1,347,250, which is $1,250 more than $1,346,000, the amount calculated in the example using the proposed methodology.
In a scenario where a hospital makes larger reductions to the number of FTEs, the proposed methodology may be more beneficial. For example, using the PRAs and the Medicare patient load from the example above, assume a hospital has 90 weighted FTEs (50 primary care and 40 nonprimary care) in FY 2000, 85 weighted FTEs (50 primary care and 35 nonprimary care) in FY 2001, and 70 weighted FTEs (35 primary care and 35 nonprimary care) in FY 2002. If the proposed methodology is used, the payment amount of $1,292,050 would be calculated, which is $1,666 more than $1,290,386, the amount calculated if the existing methodology is used.
We proposed to revise § 413.86(g)(4) to specify that, effective for cost reporting periods beginning on or after October 1, 2001, if the hospital's total unweighted FTE count in a cost reporting period exceeds its cap, the hospital's weighted FTE count, for primary care and obstetrics and gynecology residents and nonprimary care residents, respectively, will be reduced in the same proportion that the number of these FTE residents for that cost reporting period exceeds the unweighted FTE count in the cap. We also proposed to revise § 413.86(g)(5) to specify that, effective for cost reporting periods beginning on or after October 1, 2001, the direct GME payment will be calculated using two separate rolling averages, one for primary care and obstetrics and gynecology residents and one for nonprimary care residents.
Comment: Two commenters asked whether or not the proposed new methodology for calculating direct GME payment using two separate rolling averages for primary care and nonprimary care residents is truly an "alternative," or, if finalized, would it replace the present methodology.
Response: The proposed new methodology would replace the existing rolling average methodology effective for cost reporting periods beginning on or after October 1, 2001 (the effective date of this final rule). Hospitals training both primary care and nonprimary care residents would determine two separate rolling average counts; one for primary care and one for nonprimary residents.
Comment: One commenter stated: "although the new rolling average methodology is difficult and complex, its impact on GME programs is far from clear." The commenter asked how much change in resident number and mix is necessary before this new methodology has an effect on payment, and stated that more examples would be helpful in determining this effect. The commenter also expressed hope that, if this change is finalized, we will revisit this issue after implementation and fully examine and analyze its impact on teaching program payment.
Response: As we explained in the proposed rule, whether the new methodology results in a payment difference for a hospital is dependent upon whether or not the ratio of primary care to nonprimary care FTEs changes in a 3-year period. If the ratio of the FTEs does not change over the 3-year period, there would be no difference in a direct GME payment amount derived using the new methodology versus the existing methodology. In particular, there would be an increase in direct GME payment under the revised methodology, where a hospital's proportion of primary care residents to nonprimary care residents over the last 3 years is higher than the hospital's proportion of primary care residents to nonprimary care residents in the current year. As this new rolling average methodology is implemented, we intend to evaluate hospitals' direct GME payments to further analyze the impact of using this methodology.
Comment: One commenter asked how many hospitals would still be "at risk" for changes in payment because they retain different primary care and nonprimary care PRAs, given the implementation of the 85 percent floor.
Response: As described in the impact section of this final rule in Appendix A, we estimated that, of 1,231 teaching hospitals included in the analysis, approximately 562 hospitals have PRAs that will be increased to equal 85 percent of the national average PRA. This leaves 669 hospitals with PRAs that exceed the 85 percent floor. However, not all of these hospitals will be using the new methodology because not all of them have both primary care and nonprimary care PRAs.
Comment: One commenter noted that, in order to implement the new rolling average methodology, significant changes must be made to Worksheet E, Part A, the worksheet on the Medicare cost report used for calculating a hospital's IME adjustment. The commenter also stated that past cost reports using the current cost reporting forms would have to be reopened.
Response: As we explained in the preamble to the proposed rule and above in this final rule, we have decided to institute a separate rolling average for primary care and nonprimary care residents due to an issue with respect to the current payment methodology for direct GME only . That is, when combining a hospital's primary care PRA and nonprimary care PRA on Worksheet E-3, Part IV of the Medicare cost report, we currently weight the respective PRAs by current year residents. As a result, although Congress provided that the direct GME payments should be made based on a 3-year rolling average count of weighted residents, the current methodology introduces the number of residents that a hospital is training in the current cost reporting period into the payment formula. A payment formula that incorporates the number of current year residents "dilutes" the effect of the rolling average as related to direct GME payments. However, in regard to the IME payments, we also noted that, although they are also based on a rolling average, no change in the existing methodology is needed because there is no distinction between primary care and nonprimary care residents for IME payment purposes. Therefore, while two separate rolling averages will be used for direct GME payments (one for primary care and one for nonprimary care), a single rolling average will continue to be used for IME payments under the existing methodology. We will make the necessary changes to the Medicare cost report on Worksheet E-3, Part IV, which is used for calculating a hospital's direct GME payment, to accommodate two separate rolling average calculations.
The commenter also stated that affected cost reports in which the current rolling average methodology was used would need to be reopened. However, the effective date of this change in the methodology is prospective, and will only affect cost reporting periods beginning on or after October 1, 2001. We will not be reopening past cost reports to change direct GME payment because of the new methodology.
Comment: One commenter indicated that the separation of the 3-year rolling average between primary care and nonprimary care FTEs will be difficult because the prior year FTEs were not separated into primary care and nonprimary care FTEs. The commenter asked how a provider could obtain the information from prior years if the same methodology was not used.
Response: We do not believe it will be difficult for a hospital to obtain the weighted FTE counts of its primary care and nonprimary care residents separately. This is because, in fact, although the rolling average was computed based on total residents, there are lines on Worksheet E-3, Part IV (lines 3.07 and 3.08) in which the current year weighted count of primary care and nonprimary care residents are reported separately. Therefore, the hospital and the fiscal intermediary can easily refer to these lines on prior year cost reports to determine a 3-year average for primary care and nonprimary care residents, respectively.
4. Counting Research Time as Direct and Indirect GME Costs (§§ 412.105 and 413.86)
It has come to our attention that there appears to be some confusion in the provider community as to whether the time that residents spend performing research is countable for the purposes of direct and indirect GME reimbursement. Although we did not propose to make any policy changes in the May 4 proposed rule, we did reiterate our longstanding policy regarding time that residents spend in research and proposed to incorporate this policy in the IME regulations.
Section 413.86(f) specifies that, for the purposes of determining the total number of FTE residents for the direct GME payment, residents in an approved program working in all areas of the hospital complex may be counted. Accordingly, the time the residents spend performing research as part of an approved program anywhere in the hospital complex may be counted for direct GME payment purposes. If the requirements listed at §§ 413.86(f)(3) and (f)(4) are met, a hospital may also count the time residents spend doing research in nonhospital settings for direct GME payment.
For purposes of determining the IME payment, § 412.105(f)(1)(ii) specifies that the time residents spend training in parts of the hospital that are subject to the inpatient prospective payment system, in the outpatient departments, or (effective on or after October 1, 1997, in accordance with § 413.86(f)(3) or (f)(4), as applicable) in nonhospital settings, may be counted. Section 2405.3.F.2. of the Provider Reimbursement Manual (PRM) further states that a resident must not be counted for the IME adjustment if the resident is engaged exclusively in research. Resident time spent "exclusively" in research means that the research is not associated with the treatment or diagnosis of a particular patient of the hospital. Therefore, although the research component may be part of an approved program, the time that residents devote specifically to performing research that is not related to delivering patient care, whether it occurs in the hospital complex or in non-hospital settings, may not be counted for IME payment purposes. "Exclusively research" time is not allowable for IME purposes irrespective of whether the resident is engaged only in research or spends only part of his or her time on research. Accordingly, time spent exclusively in research over the course of a program year should be subtracted from the total FTE count for that year. For example, if a resident is required to spend 3 months in a particular program year engaged in research activities unrelated to delivering patient care, that amount of time should be subtracted from the total FTE count, whether or not the research time is fulfilled in one block of time, or is distributed throughout the training year.
We note that in order to count residents for both direct GME and IME payment purposes, the residents' training must be part of an approved program. This applies whether or not the residents are doing work that is clinical in nature. There are situations where residents have completed their residency program requirements but remain for an additional period of time to continue their training (that is, to conduct research or other activities) outside the context of a formally organized approved program. As we explained in the September 29, 1989 final rule (54 FR 40306), these residents are not countable for direct GME or IME reimbursement. Rather, patient care services provided by these residents should be paid as Part B services.
We proposed to amend § 412.105(f)(1)(iii) to add a paragraph (B) to incorporate language that reflects this policy.
We received several comments disagreeing with our clarification to longstanding policy on whether the time that residents spend performing research may be included in the FTE count for the purpose of determining direct and indirect GME reimbursement.
Comment: One commenter stated that the proposed revised IME regulations at § 412.105 do not mention any requirement that residents counted for purposes of the IME adjustment and assigned to a hospital's inpatient prospective payment system or outpatient area be involved in "patient care activities." Instead, that requirement is only mentioned with reference to residents assigned to nonprovider settings. Therefore, the commenter believed that a patient care requirement in reference to counting residents in nonprovider settings implies the exclusion of the same requirement when counting residents in the hospital (specifically as it applies to counting research time for IME purposes).
Response: The clarification in the proposed rule addresses our longstanding interpretation of existing regulations and reflects longstanding general Medicare reimbursement principles. Under general Medicare reimbursement principles, as reflected in § 413.9, costs incurred by a hospital generally must be related to patient care in order to be reimbursed by Medicare.
The purpose of the IME payments is to address the additional costs that hospitals incur in treating patients. In our May 6, 1986 interim final rule (51 FR 16775), we stated: "Section 1886(d)(5)(B) of the Act provides that prospective payment hospitals receive an additional payment for the indirect costs of medical education computed in the same manner as the adjustments for those costs under regulations in effect as of January 1, 1983. Under those regulations, we provided that the indirect costs of medical education incurred by teaching hospitals are the increased operating costs ( that is, patient care costs ) that are associated with approved intern and resident programs" (emphasis added). In addition, in our September 29, 1989 final rule (54 FR 40286), we specifically state: "As used in section 1886(d)(5)(B) of the Act, 'indirect medical education' means those additional costs ( that is, patient care costs ) incurred by hospitals with graduate medical education programs. The indirect costs of medical education might, for example, include added costs resulting from an increased number of tests ordered by residents as compared to the number of tests normally ordered by more experienced physicians" (emphasis added).
Thus, payments for IME address the additional operating costs that teaching hospitals incur in furnishing patient care. Accordingly, consistent with the purpose of IME payments and general Medicare reimbursement principles, in determining the FTE count with respect to the IME adjustment, it has been our longstanding policy that we do not include residents to the extent that the residents are not involved in furnishing patient care but are instead engaged exclusively in research.
Comment: One commenter disagreed with our use of the Provider Reimbursement Manual (PRM), section 2405.3.F.2, in support of our policy on excluding residents from the IME count if the resident is "engaged exclusively in research." The commenter stated that the reference to exclusion from the resident count for residents engaged "exclusively in research" must be read in the context of the Manual provision, and not in a regulatory vacuum. The commenter believed that PRM section 2405.3.F.2 is addressing situations outside of the traditional residency program-where the resident time at issue is not part of an approved medical education program. The commenter believed that the phrase "engaged exclusively in research" refers to persons who are research scientists and not engaged in research as part of a clinical residency program.
In addition, this commenter stated that our interpretation of the word "exclusively" in this context is not reasonable and is contrary to the clear meaning of the term. The commenter argued that our interpretation practically eliminates the word "exclusively," effectively saying that a resident is "exclusively engaged in research" if that resident participates in any research at all.
Response: Section 2405.3.F.2 of the PRM (published in August 1988) was written to address "Questionable situations" for the IME FTE count. Indeed, in the introductory paragraph in this section we state: "It is recognized that situations arise in which it may be unclear whether an individual is counted as an intern or resident in an approved program for the purposes of the indirect medical education adjustment." Thus, the point of section 2405.3.F.2 of the PRM was to clarify situations for counting resident FTEs in approved programs for IME purposes. As the commenter suggested, some of the situations listed under this section address situations where the resident FTE time at issue is not part of the approved medical education program (for example, that a resident must not be counted for the IME adjustment if "the individual's services in provider settings are payable as physician services (situations in which it is clear that the otherwise eligible resident is 'moonlighting')".) (Section 2405.3.F.2. of the PRM). However, this section in the PRM was written to clarify counting rules for IME purposes in various situations. In addition to clarifying situations where resident time is spent in an unapproved program, this section in the PRM certainly also clarifies the rules for determining resident time spent in an approved program-such as time the resident is "engaged exclusively in research" (as cited in the proposed rule) and that "any portion of the individual's salary is subject to reasonable compensation equivalency limits." (Section 2405.3.F.2. of the PRM)
Therefore, we do not agree with the commenter that we have read this manual provision in a "regulatory vacuum". The phrase "engaged exclusively in research" is not meant only to refer to persons who are research scientists and not engaged in research as part of an approved clinical residency program, since as explained above, there is nothing in the manual provision that limits the research provision to research performed outside of an approved program.
In the proposed rule, we stated that resident time spent "exclusively" in research "means that the research is not associated with the treatment or diagnosis of a particular patient of the hospital." (66 FR 22700). The commenter argued that this interpretation of the word "exclusively" in the context of the manual provision is unreasonable and contrary to the clear meaning of the term, that under our policy, a resident would be "engaged exclusively in research" if that resident participates in any research at all. We do not agree.
Resident time spent "engaged exclusively in research" means time not associated with the care of a particular patient (see proposed § 412.105(f)(1)(iii)(B)); thus, any research time that is associated with the treatment or diagnosis of a particular hospital patient or, effective on or after October 1, 1997, of patients in nonhospital settings, that is, usual patient care, is countable for IME payment purposes. We note that this distinction between activities that are "usual patient care" and research activities is, again, longstanding Medicare policy. In April 1975, at section 500 of the PRM, we stated the principle that "Costs incurred for research purposes, over and above usual patient care, are not included as allowable costs." Indeed, since the inception of Medicare, we have distinguished between activities that are "usual patient care" and activities that are outside this scope, such as research activities.
Comment: One commenter stated that "by its very nature as a regression analysis, or statistical measure, the IME formula is not intended to be dependent on 'the treatment or diagnosis of a particular patient of the hospital.' " Another commenter stated: "our understanding of the development of the adjustment is that statistical analyses showed that the use of an intern/resident-to-bed ratio (IRB) was (and continues to be) the best proxy for the patient care cost differences between teaching and non-teaching hospitals. Given that the IRB is only a proxy, the relevance of a requirement that residents themselves must be engaged in activities related to patient care in order for their training time to be counted in the IRB is unclear."
Response: Generally, the statistical analyses used in the development of the statutory IME adjustment measured the differences between teaching and nonteaching hospitals with respect to the additional costs associated with patient care. Inpatient hospital care that involves the use of residents is costlier than inpatient hospital care that does not involve the use of residents. As the comments and the statute reflect, the hospital's ratio of interns and residents to beds is one factor in measuring the additional costs that a hospital incurs due to the use of residents in furnishing patient care. While a resident is engaged exclusively in research, the hospital is not incurring additional patient care costs due to that resident. Accordingly, we believe that the measure of additional patient care costs is more accurate if it excludes residents engaged exclusively in research.
Suppose, for example, that a teaching hospital has a total of 20 FTE residents training in prospective payment system sections of the hospital who are all involved in furnishing patient care. The amount of the IME payment to the hospital would reflect 20 FTE residents, reflecting the additional operating costs arising from the use of 20 FTE residents in furnishing patient care. Now suppose that the same hospital has the same 20 residents involved in furnishing patient care but it also has 4 additional FTE residents engaged exclusively in research. The 4 residents engaged exclusively in research do not contribute to higher operating costs and, therefore, as our longstanding policy reflects, we believe it is appropriate not to count them for purposes of the IME adjustment. Thus, in both situations, the hospital's FTE count for purposes of IME is 20. If we did make higher payments in the second situation, then the hospital would receive higher payments even though the hospital did not incur higher patient care costs.
Comment: One commenter stated that our regulations at § 413.86(e)(1)(i)(B) clearly allow research time to be counted for direct GME purposes. This commenter asserted that "it cannot be reasonably argued that research time should be counted differently for IME than direct GME based on a new, very specific definition of patient care that applies solely to IME". Another commenter stated the proposed rule is "unduly burdensome" by requiring hospitals to maintain different counts for direct GME and IME based on research activity or rotations. A third commenter stated that there is an alternative to distinguishing between direct GME and IME as it relates to research-"lawyers, often when faced with conflicting sections of the law, attempt to reconcile a common policy out of these conflicts, rather than further complicating things. You could do the same here."
Response: As we have stated above and in the proposed rule, the clarification we made concerning the counting of FTEs for research time related to the diagnosis and treatment of a particular patient for IME purposes is longstanding Medicare reimbursement policy. We were not proposing a change in Medicare policy.
We are not introducing unnecessary complexity to the direct and indirect medical education counts, since it has always been Medicare policy to require the hospital to distinguish between time spent by residents involved exclusively in research and time spent on patient care. Further, the IME and direct GME FTE counts have and will continue to differ for several reasons. Hospitals have always been able to count residents in all areas of the hospital complex for direct GME but cannot count residents working in units exempt from the prospective payment system for IME. In addition, each resident included in the hospital's direct GME FTE count is counted as 0.5 FTE if they have trained beyond the number of years required to become eligible in the specialty in which they first began training. These same residents are counted as 1.0 FTE in the hospital's IME FTE count. We reiterate that we are not making a change in policy, but merely clarifying our policy with respect to counting residents involved in GME.
With respect to research, our policies for direct GME payment are consistent with our policies for IME payment. In both contexts, we do not pay for the costs of time spent by residents engaged exclusively in research. In making payments for IME and direct GME for a given year, it is true that we treat research time differently for purposes of the IME FTE count and the direct GME FTE count, but, as explained below, this difference arises from the direct GME base year methodology and does not mean that we pay for research costs in the direct GME payment.
In the September 29, 1989 final rule implementing the direct GME base year payment methodology, we described the calculation of the per resident amounts (PRAs). Each hospital's PRA is determined by taking the hospital's total allowable graduate medical education costs (which do not include costs allocated to the nursery cost center, research , and other nonreimbursable cost centers) in a base year and dividing the costs by the number of FTE residents working in all areas of the hospital complex in the base year. (§ 413.86(e)(1)(i)) In the case of research and other nonreimbursable cost centers, costs were excluded from the PRA calculation because they were nonreimbursable in the base year, consistent with longstanding Medicare policy on Medicare cost reimbursement to teaching hospitals. Ideally, residents engaged exclusively in research would also have been excluded from the base year FTE count used in the PRA calculation. However, for a number of hospitals, the FTE count for the base year did include residents engaged exclusively in research because the 1984 base year information available when the PRAs were determined in 1990 did not distinguish between residents involved in furnishing patient care services and residents exclusively engaged in research.
In order to avoid disadvantaging these hospitals, in making direct GME payments for a given year, we have included and continue to include residents exclusively engaged in research in the direct GME FTE count both in the base year PRA calculation and in the FTE count in subsequent payment year calculations. Doing so "offsets" the effects of the inclusion of such residents in the direct GME base year FTE count (no such "offset" is necessary in the context of IME). However, because the costs were excluded in calculating the PRA, the end result is that the direct GME payment does not encompass the costs of residents engaged exclusively in research. Therefore, as with the IME payment, Medicare is not and has not been reimbursing teaching hospitals under direct GME for costs the hospital incurs associated with resident time spent in research unrelated to usual patient care.
Comment: One commenter stated that our policy on counting research time is well stated and clear. However, this commenter stated that there is much research that is done outside any funding source, but is an essential part of the resident's training. The commenter further stated that the hospital does assume these costs, and they are not part of the direct GME component, and so represent valid hospital expenditures due to the presence of residents.
Response: We certainly acknowledge that hospitals incur research costs associated with the training of interns and residents. We understand that many specialties require a research component to be completed as part of the specialties' board eligibility requirements. The question as far as IME payments are concerned is whether or not the research is associated with the diagnosis and treatment of a particular patient. As explained above, teaching hospitals receive Medicare IME payments to pay hospitals for Medicare's share of the additional costs these hospitals incur associated with patient care costs; if the research is not associated with usual patient care costs, then the resident research time is not reimbursable.
Comment: Two commenters stated that they are concerned that clarifications on the exclusion of resident FTEs from the IME payment for trainees engaged in activities that are purely research would be extended to include those individuals in an approved program that requires research activities at the same time as the delivery of patient care.
Response: As stated above, where the residents are engaged exclusively in research, it is appropriate to exclude that time from the IME payment calculation. However, consistent with longstanding policy, in the situation where residents are in an approved program participating in research activities that are associated with the diagnosis and treatment of a particular patient, we believe it is appropriate to include that time in the IME payment calculation.
5. Temporary Adjustments to FTE Cap to Reflect Residents Affected by Residency Program Closure
In the July 30, 1999 hospital inpatient prospective payment system final rule (64 FR 41522), we indicated that we would allow a temporary adjustment to a hospital's FTE resident cap under limited circumstances and if certain criteria are met when a hospital assumes the training of additional residents because of another hospital's closure. We made this change because hospitals had indicated a reluctance to accept additional residents from a closed hospital without a temporary adjustment to their caps. When we proposed this change 2 years ago, we received several comments suggesting that we include lost accreditation of a program (that is, a program's closure) in the temporary adjustment policy. We explained in our response to these comments (64 FR 41522) that we did not believe it was appropriate to expand our policy to cover any acts other than a hospital's closure. We made this decision because, unless the hospital terminates its Medicare agreement, the hospital would retain its statutory FTE cap and could affiliate with other hospitals to enable the residents to finish their training.
It has come to our attention that, despite a hospital's ability to affiliate with other hospitals when it shuts down a residency program, some hospitals for various reasons do not affiliate before their programs close, particularly when the program closes abruptly towards the end of the program year (the deadline to submit Medicare affiliation agreements is July 1 of the upcoming program year). Therefore, in the May 4 proposed rule, we proposed that if a hospital that closes its residency training program agrees to temporarily reduce its FTE cap, another hospital(s) may receive a temporary adjustment to its FTE cap to reflect residents added because of the closure of the former hospital's residency training program. For purposes of this policy on closed programs, we proposed to define "closure of a hospital residency training program" as when the hospital ceases to offer training for residents in a particular approved medical residency training program (proposed § 413.86(g)(8)(i)(B)). The methodology for adjusting the caps for the "receiving hospital" and the "hospital that closed its program" is described below.
a. Receiving hospital . We proposed that a hospital(s) may receive a temporary adjustment to its (or their) FTE cap to reflect residents added because of the closure of another hospital's residency training program if-
• The hospital is training additional residents from the residency training program of a hospital that closed its program; and
• No later that 60 days after the hospital begins to train the residents, the hospital submits to its fiscal intermediary a request for a temporary adjustment to its FTE cap, documents that the hospital is eligible for this temporary adjustment by identifying the residents who have come from another hospital's closed program and have caused the hospital to exceed its cap, specifies the length of time the adjustment is needed, and submits to its fiscal intermediary a copy of the FTE cap reduction statement by the hospital closing the program, as specified in paragraph (g)(8)(iii)(B)(2).
In general, the proposed temporary adjustment criteria are reflective of the temporary adjustment criteria for taking on the training of displaced residents from closed hospitals. We note that we proposed that more than one hospital would be eligible to apply for the temporary adjustment, because residents from one closed program may go to different hospitals, or they may finish their training at more than one hospital. We also noted that only to the extent a hospital would exceed its FTE cap by training displaced residents would it be eligible for the temporary adjustment.
Finally, we proposed that hospitals that meet the proposed criteria would be eligible to receive temporary adjustments (for cost reporting periods beginning on or after October 1, 2001, for direct GME and with discharges beginning on or after October 1, 2001 for IME) for training the displaced residents from programs that closed even before the effective date of this policy. We mentioned this because hospitals may have closed programs in the recent past and the residents from the closed programs may not have completed their training as of the effective date of this policy. For instance, if a 5-year residency program, such as surgery, closed on July 1, 1997, the 5th program year residents may still be training during this residency year (2001). We proposed that if both the receiving hospital(s) and the hospital that closed the program in this example follow the criteria described in this preamble, the receiving hospital may receive a temporary adjustment to its FTE cap for 9 months (October 1, 2001 through June 30, 2002) to accommodate the 5th year surgery residents. However, we noted that hospitals would not be eligible to receive a temporary adjustment for training the residents until the effective date of this rule (that is, October 1, 2001).
b. Hospital that closed its program(s). We proposed that a hospital that agrees to train residents who have been displaced by the closure of another hospital's program may receive a temporary FTE cap adjustment only if the hospital with the closed program(s)-
• Temporarily reduces its FTE cap by the number of FTE residents in each program year training in the program at the time of the program s closure. The yearly reduction would be determined by deducting the number of those residents who would have been training in the program year during each year had the program not closed; and
• No later than 60 days after the residents who were in the closed program begin training at another hospital, submits to its fiscal intermediary a statement signed and dated by its representative that specifies that it agrees to the temporary reduction in its FTE cap to allow the hospital training the displaced residents to obtain a temporary adjustment to its cap; identifies the residents who were training at the time of the program's closure; identifies the hospitals to which the residents are transferring once the program closes; and specifies the reduction for the applicable program years.
Unlike the closed hospital policy at § 413.86(g)(8), we proposed under this closed program policy (which we proposed to amend § 413.86(g)(8) to include), that in order for the receiving hospital(s) to qualify for a temporary adjustment to its FTE cap, the hospitals that are closing their programs would need to reduce their FTE cap for the duration of time the displaced residents would need to finish their training. We proposed this change because, as explained below, the hospital that closes the program still has the FTE slots in its cap, even if the hospital chooses not to fill the slots with residents. We believe it is inappropriate to allow an increase to the receiving hospital's cap without an attendant temporary decrease to the cap of the hospital with the closed program, even if the increase is only temporary. We noted that even under the proposed closed program policy, the hospital that closes its program may choose instead to affiliate with another hospital by July 1 of the next residency year so that the residents can more easily finish their training.
We proposed that the cap reduction for the hospital with the closed program would be based on the number of FTE residents in each program year who were in the program at the program's closure, and who began training at another hospital, rather than the count of residents each year at the hospital(s) receiving the temporary adjustment(s). We believe it would be too burdensome administratively to require the hospital closing the program to keep track of the status of the residents when they are training at other hospitals. For instance, Joe Smith, a resident who is a PGY 1 when Hospital X closes its pathology residency program, may then finish his training at Hospital Y. The resident trains for one year at Hospital Y as a PGY 2, but decides to drop out of the program before finishing. It would be burdensome to require Hospital X to keep track of Joe Smith's status while he is training at Hospital Y for purposes of the reduction in Hospital X's cap. Therefore, we proposed to "freeze" the basis for the reduction of the FTE cap of the hospital that closed the program based on the count and status of the residents when the hospital closes the program.
Example: Hospital A, which has a direct GME FTE cap of 20 FTEs and an IME FTE cap of 18 FTEs, is experiencing financial difficulties and decides to close down its internal medicine residency training program effective June 30, 2002. As of June 30, 2002, Hospital A is training 2 PGY 1s, 4 PGY 2s, and 6 PGY 3s in its internal medicine program. Hospitals B, C, and D take on the training of the displaced residents. These hospitals are eligible to receive temporary adjustments to their FTE caps if they follow the proposed criteria stated above. In order for Hospitals B, C, and D to receive the temporary adjustments, however, Hospital A must agree to reduce its FTE cap. According to the proposed criteria stated above, Hospital A's reduction would be:
July 1, 2002 through June 30, 2003
Direct GME FTE cap: 14 FTEs, (20 FTEs cap-2 PGY 2s-4 PGY 3s)
IME FTE cap: 12 FTEs (18 FTEs-2 PGY 2s-4 PGY 3s)
We note that no downward adjustment for the 6 PGY 3s for either cap is necessary since these residents will have completed their training in that program by the July 1, 2000 through June 30, 2003 program year.
July 1, 2003 through June 30, 2004
Direct GME FTE cap: 18 FTEs (20 FTEs cap-2 PGY 3s)
IME FTE cap: 16 FTEs (18 FTEs cap-2 PGY 3s)
July 1, 2004 through June 30, 2005
Direct GME FTE cap: 20 FTEs
IME FTE cap: 18 FTEs
We also proposed to revise § 412.105(f)(1)(ix) to make the provision relating to the adjustment to FTE caps to reflect residents affected by closure of hospitals' medical residency training programs applicable to determining the IME payment.
Comment: Several commenters commended us for extending payment of IME and direct GME to situations of program closure, explaining that this change will help stabilize the GME system and ensure that residents can continue their training without imposing financial hardship on the institutions that accept them into their programs. One commenter also noted that the tradeoff in the FTE resident cap between a hospital closing its residency program and the hospital receiving the displaced residents seems reasonable. Another commenter stated that while the proposed rule more than adequately described the requirements and procedures for allowing a hospital to receive a temporary adjustment to its FTE caps to reflect residents added because of the closure of another hospital's program, the receiving hospital is penalized because the 3-year rolling average applies to these residents. The commenter noted that, in the first and second year, the receiving hospital will be paid one third and two thirds of the costs of these displaced FTE residents because of the rolling average, although the receiving hospital is paying for these FTE residents at full cost. The commenter suggested that a temporary exception should be granted to receiving hospitals from the 3-year rolling average in the same manner as residents in new programs under § 413.86(g)(5) are excluded from the rolling average. The commenter also asked that temporary relief should be granted in the IME adjustment with regard to the application of the resident-to-bed ratio cap, wherein the relief from this cap should be an adjustment to the prior year's resident FTEs equal to the increase in the current year's FTEs which is attributable to the transferred residents.
Response: We understand the commenter's concern regarding the inclusion of the resident FTEs displaced by the closure of another hospital's program in the receiving hospital's rolling average count of residents, for both direct GME and IME purposes. In addition, we believe that a similar concern also exists in regard to the inclusion of residents in the receiving hospital's rolling average calculation for residents displaced by the closure of another hospital. Therefore, we are revising proposed § 412.105(f)(1)(v) for IME and adding a paragraph (vi) to proposed § 413.86(g)(5) for direct GME to specify that FTE residents that are displaced by the closure of either another hospital or another hospital's program are added after the calculation of the rolling average for the receiving hospital for the duration of time that those displaced FTE residents are training at the receiving hospital.
In regard to providing temporary relief to the receiving hospital's IME resident-to-bed ratio cap for the displaced residents, while we understand the commenter's concern about this issue as well, at this time we have decided not to allow the exclusion of these displaced residents in applying the resident-to-bed ratio cap. Under existing IME policy, the receiving hospital may be held to a lower cap in the first year of training the displaced residents. However, the receiving hospital may benefit from the higher cap in the year following the final year of the displaced residents' training. Effective in the first year that the receiving hospital takes on the displaced residents, it will be capped by the prior year's lower resident-to-bed ratio because the displaced residents will not be included in the prior year FTE count. However, an increase in the current year's ratio will establish a higher cap for the following year. Furthermore, in the last year that the receiving hospital is training the displaced residents, a higher cap will be established for the following year in which all the displaced residents will have left the hospital since they have completed their training. Therefore, we believe it is unnecessary to exclude displaced residents in applying the resident-to-bed ratio cap. While we are not making any changes to address this issue at this time, we will consider suggestions for possible changes in the future, if warranted.
Comment: One commenter stated that it is unclear at what rate the payments for IME and direct GME will be made for the hospital receiving the displaced residents. The commenter asked if Medicare would pay that hospital at the same rate that the hospital with the closed program was paid for its residents, or would the receiving hospital receive Medicare payment at the same rate it currently is paid.
Response: The receiving hospital will receive payment for the displaced residents using its own rates-that is, the same rates as those used for residents in its own programs. The receiving hospital will use its own bed count for IME payment purposes, and its own PRA and Medicare patient load for direct GME payment purposes.
Comment: One commenter stated that, although the commenter supports the proposal for allowing temporary adjustments for residents coming from a closed program, the commenter believed that a mechanism should be established to "permanently preserve resident positions, as opposed to individual residents," so long as there is no increase in the total number of FTE residents for which Medicare payment is made.
Response: In proposing § 413.86(g)(8)(iii), which allows a hospital to receive a temporary adjustment to its FTE caps to reflect residents added because of the closure of another hospital's program, we have attempted to make these regulations consistent with the existing regulations at § 413.86(g)(8). These existing regulations allow a hospital to receive a temporary adjustment to its FTE caps to reflect residents added because of the closure of another hospital. Therefore, because the regulations only allow for a temporary cap adjustment in situations involving hospital closure, we believe that it is appropriate to only allow for a temporary adjustment in situations involving program closure, as well.
6. Conforming Change to Regulations Governing Payment to Federally Qualified Health Centers (§ 405.2468(f))
We have discovered a technical error in the regulations at § 405.2468(f) regarding payment to federally qualified health centers (FQHCs) and rural health centers (RHCs) for the costs of graduate medical education. Specifically, § 405.2468(f)(6)(ii)(D) provides that "The costs associated with activities described in § 413.85(d) of this chapter" are not allowable graduate medical education costs. We recently amended § 413.85 in a final rule (66 FR 3358, January 12, 2001) regarding Medicare pass-through payment for approved nursing and allied health education programs. However, we inadvertently did not make a conforming change to § 405.2468(f)(6)(ii)(D). Section 405.2468(f)(6)(ii)(D) should read "The costs associated with activities described in § 413.85(h) of this chapter." We proposed to revise § 405.2468(f)(6)(ii)(D) to reflect this change.
7. Provisions of the August 1, 2000 Interim Final Rule With Comment Period
The following provisions were included in the August 1, 2000 interim final rule with comment period. We are presenting a discussion of these provisions here in order to respond to the public comments received on the provisions and to finalize the rule.
Section 1886(h) of the Act, as revised by Public Law 105-33, caps the number of residents a hospital may count for direct GME and IME. In general, the total number of residents in the fields of allopathic or osteopathic medicine in a hospital may not exceed the number of such FTE residents in the hospital with respect to the hospital's most recent cost reporting period ending on or before December 31, 1996. In the regulations we published on August 29, 1997 (62 FR 46003), May 12, 1998 (63 FR 26327), July 31, 1998 (63 FR 40986), and July 30, 1999 (64 FR 41517), we established special rules for adjusting the FTE resident caps for indirect and direct GME for new medical residency programs. Public Law 106-113 further revised sections 1886(d) and 1886(h) of the Act to allow a hospital's caps to be adjusted if certain additional criteria are met.
a. Counting Primary Care Residents on Certain Approved Leaves of Absence in Base-Year FTE Count (Section 407(a)(1) of Public Law 106-113 and New 42 CFR 412.105(f)(1)(xi) and 413.86(g)(9))
The limit that was placed on the number of residents that a hospital may count for purposes of direct GME and IME is based on the number of residents in the hospital's most recent cost reporting period ending on or before December 31, 1996. In the situation where a primary care resident was previously training in a hospital's residency program, but was on an approved leave of absence during the hospital's most recent cost reporting period ending on or before December 31, 1996, the hospital's FTE cap may be lower than it would have been had the resident not been on an approved leave of absence. Section 407(a) of Public Law 106-113 amended section 1886(h)(4)(F) of the Act to direct the Secretary to count an individual for purposes of determining a hospital's FTE cap, to the extent that the individual would have been counted as a primary care resident for purposes of the FTE cap but for the fact that the individual was on maternity or disability leave or a similar approved leave of absence.
The statute allows a hospital to receive an adjustment for those residents to its individual FTE cap of up to three additional FTE residents. We provided that, in order for a hospital to receive this adjustment, the leave of absence must have been approved by the residency program director to allow the residents to be absent from the program and return to the program after the absence. We required that no later than 6 months after the date of publication of this interim final rule, the hospital must submit a request to the fiscal intermediary for an adjustment to its FTE cap and must provide contemporaneous documentation of the approval of the leave of absence by the residency program director, specific to each additional resident that is to be counted for purposes of the adjustment. For example, a letter to the resident by the residency program director before the resident takes the leave would be sufficient documentation of prior approval of the leave of absence.
Under section 407(a)(3) of Public Law 106-113, this provision is effective for direct GME FTE counts with cost reporting periods beginning on or after November 29, 1999, and for IME FTE counts, with discharges occurring in cost reporting periods beginning on or after November 29, 1999.
We added §§ 412.105(f)(1)(xi) and 413.86(g)(9) to our regulations to incorporate the provisions of section 407(a) of Public Law 106-113.
We received one comment concerning section 407(a)(1) of Public Law 106-113, as implemented at §§ 412.105(f)(1)(xi) and 413.86(g)(9), concerning the counting of primary care residents in certain approved leaves of absence in base-year FTE counts.
Comment: One commenter asked us to consider allowing hospitals to count FTE residents for residents who had been training in an approved residency program at a hospital but then left the hospital during the 1996 base-year and never returned. The commenter stated that the FTE slot in which the "abandoning" resident vacated sometime in 1996 was filled by another resident in 1997 and thereafter, but the hospital has never received any direct or indirect GME payment for this FTE slot.
Response: Section 407(a) of Public Law 106-113 amended section 1886(h)(4)(F) of the Act to direct the Secretary to count an individual for purposes of determining a hospital's FTE cap to the extent that the individual would have been counted as a primary care resident for purposes of the FTE cap but for the fact that the individual "was on maternity or disability leave or a similar approved leave of absence." We believe that this provision was not intended to apply to residents who leave the program in the base-year and never return. The statutory language is quite clear that in order for a hospital to count residents in this provision, the resident must have been on an "approved leave of absence." A "leave of absence" necessarily translates to a resident being away and then returning to the hospital at which the resident had been training.
b. Adjustments to the FTE Cap for Rural Hospitals (Section 407(b)(1) of Public Law 106-113 and 42 CFR 412.105(f)(l)(iv) and 413.86(g)(4))
Public Law 105-33 included several provisions with the intent of encouraging physician training and practice in rural areas. Section 1886(h)(4)(H)(i) of the Act, as added by section 4623 of Public Law 105-33, directed the Secretary, in promulgating rules for the purpose of the FTE cap, to give special consideration to facilities that meet the needs of underserved rural areas. Consistent with the intent of this provision, section 407(b) of Public Law 106-113 provides a 30-percent expansion of a rural hospital's direct and indirect FTE count for purposes of establishing the hospital's individual FTE cap. Specifically, section 407(b) provided that, effective for direct GME with cost reporting periods beginning on or after April 1, 2000, and for IME, with discharges occurring on or after April 1, 2000, the FTE count may equal 130 percent of the number of unweighted residents the rural hospital counted in its most recent cost reporting period ending on or before December 31, 1996.
For example, if a hospital located in a rural area had 10 unweighted FTEs for its count for both direct GME and IME in its most recent cost reporting period ending on or before December 31, 1996, under this new provision the hospital would have a FTE cap of 13 unweighted FTEs, instead of 10 unweighted FTEs, because the hospital is located in a rural area. The revised FTE cap is equal to 130 percent of the number of unweighted residents in its most recent cost reporting period ending on or before December 31, 1996. The rural hospital's new FTE cap, effective April 1, 2000, is now 13 FTEs. However, if a hospital located in a rural area had zero unweighted FTEs for its count for both direct GME and IME in its most recent cost reporting period ending on or before December 31, 1996, under this new provision, this hospital would receive no adjustment to its FTE cap (130 percent of zero is zero FTEs).
We incorporated the provision of section 407(b) of Public Law 106-113 in §§ 412.105(f)(1)(iv) and 413.86(g)(4). We did not receive any comments on this provision.
c. Rural Track FTE Limitation for Purposes of GME and IME for Urban Hospitals that Establish Separately Accredited Approved Medical Programs in a Rural Area (Section 407(c) of Public Law 106-113 and new 42 CFR 412.105(f)(1)(x) and 413.86(g)(11))
In order to encourage the training of physicians in rural areas, section 407(c) of Public Law 106-113 amended section 1886(h)(4)(H) of the Act to add a provision that in the case of a hospital that is not located in a rural area but establishes separately accredited approved medical residency training programs (or rural tracks) in a rural area or has an accredited training program with an integrated rural track, an adjustment may be made to the hospital's cap on the number of residents. For direct GME, the amendment applies to payments to hospitals for cost reporting periods beginning on or after April 1, 2000; for IME, the amendment applies to discharges occurring on or after April l, 2000.
Section 407(c) of Public Law 106-113 did not define "rural tracks" or an "integrated rural track," nor are these terms defined elsewhere in the Social Security Act or in any applicable Federal regulations. Currently, there are a number of accredited residency programs, particularly 3-year primary care residency programs, in which residents train for 1 year of the program at an urban hospital and are then rotated for training for the other 2 years of the 3-year program to a rural facility. These separately accredited "rural track" programs are identified by the Accreditation Council of Graduate Medical Education (ACGME) as "1-2" rural track programs. Accordingly, we implemented section 407(c) to address these "1-2" programs. In addition, we implemented section 407(c) to account for other programs that are not "1-2" programs but which include rural training portions.
As stated above, since there is no existing definition of "rural track" or "integrated rural track," we defined at § 413.86(b) a "rural track" and an "integrated rural track" as an approved medical residency training program established by an urban hospital in which residents train for a portion of the program at the urban hospital and then rotate for a portion of the program to a rural hospital(s) or to a rural nonhospital site(s). We noted that "rural track" and "integrated rural track," for purposes of this definition, are synonymous.
We amended § 413.86 to add paragraph (g)(11) (and amended § 412.105 to add paragraph (f)(1)(x)) to specify that, for direct GME, for cost reporting periods beginning on or after April 1, 2000, (or, for IME, for discharges occurring on or after April 1, 2000), an urban hospital that establishes a new residency program, or has an existing residency program, with a rural track (or an integrated rural track) may include in its FTE count residents in those rural tracks, in addition to the residents subject to the FTE cap at § 413.86(g)(4). An urban hospital may count the residents in the rural track up to a "rural track FTE limitation" for that hospital. We defined this rural track FTE limitation at § 413.86(b) as the maximum number of residents training in a rural track residency program that an urban hospital may include in its FTE count, that is in addition to the number of FTE residents already included in the hospital's FTE cap.
Generally, the rural track policy is divided into two categories: Rural track programs in which residents are rotated to a rural area for at least two-thirds of the duration of the program; and rural track programs in which residents are rotated to a rural area for less than two-thirds of the duration of the program. These two categories are then subdivided according to where the residents are training in the rural area; the residents may be trained in a rural hospital or the residents may be trained in a rural nonhospital site. To account for rural track residency programs with rural rotations that have program lengths greater than or less than 3 years, or that are not "1-2" programs, we specified "two-thirds of the length of the program," instead of "2 out of 3 program years," as a qualification to count FTEs in the rural track.
In the interim final rule with comment period, we specified that urban hospitals that wish to count FTE residents in rural tracks, up to a rural track FTE limitation, must comply with the conditions discussed below:
(1) Rotating Residents for at Least Two-Thirds of the Program to a Rural Hospital(s)
In the August 1, 2000 interim final rule with comment period, we specified at § 413.86(g)(11)(i) that if an urban hospital rotates residents in the rural track program to a rural hospital(s) for at least two-thirds of the duration of the program, the urban hospital may include those residents in its FTE count for the time the rural track residents spend at the urban hospital. The urban hospital may include in its FTE count those residents in the rural track training at the urban hospital, not to exceed its rural track FTE limitation, determined as follows:
• For the first 3 years of the rural track's existence, the rural track FTE limitation for each urban hospital will be the actual number of FTE residents training in the rural track at the urban hospital.
• Beginning with the fourth year of the rural track's existence, the rural track FTE limitation is equal to the product of: (1) The highest number of residents in any program year who, during the third year of the rural track's existence, are training in the rural track at the urban hospital or the rural hospital(s) and are designated at the beginning of their training to be rotated to the rural hospital(s) for at least two-thirds of the duration of the program; and (2) the number of years those residents are training at the urban hospital.
We utilized the term "designated" at § 413.86(g)(11)(i) (as well as at §§ 413.86(g)(11)(ii) and (iv)) to refer to the calculation of the rural track FTE limitation. "Designated" means that the residents must actually have enrolled in that rural track program to rotate for a portion of the rural track program to a rural area (either rural hospital(s) or rural nonhospital site(s)). To be counted as an FTE in this first scenario, these enrolled residents must actually rotate for at least two-thirds of the duration of the program to a rural hospital(s). If a resident, at the beginning of his or her training, intends to train in the rural area for at least two-thirds of the duration of the program, but ultimately never does so, this resident would be proportionately excluded from the urban hospital's rural track FTE limitation.
We noted that if the residents in the rural track are rotating to a rural hospital(s), the rural hospital(s) may be eligible to count the residents as part of its FTE count. If the rural track residency program is a new residency program as specified in redesignated § 413.86(g)(12), the rural hospital may be eligible to receive an FTE cap adjustment for those residents training in the rural track for the time those residents are training at the rural hospital(s), in accordance with the provisions of existing § 413.86(g)(6)(iii). If the rural track residency program is an existing residency program, a rural hospital may be eligible to count the FTE residents training in the rural track at the rural hospital(s), in accordance with the provisions of § 413.86(g)(4), as amended in the interim final rule with comment period to implement section 407(b)(1) of Public Law 106-113.
(2) Rotating Residents for at Least Two-Thirds of the Program to a Rural Nonhospital Site
In the August 1, 2000 interim final rule with comment period, we specified at § 413.86(g)(11)(ii) that if an urban hospital rotates residents in the rural track program to a rural nonhospital site(s) for at least two-thirds of the duration of the program, the urban hospital may include those residents in its FTE count, subject to the requirements under existing § 413.86(f)(4). The urban hospital may include in its FTE count those residents in the rural track, not to exceed its rural track FTE limitation, determined as follows:
• For the first 3 years of the rural track's existence, the rural track FTE limitation for each urban hospital will be the actual number of FTE residents training in the rural track at the urban hospital and the rural nonhospital site.
• Beginning with the fourth year of the rural track's existence, the rural track FTE limitation is equal to the product of: (1) The highest number of residents in any program year who, during the third year of the rural track's existence, are training in the rural track at the urban hospital and are designated at the beginning of their training to be rotated to a rural nonhospital site(s) for at least two-thirds of the duration of the program and the rural nonhospital site(s); and,(2) the number of years in which the residents are expected to complete each program based on the minimum accredited length for the type of program.
We note that we specified at § 413.86(g)(11)(ii) that an urban hospital may include in its FTE count those residents in the rural track rotating to a rural nonhospital site, subject to the requirements under existing § 413.86(f)(4). Section 413.86(f)(4) provides, in part, that a hospital that incurs "all or substantially all" of the costs of training residents in a nonhospital site may include those residents in determining the number of FTE residents (not to exceed the FTE cap) for that hospital. Under this rural track policy, where the urban hospital rotates residents for at least two-thirds of the residency program to a rural nonhospital site, the urban hospital would be eligible to include in its FTE count residents training in the rural track up to its rural track FTE limitation, but the urban hospital must still reimburse the rural nonhospital site for the costs of training those residents, as specified under § 413.86(f)(4). In the August 1, 2000 interim final rule with comment period (66 FR 47034), we included an example of application of this policy.
(3) Rotating Residents for Less Than Two-Thirds of the Program to a Rural Hospital(s)
In the August 1, 2000 interim final rule with comment period, we specified at § 413.86(g)(11)(iii) that if an urban hospital rotates residents in the rural track program to a rural hospital(s) for periods of time that are less than two-thirds of the duration of the program, the urban hospital may not include those residents in its FTE count, nor may the urban hospital include those residents as part of its rural track FTE limitation. However, we noted that, in this scenario, if the rural track residency program is a new residency program as specified in redesignated § 413.86(g)(12), the rural hospital may be eligible to receive an FTE cap adjustment for those residents training in the rural track, in accordance with the provisions of existing § 413.86(g)(6)(iii). If the rural track residency program is an existing residency program, a rural hospital may count the FTE residents training in the rural track at the rural hospital(s), in accordance with the provisions of § 413.86(g)(4), as amended, to incorporate the provisions of section 407(b)(1) of Public Law 106-113.
We are not permitting an urban hospital to count the time of residents training at the urban hospital in a rural track rotating to a rural hospital(s) for less than two-thirds the duration of the program (either as part of the urban hospital's FTE count or as part of its rural track FTE limitation), because to do so would inappropriately allow the urban hospital to circumvent the FTE caps by creating a new program with minimal training in a rural track. However, in this situation, like the other three provisions that concern the training of residents in rural areas, we indicated that we will allow Medicare payment for the rural portion of the training to the rural hospital.
(4) Rotating Residents for Less Than Two-Thirds of the Program to a Rural Nonhospital Site
In the August 1, 2000 interim final rule with comment period, we specified at § 413.86(g)(11)(iv) that if an urban hospital rotates residents in the rural track program to a rural nonhospital site(s) for periods of time that are less than two-thirds of the duration of the program, the urban hospital may include those residents in its FTE count, subject to the requirements under existing § 413.86(f)(4). The urban hospital may include in its FTE count those residents in the rural track, not to exceed its rural track FTE limitation, determined as follows:
• For the first 3 years of the rural track's existence, the rural track FTE limitation for the urban hospital will be the actual number of FTE residents training in the rural track at the rural nonhospital site.
• Beginning with the fourth year of the rural track's existence, the rural track FTE limitation is equal to the product of: (a) The highest number of residents in any program year who, during the third year of the rural track's existence, are training in the rural track at the rural nonhospital site(s); and (b) the length of time in which the residents are being trained at the rural nonhospital site(s).
We noted that, in this situation, an urban hospital would not be able to count the FTE for the rural track resident while the resident is training at the urban hospital. The rural track FTE count and the rural track FTE limitation for the urban hospital would be limited to account for the residents training at the rural nonhospital site.
As in the second scenario at § 413.86(g)(11)(ii), we specified at § 413.86(g)(11)(iv) that an urban hospital may include in its FTE count those residents in the rural track rotating to a rural nonhospital site, subject to the requirements under § 413.86(f)(4). Under the rural track policy, where the urban hospital rotates residents for less than two-thirds of the residency program to a rural nonhospital site, the urban hospital would be eligible to include in its FTE count residents training in the rural track up to its rural track FTE limitation, but the urban hospital must still reimburse the rural nonhospital site for the costs of training those residents, as specified under § 413.86(f)(4).
We noted that, in this last scenario, we are allowing the urban hospital to receive a rural track FTE limitation even in situations where it is rotating residents to a rural area for a minimal period of time (less than two-thirds the duration of the program). However, we believe that this last scenario can be distinguished from the third scenario in which the urban hospital is again rotating residents to a rural area for a minimal portion of the program but to a rural hospital instead of a rural nonhospital site. In the third scenario, we allow Medicare payment to go to the rural hospital for the portion of the urban hospital program that involves rural training (but not to the urban hospital, if the rural hospital is receiving an FTE cap adjustment for that training). However, in the last scenario, we allow the urban hospital to include the rural track residents in its FTE count (and as part of its rural track FTE limitation), based on how long it rotates the residents to the rural nonhospital site (and also incurs all or substantially all of the training costs). We do not believe that the urban hospital can circumvent its FTE cap in this last scenario because it will only count the rural track residents based on the portion of training in the rural nonhospital site. In the interim final rule with comment period (66 FR 47035), we included an example of the last scenario.
(5) Conditions That Apply to All Urban Hospitals
In the August 1, 2000 interim final rule with comment period, we specified that all urban hospitals that wish to count FTE residents in rural tracks, not to exceed their respective rural track FTE limitations, must also comply with each of the following conditions, as stated at §§ 413.86(g)(11)(v) and (vi):
• A hospital may not include in its FTE count residents who are training in a rural track residency program that were already included as part of the hospital's FTE cap (if the rural track program was in existence during the hospital's most recent cost reporting period ending on or before FY 1996).
• A hospital must base its count of residents in a rural track on written contemporaneous documentation that each resident enrolled in a rural track program at the urban hospital intends to rotate for a portion of the residency program to a rural area. For example, written contemporaneous documentation might be a letter of intent signed and dated by the rural track residency program director and the resident at the time of the resident's entrance into the rural track program as a PGY 1.
• All residents who are included by the hospital as part of its FTE count (not to exceed its rural track FTE limitation) must ultimately train in the rural area.
• If we find that residents who are included by the urban hospital as part of its FTE count did not actually complete the training in the rural area, we will reopen the urban hospital's cost report within the 3-year reopening period (as specified in § 405.1885) and adjust the hospital's Medicare GME payments (and, where applicable, the hospital's rural track FTE limitation).
We received several comments regarding the provisions of section 407 of Public Law 106-113 implemented in the August 1, 2000 interim final rule with comment period.
Comment: One commenter cited studies that found that more than half of residents with as little as 3 months of rural training became rural physicians, and, therefore, to best serve the intent of the legislation and significantly increase the number of rural physicians, we should fully fund FTEs with less than two-thirds total training in rural areas.
Response: Section 1886(h)(4)(H)(iv) of the Act, as added by section 407(c) of Public Law 106-113, provides for adjustments to the FTE cap "[i]n the case of a hospital that is not located in a rural area but establishes separately accredited approved medical residency training programs (or rural tracks) in a[] rural area * * *." Thus, in order for a hospital to receive an adjustment under this provision, the training program must be separately accredited. The ACGME has established criteria to separately accredit programs that involve training in rural areas; under these criteria, a training program may be separately accredited if residents in the program train for at least 2 years of the 3-year program at a rural facility. Currently, the ACGME does not separately accredit a program as a rural track program or a program in a rural area unless it meets this "1-2" condition. We make an adjustment to the FTE cap under the rural track provision only if a program is separately accredited, and in order to be separately accredited, the program must meet ACGME's "1-2" criteria. We are amending the regulations at § 413.86 by adding paragraph (g)(11) to reflect this policy .
Furthermore, we believe that incorporating the ACGME's criteria reasonably identifies the situations in which an adjustment to the FTE cap under the rural track provision is warranted. We believe that it is important to limit adjustments under this provision to situations in which residents receive a significant amount of training in rural areas. While we certainly agree that post-residency physician retention in rural areas is important, we believe that it is also important to prevent hospitals from receiving adjustments to the FTE cap in situations when an adjustment is not warranted. We believe that, if an urban hospital could receive an adjustment to its FTE cap by providing only a nominal amount of training in a rural area, then hospitals might be able to inappropriately circumvent the FTE caps. Thus, our policy reflects the requirements of the statute as well as a balancing of considerations (permitting adjustments for hospitals that establish programs that provide a significant amount of training in rural areas, and preventing adjustments for hospitals that do not warrant an adjustment).
Comment: One commenter noted that, for cost reporting periods beginning on or after April 1, 2000, section 407 of Public Law 106-113 allows rural hospitals to increase their FTE resident caps by 30 percent and urban hospitals with rural training tracks to count those residents in rural tracks. The commenter had two concerns: (1) What happens to rural track programs that were in existence between January 1, 1997 and April 1, 2000; and (2) if the intent of the rural track provision is to encourage training in rural areas, then rural track programs in existence between January 1, 1997 and April 1, 2000 should also be permitted to expand by 30 percent.
Response: Section 1886(h)(4)(F) of the Act, as added by section 407(b) of Public Law 106-113, and as implemented at §§ 413.86(g)(4) and 412.105(f)(1)(iv), provides for a 30-percent expansion to a rural hospital's direct and indirect FTE counts for purposes of establishing the hospital's individual FTE cap. Section 407(c) provides for an adjustment to the FTE cap of urban hospitals for training residents in rural areas. Section 407(b) clearly only applies to rural hospitals, and not to urban hospitals, regardless of whether or not the urban hospitals train residents in rural areas. Therefore, while the general intent of the provisions at section 407 is to encourage training in rural areas, only those rural hospitals that have a FTE resident cap based on the count of residents in the hospital's cost reporting period ending on or before December 31, 1996, may qualify for a 30-percent increase to that FTE cap under the amendments made by section 407(b).
To address the commenter's uncertainty concerning what happens to rural track programs that were in existence between January 1, 1997 and April 1, 2000, we point to our language at §§ 413.86(g)(11) and 412.105(f)(1)(x) which states that for cost reporting periods beginning on or after April 1, 2000, "an urban hospital that establishes a new residency program, or has an existing residency program, with a rural track (or an integrated rural track) may include in its FTE count residents in those tracks * * *" (emphasis added). Thus, urban hospitals with rural tracks that were in existence between January 1, 1997 and April 1, 2000, and continue to be in existence afterApril 1, 2000, may be eligible for Medicare payment under this provision. We note that urban hospitals with rural tracks that were established before January 1, 1997, and continued to exist after April 1, 2000, may be eligible for payment under this rural track provision, as well.
We note that we have received questions from the provider industry regarding the application of the rural track FTE limitation and rural track FTE count to hospitals with rural track programs that have already been in existence before April 1, 2000. Generally, the methodology at § 413.86(g)(11) states that the actual count of residents for the first 3 years of the rural track's existence is to be used as the hospital's rural track FTE limitation, and beginning with the fourth year, the rural track FTE limitation is determined based on the number of residents training in the rural track in the third year of the program's existence. However, if a rural track program has been in existence for at least 3 years prior to April 1, 2000, the provision regarding using the actual count of residents in the first 3 years of the program would not apply. Rather, for such a program, the rural track FTE limitation would take effect immediately on April 1, 2000. The limitation would be based on the highest number of residents in any program year training in the rural track in the third year of the program, depending on the amount of time the residents spent in the rural area, subject to the regulations at § 413.85(g)(11)(i) through (iv). It would be the responsibility of the hospital to provide the necessary information regarding the third year of the program to the fiscal intermediary. For example, if the third year of the rural track's existence is July 1, 1997 to June 30, 1998, the rural track FTE limitation would be based on the highest number of residents in any program year in 1997-1998 training year. The urban hospital may begin to count the additional FTEs up to its rural track FTE limitation in its cost reporting period beginning on or after April 1, 2000 for direct GME, and for discharges occurring on or after April 1, 2000 for IME.
Comment: One commenter noted that the interim final rule with comment period states that "all residents that are included by the hospital as part of its FTE count must ultimately train in the rural area." The commenter expressed concern that we are requiring hospitals to designate specific individuals, rather than FTEs, and that basing payment on individuals rather than FTEs would set a poor precedent. The commenter further stated that, while specific individuals may not remain in a program, hospitals should be permitted to fill these slots with FTEs and receive payment.
Response: The commenter is concerned with the provision at § 413.86(g)(11)(v)(C), which states that all residents that are included by the hospital as part of its FTE count under this provision must ultimately train in the rural area. As the commenter correctly assesses, this particular provision would link the rural track policy to specific individual residents, rather than FTEs. We made this link to individuals rather than FTEs because we believe the additional provision at § 413.86(g)(11)(v)(C) (as well as the provision at §§ 413.86(g)(11)(v)(B)) was necessary in order to ensure that urban hospitals did not count additional FTE residents who did not actually rotate at any time to a rural area.
However, we understand the commenter's concern about permitting hospitals to fill slots with FTEs that are open because individuals did not remain in the program. We agree that where a hospital fills a vacated FTE slot in a rural 1-2 program with another resident, it would be consistent with the intent of the rural track provision to allow the urban hospital to count the time of the resident who left the training program. Accordingly, we are amending the regulations at § 413.86(g)(11)(v)(C) to allow for the counting of the resident's time at the urban hospital where, for example, a resident who just completed her PGY1 year at the urban hospital decides to drop out of the program, and then the urban hospital fills the vacated FTE slot with another PGY2 resident who then continues and completes the rural portion of the rural track program. We note that we would not allow for the counting of the time at the urban hospital for the first year of training for that resident who left the program where the urban hospital fills the vacated FTE slot with another PGY1 resident who first begins to train in the urban hospital, since, in effect, this would result in double counting one FTE at the urban hospital without the required amount of training occurring in the rural area.
Comment: One commenter expressed concern with the provision at § 413.86(g)(11)(v)(A) that states "an urban hospital may not include in its rural track FTE limitation or FTE count residents who are training in a rural track residency program that were already included as part of the hospital's FTE cap." The commenter stated that this provision fails to account for the fact that many hospitals may have "backed out" residents training time in rural sites from their base year FTE cost reports. The commenter stated further that this provision may be interpreted by cost report accountants to mean that appeals to include FTEs that were excluded by Public Law 105-33 are prohibited.
Response: We believe the commenter is confusing the provision at § 413.86(g)(11)(v)(A), that an urban hospital may not include in its rural track FTE limitation or rural track FTE count residents who are training in a rural track residency program that were already included as part of the hospital's FTE cap, and the policy contained in section 4623 of Public Law 105-33, as implemented at §§ 412.105(f)(1)(iv) and 413.86(g)(4), which places a limit on the count of residents, or hospitals' FTE caps. The intent of the provision at § 413.86(g)(11)(v)(A) is to encourage more residency training in rural areas by providing for Medicare payment to an urban hospital for FTE residents who are training in a rural area and are not already included as part of the hospital's FTE cap. Whether or not there are many hospitals that have "backed out" resident training time in rural sites from their base year FTE cost reports is irrelevant to this rural track requirement. The possible mistaken exclusion of the count of resident FTEs spent in rural settings is an issue relevant to the determination of a hospital's initial FTE cap as provided for at §§ 412.105(f)(1)(iv) and 413.86(g)(4). The rural track requirement at § 413.86(g)(11)(v)(A) was not intended to provide for adjustments to reflect FTEs that were excluded from the FTE cap.
With regard to rural training, generally, and the determination of a hospital's FTE cap under §§ 412.105(f)(1)(iv) and 413.86(g)(4), a FTE resident should not have been included in the hospital's FTE cap to the extent that, in that cost reporting year, the resident was rotating to another rural hospital, or if the resident was rotating to a rural nonhospital to which the urban hospital was not paying all or substantially all of the costs of training (see § 413.86(f)(3)).
To clarify the intent of the requirement that "an urban hospital may not include in its rural track FTE limitation or FTE count residents who are training in a rural track residency program that were already included as part of the hospital's FTE cap," we are providing the following example:
• Assume there are 10 unweighted FTE residents training at an urban Hospital A in the hospital's most recent cost reporting period ending on or before December 31, 1996, thereby establishing Hospital A's FTE cap at 10.
• In July 2002, Hospital A starts a rural training track program. In addition to devoting 2 out of its 10 FTE slots to the rural track, Hospital A recruits an additional 2 FTEs to participate in the rural track, for a total of 12 FTEs to be trained in that cost reporting year.
• These 4 FTEs will complete 1 year of training at Hospital A and 2 years of training at a rural nonhospital site. This type of program is modeled after the scenario outlined at § 413.86(g)(11)(ii), where the urban hospital may include in its FTE count the FTEs in the rural track at the urban hospital and at the rural nonhospital site. (Hospital A is complying with the requirements at § 413.86(f)(4) regarding the counting of residents in nonhospital sites).
However, when calculating the rural track FTE limitation in the fourth year of the rural track's existence, Hospital A may not include in its rural track FTE limitation those FTEs that were already included as part of the hospital's initial FTE cap. Two of the hospital's four FTEs training in the rural track were already included in the hospital's FTE cap. Therefore, beginning July 2002, only two FTEs may be included to determine the hospital's rural track FTE limitation, as well as its rural track FTE count. Since it is the two FTEs that Hospital A added when it started the rural track that have caused the hospital to exceed its FTE cap, only two FTEs may be counted above the FTE cap for the hospital's rural track FTE count and limitation. However, we note that the other two FTEs training in the rural track that were not included as part of the hospital's rural FTE count and limitation because they had already been included as part of the hospital's FTE cap, may still be counted by the hospital in its general FTE count, according to §§ 412.105(f) and 413.86(f).
Comment: One commenter requested that, since rural hospitals often do not have the resources or infrastructure to claim their GME costs on a Medicare cost report, we should revise the regulations to allow urban hospitals to claim the resident FTEs training at the rural hospitals, as long as the urban hospitals are providing "adequate funding" to the rural hospital, similar to our Medicare policy on nonhospital settings.
Response: In regard to the request to allow urban hospitals to claim the FTEs training in rural hospitals, while we understand that it is not uncommon for urban hospitals to incur the costs of training residents in rural hospitals because the rural hospitals cannot incur the costs themselves, there is longstanding policy that prohibits one hospital from claiming the training time of FTEs training at another hospital. First, section 1886(h)(4)(B) of the Act states that the rules governing the direct GME computation of count of the number of FTE residents "shall take into account individuals who serve as residents for only a portion of a period with a hospital or simultaneously with more than one hospital." Accordingly, the September 4, 1990 Federal Register (55 FR 36065) states that "* * * the other hospital is required to include the portion of time the resident spent at its facility in its FTE count consistent with § 413.86(f)." Further, the regulations at § 413.86(f)(2) state that "No individual may be counted as more than one FTE * * *. [I]f a resident spends time in more than one hospital * * * the resident counts as partial FTE based on the proportion of time worked at the hospital to the total time worked * * *." Therefore, even though the urban hospital incurs the training costs and the rural hospital does not claim the FTEs for Medicare direct GME and IME payment purposes, the urban hospital is precluded from claiming any FTEs training at the rural hospital (or any other hospital, for that matter). The commenter is correct in stating that a hospital may count the time residents spend in nonhospital settings if they comply with the criteria at § 413.86(f)(4). However, this regulation implements statutory provisions (sections 1886(d)(5)(B)(iv) and 1886(h)(4)(E) of the Act), which specifically provide for Medicare direct GME and IME payment to be made to hospitals for training residents in nonhospital settings.
Comment: One commenter objected to the policy in the interim final rule with comment period that the terms "rural track" and "integrated rural track" are synonymous. The commenter (a hospital) believed that we have the authority to develop a new definition for "integrated rural track" based on our interpretations of congressional intent, and we should not wait for further clarification from Congress at the expense of the commenter's particular allopathic family practice residency program. The commenter described this program as one in which the residents train in the rural setting for approximately 7 months out of a 3-year program, and for the remainder of the program when the residents spend training in the urban setting, the residents treat rural patients. The commenter proposed the following new definition for integrated rural track: " Accredited Training Program with an Integrated Rural Track -refers to an accredited program that provides at least 6 months of training at a rural location in addition to 2 years of rural training at an urban location. The 6 months of rural training should be conducted as part of all 3 years of training. The program should also establish a continuity of care with patients in a rural area for at least one program year."
Response: When we implemented this provision on August 1, 2000, we did so based on discussions with the Accreditation Council for Graduate Medical Education (ACGME), which accredits rural track programs. The ACGME specifically identifies and separately accredits programs with 1 year of training in an urban hospital and 2 years of training in a rural facility as "rural tracks." However, the ACGME explained that it did not have a separate definition of "integrated rural track" and, in particular, did not separately classify programs with portions of rural training of less than 2 years as "integrated rural tracks". In response to questions raised on this provision, we have followed up with the ACGME to confirm whether a definition of, or criteria for identifying programs with, "integrated rural tracks" had been established. We were informed that the term "integrated rural track" is not, and never was, a term that is used by the ACGME in accrediting its programs. Other than the 1-2 programs that specifically incorporate 2 years of rural training, the ACGME does not grant unique accreditation to programs with a rural focus, nor do any of the other accreditation organizations listed at § 415.152.
In addition, we do not believe it is administratively feasible for us to review documentation and confirm that the training at the urban hospital, as suggested by the commenter, is rural in nature, based on the patient load treated by the residents at the urban hospital. We currently do not have a way of tying patient data to the residents that treat them. Accordingly, for purposes of this policy, until we believe we can appropriately categorize and define rural tracks and integrated rural tracks separately, we will continue to define these terms synonymously. We remain open to adopting another definition of a separately accredited training program, and we welcome suggestions for definitions that would be administratively feasible to apply.
Comment: One commenter suggested that we add a fifth scenario to those already described at § 413.86(g)(11). The commenter proposed the following regulation text:
Rotating Residents of an Accredited Training Program with an Integrated Rural Track to a Rural Nonhospital Site -If an urban hospital rotates residents in an accredited training program with an integrated rural track to a rural nonhospital site throughout all 3 years of training, the urban hospital may include those residents in its FTE count, subject to the requirements under existing § 413.86(g)(4). The urban hospital may include in its FTE count those residents in the rural track, not to exceed its rural track FTE limitation, determined as follows:
(A) For the first 3 years of the integrated rural track's existence, the rural track FTE limitation for each urban hospital will be the actual number of FTE residents training in the rural track at the urban hospital and the rural nonhospital site.
(B) Beginning with the fourth year of the integrated rural track's existence, the rural track FTE limitation is equal to the product of:
( 1 ) The highest number of residents in any program year who, during the third year of the integrated rural track's existence, are training in the integrated rural track at the urban hospital and are designated at the beginning of their training to be rotated to a rural nonhospital site throughout all 3 years of training, and
( 2 ) The number of years in which the residents are expected to complete each program based on the minimum accredited length for the type of program.
(C) This would apply to accredited training programs with integrated rural tracks that were in existence prior to 1997.
The commenter explained that this language is designed to address the unique program at the commenter's hospital, and it also is date sensitive so that newer programs would be required to comply with the existing criteria in the existing regulations.
Response: We have concerns about the commenter's proposal. First, the commenter assumes a separate definition of "integrated rural track," which, as explained above, we currently do not have. Even if we were to adopt such a change in policy, the cut-off date of 1997 in paragraph (C) of the commenter's proposed changes seems arbitrary; there is nothing in the statute that would serve as a basis to simply grandfather existing "integrated rural track" programs and not provide for new ones post-1997. Accordingly, we are not adopting such a change in our rural track policy as the one described by the commenter.
Comment: One commenter thought that if a hospital's rural track program has been in existence since 1993, then the 4th program year is 1997. The commenter explained that when the FTE cap went into effect, the hospital was capped at 15 FTEs. The hospital subsequently added another three residents at its own expense. The commenter stated that it interprets § 413.86(g)(11)(v)(A) to mean that the hospital would only be able to count the additional three FTE residents for the rural track count. The commenter urged us to reconsider this language as it relates to hospitals with only one residency program, because the commenter was unsure whether or not all the residents in the program count toward the rural track FTE count. The commenter believed that for hospitals with only one residency program that existed prior to 1996, all rural track residents included in the original hospital FTE cap should be counted toward the rural FTE count.
Response: The commenter correctly interprets the intent of the regulation at § 413.86(g)(11)(v)(A), which states that only those FTEs in the rural track that were not already counted as part of the hospital's FTE cap may be considered when calculating the hospital's rural track FTE limitation and count. In the scenario the commenter outlined above, if the first program year of the rural track program began on July 1, 1993, then the fourth program year would begin on July 1, 1996, not in 1997. Because 15 FTEs were already included in the hospital's FTE cap, assuming the urban hospital qualifies to count the FTEs, only 3 out of the 18 FTE residents training in the program may be considered in determining the hospital's rural track FTE limitation and counts (the specific rural FTE limitation and count are dependent upon which scenario the hospital's program fits under § 413.86(g)(11)).
We do not believe it is necessary to revise this policy for hospitals whose only GME program is the rural track program that was in existence prior to 1996, as the commenter suggested. Hospitals that had rural track programs in existence in 1996 were able to count those residents training at the urban hospital at that time as part of their initial FTE caps. Our existing policy on rural tracks at § 413.86(g)(11) provides additional assistance to these hospitals by allowing them to count separately in their rural track FTE limitations, FTE residents not included in the FTE cap but participating in a rural track.
Accordingly, we are adopting the provisions in the August 1, 2000 interim final rule with comment period implementing section 407(c) of Public Law 106-113 as final.
In addition, we are making a technical correction. The regulations at § 413.86(g)(6) currently state, "If a hospital established a new medical residency training program as defined in paragraph (g)(9) of this section * * *." When we revised the regulations at § 413.86(g)(9) to redesignate the paragraph as § 413.86(g)(12) in the August 1, interim final rule with comment period, we inadvertently did not make a corresponding revision at § 413.86(g)(6). Therefore, we are revising § 413.86(g)(6) to read "If a hospital established a new medical residency training program as defined in paragraph (g)(12) of this section * * *" We are making the same revision to the regulations for IME at § 412.105(f)(vii).
d. Not Counting Against Numerical Limitation Certain Residents Transferred from a Department of Veterans AffairsHospital's Residency Program That Loses Accreditation(Section 407(d) of Public Law 106-113 and new 42 CFR 412.105(f)(1)(xii) and 413.86(g)(10))
Section 407(d) of Public Law 106-113 addressed the situation where residents were training in a residency training program at a Veterans Affairs (VA) hospital and then were transferred on or after January 1, 1997, and before July 31, 1998, to a non-VA hospital because the program in which the residents were training would lose its accreditation by the ACGME if the residents continued to train at the VA hospital. In this situation, the non-VA hospital may receive a temporary adjustment to its FTE cap to reflect those residents who were transferred to the non-VA hospital for the duration that those transferred residents were training at the non-VA hospital. In the August 1, 2000 interim final rule with comment period, we specified that, in order to receive this adjustment, the non-VA hospital must submit a request to its fiscal intermediary for a temporary adjustment to its FTE cap, document that the hospital is eligible for this temporary adjustment by identifying the residents who have come from the VA hospital, and specify the length of time the adjustment is needed.
We noted that section 407(d) of Public Law 106-113 only refers to programs that would lose their accreditation by the ACGME. This provision does not apply to accreditation by the American Osteopathy Association (AOA), the American Podiatry Association (APA), or the American Dental Association (ADA).
Under section 407(d)(3) of Public Law 106-113, this policy is effective as if included in the enactment of Public Law 105-33, that is, for direct GME, with cost reporting periods beginning on or after October 1, 1997, and for IME, discharges occurring on or after October 1, 1997. If a hospital is owed payments as a result of this provision, payments must be made immediately.
We added §§ 412.105(f)(1)(xii) and 413.86(g)(10) to incorporate the provisions of section 407(d) of Public Law 106-113.
We did not receive any comments on this provision and are adopting it as final.
e. Initial Residency Period for Child Neurology Residency Programs (Section 312 of Public Law 106-113 and 42 CFR 413.86(g)(1))
Generally, section 1886(h)(5)(F) of the Act defines the term "initial residency period" to mean the "period of board eligibility." The period of board eligibility is defined in section 1886(h)(5)(G) of the Act as the period recognized by ACGME as specified in the Graduate Medical Education Directory which is published by the American Medical Association. The initial residency period limitation was designed to limit full Medicare payment for direct GME to the time required to train in a single specialty. Therefore, the initial residency period is determined based on the minimum time required for a resident to become board eligible in a specialty and the published periods included in the Graduate Medical Education Directory. During the initial residency period, the residents are weighted at 1.0 FTE for purposes of Medicare payment. Residents seeking additional specialty or subspecialty training are weighted at 0.5 FTE.
In order to become board eligible in child neurology, residents must complete training in more than one specialty. Thus, for example, before the effective date of section 312 of Public Law 106-113, if a resident enrolled in a child neurology residency program by first completing 2 years of training in pediatrics (which is associated with a 3-year initial residency period), followed by 3 years of training in child neurology, the resident would be limited by the initial residency period of pediatrics. Section 312 of Public Law 106-113 amended section 1886(h)(5) of the Act by adding at the end a clause (v) which states that "in the case of a resident enrolled in a child neurology residency training program, the period of board eligibility and the initial residency period shall be the period of board eligibility for pediatrics plus 2 years." (The initial residency period for pediatrics is currently 3 years). The policy under section 312(b) of Public Law 106-113 applies to future child neurology residents and to child neurology residents who have already begun their training (for whom an initial residency period was already established). However, it does not apply to residents who have completed their child neurology training before July 1, 2000.
In the August 1, 2000 interim final rule with comment period, we revised § 413.86(g)(1) to reflect that, effective on or after July 1, 2000, for residency programs that began before, on, or after November 29, 1999, the period of board eligibility and the initial residency period for child neurology is now the period of board eligibility for pediatrics plus 2 years. We noted that the initial residency period is the same for all child neurology residents, regardless of whether or not the resident completes the first year of training in pediatrics or neurology.
We did not receive any comments on this provision and are adopting it as final.
f. Technical Amendment
In the August 1, 2000 interim final rule with comment period, we indicated that it had come to our attention that the first sentence of the then existing § 413.86(g)(1) contains a technical error. The first sentence of this paragraph reads "For purposes of this section, an initial residency period is the number of years necessary to satisfy the minimum requirements for certification in a specialty or subspecialty, plus one year." This section of the regulation was revised as a result of section 13563(b) of Public Law 103-66, and was effective only until June 30, 1995. Generally, effective July 1, 1995, an initial residency period is defined as the minimum number of years required for board eligibility. Therefore, we revised the first sentence of paragraph (g)(1) of § 413.86 accordingly. The remainder of paragraph (g)(1) of § 413.86 was unchanged.
We did not receive any comments on this provision and are adopting it as final.
I. Additional Payment to Hospitals that Operate Approved Nursing and Allied Health Education Programs
Under sections 1861(v) and 1886(a) of the Act, hospitals that operate approved nursing or allied health education programs may be eligible for the reimbursement of their reasonable costs of operating such programs. Section 1886(h) of the Act establishes the methodology for determining payments to hospitals for the direct costs of GME programs. Section 1886(h) of the Act, as implemented in regulations at 42 CFR 413.86, specifies that Medicare payments for direct costs of GME are based on a prospectively determined per resident amount (PRA). The PRA is multiplied by the number of full-time equivalent residents working in all areas of the hospital complex (and nonhospital sites, where applicable), and the product is then multiplied by the hospital's Medicare share of total inpatient days to determine Medicare's direct GME payment.
Section 1886(h)(3)(D) of the Act, as added by section 4624 of Public Law 105-33, provides a 5-year phase-in of payments to teaching hospitals for direct costs of GME associated with services to Medicare+Choice (managed care) enrollees for portions of cost reporting periods occurring on or after January 1, 1998. The amount of payment for direct GME is calculated by (1) multiplying the aggregate approved amount (that is, the product of the PRA and the number of FTE residents working in all areas of the hospital (and nonhospital sites, if applicable)), by the ratio of the number of inpatient bed days that are attributable to Medicare+Choice enrollees to total inpatient bed days, and (2) multiplying the result by an applicable percentage.
The applicable percentages are 20 percent for portions of cost reporting periods occurring in calendar year 1998, 40 percent in calendar year 1999, 60 percent in calendar year 2000, 80 percent in calendar year 2001, and 100 percent in calendar year 2002 and subsequent years. (Section 1886(d)(11) of the Act, as added by section 4622 of Public Law 105-33, provides a 5-year phase-in of payments to teaching hospitals for IME associated with services to Medicare+Choice enrollees for portions of cost reporting periods occurring on or after January 1, 1998, as well. However, the Medicare+Choice IME payments are irrelevant for the purposes of this section of the interim final rule with comment period, because although section 541 of Public Law 106-113 affects the payments for Medicare+Choice direct GME, it in no way affects the payments for Medicare+Choice IME.)
1. Provisions of the August 1, 2000 Interim Final Rule with Comment Period (Section 541 of Public Law 106-113 and 42 CFR 413.86(d) and 413.87)
Section 541 of Public Law 106-113 further amended section 1886 of the Act by adding subsection (l) and amending section 1886(h)(3)(D) to provide for additional payments to hospitals for nursing and allied health education programs associated with services to Medicare+Choice enrollees. Hospitals that operate approved nursing or allied health education programs, as defined under the regulations at 42 CFR 413.85, and receive Medicare reasonable cost reimbursement for these programs, would receive additional payments. This provision is effective for portions of cost reporting periods occurring in a calendar year, beginning with calendar year 2000.
Section 1886(l) of the Act, as added by section 541 of Public Law 106-113, specifies the methodology to be used to calculate these additional payments and places a limitation, that is, $60 million, on the total amount that is projected to be expended in any calendar year. We refer to the total amount of $60 million or less as the payment "pool." We emphasize that we use the term "pool" solely for ease of reference; the term reflects an estimated dollar figure, a number that is plugged into a formula to calculate the amount of additional payments. The term "pool" does not refer to a discrete fund of money that is set aside in order to make the additional payments (thus, for example, if the estimated "pool" is $50 million, we use the number $50 million to calculate the amount of additional payments, but this does not mean that we set aside $50 million in a separate fund from which we make the additional payments). The total amount of additional payments is based on the ratio of estimated total direct GME payments for Medicare+Choice enrollees to estimated total Medicare direct GME payments, multiplied by the total Medicare nursing and allied health education payments. Under section 541 of Public Law 106-113, a hospital would receive its share of these additional payments in proportion to the amount of Medicare nursing and allied health education payments received in the cost reporting period that ended in the fiscal year that is 2 years prior to the current calendar year, to the total amount of nursing and allied health payments made to all hospitals in that cost reporting period. Section 541(b) of Public Law 106-113 amended section 1886(h)(3) of the Act to provide that direct GME payments for Medicare+Choice utilization will be reduced to account for the additional payments that are made for nursing and allied health education programs under the provisions of section 1886(l) of the Act.
In the August 1, 2000 interim final rule with comment period, we implemented section 541 by establishing regulations at 42 CFR 413.87 to incorporate the provisions of section 1886(l) of the Act. We specified the rules for a hospital's eligibility to receive the additional payment under section 1886(l), the requirements for determining the additional payment to each eligible hospital, and the methodologies for calculating each additional payment and for calculating the payment "pool." The preamble language regarding § 413.87 can be found in the August 1, 2000 interim final rule with comment period (65 FR 47036 through 47039).
We also made a conforming change to §§ 413.86(d)(4) through (d)(6) to account for the revised methodology in determining a hospital's Medicare+Choice direct GME payments.
2. Provisions of the June 13, 2001 Interim Final Rule with Comment Period
a. Additional Payment to Hospitals That Operate Approved Nursing and Allied Health Programs (Section 512 of Public Law 106-554 and 42 CFR 413.87)
Public Law 106-554 further amended section 1886(l)(2)(C) of the Act. Specifically, section 512 of Public Law 106-554 changed the formula for determining the additional amounts to be paid to hospitals for Medicare+Choice nursing and allied health costs. Under Public Law 106-113, as described above, the additional payment amount was determined based on the proportion of each individual hospital's nursing and allied health education payments to total nursing and allied health education payments made across all hospitals. This formula does not account for a hospital's specific Medicare+Choice utilization. Section 512 of Public Law 106-554 revised this payment formula to specifically account for each hospital's Medicare+Choice utilization. Accordingly, we made conforming changes at § 413.87 to reflect this change. The changes are effective for portions of cost reporting periods occurring on or after January 1, 2001. We refer the reader to the preamble of the June 13 interim final rule with comment period for a detailed description of the revised methodology for calculating the additional payments (66 FR 32178).
We revised § 413.87 to incorporate the provisions of section 512 of Public Law 106-554.
b. Technical Amendment
In the June 13, 2001 interim final rule with comment period, we indicated that it had come to our attention that the regulations at § 413.86(d)(4) and § 413.87(d) contained errors. The regulations at § 413.86(d)(4) had read, "Effective for cost reporting periods beginning on or after January 1, 2000, the product derived from step three is reduced in accordance with the provisions of § 413.87(f)." Consistent with the statutory effective date and to clarify the intent of the reference to § 413.87(f), we revised § 413.86(d)(4) to state that, "Effective for portions of cost reporting periods occurring on or after January 1, 2000, the product derived from step three is reduced by a percentage equal to the ratio of the Medicare+Choice nursing and allied health payment "pool" for the current calendar year as described at § 413.87(f), to the projected total Medicare+Choice direct GME payments made to all hospitals for the current calendar year." We also made a conforming change to § 413.87(d), which had read, "Subject to the provisions of paragraph (f) of this section * * *." Instead, we revised this language to state, "Subject to the provisions of § 413.86(d)(4) * * *."
J. Payment for Bad Debts (Section 541 of Public Law 106-554 and 42 CFR 413.80)
Section 4451 of Public Law 105-33 required that allowable bad debt reimbursement for hospitals be reduced by 25 percent for cost reporting periods beginning during FY 1998, by 40 percent for cost reporting periods beginning during FY 1999, and by 45 percent for cost reporting periods beginning during a subsequent fiscal year.
In the June 13, 2001 interim final rule with comment period (66 FR 32183), we implemented section 541 of Public Law 106-554. Section 541 amended section 1861(v)(1)(T) of the Act, thereby modifying the reduction in payment for Medicare beneficiary bad debt for hospitals made by section 4451 of Public Law 105-33. Specifically, this provision reduced the amount of bad debts otherwise treated as allowable reductions in revenue, attributable to the deductibles and coinsurance amounts, by 30 percent for cost reporting periods beginning during FY 2001 and later. Therefore, for cost reporting periods beginning during the year 2001 and later, hospital bad debt amounts otherwise allowable will be reimbursed at 70 percent of the total allowable amount. In the June 13 interim final rule with comment period, we revised § 413.80 to implement this change.
We did not receive any comments on this provision and, therefore, are adopting the proposed revision to § 413.80 as final.
V. Changes to the Prospective Payment System for Capital-Related Costs
A. End of the Transition Period
Federal fiscal year (FY) 2001 is the last year of the 10-year transition period established to phase in the prospective payment system for hospital capital-related costs. For the readers' benefit, we are providing a summary of the statutory basis for the system, the development and evolution of the system, the methodology used to determine capital-related payments to hospitals, and the policy for providing exceptions payments during the transition period.
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." Under the statute, the Secretary has broad authority in establishing and implementing the capital prospective payment system. We initially implemented the capital prospective payment system in the August 30, 1991 final rule (56 FR 43409), in which we established a 10-year transition period to change the payment methodology for Medicare inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate).
The 10-year transition period established to phase-in the prospective payment system for capital-related costs is effective for cost reporting periods beginning on or after October 1, 1991 (FY 1992) and before October 1, 2001 (FY 2002). Beginning in FY 2001, the last year of the 10-year transition period for the prospective payment system for hospital capital-related costs, capital prospective payment system payments are based solely on the Federal rate for the vast majority of hospitals. Since FY 2001 is the final year of the capital transition period, we will no longer determine a hospital-specific rate for FY 2002 in section III. of the Addendum of this final rule. For cost reporting periods beginning on or after October 1, 2001, payment for capital-related costs for all hospitals, except those defined as new hospitals under § 412.324(b), will be determined based solely on the capital standard Federal rate.
Generally, during the transition period, inpatient capital-related costs are paid on a per discharge basis, and the amount of payment depends on the relationship between the hospital-specific rate and the Federal rate during the hospital's base year. A hospital with a base year hospital-specific rate lower than the Federal rate is paid under the fully prospective payment methodology during the transition period. This method is based on a dynamic blend percentage of the hospital's hospital-specific rate and the applicable Federal rate for each year during the transition period. A hospital with a base period hospital-specific rate greater than the Federal rate is paid under the hold-harmless payment methodology during the transition period.
During the transition period, a hospital paid under the hold-harmless payment methodology receives the higher of (1) a blended payment of 85 percent of reasonable cost for old capital plus an amount for new capital based on a portion of the Federal rate; or (2) a payment based on 100 percent of the adjusted Federal rate. The amount recognized as old capital is generally limited to the allowable Medicare capital-related costs that were in use for patient care as of December 31, 1990. Under limited circumstances, capital-related costs for assets obligated as of December 31, 1990, but put in use for patient care after December 31, 1990, also may be recognized as old capital if certain conditions were met. These costs are known as obligated capital costs. New capital costs are generally defined as allowable Medicare capital-related costs for assets put in use for patient care after December 31, 1990.
Hospitals that are defined as "new" for the purposes of capital payments during the transition period (see § 412.300(b)) will continue to be paid according to the applicable payment methodology outlined in § 412.324. During the transition period, new hospitals are exempt from the prospective payment system for capital-related costs for their first 2 years of operation and are paid 85 percent of their reasonable capital-related costs during that period. The hospital's first 12-month cost reporting period (or combination of cost reporting periods covering at least 12 months), beginning at least 1 year after the hospital accepts its first patient, serves as the hospital's base period. Those base year costs qualify as old capital and are used to establish its hospital-specific rate used to determine its payment methodology under the capital prospective payment system. Effective with the third year of operation and through the remainder of the transition period, the hospital will be paid under either the fully prospective methodology or the hold-harmless methodology. If the fully prospective methodology is applicable, the hospital is paid using the appropriate transition blend of its hospital-specific rate and the Federal rate for that fiscal year until the conclusion of the transition period, at which time the hospital will be paid based on 100 percent of the Federal rate. If the hold-harmless methodology is applicable, the hospital will receive hold-harmless payment for assets in use during the base period for 8 years, which may extend beyond the 10-year transition period.
The basic methodology for determining capital prospective payments based on the Federal rate is set forth in § 412.312. For the purpose of calculating payments for each discharge, the standard Federal rate is adjusted as follows:
(Standard Federal Rate) × (DRG Weight) × (GAF) × (Large Urban Add-on, if applicable) × (COLA Adjustment for Hospitals Located in Alaska and Hawaii) × (1 + DSH Adjustment Factor + IME Adjustment Factor)
Hospitals may also receive outlier payments for those cases that qualify under the thresholds established for each fiscal year. Section 412.312(c) provides for a single set of thresholds to identify outlier cases for both inpatient operating and inpatient capital-related payments.
In accordance with section 1886(d)(9)(A) of the Act, under the prospective payment system for inpatient operating costs, hospitals located in Puerto Rico are paid for operating costs under a special payment formula. Prior to FY 1998, hospitals in Puerto Rico were paid a blended rate that consisted of 75 percent of the applicable standardized amount specific to Puerto Rico hospitals and 25 percent of the applicable national average standardized amount. However, effective October 1, 1997, under amendments to the Act enacted by section 4406 of Public Law 105-33, operating payments to hospitals in Puerto Rico are based on a blend of 50 percent of the applicable standardized amount specific to Puerto Rico hospitals and 50 percent of the applicable national average standardized amount. In conjunction with this change to the operating blend percentage, effective with discharges on or after October 1, 1997, we compute capital payments to hospitals in Puerto Rico based on a blend of 50 percent of the Puerto Rico rate and 50 percent of the Federal rate as specified in the regulations at § 412.374. For capital-related costs, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital-related costs.
In the August 30, 1991 final rule (56 FR 43409), we established a capital exceptions policy, which provided for exceptions payments during the transition period (§ 412.348). Section 412.348 provides that during the transition period, a hospital may receive additional payment under the exceptions process when its regular payments are less than a minimum percentage, established by class of hospital, of the hospital's reasonable capital-related costs. The amount of the exceptions payment is the difference between the hospital's minimum payment level and the payments the hospital would have received under the capital prospective payment system in the absence of an exceptions payment. The comparison is made on a cumulative basis for all cost reporting periods during which the hospital has been subject to the capital prospective payment transition rules. The minimum payment percentages throughout the transition period for regular capital exceptions payments by class of hospitals are:
• For sole community hospitals, 90 percent;
• For urban hospitals with at least 100 beds that have a disproportionate share patient percentage of at least 20.2 percent or that received more than 30 percent of their net inpatient care revenues from State or local governments for indigent care, 80 percent;
• For all other hospitals, 70 percent of the hospital's reasonable inpatient capital-related costs.
The provision for "regular" exceptions payments expires at the end of the transition period, that is, for cost reporting periods beginning after September 30, 2001. Capital prospective payment system payments are no longer adjusted to reflect regular exceptions payments at § 412.348 after that date. Accordingly, for cost reporting periods beginning on or after October 1, 2001, all hospitals other than those defined as "new" under § 412.324(b) will receive only the per discharge payment based on the Federal rate for capital costs (plus any applicable DSH or IME and outlier adjustments) unless a hospital qualifies for a special exceptions payment under § 412.348(g).
B. Special Exceptions Process
In the August 30, 1991 final rule (56 FR 43409), we established a capital exceptions policy at § 412.348, which provided for regular exception payments during the transition period. In the September 1, 1994 final rule (59 FR 45385), we added the special exceptions process, describing it as "* * * narrowly defined, focusing on a small group of hospitals who found themselves in a disadvantaged position. The target hospitals were those who had an immediate and imperative need to begin major renovations or replacements just after the beginning of the capital prospective payment system. These hospitals would not be eligible for protection under the old capital and obligated capital provisions, and would not have been allowed any time to accrue excess capital prospective payments to fund these projects."
Under the special exceptions provisions at § 412.348(g), an additional payment may be made through the 10th year beyond the end of the capital prospective payment system transition period for eligible hospitals that meet (1) a project need requirement as described at § 412.348(g)(2), which, in the case of certain urban hospitals, includes an excess capacity test; and (2) a project size requirement as described at § 412.348(g)(5). Eligible hospitals include sole community hospitals, urban hospitals with at least 100 beds that have a disproportionate share patient percentage of at least 20.2 percent, and hospitals with a combined Medicare and Medicaid inpatient utilization of at least 70 percent.
When we established the special exceptions process, we selected the hospital's cost reporting period beginning before October 1, 2001, as the project completion date in order to limit cost-based exceptions payments to a period of not more than 10 years beyond the end of the 10-year transition to the fully Federal capital prospective payment system. Therefore, hospitals are eligible to receive special exceptions payments for the 10 years after the cost reporting year in which they complete their project. Generally, if a project is completed in the hospital cost reporting period ending September 29, 2002, exceptions payments would continue through September 29, 2012. In addition, we believe that, for projects completed after the deadline, hospitals would have had the opportunity to reserve their prior years' capital prospective payment system payments for financing projects. We note that the August 1, 2000 final rule (65 FR 47095) incorrectly stated that special exceptions payments could extend through September 30, 2011; the date should have been September 29, 2012.
For each cost reporting period, the amount of the special exceptions payment is determined by comparing the cumulative payments made to the hospital under the capital payment system to the cumulative minimum payment levels applicable to the hospital for each cost reporting period subject to the prospective payment system. This comparison is offset or reduced by (1) any amount by which the hospital's cumulative payments exceed its cumulative minimum payments under the regular exceptions process for all cost reporting periods during which the hospital has been subject to the capital prospective payment system; and (2) any amount by which the hospital's current year Medicare inpatient operating and capital prospective payment system payments (excluding 75 percent of its operating DSH payments) exceed its Medicare inpatient operating and capital costs (or its Medicare inpatient margin). During the capital prospective payment system transition period, the minimum payment level under the regular exceptions process varied by class of hospital as set forth in § 412.348(c) and described in section V.A. of this preamble. After the transition period and for the duration of the special exceptions provision, the minimum payment level is 70 percent as set forth in § 412.348(g)(6).
As we indicated in the July 30, 1999 final rule (64 FR 41526), we have little information about the number of hospitals that may qualify for special exceptions payments or the projected dollar amount of special exception payments, because no hospitals are currently being paid under the special exceptions process. Until FY 2002, the special exceptions provision pays either the same as the regular exceptions process or less for high DSH and sole community hospitals. In accordance with § 412.348(g)(7), a qualifying hospital may receive additional payments for up to 10 years from the year in which it completes a project that meets the project need and project size requirements of the special exception provision in §§ 412.348(g)(2) through (g)(5). Because a qualifying project under the special exceptions provision at § 412.348(g) must be completed (put into use for patient care) by the end of the hospital's last cost reporting period beginning before the end of the transition period (September 30, 2001), a hospital may receive special exception payments for 10 years through September 30, 2012. For example, an eligible hospital that completes a qualifying project in October 1993 (FY 1994) will be eligible to receive special exception payments up through FY 2003 (September 30, 2003).
In order to assist our fiscal intermediaries in determining the end of the 10-year period in which an eligible hospital will no longer be entitled to receive special exception payments, in the May 4, 2001 proposed rule, we proposed to add a new § 412.348(g)(9) to require that hospitals eligible for special exception payments under § 412.348(g) submit documentation to the intermediary indicating the completion date of their project (the date the project was put in use for patient care) that meets the project need and project size requirements outlined in §§ 412.348(g)(2) through (g)(5). We proposed that, in order for an eligible hospital to receive special exception payments, this documentation would have to be submitted in writing to the intermediary by the later of October 1, 2001, or within 3 months of the end of the hospital's last cost reporting period beginning before October 1, 2001, during which a qualifying project was completed. For example, if a hospital completed a qualifying project in March 1995, it would be required to submit documentation to the intermediary by October 1, 2001. If a hospital with a 12-month cost reporting period beginning on July 1 completed a qualifying project in November 2001, it would be required to submit documentation to the intermediary no later than September 30, 2002, which is 3 months after the end of its 12-month cost reporting period that began on July 1, 2001.
We did not receive any comments on our proposed revision to § 412.348 to add paragraph (g)(9). Accordingly, we are adopting the proposed revision as final without change.
C. Exceptions Minimum Payment Level
Section 412.348(h) limits the estimated aggregate amount of exceptions payments under both the regular exceptions and special exceptions process to no more than 10 percent of the total estimated capital prospective payment system payments in a given fiscal year. Consistent with the requirements for regular exceptions at § 412.348(c), in the May 4, 2001 proposed rule, we proposed that if we estimate that special exception payments would exceed 10 percent of total capital prospective payment system payments for a given fiscal year, we will adjust the minimum payment level of 70 percent by one percentage point increments until the estimated payments are within the 10-percent limit. For example, we could set the minimum payment level at 69 percent to ensure that estimated aggregate special exceptions payments do not exceed 10 percent of estimated total capital prospective payment system payments. If the estimate of aggregate special exceptions payments were still projected to exceed 10 percent of total capital prospective payment system payments, we would continue reducing the minimum payment level by one percentage point increments until the requirements in § 412.348(h) were satisfied. We proposed to revise § 412.348(g)(6) accordingly to reflect this policy.
We received no comments on this proposed change. Thus, we are revising § 412.348(g)(6) accordingly.
D. Exceptions Adjustment Factor
Section 412.308(c)(3) requires that the standard capital Federal rate be reduced by an adjustment factor equal to the estimated proportion of additional payments for both regular exceptions and special exceptions under § 412.348 relative to total capital prospective payment system payments. In estimating the proportion of regular exceptions payments to total capital prospective payment system payments during the transition period, we used the model originally developed for determining budget neutrality (described in Appendix B of this final rule) to determine the exception adjustment factor, which was applied to both the Federal and hospital-specific rates. In the May 4, 2001 proposed rule, we described our proposed methodology for determining the special exceptions adjustment used in establishing the Federal capital rate as follows:
Under the special exceptions provision specified at § 412.348(g)(1), eligible hospitals include SCHs, urban hospitals with at least 100 beds that have a disproportionate share patient percentage of at least 20.2 percent or qualify for DSH payments under § 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 exception payments if it meets (1) a project need requirement as described at § 412.348(g)(2), which, in the case of certain urban hospitals, includes an excess capacity test; (2) an age of assets test as described at § 412.348(g)(3); and (3) a project size requirement as described at § 412.348(g)(5).
In order to determine the estimated proportion of special exceptions payments to total capital payments, we attempted to identify the universe of eligible hospitals that may potentially qualify for special exception payments. First, we identified hospitals that met the eligibility requirements at § 412.348(g)(1). Then we determined each hospital's average fixed asset age in the earliest available cost report starting in FY 1992 and later. For each of those hospitals, we calculated the average fixed asset age by dividing the accumulated depreciation by the current year's depreciation. In accordance with § 412.348(g)(3), a hospital must have an average age of buildings and fixed assets above the 75th percentile of all hospitals in the first year of capital prospective payment system. In the September 1, 1994 final rule (59 FR 45385), we stated that, based on the June 1994 update of the cost report files in HCRIS, the 75th percentile for buildings and fixed assets for FY 1992 was 16.4 years. However, we noted that we would make a final determination of that value on the basis of more complete cost report information at a later date. In the August 29, 1997 final rule (62 FR 46012), based on the December 1996 update of HCRIS and the removal of outliers, we finalized the 75th percentile for buildings and fixed assets for FY 1992 as 15.4 years. Thus, for the proposed rule, we eliminated any hospitals from the potential universe of hospitals that may qualify for special exception payments if its average age of fixed assets did not exceed 15.4 years.
For the hospitals remaining in the potential universe, we proposed to estimate the project-size by using the fixed capital acquisitions shown on Worksheet A7 from the following HCRIS cost reports updated through December 2000.
| PPS Year | Cost reports periods beginning in . . . |
|---|---|
| IX | FY 1992 |
| X | FY 1993 |
| XI | FY 1994 |
| XII | FY 1995 |
| XIII | FY 1996 |
| XIV | FY 1997 |
| XV | FY 1998 |
| XVI | FY 1999 |
Because the project phase-in may overlap 2 cost reporting years, we proposed to add together the fixed acquisitions from sequential pairs of cost reports to determine project size. Under § 412.348(g)(5), the project-size must meet the following requirements: (1) $200 million; or (2) 100 percent of its operating cost during the first 12-month cost reporting period beginning on or after October 1, 1991. We proposed to calculate the operating costs from the earliest available cost report starting in FY 1992 and later by subtracting inpatient capital costs from inpatient costs (for all payers). We proposed not to subtract the direct medical education costs as those costs are not available on every update of the HCRIS minimum data set. If the hospital met the project size requirement, we assumed that it also met the project need requirements at § 412.348(g)(2) and the excess capacity test for urban hospitals at § 412.348(g)(4).
Because we estimate that so few hospitals will qualify for special exceptions, projecting costs, payments, and margins would result in high statistical variance. Consequently, we modeled the effects of special exceptions using historical data based on hospitals' actual cost experiences. If we determined that a hospital may qualify for special exceptions, we modeled special exceptions payments from the project start date through the last available cost report (FY 1999). For purposes of modeling, we used the cost and payment data on the cost reports from HCRIS assuming that special exceptions would begin at the start of the qualifying project. In other words, when modeling costs and payment data we proposed to ignore any regular exception payments that these hospitals may otherwise have received as if there had not been regular exceptions during the transition period. In projecting an eligible hospital's special exception payments, we applied the 70-percent minimum payment level, the cumulative comparison of current year capital prospective payment system payments and costs, and the cumulative operating margin offset (excluding 75 percent of operating DSH payments).
Because hospitals may receive regular exceptions payments up through the end of their last cost reporting period beginning before October 1, 2001, hospitals with cost reporting periods beginning on a day other than October 1 will continue to receive regular exception payments until the end of their FY 2002 cost reporting period. Therefore, these hospitals will only receive special exception payments for the remainder of Federal FY 2002. Consequently, the special exceptions payments made in FY 2002 will be less than for subsequent years since they are only being paid a special exception payment for a portion of FY 2002.
Based on more recent data and HCRIS cost reports updated through March 2001, our modeling of special exception payments produced the following results:
| Cost report | Number of hospitals eligible for special exceptions | Special exceptions as a fraction of capital payments to all hospitals | Special exceptions as a fraction of capital payments to all hospitals weighted by portion of FY 2002 for which special exceptions are paid |
|---|---|---|---|
| PPS IX | |||
| PPS X | |||
| PPS XI | 3 | ||
| PPS XII | 6 | 0.0001 | 0.0001 |
| PPS XIII | 7 | 0.0001 | 0.0000 |
| PPS XIV | 14 | 0.0002 | 0.0001 |
| PPX XV | 17 | 0.0009 | 0.0002 |
| PPS XVI | 23 | 0.0009 | 0.0007 |
Currently, the PPS XVI cost reports in HCRIS are incomplete because there is a 2-year lag time between the end of a hospital's cost reporting period and the submission and processing of the cost reports for HCRIS. In particular, we have not received all the cost reports for hospitals whose cost reporting periods begin in July. We expect that more hospitals may qualify for special exceptions once data from later HCRIS updates are available. In addition, hospitals still have two more cost reporting periods (PPS XVII and PPS XVIII) to complete their projects in order to be eligible for special exceptions.
In the May 4, 2001 proposed rule (66 FR 22705), we estimated that about 30 additional hospitals could qualify for special exceptions. Based on more recent data, we still estimate that about 30 additional hospitals could qualify for special exceptions. Thus, we project that special exception payments as a fraction of capital payments to all hospitals is approximately 0.0025. However, after weighting this amount to account for the FY 2002 phase-in of special exception payments, we project that this factor is approximately 0.0012. These projections have not changed since the publication of the May 4, 2001 proposed rule (66 FR 22706). We received no comments on our proposed methodology for determining the special exceptions adjustment used in establishing the capital Federal rate. Because special exceptions are budget neutral, we will offset the Federal capital rate by 0.12 percent for special exceptions for FY 2002. Therefore, the final special exceptions adjustment factor is equal to 0.9988 (1-0.0012) to account for special exception payments in FY 2002.
E. Provisions Relating to Capital Prospective Payments in the June 13, 2001 Interim Final Rule With Comment Period
In the June 13, 2001 interim final rule with comment period, we implemented section 301(b) of Public Law 106-554 (66 FR 32176). Section 301(b) provides for a special rule for payment for the operating standardized amounts for hospitals other than SCHs for FY 2001. For discharges occurring on or after April 1, 2001, and before October 1, 2001, the update to the operating standardized amounts for hospitals other than SCHs is equal to the market basket percentage increase plus 1.1 percentage points. This provision amends the prior statutory 1.1 percent reduction to the update to the FY 2001 operating standardized amounts for hospitals other than SCHs as provided by section 4401(a)(1) of Public Law 105-33 and 406 of Public Law 106-113.
Section 1886(d)(3)(B) of the Act directs the Secretary to adjust the inpatient operating national standardized amounts to account for the estimated proportion of operating DRG payments made to payments in outlier cases. Accordingly, as a result of this change to the update to the operating standardized amounts for discharges occurring on or after April 1, 2001 and before October 1, 2001, we revised the fixed-loss outlier threshold. The regulations at § 412.312(c) establish a unified outlier methodology for inpatient operating and inpatient capital-related costs, which utilizes a single set of thresholds to identify outlier cases for both inpatient operating and inpatient capital prospective payment system payments.
Because operating DRG payments increased as a result of implementing section 301 of Public Law 106-554, the fixed-loss outlier threshold decreased, which resulted in an increase in estimated outlier payments. Thus, the capital national outlier adjustment factor was revised. Since the revision to the fixed-loss outlier threshold also affected total capital payments, the exceptions adjustment factor was also revised in order to maintain budget neutrality. The exceptions adjustment factor is determined based on an estimate of the ratio of exception payments to total capital payments. The GAF/DRG budget neutrality factor was also revised. We discuss the impact of changes to the rates and payments under the capital prospective payment system that result from implementation of section 301 of Public Law 106-554 in further detail in the Addendum of this final rule.
We did not receive any comments on the revised FY 2001 capital Federal rate for discharges occurring on or after April 1, 2001 and before October 1, 2001 as a result of implementing section 301(b) of Public Law 106-554.
VI. Changes for Hospitals and Hospital Units Excluded From the Prospective Payment System
A. Limits on and Adjustments to the Target Amounts for Excluded Hospitals and Units (§§ 413.40(b)(4) and (g))
1. Updated Caps for Existing Hospitals and Units
Section 1886(b)(3) of the Act (as amended by section 4414 of Public Law 105-33) established caps on the target amounts for certain existing hospitals and units excluded from the prospective payment system for cost reporting periods beginning on or after October 1, 1997 through September 30, 2002. The caps on the target amounts apply to the following three classes of excluded hospitals: psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals.
In addition, section 4416 of Public Law 105-33 limited payments for psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals that first received payments on or after October 1, 1997. Payment for these hospitals and units is limited to the lesser of the hospital's operating costs per case or 110 percent of the national median of target amounts for the same class of hospitals for cost reporting periods ending during FY 1996, updated and adjusted for differences in area wage levels.
A discussion of how the caps on the target amounts and the payment limitation were calculated can be found in the August 29, 1997 final rule with comment period (62 FR 46018); the May 12, 1998 final rule (63 FR 26344); the July 31, 1998 final rule (63 FR 41000), and the July 30, 1999 final rule (64 FR 41529). For purposes of calculating the caps for existing facilities, the statute required the Secretary to estimate the national 75th percentile of the target amounts for each class of hospital (psychiatric, rehabilitation, or long-term care) for cost reporting periods ending during FY 1996 without adjusting for differences in area wage levels. Under section 1886(b)(3)(H)(iii) of the Act, the resulting amounts are updated by the market basket percentage to the applicable fiscal year.
Section 121 of Public Law 106-113 amended section 1886(b)(3)(H) of the Act to also provide for an appropriate wage adjustment to the caps on the target amounts for existing psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals, effective for cost reporting periods beginning on or after October 1, 1999, through September 30, 2002. On August 1, 2000, we published an interim final rule with comment period that implemented this provision for cost reporting periods beginning on or after October 1, 1999 and before October 1, 2000 (65 FR 47026) and a final rule that implemented this provision for cost reporting periods beginning on or after October 1, 2000 (65 FR 47054). This final rule addresses the wage adjustment to the caps and payment limitations for cost reporting periods beginning on or after October 1, 2001 as proposed in the May 4, 2001 proposed rule.
For purposes of calculating the caps, section 1886(b)(3)(H)(ii) of the Act requires the Secretary to first "estimate the 75th percentile of the target amounts for such hospitals within such class for cost reporting periods ending during fiscal year 1996." Furthermore, section 1886(b)(3)(H)(iii), as added by Public Law 106-113, requires the Secretary to also provide for existing hospitals "an appropriate adjustment to the labor-related portion of the amount determined under such subparagraph to take into account the differences between average wage-related costs in the area of the hospital and the national average of such costs within the same class of hospital."
Consistent with the broad authority conferred on the Secretary by section 1886(b)(3)(H)(iii) of the Act to determine the appropriate wage adjustment, we account for differences in wage-related costs by adjusting the caps to account for the following:
First, as stated in the May 4 proposed rule, we adjust each hospital's target amount to account for area differences in wage-related costs. For each class of hospitals (psychiatric, rehabilitation, and long-term care), we determine the labor-related portion of each hospital's FY 1996 target amount by multiplying its target amount by the actuarial estimate of the labor-related portion of costs (or 0.71553). Similarly, we determine the nonlabor-related portion of each hospital's FY 1996 target amount by multiplying its target amount by the actuarial estimate of the nonlabor-related portion of costs (or 0.28447).
Next, as we stated in the May 4 proposed rule, we account for wage differences among hospitals within each class by dividing the labor-related portion of each hospital's target amount by the hospital's wage index under the hospital inpatient prospective payment system. Within each class, each hospital's wage-neutralized target amount was calculated by adding the wage-neutralized labor-related portion of its target amount and the nonlabor-related portion of its target amount. Then, the wage-neutralized target amounts for hospitals within each class were arrayed in order to determine the national 75th percentile caps on the target amounts for each class.
Taking into account the national 75th percentile of the target amounts for cost reporting periods ending during FY 1996 (wage-neutralized using the FY 2000 acute care wage index), the wage adjustment provided for under Public Law 106-113, and the applicable update factor based on the market basket percentage increase for FY 2001, in the August 1, 2000 final rule (65 FR 47096), we established the FY 2001 caps on the target amounts as follows:
| Class of excluded hospital or unit | FY 2001 labor- related share | FY 2001 nonlabor- related share |
|---|---|---|
| Psychiatric | $8,131 | $3,233 |
| Rehabilitation | 15,164 | 6,029 |
| Long Term Care | 29,284 | 11,642 |
In reviewing our methodology for wage neutralizing the hospital specific target amounts, it appears that we incorrectly used the FY 2000 hospital inpatient prospective payment system wage index published in Tables 4A and 4B of the July 30, 1999 final rule (64 FR 41585 through 41593), which is based on wage data after taking into account geographic reclassification under section 1886(d)(8) of the Act. As stated in the May 4 proposed rule, we are revising the methodology of wage neutralizing the hospital-specific target amounts using pre-reclassified wage data. We recalculate the limit for new excluded hospitals and units, as well as calculate the cap for existing excluded hospitals and units, using the pre-reclassification wage index. The pre-reclassification wage index is the same wage index used under the prospective payment system for skilled nursing facilities (SNFs) and was included in Table 7 of the July 30, 1999 SNF final rule (64 FR 41690). (We note that both SNFs and ambulatory surgical centers use the prospective payment system inpatient wage index without regard to the prospective payment system reclassification as a proxy for variations in local costs.)
As we stated in the August 1, 2000 final rule, long-term care hospitals, rehabilitation hospitals and units, and psychiatric hospitals and units that are exempt from the prospective payment system are not subject to the prospective payment system hospital reclassification system under section 1886(d)(10)(A) of the Act. This section establishes the MGCRB for the purpose of evaluating applications from short-term, acute care providers. There is no equivalent statutory mandate for HCFA to develop an alternative board for long-term care hospitals, psychiatric hospitals and units, and rehabilitation hospitals and units. In addition, while it would be feasible to allow units physically located in prospective payment system hospitals that have been reclassified by the MGCRB to use the wage index for the area to which that hospital has been reclassified, at the present time there is no process in place to make reclassification determinations for freestanding excluded providers. There are approximately 1,000 freestanding excluded providers. Therefore, in the interest of equity, we believe that, in determining a hospital's wage-adjusted cap on its target amount, it is appropriate for excluded hospitals and units to use the wage index associated with the area in which they are physically located (MSA or rural area) and the prospective payment system reclassification under section 1886(d)(10) of the Act is not applicable. This policy is also consistent with the policy for SNFs and ambulatory surgical centers that use the acute care, inpatient hospital prospective payment system wage index and that does not allow for reclassifications since there is no analogous determinations process to the MGCRB. The MGCRB only has authority over the prospective payment system for acute care hospitals.
Therefore, based on the broad authority conferred on the Secretary by section 1886(b)(3)(H)(iii) of the Act to determine the appropriate wage adjustment to the caps, we have determined the labor-related and nonlabor-related portions of the caps on the target amounts for FY 2002 using the methodology outlined above.
| Class of excluded hospital or unit | FY 2001 labor- related share | FY 2001 nonlabor- related share |
|---|---|---|
| Psychiatric | $8,429 | $3,351 |
| Rehabilitation | $15,736 | $6,256 |
| Long-Term Care | $31,490 | $12,519 |
These labor-related and nonlabor-related portions of the caps on the target amounts for FY 2002 are based on the current estimate of the market basket increase for excluded hospitals and units for FY 2002 of 3.3 percent and reflect the change in applying the pre-reclassified hospital inpatient prospective payment system wage index as discussed above. Furthermore, in accordance with section 307(a) of Public Law 106-554, which amended section 1886(b)(3) of the Act, the labor-related and nonlabor-related portions of the cap for long-term care hospitals for FY 2002 are increased by 2 percent. A further discussion of this provision as it appeared in the June 13, 2001 interim final rule with comment period (66 FR 32181) that will implement provisions of Public Law 106-554 for FY 2001 and for periods in FY 2001 from April 1, 2001 through September 30, 2001, appears in section VI.A.4. of this preamble.
Finally, to determine payments described in § 413.40(c), the cap on the hospital's target amount per discharge is determined by adding the hospital's nonlabor-related portion of the national 75th percentile cap to its wage-adjusted, labor-related portion of the national 75th percentile cap. A hospital's wage-adjusted, labor-related portion of the target amount is calculated by multiplying the labor-related portion of the national 75th percentile cap for the hospital's class by the hospital's applicable wage index. For FY 2002, a hospital's applicable wage index is the pre-reclassified wage index under the hospital inpatient prospective payment system (see § 412.63). The wage index values are computed based on the same data used to compute the FY 2002 wage index values for the hospital inpatient prospective payment system without taking into account changes in geographic reclassification under the following: Section 1886(d)(8)(B) of the Act for certain rural hospitals; section 401 of Public Law 106-113; reclassifications based on MGCRB decisions; or the Secretary's decisions under sections 1886(d)(8) through (d)(10) of the Act. For cost reporting periods beginning on or after October 1, 2001 and before October 1, 2002, the pre-reclassified wage index is in Tables 4G and 4H of this final rule. A hospital's applicable wage index corresponds to the area in which the hospital or unit is physically located (MSA or rural area).
2. New Excluded Hospitals and Units
a. Updated Caps (§ 413.40(f))
Section 1886(b)(7) of the Act establishes a payment methodology for new psychiatric hospitals and units, new rehabilitation hospitals and units, and new long-term care hospitals. Under the statutory methodology, for a hospital that is within a class of hospitals specified in the statute and first receives payments as a hospital or unit excluded from the prospective payment system on or after October 1, 1997, the amount of payment will be determined as follows: For the first two 12-month cost reporting periods, the amount of payment is the lesser of (1) the operating costs per case; or (2) 110 percent of the national median of target amounts for the same class of hospitals for cost reporting periods ending during FY 1996, updated to the first cost reporting period in which the hospital receives payments as adjusted for differences in area wage levels.
As discussed earlier, in reviewing our methodology for wage neutralizing the hospital-specific target amounts, it appears we incorrectly used the FY 2000 hospital inpatient prospective payment system wage index published in Tables 4A and 4B of the July 30, 1999 final rule, which is based on wage data after taking into account geographic reclassifications under section 1886(d)(8) of the Act. Therefore, as we proposed in the May 4 proposed rule, we also are revising the methodology of wage neutralizing the hospital-specific target amounts using pre-reclassified wage data in our calculation of the limit for new excluded hospitals and units.
The amounts included in the following table reflect the updated and recalculated 110 percent of the wage neutralized national median target amounts for each class of excluded hospitals and units for cost reporting periods beginning during FY 2002. These figures are updated to reflect the projected market basket increase of 3.3 percent. For a new provider, the labor-related share of the target amount is multiplied by the appropriate geographic area wage index, without regard to prospective payment system reclassifications, and added to the nonlabor-related share in order to determine the per case limit on payment under the statutory payment methodology for new providers.
| Class of excluded hospital or unit | FY 2002 labor- related share | FY 2002 nonlabor- related share |
|---|---|---|
| Psychiatric | $6,815 | $2,709 |
| Rehabilitation | $13,465 | $5,353 |
| Long-Term Care | $16,701 | $6,640 |
b. Changes in Type of Hospital Classification (§§ 412.23 and 412.25)
Section 1886(b)(3) of the Act (as amended by section 4414 of Public Law 105-33) establishes caps on the target amounts for existing psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals for cost reporting periods beginning on or after October 1, 1997 through September 30, 2002. Section 4416 of Public Law 105-33 amended section 1886(b)(7) of the Act to provide for a limitation on payment for new excluded psychiatric hospitals and units, new rehabilitation hospitals and units, and new long-term care hospitals. Since the establishment of the caps on target amounts and the payment limitations, there has been an increase in the number of hospitals requesting a change from one classification type to another (for example, from rehabilitation to long-term care). Regulations at § 412.22(d) state that "For purposes of exclusion from the prospective payment systems under this subpart, the status of each currently participating hospital (excluded or not excluded) is determined at the beginning of each cost reporting period and is effective for the entire cost reporting period. Any changes in the status of the hospital are made only at the start of a cost reporting period." Even though the existing regulations directly address only a hospital that changes from a prospective payment system hospital to an excluded hospital, our longstanding policy has been that a change of any classification type can be effective only at the beginning of the provider's cost reporting period. As we stated in the May 4 proposed rule, although the existing regulations do not directly address changes in a classification type of excluded hospital, we believe that a change from one classification type of excluded hospital to another type of excluded hospital is analogous to a change from a prospective payment system hospital to an excluded hospital. Therefore, based on our belief that it would be consistent with our longstanding policy, we proposed to amend our regulations to specify that a change from one excluded hospital classification type to another type is allowed only at the beginning of the hospital's cost reporting period.
The rationale underlying our present policy of requiring that these types of changes should only be effective at the beginning of the cost reporting period is the need to avoid any undue (and possibly significant) administrative burden that could result from doing otherwise (for example, cost allocation, cost reporting requirements, certification issues). If we were to accept changes in an excluded hospital's classification type from one type of classification to another, other than at the beginning of the cost reporting period, the hospital would need to file a terminating cost report with respect to its original classification as well as file a separate cost report for the remainder of the cost reporting period with respect to its new classification. Filing these cost reports would involve gathering the appropriate cost data, allocating the data, and apportioning the data between the two hospital classes. Additionally, we would have to validate the cost reports. To allow these types of changes in the middle of a cost reporting period would result in a significant administrative burden. We point out that this burden is applicable equally for either a change from a prospective payment system hospital to an excluded hospital, or a change from one excluded hospital classification type to another classification type. Therefore, as we proposed in the May 4 proposed rule, we are amending the regulations to provide that the effective date of any of these classification changes is only at the beginning of a provider's cost reporting period (§ 412.23(i), for excluded hospitals, and § 412.25(f), for excluded units).
We did not receive any public comments on our proposed revisions of §§ 412.23(i) and 412.25(f). Therefore, we are adopting the proposed revisions as final.
3. Effective Date of Exclusion of Long-Term Care Hospitals
Existing regulations at § 412.23(e) require a newly established long-term care hospital to operate for at least 6 months with an average length of stay in excess of 25 days in order to qualify for exclusion from the inpatient hospital prospective payment system as a long-term care hospital. Other regulations at § 412.22(d) allow changes in a hospital's status from not excluded to excluded to occur only at the start of a cost reporting period. These two regulations, taken together, typically require a hospital to operate for at least 6 months under the prospective payment system before becoming eligible for payment at the more favorable rate under section 1886(b)(3) of the Act.
These regulations were challenged in litigation by a chain organization that operates a large number of long-term care hospitals ( Transitional Hospitals Corporation of Louisiana, Inc. v. Shalala , 222 F.3d 1019 (D.C. Cir. 2000) ( THC )). Although the court of appeals in this case found that the Secretary has ample authority to adopt current regulatory provisions, it also concluded that the Secretary could have considered other policy options. Consequently, it remanded the case to the agency for the agency to consider whether it wanted to continue its existing policy or adopt a policy of either "self-certification" or "retroactive adjustment." Generally, under a self-certification approach, hospitals that have not yet demonstrated the required average length of stay would be excluded from the prospective payment system based on a commitment to maintain such a length of stay. Under a retroactive adjustment approach, a hospital's long-term care classification would be made effective with the beginning of the 6-month period in which it demonstrated the required average length of stay. Payments for that period initially would be made under the prospective payment system and then adjusted retroactively to amounts payable for an excluded long-term care hospital once length of stay was successfully established.
As directed by the court of appeals, we reviewed the issues raised in this case in light of the court's decision, and specifically considered the options of self-certification and retroactive adjustment. Our proposals, and the alternatives we considered before arriving at them, are explained in detail in the May 4, 2001 proposed rule (66 FR 22708) and summarized below.
Although we understood that we have discretion to select other policy options, we proposed to continue our policy of requiring hospitals seeking long-term care hospital classification to demonstrate the required average length of stay based on 6 months of data, instead of permitting these hospitals to "self-certify" the required average length of stay.
We noted that the statute provides the agency with broad authority to determine the methodology by which facilities can qualify for exclusion as long-term care hospitals (section 1886(d)(1)(B)(iv)(I) of the Act specifies that "a hospital which has an average inpatient length of stay (as determined by the Secretary) of greater than 25 days" qualifies for exclusion as a long-term care hospital). As the court of appeals decided, the parenthetical phrase as determined by the Secretary "gives the Secretary considerable leeway to determine whether to require prospective, contemporaneous, or retrospective evaluation and payment." ( THC at 1026.)
Having proposed to continue our policy of not allowing a hospital to self-certify the required average length of stay in order to be paid as an excluded long-term care hospital, we also considered the effective date of excluded status for a hospital that has demonstrated the required average length of stay. We considered making long-term care classification effective retroactively with the beginning of the 6-month period in which the hospital demonstrated the required average length of stay. However, we believe that such retroactive application of excluded status is inappropriate.
Therefore, we proposed to continue our policy that a hospital's payment as a long-term care hospital would be effective with the beginning of the hospital's cost reporting period that follows the determination to classify the hospital as a long-term care hospital.
Comment: One commenter expressed general approval of the policies set forth in the May 4 proposed rule, stating that hospitals seeking long-term care status should be required to demonstrate the required length of stay based on 6 months of data.
Response: We appreciate the support of the commenter for our proposed policy.
Comment: Another commenter disagreed with our proposed policy and requested that we reconsider it. This commenter stated that our proposals were inconsistent with the purpose of the prospective payment system exclusion, resulted in disparate treatment of similarly situated providers, and produced inappropriate reimbursement shortfalls. The commenter also argued that our reliance on the general prospective nature of the prospective payment system was misplaced and inconsistent with our regulations.
Response: We have examined the commenter's contentions in detail but have concluded that they do not warrant adoption of a policy different from the one we have proposed. First, we disagree that our proposal is inconsistent with the purpose of the long-term care hospital exclusion. We agree with the commenter that the purpose of the exclusion is to ensure adequate reimbursement to hospitals that treat long-stay patients. However, the question addressed by our proposed policy is how to determine which providers meet the criteria for being considered hospitals that treat such patients. We believe that our proposed policy is the most appropriate methodology for making this determination. We believe that our proposed policy furthers the purpose of the exclusion by ensuring that only hospitals that can demonstrate compliance with the statutorily required length of stay receive long-term care hospital status. It also ensures that decisions granting such status are implemented in accordance with the general goals of the prospective payment system and our longstanding policies regarding the effective dates of changes in the various components of providers' prospective payment system payment rates.
Second, we do not agree with the commenter's contention that our proposed policy results in disparate treatment of similarly situated providers because we allow rehabilitation hospitals to self-certify that they will meet certain aspects of the criteria for exclusion but do not allow long-term care hospitals to do so. We dealt with this issue at length in the May 4 proposed rule and explained there that the differences in the nature of the two types of facilities, and the differences in their statutory and regulatory definitions, justified their varying treatment for these purposes. The commenter's assertion that the self-certification option that is permitted as to rehabilitation facilities and the same type of option that is not permitted as to long-term care hospitals both relate to the types of patient to be admitted-even if true in some general sense-is not sufficient in our view to overcome the clear differences in the two types of facilities that informs our different treatment of them.
Similarly, the fact that long-term care hospitals must meet a series of regulatory conditions of participation does not make them sufficiently similar to rehabilitation hospitals so as to make the use of self-certification by long-term care hospitals appropriate, as the commenter suggested. All hospitals must meet conditions of participation to participate in the Medicare program. However, that does not change the fact that, as pointed out in the May 4 proposed rule, the statute itself requires that a hospital meet the length of stay criterion to qualify as a long-term care hospital, while the statute grants the Secretary broad authority to promulgate various criteria for a hospital to qualify as a rehabilitation hospital. It is the additional certainty supplied by the additional criteria for status as a rehabilitation hospital under this authority that has led us to allow rehabilitation hospitals to self-certify that they will comply with the remaining criterion. Such certainty is lacking in the case of long-term care hospitals, since the length-of-stay criterion is extremely difficult to predict into the future at any particular point in time.
Conditions of participation exist as a matter of Medicare survey and certification activities to ensure that the provider meets the requirements of participation in the program, not as definitional criteria that establish a hospital's status for payment purposes. As a result, they do not provide the type of additional certainty that derives from the nature and number of rehabilitation hospital criteria and that might warrant allowing long-term care facilities to self-certify that they will meet the required average length of stay. The commenter also pointed out that there are various criteria in § 412.22(e) that a facility must meet to qualify as a hospital within a hospital. However, the existence of these criteria does not alter the fact that a hospital must meet the statutory length-of-stay criterion in order to qualify as a long-term care hospital, making self-certification by such a hospital inappropriate.
The commenter suggested that, if we reject its suggestion to allow self-certification by long-term care hospitals, we should then adopt a policy whereby we would pay a long-term care hospital provisionally under the prospective payment system during its initial cost reporting period; evaluate compliance with the length-of-stay requirement at the end of that period; and, if the requirement had been met, retroactively adjust its reimbursement to provide for payment on a reasonable cost basis. We do not agree with the commenter that such a scheme would result in no significant administrative burden because the retroactive adjustments could be made as part of the cost report review process. Whether performed as part of this process or not, the scheme the commenter suggested would result in just the type of burden that has generally led to our making changes in components of the prospective payment system rates prospective only, as noted in the May 4 proposed rule. As also noted in the proposed rule, such prospective only changes are consistent with our approach, validated by the courts in cases like THC, Methodist Hospital of Sacramento , and County of Los Angeles , of balancing absolute accuracy and finality and favoring the latter in the context of the prospective payment system. We find nothing in the commenter's suggestions on this point that persuades us to depart from our intention to adopt our proposed policy.
Third, we disagree with the commenter's statement that our proposed policy produces inappropriate reimbursement shortfalls. To the contrary, as noted above, our policy is designed to identify those hospitals that qualify for appropriate payment as long-term care facilities, in accordance with principles of prospectivity that have been approved by the courts. Although the commenter stated that Congress did not intend for us to require that new long-term care hospitals wait at least 6 months before being excluded from the hospital inpatient prospective payment system, the court of appeals in THC specifically found that the Medicare statute did not preclude just such a policy. We also note that, while the policy described in the May 4 proposed rule is one of longstanding, Congress has never seen fit to amend the statute to require us to implement long-term care exclusions immediately upon a new hospital's participation in the program.
Finally, we do not agree with the commenter that our reliance on the prospective nature of the prospective payment system in arriving at our proposed policy is misplaced or that the policy conflicts with our regulations. As to the former point, as noted above, we believe that the court decisions in THC, Methodist Hospital of Sacramento , and County of Los Angeles directly support the adoption of our proposed policy. We do not find the commenter's analyses of these cases persuasive. They cannot be distinguished on the basis that they apply to hospitals paid under the hospital inpatient prospective payment system but not to hospitals excluded from the prospective payment system, as the commenter suggested. Making the determination whether a hospital is excluded from or subject to the hospital inpatient prospective payment is an important part of implementing the prospective payment system payment methodology, and, like other aspects of that implementation, should be guided by the general principles underlying the prospective payment system. That is especially so since the "default" payment mode for acute care hospitals is payment subject to the hospital inpatient prospective payment system, and reasonable cost payment does not result until it is determined (again, as part of administering the prospective payment system) that the hospital's status should change to excluded status.
Moreover, while the court of appeals in Methodist Hospital may have stated that retroactive corrections are not necessarily inconsistent with the hospital inpatient prospective payment system, all three cases stand for the proposition that neither is the agency's prospective only policy inconsistent with the statute. Indeed, that is largely the point of the court of appeals' decision in THC -that the agency has broad statutory authority to adopt retroactive, contemporaneous, or prospective application of decisions granting long-term care status. For the reasons set out in the May 4 proposed rule and in this final rule, we have elected the latter policy. The policy at issue here is thus quite different from the one at issue in Georgetown University Hospital v. Bowen , 862 F.2d 323 (D.C. Cir.1988), which the commenter also cited, because the court of appeals held that that policy was contrary to express Congressional intent.
Nor is our proposed policy contrary to our regulations. The only regulations that the commenter cited in support of this point are those that implement the statutory requirement that a hospital cost report be subject to retroactive adjustment upon review by the intermediary after the close of the applicable cost reporting period. However, those regulations, and the statutory provisions they implement, merely establish a year end "book-balancing" process to reconcile the amount of estimated payments made to the provider during the year with the actual amount of reimbursement the provider is due for that year, determined in accordance with the methods prescribed by the agency. Among those methods is prospective only application of the prospective payment system status decisions. These regulations then are in no way inconsistent with our proposed policy.
4. Payment for Long-Term Care Hospital Costs: Provisions of the June 13, 2001 Interim Final Rule with Comment Period (Section 307 of Public Law 106-554 and 42 CFR 413.40(c)(4))
a. Increase in the Limitation on the Target Amounts for Long-Term Care Hospitals
As stated in the June 13 interim final rule with comment period (66 FR 32181), in the August 29, 1997 final rule with comment period (62 FR 46018), in accordance with section 4414 of Public Law 105-33, we implemented section 1886(b)(3)(H) of the Act, which provides for caps on the target amounts for existing and new excluded hospitals and units for cost reporting periods beginning on or after October 1, 1997, through September 30, 2002. The caps on the target amounts apply to three classes of excluded hospitals: psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals. In establishing the caps on the payment amounts within each class of hospital for new hospitals, section 1886(b)(7)(C) of the Act, as amended by section 4416 of Public Law 105-33, instructed the Secretary to provide an appropriate adjustment to take into account area differences in average wage-related costs. However, because the statutory language under section 4414 of Public Law 105-33 did not provide for the Secretary to adjust for area differences in wage-related costs in establishing the caps on the target amounts within each class of hospital for existing hospitals, we did not adjust for wage-related differences for existing facilities. In the August 1, 2000 interim final rule with comment period (65 FR 47039), we implemented section 121 of Public Law 106-113, which further amended section 1886(b)(3)(H) of the Act by directing the Secretary to provide for an appropriate wage adjustment to the caps on the target amounts for all psychiatric hospitals and units, rehabilitation hospitals and units and long-term care hospitals, effective for cost reporting periods beginning on or after October 1, 1999, through September 30, 2002. For purposes of calculating the caps, section 1886(b)(3)(H)(ii) of the Act requires the Secretary to first "estimate the 75th percentile of the target amounts for such hospitals within such class for cost reporting periods ending during fiscal year 1996." Section 1886(b)(3)(H)(iii) of the Act, as added by section 121 of Public Law 106-113, requires the Secretary to provide for "an appropriate adjustment to the labor-related portion of the amount determined under such subparagraph to take into account differences between average wage-related costs in the area of the hospital and the national average of such costs within the same class of hospital."
The August 1, 2000 final rule (65 FR 47096) listed the FY 2001 labor-related share and nonlabor-related share of the national 75th percentile wage-neutralized cap for long-term care hospitals as follows:
• Labor-related Share: $29,284
• Nonlabor-related Share: $11,642
The final rule also discussed that within each class a hospital's wage-adjusted cap on its target amount is determined by adding the hospital's nonlabor-related portion of the national wage-neutralized cap to its wage-adjusted labor-related portion of the national wage-neutralized cap. A hospital's wage-adjusted labor-related portion is calculated by multiplying the labor-related portion of the national wage-neutralized 75th percentile cap for the hospital's class by the hospital's applicable wage index. For FY 2001, a hospital's applicable wage index is the wage index under the hospital inpatient prospective payment system as shown in Tables 4A and 4B of the August 1, 2000 final rule (65 FR 47149 through 47156) corresponding to the area in which the hospital is physically located (MSA or rural area).
Section 307(a) of Public Law 106-554 further amended section 1886(b)(3) of the Act and provides for a 2-percent increase to the wage-adjusted 75th percentile cap on the target amount for long-term care hospitals effective for cost reporting periods beginning during FY 2001. This provision is only applicable to long-term care hospitals that were subject to the cap for existing excluded providers as specified in § 413.40(c).
In accordance with section 1886(b)(3) of the Act as amended, for cost reporting periods beginning during FY 2001, in the June 13 interim final rule with comment period, we specified the following revised labor-related and nonlabor-related shares of the cap on the target amount for long-term care hospitals, which reflect the 2-percent increase:
| FY 2001 labor- related share | FY 2001 nonlabor- related share |
|---|---|
| $29,870 | $11,875 |
Note that the national 75th percentile wage-neutralized caps on the target amount for the other excluded hospitals and units subject to the caps under section 1886(b)(3)(H) of the Act (psychiatric and rehabilitation) are not affected by section 307 of Public Law 106-554. In the June 13 interim final rule with comment period, we revised the regulations at § 413.40(c)(4)(iii) to incorporate this change.
We did not receive any public comments on our proposed revision of § 413.40(c)(4)(iii) to incorporate this provision of the statute and, therefore, are adopting it as final.
b. Increase in the Target Amounts for Long-Term Care Hospitals
As stated in the June 13, 2001 interim final rule with comment period (66 FR 32181), in the August 29, 1997 final rule with comment period (62 FR 46016) we implemented the amendment to section 1886(b)(3)(B) of the Act, as made by section 4411 of Public Law 105-33, which set forth the applicable rate-of-increase percentage for cost reporting periods beginning during FY 1999 through FY 2002. The rate-of-increase is equal to the market basket increase percentage minus an amount based on the percentage by which the hospital's operating costs exceed the hospital's ceiling for the most recent available cost reporting period. The applicable rate-of-increase percentages (update factors) for FY 2001 are described in the August 1, 2000 final rule (65 FR 47125). For FY 2001, the market basket increase percentage was forecast at 3.4 percent, which results in an update for long-term care hospitals for FY 2001 of between 0.9 percent and 3.4 percent, or 0 percent, depending on the hospital's costs in relation to its rate-of-increase limit.
In addition to the increase to the cap on the target amounts for long-term care hospitals, section 307(a) of Public Law 106-554 also amended section 1886(b)(3) of the Act to provide for a 25-percent increase to the target amounts determined under section 1886(b)(3)(A) of the Act for long-term care hospitals, for cost reporting periods beginning in FY 2001, subject to the applicable cap on the target amounts. Thus, this provision required a revision to the determination of each long-term care hospital's FY 2001 target amount as specified in § 413.40(c)(4). As stated in the June 13 interim final rule with comment period, for cost reporting periods beginning during FY 2001, the hospital-specific target amount otherwise determined for a long-term care hospital as specified in the regulations at § 413.40(c)(4)(ii) is multiplied by 1.25 (that is, increased by 25 percent), subject to the limitation that the revised FY 2001 target amounts for a long-term care hospital cannot exceed its wage-adjusted national cap as required by section 1886(b)(3) of the Act, as amended by section 307(a) of Public law 106-554. We noted that the 25-percent increase to the target amount under section 307(a) of Public Law 106-554 is applicable only to long-term care hospitals, and not to other excluded hospitals as defined in section 1886(d)(1)(B) of the Act (psychiatric and rehabilitation hospitals and units, children's and cancer hospitals).
In the June 13, 2001 interim final rule with comment period, we revised the regulations at § 413.40(c)(4)(iii) to incorporate this change.
We did not receive any public comments on this revision of § 413.40(c)(4)(iii) to incorporate this provision of the statute and, therefore, are adopting it as final.
5. Development of Prospective Payment System for Inpatient Rehabilitation Hospitals and Units
Section 1886(j) of the Act, as added by section 4421 of Public Law 105-33, provided the phase-in of a case-mix adjusted prospective payment system for inpatient rehabilitation services (freestanding hospitals and units) for cost reporting periods beginning on or after October 1, 2000 and before October 1, 2002, with a fully implemented system for cost reporting periods beginning on or after October 1, 2002. Section 1886(j) of the Act was amended by section 125 of Public Law 106-113 to require the Secretary to use the discharge as the payment unit under the prospective payment system for inpatient rehabilitation services and to establish classes of patient discharges by functional-related groups. Section 305 of Public Law 106-554 further amended section 1886(j) of the Act to allow hospitals to elect to be paid the full Federal prospective payment rather than the transitional period payments specified in the Act.
Shortly, we will be issuing a final rule on the establishment of the prospective payment system for inpatient rehabilitation facilities, to be effective January 1, 2002.
6. Increase in the Incentive Payment for Excluded Psychiatric Hospitals and Units: Provision of the June 13, 2001 Interim Final Rule with Comment Period (Section 306 of Public Law 106-554 and 42 CFR 413.40(d)(2))
As we stated in the June 13 interim final rule with comment period (66 FR 32181), for cost reporting periods beginning before October 1, 1997, a hospital that had inpatient operating costs less than, or equal to, its ceiling was paid its costs plus the lower of 50 percent of the difference between inpatient operating costs and the ceiling or 5 percent of the ceiling. Section 4415 of Public Law 105-33 amended section 1886(b)(1)(A) of the Act to provide that for cost reporting periods beginning on or after October 1, 1997, if a hospital's net inpatient operating costs are less than or equal to, the ceiling, the amount of the bonus payment would be the lower of 15 percent of the difference between the inpatient operating costs and the ceiling or 2 percent of the ceiling. Section 306 of the Public Law 106-554 further amended section 1886(b)(1)(A) of the Act, as it applied to a psychiatric hospital or unit, to provide that effective for cost reporting periods beginning on or after October 1, 2000, and before October 1, 2001, if a psychiatric hospital or unit's net inpatient operating costs are less than, or equal to, the ceiling, the amount of the bonus payment is the lower of 15 percent of the difference between the inpatient operating costs and the ceiling, or 3 percent of the ceiling.
In the June 13 interim final rule with comment period, we revised the regulations at § 413.40(d)(2) to incorporate this change.
We did not receive any public comments on our revision to § 413.40(d)(2) in the interim final rule with comment period to incorporate this provision of the statute and, therefore, are adopting it as final.
7. Changes in the Types of Patients Served or Inpatient Care Services That Distort the Comparability of a Cost Reporting Period to the Base Year are Grounds for Requesting an Adjustment Payment in Accordance with Section 1886(b)(4) of the Act
Section 4419(b) of Public Law 104-33 requires the Secretary to publish annually in the Federal Register a report describing the total amount of adjustment (exception) payments made to excluded hospitals and units, by reason of section 1886(b)(4) of the Act, during the previous fiscal year. However, the data on adjustment payments made during the previous fiscal year are not available in time to publish a report describing the total amount of adjustment payments made to all excluded hospitals and units in the subsequent year's final rule published in the Federal Register .
The process of requesting, adjudicating, and awarding an adjustment payment for a given cost reporting period occurs over a 2-year period or longer. An excluded hospital or unit must first file its cost report for the previous fiscal year with its intermediary within 5 months after the close of the previous fiscal year. The fiscal intermediary then reviews the cost report and issues a Notice of Program Reimbursement (NPR) in approximately 2 months. If the hospital's operating costs are in excess of the ceiling, the hospital may file a request for an adjustment payment within 6 months from the date of the NPR. The intermediary, or CMS, depending on the type of adjustment requested, then reviews the request and determines if an adjustment payment is warranted. This determination is often not made until more than 6 months after the date the request is filed. Therefore, it is not possible to provide data in a final rule on adjustments granted for cost reports ending in the previous Federal fiscal year, since those adjustments have not even been requested by that time. However, in an attempt to provide interested parties at least some relevant data on adjustments, we are publishing data on requests for adjustments that were processed by the fiscal intermediaries or CMS during the previous Federal fiscal year.
The table below includes the most recent data available from the intermediaries and CMS on adjustment payments that were adjudicated during FY 2000. By definition, these were for cost reporting periods ending in years prior to FY 1999. The total adjustment payments awarded to excluded hospitals and units during FY 2000 are $12,344,419. The table depicts for each class of hospital, in aggregate, the number of adjustment requests adjudicated, the excess operating cost over the ceiling, and the amount of the adjustment payment.
| Class of hospital | Number | Excess cost over ceiling | Adjustment payment |
|---|---|---|---|
| Psychiatric | 40 | $19,172,613 | $9,114,944 |
| Rehabilitation | 8 | 6,128,515 | 2,254,393 |
| Long-Term Care | 3 | 827,821 | 814,971 |
| Children's | 1 | 160,111 | 160,111 |
B. Critical Access Hospitals (CAHs)
Section 4201 of Public Law 105-33 amended section 1820 of the Act to create a nationwide Medicare Rural Hospital Flexibility (MRHF) Program to replace the 7-State Essential Access Community Hospital/Rural Primary Care Hospital (EACH/RPCH) program. Under section 1820(c)(2) of the Act, as amended, a State could designate certain rural hospitals as CAHs if they were located a specified distance from other hospitals, made 24-hour emergency care available, and kept inpatients for a limited period of time. Additionally, CAH staffing requirements differed from those of other hospitals under Medicare and CAHs received payment for inpatient and outpatient services on the basis of reasonable cost. A comprehensive discussion of CAHs within the context of the MRHF Program may be found in the August 29, 1997 Federal Register (62 FR 45970 and 46008-46010).
1. Permitting Certain Facilities to be Designated as CAHs (Section 401(b) of Public Law 106-113 and 42 CFR 485.610)
As discussed in the August 1, 2000 interim final rule with comment period, one of the threshold criteria for designation as a CAH under section 1820(c)(2)(B)(i) of the Act is that the hospital must be rural as defined in section 1886(d)(2)(D)(ii) of the Act. Section IV.A. of the interim final rule with comment period discussed the option of urban to rural classification for a "subsection (d)" hospital authorized by section 401(a) of Public Law 106-113 under an amendment to section 1886(d)(8) of the Act. Section 401(b)(2) of Public Law 106-113 amended section 1820(c)(2)(B) of the Act to authorize a State to designate a hospital in an urban area as a CAH if, under one of the criteria set forth in section 1886(d)(8)(E) of the Act, it would be treated as being located in the rural area of the State in which the hospital is located. Section 401(b)(2) only provides authority for a hospital to meet the rural requirement. We note that the hospital would have to otherwise meet the statutory and regulatory requirements governing CAH designation.
The first criteria in section 401(a) specified that a hospital will be treated as located in a rural area if the hospital is located in a rural census tract of an MSA, as determined under the most recent Goldsmith Modification, originally published in the Federal Register on February 27, 1992. In Appendix B of the August 1, 2000 interim final rule with comment period, we published a listing of existing hospitals that may qualify as CAHs because they are located in Goldsmith areas.
In the August 1, 2000 interim final rule, we specified that the application procedures and effective dates for an urban hospital seeking to reclassify as rural in order to apply for CAH status under section 1820(c)(2)(B)(i) of the Act were set forth in new § 412.103 that implements section 401(a), and discussed in section IV.C. of that interim final rule with comment period (65 FR 47041). In the August 1 interim final rule with comment period, we revised the regulations on location for CAHs at § 485.610(b) to reflect this amendment.
We did not receive any comments on the revised section of the regulations in the interim final rule with comment period and have not made any further changes to it.
2. Exclusion of CAHs From Payment Window Requirements
Section 1886 of the Act specifies the requirements governing payment to full-service hospitals for the operating costs of inpatient hospital services under both the inpatient hospital prospective payment system and the limits on the target amounts for hospitals excluded from the prospective payment system. "Operating costs of inpatient hospital services" are defined in section 1886(a)(3) of the Act, which provides in part that costs of certain services provided to a beneficiary during the 3 days (or in the case of an excluded hospital or unit, during the 1 day) immediately preceding the patient's admission are to be included in the payments for costs under the inpatient hospital prospective payment system, or costs subject to the target amount for excluded hospitals and units. This part of the definition is sometimes referred to as the "payment window" requirement. Regulations implementing the payment window requirement are found at § 412.2(c)(5) for hospitals subject to the prospective payment system, and § 413.40(c)(2) for hospitals excluded from the prospective payment system.
As we stated in the May 4, 2001 proposed rule, payment to CAHs for inpatient services is not made under the inpatient hospital prospective payment system mandated by section 1886 of the Act, nor are CAHs considered to be hospitals excluded from the inpatient hospital prospective payment system. Instead, payment is made on a reasonable cost basis, as mandated by section 1814(l) of the Act. Neither section 1814(l) nor section 1861(v) of the Act (which defines "reasonable cost") requires application of the payment window to services furnished on an outpatient basis immediately before admission to a CAH. Therefore, we stated in the May 4 proposed rule that we have determined that the payment window provision does not apply to CAHs. To clarify this point and avoid possible misapplication of the payment window, we proposed to amend § 413.70(a)(l) to provide that the requirements of §§ 412.2(c)(5) and 413.40(c)(2) do not apply to CAHs.
Comment: Several commenters expressed support for the proposal to explicitly exclude CAHs from the payment window requirements. None of the commenters opposed the proposal or suggested changes to it.
Response: We appreciate the commenters' support and are adopting the proposed regulation amendments as final.
3. Availability of CRNA Pass-Through for CAHs
Generally, anesthesia services furnished to a hospital patient by a certified registered nurse anesthetist (CRNA) must be billed to the Part B carrier and payment is made under the applicable fee schedule provisions of § 414.60. However, certain rural hospitals that furnish no more than 500 surgical procedures requiring anesthesia per year and meet other specified requirements are exempted from the fee schedule. These hospitals are paid on a reasonable cost basis for their costs of anesthesia services furnished by qualified nonphysician anesthetists. The exemption is provided in accordance with section 9320(k) of the Omnibus Budget Reconciliation Act of 1986 (Public Law 99-509) (as added by section 608(c)(2) of the Family Support Act of 1988 (Public Law 100-185), as amended by section 6132 of the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239)). We have codified this exemption at § 412.113(c).
We pointed out in the May 4 proposed rule that, although § 412.113(c) does not specifically extend eligibility for the pass-through payment for CRNAs to CAHs, some CAHs have pointed out that they are similar to the rural hospitals that are eligible for this payment, in that they also furnish low volumes of surgical procedures requiring anesthesia and could face the same problem of potentially inadequate payment for CRNA services if they are not allowed to qualify for the pass-through payment. We share this concern.
We recognize that the legislation cited above, which provides the legal basis for the pass-through payments, refers only to "hospitals," not to CAHs. Moreover, section 1861(e) of the Act states that "the term "hospital" does not include, unless the context otherwise requires, a critical access hospital * * *." It is clear from section 1861(e) of the Act that CAHs are not to be considered hospitals under the Medicare law for most purposes. However, the reference to "context" in the provision indicates that CAHs may be classified as hospitals where, in specific contexts, it would be consistent with the purpose of the legislation to do so.
We stated that we believe this is the case with the statutory provisions authorizing pass-through payments for CRNA costs. The purpose of the pass-through legislation is to provide small rural hospitals with low surgical volumes with relief from the difficulties they might otherwise have in furnishing CRNA services for their patients. CAHs are by definition limited-service facilities located in rural areas and, as such, they serve a population much like those served by hospitals eligible for the pass-through payments. In some cases, an institution that now participates as a CAH may even have been eligible for the pass-through payments when it participated as a hospital. Such an institution would clearly be disadvantaged if it were to lose this status. Thus, in accordance with section 1861(e) of the Act and in light of the context of the pass-through legislation cited above, we consider CAHs to be "hospitals" for purposes of extending eligibility for the CRNA pass-through payments to them.
Therefore, in the May 4 proposed rule, we proposed to add a new § 413.70(a)(3) and revise §§ 413.70(a)(2), (b)(1), and (b)(6) to permit CAHs that meet the criteria for the pass-through payments in § 412.113(c) to qualify for pass-through payments for the costs of anesthesia services for both inpatient and outpatient surgeries, on the same basis as full service rural hospitals. As an unrelated technical correction, we proposed to revise § 413.70(b)(2)(i)(C) to delete the incorrect reference to § 413.130(j)(2) and replace it with a reference to reduction in capital costs under § 413.130(j). We also proposed to revise § 412.113(c) by changing the term "hospital" to "hospital or CAH".
Comment: Several commenters favored extension of the CRNA pass-through to CAHs. However, some commenters suggested that the pass-through be made available to all CAHs, even if they furnish 500 or more surgical procedures requiring anesthesia service in the prior year.
Response: Section 412.113(c), which is based on the provisions of the Medicare law, is specific with respect to the volume of surgeries that may be performed by facilities qualifying for the CRNA pass-through. The volume of surgeries is a criterion for a hospital to qualify for CRNA pass-through. As we are treating CAHs as hospitals for purposes of the CRNA pass-through, a CAH would have to meet the same qualifying criteria as would a hospital. Accordingly, we are not adopting the commenters' suggestion that the 500 procedure criterion be revised for CAHs.
Comment: One commenter stated that anesthesia services in many rural facilities are furnished by anesthesiologists rather than CRNAs, and suggested that pass-through also be made available for the costs of anesthesia services provided by anesthesiologists.
Response: The Medicare law is specific to CRNAs and does not offer similar treatment for costs of services of anesthesiologists. Therefore, we are not adopting this suggestion.
4. Payment to CAHs for Emergency Room On-Call Physicians (§ 413.70(b)(4))
Under section 1834(g) of the Act, Medicare payment to a CAH for facility services to Medicare outpatients is the reasonable costs of the CAH in providing such services. The term "reasonable cost" is defined in section 1861(v) of the Act and in regulations at 42 CFR Part 413, including, with specific reference to CAHs, § 413.70. Consistent with the general policies stated in section 2109 of the Medicare Provider Reimbursement Manual (PRM), Part I (HCFA Publication 15-1), the reasonable cost of CAH services to outpatients may include reasonable costs of compensating physicians who are on standby status in the emergency room (that is, physicians who are present and ready to treat patients if necessary). However, under existing policy, the reasonable cost of CAH services to outpatients may not include any costs of compensating physicians who are not present in the facility but are on call.
Section 204 of Public Law 106-554 further amended section 1834(g) of the Act (as amended by section 201 of Public Law 106-554) by adding a new paragraph (5). New section 1834(g)(5) of the Act provides that, in determining the reasonable costs of outpatient CAH services under sections 1834(g)(1) and 1834(g)(2)(A) of the Act, the Secretary shall recognize as allowable costs amounts (as defined by the Secretary) for reasonable compensation and related costs for emergency room physicians who are on call (as defined by the Secretary) but who are not present on the premises of the CAH involved, are not otherwise furnishing physicians' services, and are not on call at any other provider or facility. The provisions of section 204 of Public Law 106-554 are effective for cost reporting periods beginning on or after October 1, 2001.
As we provided in the May 4 proposed rule, to implement the provisions of section 1834(g)(5) of the Act, we proposed to add a new paragraph (4) to § 413.70(b). The proposed § 413.70(b)(4) would permit the reasonable costs of CAH outpatient services to include the reasonable compensation and related costs of emergency room on-call physicians under the terms and conditions specified in the statute. As directed in the statute, under § 413.70(b)(4)(ii)(A) of the proposed rule, we defined "amounts for reasonable compensation and related costs" as those allowable costs of compensating emergency room physicians for being on call, to the extent these costs are found to be reasonable under the rules in § 413.70(b)(2).
In addition, as specified under § 413.70(b)(4)(ii)(A) of the proposed rule, we defined an "emergency room physician who is on call" as a doctor of medicine or osteopathy with training or experience in emergency care who is immediately available by telephone or radio contact, and who is available on site within the timeframes specified in our existing regulations under § 485.618(d). Existing § 485.618(d) specifies that the physician must be available on site (1) Within 30 minutes, on a 24-hour a day basis, if the CAH is located in an area other than an area described in item (2); or (2) within 60 minutes, on a 24-hour a day basis, if all of the following requirements are met:
• The CAH is located in an area designated as a frontier area (that is, an area with fewer than six residents per square mile based on the latest population data published by the Bureau of the Census) or in an area that meets criteria for a remote location adopted by the State in its rural health care plan, and approved by HCFA, under section 1820(b) of the Act.
• The State has determined under criteria in its rural health care plan that allowing an emergency response time longer than 30 minutes is the only feasible method of providing emergency care to residents of the area served by the CAH.
• The State maintains documentation showing that the response time of up to 60 minutes at a particular CAH it designates is justified because other available alternatives would increase the time needed to stabilize a patient in an emergency.
We also believe that it is essential that physicians who are paid to be in on-call status in fact come to the facility when summoned. Therefore, we proposed to specify that costs of on-call emergency room physicians are allowable only if the costs are incurred under written contracts that require them to come to the CAH when their presence is medically required.
Comment: One commenter noted that existing regulations at § 413.70(a)(2) prohibit application, in making reasonable cost determinations for CAHs, of the reasonable compensation equivalent (RCE) limits on physician services to providers. The commenter expressed concern that more explicit reasonableness guidelines may be needed to ensure that costs recognized for on-call services are reasonable.
Response: We understand the commenter's concern, but note that existing reasonable cost rules at § 413.9(c)(2) authorize intermediaries to disallow costs of services that are "substantially out of line" with costs of other, similar providers in the same area. We will continue to monitor these costs and will consider proposing further or more specific reasonableness standards if necessary.
Comment: One commenter stated that contracts for emergency services are typically executed between a CAH and a physician group, and, for legal purposes, the individual physician is not distinguishable from the group. The commenter further stated that if the regulations prohibit the "physician" from otherwise furnishing services or being on call at another facility, the proposed language of the regulation may inadvertently prohibit any member of the physicians group from otherwise furnishing services or being on call.
Response: We have reconsidered the proposed language of § 413.70(b)(4) in the light of this comment, but find no basis for interpreting the proposed revised language in the way the commenter has suggested may occur. The proposed revised language makes it clear that it is the individual physician who is on call for the CAH that may not be otherwise engaged in furnishing physician's services, or on call at another provider or facility.
We are adopting proposed § 413.70(b)(4) as final.
5. Treatment of Ambulance Services Furnished by Certain CAHs (§ 413.70(b)(5))
Under section 1861(s)(7) of the Act, Medicare Part B covers and pays for ambulance services, to the extent prescribed in regulations, when the use of other methods of transportation would be contraindicated. Various Congressional reports indicate that Congress intended that (1) the ambulance benefit cover transportation services only if other means of transportation are contraindicated by the beneficiary's medical condition; and (2) only ambulance services to local facilities be covered unless necessary services are not available locally, in which case, transportation to the nearest facility furnishing those services is covered. (H.R. Rept. No. 89-213, 89th Cong., 1st Sess. at 37 (1995) and S. Rept. No. 89-404, 89th Cong., 1st Sess., Pt. I, at 43 (1995).
The Medicare program currently pays for ambulance services on a reasonable cost basis when furnished by a provider and on a reasonable charge basis when furnished by a supplier. (The term "provider" includes all Medicare-participating institutional providers that submit claims for Medicare ambulance services (hospitals, CAHs, SNFs, and home health agencies).) The term "supplier" means an entity that is independent of any provider. The reasonable charge methodology that is the basis of payment for ambulance services is determined by the lowest of the customary, prevailing, actual, or inflation indexed charge.
Section 4531(a)(1) of Public Law 105-33 amended section 1861(v)(1) of the Act and imposed an additional per trip limitation on reasonable cost payment to hospitals and CAHs for ambulance service. As amended, the statute provides that, in determining the reasonable cost of ambulance services furnished by a provider of services, the Secretary shall not recognize the cost per trip in excess of the prior year's reasonable cost per trip updated by an inflation factor. This trip limit provision was first effective for services furnished during Federal fiscal year 1998 (October 1, 1997 through September 30, 1998).
Section 205 of Public Law 106-554 amended section 1834(l) of the Act by adding a new paragraph (8) to that section. New section 1834(l)(8) provides that the Secretary is to pay the reasonable costs incurred in furnishing ambulance services if such services are furnished by a CAH (as defined in section 1861(mm)(1) of the Act), or by an entity owned and operated by the CAH. This provision in effect eliminates any trip limit that CAHs had been subject to as a result of section 1861(v)(1) of the Act, as amended by Public Law 105-33. However, section 205 further states that in order to receive reasonable cost reimbursement for the furnishing of ambulance services, the CAH or entity must be the only provider or supplier of ambulance services located within a 35-mile drive of the CAH. Section 205 is effective for services furnished on or after December 21, 2000, the date of enactment of Public Law 106-554.
As stated in the May 4 proposed rule, to implement the provisions of section 1834(l)(8) of the Act, we proposed to add a new paragraph (5) to § 413.70(b) to permit a CAH, or an entity owned or operated by a CAH, to be paid for furnishing ambulance services on a reasonable cost basis if the CAH or entity is the only provider or supplier of ambulance services within a 35-mile drive of the CAH. In determining whether there is any other provider or supplier of ambulance services within a 35-mile drive of a CAH or entity, we first identify the site where the nearest other ambulance provider or supplier garages its vehicles, and then determine whether that site is within 35 miles, calculated as the shortest distance in miles measured over improved roads. An improved road for this purpose is be defined as any road that is maintained by a local, State, or Federal government entity, and is available for use by the general public. Consistent with the change, in the May 4 proposed rule concerning § 412.92(c)(1) relating to SCH determinations (as explained in section IV.A. of this preamble), we proposed to consider improved roads to include the paved surface up to the front entrance of the hospital and, for purposes of § 413.70(b)(5), the front entrance of the garage.
Comment: Several commenters recommended that we support a legislative change that would eliminate the 35-mile requirement and allow all designated CAHs owning ambulance services to be reimbursed at cost. Another commenter requested that we support a legislative change to address situations where the distance requirement involves mountainous terrain or only secondary roads and that in such cases the mileage requirement be 15 miles.
Response: As the commenters pointed out, the statute as currently worded is clear as to applicability of the 35-mile rule in connection with the requirements for cost reimbursement of ambulance services furnished by CAHs. Therefore, we are not making any changes in the final regulation based on these comments.
Comment: One commenter described a situation where both the CAH and ambulance services are wholly owned by a city but the CAH provides operating services to the ambulance company. The commenter asked whether in such a case the ambulance services could be considered to be furnished by an entity that is wholly owned and operated by the CAH.
Response: As stated in section 205 of the Public Law 106-554, payment on a reasonable cost basis may be made for ambulance services furnished by a CAH, or an entity owned and operated by the CAH. The legislation does not allow us to extend similar treatment to ambulance services that may be operated but not owned by a CAH. Accordingly, we are not making any changes in this final rule based on this comment.
We are adopting proposed § 413.70(b)(5) as final without change.
6. Qualified Practitioners for Preanesthesia and Postanesthesia Evaluation in CAHs
Section 1820 of the Act sets forth the conditions for designating certain hospitals as CAHs. Implementing regulations for section 1820 of the Act are located in 42 CFR part 485, Subpart F. Included in the conditions of participation regulations for CAHs in subpart F is the condition for surgical services (§ 485.639). Existing § 485.639 specifies that preanesthesia and postanesthesia services in a CAH can only be performed by a doctor of medicine or osteopathy, including an osteopathic practitioner recognized under section 1101(a)(7) of the Act; a doctor of dental surgery or dental medicine; or a doctor of podiatric medicine. This Medicare condition of participation requirement regarding preanesthesia and postanesthesia evaluations for CAHs differs from, and is more restrictive than, the current requirement for acute care hospitals in general. In an acute care hospital, the CRNA is listed among the practitioners who may perform the preanesthesia and postanesthesia evaluations.
Our principal consideration in regulating providers is to ensure patient safety and high quality patient outcomes. As circumstances and health care environments change, we reassess regulations and propose changes accordingly.
In the May 4 proposed rule, we stated that when the regulations for the initial Rural Primary Care Hospital (RPCH) program (which later became the CAH program) were adopted, RPCHs were limited to patient stays of no more than 72 hours and to bed counts of no more than 6 acute care beds. We initially viewed RPCHs as very limited-service facilities that would be unlikely to perform any surgery beyond what might be done in a physician's office; therefore, we did not have a condition of participation for surgery. Section 102(a)(1) of the Social Security Amendments of 1994, Public Law 103-432, specifically authorized surgical care in RPCHs. In June 1995, we proposed a surgical condition of participation that incorporated the ambulatory surgery center (ASC) standards. We expected that the types of procedures done in a RPCH would most likely be those that could be done in ASCs. At the time, we received no comments in response to the proposed standards and therefore adopted them in the final RPCH conditions of participation that were published on September 1, 1995 (60 FR 45851).
In 1997, the RPCH (now CAH) program was expanded through a statutory change to include all States and to allow for an increase in bed size and length of stay (August 29, 1997 final rule, 62 FR 46035). Since that time, the program's original conditions of participation have been revised (and more recently have been proposed to be revised) to remove possible barriers to access to care. One example of our latest effort is our proposed rule to eliminate the Federal requirement for physician supervision of CRNAs in CAHs as well as in acute care hospitals and ASCs that was published in the Federal Register on January 18, 2001 (66 FR 96570).
Recently, provider and medical groups have suggested that CAHs may be at risk of losing the ability to provide access to appropriate surgical services without the full support of available CRNAs. They indicated that the existing regulations place the responsibility of the preanesthesia and postanesthesia evaluations on the operating practitioner, thereby creating a higher standard for CAHs than for other hospitals.
In an effort to eliminate or minimize potential access issues in rural areas and to recognize the CAH's program expansion, in the May 4, 2001 proposed rule, we proposed to revise § 485.639(b) to allow CRNAs to perform preanesthesia and postanesthesia evaluations in a CAH. As with any licensed independent health care provider, the proposed change would not permit CRNAs to practice beyond his or her licensed scope of practice or the approved policies and procedures of the CAH.
We received 26 comments on our proposal.
Comment: Almost all of the 26 commenters supported our proposed change to the existing CAH conditions of participation to remove the requirement that only physicians can perform the preanesthesia and postanesthesia evaluations. The proposed regulation includes CRNAs among the practitioners that may perform these services. The commenters stated that the existing anesthesia evaluation requirements for CAHs are more restrictive than the requirements for hospitals and they impose an unnecessary burden on operating surgeons and the facilities.
Response: We appreciate the commenters' support.
Comment: One commenter stated that the proposed amendment to the condition of participation for surgical services under § 485.639(b) is ill-advised and should not be adopted, or, at the very least, should be postponed until the regulation regarding physician supervision of CRNAs in hospitals is finalized.
Response: The commenter correctly notes that we have not finalized the regulation to amend the physician supervision requirement for CRNAs (66 FR 96570, January 18, 2001). Our proposal that CRNAs perform preanesthesia and postanesthesia evaluations in CAHs in our May 4, 2001 proposed rule does not conflict with the January 18, 2001 proposed physician supervision regulation because our proposal does not affect current requirements for CRNAs, such as physician supervision. We mentioned the proposed physician supervision regulation in the preamble to the May 4 proposed rule as an example of our continual effort to review and evaluate our policies and regulations to better facilitate patient access and improve patient outcomes.
Comment: One commenter stated that there is no basis for us to assume that the safety-oriented anesthesia standards for CAHs should be any less stringent than those applicable to ambulatory surgical centers (ASCs).
Response: We acknowledge the commenter's concern regarding the anesthesia risk and evaluation standard for ASCs. Our existing conditions for coverage for ASCs require examination of patients by a physician immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. The ASC conditions for coverage also require evaluation of patients by a physician for proper anesthesia recovery prior to discharge from the ASC. We expect to review and modify the ASC condition of coverage, including the current anesthesia risk and evaluation standard, through a notice of proposed rulemaking in 2002. At that time, we will consider the commenter's concern.
Comment: One commenter stated that according to a recent national survey of one-third of rural hospital chief executives, almost 80 percent of the respondents reported that their institutions perform high-complexity surgery, such as gall bladder and stomach surgery. The commenter further stated that the hospital conditions of participation require that the preoperative evaluation be conducted by an individual qualified to administer anesthesia, but in the cases of a nurse anesthetist, the anesthesia provider must work under the supervision of the operating practitioner or an anesthesiologist. As such, the commenter summarized that the hospital requirements are not less stringent than the CAH requirements.
Response: The commenter has misunderstood the proposal to mean that physician supervision for CRNAs is eliminated. The proposed regulation, as noted in response to a previous comment, will not remove physician supervision of CRNAs.
Unlike in acute care hospitals, CRNAs are currently listed among the qualified practitioners who can administer anesthesia under physician supervision in CAHs but they cannot perform the preanesthesia and postanesthesia evaluations. In response to the provider industry's concerns with access to care, our proposal was that CRNAs be allowed to perform preanesthesia and postanesthesia evaluations.
We are adopting the proposed § 485.639(b) as final without change.
7. Clarification of Location Requirements for CAHs (§§ 485.610(b) and (c))
Under section 1820(c)(2)(B)(i) of the Act, a facility seeking designation by the State as a CAH must meet two distinct types of location requirements. First, the facility must either be actually located in a county or equivalent unit of local government in a rural area, as defined in section 1886(d)(2)(D) of the Act, or it must be located in an urban area as defined in section 1886(d)(2)(D) of the Act, but be treated as being located in a rural area under section 1886(d)(8)(E) of the Act. Second, the facility must also be located more than a 35-mile drive (or, in the case of mountainous terrain or in areas with only secondary roads available, a 15-mile drive) from a hospital or similar facility described in section 1820(c) of the Act, or it must be certified by the State as being a necessary provider of health care services to residents in the area. Implementing regulations for these provisions were published in an interim final rule with comment period in the Federal Register on August 1, 2000 (65 FR 47026) and are set forth at § 485.610(b).
As we indicated in the May 4 proposed rule, recently, concern has been expressed that § 485.610(b) does not accurately reflect the fact that a facility may satisfy the "rural location" requirement either by actually being located in a rural area or by being located in an urban area but qualifying for treatment as rural under section 1886(d)(8)(E) of the Act. In addition, we have received questions as to whether a potential CAH must meet both the rural location requirement and the requirement for location relative to other facilities (or certification by the State as a "necessary provider").
To avoid any further confusion, and ensure that our regulations reflect the provisions of the law accurately, we proposed to revise § 485.610(b) to clarify that a potential CAH must either be actually located in a rural area, or be treated as being rural under section 1886(d)(8)(E) of the Act. In addition, we proposed to place the provisions of the existing § 485.610(b)(5) in a newly created paragraph (c) entitled, "Location relative to other facilities or necessary provider certification". We proposed to relocate this provision in order to clarify that these criteria are separate from the rural location criteria. These changes do not reflect any change in policy; they are merely an attempt to improve the clarity of the regulations.
We did not receive any comments on these proposed changes and, therefore, are adopting them as final.
8. Other Legislative Changes Affecting CAHs
a. 96-hour Average Length of Stay Standard (Section 403(a) of Public Law 106-113 and 42 CFR 485.620(b))
As stated in the August 1, 2000 interim final rule with comment period, prior to the enactment of Public Law 106-113, section 1820(c)(2)(B)(iii) of the Act limited CAH designation only to facilities that provided inpatient care to each patient for a period of time not to exceed 96 hours, unless a longer period was required because of inclement weather or other emergency conditions, or a peer review organization (PRO) or equivalent entity, on request, waived the 96-hour restriction. Section 403(a) of Public Law 106-113 amended section 1820(c)(2)(B)(iii) of the Act to require that the 96-hour limit on stays be applied on an annual average basis, and to delete the provisions regarding waiver of longer stays. Therefore, CAHs will be permitted to keep some individual patients more than 96 hours without a waiver request, so long as the facility's average length of acute stays in any 12-month cost reporting period is not more than 96 hours.
The effective date of this provision is November 29, 1999.
In the August 1, 2000 interim final rule with comment period, we revised the regulations on conditions of participation for length of stay for CAHs at § 485.620(b) to reflect this change.
Comment: One commenter noted that 96-hour length of stay limitation for CAHs clearly contemplates that the facility-wide average length of stay be computed as an hourly average, while Medicare cost report instructions require inpatient utilization to be reported by days of care rather than hours. The commenter expressed concern that if cost report data on days of care are converted to an hourly equivalent, this might overstate the length of stay for some facilities, since patients in the facility for only a few hours might be counted as having been inpatients for a full 24 hours. The commenter requested that we provide further directions to the fiscal intermediaries on the exact data to be used and the precise method to capture the length of stay average.
Response: We understand the commenter's concern and will ensure that any directions to intermediaries and State agencies on determining facility-wide average length of stay provide for calculating that average accurately. However, no change is needed to the proposed regulation and we are adopting it as final.
b. For-Profit Facilities (Section 403(b) of Public Law 106-113 and 42 CFR 485.610(a))
As stated in the August 1, 2000 interim final rule with comment period, prior to enactment of Public Law 106-113, section 1820(c)(2)(B) of the Act allowed only nonprofit or public hospitals to be designated as CAHs. Section 403(b) of Public Law 106-113 revises section 1820(c)(2)(B) of the Act to remove the words "nonprofit or public" before "hospitals", thus enabling for-profit hospitals to qualify for CAH status.
In that interim final rule with comment period, we revised the regulations on the conditions of participation related to the status and location for CAHs at § 485.610(a) to reflect this change.
We did not receive any comments on this provision and are adopting the revision to § 485.610(a) as final.
c. Closed and Downsized Hospitals (Section 403(c) of Public Law 106-113 and 42 CFR 485.610(a)(1))
Under section 1820(c)(2) of the Act, CAH designation was available only to facilities currently operating as hospitals. As stated in the August 1, 2000 interim final rule with comment period, section 403(c) of Public Law 106-113 amended the statute to permit a State to designate as a CAH a facility that previously was a hospital but ceased operations on or after November 29, 1989 (10 years prior to the enactment of Public Law 106-113), if that facility fulfills the criteria under section 1820(c)(2)(B) of the Act for CAH designation as of the effective date of its designation. The amendment also allows CAH designation for facilities that previously had been hospitals, but are currently State-licensed health clinics or health centers if they meet the revised criteria for designation under section 1820(c)(2) of the Act as of the effective date of designation. In the August 1 interim final rule with comment period, we revised the CAH criteria for State certification under regulations at § 485.610(a)(1) to reflect this change.
Although we received no public comment on the revision to § 485.610(a)(1), we have determined that one technical revision to § 486.610 is needed. We are making a technical correction to paragraph (a)(2) of § 485.610. Currently, that paragraph states that a closed facility may qualify for designation as a CAH only if it meets applicable criteria for designation under Subpart F of Part 485 "as of November 29, 1999." However, under section 1820(c)(2)(C)(ii) of the Act, as added by section 403(c)(2) of Public Law 106-113, the facility must meet all other applicable requirements for CAH designation by the State as of the effective date of its designation as a CAH. Therefore, we are revising § 485.610(a)(2) to state that a closed facility may qualify for designation as a CAH only if it meets applicable criteria for designation under Subpart F of Part 485 as of the effective date of that designation.
In the August 1, 2000 final rule (65 FR 47052), we revised § 485.610 to reflect the provisions of section 403(c) of Public Law 106-113. However, we inadvertently did not make a conforming change to § 485.612, which continues to state that the applicant facility must be a hospital with a provider agreement to participate in the Medicare program at the time it applies for designation as a CAH. To correct this oversight and reflect the provisions of section 403(c) in the regulations at § 485.612, in the June 13, 2001 interim final rule with comment period (66 FR 32183), we revised § 485.612 to state that the requirement to have a provider agreement as a hospital at the time of application does not apply to recently closed facilities as described in § 485.610(a)(2) or to health clinics or health centers as described in § 485.610(a)(3).
We did not receive any comments on this provision and are adopting the provisions as final without change.
d. Elimination of Coinsurance for Clinical Diagnostic Laboratory Tests Furnished by a CAH (§§ 410.152 and 413.70))
As we indicated in both the August 1, 2000 and June 13, 2001 interim final rules with comment period, under the law in effect before the enactment of Public Law 106-113, clinical diagnostic laboratory services furnished by a CAH to its outpatients were, like other outpatient CAH services, paid for on a reasonable cost basis, subject to the Part B deductible and coinsurance provisions. With respect to coinsurance, this meant that the beneficiary was responsible for payment of 20 percent of the CAH's customary charges for the services and the CAH received payment from the Medicare program equal to 80 percent of its reasonable costs of furnishing the services.
In the August 1, 2000 interim final rule with comment period (65 FR 47042), we implemented section 403(e) of Public Law 106-113, which amended section 1833(a) of the Act and eliminated the Part B coinsurance and deductible for laboratory tests furnished by a CAH on an outpatient basis. Thus, CAHs were not permitted to impose a deductible or coinsurance charge on the beneficiary for these services. Also, in accordance with section 1833(a)(1)(D) and (a)(2)(D), as also amended by section 403(e) of Public Law 106-113, Medicare Part B was to pay 100 percent of the least of the amount determined under the local laboratory fee schedule, the national limitation amount for that test, or the amount of the charges billed for the tests.
The effect of this change was that clinical diagnostic laboratory tests furnished by a CAH to its outpatients, were paid for on the same basis as clinical diagnostic laboratory tests furnished by full-service hospitals to outpatients. Section 403(e)(2) of Public Law 106-113 provided that this provision was effective with respect to services furnished on or after November 29, 1999. In the August 1, 2000 interim final rule with comment period, we clarified our policy and incorporated the provisions of section 403(e) of Public Law 106-113 in §§ 410.152 and 413.70 of the regulations.
As we indicated in the June 13, 2001 interim final rule with comment period (66 FR 32172), section 201(a) of Public Law 106-554 amended section 1834(g) of the Act to provide that there will be no collection of coinsurance, deductible, copayments, or any other type of cost sharing from Medicare beneficiaries with respect to outpatient clinical diagnostic laboratory services in a CAH.
Section 201(a) further provided that payment for these services will be made on a reasonable cost basis. Section 201(b) of the Public Law 106-554 amended section 1833(a) of the Act by eliminating any reference to CAHs receiving payment for outpatient clinical diagnostic laboratory services on a fee schedule basis. These amendments are effective for services furnished on or after November 29, 1999.
In the June 13 interim final rule with comment period, we incorporated the provisions of section 201 of Public Law 106-554 in § 413.70 of the regulations and changed the references cited in § 410.152(k)(2). To prevent any misunderstanding of the scope of section 201(a), we further revised § 413.70(b)(3)(iii) to clarify that payment to a CAH for clinical diagnostic laboratory tests for individuals who are not inpatients of the CAH will be made on a reasonable cost basis only if the individuals are outpatients of the CAH at the time the specimens are collected. Outpatient status will be determined under the definition in § 410.2, which provides that an "outpatient" is a person who has not been admitted as an inpatient but is registered as an outpatient and receives services (rather than supplies alone) from the CAH.
We indicated that we recognize that CAHs may appropriately function as reference laboratories, by performing clinical diagnostic laboratory tests on specimens from persons who do not meet the "outpatient" definition but have the specimens drawn at other locations, such as physician offices. Payment for clinical diagnostic laboratory tests for these other individuals (that are persons who are not patients of the CAH when the specimens are collected) will be made in accordance with the provisions of sections 1833(a)(1)(D) and 1833(a)(2)(D) of the Act.
Comment: One commenter on the August 1, 2000 interim final rule expressed the view that it was Congress' intent to pay CAHs for clinical diagnostic laboratory tests for outpatients on the basis of reasonable costs, not on the basis of a laboratory fee schedule. The commenter suggested that we develop and implement regulations permitting reasonable cost payment for these laboratory services.
Response: As explained earlier, section 201(a) of Public Law 106-554 subsequently modified the Medicare law to clearly require reasonable cost payment for those services and we have implemented that provision in the June 13, 2001 interim final rule with comment period (which is being finalized in this final rule).
Comment: Some commenters stated that CAHs frequently perform clinical diagnostic laboratory tests on specimens drawn from patients at physician offices, nursing homes, and assisted living facilities in the community where the CAH is located, and in other rural communities. The commenters recommended that reasonable cost payment be made to the CAH for these services because, in the commenters' view, doing so would help support the provision of health care in these settings.
Response: As explained above and in the preamble to the June 13 interim final rule with comment period, section 201(a) of Public Law 106-554 mandates reasonable cost payment to CAHs for clinical diagnostic laboratory tests to CAH patients but does not provide similar payment when the CAH functions as a reference laboratory for patients who do not come to the CAH but are seen at other locations. The statute does not provide for such payment for services to non-CAH patients. We believe these laboratory services provided to individuals who are not patients of a CAH should be paid for on the same basis as such services are generally paid for regardless of the fact that the CAH reference laboratory performed the testing, and that payment for them on a reasonable cost basis would extend the CAH payment methodology far beyond the CAH itself. Thus, we are not adopting the commenters' recommendation.
Comment: One commenter suggested that we not require CAHs to refund coinsurance amounts collected from beneficiaries and third-party payers for clinical diagnostic laboratory tests furnished to outpatients on or after November 29, 1999. The commenter stated that this would be appropriate because there has been confusion among some CAHs as to their responsibilities in this area, and returning these amounts could be burdensome for the CAHs.
Response: Public Law 106-554 clearly and consistently states that, effective November 29, 1999, these services are not subject to deductible or coinsurance amounts. Medicare Intermediary Manual Transmittal No. 1799 and Medicare Hospital Manual Transmittal No. 757, issued in June 2000, reemphasized this point. Therefore, we are not making any change in this final rule based on this comment.
e. Assistance With Fee Schedule Payment for Professional Services Under All-Inclusive Rate
Prior to enactment of Public Law 106-113, section 1834(g) of the Act provided that the amount of payment for outpatient CAH services would be the reasonable costs of the CAH in providing such services. However, the reasonable costs of the CAH's services to outpatients included only the CAH's costs of providing facility services, and did not include any payment for professional services. Physicians and other practitioners who furnished professional services to CAH outpatients billed the Part B carrier for these services and were paid under the physician fee schedule in accordance with the provisions of section 1848 of the Act.
In the August 1, 2000 final rule (65 FR 47100), we implemented section 403(d) of Public Law 106-113, which amended section 1834(g) of the Act to permit the CAH to elect to be paid for its outpatient services under an optional method. CAHs making this election would be paid amounts equal to the sum of the following costs, less the amount that the hospital may charge as described in section 1866(a)(2)(A) of the Act (that is, Part A and Part B deductibles and coinsurance amounts):
• For facility services, not including any services for which payment may be made as outpatient professional services, the reasonable costs of the CAH in providing the services; and
• For professional services otherwise included within outpatient CAH services, the amounts that would otherwise be paid under Medicare if the services were not included as outpatient CAH services.
Section 403(d) of Public Law 106-113 added section 1834(g)(3) to the Act to further specify that payment amounts under this optional method are to be determined without regard to the amount of the customary or other charge. The amendment made by section 403(d) was effective for cost reporting periods beginning on or after October 1, 2000.
In the June 13, 2001 interim final rule with comment period (66 FR 32172), we implemented section 202 of Public Law 106-554, which amended section 1834(g) of the Act to provide that when a CAH elects the option to be paid for Medicare outpatient services under the reasonable costs for facility services plus fee schedule amounts for professional services method, Medicare will pay 115 percent of the amount it would otherwise pay for the professional services. This provision is effective for items and services furnished on or after July 1, 2001.
In the June 13 interim final rule with comment period, we revised the regulations at § 413.70(b)(3) to reflect the change in the level of payment for professional services under the alternative payment method for outpatient CAH services.
Comment: One commenter asked for an explanation of the relationship between payment to CAHs for CRNA services to outpatients at 115 percent of the amounts that would otherwise be payable under the physician fee schedule, and the pass-through of CRNA services costs under § 412.113(c) as described in the proposed rule published on May 4, 2001 (66 FR 22646).
Response: Under the proposed changes to §§ 413.70 and 412.113(c) that we included in our May 4, 2001 proposed rule, a CAH would be able to qualify for the CRNA pass-through (that is, reasonable costs payment for its costs of compensating CRNAs for their professional services to inpatients and outpatients) on the same basis as a hospital. If a particular CAH qualified for the CRNA pass-through and chose to claim payment under that method for its CRNA compensation costs, it would be paid on a reasonable cost basis for those costs. However, neither the CAH nor the individual CRNAs would then be permitted to bill under the physician fee schedule for any CRNA services to CAH patients. In particular, if the CAH chose the elective (115 percent) method of payment for professional services to CAH outpatients, its billings for those services could not include any amounts for CRNA services.
If a CAH was not qualified for the CRNA pass-through (because, for example, it furnished 500 or more surgical procedures requiring anesthesia per year), or was qualified but chose not to claim payment under the pass-through method, but did choose payment for professional services to CAH outpatients under the elective (115 percent) method, payment for CRNA services to outpatients would be made under the elective (115 percent) method. Under these circumstances, the CAH could not claim any CRNA compensation costs for the services on its cost report.
Comment: One commenter asked whether payment under the optional method described in § 413.70(b)(3) is available for all professional services to CAH outpatients in CAH space, including professional services the commenter described as "clinic visits".
Response: The optional method applies to professional services otherwise included within outpatient CAH services provided to CAH outpatients. Outpatient CAH services are those medical and other services furnished by a CAH on an outpatient basis. Services that are not otherwise provided in a CAH on an outpatient basis, such as services provided by a home health agency owned or operated by a CAH, are paid under the payment rules applicable to the specific provider or supplier type and cannot be made under the optional method of payment for outpatient CAH services.
Comment: One commenter asked whether physicians and other practitioners who would otherwise be permitted to bill the Medicare Part B carrier for their professional services provided to CAH patients could reassign their Part B billing rights for those services to the CAH under the existing reassignment rules.
Response: The commenter is correct in understanding that practitioners may reassign their billing rights for professional services provided to CAH patients under applicable reassignment rules. Such reassignment would be needed to help ensure that there is not duplicate billing for those services.
Comment: One commenter stated that our current manual instructions require all professional services to the outpatients of a particular CAH to be billed under either the method in § 413.70(b)(2) (reasonable costs for facility services, with billing by the practitioner to the carrier for professional services) or the optional method in § 413.70(b)(3) (reasonable costs for facility services with billing by the CAH for professional services). The commenter asked whether a CAH would be permitted to elect the § 413.70(b)(3) method on a practitioner-by-practitioner basis, so that some practitioners' services would be billed by the CAH while others would be billed by the practitioner.
Response: We appreciate the commenter's request and note that we have already addressed this issue in our regulations. Specifically, the regulations at § 413.70(b)(3)(i) state that once a CAH elects the optional method for payment of outpatient CAH services for a cost reporting period, the optional payment method remains in effect for all of that period and applies to all outpatient CAH services furnished to outpatients of the CAH during that period.
Comment: Some commenters noted that section 202 of Pubic Law 106-554 makes the 115 percent payment option for professional services to CAH outpatients available for services furnished on or after July 1, 2001. However, the commenters also stated that our program instructions state that the systems changes needed to permit payment at that level will not be available before October 1, 2001. The commenters asked for confirmation that the payment at the 115 percent level for services furnished on or afterJuly 1, 2001, will be made available to CAHs electing payment under the optional method, and suggested various alternatives, including possible retroactive payment adjustments by the intermediary, by which this could be accomplished.
Response: We appreciate the commenters' suggestions. We will continue to explore all feasible approaches to ensuring that payment is made in accordance with statutory requirements and will consider the various suggestions made by the commenter as we work to achieve this result.
f. Conforming Change-Conditions of Participation Relating to Compliance With Hospital Requirements at Time of Application for CAH Designation (§ 485.612)
Under the law in effect prior to enactment of Public Law 106-113, CAH status was available to facilities only if they were hospitals at the time of their application for designation as CAHs. This requirement was implemented through regulations at § 485.610 (Condition of participation: Status and limitations) and § 485.612 (Condition of Participation: Compliance with hospital requirements at time of application). As we previously noted, section 403(c) of Public Law 106-113 added subparagraphs (C) and (D) to section 1820(c)(2) of the Act to specify that recently closed facilities and facilities that had downsized from hospital status to being a clinic or health center would also be eligible to apply for CAH designation.
As noted earlier, in the August 1, 2000 final rule(65 FR 47052), we revised our regulations at § 485.610 to reflect the provisions of section 403(c) of the Public Law 106-113. However, we inadvertently did not make a conforming change to § 485.612, which continues to state that the applicant facility must be a hospital with a provider agreement to participate in the Medicare program at the time it applies for designation as a CAH. To correct this oversight and reflect the provisions of section 403(c) in the regulations at § 485.612, in the June 13, 2001 interim final rule with comment period(66 FR 32183), we revised § 485.612 to state that the requirement to have a provider agreement as a hospital at the time of application does not apply to recently closed facilities as described in § 485.610(a)(2) or to health clinics or health centers as described in § 485.610(a)(3).
We did not receive any comments on this regulation revision and are adopting it as final.
g. Participation in Swing-Bed Program (Section 403(f) of Public Law 106-113)
Section 403(f) of Public Law 106-113, entitled "Improvements in the Critical Access Hospital Program," included a provision on swing-bed agreements. In the August 1, 2000 interim final rule with comment period, we indicated that since our existing regulations at § 485.645 already provide for swing beds in CAHs, we were not making any changes to our regulations based on this provision.
We did not receive any comments on this provison and are adopting our interim decision not to make any changes to our regulations as final.
C. Hospital Swing Bed Program
In the August 1, 2000 interim final rule with comment period (65 FR 47042), we indicated that section 408(a) of Public Law 106-113 amended section 1883(b) of the Act to remove the provision that in order for a hospital to enter into an agreement to provide Medicare post-hospital extended care services, the hospital had to be granted a certificate of need for the provision of long-term care services from the State health planning and development agency (designated under section 1521 of the Public Health Service Act) for the State in which the hospital is located. Section 408(b) of Public Law 106-113 amended section 1883(d) of the Act to remove the provisions under paragraphs (d)(2) and (d)(3) that placed restrictions on lengths of stays in hospitals with more than 49 beds for post-hospital extended care services. These provisions are effective on the first day after the expiration of the transition period under section 1888(e)(2)(E) of the Act for payment for covered skilled nursing facility (SNF) services under the Medicare program; that is, at the end of the transition period for the SNF prospective payments system that began with the facility's first cost reporting period beginning on or after July 1, 1998 and extend through the end of the facility's third cost reporting period after this date.
The Medicare regulations that implemented the provision of section 1883(b) of the Act are located at § 482.66(a)(3). The regulations that implemented the provisions of sections 1883(d)(2) and (d)(3) of the Act are located at §§ 482.66(a)(6) and (a)(7). As a result of the changes made by section 408(a) and (b) of Public Law 106-113, in the August 1, 2000 interim final rule with comment period, we removed §§ 482.66(a)(3), (a)(6), and (a)(7). (Existing paragraphs (a)(4) and (a)(5) were redesignated as (a)(3) and (a)(4), respectively, as a result of the removal of existing paragraph (a)(3).)
We did not receive any comments on our revisions to the regulations in the interim final rule with comment period and are adopting them as final.
VII. MedPAC Recommendations
On March 1, 2001, the Medicare Payment Advisory Commission (MedPAC) issued its annual report to Congress, including several recommendations related to the inpatient operating payment system. Those related to the inpatient prospective payment systems included: accounting for new technology in hospital prospective payment systems, implementation of an occupational-mix adjusted wage index for FY 2005, financial performance and inpatient payment issues, and elimination of the weighting factors for direct GME for specialties with training beyond the initial residency period. In the May 4, 2001 proposed rule, we responded to these recommendations (66 FR 22713-22714).
In addition, we addressed Recommendation 5A concerning the update factor for inpatient hospital operating costs and for hospitals and hospital distinct-part units excluded from the prospective payment system in Appendix D to the proposed rule (and in Appendix C of this final rule).
A. Accounting for New Technology in Hospital Prospective Payment Systems (Recommendations 3D and 3E)
Recommendation 3D: For the inpatient payment system, the Secretary should develop formalized procedures for expeditiously assigning codes, updating relative weights, and investigating the need for patient classification changes to recognize the costs of new and substantially improved technologies.
Response: Section 533 of Public Law 106-554 directs the Secretary to develop a mechanism for ensuring adequate payment under the hospital inpatient prospective payment system for new medical services and technologies, and to report to Congress on ways to more expeditiously incorporate new services and technologies into that system. The discussion relating to new medical services and technologies was included in section II.D. of the May 4, 2001 proposed rule.
MedPAC states that a more formal system for assigning codes and investigating the need for DRG changes would have enabled the current system to more adequately respond to new technology. Although we believe the current process for assigning new codes has the advantage of being well-understood, we proposed a new process in the May 4 proposed rule. We will be finalizing this process in a separate final rule.
Recommendation 3E: Additional payments in the inpatient payment system should be limited to new or substantially improved technologies that add significantly to the cost of care in a diagnosis related group and should be made on a budget-neutral basis.
Response: Section 533 of Public Law 106-554 directed the Secretary to establish a mechanism by October 1, 2001. We will be finalizing this process in a separate final rule.
B. Occupational-Mix Adjusted Wage Index for FY 2005 (Recommendation 4)
Recommendation: To implement an occupation-mix adjusted wage index in FY 2005, the Secretary should collect data on wage rates by occupation in the fiscal year 2002 Medicare cost reports. Hospital-specific wage rates for each occupation should be supplemented by data on the mix of occupations for each provider type. The Secretary also should continue to improve the accuracy of the wage index by investigating differences in wages across areas for each type of provider and in the substitution of one occupation for another.
Response: In the May 4 proposed rule, we proposed to collect occupational mix data from hospitals through a supplemental survey to the cost report for cost reporting periods beginning during FY 2001. A more complete discussion of the proposed methodology in the May 4 proposed rule (66 FR 22674) and the public comments we received and our responses can be found in section III.C.3. of this final rule.
C. Financial Performance and Inpatient Payment Issues (Recommendations 5B, 5C, and 5D)
Recommendation 5B: In collecting sample patient-level data, CMS should seek to balance the goals of minimizing payment errors and furthering understanding of the effects of coding on case-mix change.
Response: The sample data referred to by MedPAC is the Payment Error Prevention Program (PEPP) Surveillance Sample. These data are collected to monitor the payment error rate for Medicare inpatient prospective payment system services and provide outcome data to measure PROs' performance in reducing payment errors in their respective States. This information can be appropriately weighted to reflect the true distribution of DRGs nationally. The sample data supplant the DRG validation sample that MedPAC used in its original 1996 through 1998 estimates. The current PEPP Surveillance Sample doubles the size of the earlier DRG validation sample. It is comprised of approximately 60,000 cases per year. We believe this is a sufficient number of cases to both monitor case-mix index changes and PRO performance on payment error reduction.
Recommendation 5C: Although the Benefits Improvement and Protection Act of 2000 improved the equity of the hospital disproportionate share adjustment, Congress still needs to reform this adjustment by:
• Including the costs of all poor patients in calculating low-income shares used to distribute disproportionate share payments; and
• Using the same formula to distribute payments to all hospitals covered by prospective payment.
Response: CMS is participating in a Medicare Technical Advisory Group workgroup concerning technical issues related to the collection of uncompensated care data relative to the Medicare disproportionate share formula. A worksheet and instructions to collect these data will be sent out for prior consultation this summer for revisions to the cost reports applicable for cost reporting periods beginning on or after October 1, 2001.
Recommendation 5E: The Congress should protect urban hospitals from the adverse effect of nearby hospitals being reclassified to areas with higher wage indexes by computing each area's wage index as if none of the hospitals located in the area had been reassigned.
Response: In the May 4 proposed rule as in this final rule, CMS includes the wage data for a reclassified hospital in both the area to which it is reclassified and the area where the hospital is physically located. We agree with MedPAC and believe that this will provide consistency and predictability in hospital reclassification and wage indices.
D. Specialties With Training Beyond the Initial Residency Period (Recommendation 10)
Recommendation: The Congress should eliminate the weighting factors that currently determine Medicare's direct graduate medical education payments and count all residencies equally through completion of residents' first specialty or combined program and subspecialty if one is pursued. Residents training longer than the minimum number of years required for board eligibility in a specialty, combined program, or subspecialty should not be included in hospitals' direct graduate medical education resident counts. These policy changes should be implemented in a budget-neutral manner through adjustments to the per resident payment amounts.
Response: Currently, Medicare payments to hospitals for direct GME is dependent, in part, on the initial residency period of the residents. Generally, the initial residency period is defined at § 413.86(g)(1) as the minimum number of years required for board eligibility, not to exceed 5 years. For purposes of determining the direct GME payment, residents are weighted at 1.0 FTE within the initial residency period, and at .5 FTE beyond the initial residency period. The limitation on the initial residency period was designed by Congress to limit full Medicare direct GME payment to the time required to train in a single specialty.
MedPAC states that Medicare's current direct GME payment policy of limiting full funding to the first specialty in which a resident trains provides a disincentive for hospitals to offer training in subspecialties or combined programs and, therefore, may influence hospitals' decisions on the types of residents that they train. MedPAC believes that Medicare should not influence workforce policy and recommends that the disincentive be removed to make Medicare payments policies neutral with regard to programs with prerequisites, subspecialties, and combined programs. Accordingly, MedPAC recommends that Congress eliminate the weighting factors associated with direct GME payment so that all residents would be counted for full direct GME payment through the completion of their first specialty, combined program, or subspecialty. Residents training beyond the minimum number of years required for board eligibility in a specialty, combined program, or subspecialty should not be counted for purposes of the direct GME payment.
MedPAC also believes that eliminating the weighting factors could potentially increase Medicare's direct GME payments by approximately 5 to 8 percent. Therefore, MedPAC recommends that hospitals' per resident amounts (PRAs), which are used to calculate the direct GME payment, be reduced so that this change can be implemented, to the extent possible, in a budget-neutral manner. MedPAC explains that, although further research is needed, it appears that hospitals with substantial subspecialty training (that is, at least 15 percent of the resident mix) would likely see a small net increase in payments, despite the reduction to the PRAs, while hospitals that do not have subspecialty training would likely see a small decrease in payments.
In response to MedPAC's recommendation, we question MedPAC's estimate that eliminating the weighting factors could increase Medicare direct GME payments by only 5 to 8 percent. We believe that subspecialty training constitutes a significant portion of all GME programs, and, consequently, the elimination of the weighting factors could potentially increase payments by far more than 8 percent. If budget neutrality is to be maintained, this could mean that the attendant reductions to the PRAs could be much greater than MedPAC might assume. For those teaching hospitals that have substantial subspecialty training, there is no guarantee that the decreases in the PRAs will be offset by the increases in the direct GME payments due to the elimination of the weighting factors.
While the recommendation would remove the existing disincentive for training in subspecialties, we believe the reductions to the PRAs, whether they are minimal or more significant, will be far more detrimental to the smaller teaching hospitals that have little or no subspecialty training. Many of these hospitals provide care to beneficiaries in rural, underserved areas and in nonhospital settings. We believe these conditions may discourage the expansion of residency training in these areas. It may be inappropriate to limit the direct GME funding to such hospitals, considering Congress' initiatives to encourage residency training in rural, underserved areas and in nonhospital settings. We also are unclear as to how MedPAC would implement the proposed reduction to the PRAs. MedPAC did not explain in its recommendation how it would propose to do this.
VIII. 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.hcfa.gov/stats/pubfiles.html. In our May 4, 2001 proposed rule, we published a list of data files that are available for purchase (66 FR 22714-22716).
B. Information Collection Requirements
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.
In the May 4, 2001 proposed rule, we solicited public comments on each of these issues for the following sections that contain information collection requirements.
Section 412.230(e)(2)(ii)Criteria for an Individual Hospital Seeking Redesignation to Another Rural Area or an Urban Area; § 412.232(d)(2)(ii) Criteria for All Hospitals in a Rural County Seeking Urban Redesignation; § 412.235 Criteria for All Hospitals in a State Seeking a Statewide Wage Index; and Revised § 412.273 Withdrawing an Application or Terminating an Approved 3-Year Reclassification
Proposed §§ 412.230(e)(2)(ii) and 412.232(d)(2)(ii) specified that, for hospital-specific data for wage index changes for redesignations effective beginning FY 2003, the hospital must provide a 3-year average of its average hourly wages using data from the CMS hospital wage survey used to construct the wage index in effect for prospective payment purposes. For other data, the hospital must provide a weighted 3-year average of the average hourly wage in the area in which the hospital is located and a weighted 3-year average of the average hourly wage in the area to which the hospital seeks reclassification. Proposed new § 412.235 specifies that in order for all prospective payment system hospitals in a State to use a statewide wage index, the hospitals as a group must submit an application to the MGCRB for a decision for reclassifications for wage index purposes. The proposed changes to § 412.273 incorporated proposed revised procedures for hospitals that request withdraw of their wage index application or termination of their wage index reclassification.
The final versions of these proposed changes, discussed in detail in section IV.G. of this final rule, implement sections 304 (a) and (b) of Public Law 106-554.
The information collection requirements associated with a hospital's application to the MGCRB for geographic reclassifications, including reclassifications for wage index purposes and the required submittal of wage data, that are codified in Part 412 are currently approved by OMB under OMB Approval Number 0938-0573, with an expiration date of September 30, 2002.
Section 412.348(g)(9)Exception Payments
As discussed in section V. of the May 4 proposed rule, Medicare makes special exceptions payments for capital-related costs through the 10th year beyond the end of the capital prospective payment system transition period for eligible hospitals that complete a project that meets certain requirements specified in § 412.348. In order to assist our fiscal intermediaries in determining the end of the 10-year period in which an eligible hospital will no longer be entitled to receive special exception payments, we proposed to add a new § 412.348(g)(9) to require that hospitals eligible for special exception payments under § 412.348(g) submit documentation to the intermediary indicating the completion date of their project (the date the project was put in use for patient care) that meets the project need and project size requirements outlined in §§ 412.348 (g)(2) through (g)(5). We proposed that, in order for an eligible hospital to receive special exception payments, this documentation would have to be submitted in writing to the intermediary by the later of October 1, 2001, or within 3 months of the end of the hospital's last cost reporting period beginning before October 1, 2001, during which a qualifying project was completed.
Because this provision is expected to affect less than 10 hospitals on an annual basis, this requirement is not subject to the PRA as stipulated under 5 CFR 1320.3(c).
In the August 1, 2000 interim final rule with comment period, we solicited public comments on each of these issues for the following section that contains information collection requirements.
Section 412.103(b)Special treatment: Hospitals Located in Urban Areas and That Apply for Reclassification as Rural; Application Requirements
Section 412.103(b) specifies that a facility seeking reclassification under sections 401 (a) or (b) of Public Law 106-113 must apply in writing to the CMS Regional Office and include documentation of the criteria on which its request is based. The application must be mailed; facsimile or other electronic means are not acceptable.
The hospital's application must include a copy of the State law or regulation or other authoritative document verifying that the requesting hospital is situated in an area determined to be rural by the State or the hospital is considered to be a rural hospital.
We estimate that it will take each hospital approximately 30 minutes to complete the application process. We estimate that additional time would be needed to collect the required documentation. This recordkeeping should take no more than approximately 2 hours. Therefore, the paperwork burden associated with the reclassification process would add up to an additional 2 1⁄2 hours per hospital that request reclassification under section 401 of Public Law 106-113.
This information collection requirement has been submitted to the Office of Management and Budget for approval and is not effective until OMB approves it.
If you have any comments on any of these information collection and recordkeeping requirements, please mail one original and three copies within 30 days of the publication date directly to the following:
Centers for Medicare Medicaid Services, Office of Information Services, Information Technology Investment Management Group,Division of HCFA Enterprise Standards,Room N2-14-26,7500 Security Boulevard,Baltimore, MD 21244-1850,Attn: John Burke, CMS-1158/31/78-F.
And
Office of Information and Regulatory Affairs, Room 10235, New Executive Office Building,Washington, DC 20503,Attn: Allison Eydt, HCFA Desk Officer.
List of Subjects
42 CFR Part 405
Administrative practice and procedure, Health facilities, Health professions, Kidney diseases, Medicare, Reporting and recordkeeping requirements, Rural areas,X-rays.
42 CFR Part 410
Health facilities, Health professions, Kidney diseases, Laboratories, Medicare, Reporting and recordingkeeping requirements, Rural areas, X-rays.
42 CFR Part 412
Administrative practice and procedure, Health facilities, Medicare, Puerto Rico, Reporting and recordkeeping requirements.
42 CFR Part 413
Health facilities, Kidney diseases, Medicare, Puerto Rico, Reporting and recordkeeping requirements.
42 CFR Part 482
Grant program-health, Hospitals, Medicaid, Medicare, Reporting and recordkeeping requirements.
42 CFR Part 485
Grant programs-health, Health facilities, Medicaid, Medicare, Reporting and recordkeeping requirements.
42 CFR Part 486
Health professions, Medicare, Organ procurement, X-rays.
Accordingly, 42 CFR chapter IV is amended as follows:
I. The interim final rule with comment period amending 42 CFR Parts 410, 412, 413, 482, and 485 which was published at 65 FR 47026 on August 1, 2000, is adopted as a final rule with the following changes:
PART 413-PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES
1. The authority citation for Part 413 is revised to read as follows:
Authority:
Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and (n), 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), 1395hh, 1395rr, 1395tt, and 1395ww).
2. Section 413.86 is amended by:
a. Revising the first sentence of the introductory text of paragraphs (g)(11)(i).
b. Revising the first sentence of the introductory text of paragraph (g)(11)(ii).
c. Revising paragraph (g)(11)(v)(C).
§ 413.86 Direct graduate medical education payments.
(g) * * *
(11) * * *
(i) If an urban hospital rotates residents to a separately accredited rural track program at a rural hospital(s) for two-thirds of the duration of the program, the urban hospital may include those residents in its FTE count for the time the rural track residents spend at the urban hospital. * * *
(ii) If an urban hospital rotates residents to a separately accredited rural track program at a rural nonhospital site(s) for two-thirds of the duration of the program, the urban hospital may include those residents in its FTE count, subject to the requirements under paragraph (f)(4) of this section. * * *
(v) * * *
(C) All residents that are included by the hospital as part of its rural track FTE count (not to exceed its rural track FTE limitation) must train in the rural area. However, where a resident begins to train in the rural track program at the urban hospital but leaves the program before completing the total required portion of training in the rural area, the urban hospital may count the time the resident trained in the urban hospital if another resident fills the vacated FTE slot and completes the training in the rural portion of the rural track program. An urban hospital may not receive graduate medical education payment for the time the resident trained at the urban hospital if another resident fills the vacated FTE slot and first begins to train at the urban hospital.
II. The interim final rule with comment period amending 42 CFR Parts 410, 412, 413, and 485 which was published at 66 FR 32172 on June 13, 2001, is adopted as a final rule with the following changes:
PART 412-PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES
1. The authority citation for Part 412 continues to read as follows:
Authority:
Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).
2. Section 412.108 is amended by revising paragraph (b) to read as follows:
§ 412.108 Special treatment; Medicare-dependent, small rural hospitals.
(b) Classification procedures. The fiscal intermediary determines whether a hospital meets the criterion in paragraph (a) of this section. A hospital must notify its fiscal intermediary to be considered for MDH status based on the criterion under paragraph (a)(1)(iii)(C) of this section. Any hospital that believes it meets this criterion to qualify as an MDH, based on at least two of the three most recent audited cost reporting periods, must submit a written request to its intermediary. The intermediary will make its determination and notify the hospital within 90 days from the date that it receives the hospital's request and all of the required documentation. If a hospital disagrees with an intermediary's determination, it should notify its intermediary and submit documentable evidence that it meets the criteria. The intermediary determination is subject to review under subpart R of part 405 of this chapter. MDH status is effective 30 days after the date of written notification of approval. The time required by the intermediary to review the request is considered good cause for granting an extension of the time limit for the hospital to apply for such a review.
III. For the reasons set forth in the preamble to this final rule, 42 CFR Chapter IV is amended as set forth below:
PART 405-FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
A. Part 405 is amended as set forth below:
1. The authority citation for Part 405 continues to read as follows:
Authority:
Secs. 1102, 1861, 1862(a), 1871, 1874, 1881, and 1886(k) of the Social Security Act (42 U.S.C. 1302, 1395x, 1395y(a), 1395hh, 1395kk, 1395rr, and 1395ww(k), and sec. 353 of the Public Health Service Act (42 U.S.C. 263a).
2. In § 405.2468, paragraph (f)(6)(ii) is republished and paragraph (f)(6)(ii)(D) is revised to read as follows.
§ 405.2468 Allowable costs.
(f) Graduate medical education. * * *
(6) * * *
(ii) The following costs are not allowable graduate medical education costs-
(D) The costs associated with activities described in § 413.85(h) of this chapter.
PART 412-PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES
B. Part 412 is amended as follows:
1. The authority citation for Part 412 continues to read as follows:
Authority:
Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).
2. Section § 412.2 is amended as follows:
a. The introductory text of paragraph (e) is republished.
b. Paragraph (e)(4) is revised.
§ 412.2 Basis of payment.
(e) Excluded costs. The following inpatient hospital costs are excluded from the prospective payment amounts and are paid on a reasonable cost basis:
(4) The acquisition costs of hearts, kidneys, livers, lungs, pancreas, and intestines (or multivisceral organs) incurred by approved transplantation centers.
3. Section 412.23 is amended by adding a new paragraph (i) to read as follows:
§ 412.23 Excluded hospitals: Classifications.
(i) Changes in classification of hospitals. For purposes of exclusions from the prospective payment system, the classification of a hospital is effective for the hospital's entire cost reporting period. Any changes in the classification of a hospital are made only at the start of a cost reporting period.
4. Section 412.25 is amended by adding a new paragraph (f) to read as follows:
§ 412.25 Excluded hospital units: Common requirements.
(f) Changes in classification of hospital units. For purposes of exclusions from the prospective payment system under this section, the classification of a hospital unit is effective for the unit's entire cost reporting period. Any changes in the classification of a hospital unit is made only at the start of a cost reporting period.
5. Section 412.63 is amended by revising paragraphs (t) and (u) to read as follows:
§ 412.63 Federal rates for inpatient operating costs for fiscal years after Federal fiscal year 1984.
(t) Applicable percentage change for fiscal years 2002 and 2003. The applicable percentage change for fiscal years 2002 and 2003 is the percentage increase in the market basket index for prospective payment hospitals (as defined in § 413.40(a) of this subchapter) minus 0.55 percentage points for hospitals in all areas.
(u) Applicable percentage change for fiscal year 2004 and for subsequent fiscal years. The applicable percentage change for fiscal year 2004 and for subsequent years is the percentage increase in the market basket index for prospective payment hospitals (as defined in § 413.40(a) of this subchapter) for hospitals in all areas.
6. Section 412.92 is amended as follows:
a. Paragraph (b)(1)(iii)(A) is amended by revising the phrase "50 mile radius" to read "35 mile radius".
b. Paragraph (c)(1) is revised.
§ 412.92 Special treatment: Sole community hospitals.
(c) Terminology. * * *
(1) The term miles means the shortest distance in miles measured over improved roads. An improved road for this purpose is any road that is maintained by a local, State, or Federal government entity and is available for use by the general public. An improved road includes the paved surface up to the front entrance of the hospital.
§ 412.105 Special treatment: Hospitals that incur indirect costs for graduate medical education programs.
7. Section 412.105 is amended as follows:
a. The introductory text of paragraph (a) is republished.
b. Paragraph (a)(1) is revised.
c. Paragraph (d)(3)(vi) is revised.
d. A new paragraph (d)(3)(vii) is added.
e. Paragraph (f)(1)(ii)(C) is revised.
f. Paragraph (f)(1)(iii) is revised.
g. Paragraph (f)(1)(v) is amended by adding five sentences at the end.
h. In paragraph (f)(1)(vii), the reference to "§ 413.86(g)(9)" is removed and "§ 413.86(g)(12)" is added in its place.
i. Paragraph (f)(1)(ix) is revised.
§ 412.105 Special treatment: Hospitals that incur indirect costs for graduate medical education programs.
(a) Basic data. CMS determines the following for each hospital:
(1) The hospital's ratio of full-time equivalent residents, except as limited under paragraph (f) of this section, to the number of beds (as determined under paragraph (b) of this section). Except for the special circumstances for affiliated groups and new programs described in paragraphs (f)(1)(vi) and (f)(1)(vii) of this section, for a hospital's cost reporting periods beginning on or after October 1, 1997, this ratio may not exceed the ratio for the hospital's most recent prior cost reporting period after accounting for the cap on the number of allopathic and osteopathic full-time equivalent residents as described in paragraph (f)(1)(iv) of this section, and adding to the capped numerator any dental and podiatric full-time equivalent residents. The exception for new programs described in paragraph (f)(1)(vii) of this section applies to each new program individually for which the full-time equivalent cap may be adjusted based on the period of years equal to the minimum accredited length of each new program.
(d) Determination of education adjustment factor. * * *
(3) * * *
(vi) For discharges occurring during fiscal year 2002, 1.6.
(vii) For discharges occurring on or after October 1, 2002, 1.35.
(f) Determining the total number of full-time equivalent residents for cost reporting periods beginning on or after July 1, 1991. * * *
(1) * * *
(ii) * * *
(C) Effective for discharges occurring on or after October 1, 1997, the time spent by a resident in a nonhospital setting in patient care activities under an approved medical residency training program is counted towards the determination of full-time equivalency if the criteria set forth in § 413.86(f)(3) or § 413.86(f)(4) of this subchapter, as applicable, are met.
(iii)(A) Full-time equivalent status is based on the total time necessary to fill a residency slot. No individual may be counted as more than one full-time equivalent. If a resident is assigned to more than one hospital, the resident counts as a partial full-time equivalent based on the proportion of time worked in any of the areas of the hospital listed in paragraph (f)(1)(ii) of this section, to the total time worked by the resident. A part-time resident or one working in an area of the hospital other than those listed under paragraph (f)(1)(ii) of this section (such as a freestanding family practice center or an excluded hospital unit) would be counted as a partial full-time equivalent based on the proportion of time assigned to an area of the hospital listed in paragraph (f)(l)(ii) of this section, compared to the total time necessary to fill a full-time residency slot.
(B) The time spent by a resident in research that is not associated with the treatment or diagnosis of a particular patient is not countable.
(v) * * * If a hospital qualified for an adjustment to the limit established under paragraph (f)(1)(iv) of this section for new medical residency programs created under paragraph (f)(1)(vii) of this section, the count of residents participating in new medical residency training programs above the number included in the hospital's FTE count for the cost reporting period ending during calendar year 1996 is added after applying the averaging rules in this paragraph (f)(l)(v) for a period of years. Residents participating in new medical residency training programs are included in the hospital's FTE count before applying the averaging rules after the period of years has expired. For purposes of this paragraph, for each new program started, the period of years equals the minimum accredited length for each new program. The period of years for each new program begins when the first resident begins training in each new program. Subject to the provisions of paragraph (f)(1)(ix) of this section, FTE residents that are displaced by the closure of either another hospital or another hospital's program are added to the FTE count after applying the averaging rules in this paragraph (f)(l)(v) for the receiving hospital for the duration of time that the displaced residents are training at the receiving hospital.
(ix) A hospital may receive a temporary adjustment to its full-time equivalent cap to reflect residents added because of another hospital's closure if the hospital meets the criteria specified in §§ 413.86(g)(8)(i) and (g)(8)(ii) of this subchapter. If a hospital that closes its residency training program agrees to temporarily reduce its FTE cap according to the criteria specified in §§ 413.86(g)(8)(i) and (g)(8)(iii)(B) of this subchapter, another hospital(s) may receive a temporary adjustment to its FTE cap to reflect residents added because of the closure of the residency training program if the criteria specified in §§ 413.86(g)(8)(i) and (g)(8)(iii)(A) of this subchapter are met.
8. Section 412.106 is amended by revising the heading of paragraph (e) and paragraph (e)(5) to read as follows:
§ 412.106 Special treatment: Hospitals that serve a disproportionate share of low-income patients.
(e) Reduction in payments beginning FY 1998. * * *
(5) For FY 2002, 3 percent.
§ 412.113 [Amended]
9. In § 412.113(c), including the heading for paragraph (c), the term "hospital", wherever it appears, is revised to read "hospital or CAH" (16 times).
10. Section 412.230 is amended by a new paragraph (a)(5)(v) and revising paragraph (e)(2) to read as follows:
§ 412.230 Criteria for an individual hospital seeking redesignation to another rural area or an urban area.
(a) * * *
(5) Limitations on redesignation. * * *
(v) Beginning with wage index reclassification applications for FY 2003, if a hospital is already reclassified to a given geographic area for wage index purposes for a 3-year period, and submits an application for reclassification to the same area for either the second or third year of the 3-year period, that application will not be approved.
(e) Use of urban or other rural area's wage index. * * *
(2) Appropriate wage data. For a wage index change, the hospital must submit appropriate wage data as follows:
(i) For redesignations effective through FY 2002:
(A) For hospital-specific data, the hospital must provide data from the CMS hospital wage survey used to construct the wage index in effect for prospective payment purposes during the fiscal year prior to the fiscal year for which the hospital requests reclassification.
(B) For data for other hospitals, the hospital must provide data concerning the average hourly wage in the area in which the hospital is located and the average hourly wage in the area to which the hospital seeks reclassification. The wage data are taken from the CMS hospital wage survey used to construct the wage index in effect for prospective payment purposes during the fiscal year prior to the fiscal year for which the hospital requests reclassification.
(C) If the hospital is requesting reclassification under paragraph (e)(1)(iv)(B) of this section, the hospital must provide occupational-mix data to demonstrate the average occupational mix for each employment category in the area to which it seeks reclassification. Occupational-mix data can be obtained from surveys conducted by the American Hospital Association.
(ii) For redesignations effective beginning FY 2003:
(A) For hospital-specific data, the hospital must provide a weighted 3-year average of its average hourly wages using data from the CMS hospital wage survey used to construct the wage index in effect for prospective payment purposes.
(B) For data for other hospitals, the hospital must provide a weighted 3-year average of the average hourly wage in the area in which the hospital is located and a weighted 3-year average of the average hourly wage in the area to which the hospital seeks reclassification. The wage data are taken from the CMS hospital wage survey used to construct the wage index in effect for prospective payment purposes.
11. Section 412.232 is amended by revising paragraph (d)(2) to read as follows:
§ 412.232 Criteria for all hospitals in a rural county seeking urban redesignation.
(d) Appropriate data. * * *
(2) Appropriate wage data. The hospitals must submit appropriate data as follows:
(i) For redesignations effective through FY 2002:
(A) For hospital-specific data, the hospitals must provide data from the CMS wage survey used to construct the wage index in effect for prospective payment purposes during the fiscal year prior to the fiscal year for which the hospitals request reclassification.
(B) For data for other hospitals, the hospitals must provide the following:
( 1 ) The average hourly wage in the adjacent area, which is taken from the CMS hospital wage survey used to construct the wage index in effect for prospective payment purposes during the fiscal year prior to the fiscal year for which the hospitals request reclassification.
( 2 ) Occupational-mix data to demonstrate the average occupational mix for each employment category in the adjacent area. Occupational-mix data can be obtained from surveys conducted by the American Hospital Association.
(ii) For redesignations effective beginning FY 2003:
(A) For hospital-specific data, the hospital must provide a weighted 3-year average of its average hourly wages using data from the CMS hospital wage survey used to construct the wage index in effect for prospective payment purposes.
(B) For data for other hospitals, the hospital must provide a weighted 3-year average of the average hourly wage in the area in which the hospital is located and a weighted 3-year average of the average hourly wage in the area to which the hospital seeks reclassification. The wage data are taken from the CMS hospital wage survey used to construct the wage index in effect for prospective payment purposes.
12. Section 412.235 is added to read as follows:
§ 412.235 Criteria for all hospitals in a State seeking a statewide wage index redesignation.
(a) General criteria. For all prospective payment system hospitals in a State to be redesignated to a statewide wage index, the following conditions must be met:
(1) All prospective payment system hospitals in the State must apply as a group for reclassification to a statewide wage index through a signed single application.
(2) All prospective payment system hospitals in the State must agree to the reclassification to a statewide wage index through a signed affidavit on the application.
(3) All prospective payment system hospitals in the State must agree, through an affidavit, to withdrawal of an application or to termination of an approved statewide wage index reclassification.
(4) All hospitals in the State must waive their rights to any wage index classification that they would otherwise receive absent the statewide wage index classification, including a wage index that any of the hospitals might have received through individual geographic reclassification.
(5) New hospitals that open within the State prior to the deadline for submitting an application for a statewide wage index reclassification (September 1), regardless of whether a group application has already been filed, must agree to the use of the statewide wage index as part of the group application. New hospitals that open within the State after the deadline for submitting a statewide wage index reclassification application or during the approved reclassification period will be considered a party to the statewide wage index application and reclassification.
(b) Effect on payments.
(1) An individual hospital within the State may receive a wage index that could be higher or lower under the statewide wage index reclassification in comparison to its otherwise redesignated wage index.
(2) Any new prospective payment system hospital that opens in the State during the effective period of an approved statewide wage index reclassification will be designated to receive the statewide wage index for the duration of that period.
(c) Terms of the decision.
(1) A decision by the MGCRB on an application for a statewide wage index reclassification will be effective for 3 years beginning with discharges occurring on the first day (October 1) of the second Federal fiscal year following the Federal fiscal year in which the hospitals filed a complete application.
(2) The procedures and timeframes specified in § 412.273 apply to withdrawals of applications for redesignation to a statewide wage index and terminations of approved statewide wage index reclassifications, including the requirement that, to withdraw an application or terminate an approved reclassification, the request must be made in writing by all hospitals that are party to the application, except hospitals reclassified into the State for purposes of receiving the statewide wage index.
13. Section 412.273 is amended as follows:
a. The title of the section is revised.
b. Paragraphs (b) and (c) are redesignated as paragraphs (c) and (d), respectively.
c. A new paragraph (b) is added.
d. Redesignated paragraph (c) is revised.
§ 412.273 Withdrawing an application or terminating an approved 3-year reclassification.
(b) Request for termination of approved 3-year wage index reclassifications.
(1) A hospital, or a group of hospitals, that has been issued a decision on its application for a 3-year reclassification for wage index purposes only or for redesignation to a statewide wage index and has not withdrawn that application under the procedures specified in paragraph (a) of this section may request termination of its approved 3-year wage index reclassification under the following conditions:
(i) The request to terminate must be received by the MGCRB within 45 days of the publication of the annual notice of proposed rulemaking concerning changes to the inpatient hospital prospective payment system and proposed payment rates for the fiscal year for which the termination is to apply.
(ii) A request to terminate a 3-year reclassification will be effective only for the full fiscal year(s) remaining in the 3-year period at the time the request is received. Requests for terminations for part of a fiscal year will not be considered.
(2) Reapplication within the approved 3-year period.
(i) If a hospital elects to withdraw its wage index application after the MGCRB has issued its decision, it may terminate its withdrawal in a subsequent fiscal year and request the MGCRB to reinstate its wage index reclassification for the remaining fiscal year(s) of the 3-year period.
(ii) A hospital may apply for reclassification for purposes of the wage index to a different area (that is, an area different from the one to which it was originally reclassified for the 3-year period). If the application is approved, the reclassification will be effective for 3 years.
(c) Written request only. A request to withdraw an application or terminate an approved reclassification must be made in writing to the MGCRB by all hospitals that are party to the application or reclassification.
14. Section 412.274 is amended by revising paragraph (b) to read as follow:
§ 412.274 Scope and effect of an MGCRB decision.
(b) Effective date and term of the decision.
(1) A standardized amount classification change is effective for one year beginning with discharges occurring on the first day (October 1) of the second Federal fiscal year following the Federal fiscal year in which the complete application is filed and ending effective at the end of that Federal fiscal year (the end of the next September 30).
(2) A wage index classification change is effective for 3 years beginning with discharges occurring on the first day (October 1) of the second Federal fiscal year in which the complete application is filed.
15. Section 412.348 is amended by revising paragraph (g)(6) and adding a new paragraph (g)(9) to read as follows:
§ 412.348 Exception payments.
(g) Special exceptions process. * * *
(6) Minimum payment level.
(i) The minimum payment level for qualifying hospitals will be 70 percent.
(ii) CMS will adjust the minimum payment level in one percentage point increments as necessary to satisfy the requirement specified in paragraph (h) of this section that total estimated payments under the exceptions process not exceed 10 percent of the total estimated capital prospective payment system payments for the same fiscal year.
(9) Notification requirement. Eligible hospitals must submit documentation to the intermediary indicating the completion date of a project that meets the project need requirement under paragraph (g)(2) of this section, the project size requirement under paragraph (g)(5) of this section, and, in the case of certain urban hospitals, an excess capacity test under paragraph (g)(4) of this section, by the later of October 1, 2001 or within 3 months of the end of the hospital's last cost reporting period beginning before October 1, 2001, during which a qualifying project was completed.
PART 413-PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES
C. Part 413 is amended as follows:
1. The authority citation for Part 413 continues to read as follows:
Authority:
Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and (n), 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), 1395hh, 1395rr, 1395tt, and 1395ww).
2. Section 413.70 is amended as follows:
a. Paragraph (a)(1) is republished.
b. A new paragraph (a)(1)(iv) is added.
c. Paragraph (a)(2) is revised.
d. A new paragraph (a)(3) is added.
e. Paragraph (b)(1) is revised.
f. Paragraph (b)(2)(i)(C) is revised.
g. New paragraphs (b)(4), (b)(5) and (b)(6) are added.
§ 413.70 Payment for services of a CAH.
(a) Payment for inpatient services furnished by a CAH.
(1) Payment for inpatient services of a CAH is the reasonable costs of the CAH in providing CAH services to its inpatients, as determined in accordance with section 1861(v)(1)(A) of the Act and the applicable principles of cost reimbursement in this part and in Part 415 of this chapter, except that the following payment principles are excluded when determining payment for CAH inpatient services:
(iv) The payment window provisions for preadmission services, specified in § 412.2(c)(5) of this subchapter and § 413.40(c)(2).
(2) Except as specified in paragraph (a)(3) of this section, payment to a CAH for inpatient services does not include any costs of physician services or other professional services to CAH inpatients, and is subject to the Part A hospital deductible and coinsurance, as determined under subpart G of part 409 of this chapter.
(3) If a CAH meets the criteria in § 412.113(c) of this subchapter for pass-through of costs of anesthesia services furnished by qualified nonphysician anesthetists employed by the CAH or obtained under arrangements, payment to the CAH for the costs of those services is made in accordance with § 412.113(c).
(b) Payment for outpatient services furnished by CAH.
(1) General.
(i) Unless the CAH elects to be paid for services to its outpatients under the method specified in paragraph (b)(3) of this section, the amount of payment for outpatient services of a CAH is the amount determined under paragraph (b)(2) of this section.
(ii) Except as specified in paragraph (b)(6) of this section, payment to a CAH for outpatient services does not include any costs of physician services or other professional services to CAH outpatients.
(2) Reasonable costs for facility services.
(i) * * *
(C) Any type of reduction to operating or capital costs under § 413.124 or § 413.130(j).
(4) Costs of emergency room on-call physicians.
(i) Effective for cost reporting periods beginning on or after October 1, 2001, the reasonable costs of outpatient CAH services under paragraph (b) of this section may include amounts for reasonable compensation and related costs for an emergency room physician who is on call but who is not present on the premises of the CAH involved, is not otherwise furnishing physicians' services, and is not on call at any other provider or facility.
(ii) For purposes of this paragraph (b)(4)-
(A) "Amounts for reasonable compensation and related costs" means all allowable costs of compensating emergency room physicians who are on call to the extent the costs are found to be reasonable under the rules specified in paragraph (b)(2) of this section and the applicable sections of Part 413. Costs of compensating emergency room physicians are allowable only if the costs are incurred under written contracts that require the physician to come to the CAH when the physician's presence is medically required.
(B) An "emergency room physician who is on call' means a doctor of medicine or osteopathy with training or experience in emergency care who is immediately available by telephone or radio contact, and is available on site within the timeframes specified in § 485.618(d) of this chapter.
(5) Costs of ambulance services.
(i) Effective for services furnished on or after December 21, 2000, payment for ambulance services furnished by a CAH or an entity that is owned and operated by a CAH is the reasonable costs of the CAH or the entity in furnishing those services, but only if the CAH or the entity is the only provider or supplier of ambulance services located within a 35-mile drive of the CAH or the entity.
(ii) For purposes of paragraph (b)(5) of this section, the distance between the CAH or the entity and the other provider or supplier of ambulance services will be determined as the shortest distance in miles measured over improved roads between the CAH or the entity and the site at which the vehicles of the closest provider or supplier of ambulance services are garaged. An improved road for this purpose is any road that is maintained by a local, State, or Federal government entity and is available for use by the general public. An improved road will be considered to include the paved surface up to the front entrance of the hospital and the front entrance of the garage.
(6) If a CAH meets the criteria in § 412.113(c) of this subchapter for pass-through of costs of anesthesia services furnished by nonphysician anesthetists employed by the CAH or obtained under arrangement, payment to the CAH for the costs of those services is made in accordance with § 412.113(c) of this chapter.
3. Section 413.86 is amended as follows:
a. Paragraph (e)(4)(ii)(C)( 1 ) is revised.
b. Paragraph (e)(5)(iv) is removed.
c. Paragraph (g)(4) is revised.
d. Paragraph (g)(5) is revised.
e. In paragraph (g)(6), the reference to "paragraph (g)(9)" is removed and "paragraph (g)(12)" is added in its place.
f. Paragraph (g)(8) is revised.
§ 413.86 Direct graduate medical education payments.
(e) Determining per residents amounts for the base period. * * *
(4) * * *
(ii) * * *
(C) Determining necessary revisions to the per resident amount. * * *
( 1 ) Floor. ( i ) For cost reporting periods beginning on or after October 1, 2000, and before October 1, 2001, if the hospital's per resident amount would otherwise be less than 70 percent of the locality-adjusted national average per resident amount for FY 2001 (as determined under paragraph (e)(4)(ii)(B) of this section), the per resident amount is equal to 70 percent of the locality-adjusted national average per resident amount for FY 2001.
( ii ) For cost reporting periods beginning on or after October 1, 2001, and before October 1, 2002, if the hospital's per resident amount would otherwise be less than 85 percent of the locality-adjusted national average per resident amount for FY 2002 (as determined under paragraph (e)(4)(ii)(B) of this section), the per resident amount is equal to 85 percent of the locality-adjusted national average per resident amount for FY 2002.
( iii ) For subsequent cost reporting periods beginning on or after October 1, 2002, the hospital's per resident amount is updated using the methodology specified under paragraph (e)(3)(i) of this section.
(g) Determining the weighted number of FTE residents. * * *
(4) For purposes of determining direct graduate medical education payments-
(i) For cost reporting periods beginning on or after October 1, 1997, a hospital's unweighted FTE count for residents in allopathic and osteopathic medicine may not exceed the hospital's unweighted FTE count (or, effective for cost reporting periods beginning on or after April 1, 2000, 130 percent of the unweighted FTE count for a hospital located in a rural area) for these residents for the most recent cost reporting period ending on or before December 31, 1996.
(ii) If a hospital's number of FTE residents in a cost reporting period beginning on or after October 1, 1997, and before October 1, 2001, exceeds the limit described in this paragraph (g), the hospital's total weighted FTE count (before application of the limit) will be reduced in the same proportion that the number of FTE residents for that cost reporting period exceeds the number of FTE residents for the most recent cost reporting period ending on or before December 31, 1996.
(iii) If the hospital's number of FTE residents in a cost reporting period beginning on or after October 1, 2001 exceeds the limit described in this paragraph (g), the hospital's weighted FTE count (before application of the limit), for primary care and obstetrics and gynecology residents and nonprimary care residents, respectively, will be reduced in the same proportion that the number of FTE residents for that cost reporting period exceeds the number of FTE residents for the most recent cost reporting period ending on or before December 31, 1996.
(iv) Hospitals that are part of the same affiliated group may elect to apply the limit on an aggregate basis.
(v) The fiscal intermediary may make appropriate modifications to apply the provisions of this paragraph (g)(4) based on the equivalent of a 12-month cost reporting period.
(5) For purposes of determining direct graduate medical education payment-
(i) For the hospital's first cost reporting period beginning on or after October 1, 1997, the hospital's weighted FTE count is equal to the average of the weighted FTE count for the payment year cost reporting period and the preceding cost reporting period.
(ii) For cost reporting periods beginning on or after October 1, 1998, and before October 1, 2001, the hospital's weighted FTE count is equal to the average of the weighted FTE count for the payment year cost reporting period and the preceding two cost reporting periods.
(iii) For cost reporting periods beginning on or after October 1, 2001, the hospital's weighted FTE count for primary care and obstetrics and gynecology residents is equal to the average of the weighted primary care and obstetrics and gynecology counts for the payment year cost reporting period and the preceding two cost reporting periods, and the hospital's weighted FTE count for nonprimary care residents is equal to the average of the weighted nonprimary care FTE counts for the payment year cost reporting period and the preceding two cost reporting periods.
(iv) The fiscal intermediary may make appropriate modifications to apply the provisions of this paragraph (g)(5) based on the equivalent of 12-month cost reporting periods.
(v) If a hospital qualifies for an adjustment to the limit established under paragraph (g)(4) of this section for new medical residency programs created under paragraph (g)(6) of this section, the count of the residents participating in new medical residency training programs above the number included in the hospital's FTE count for the cost reporting period ending during calendar year 1996 is added after applying the averaging rules in this paragraph (g)(5) for a period of years. Residents participating in new medical residency training programs are included in the hospital's FTE count before applying the averaging rules after the period of years has expired. For purposes of this paragraph (g)(5), for each new program started, the period of years equals the minimum accredited length for each new program. The period of years begins when the first resident begins training in each new program.
(vi) Subject to the regulations at paragraph (g)(8) of this section, FTE residents that are displaced by the closure of either another hospital or another hospital's program are added to the FTE count after applying the averaging rules in this paragraph (g)(5) for the receiving hospital for the duration of the time that the displaced residents are training at the receiving hospital.
(8) Closure of hospital or hospital residency program.
(i) Definitions. For purposes of this paragraph (g)(8)-
(A) "Closure of a hospital" means the hospital terminates its Medicare agreement under the provisions of § 489.52 of this chapter.
(B) "Closure of a hospital residency training program" means the hospital ceases to offer training for residents in a particular approved medical residency training program.
(ii) Closure of a hospital. A hospital may receive a temporary adjustment to its FTE cap to reflect residents added because of another hospital's closure if the hospital meets the following criteria:
(A) The hospital is training additional residents from a hospital that closed on or after July 1, 1996.
(B) No later than 60 days after the hospital begins to train the residents, the hospital submits a request to its fiscal intermediary for a temporary adjustment to its FTE cap, documents that the hospital is eligible for this temporary adjustment by identifying the residents who have come from the closed hospital and have caused the hospital to exceed its cap, and specifies the length of time the adjustment is needed.
(iii) Closure of a hospital's residency training program. If a hospital that closes its residency training program voluntarily agrees to temporarily reduce its FTE cap according to the criteria specified in paragraph (g)(8)(iii)(B) of this section, another hospital(s) may receive a temporary adjustment to its FTE cap to reflect residents added because of the closure of the residency training program if the criteria specified in paragraph (g)(8)(iii)(A) of this section are met.
(A) Receiving hospital(s). A hospital may receive a temporary adjustment to its FTE cap to reflect residents added because of the closure of another hospital's residency training program if-
( 1 ) The hospital is training additional residents from the residency training program of a hospital that closed a program; and
( 2 ) No later than 60 days after the hospital begins to train the residents, the hospital submits to its fiscal intermediary a request for a temporary adjustment to its FTE cap, documents that it is eligible for this temporary adjustment by identifying the residents who have come from another hospital's closed program and have caused the hospital to exceed its cap, specifies the length of time the adjustment is needed, and submits to its fiscal intermediary a copy of the FTE reduction statement by the hospital that closed its program, as specified in paragraph (g)(8)(iii)(B)( 2 ) of this section.
(B) Hospital that closed its program(s). A hospital that agrees to train residents who have been displaced by the closure of another hospital's program may receive a temporary FTE cap adjustment only if the hospital with the closed program-
( 1 ) Temporarily reduces its FTE cap based on the FTE residents in each program year training in the program at the time of the program's closure. This yearly reduction in the FTE cap will be determined based on the number of those residents who would have been training in the program during that year had the program not closed; and
( 2 ) No later than 60 days after the residents who were in the closed program begin training at another hospital, submit to its fiscal intermediary a statement signed and dated by its representative that specifies that it agrees to the temporary reduction in its FTE cap to allow the hospital training the displaced residents to obtain a temporary adjustment to its cap; identifies the residents who were in training at the time of the program's closure; identifies the hospitals to which the residents are transferring once the program closes; and specifies the reduction for the applicable program years.
PART 485-CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS
D. Part 485 is amended as follows:
1. The authority citation for part 485 continues to read as follows:
Authority:
Secs. 1102 and 1871 of the Act (42 U.S.C. 1302 and 1395hh).
2. Section 485.610 is amended by revising paragraphs (a)(2)(ii) and (b) and adding a new paragraph (c) to read as follows:
§ 485.610 Condition of participation: Status and location.
(a) * * *
(2) * * *
(ii) Meets the criteria for designation under this subpart as of the effective date of its designation; or
(b) Standard: Location in a rural area or treatment as rural. The CAH meets the requirements of either paragraph (b)(1) or (b)(2) of this section.
(1) The CAH meets the following requirements:
(i) The CAH is located outside any area that is a Metropolitan Statistical Area, as defined by the Office of Management and Budget, or that has been recognized as urban under § 412.62(f) of this chapter;
(ii) The CAH is not deemed to be located in an urban area under § 412.63(b) of this chapter; and
(iii) The CAH has not been classified as an urban hospital for purposes of the standardized payment amount by CMS or the Medicare Geographic Classification Review Board under § 412.230(e) of this chapter, and is not among a group of hospitals that have been redesignated to an adjacent urban area under § 412.232 of this chapter.
(2) The CAH is located within a Metropolitan Statistical Area, as defined by the Office of Management and Budget, but is being treated as being located in a rural area in accordance with § 412.103 of this chapter.
(c) Standard: Location relative to other facilities or necessary provider certification. The CAH is located more than a 35-mile drive (or, in the case of mountainous terrain or in areas with only secondary roads available, a 15-mile drive) from a hospital or another CAH, or the CAH is certified by the State as being a necessary provider of health care services to residents in the area.
3. Section 485.639 is amended by revising paragraph (b) to read as follows:
§ 485.639 Condition of participation: Surgical services.
(b) Anesthetic risk and evaluation.
(1) A qualified practitioner, as specified in paragraph (a) of this section, must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed.
(2) A qualified practitioner, as specified in paragraph (c) of this section, must examine each patient before surgery to evaluate the risk of anesthesia.
(3) Before discharge from the CAH, each patient must be evaluated for proper anesthesia recovery by a qualified practitioner, as specified in paragraph (c) of this section.
4. Section 485.643 is amended by revising paragraph (f) to read as follows:
§ 485.643 Condition of participation: Organ, tissue, and eye procurement.
(f) For purposes of these standards, the term "organ" means a human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs).
PART 486-CONDITIONS FOR COVERAGE OF SPECIALIZED SERVICES FURNISHED BY SUPPLIERS
F. Part 486 is amended as follows:
1. The authority citation for Part 486 continues to read as follows:
Authority:
Sections 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).
2. Section 486.302 is amended by revising the definition of "organ" to read as follows:
§ 486.302 Definitions.
"Organ" means a human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs).
(Catalog of Federal Domestic Assistance Program No. 93.773, Medicare-Hospital Insurance)
Dated: July 23, 2001.
Thomas A. Scully,
Administrator, Centers for Medicare Medicaid Services.
Dated: July 24, 2001.
Tommy G. Thompson,
Secretary.
Editorial Note:
The following Addendum and appendixes will not appear in the Code of Federal Regulations.
Addendum-Schedule of Standardized Amounts Effective With Discharges Occurring On or After October 1, 2001 and Update Factors and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2001
I. Summary and Background
In this Addendum, we are setting forth the amounts and factors for determining prospective payment rates for Medicare inpatient operating costs and Medicare inpatient capital-related costs. We are also setting forth rate-of-increase percentages for updating the target amounts for hospitals and hospital units excluded from the prospective payment system.
For discharges occurring on or after October 1, 2001, except for SCHs, MDHs, and hospitals located in Puerto Rico, each hospital's payment per discharge under the prospective payment system will be based on 100 percent of the Federal national rate.
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 cost per discharge, the updated hospital-specific rate based on FY 1987 cost per discharge, or, if qualified, 50 percent of the updated hospital-specific rate based on FY 1996 cost per discharge, plus the greater of 50 percent of the updated FY 1982 or FY 1987 hospital-specific rate or 50 percent of the Federal DRG payment rate. Section 213 of Public Law 106-554 amended section 1886(b)(3) of the Act to allow all SCHs to rebase their hospital-specific rate based on their FY 1996 cost 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 50 percent of the difference between the Federal national rate and the updated hospital-specific rate based on FY 1982 or FY 1987 cost per discharge, whichever is higher.
For hospitals in Puerto Rico, the payment per discharge is based on the sum of 50 percent of a Puerto Rico rate and 50 percent of a Federal national rate. (See section II.D.3. of this Addendum for a complete description.)
As discussed below in section II. of this Addendum, we are making changes in the determination of the prospective payment rates for Medicare inpatient operating costs for FY 2002. The changes, to be applied prospectively, affect the calculation of the Federal rates. In section III. of this Addendum, we finalize changes to the prospective payment rates for inpatient operating costs for FY 2001, as set forth in the June 13, 2001 interim final rule with comment period. In section IV. of this Addendum, we discuss our changes for determining the prospective payment rates for Medicare inpatient capital-related costs for FY 2002. Section V. of this Addendum sets forth our changes for determining the rate-of-increase limits for hospitals excluded from the prospective payment system for FY 2002. The tables to which we refer in the preamble to this final rule are presented at the end of this Addendum in section VI.
II. Changes to Prospective Payment Rates for Inpatient Operating Costs for FY 2002
The basic methodology for determining prospective payment rates for inpatient operating costs is set forth at § 412.63. The basic methodology for determining the prospective payment rates for inpatient operating costs for hospitals located in Puerto Rico is set forth at §§ 412.210 and 412.212. Below, we discuss the factors used for determining the prospective payment rates. The Federal and Puerto Rico rate changes will be effective with discharges occurring on or after October 1, 2001.
In summary, the standardized amounts set forth in Tables 1A and 1C of section VI. of this Addendum reflect-
• Updates of 2.75 percent for all areas (that is, the market basket percentage increase of 3.3 percent minus 0.55 percentage points);
• An adjustment to ensure budget neutrality as provided for under sections 1886(d)(4)(C)(iii) and (d)(3)(E) of the Act, by applying new budget neutrality adjustment factors to the large urban and other standardized amounts;
• An adjustment to ensure budget neutrality as provided for in section 1886(d)(8)(D) of the Act by removing the FY 2001 budget neutrality factor and applying a revised factor;
• An adjustment to apply the revised outlier offset by removing the FY 2001 outlier offsets and applying a new offset; and
• An adjustment in the Puerto Rico standardized amounts to reflect the application of a Puerto Rico-specific wage index.
A. Calculation of Adjusted Standardized Amounts
1. Standardization of Base-Year Costs or Target Amounts
Section 1886(d)(2)(A) of the Act required the establishment of base-year cost data containing allowable operating costs per discharge of inpatient hospital services for each hospital. The preamble to the September 1, 1983 interim final rule (48 FR 39763) contains a detailed explanation of how base-year cost data were established in the initial development of standardized amounts for the prospective payment system and how they are used in computing the Federal rates.
Section 1886(d)(9)(B)(i) of the Act required us to determine the Medicare target amounts for each hospital located in Puerto Rico for its cost reporting period beginning in FY 1987. The September 1, 1987 final rule (52 FR 33043, 33066) contains a detailed explanation of how the target amounts were determined and how they are used in computing the Puerto Rico rates.
The standardized amounts are based on per discharge averages of adjusted hospital costs from a base period or, for Puerto Rico, adjusted target amounts from a base period, updated and otherwise adjusted in accordance with the provisions of section 1886(d) of the Act. Sections 1886(d)(2)(B) and (d)(2)(C) of the Act required 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 (IME) costs, and costs to hospitals serving a disproportionate share of low-income patients.
Under sections 1886(d)(2)(H) and (d)(3)(E) of the Act, in making payments under the prospective payment system, the Secretary estimates from time to time the proportion of costs that are wages and wage-related costs. Since October 1, 1997, when the market basket was last revised, we have considered 71.1 percent of costs to be labor-related for purposes of the prospective payment system. The average labor share in Puerto Rico is 71.3 percent. We are revising the discharge-weighted national standardized amount for Puerto Rico to reflect the proportion of discharges in large urban and other areas from the FY 2000 MedPAR file.
2. Computing Large Urban and Other Area Averages
Sections 1886(d)(2)(D) and (d)(3) of the Act require the Secretary to compute two average standardized amounts for discharges occurring in a fiscal year: one for hospitals located in large urban areas and one for hospitals located in other areas. In addition, under sections 1886(d)(9)(B)(iii) and (d)(9)(C)(i) of the Act, the average standardized amount per discharge must be determined for hospitals located in large urban and other areas in Puerto Rico. Hospitals in Puerto Rico are paid a blend of 50 percent of the applicable Puerto Rico standardized amount and 50 percent of a national standardized payment amount.
Section 1886(d)(2)(D) of the Act defines "urban area" as those areas within a Metropolitan Statistical Area (MSA). A "large urban area" is defined as an urban area with a population of more than 1 million. In addition, section 4009(i) of Public Law 100-203 provides that a New England County Metropolitan Area (NECMA) with a population of more than 970,000 is classified as a large urban area. As required by section 1886(d)(2)(D) of the Act, population size is determined by the Secretary based on the latest population data published by the Bureau of the Census. Urban areas that do not meet the definition of a "large urban area" are referred to as "other urban areas." Areas that are not included in MSAs are considered "rural areas" under section 1886(d)(2)(D) of the Act. Payment for discharges from hospitals located in large urban areas will be based on the large urban standardized amount. Payment for discharges from hospitals located in other urban and rural areas will be based on the other standardized amount.
Based on 1999 population estimates published by the Bureau of the Census, 63 areas meet the criteria to be defined as large urban areas for FY 2002. These areas are identified in Table 4A.
3. Updating the Average Standardized Amounts
Under section 1886(d)(3)(A) of the Act, we update the average standardized amounts each year. In accordance with section 1886(d)(3)(A)(iv) of the Act, we are updating the large urban areas' and the other areas' average standardized amounts for FY 2002 using the applicable percentage increases specified in section 1886(b)(3)(B)(i) of the Act. Section 1886(b)(3)(B)(i)(XVII) of the Act as amended by section 301 of Public Law 106-554 specifies that the update factor for the standardized amounts for FY 2002 is equal to the market basket percentage increase minus 0.55 percentage points for hospitals in all areas. Section 301 also established that the update factor for FY 2003 is equal to the market basket percentage increase minus 0.55 percentage points. We are revising § 412.63 to reflect these changes.
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 2002 is 3.3 percent. Thus, for FY 2002, the update to the average standardized amounts equals 2.75 percent for hospitals in all areas.
As in the past, we are adjusting the FY 2001 standardized amounts to remove the effects of the FY 2001 geographic reclassifications and outlier payments before applying the FY 2002 updates. That is, we are increasing the standardized amounts to restore the reductions that were made for the effects of geographic reclassification and outliers. We then apply the new offsets to the standardized amounts for outliers and geographic reclassifications for FY 2002.
Although the update factors for FY 2002 are set by law, we are required by section 1886(e)(3) of the Act to report to the Congress our initial recommendation of update factors for FY 2002 for both prospective payment hospitals and hospitals excluded from the prospective payment system.
We have included our final recommendations on the update factors in Appendix C to this final rule.
4. Other Adjustments to the Average Standardized Amounts
a. Recalibration of DRG Weights and Updated Wage Index-Budget Neutrality Adjustment
Section 1886(d)(4)(C)(iii) of the Act specifies that, beginning in FY 1991, the annual DRG reclassification and recalibration of the relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. As discussed in section II of the preamble, we normalized the recalibrated DRG weights by an adjustment factor, so that the average case weight after recalibration is equal to the average case weight prior to recalibration.
Section 1886(d)(3)(E) of the Act 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.
To comply with the requirement of section 1886(d)(4)(C)(iii) of the Act that DRG reclassification and recalibration of the relative weights be budget neutral, and the requirement in section 1886(d)(3)(E) of the Act that the updated wage index be budget neutral, we used FY 2000 discharge data to simulate payments and compared aggregate payments using the FY 2001 relative weights and wage index to aggregate payments using the FY 2002 relative weights and wage index. The same methodology was used for the FY 2001 budget neutrality adjustment. (See the discussion in the September 1, 1992 final rule (57 FR 39832).) Based on this comparison, we computed a budget neutrality adjustment factor equal to 0.995821. We also adjust the Puerto Rico-specific standardized amounts for the effect of DRG reclassification and recalibration. We computed a budget neutrality adjustment factor for Puerto Rico-specific standardized amounts equal to 0.997209. These budget neutrality adjustment factors are applied to the standardized amounts without removing the effects of the FY 2001 budget neutrality adjustments. For FY 2001, we used an average of the budget neutrality factor that was in effect from October 1, 2000 through March 30, 2001 and the budget neutrality factor that was in effect from April 1, 2001 through September 30, 2001 (0.997225 and 0.997122, respectively). We do not remove the prior budget neutrality adjustment because estimated aggregate payments after the changes in the DRG relative weights and wage index should equal estimated aggregate payments prior to the changes. If we removed the prior year adjustment, we would not satisfy this condition.
In addition, we will continue to apply these same adjustment factors to the hospital-specific rates that are effective for cost reporting periods beginning on or after October 1, 2001. (See the discussion in the September 4, 1990 final rule (55 FR 36073).)
b. Reclassified Hospitals-Budget Neutrality Adjustment
Section 1886(d)(8)(B) of the Act provides that, 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 Medicare Geographic Classification Review Board (MGCRB). Under section 1886(d)(10) of the Act, a hospital may be reclassified for purposes of the standardized amount or the wage index, or both.
Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amounts so as to ensure that aggregate payments under the prospective payment system after implementation of the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act are equal to the aggregate prospective payments that would have been made absent these provisions. To calculate this budget neutrality factor, we used FY 2000 discharge data to simulate payments, and compared total prospective payments (including IME and disproportionate share hospital (DSH) payments) prior to any reclassifications to total prospective payments after reclassifications. Based on these simulations, we are applying an adjustment factor of 0.990675 to ensure that the effects of reclassification are budget neutral.
The adjustment factor is applied to the standardized amounts after removing the effects of the FY 2001 budget neutrality adjustment factor. We note that the proposed FY 2002 adjustment reflected wage index and standardized amount reclassifications approved by the MGCRB or the Administrator as of February 28, 2001, and the effects of section 304 of Public Law 106-554 to extend wage index reclassifications for 3 years. The effects of any additional reclassification changes that occurred as a result of appeals and reviews of the MGCRB decisions for FY 2002 or from a hospital's request for the withdrawal of a reclassification request for FY 2002 are reflected in the final budget neutrality adjustment required under section 1886(d)(8)(D) of the Act and published in this final rule.
c. Outliers
Section 1886(d)(5)(A) of the Act provides for payments in addition to the basic prospective payments for "outlier" cases, cases involving extraordinarily high costs (cost outliers). Section 1886(d)(3)(B) of the Act requires the Secretary to adjust both the large urban and other area national standardized amounts by the same factor to account for the estimated proportion of total DRG payments made to outlier cases. Similarly, section 1886(d)(9)(B)(iv) of the Act requires the Secretary to adjust the large urban and other standardized amounts applicable to hospitals in Puerto Rico to account for the estimated proportion of total DRG payments made to outlier cases. Furthermore, under section 1886(d)(5)(A)(iv) of the Act, outlier payments for any year must be projected to be not less than 5 percent nor more than 6 percent of total payments based on DRG prospective payment rates.
i. FY 2002 outlier thresholds. For FY 2001, the fixed loss cost outlier threshold published in the August 1, 2000 final rule was equal to the prospective payment rate for the DRG plus the IME and DSH payments plus $17,550 ($16,036 for hospitals that have not yet entered the prospective payment system for capital-related costs). As a result of the change made by Public Law 106-554 to the update factor for the operating standardized amounts, this threshold was applicable for discharges on or after October 1, 2000 and before April 1, 2001. For discharges occurring on or after April 1, 2001 and before October 1, 2001, the threshold was equal to the prospective payment rate for the DRG plus the IME and DSH payments plus $16,350 ($14,940 for hospitals that have not yet entered the prospective payment system for capital-related costs). The revision to the threshold was discussed in the interim final rule with comment period published on June 13, 2001 (66 FR 32176). (In the June 13, 2001 interim final rule with comment period, the fixed loss amount was stated as $16,500. This was an error; the correct amount is $16,350. This is the amount that has been applied to discharges since April 1, 2001, in the PRICER software used to determine payments.) The marginal cost factor for cost outliers (the percent of costs paid after costs for the case exceed the threshold) was 80 percent.
For FY 2002, we proposed to establish a fixed loss cost outlier threshold equal to the prospective payment rate for the DRG plus the IME and DSH payments plus $21,000. The capital prospective payment system is fully phased in, effective FY 2002. Therefore, we no longer are establishing a separate threshold for hospitals that have not yet entered the prospective payment system for capital-related costs. We proposed to maintain the marginal cost factor for cost outliers at 80 percent.
In this final rule, we are establishing a fixed loss cost outlier threshold equal to the prospective rate for the DRG plus the IME and DSH payment plus $21,025. In addition, we are maintaining the marginal cost factor for cost outliers at 80 percent. To calculate the final FY 2002 outlier thresholds, we simulated payments by applying FY 2002 rates and policies to the March 2001 update of the FY 2000 MedPAR file and the March 2001 update of the Provider-Specific File.
We apply a cost inflation factor to update costs for the cases used to simulate payments. For FY 2000, we used a cost inflation factor of zero percent. For FY 2001, we used a cost inflation factor (or cost adjustment factor) of 1.8 percent. To set the proposed FY 2002 outlier thresholds, we used a 2-year cost inflation factor of 5.5 percent (to inflate FY 2000 charges to FY 2002). We are using a cost inflation factor of 2.8 percent per year to set the final FY 2002 outlier thresholds (this equates to a 2-year cost inflation factor of 5.7 percent). This factor reflects our analysis of the best available cost report data as well as calculations (using the best available data) indicating that the percentage of actual outlier payments for FY 2000 is higher than we projected before the beginning of FY 2000, and that the percentage of actual outlier payments for FY 2001 will likely be higher than we projected before the beginning of FY 2001. The calculations of "actual" outlier payments are discussed further below.
Comment: Several commenters noted that the proposed threshold was almost 20 percent higher than the threshold effective for FY 2001. The commenters believed that we should verify the amount of cost outliers paid in a year and reconcile accordingly. One commenter also suggested that we amend our method of calculating the threshold so that the threshold is set at a level that reflects FY 2001 threshold plus a reasonable updating factor to account for inflation.
Response: As indicated in the proposed rule, and as explained in numerous previous Federal Register documents, under the policy we have maintained since the inception of the hospital inpatient prospective payment system for operating costs, we do not make retroactive adjustments to reconcile differences between the percentage of outlier payments projected before a given fiscal year and the "actual" outlier payments for that fiscal year.
In accordance with section 1886(d)(5)(A) of the Act, we set outlier thresholds for an upcoming fiscal year so that outlier payments for the fiscal year are projected to equal a specified percentage between 5 and 6 percent of total payments based on DRG prospective payment rates. To set the thresholds, we simulate payments using the best available data. We believe that the methodology suggested by the commenter, simply updating the FY 2001 thresholds to account for inflation, would not be appropriate because, among other reasons, the methodology would not reflect the use of the most recent complete data with respect to discharges and costs. The difference between the FY 2001 outlier thresholds and the FY 2002 outlier thresholds arises from differences reflected in the data used to set the respective thresholds.
ii. Other changes concerning outliers. In accordance with section 1886(d)(5)(A)(iv) of the Act, we calculated outlier thresholds so that outlier payments are projected to equal 5.1 percent of total payments based on DRG prospective payment rates. In accordance with section 1886(d)(3)(E), we reduced the FY 2002 standardized amounts by the same percentage to account for the projected proportion of payments paid to outliers.
As stated in the September 1, 1993 final rule (58 FR 46348), we establish outlier thresholds that are applicable to both inpatient operating costs and inpatient capital-related costs. When we modeled the combined operating and capital outlier payments, we found that using a common set of thresholds resulted in a higher percentage of outlier payments for capital-related costs than for operating costs. We project that the thresholds for FY 2002 will result in outlier payments equal to 5.1 percent of operating DRG payments and 5.8 percent of capital payments based on the Federal rate.
The proposed outlier adjustment factors applied to the standardized amounts for FY 2002 were as follows:
| Operating standardized amounts | Capital federal rate | |
|---|---|---|
| National | 0.948910 | 0.974711 |
| Puerto Rico | 0.942593 | 0.970336 |
Based on simulations of payments using updated data, the final outlier adjustment factors applied to the standardized amounts for FY 2002 are as follows:
| Operating standardized amounts | Capital federal rate | |
|---|---|---|
| National | 0.948928 | 0.942440 |
| Puerto Rico | 0.974762 | 0.970140 |
As in the proposed rule, we apply the outlier adjustment factors after removing the effects of the FY 2001 outlier adjustment factors on the standardized amounts.
Table 8A in section VI. of this Addendum contains the updated statewide average operating cost-to-charge ratios for urban hospitals and for rural hospitals to be used in calculating cost outlier payments for those hospitals for which the fiscal intermediary is unable to compute a reasonable hospital-specific cost-to-charge ratio. These statewide average ratios replace the ratios published in the August 1, 2000 final rule (65 FR 47054). Table 8B contains comparable statewide average capital cost-to-charge ratios. These average ratios will be used to calculate cost outlier payments for those hospitals for which the fiscal intermediary computes operating cost-to-charge ratios lower than 0.1903547 or greater than 1.3148656 and capital cost-to-charge ratios lower than 0.0119230 or greater than 0.1677417. This range represents 3.0 standard deviations (plus or minus) from the mean of the log distribution of cost-to-charge ratios for all hospitals. We note that the cost-to-charge ratios in Tables 8A and 8B will be used during FY 2002 when hospital-specific cost-to-charge ratios based on the latest settled cost report are either not available or outside the three standard deviations range.
iii. FY 2000 and FY 2001 outlier payments. In the August 1, 2000 final rule (65 FR 47054), we stated that, based on available data, we estimated that actual FY 2000 outlier payments would be approximately 6.2 percent of actual total DRG payments. This was computed by simulating payments using the March 2000 update of the FY 1999 bill data available at the time. That is, the estimate of actual outlier payments did not reflect actual FY 2000 bills but instead reflected the application of FY 2000 rates and policies to available FY 1999 bills. Our current estimate, using available FY 2000 bills, is that actual outlier payments for FY 2000 were approximately 7.6 percent of actual total DRG payments. We note that the MedPAR file for FY 2000 discharges continues to be updated. Thus, the data indicate that, for FY 2000, the percentage of actual outlier payments relative to actual total payments is higher than we projected before FY 2000 (and thus exceeds the percentage by which we reduced the standardized amounts for FY 2000). In fact, the data indicate that the proportion of actual outlier payments for FY 2000 exceeds 6.0 percent. Nevertheless, consistent with the policy and statutory interpretation we have maintained since the inception of the prospective payment system, we do not plan to recoup money and make retroactive adjustments to outlier payments for FY 2000.
We currently estimate that actual outlier payments for FY 2001 will be approximately 6.2 percent of actual total DRG payments, 1.1 percentage points higher than the 5.1 percent we projected in setting outlier policies for FY 2001. This estimate is based on simulations using the March 2001 update of the Provider-Specific File and the March 2001 update of the FY 2000 MedPAR file (discharge data for FY 2000 bills). We used these data to calculate an estimate of the actual outlier percentage for FY 2001 by applying FY 2001 rates and policies to available FY 2000 bills.
5. FY 2002 Standardized Amounts
The adjusted standardized amounts are divided into labor and nonlabor portions. Table 1A contains the two national standardized amounts that are applicable to all hospitals, except hospitals in Puerto Rico. Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion of the Puerto Rico payment rate is based on the discharge-weighted average of the national large urban standardized amount and the national other standardized amount (as set forth in Table 1A). The labor and nonlabor portions of the national average standardized amounts for Puerto Rico hospitals are set forth in Table 1C. This table also includes the Puerto Rico standardized amounts.
Comment: Several commenters were unable to reconcile the standardized amounts published in the proposed rule for FY 2002 with the rates which were in effect for FY 2001. These commenters requested that we clarify, by category, the increases and decreases applied to the standardized amounts in the proposed rule in order to illustrate the method under which the rates were established.
Response: The confusion likely arises from the two different rates that were effective during FY 2001. Prior to the passage of Public Law 106-554, section 1886(b)(3)(B)(i) of the Act set the update to the standardized amounts for FY 2001 as the market basket percentage increase minus 1.1 percentage points. Section 301(a) of Public Law 106-554 revised section 1886(b)(3)(B)(i) of the Act to set the update to the standardized amounts for FY 2001 equal to the full market basket percentage increase.
Further, section 301(b) of Public Law 106-554 included a special provision to implement the full market basket update for purposes of making payments for FY 2001 only. Under this special provision, for discharges occurring on or after October 1, 2000 and before April 1, 2001, the update factor (other than for SCHs) is equal to the market basket percentage increase minus 1.1 percentage points. For discharges occurring on or after April 1, 2001 and before October 1, 2001, the update factor (other than SCHs) is equal to the market basket percentage increase plus 1.1 percentage points.
However, section 547 of Public Law 106-554 makes this special rule applicable solely to payments in FY 2001 and the payment increases under section 301(b) in this fiscal year are not to be taken into account in developing payments for future fiscal years. Consequently, when we established the rates for FY 2002, we based the calculation on FY 2001 standardized amounts reflecting the full FY 2001 market basket percentage increase of 3.4 percent. Since the standardized amounts calculated using the full market basket were not actually used for payment during FY 2001, they were not published in either the August 1, 2000 final rule or the June 13, 2001 interim final rule with comment period.
To arrive at the final FY 2002 standardized amounts, we updated the standardized amounts through FY 2001 using the full market basket of 3.4 percent (without applying a geographic budget neutrality factor or outlier factor), then multiplied this amount by: the update factor for FY 2002; the wage and recalibration budget neutrality factor; the geographic reclassification budget neutrality factor; and the outlier factor established for FY 2002. The calculation below details this reconciliation process using the large urban area standardized amount as an example. Although the commenters requested a reconciliation of the proposed rates, the example below reconciles the final FY 2002 rates, as those are the amounts actually in effect for the fiscal year. To reconcile the rates in the proposed rule, the exact same methodology applies.
| Labor | Nonlabor | |
|---|---|---|
| FY 2001 Standardized Amount with Full Market Basket Update/No Reclassification, Budget Neutrality or Outlier Offset | $3,072.51 | $1,248.88 |
| Update Factor: (Market Basket Percentage Increase minus 0.55 percent) | 1.0275 | 1.0275 |
| FY 2002 Wage Index and DRG reclassification/recalculation budget neutrality factor | 0.995821 | 0.995821 |
| FY 2002 Reclassification budget neutrality factor | 0.990675 | 0.990675 |
| Outlier Factor | 0.948928 | 0.948928 |
| Final Rate for FY 2002 (after multiplying FY 2001 base rate by above factors) | $2,955.44 | $1,201.30 |
B. Adjustments for Area Wage Levels and Cost of Living
Tables 1A and 1C, as set forth in this Addendum, contain the labor-related and nonlabor-related shares that will be used to calculate the prospective payment rates for hospitals located in the 50 States, the District of Columbia, and Puerto Rico. This section addresses two types of adjustments to the standardized amounts that are made in determining the prospective payment rates as described in this Addendum.
1. Adjustment for Area Wage Levels
Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require that we make an adjustment to the labor-related portion of the prospective payment rates to account for area differences in hospital wage levels. This adjustment is made by multiplying the labor-related portion of the adjusted standardized amounts by the appropriate wage index for the area in which the hospital is located. In section III. of this preamble, we discuss the data and methodology for the FY 2002 wage index. The wage index is set forth in Tables 4A, 4B, 4C, and 4F of this Addendum.
2. Adjustment for Cost-of-Living in Alaska and Hawaii
Section 1886(d)(5)(H) of the Act authorizes an adjustment to take into account the unique circumstances of hospitals in Alaska and Hawaii. Higher labor-related costs for these two States are taken into account in the adjustment for area wages described above. For FY 2002, we are adjusting the payments for hospitals in Alaska and Hawaii by multiplying the nonlabor portion of the standardized amounts by the appropriate adjustment factor contained in the table below.
| Alaska-All areas | 1.25 |
| Hawaii: | |
| County of Honolulu | 1.25 |
| County of Hawaii | 1.165 |
| County of Kauai | 1.2325 |
| County of Maui | 1.2375 |
| County of Kalawao | 1.2375 |
(The above factors are based on data obtained from the U.S. Office of Personnel Management.)
C. DRG Relative Weights
As discussed in section II. of the preamble, we have developed a classification system for all hospital discharges, assigning them into DRGs, and have developed relative weights for each DRG that reflect the resource utilization of cases in each DRG relative to Medicare cases in other DRGs. Table 5 of section VI. of this Addendum contains the relative weights that we will use for discharges occurring in FY 2002. These factors have been recalibrated as explained in section II. of the preamble.
D. Calculation of Prospective Payment Rates for FY 2002
General Formula for Calculation of Prospective Payment Rates for FY 2002
The prospective payment rate for all hospitals located outside of Puerto Rico, except SCHs and MDHs, equals the Federal rate.
The prospective payment rate for SCHs equals whichever of the following rates yields the greatest aggregate payment: the Federal rate, the updated hospital-specific rate based on FY 1982 cost per discharge, the updated hospital-specific rate based on FY 1987 cost per discharge, or, if qualified, 50 percent of the updated hospital-specific rate based on FY 1996 cost per discharge, plus the greater of 50 percent of the updated FY 1982 or FY 1987 hospital-specific rate or 50 percent of the Federal rate. Section 213 of Public Law 106-554 amended section 1886(b)(3) of the Act to allow all SCHs to rebase their hospital-specific rate based on their FY 1996 cost per discharge.
The prospective payment rate for MDHs equals 100 percent of the Federal rate, or, if the greater of the updated FY 1982 hospital-specific rate or the updated FY 1987 hospital-specific rate is higher than the Federal rate, 100 percent of the Federal rate plus 50 percent of the difference between the applicable hospital-specific rate and the Federal rate.
The prospective payment rate for Puerto Rico equals 50 percent of the Puerto Rico rate plus 50 percent of a discharge-weighted average of the Federal large urban standardized amount and the Federal other standardized amount.
1. Federal Rate
For discharges occurring on or after October 1, 2001 and before October 1, 2002, except for SCHs, MDHs, and hospitals in Puerto Rico, the hospital's payment is based exclusively on the Federal national rate. The payment amount is determined as follows:
Step 1-Select the appropriate national standardized amount considering the type of hospital and designation of the hospital as large urban or other (see Table 1A in section VI. of this Addendum).
Step 2-Multiply the labor-related portion of the standardized amount by the applicable wage index for the geographic area in which the hospital is located (see Tables 4A, 4B, and 4C of section VI. of this Addendum).
Step 3-For hospitals in Alaska and Hawaii, multiply the nonlabor-related portion of the standardized amount by the appropriate cost-of-living adjustment factor.
Step 4-Add the amount from Step 2 and the nonlabor-related portion of the standardized amount (adjusted, if appropriate, under Step 3).
Step 5-Multiply the final amount from Step 4 by the relative weight corresponding to the appropriate DRG (see Table 5 of section VI. of this Addendum).
2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs)
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 cost per discharge, the updated hospital-specific rate based on FY 1987 cost per discharge, or, if qualified, 50 percent of the updated hospital-specific rate based on FY 1996 cost per discharge, plus the greater of 50 percent of the updated FY 1982 or FY 1987 hospital-specific rate or 50 percent of the Federal DRG payment rate.
Section 1886(d)(5)(G) of the Act provides that MDHs are paid based on whichever of the following rates yields the greatest aggregate payment: the Federal rate or the Federal rate plus 50 percent of the difference between the Federal rate and the greater of the updated hospital-specific rate based on FY 1982 and FY 1987 cost per discharge.
Hospital-specific rates have been determined for each of these hospitals based on either the FY 1982 cost per discharge, the FY 1987 cost per discharge or, for qualifying SCHs, the FY 1996 cost per discharge. For a more detailed discussion of the calculation of the hospital-specific rates, we refer the reader to the September 1, 1983 interim final rule (48 FR 39772); the April 20, 1990 final rule with comment (55 FR 15150); the September 4, 1990 final rule (55 FR 35994); and the August 1, 2000 final rule (65 FR 47082).
a. Updating the FY 1982, FY 1987, and FY 1996 Hospital-Specific Rates for FY 2002
We are increasing the hospital-specific rates by 2.75 percent (the hospital market basket percentage increase minus 0.55 percentage points) for SCHs and MDHs for FY 2002. Section 1886(b)(3)(C)(iv) of the Act provides that the update factor applicable to the hospital-specific rates for SCHs equal the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for SCHs in FY 2002, is the market basket rate of increase minus 0.55 percentage points. Section 1886(b)(3)(D) of the Act provides that the update factor applicable to the hospital-specific rates for MDHs equals the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for FY 2002, is the market basket rate of increase minus 0.55 percentage points.
b. Calculation of Hospital-Specific Rate
For SCHs, the applicable FY 2002 hospital-specific rate is based on the following: the hospital-specific rate calculated using the greater of the FY 1982 or FY 1987 costs, increased by the applicable update factor; or, if the hospital-specific rate based on cost per case in FY 1996 is greater than the hospital-specific rate using either the FY 1982 or the FY 1987 costs, the greater of 50 percent of the hospital-specific rate based on the FY 1982 or FY 1987 costs, increased by the applicable update factor, or 50 percent of the Federal rate plus 50 percent of its rebased FY 1996 hospital-specific rate updated through FY 2002. For MDHs, the applicable FY 2002 hospital-specific rate is calculated by increasing the hospital's hospital-specific rate for the preceding fiscal year by the applicable update factor, which is the same as the update for all prospective payment hospitals. In addition, for both SCHs and MDHs, the hospital-specific rate is adjusted by the budget neutrality adjustment factor (that is, by 0.995821) as discussed in section II.A.4.a. of this Addendum. The resulting rate is used in determining the payment rate an SCH or MDH is paid for its discharges beginning on or after October 1, 2001.
3. General Formula for Calculation of Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2001 and Before October 1, 2002
a. Puerto Rico Rate
The Puerto Rico prospective payment rate is determined as follows:
Step 1-Select the appropriate adjusted average standardized amount considering the large urban or other designation of the hospital (see Table 1C of section VI. of the Addendum).
Step 2-Multiply the labor-related portion of the standardized amount by the appropriate Puerto Rico-specific wage index (see Table 4F of section VI. of the Addendum).
Step 3-Add the amount from Step 2 and the nonlabor-related portion of the standardized amount.
Step 4-Multiply the result in Step 3 by 50 percent.
Step 5-Multiply the amount from Step 4 by the appropriate DRG relative weight (see Table 5 of section VI. of the Addendum).
b. National Rate
The national prospective payment rate is determined as follows:
Step 1-Multiply the labor-related portion of the national average standardized amount (see Table 1C of section VI. of the Addendum) by the appropriate national wage index (see Tables 4A and 4B of section VI. of the Addendum).
Step 2-Add the amount from Step 1 and the nonlabor-related portion of the national average standardized amount.
Step 3-Multiply the result in Step 2 by 50 percent.
Step 4-Multiply the amount from Step 3 by the appropriate DRG relative weight (see Table 5 of section VI. of the Addendum).
The sum of the Puerto Rico rate and the national rate computed above equals the prospective payment for a given discharge for a hospital located in Puerto Rico.
III. Changes to the Prospective Payment Rates for Inpatient Operating Costs for FY 2001 (Section 301 of Public Law 106-554 and 42 CFR 412.63(s))
In the June 13, 2001 interim final rule with comment period, we implemented section 301(a) of Public Law 106-554 as it applied to FY 2001. Section 301(a) amended section 1886(b)(3)(B)(i) of the Act by changing the percentage increase for the hospital inpatient payment rates for FYs 2001, 2002, and 2003. Previously, section 1886(b)(3)(B)(i) (as amended by section 406 of Public Law 106-113) established the update factor to the payment rates for inpatient prospective payment system hospitals (other than SCHs, who received the full market basket update effective October 1, 2000) as the market basket percentage increase minus 1.1 percent for FYs 2001 and 2002; the update factor for FY 2003 and subsequent fiscal years was established as the full market basket percentage increase. Section 301(a) of Public Law 106-554 amended section 1886(b)(3)(B)(i) of the Act and changed the update factor for FY 2001 to the full market basket percentage increase. (Section 301(a) also revised the update factors that apply to FYs 2002 and 2003, as discussed in section II. of this Addendum.) Prior to enactment of Public Law 106-554, the update factor for FY 2002 was the market basket percentage increase minus 1.1 percentage points and the update factor for FY 2003 was the full market basket percentage increase. Section 301(a) of Public Law 106-554 amended section 1886(b)(3)(B)(i) of the Act to revise the update factor for FYs 2002 and 2003 to be the market basket percentage increase minus 0.55 percentage points.
Further, section 301(b) of Public Law 106-554 provided a special rule to implement the full market basket update to inpatient hospital prospective payment rates for FY 2001. Under this special rule, for discharges occurring on or after October 1, 2000 and before April 1, 2001, the update factor for inpatient prospective payment system hospitals (other than SCHs) is equal to the market basket percentage increase minus 1.1 percentage points. For discharges occurring on or after April 1, 2001 and before October 1, 2001, the update factor for the payment rates for inpatient prospective payment system hospitals (other than SCHs) is equal to the market basket percentage increase plus 1.1 percentage points. Section 547 of Public Law 106-554 makes this special rule applicable solely to payments in FY 2001 and the payment increases resulting for FY 2001 are not taken into account in developing payments for future fiscal years.
As directed by the special rule in section 301(b) of Public Law 106-554, any discharges occurring on or after October 1, 2000, and before April 1, 2001, are paid in accordance with the standardized amounts set forth in the FY 2001 hospital inpatient prospective payment system final rule published in the August 1, 2000 Federal Register (65 FR 47126). These rates were calculated using the market basket percentage increase of 3.4 percent minus 1.1 percentage points, for a 2.3 percent increase (see 65 FR 47112), as directed by section 1886(b)(3)(B)(i) of the Act prior to the passage of Public Law 106-554.
To implement the special rule under section 301(b) of Public Law 106-554, in the June 13 interim final rule with comment period, we recomputed the standardized amounts effective for discharges occurring on or after April 1, 2001. That is, we replaced the update factor of 2.3 percent applied to the standardized amounts in the August 1, 2000 final rule, with the update factor of 4.5 percent (the market basket percentage increase plus 1.1 percentage points, or 3.4 plus 1.1 percentage points).
| Large urban areas | Labor-related | Nonlabor-related | Other areas | Labor-related | Nonlabor-related | |
|---|---|---|---|---|---|---|
| National | $2,925.82 | $1,189.26 | $2,879.51 | $1,170.43 | ||
| National PR | 2,900.64 | 1,179.02 | 2,900.64 | 1,179.02 | ||
| Puerto Rico | 1,402.79 | 564.66 | 1,380.58 | 555.72 | ||
| SCHs | 2,895.02 | 1,176.74 | 2,849.20 | 1,158.11 |
A. Budget Neutrality
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 projected to be the same as those that would have been made without such adjustments. 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 projected to be the same as those that would have been made without the change in the wage index.
Finally, under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amounts so as to ensure that final aggregate payments under the prospective payment system are projected to equal the aggregate prospective payments that would have been made absent the geographic reclassification provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act.
The distributive effects on hospital payments of the IME and DSH changes also included in Public Law 106-554 required us to recalculate the budget neutrality factors that are required by section 1886(d)(8)(D) of the Act.
As we stated in the June 13, 2001 interim final rule with comment period, the budget neutrality factors that were used to establish the standardized amounts effective for discharges occurring on or after October 1, 2000 were: 0.997225 for the DRG reclassification and recalibration and updated wage index (65 FR 47112); and 0.993187 for geographic reclassification (65 FR 47113). Using the same methodology that was used to calculate the budget neutrality factors in the August 1, 2000 final rule, the corresponding budget neutrality factors for the standardized amounts effective for discharges occurring on or after April 1, 2001 and before October 1, 2001 are 0.997122 and 0.993279. The FY 2001 budget neutrality factor for Puerto Rico did not change. Therefore, the budget neutrality factor for Puerto Rico as published in the August 1, 2000 Federal Register (65 FR 47112) remained in effect for discharges occurring on or after April 1, 2001 and before October 1, 2001.
B. Outliers
In accordance with section 1886(d)(3)(B) of the Act, which directs the Secretary to adjust the national standardized amounts to account for the estimated proportion of total payments made to outlier cases, the fixed-loss outlier threshold was also revised as a result of the change made by Public Law 106-554 to the update factor for the operating standardized amounts. For discharges occurring on or after April 1, 2001 and before October 1, 2001, we established a fixed-loss cost outlier threshold equal to the prospective payment rate for the DRG, plus IME and DSH payments, plus $16,350 ($14,940 for hospitals that have not yet entered the prospective payment system for capital-related costs). (In the June 13, 2001 interim final rule with comment period, the fixed loss amount was stated as $16,500. This was an error. The correct amount is $16,350. This is the amount that has been applied to discharges since April 1, 2001, in the PRICER software used to determine payments.) In determining the outlier threshold, we used the same methodology employed to determine the outlier threshold for FY 2001 (65 FR 47113 through 47114). Outlier payments for discharges occurring on or after October 1, 2000 and before April 1, 2001, will be determined in accordance with the standardized amounts and outlier thresholds set forth in the FY 2001 final rule published in the August 1, 2000 Federal Register (65 FR 47113).
Although the market basket percentage used to update SCHs was not revised by Public Law 106-554, the standardized amounts applied to these hospitals for discharges occurring on or after April 1, 2001 and before October 1, 2001 also increase slightly. This increase in SCH rates is due to the budget neutrality factors effective for this portion of the fiscal year.
For discharges occurring on or after April 1, 2001 and before October 1, 2001, the outlier adjustment factors are as follows:
| Operating standardized amounts | Capital federal rate | |
|---|---|---|
| National | 0.948929 | 0.937854 |
| Puerto Rico | 0.973671 | 0.967355 |
III. Changes to Payment Rates for Inpatient Capital-Related Costs for FY 2002
The prospective payment system for hospital inpatient capital-related costs was implemented for cost reporting periods beginning on or after October 1, 1991. Effective with that cost reporting period and during a 10-year transition period extending through FY 2001, hospital inpatient capital-related costs are paid on the basis of an increasing proportion of the capital prospective payment system Federal rate and a decreasing proportion of a hospital's historical costs for capital.
The basic methodology for determining Federal capital prospective rates is set forth at §§ 412.308 through 412.352. Below we discuss the factors that we used to determine the capital Federal rate rate and the hospital-specific rates for FY 2002. The rates, which will be effective for discharges occurring on or after October 1, 2001. As we stated in section V. of the preamble of this final rule, we are no longer determining an update to the capital hospital-specific rate, since FY 2001 is the last year of the 10-year transition period, and beginning in FY 2002 all hospitals (except "new" hospitals under § 412.324(b)) will be paid based on 100 percent of the capital Federal rate.
For FY 1992, we computed the standard Federal payment rate for capital-related costs under the prospective payment system by updating the FY 1989 Medicare inpatient capital cost per case by an actuarial estimate of the increase in Medicare inpatient capital costs per case. Each year after FY 1992, we update the standard Federal rate, as provided in § 412.308(c)(1), to account for capital input price increases and other factors. Also, § 412.308(c)(2) provides that the Federal rate is adjusted annually by a factor equal to the estimated proportion of outlier payments under the Federal rate to total capital payments under the Federal rate. In addition, § 412.308(c)(3) requires that the Federal rate be reduced by an adjustment factor equal to the estimated proportion of payments for (regular and special) exceptions under § 412.348. Furthermore, § 412.308(c)(4)(ii) requires that the Federal rate be adjusted so that the annual DRG reclassification and the recalibration of DRG weights and changes in the geographic adjustment factor are budget neutral. For FYs 1992 through 1995, § 412.352 required that the Federal rate also be adjusted by a budget neutrality factor so that aggregate payments for inpatient hospital capital costs were projected to equal 90 percent of the payments that would have been made for capital-related costs on a reasonable cost basis during the fiscal year. That provision expired in FY 1996. Section 412.308(b)(2) describes the 7.4 percent reduction to the rate that was made in FY 1994, and § 412.308(b)(3) describes the 0.28 percent reduction to the rate made in FY 1996 as a result of the revised policy of paying for transfers. In the FY 1998 final rule with comment period (62 FR 45966), we implemented section 4402 of Public Law 105-33, which requires that for discharges occurring on or after October 1, 1997, and before October 1, 2002, the unadjusted standard Federal rate is reduced by 17.78 percent. A small part of that reduction will be restored effective October 1, 2002.
To determine the appropriate budget neutrality adjustment factor and the regular exceptions payment adjustment, we developed a dynamic model of Medicare inpatient capital-related costs, that is, a model that projects changes in Medicare inpatient capital-related costs over time. With the expiration of the budget neutrality provision, the model is still used to estimate the regular exceptions payment adjustment and other factors. The model and its application are described in greater detail in Appendix B of this final rule.
In accordance with section 1886(d)(9)(A) of the Act, under the prospective payment system for inpatient operating costs, hospitals located in Puerto Rico are paid for operating costs under a special payment formula. Prior to FY 1998, hospitals in Puerto Rico were paid a blended rate that consisted of 75 percent of the applicable standardized amount specific to Puerto Rico hospitals and 25 percent of the applicable national average standardized amount. However, effective October 1, 1997, as a result of section 4406 of Public Law 105-33, operating payments to hospitals in Puerto Rico are based on a blend of 50 percent of the applicable standardized amount specific to Puerto Rico hospitals and 50 percent of the applicable national average standardized amount. In conjunction with this change to the operating blend percentage, effective with discharges on or after October 1, 1997, we compute capital payments to hospitals in Puerto Rico based on a blend of 50 percent of the Puerto Rico rate and 50 percent of the Federal rate.
Section 412.374 provides for the use of this blended payment system for payments to Puerto Rico hospitals under the prospective payment system for inpatient capital-related costs. Accordingly, for capital-related costs, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital.
A. Determination of Federal Inpatient Capital-Related Prospective Payment Rate Update
In the August 1, 2000 final rule (65 FR 47122), we established a Federal rate of $382.03 for FY 2001. In the June 13, 2001 interim final rule with comment, as a result of implementing section 301(b) of Public Law 106-554, we established a Federal rate of $380.85 for discharges occurring on or after April 1, 2001 and before October 1, 2001 (66 FR 32180). (See section V.E. of the preamble and section III.A.5 of this Addendum for a fuller discussion of the provisions of section 301(b) of Public Law 106-554.) In accordance with section 547 of Public Law 106-554, the special payment increases provided by Public Law 106-554 effective between April and October 2001 do not apply for discharges occurring after FY 2001 and are not taken into account in determining the payment rates in subsequent years. Thus, the adjustments and rates published in the August 1, 2000 final rule were used in determining the FY 2002 capital rates. As a result of the changes to the factors used to establish the Federal rate in this addendum, the FY 2002 Federal rate is $390.74.
In the discussion that follows, we explain the factors that were used to determine the FY 2002 Federal rate. In particular, we explain why the FY 2002 Federal rate has increased 2.28 percent compared to the FY 2001 Federal rate (published in the August 1, 2000 final rule (65 FR 47122)). We also estimate aggregate capital payments will increase by 4.27 percent during this same period. This increase is primarily due to the increase in the number of hospital admissions and the increase in case-mix. This increase in capital payments is slightly less than last year (5.48 percent) because with the end of the transition period the remaining hold harmless hospitals receiving "cost-based" payments will begin being paid based on 100 percent of the Federal rate.
Total payments to hospitals under the prospective payment system are relatively unaffected by changes in the capital prospective payments. Since capital payments constitute about 10 percent of hospital payments, a 1 percent change in the capital Federal rate yields only about 0.1 percent change in actual payments to hospitals. Aggregate payments under the capital prospective payment system are estimated to increase in FY 2002 compared to FY 2001.
1. Standard Federal Rate Update
Under § 412.308(c)(1), the standard Federal rate is updated on the basis of an analytical framework that takes into account changes in a capital input price index and other factors. The update framework consists of a capital input price index (CIPI) and several policy adjustment factors. Specifically, we have adjusted the projected CIPI rate of increase as appropriate each year for case-mix index-related changes, for intensity, and for errors in previous CIPI forecasts. The proposed rule reflected an update factor for FY 2002 under that framework of 1.1 percent, based on data available at that time. Under the update framework, the final update factor for FY 2002 is 1.3 percent. This update factor is based on a projected 0.7 percent increase in the CIPI, a 0.3 percent adjustment for intensity, a 0.0 percent adjustment for case-mix, a 0.0 percent adjustment for the FY 2000 DRG reclassification and recalibration, and a forecast error correction of 0.3 percent. We explain the basis for the FY 2002 CIPI projection in section II.C. of this Addendum. Below we describe the policy adjustments that have been applied.
The case-mix index is the measure of the average DRG weight for cases paid under the prospective payment system. Because the DRG weight determines the prospective payment for each case, any percentage increase in the case-mix index corresponds to an equal percentage increase in hospital payments.
The case-mix index can change for any of several reasons:
• The average resource use of Medicare patients changes ("real" case-mix change);
• Changes in hospital coding of patient records result in higher weight DRG assignments ("coding effects"); and
• The annual DRG reclassification and recalibration changes may not be budget neutral ("reclassification effect").
We define real case-mix change as actual changes in the mix (and resource requirements) of Medicare patients as opposed to changes in coding behavior that result in assignment of cases to higher weighted DRGs but do not reflect higher resource requirements. In the update framework for the prospective payment system for operating costs, we adjust the update upwards to allow for real case-mix change, but remove the effects of coding changes on the case-mix index. We also remove the effect on total payments of prior changes to the DRG classifications and relative weights, in order to retain budget neutrality for all case-mix index-related changes other than patient severity. (For example, we adjusted for the effects of the FY 2000 DRG reclassification and recalibration as part of our FY 2002 update recommendation.) We have adopted this case-mix index adjustment in the capital update framework as well.
For FY 2002, we are projecting a 1.0 percent increase in the case-mix index. We estimate that real case-mix increase will equal 1.0 percent in FY 2002. Therefore, the net adjustment for case-mix change in FY 2002 is 0.0 percentage points.
We estimate that FY 2000 DRG reclassification and recalibration will result in a 0.0 percent change in the case-mix when compared with the case-mix index that would have resulted if we had not made the reclassification and recalibration changes to the DRGs. Therefore, we are making a 0.0 percent adjustment for DRG reclassification and recalibration in the update recommendation for FY 2002.
The capital update framework contains an adjustment for forecast error. The input price index forecast is based on historical trends and relationships ascertainable at the time the update factor is established for the upcoming year. In any given year, there may be unanticipated price fluctuations that may result in differences between the actual increase in prices and the forecast used in calculating the update factors. In setting a prospective payment rate under the framework, we make an adjustment for forecast error only if our estimate of the change in the capital input price index for any year is off by 0.25 percentage points or more. There is a 2-year lag between the forecast and the measurement of the forecast error. A forecast error of 0.3 percentage points was calculated for the FY 2000 update. That is, current historical data indicate that the forecasted FY 2000 CIPI used in calculating the FY 2000 update factor (0.6 percent) understatethe actual realized price increases (0.9 percent) by 0.3 percentage points. This under-prediction was due to prices from municipal bond yields declining slower than expected. Therefore, we are making a 0.0 3 percent adjustment for forecast error in the update for FY 2002.
Under the capital prospective payment system framework, we also make an adjustment for changes in intensity. We calculate this adjustment using the same methodology and data as in the framework for the operating prospective payment system. The intensity factor for the operating update framework reflects how hospital services are utilized to produce the final product, that is, the discharge. This component accounts for changes in the use of quality-enhancing services, changes in within-DRG severity, and expected modification of practice patterns to remove cost-ineffective services.
We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services), and changes in real case-mix. The use of total charges in the calculation of the proposed intensity factor makes it a total intensity factor, that is, charges for capital services are already built into the calculation of the factor. Therefore, we have incorporated the intensity adjustment from the operating update framework into the capital update framework. Without reliable estimates of the proportions of the overall annual intensity increases that are due, respectively, to ineffective practice patterns and to the combination of quality-enhancing new technologies and within-DRG complexity, we assume, as in the revised operating update framework, that one-half of the annual increase is due to each of these factors. The capital update framework thus provides an add-on to the input price index rate of increase of one-half of the estimated annual increase in intensity to allow for within-DRG severity increases and the adoption of quality-enhancing technology.
For FY 2002, we have developed a Medicare-specific intensity measure based on a 5-year average, using FY 1996 through 2000 data. In determining case-mix constant intensity, we found that observed case-mix increase was 1.6 percent in FY 1996, 0.3 percent in FY 1997, -0.4 percent in FY 1998, and -0.3 in FY 1999, and -0.7 percent in FY 2000. Since we found an increase in case-mix of 1.6 for FY 1996, which was outside of the range of 1.0 to 1.4 percent, we estimate that real case-mix increase was 1.0 to 1.4 percent for that year. The estimate of 1.0 to 1.4 percent is supported by past studies of case-mix change by the RAND Corporation. The most recent study was "Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988" by G. M. Carter, J. P. Newhouse, and D. A. Relles, R-4098-HCFA/ProPAC (1991). The study suggested that real case-mix change was not dependent on total change, but was usually a fairly steady 1.0 to 1.4 percent per year. We use 1.4 percent as the upper bound because the RAND study did not take into account that hospitals may have induced doctors to document medical records more completely in order to improve payment. Following that study, we consider up to 1.4 percent of observed case-mix change as real for FY 1996 through FY 2000. Based on this analysis, we believe that all of the observed case-mix increase for FY 1997, FY 1998, and FY 1999, and FY 2000 is real. The increases for FY 1996 was in excess of our estimate of real case-mix increase.
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. Based upon an upper limit of 1.0 percent real case-mix increase, we estimate that case-mix constant intensity increased by an average 0.3 percent during FYs 1996 through 2000, for a cumulative increase of 1.4 percent, given estimates of real case-mix of -1.0 percent for FY 1996, 0.3 percent for FY 1997, -0.4 for FY 1998, and -0.3 for FY 1999, and -0.7 percent for FY 2000. Based upon an upper limit of 1.4 percent real case-mix increase, we estimate that case-mix constant intensity declined increase by an average 0.2 percent during FYs 1996 through 2000, for a cumulative increase of 1.2 percent, given that real case-mix increase was 1.4 percent for FY 1996, 0.3 percent for FY 1997, -0.4 for FY 1998, -0.3 for FY 1999, and -0.7 percent for FY 2000. Since we estimate that intensity has increased during that period, we are recommending a 0.3 percent intensity adjustment for FY 2002.
2. Outlier Payment Adjustment Factor
Section 412.312(c) establishes a unified outlier methodology for inpatient operating and inpatient capital-related costs. A single set of thresholds is used to identify outlier cases for both inpatient operating and inpatient capital-related payments. 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 prospective payment system 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 August 1, 2000 final rule, we estimated that outlier payments for capital in FY 2001 would equal 5.91 percent of inpatient capital-related payments based on the Federal rate (65 FR 47121). Accordingly, we applied an outlier adjustment factor of 0.9409 to the Federal rate. Based on the thresholds as set forth in section II.A.4.c. of this Addendum, we estimate that outlier payments for capital will equal 5.76 percent of inpatient capital-related payments based on the Federal rate in FY 2002. Therefore, we are establishing an outlier adjustment factor of 0.9424 to the Federal rate. Thus, the projected percentage of capital outlier payments to total capital standard payments for FY 2002 is lower than the percentage for FY 2001.
The outlier reduction factors are not built permanently into the rates; that is, they are not applied cumulatively in determining the Federal rate. As explained previously, in accordance with section 547 of Public Law 106-554, the FY 2002 rates are based on the FY 2001 adjustments and rates published in the August 1, 2000 final rule (65 FR 47122). Therefore, the net change in the outlier adjustment to the Federal rate for FY 2002 is 1.0016 (0.9424/0.9409). The outlier adjustment increases the FY 2002 Federal rate by 0.16 percent compared with the FY 2001 outlier adjustment.
3. Budget Neutrality Adjustment Factor for Changes in DRG Classifications and Weights and the Geographic Adjustment Factor
Section 412.308(c)(4)(ii) requires that the Federal rate be adjusted so that aggregate payments for the fiscal year based on the Federal rate after any changes resulting from the annual DRG reclassification and recalibration and changes in the geographic adjustment factor (GAF) are projected to equal aggregate payments that would have been made on the basis of the Federal rate without such changes. We use the actuarial model, described in Appendix B of this final rule, to estimate the aggregate payments that would have been made on the basis of the Federal rate without changes in the DRG classifications and weights and in the GAF. We also use the model to estimate aggregate payments that would be made on the basis of the Federal rate as a result of those changes. We then use these figures to compute the adjustment required to maintain budget neutrality for changes in DRG weights and in the GAF.
For FY 2001, we calculated a GAF/DRG budget neutrality factor of 0.9979. In the proposed rule for FY 2002, we proposed a GAF/DRG budget neutrality factor of 0.9913. In this final rule, based on calculations using updated data, we are applying a factor of 0.9934. The GAF/DRG budget neutrality factors are built permanently into the rates; that is, they are applied cumulatively in determining the Federal rate. This follows from the requirement that estimated aggregate payments each year be no more or less than they would have been in the absence of the annual DRG reclassification and recalibration and changes in the GAF. As explained previously, in accordance with section 547 of Public Law 106-554, the FY 2002 adjustments and rates are based on the FY 2001 adjustment and rates published in the August 1, 2000 final rule (65 FR 47122). The incremental change in the adjustment from FY 2001 to FY 2002 is 0.9934. The cumulative change in the rate due to this adjustment is 0.9927 (the product of the incremental factors for FY 1993, FY 1994, FY 1995, FY 1996, FY 1997, FY 1998, FY 1999, FY 2000, FY 2001 and the incremental factor for FY 2002:0.9980 ×1.0053 ×0.9998 ×0.9994 ×0.9987 ×0.9989 ×1.0028 ×0.9985 ×0.9979 ×0.9934 =0.9927).
This factor accounts for DRG reclassifications and recalibration and for changes in the GAF. It also incorporates the effects on the GAF of FY 2002 geographic reclassification decisions made by the MGCRB compared to FY 2001 decisions. However, it does not account for changes in payments due to changes in the DSH and IME adjustment factors or in the large urban add-on.
4. Exceptions Payment Adjustment Factor
Section 412.308(c)(3) requires that the standard Federal rate for inpatient capital-related costs be reduced by an adjustment factor equal to the estimated proportion of additional payments for exceptions under § 412.348 relative to total capital payments payments under the hospital-specific rate and Federal rate. We use the model originally developed for determining the budget neutrality adjustment factor to determine the regular exceptions payment adjustment factor. We describe that model in Appendix B to this final rule. An adjustment for regular exceptions is necessary for determining the FY 2002 rates because we will continue to pay regular exceptions for cost reporting periods beginning before October 1, 2001 but ending in FY 2002, in accordance with § 412.312(c)(3). In FY 2003 and later, no payments will be made under the regular exceptions provision, and then we will only compute a budget neutrality adjustment under § 412.348(d) for special exceptions. We describe the methodology to determine the special exceptions adjustment in section V.D. of this final rule. For FY 2002, the exceptions adjustment is a combination of the adjustment that would be made under the regular exceptions provision and under the special exceptions provision under § 412.348(g).
For FY 2001, we estimated that exceptions payments would equal 2.15 percent of aggregate payments based on the Federal rate. Therefore, we applied an exceptions reduction factor of 0.9785 (1-;0.0215) in determining the Federal rate. In the May 4, 2001 proposed rule, we estimated that regular exceptions payments for FY 2002 would equal 0.63 percent of aggregate payments based on the Federal rate, we estimated that special exceptions payments for FY 2002 would equal 0.12 percent of aggregate payments based on the Federal rate. Therefore, we estimated that total exceptions payments for FY 2002 would equal 0.75 percent (0.63 + 0.12 = 0.75) of aggregate payments based on the Federal rate, and we proposed an exceptions payment reduction factor of 0.9925 (1-;0.0075) to the Federal rate for FY 2002. The proposed exceptions reduction factor for FY 2002 was 1.43 percent higher than the factor for FY 2001 published in the August 1, 2000 final rule.
For this final rule, based on updated data, we estimate that regular exceptions payments for FY 2002 will equal 0.59 percent of aggregate payments based on the Federal rate, and we estimate that special exceptions payments for FY 2002 will equal 0.12 percent of aggregate payments based on the Federal rate. We estimate that total exceptions payments for FY 2002 will be 0.71 percent (0.59 + 0.12 = 0.71). Thus, the FY 2002 exceptions payment reduction factor is 0.9929 (1-0.0071). The exceptions reduction factor for FY 2002 is 1.47 percent higher than the factor for FY 2001 published in the August 1, 2000 final rule. This increase is primarily due to the expiration of the regular exceptions provision and the narrowly defined nature of the special exceptions policy.
The exceptions reduction factors are not built permanently into the rates; that is, the factors are not applied cumulatively in determining the Federal rate. As explained previously, in accordance with section 547 of Public Law 106-554, the FY 2002 adjustments and rates are based on the FY 2001 adjustments and rates published in the August 1, 2000 final rule (65 FR 47122). Therefore, the net adjustment to the FY 2002 Federal rate is 0.9929/0.9785, or 1.0147.
5. Standard Capital Federal Rate for FY 2002
For FY 2001, the capital Federal rate was $382.03 for discharges occurring between October 1, 2000 and April 1, 2001. As a result of implementing section 301(b) of Public Law 106-554, for discharges occurring from April to October 2001, the capital Federal rate was $380.85. However, as explained previously, in accordance with section 547 of Public Law 106-554, the FY 2002 adjustments and rates are based on the FY 2001 adjustments and rates published in the August 1, 2000 final rule (65 FR 47122). As a result of changes we are making to the factors used to establish the Federal rate, in this final rule we are establishing the capital Federal rate for FY 2002 of $390.74. The Federal rate for FY 2002 was calculated as follows:
• The FY 2002 update factor is 1.0130; that is, the update is 1.30 percent.
• The FY 2002 budget neutrality adjustment factor that is applied to the standard Federal payment rate for changes in the DRG relative weights and in the GAF is 0.9934.
• The FY 2002 outlier adjustment factor is 0.94214.
• The FY 2002 (regular and special) exceptions payments adjustment factor is 0.9929.
Since the Federal rate has already been adjusted for differences in case-mix, wages, cost-of-living, indirect medical education costs, and payments to hospitals serving a disproportionate share of low-income patients, we have made no additional adjustments in the standard Federal rate for these factors, other than the budget neutrality factor for changes in the DRG relative weights and the GAF.
We are providing a chart that shows how each of the factors and adjustments for FY 2002 affected the computation of the FY 2002 Federal rate in comparison to the FY 2001 Federal rate. The FY 2002 update factor has the effect of increasing the Federal rate by 1.30 percent compared to the FY 2001 rate published in the August 1, 2000 final rule, while the geographic and DRG budget neutrality factor has the effect of decreasing the Federal rate by 0.66 percent. The FY 2002 outlier adjustment factor has the effect of increasing the Federal rate by 0.16 percent compared to the FY 2001 rate published in the August 1, 2000 final rule. The FY 2002 (regular and special) exceptions reduction factor has the effect of increasing the Federal rate by 1.47 percent compared to the exceptions reduction for FY 2001. The combined effect of all the proposed changes is to increase the Federal rate by 2.28 percent compared to the Federal rate for FY 2001.
| FY 2001 | FY 2002 | Change | Percent change | |
|---|---|---|---|---|
| Update factor1 | 1.0090 | 1.0130 | 1.0130 | 1.30 |
| GAF/DRG Adjustment Factor1 | 0.9979 | 0.9934 | 0.9934 | -0.66 |
| Outlier Adjustment Factor2 | 0.9409 | 0.9424 | 1.0016 | 0.16 |
| Exceptions Adjustment Factor2 | 0.9785 | 0.9929 | 1.0147 | 1.47 |
| Federal Rate | $382.03 | $390.74 | 1.0228 | 2.28 |
| 1 The update factor and the GAF/DRG budget neutrality factors are built permanently into the rates. Thus, for example, the incremental change from FY 2000 to FY 2001 resulting from the application of the 0.9934 GAF/DRG budget neutrality factor for FY 2001 is 0.9934. | ||||
| 2 The outlier reduction factor and the exceptions reduction factor are not built permanently into the rates; that is, these factors are not applied cumulatively in determining the rates. Thus, for example, the net change resulting from the application of the FY 2001 outlier reduction factor is 0.9424/0.9409, or 1.0016. | ||||
As stated previously in this section, the FY 2002 Federal rate has increased 2.28 percent compared to the FY 2001 capital Federal rate as a result of the FY 2002 factors and adjustments applied to the capital Federal rate. Specifically, the capital update factor increased the capital Federal rate 1.30 percent over FY 2001. The exceptions reduction factor increased 1.47 percent from 0.9875 to 0.9929 for FY 2002, which results in an increase to the capital Federal rate for FY 2002. Also, the outlier adjustment factor increased 0.16 percent from 0.9409 for FY 2001 to 0.9424 for FY 2002, which results in an increase to the capital Federal rate in FY 2002 compared to FY 2001. The GAF/DRG adjustment factor decreased 0.66 percent from 0.9979 for FY 2001 to 0.9934 for FY 2002, which results in a decrease the capital Federal rate for FY 2002 compared to FY 2001. The effect of all these changes is a 2.28 percent increase in the FY 2002 capital Federal rate compared to FY 2001.
We are also providing a chart that shows how the final FY 2002 capital Federal rate differs from the proposed FY 2002 capital Federal rate.
| Proposed FY 2002 | Final FY 2002 | Change | Percent change | |
|---|---|---|---|---|
| Update factor | 1.0110 | 1.0130 | 1.0020 | 0.20 |
| GAF/DRG Adjustment Factor | 0.9913 | 0.9934 | 1.0021 | 0.21 |
| Outlier Adjustment Factor | 0.9426 | 0.9424 | 0.9998 | -0.02 |
| Exceptions Adjustment Factor | 0.9925 | 0.9929 | 1.0004 | 0.04 |
| Federal Rate | $389.09 | $390.74 | 1.0042 | 0.42 |
6. Special Rate for Puerto Rico Hospitals
As explained at the beginning of section II.D. of this Addendum, hospitals in Puerto Rico are paid based on 50 percent of the Puerto Rico rate and 50 percent of the Federal rate. The Puerto Rico rate is derived from the costs of Puerto Rico hospitals only, while the Federal rate is derived from the costs of all acute care hospitals participating in the prospective payment system (including Puerto Rico). To adjust hospitals' capital payments for geographic variations in capital costs, we apply a GAF to both portions of the blended rate. The GAF is calculated using the operating prospective payment system wage index and varies, depending on the MSA or rural area in which the hospital is located. We use the Puerto Rico wage index to determine the GAF for the Puerto Rico part of the capital-blended rate and the national wage index to determine the GAF for the national part of the blended rate.
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. The Puerto Rico GAF budget neutrality factor is 0.9899, while the DRG adjustment is 0.9967, for a combined cumulative adjustment of 0.9866.
In computing the payment for a particular Puerto Rico hospital, the Puerto Rico portion of the rate (50 percent) is multiplied by the Puerto Rico-specific GAF for the MSA in which the hospital is located, and the national portion of the rate (50 percent) is multiplied by the national GAF for the MSA in which the hospital is located (which is computed from national data for all hospitals in the United States and Puerto Rico). In FY 1998, we implemented a 17.78 percent reduction to the Puerto Rico rate as a result of Public Law 105-33.
For FY 2001, before application of the GAF, the special rate for Puerto Rico hospitals was $185.06. As explained previously, in accordance with section 547 of Public Law 106-554, the FY 2002 adjustments and rates are based on the FY 2001 rates published in the August 1, 2000 final rule. With the changes we proposed to the factors used to determine the rate, the proposed FY 2002 special rate for Puerto Rico was $188.67. In this final rule, based on the final factors, the FY 2002 capital rate for Puerto Rico is $187.73.
7. Changes in the Capital Prospective Payment System Rates for FY 2001
In the June 13, 2001 interim final rule with comment period, we implemented section 301(b) of Public Law 106-554 (66 FR 32180).
Section 301(b) of Public Law 106-554 provided a special rule to implement the full market basket update to inpatient hospital operating prospective payment rates for FY 2001. Under this special rule, for discharges occurring on or after October 1, 2000 and before April 1, 2001, the update factor for inpatient prospective payment system hospitals (other than SCHs) is equal to the market basket percentage increase minus 1.1 percentage points. For discharges occurring on or after April 1, 2001 and before October 1, 2001, the update factor for the payment rates for inpatient prospective payment system hospitals (other than SCHs) is equal to the market basket percentage increase plus 1.1 percentage points. Section 547 of Public Law 106-554 makes this special rule applicable solely to payments in FY 2001, and the payment increases resulting for FY 2001 are not taken into account in developing payments for future fiscal years.
As directed by the special rule in section 301(b) of Public Law 106-554, any discharges occurring on or after October 1, 2000, and before April 1, 2001, will be paid in accordance with the standardized amounts set forth in the FY 2001 hospital inpatient prospective payment system final rule published in the August 1, 2000 Federal Register (65 FR 47126). These rates were calculated using the market basket percentage increase of 3.4 percent minus 1.1 percentage points, for a 2.3 percent increase (see 65 FR 47112), as directed by section 1886(b)(3)(B)(i) of the Act, prior to the passage of Public Law 106-554.
As stated in the June 13, 2001 interim final rule with comment period, to implement the special rule under section 301(b) of Public Law 106-554, we recomputed the standardized amounts effective for discharges occurring on or after April 1, 2001. That is, we replaced the update factor of 2.3 percent applied to the standardized amounts in the August 1, 2000 final rule, with the update factor of 4.5 percent (the market basket percentage increase plus 1.1 percentage point, or 3.4 plus 1.1 percentage points).
As published in the June 13, 2001 interim final rule with comment period (66 FR 32180), the revised capital Federal rate for discharges occurring on or after April 1 2001, and before October 1, 2001, are shown in the table below.
| National Rate | $380.85 |
| Puerto Rico Rate | $184.61 |
Section 1886(d)(3)(B) of the Act directs the Secretary to adjust the inpatient operating national standardized amounts to account for the estimated proportion of operating DRG payments made to payments in outlier cases. Accordingly, as a result of this change to the update to the operating standardized amounts for discharges occurring on or after April 1, 2001, and before October 1, 2001, we revised the fixed-loss outlier thresholds. The regulations at § 412.312(c) establish a unified outlier methodology for inpatient operating and inpatient capital-related costs, which utilizes a single set of thresholds to identify outlier cases for both inpatient operating and inpatient capital prospective payment system payments. Because operating DRG payments increased as a result of section 301 of Public Law 106-554, we decreased the fixed-loss threshold. The decrease in the outlier threshold also results in an increase in the estimated outlier payments for capital from 5.91 percent to 6.21 percent. Thus, the capital national outlier adjustment factor was revised from 0.9409 (as specified in the August 1, 2000 final rule (65 FR 47121)) to 0.9379 (as specified in the June 13, 2001 interim final rule with comment period).
As stated earlier, the basic methodology for determining the capital Federal rate is set forth in §§ 412.308 through 412.352. Although the operating update to the standardized amounts was affected by section 301 of Public Law 106-554, the standard capital Federal rate update remained unchanged (0.9 percent). The exceptions adjustment factor was determined based on an estimate of the ratio of exception payments to total capital payments. As a result of the fixed-cost outlier threshold, which affects total capital payments, in order to maintain budget neutrality for exception payments, we revised the exception adjustment factor from 0.9785 to 0.9787. The national GAF/DRG budget neutrality factor was also revised from 0.9979 to 0.9978. The Puerto Rico GAF/DRG budget neutrality factor remained unchanged (1.0037). Accordingly, as a result of the revisions to the capital outlier reduction factor and the capital exceptions adjustment factor, for discharges occurring on or after April 1, 2001, and before October 1, 2001, the national capital Federal rate was revised from $382.03 (65 FR 47127) to $380.85 and the Puerto Rico capital rate was revised from $185.06 (65 FR 47127) to $184.61.
In accordance with § 412.328(e), the hospital-specific rate is determined using the update factor and the exceptions adjustment factor. As a result of revising the exceptions adjustment factor to account for the change to the fixed-loss outlier threshold resulting from the special payment rule for FY 2001 provided for under section 301(b) of Public Law 106-554, for discharges occurring on or after April 1, 2001, and before October 1, 2001, the cumulative net adjustment to the hospital-specific rate was revised from 1.0147 (65 FR 47124) to 1.0145. For discharges occurring on or after April 1, 2001, and before October 1, 2001, the hospital-specific rate was determined by multiplying the FY 2000 hospital-specific rate by the cumulative net adjustment of 1.0145.
B. Calculation of Inpatient Capital-Related Prospective Payments for FY 2002
With the end of the capital prospective payment system transition period, all hospitals (except "new" hospitals under § 412.324(b)) will be paid based on 100 percent of the Federal rate in FY 2002. The applicable Federal rate was determined by making adjustments as follows:
• For outliers, by dividing the standard Federal rate by the outlier reduction factor for that fiscal year; and
• For the payment 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 2002, the standard Federal rate is adjusted as follows: (Standard Federal Rate) × (DRG weight) × (GAF) × (Large Urban Add-on, if applicable) × (COLA adjustment for hospitals located in Alaska and Hawaii) × (1 + Disproportionate Share Adjustment Factor + IME Adjustment Factor, if applicable). The result is the adjusted Federal rate.
Hospitals also may receive outlier payments for those cases that qualifyFY under the thresholds established for each fiscal year. Section 412.312(c) provides for a single set of thresholds to identify outlier cases for both inpatient operating and inpatient capital-related payments. The outlier thresholds for FY 2002 are in section II.A.4.c. of this Addendum. For FY 2002, 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 $21,025.
During the capital prospective payment system transition period, a hospital also may receive an additional payment under the regular exceptions process through its cost reporting period beginning before October 1, 2001, but ending in FY 2002 if its total inpatient capital-related payments are less than a minimum percentage of its allowable Medicare inpatient capital-related costs. The minimum payment level is established by class of hospital under § 412.348(c). Under § 412.348(d), the amount of a regular exceptions payment is determined by comparing the cumulative payments made to the hospital under the capital prospective payment system to the cumulative minimum payment levels applicable to the hospital for each cost reporting period subject to that system. Any amount by which the hospital's cumulative payments exceed its cumulative minimum payment is deducted from the additional payment that would otherwise be payable for a cost reporting period.
An eligible hospital may qualify for a special exception payment under § 412.348(g) for up through the 10th year beyond the end of the capital transition period if it meets (1) a project need requirement described at § 412.348(g)(2), which in the case of certain urban hospitals includes an excess capacity test; and (2) a project size requirement as described at § 412.348(g)(5). Eligible hospitals include sole community hospitals, urban hospitals with at least 100 beds that have a DSH patient percentage of at least 20.2 percent, and hospitals that have a combined Medicare and Medicaid inpatient utilization of at least 70 percent. Under § 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 prospective payment system 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 prospective payment system; 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. The minimum payment level is 70 percent for all eligible hospitals under § 412.348(g).
New hospitals, as defined under § 412.300, are exempted from the capital prospective payment system for their first 2 years of operation and are paid 85 percent of their reasonable costs during that period. A new hospital's old capital costs are its allowable costs for capital assets that were put in use for patient care on or before the later of December 31, 1990, or the last day of the hospital's base year cost reporting period, and are subject to the rules pertaining to old capital and obligated capital as of the applicable date. Effective with the third year of operation through the remainder of the transition period, we will pay the hospital under either the fully prospective methodology, using the appropriate transition blend in that Federal fiscal year, or the hold-harmless methodology. If the hold-harmless methodology is applicable, the hold-harmless payment for assets in use during the base period would extend for 8 years, even if the hold-harmless payments extend beyond the normal transition period.
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 costs during a given year. The CIPI differs from the operating input price index in one important aspect-the CIPI reflects the vintage nature of capital, which is the acquisition and use of capital over time. Capital expenses in any given year are determined by the stock of capital in that year (that is, capital that remains on hand from all current and prior capital acquisitions). An index measuring capital price changes needs to reflect this vintage nature of capital. Therefore, the CIPI was developed to capture the vintage nature of capital by using a weighted-average of past capital purchase prices up to and including the current year.
Using Medicare cost reports, American Hospital Association (AHA) data, and Securities Data Company data, a vintage-weighted price index was developed to measure price increases associated with capital expenses. We periodically update the base year for the operating and capital input prices to reflect the changing composition of inputs for operating and capital expenses. Currently, the CIPI is based to FY 1992 and was last rebased in 1997. The most recent discussion of the cost category weights in the CIPI was in the final rule with comment period for FY 1998 published on August 29, 1997 (62 FR 46050).
2. Forecast of the CIPI for Federal Fiscal Year 2002
We are forecasting the CIPI to increase 0.7 percent for FY 2002. This reflects a projected 1.4 percent increase in vintage-weighted depreciation prices (building and fixed equipment, and movable equipment) and a 3.3 percent increase in other capital expense prices in FY 2002, partially offset by a 2.0 percent decline in vintage-weighted interest rates in FY 2002. The weighted average of these three factors produces the 0.7 percent increase for the CIPI as a whole.
IV. Changes to Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages
The inpatient operating costs of hospitals and hospital units excluded from the prospective payment system are subject to rate-of-increase limits established under the authority of section 1886(b) of the Act, which is implemented in regulations at § 413.40. Under these limits, a hospital-specific target amount (expressed in terms of the inpatient operating cost per discharge) is set for each hospital, based on the hospital's own historical cost experience trended forward by the applicable rate-of-increase percentages (update factors). In the case of a psychiatric hospital or hospital unit, a rehabilitation hospital or hospital unit, or a long-term care hospital, the target amount may not exceed the updated figure for the 75th percentile of target amounts adjusted to take into account differences between average wage-related costs in the area of the hospital and the national average of such costs within the same class of hospital for hospitals and units in the same class (psychiatric, rehabilitation, and long-term care) for cost reporting periods ending during FY 1996. The target amount is multiplied by the number of Medicare discharges in a hospital's cost reporting period, yielding the ceiling on aggregate Medicare inpatient operating costs for the cost reporting period.
Each hospital-specific target amount is adjusted annually, at the beginning of each hospital's cost reporting period, by an applicable update factor.
Section 1886(b)(3)(B) of the Act, which is implemented in regulations at § 413.40(c)(3)(vii), provides that for cost reporting periods beginning on or after October 1, 1998 and before October 1, 2002, the update factor for a hospital or unit depends on the hospital's or hospital unit's costs in relation to the ceiling for the most recent cost reporting period for which information is available. For hospitals with costs exceeding the ceiling by 10 percent or more, the update factor is the market basket increase. For hospitals with costs exceeding the ceiling by less than 10 percent, the update factor is the market basket minus .25 percent for each percentage point by which costs are less than 10 percent over the ceiling. For hospitals with costs equal to or less than the ceiling but greater than 66.7 percent of the ceiling, the update factor is the greater of 0 percent or the market basket minus 2.5 percent. For hospitals with costs that do not exceed 66.7 percent of the ceiling, the update factor is 0.
The most recent forecast of the market basket increase for FY 2002 for hospitals and hospital units excluded from the prospective payment system is 3.3 percent. Therefore, the update to a hospital's target amount for its cost reporting period beginning in FY 2002 would be between 0.8 and 3.3 percent, or 0 percent, depending on the hospital's or unit's costs in relation to its rate-of-increase limit.
In addition, § 413.40(c)(4)(iii) requires that for cost reporting periods beginning on or after October 1, 1998, and before October 1, 2002, the target amount for each psychiatric hospital or hospital unit, rehabilitation hospital or hospital unit, and long-term care hospital cannot exceed a cap on the target amounts for hospitals in the same class.
Section 1886(b)(3)(H) of the Act, as amended by section 121 of Public Law 106-113, provides for an appropriate wage adjustment to the caps on the target amounts for psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals, effective for cost reporting periods beginning on or after October 1, 1999, through September 30, 2002. On August 1, 2000, we published an interim final rule with comment period that implemented this provision for cost reporting periods beginning on or after October 1, 1999 and before October 1, 2000 (65 FR 47026) and a final rule that implemented the provision for cost reporting periods beginning on or after October 1, 2000, and before October 1, 2001 (65 FR 47054). This final rule addresses the wage adjustment to the caps for cost reporting periods beginning on or after October 1, 2001.
As discussed in section VI. of the preamble of this final rule, the cap on the target amount per discharge is determined by adding the hospital's nonlabor-related portion of the national 75th percentile cap to its wage-adjusted, labor-related portion of the national 75th percentile cap (the labor-related portion of costs equals 0.71553 and the nonlabor-related portion of costs equals 0.28447). A hospital's wage-adjusted, labor-related portion of the target amount is calculated by multiplying the labor-related portion of the national 75th percentile cap for the hospital's class by the wage index under the hospital inpatient prospective payment system (see § 412.63), without taking into account reclassifications under sections 1886(d)(8)(B) and (d)(10) of the Act.
As discussed in section VI. of the preamble of this final rule, we have made an adjustment to the caps on target amounts for new and existing excluded hospitals and units. In calculating the wage-adjusted caps on target amounts for new and existing excluded and units for FY 2001, we inadvertently made an error. In wage neutralizing FY 1996 target amounts, we used the FY 2000 hospital inpatient prospective payment system wage index published in Tables 4A and 4B of the July 30, 1999 final rule (64 FR 41585 through 41593), which is based on wage data after taking into account geographic reclassifications under section 1886(d)(8) of the Act. We have used pre-reclassified wage data in our recalculation of the caps for FY 2002. We recalculated both the limits for new excluded hospitals and units and the caps for existing excluded hospitals and units, using the same wage index used under the prospective payment system for skilled nursing facilities (SNF) as shown in Table 7 of the July 30, 1999 SNF final rule (64 FR 41690). We do not anticipate a significant impact on overall payments to these hospitals and units.
Section 307(a) of Public Law 106-554 amended section 1886(b)(3) of the Act to provide for a 2-percent increase to the wage-adjusted 75th percentile cap on the target amount for long-term care hospitals, effective for cost reporting periods beginning during FY 2001. This provision is applicable to long-term care hospitals that were subject to the cap for existing excluded hospitals and units, as specified in § 413.40(c).
In addition to the increase to the cap on the target amounts for long-term care hospitals, section 307(a) of Public Law 106-554 amended section 1886(b)(3)(A) of the Act to make the section applicable to all long-term care hospitals, effective for cost reporting periods beginning during FY 2001. This provision requires a revision to the determination of each long-term care hospital's FY 2001 target amount as specified in § 413.40(c)(4). For cost reporting periods beginning during FY 2001, the hospital-specific target amount otherwise determined for a long-term care hospital as specified under § 413.40(c)(4)(ii) is multiplied by 1.25 (that is, increased by 25 percent). However, the revised FY 2001 target amount for a long-term care hospital cannot exceed its wage-adjusted national cap as required by section 1886(b)(3) of the Act, as amended by section 307(a) of Public Law 106-554.
For cost reporting periods beginning in FY 2002, in the May 4, 2001 proposed rule, we included the following proposed caps:
| Class of excluded hospital or unit | Labor-related share | Nonlabor-related share |
|---|---|---|
| Psychiatric | $8,404 | $ 3,341 |
| Rehabilitation | $15,689 | $6,237 |
| Long-Term Care | $31,399 | $12,483 |
In this final rule, using updated data, we have recalculated the proposed caps for cost reporting periods beginning in FY 2002. The final FY 2002 caps are listed below:
| Class of excluded hospital or unit | Labor-related shae | Nonlabor-related share |
|---|---|---|
| Psychiatric | $8,429 | $3,351 |
| Rehabilitation | $15,736 | $6,256 |
| Long-Term Care | $31,490 | $12,519 |
Regulations at § 413.40(d) specify the formulas for determining bonus and relief payments for excluded hospitals and specify established criteria for an additional bonus payment for continuous improvement. Regulations at § 413.40(f)(2)(ii) specify the payment methodology for new hospitals and hospital units (psychiatric, rehabilitation, and long-term care) effective October 1, 1997.
V. Tables
This section contains the tables referred to throughout the preamble to this final rule and in this Addendum. For purposes of this final rule, and to avoid confusion, we have retained the designations of Tables 1 and 5 that were first used in the September 1, 1983 initial prospective payment final rule (48 FR 39844). Tables 1A, 1C, 1D, 2, 3A, 3B, 4A, 4B, 4C, 4F, 4G, 4H, 5, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 7A, 7B, 8A, and 8B are presented below. The tables presented below are as follows:
Table 1A-National Adjusted Operating Standardized Amounts, Labor/Nonlabor
Table 1C-Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
Table 1D-Capital Standard Federal Payment Rate
Table 2-Hospital Average Hourly Wage for Federal Fiscal Years 2000 (1996 Wage Data), 2001 (1997 Wage Data) and 2002 (1998 Wage Data) Wage Indexes and 3-Year Average of Hospital Average Hourly Wages
Table 3A-FY 2002 and 3-Year Average Hourly Wage for Urban Areas
Table 3B-FY 2002 and 3-Year Average Hourly Wage for Rural Areas
Table 4A-Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas
Table 4B-Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas
Table 4C-Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified
Table 4F-Puerto Rico Wage Index and Capital Geographic -Adjustment Factor (GAF)
Table 4G-Pre-Reclassified Wage Index for Urban Areas
Table 4H-Pre-Reclassified Wage Index for Rural Areas
Table 5-List of Diagnosis Related Groups (DRGs), Relative Weighting Factors, 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
Table 6H-Deletions to the CC Exclusions List
Table 7A-Medicare Prospective Payment System Selected -Percentile Lengths of Stay FY 2000 MedPAR Update 3/01 -GROUPER V18.0
Table 7B-Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2000 MedPAR Update 3/01 GROUPER V19.0
Table 8A-Statewide Average Operating Cost-to-Charge Ratios for Urban and Rural Hospitals (Case Weighted) July 2001
Table 8B-Statewide Average Capital Cost-to-Charge Ratios (Case Weighted) July 2001
| Large Urban Areas | Labor-related | Nonlabor-related | Other Areas | Labor-related | Nonlabor-related |
|---|---|---|---|---|---|
| $2,955.44 | $1,201.30 | $2,908.65 | $1,182.27 |
| Large Urban Areas | Labor | Nonlabor | Other Areas | Labor | Nonlabor | |
|---|---|---|---|---|---|---|
| National PR | $2,929.57 | $1,190.78 | $2,929.57 | $1,190.78 | ||
| Puerto Rico | 1,420.07 | 571.61 | 1,397.59 | 562.56 |
| Rate | |
|---|---|
| National | $390.74 |
| Puerto Rico | 187.73 |
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* Asterisk denotes wage data not available for the provider that year.** The 3-year average hourly wage is weighted by salaries and hours.
| Provider No. | Average Hourly Wage FY 00 | Average Hourly Wage FY 01 | Average Hourly Wage FY 02 | Average** Hourly Wage (3 yrs) |
|---|---|---|---|---|
| 010001 | 15.8484 | 16.4088 | 17.4467 | 16.5711 |
| 010004 | 15.0194 | 17.9732 | 19.0010 | 17.1863 |
| 010005 | 16.2615 | 17.5985 | 18.6554 | 17.4986 |
| 010006 | 17.3081 | 16.7480 | 17.6115 | 17.2150 |
| 010007 | 14.8048 | 15.4798 | 15.6788 | 15.3288 |
| 010008 | 17.6549 | 14.7443 | 17.4728 | 16.6080 |
| 010009 | 17.5328 | 18.7731 | 18.4979 | 18.2633 |
| 010010 | 15.9090 | 16.4468 | 16.4664 | 16.2848 |
| 010011 | 20.6261 | 20.7972 | 22.4292 | 21.2601 |
| 010012 | 19.2992 | 17.7171 | 15.8686 | 17.5430 |
| 010015 | 18.3461 | 15.4510 | 19.1178 | 17.5372 |
| 010016 | 16.1311 | 17.2473 | 20.2198 | 17.8844 |
| 010018 | 18.9617 | 17.6449 | 18.9388 | 18.5180 |
| 010019 | 15.4910 | 16.3493 | 17.0856 | 16.3311 |
| 010021 | 14.6297 | 16.2919 | 15.1241 | 15.3000 |
| 010022 | 20.5050 | 18.5879 | 17.6435 | 18.8422 |
| 010023 | 16.2581 | 16.1025 | 16.3209 | 16.2283 |
| 010024 | 16.0263 | 16.2900 | 15.9034 | 16.0692 |
| 010025 | 14.5311 | 15.1356 | 15.1548 | 14.9441 |
| 010027 | 14.9278 | 11.7900 | 16.8595 | 14.1053 |
| 010029 | 16.4103 | 17.6461 | 18.3605 | 17.4403 |
| 010031 | 18.0194 | 18.7835 | 18.6402 | 18.4877 |
| 010032 | 12.6540 | 12.5995 | 15.3590 | 13.6017 |
| 010033 | 19.6797 | 20.3923 | 21.2986 | 20.4581 |
| 010034 | 14.7342 | 15.0959 | 15.3639 | 15.0606 |
| 010035 | 17.4788 | 20.1853 | 15.9439 | 17.6916 |
| 010036 | 17.2880 | 17.8140 | 17.7166 | 17.6061 |
| 010038 | 18.3309 | 18.2671 | 19.6098 | 18.7632 |
| 010039 | 18.8080 | 20.1045 | 20.3406 | 19.7778 |
| 010040 | 19.1030 | 18.9376 | 20.0983 | 19.3415 |
| 010043 | 16.2022 | 30.7489 | 18.6640 | 19.9982 |
| 010044 | 17.0229 | 22.0091 | 24.0265 | 20.8906 |
| 010045 | 15.0065 | 15.2200 | 17.0417 | 15.7248 |
| 010046 | 17.1822 | 17.3970 | 18.9737 | 17.8750 |
| 010047 | 16.3803 | 13.3521 | 15.4190 | 15.2030 |
| 010049 | 14.4823 | 14.7590 | 15.5246 | 14.9487 |
| 010050 | 15.4159 | 18.5163 | 17.9830 | 17.2796 |
| 010051 | 9.9390 | 11.9275 | 11.8108 | 11.1940 |
| 010052 | 13.8649 | 16.5486 | 18.0653 | 16.1248 |
| 010053 | 13.1778 | 14.6267 | 15.5649 | 14.5406 |
| 010054 | 17.1246 | 18.5103 | 19.4955 | 18.4846 |
| 010055 | 18.1930 | 18.9526 | 18.8590 | 18.6711 |
| 010056 | 19.0783 | 19.2175 | 19.6577 | 19.3204 |
| 010058 | 12.7809 | 16.1702 | 16.9715 | 15.1274 |
| 010059 | 18.1886 | 19.1286 | 18.8020 | 18.7124 |
| 010061 | 15.9215 | 14.9547 | 14.5003 | 15.1112 |
| 010062 | 13.5690 | 14.7732 | 12.3259 | 13.5151 |
| 010064 | 20.8966 | 20.4139 | 19.5256 | 20.2712 |
| 010065 | 15.6357 | 16.4049 | 16.8752 | 16.3279 |
| 010066 | 12.0681 | 15.4317 | 13.1559 | 13.4757 |
| 010068 | 18.7367 | 12.0525 | 18.6925 | 15.8875 |
| 010069 | 13.5684 | 13.8636 | 14.7211 | 14.0429 |
| 010072 | 14.3481 | 14.9526 | 16.2339 | 15.1957 |
| 010073 | 12.8328 | 13.8601 | 14.1273 | 13.6015 |
| 010078 | 17.7110 | 17.9202 | 18.1363 | 17.9248 |
| 010079 | 16.8701 | 16.4421 | 17.0648 | 16.7882 |
| 010080 | 13.8473 | * | * | 13.8473 |
| 010081 | 16.9823 | 18.9474 | 17.2996 | 17.7081 |
| 010083 | 16.2146 | 16.8933 | 18.0312 | 17.0916 |
| 010084 | 18.7794 | 18.4965 | 18.7769 | 18.6812 |
| 010085 | 18.8696 | 18.4744 | 19.9023 | 19.0736 |
| 010086 | 14.9255 | 16.6694 | 16.5711 | 16.0968 |
| 010087 | 18.3889 | 19.0033 | 18.0567 | 18.5192 |
| 010089 | 16.6090 | 16.8042 | 17.7800 | 17.0521 |
| 010090 | 18.1121 | 18.3866 | 18.9445 | 18.4882 |
| 010091 | 16.3620 | 13.9405 | 17.0799 | 15.6820 |
| 010092 | 16.4980 | 16.9900 | 17.8144 | 17.1322 |
| 010094 | 18.5603 | * | * | 18.5603 |
| 010095 | 11.8993 | 12.4525 | 12.2597 | 12.2090 |
| 010097 | 12.8955 | 13.0413 | 12.7286 | 12.8889 |
| 010098 | 14.2787 | 15.9165 | 14.0300 | 14.6833 |
| 010099 | 15.9309 | 15.9874 | 15.5619 | 15.8073 |
| 010100 | 15.4826 | 17.2011 | 17.9430 | 16.9229 |
| 010101 | 15.4173 | 15.3859 | 14.4625 | 15.0781 |
| 010102 | 12.7251 | 13.7933 | 13.8136 | 13.4259 |
| 010103 | 19.3115 | 17.9358 | 17.7242 | 18.3325 |
| 010104 | 18.0997 | 17.7126 | 16.8457 | 17.5501 |
| 010108 | 20.7914 | 17.9017 | 19.4617 | 19.3047 |
| 010109 | 14.0870 | 15.3107 | 14.6752 | 14.6907 |
| 010110 | 15.9066 | 15.6317 | 15.8283 | 15.7917 |
| 010112 | 15.1056 | 15.1401 | 16.8271 | 15.6716 |
| 010113 | 17.2440 | 16.9683 | 16.8936 | 17.0309 |
| 010114 | 17.2612 | 15.2454 | 17.0760 | 16.4722 |
| 010115 | 13.7524 | 14.6268 | 14.2261 | 14.2120 |
| 010118 | 16.6889 | 18.8477 | 17.0834 | 17.5145 |
| 010119 | 18.1707 | 18.8024 | 19.3942 | 18.9605 |
| 010120 | 17.0332 | 17.2336 | 18.2567 | 17.5146 |
| 010121 | 15.1806 | 14.6444 | 14.5262 | 14.8160 |
| 010123 | 18.1604 | 16.7344 | 19.2140 | 17.9949 |
| 010124 | 16.2666 | 16.2846 | 16.7465 | 16.4273 |
| 010125 | 14.4153 | 15.5304 | 16.0136 | 15.3557 |
| 010126 | 17.6405 | 19.5710 | 19.1065 | 18.7347 |
| 010127 | 19.6095 | 19.5190 | 18.2786 | 19.1726 |
| 010128 | 12.5747 | 14.5056 | 14.4322 | 13.6385 |
| 010129 | 14.4267 | 14.7286 | 16.1733 | 15.1385 |
| 010130 | 16.3465 | 16.6809 | 19.5573 | 17.3907 |
| 010131 | 17.9076 | 17.8260 | 20.1883 | 18.6602 |
| 010134 | 10.7817 | 18.8835 | 19.9856 | 15.8677 |
| 010137 | 15.9348 | 12.1217 | 20.5828 | 15.9236 |
| 010138 | 12.1295 | 12.8675 | 14.5254 | 13.1763 |
| 010139 | 19.9487 | 19.0001 | 20.4331 | 19.7578 |
| 010143 | 15.7144 | 16.7911 | 17.6212 | 16.7651 |
| 010144 | 17.1211 | 17.1320 | 18.2040 | 17.4771 |
| 010145 | 20.7460 | 20.8434 | 20.5895 | 20.7209 |
| 010146 | 18.8561 | 18.5198 | 19.1415 | 18.8309 |
| 010148 | 14.6443 | 12.2214 | 15.8349 | 13.9784 |
| 010149 | 17.0836 | 18.6333 | 18.0156 | 17.9216 |
| 010150 | 16.9749 | 17.8951 | 18.9359 | 17.9332 |
| 010152 | 17.3835 | 17.8306 | 18.7677 | 18.0088 |
| 010155 | 16.7028 | 9.0300 | 15.0689 | 12.5183 |
| 010158 | * | 17.3227 | 18.3957 | 17.8637 |
| 020001 | 27.9690 | 28.1747 | 28.0394 | 28.0627 |
| 020002 | 26.9145 | 24.5815 | 25.1987 | 25.5092 |
| 020004 | 26.3979 | 30.5667 | 25.4679 | 27.5927 |
| 020005 | 29.0068 | 30.2920 | 29.2378 | 29.5337 |
| 020006 | 26.7706 | 31.2404 | 28.1417 | 28.8630 |
| 020007 | 24.9555 | 27.8319 | 32.3852 | 28.0097 |
| 020008 | 30.4712 | 29.4146 | 30.8691 | 30.2487 |
| 020009 | 23.1801 | 20.1930 | 18.4660 | 20.3801 |
| 020010 | 18.6417 | 23.6727 | 22.7559 | 21.4818 |
| 020011 | 29.4697 | 30.4727 | 28.0658 | 29.3006 |
| 020012 | 23.9259 | 24.8543 | 25.5320 | 24.7635 |
| 020013 | 26.8172 | 23.8847 | 28.1557 | 26.0576 |
| 020014 | 24.0932 | 27.3823 | 24.5875 | 25.3179 |
| 020017 | 24.9714 | 26.8319 | 28.0572 | 26.6405 |
| 020024 | 22.7263 | 24.0872 | 25.3205 | 24.0621 |
| 020025 | 27.1529 | 21.7557 | 20.2583 | 22.6334 |
| 030001 | 19.8695 | 20.3673 | 21.7869 | 20.6506 |
| 030002 | 21.6263 | 21.5977 | 21.8375 | 21.6886 |
| 030003 | 23.6722 | 23.4833 | 22.6804 | 23.3063 |
| 030004 | 17.7333 | 14.0711 | 15.5478 | 15.4308 |
| 030006 | 17.6409 | 18.2668 | 20.0273 | 18.6274 |
| 030007 | 18.5602 | 19.6708 | 21.5169 | 19.9379 |
| 030008 | * | 22.2758 | 22.2190 | 22.2524 |
| 030009 | 17.9343 | 18.1794 | 18.7557 | 18.2786 |
| 030010 | 18.7997 | 19.0907 | 19.5123 | 19.1422 |
| 030011 | 20.0784 | 19.2973 | 19.4310 | 19.5785 |
| 030012 | 19.4245 | 18.9918 | 20.6585 | 19.6997 |
| 030013 | 21.0182 | 20.7458 | 20.0535 | 20.5870 |
| 030014 | 19.4697 | 19.9315 | 19.7966 | 19.7342 |
| 030016 | 20.5606 | 19.3967 | 19.4785 | 19.8559 |
| 030017 | 20.4185 | 22.8765 | 21.7938 | 21.6805 |
| 030018 | 18.9115 | 20.2032 | 20.8980 | 20.0193 |
| 030019 | 19.9211 | 21.7005 | 21.2540 | 20.9846 |
| 030022 | 15.7886 | 19.2966 | 19.5794 | 17.6713 |
| 030023 | 22.4365 | 23.6697 | 24.1678 | 23.4686 |
| 030024 | 21.6692 | 22.2541 | 23.6009 | 22.5290 |
| 030025 | 17.6759 | 12.7254 | 11.9894 | 13.7385 |
| 030027 | 17.5796 | 15.7554 | 17.6555 | 16.9563 |
| 030030 | 21.6249 | 20.8303 | 21.6932 | 21.3795 |
| 030033 | 16.8396 | 20.0044 | 20.2820 | 18.9069 |
| 030034 | 19.0868 | 16.8241 | 20.8689 | 18.8279 |
| 030035 | 19.7153 | 19.2781 | 20.0226 | 19.6580 |
| 030036 | 18.9449 | 20.7567 | 21.6371 | 20.4743 |
| 030037 | 21.4376 | 22.8266 | 23.7615 | 22.6712 |
| 030038 | 22.0777 | 22.6776 | 22.9822 | 22.5885 |
| 030040 | 17.9722 | 18.5456 | 19.7636 | 18.7537 |
| 030041 | 17.4389 | 15.8921 | 18.8717 | 17.2718 |
| 030043 | 20.7721 | 20.9341 | 20.5598 | 20.7468 |
| 030044 | 16.4654 | 16.8649 | 17.6575 | 17.0214 |
| 030047 | 19.6916 | 22.6401 | 21.4412 | 21.2271 |
| 030049 | 19.0896 | 19.0881 | 19.3580 | 19.1639 |
| 030054 | 14.4861 | 15.3338 | 15.0657 | 14.9801 |
| 030055 | 18.2751 | 16.3613 | 20.2991 | 18.2684 |
| 030059 | 21.7100 | 24.0465 | 22.6279 | 22.7570 |
| 030060 | 16.7661 | 19.2461 | 18.6313 | 18.2043 |
| 030061 | 17.3470 | 18.9063 | 19.9047 | 18.7238 |
| 030062 | 17.4825 | 17.6738 | 18.7172 | 17.9978 |
| 030064 | 18.5391 | 19.5673 | 20.3837 | 19.5213 |
| 030065 | 19.9277 | 20.5130 | 20.7838 | 20.4254 |
| 030067 | 15.6207 | 14.4446 | 17.2778 | 15.7364 |
| 030068 | 17.3482 | 17.3614 | 17.7208 | 17.4823 |
| 030069 | 19.0013 | 19.0961 | 21.0936 | 19.7255 |
| 030080 | 19.9865 | 20.5144 | 20.6581 | 20.3684 |
| 030083 | 23.6433 | 23.3355 | 23.5229 | 23.4991 |
| 030085 | 17.8402 | 21.0954 | 20.8690 | 19.9451 |
| 030086 | 18.5030 | 19.5436 | * | 19.0352 |
| 030087 | 20.0469 | 21.4084 | 21.9465 | 21.1838 |
| 030088 | 19.5772 | 19.8682 | 20.5340 | 20.0152 |
| 030089 | 19.9018 | 20.4019 | 20.9516 | 20.4404 |
| 030092 | 21.5628 | 20.6986 | 21.8308 | 21.3646 |
| 030093 | 19.4688 | 19.7262 | 20.4314 | 19.9052 |
| 030094 | 19.4773 | 21.6218 | 22.8123 | 21.4086 |
| 030095 | 14.2499 | 13.7293 | 13.7664 | 13.9087 |
| 030099 | 18.0747 | 16.1541 | 18.2263 | 17.4781 |
| 030100 | * | * | 23.7609 | 23.7609 |
| 030101 | * | * | 19.2547 | 19.2547 |
| 030102 | * | * | 18.2413 | 18.2413 |
| 040001 | 15.5735 | 15.1624 | 16.9178 | 15.8741 |
| 040002 | 14.0865 | 13.0592 | 15.1107 | 14.0333 |
| 040003 | 14.0027 | 14.2089 | 15.5740 | 14.5731 |
| 040004 | 17.2926 | 17.8476 | 17.9034 | 17.6718 |
| 040005 | 12.8825 | 13.2597 | 11.1318 | 12.3937 |
| 040007 | 19.5299 | 21.9583 | 18.6998 | 19.9568 |
| 040008 | 12.6974 | 15.3040 | 14.7985 | 14.3087 |
| 040010 | 17.6231 | 18.6023 | 19.4913 | 18.6031 |
| 040011 | 12.2654 | 14.5319 | 16.0995 | 14.1756 |
| 040014 | 15.3853 | 17.6340 | 18.1434 | 17.0051 |
| 040015 | 14.6045 | 16.5891 | 15.5207 | 15.5649 |
| 040016 | 17.5431 | 19.0295 | 20.2321 | 18.9152 |
| 040017 | 14.9533 | 13.5098 | 15.4736 | 14.6592 |
| 040018 | 17.5602 | 17.6027 | 18.7463 | 17.9749 |
| 040019 | 25.7080 | 22.6769 | 23.4163 | 23.8479 |
| 040020 | 14.8059 | 16.4827 | 18.9844 | 16.6335 |
| 040021 | 16.4628 | 17.6398 | 19.6835 | 17.8176 |
| 040022 | 16.0006 | 17.0397 | 20.8281 | 17.7640 |
| 040024 | 15.7282 | 14.4541 | 17.6607 | 15.9615 |
| 040025 | 10.9496 | 11.5079 | 13.4705 | 11.8847 |
| 040026 | 18.2398 | 19.5563 | 19.7924 | 19.1863 |
| 040027 | 14.5406 | 16.0975 | 17.4431 | 16.0716 |
| 040028 | 12.8409 | 14.6584 | 13.9946 | 13.7921 |
| 040029 | 17.7777 | 17.8787 | 21.1370 | 18.9480 |
| 040030 | 14.1541 | 13.5428 | 11.2402 | 12.7784 |
| 040032 | 13.3280 | 13.7030 | 13.2872 | 13.4471 |
| 040035 | 11.2123 | 12.8300 | 10.9569 | 11.6408 |
| 040036 | 17.9080 | 18.9757 | 20.2012 | 19.0415 |
| 040037 | 13.4815 | 14.6559 | 14.0941 | 14.0704 |
| 040039 | 13.8386 | 14.3576 | 14.7177 | 14.3115 |
| 040040 | 17.4283 | 18.0895 | 19.1984 | 18.2668 |
| 040041 | 13.3613 | 15.9896 | 16.4624 | 15.2103 |
| 040042 | 14.6641 | 15.2142 | 15.2057 | 15.0333 |
| 040044 | 11.4422 | 12.6275 | 13.3501 | 12.5381 |
| 040045 | 18.7724 | 14.9429 | 16.2469 | 16.4870 |
| 040047 | 16.3948 | 16.8654 | 17.5336 | 16.9538 |
| 040048 | 15.8203 | * | * | 15.8203 |
| 040050 | 11.7934 | 13.3818 | 14.0036 | 13.0341 |
| 040051 | 16.2803 | 15.8627 | 16.6039 | 16.2390 |
| 040053 | 15.8193 | 16.3610 | 15.0219 | 15.7502 |
| 040054 | 15.0412 | 15.3219 | 14.2577 | 14.8844 |
| 040055 | 16.1029 | 17.1269 | 18.0414 | 17.0866 |
| 040058 | 15.6706 | 17.6766 | 16.4278 | 16.6344 |
| 040060 | 11.4686 | 12.8148 | 17.9805 | 13.6105 |
| 040062 | 17.2757 | 18.2048 | 17.8902 | 17.8204 |
| 040064 | 12.4007 | 10.7255 | 11.5029 | 11.4801 |
| 040066 | 17.6429 | 18.3377 | 19.7144 | 18.5416 |
| 040067 | 13.4930 | 14.6014 | 14.4741 | 14.1956 |
| 040069 | 16.1147 | 17.5052 | 17.0026 | 16.8681 |
| 040070 | 15.4757 | 16.9027 | 16.9700 | 16.4358 |
| 040071 | 16.3022 | 16.9610 | 17.6144 | 16.9553 |
| 040072 | 15.8425 | 16.0895 | 17.4960 | 16.4940 |
| 040074 | 17.3819 | 18.3224 | 18.7542 | 18.1968 |
| 040075 | 12.7496 | 13.3623 | 14.0975 | 13.3977 |
| 040076 | 18.5512 | 19.0732 | 20.5840 | 19.3801 |
| 040077 | 12.4625 | 12.9211 | 13.9114 | 13.0965 |
| 040078 | 17.8573 | 18.7600 | 18.5821 | 18.4100 |
| 040080 | 15.7397 | 19.2461 | 19.3707 | 18.0636 |
| 040081 | 10.6791 | 11.3169 | 11.1332 | 11.0311 |
| 040082 | 16.5127 | 16.2152 | 15.1331 | 15.9302 |
| 040084 | 17.2469 | 17.2613 | 17.7295 | 17.4070 |
| 040085 | 15.7765 | 16.8957 | 16.5216 | 16.3838 |
| 040088 | 15.6710 | 17.9636 | 17.1624 | 16.9372 |
| 040090 | 17.5503 | 17.8282 | 19.0824 | 18.0989 |
| 040091 | 17.0444 | 19.8700 | 20.1378 | 18.8893 |
| 040093 | 12.9010 | 12.3537 | 13.9741 | 13.0114 |
| 040100 | 14.9688 | 14.7587 | 15.6833 | 15.1704 |
| 040105 | 14.2409 | 15.3319 | 14.3896 | 14.6616 |
| 040106 | 15.4000 | 15.6545 | 18.1341 | 16.4515 |
| 040107 | 19.6184 | 18.8120 | 17.8628 | 18.6841 |
| 040109 | 13.9807 | 14.6266 | 16.6278 | 15.0815 |
| 040114 | 18.3133 | 18.8743 | 21.1231 | 19.3828 |
| 040116 | 19.5695 | 20.2716 | * | 19.9151 |
| 040118 | 17.4300 | 19.3720 | 18.2123 | 18.3407 |
| 040119 | 15.3847 | 15.5338 | 16.9407 | 15.9572 |
| 040124 | 17.2547 | 19.1349 | 19.2889 | 18.5723 |
| 040126 | 11.6845 | 12.5368 | 11.6517 | 11.9404 |
| 040132 | 13.1760 | 17.5179 | 10.3875 | 13.4483 |
| 040134 | * | 18.0787 | 19.0185 | 18.5701 |
| 040135 | * | 22.6761 | 23.0084 | 22.8797 |
| 050002 | 27.6006 | 37.8295 | 36.9630 | 33.5586 |
| 050006 | 19.5272 | 19.5594 | 18.2061 | 19.0382 |
| 050007 | 29.5398 | 30.7126 | 30.8676 | 30.4910 |
| 050008 | 25.8570 | 26.2458 | 26.3682 | 26.1654 |
| 050009 | 26.2506 | 26.8159 | 28.4734 | 27.2303 |
| 050013 | 24.8541 | 23.2201 | 28.0569 | 25.1985 |
| 050014 | 24.5302 | 22.8478 | 23.6745 | 23.6450 |
| 050015 | 25.3838 | 26.2481 | 27.7731 | 26.4938 |
| 050016 | 20.1542 | 20.5566 | 21.2045 | 20.6377 |
| 050017 | 23.6639 | 23.9625 | 25.6178 | 24.4113 |
| 050018 | 14.6622 | 15.4721 | 15.2903 | 15.1444 |
| 050021 | 28.5003 | 25.8966 | * | 27.2682 |
| 050022 | 22.9583 | 24.0318 | 24.5254 | 23.8802 |
| 050024 | 20.3427 | 21.3989 | 22.4274 | 21.4070 |
| 050025 | 21.9952 | 23.3896 | 24.8245 | 23.3764 |
| 050026 | 28.6850 | 27.8736 | 23.1904 | 26.4206 |
| 050028 | 16.4531 | 16.4671 | 17.6138 | 16.8496 |
| 050029 | 23.2911 | 25.1259 | 24.6839 | 24.3441 |
| 050030 | 21.0096 | 20.9812 | 21.5621 | 21.1955 |
| 050032 | 22.5868 | 25.2010 | 24.3598 | 24.0616 |
| 050033 | 24.5609 | 24.9328 | 32.0179 | 27.2378 |
| 050036 | 20.4703 | 21.2420 | 21.8239 | 21.1856 |
| 050038 | 27.8274 | 28.6528 | 29.9698 | 28.8293 |
| 050039 | 22.2524 | 22.7117 | 22.8288 | 22.6033 |
| 050040 | 30.6664 | 32.1287 | 30.2607 | 31.0150 |
| 050042 | 22.2343 | 24.8067 | 24.5260 | 23.8317 |
| 050043 | 33.2286 | 32.9958 | 33.8255 | 33.3456 |
| 050045 | 20.7307 | 19.8831 | 21.1474 | 20.5973 |
| 050046 | 31.3831 | 25.3185 | 25.2005 | 27.4555 |
| 050047 | 29.4412 | 29.9255 | 29.9580 | 29.7840 |
| 050051 | 17.8401 | 17.8945 | 18.7809 | 18.1179 |
| 050054 | 19.3686 | 20.7212 | 22.0982 | 20.7075 |
| 050055 | 29.0872 | 29.3984 | 29.2730 | 29.2593 |
| 050056 | 23.8507 | 27.4321 | 23.8396 | 24.9757 |
| 050057 | 21.7581 | 21.1554 | 20.7420 | 21.1969 |
| 050058 | 25.7261 | 23.1641 | 23.3009 | 23.9601 |
| 050060 | 20.9219 | 20.7747 | 20.5450 | 20.7207 |
| 050061 | 23.7443 | 23.5454 | 24.5488 | 23.9503 |
| 050063 | 23.0724 | 24.8851 | 25.7593 | 24.5061 |
| 050065 | 21.1848 | 24.0420 | 24.6290 | 23.1479 |
| 050066 | 21.4187 | 16.5725 | 16.1649 | 17.6784 |
| 050067 | 21.3029 | 23.1966 | 25.8857 | 23.3989 |
| 050068 | 28.4804 | 20.6851 | 19.3615 | 22.4409 |
| 050069 | 29.2980 | 25.9420 | 24.6153 | 26.4351 |
| 050070 | 32.5964 | 32.5166 | 34.0721 | 33.0817 |
| 050071 | 33.1379 | 33.1850 | 34.4367 | 33.6139 |
| 050072 | 32.9660 | 33.2858 | 39.7321 | 35.2928 |
| 050073 | 34.6111 | 33.3922 | 32.8555 | 33.5664 |
| 050075 | 33.5246 | 33.9095 | 33.7160 | 33.7090 |
| 050076 | 33.8835 | 27.7797 | 33.9752 | 31.7128 |
| 050077 | 23.2986 | 24.1019 | 24.1404 | 23.8541 |
| 050078 | 22.8023 | 23.0736 | 24.3150 | 23.3638 |
| 050079 | 34.4253 | 33.2432 | 30.0167 | 32.3461 |
| 050082 | 21.7004 | 22.1009 | 23.7617 | 22.5498 |
| 050084 | 23.0966 | 23.5866 | 25.4517 | 24.0054 |
| 050088 | 24.0634 | 20.8406 | 24.9641 | 23.1779 |
| 050089 | 20.0194 | 20.9117 | 22.8450 | 21.2533 |
| 050090 | 23.8969 | 23.4097 | 24.6070 | 23.9625 |
| 050091 | 22.2220 | 25.2792 | 23.7713 | 23.6457 |
| 050092 | 15.3841 | 16.7969 | 17.1211 | 16.4241 |
| 050093 | 24.0837 | 25.2130 | 25.6647 | 24.9860 |
| 050095 | 33.3761 | 33.6718 | 30.4847 | 32.6392 |
| 050096 | 21.6752 | 20.0487 | 22.7394 | 21.3870 |
| 050097 | 22.6147 | 16.7054 | 22.5991 | 20.1968 |
| 050099 | 24.2921 | 24.8091 | 25.3722 | 24.8349 |
| 050100 | 30.0552 | 29.8758 | 25.2031 | 28.1754 |
| 050101 | 30.0132 | 31.0264 | 31.8957 | 30.9871 |
| 050102 | 21.2947 | 22.2937 | 24.0014 | 22.4745 |
| 050103 | 25.3384 | 24.7932 | 25.4133 | 25.1832 |
| 050104 | 25.4407 | 25.5797 | 26.9726 | 25.9841 |
| 050107 | 21.7649 | 21.2690 | 22.2019 | 21.7497 |
| 050108 | 25.2116 | 23.5564 | 25.1758 | 24.5678 |
| 050109 | 26.4768 | * | * | 26.4768 |
| 050110 | 20.1769 | 20.1870 | 19.9589 | 20.1175 |
| 050111 | 21.7397 | 21.5487 | 20.7897 | 21.3840 |
| 050112 | 26.2922 | 25.3015 | 26.8182 | 26.1335 |
| 050113 | 27.7805 | 28.8420 | 28.5224 | 28.4025 |
| 050114 | 25.9073 | 24.7286 | 26.6757 | 25.7599 |
| 050115 | 21.0499 | 21.3291 | 23.0182 | 21.8124 |
| 050116 | 25.5919 | 25.2130 | 24.9196 | 25.2412 |
| 050117 | 20.4379 | 23.3612 | 22.2123 | 21.9903 |
| 050118 | 23.9976 | 23.7698 | 23.7129 | 23.8243 |
| 050121 | 18.8818 | 19.5252 | 18.7272 | 19.0416 |
| 050122 | * | 26.3172 | 26.9546 | 26.6358 |
| 050124 | 23.0193 | 22.7736 | 24.5069 | 23.3667 |
| 050125 | 24.0434 | 29.6147 | 32.0230 | 28.3742 |
| 050126 | 23.8424 | 23.9247 | 24.6752 | 24.1448 |
| 050127 | 19.7654 | 22.1937 | 20.9027 | 20.9520 |
| 050128 | 24.1801 | 25.7240 | 26.6132 | 25.5185 |
| 050129 | 27.1586 | 26.5030 | 24.0108 | 25.7227 |
| 050131 | 29.0570 | 31.0732 | 32.5462 | 30.8106 |
| 050132 | 22.9139 | 24.0834 | 24.0173 | 23.6527 |
| 050133 | 24.4011 | 24.9746 | 23.2093 | 24.1354 |
| 050135 | 27.0341 | 23.2361 | 24.7157 | 24.9796 |
| 050136 | 24.4336 | 24.7921 | 24.7280 | 24.6450 |
| 050137 | 30.0725 | 32.6507 | 32.9192 | 31.8970 |
| 050138 | 37.4088 | 37.3286 | 38.1584 | 37.6483 |
| 050139 | 31.3785 | 32.9351 | 31.4984 | 31.9286 |
| 050140 | 33.6644 | 34.1499 | 32.7609 | 33.4990 |
| 050144 | 25.7483 | 27.8751 | 27.4069 | 26.9409 |
| 050145 | 33.0620 | 32.3857 | 34.5185 | 33.3152 |
| 050148 | 21.0584 | 21.9211 | 20.0971 | 20.9748 |
| 050149 | 23.3754 | 24.6078 | 26.8674 | 24.8666 |
| 050150 | 23.4777 | 24.9073 | 24.6596 | 24.3771 |
| 050152 | 27.7504 | 34.0766 | 33.3305 | 31.5833 |
| 050153 | 29.5915 | 30.5714 | 32.3389 | 30.8441 |
| 050155 | 22.9420 | 21.0257 | 25.3354 | 22.9852 |
| 050158 | 27.9789 | 27.5623 | 28.6071 | 28.0313 |
| 050159 | 25.2105 | 23.2912 | 22.5313 | 23.6099 |
| 050167 | 21.6778 | 21.9128 | 21.8796 | 21.8226 |
| 050168 | 25.2504 | 23.3511 | 25.1937 | 24.5830 |
| 050169 | 24.6361 | 22.3888 | 24.8407 | 23.8796 |
| 050170 | 22.1989 | 23.9574 | 24.3654 | 23.4164 |
| 050172 | 17.6976 | 20.1841 | 19.6120 | 19.1630 |
| 050173 | 23.3255 | 24.5545 | 24.8694 | 24.1923 |
| 050174 | 31.2136 | 30.2140 | 30.2775 | 30.5443 |
| 050175 | 27.7875 | 27.2806 | 24.7548 | 26.2477 |
| 050177 | 20.2485 | 21.7943 | 21.1396 | 21.0728 |
| 050179 | 19.2861 | 21.7175 | 23.8868 | 21.4573 |
| 050180 | 32.1883 | 31.8947 | 33.3257 | 32.5107 |
| 050183 | 19.9765 | 20.3638 | * | 20.1665 |
| 050186 | 21.9062 | 22.4155 | 23.6288 | 22.6119 |
| 050188 | 27.4364 | 28.0918 | 28.2364 | 27.9460 |
| 050189 | 23.2415 | 22.8687 | 27.4071 | 24.6245 |
| 050191 | 26.7297 | 20.8321 | 25.3516 | 24.1885 |
| 050192 | 17.8095 | 18.6701 | 14.1996 | 16.5873 |
| 050193 | 23.7260 | 22.6316 | 24.9444 | 23.7567 |
| 050194 | 28.2701 | 29.7371 | 29.5678 | 29.1714 |
| 050195 | 34.7789 | 35.5621 | 36.9068 | 35.7823 |
| 050196 | 16.6866 | 18.5180 | 18.2411 | 17.8430 |
| 050197 | 31.4513 | 35.7449 | 32.4030 | 33.0882 |
| 050204 | 24.3944 | 23.6105 | 22.7099 | 23.5849 |
| 050205 | 21.1545 | 23.6831 | 24.1691 | 23.0778 |
| 050207 | 20.8576 | 21.6214 | 22.9941 | 21.8243 |
| 050211 | 31.2175 | 31.6084 | 31.7280 | 31.5153 |
| 050213 | 20.7338 | 21.4806 | 21.4951 | 21.1847 |
| 050214 | 20.8704 | 21.7335 | 24.0276 | 22.1888 |
| 050215 | 28.4058 | 29.8563 | 35.0459 | 31.0290 |
| 050217 | 19.8913 | 19.6010 | 20.2042 | 19.9076 |
| 050219 | 25.4730 | 21.7444 | 21.2458 | 22.6404 |
| 050222 | 27.0713 | 27.4809 | 23.3563 | 25.7959 |
| 050224 | 23.7942 | 23.5316 | 23.5101 | 23.6043 |
| 050225 | 20.7978 | 23.3480 | 21.6820 | 21.9144 |
| 050226 | 26.9297 | 27.7315 | 24.4443 | 26.2380 |
| 050228 | 30.3772 | 34.0711 | 34.2596 | 32.7722 |
| 050230 | 25.3640 | 27.7357 | 26.6291 | 26.5638 |
| 050231 | 25.5798 | 26.1508 | 26.7321 | 26.1759 |
| 050232 | 23.3849 | 24.3072 | 24.5245 | 24.0793 |
| 050233 | 31.3954 | * | * | 31.3954 |
| 050234 | 28.5188 | 25.7035 | 24.6126 | 26.2702 |
| 050235 | 25.8595 | 25.2527 | 27.0922 | 26.0726 |
| 050236 | 26.2723 | 26.9803 | 25.9458 | 26.4027 |
| 050238 | 24.0043 | 24.2922 | 24.5823 | 24.2994 |
| 050239 | 20.4071 | 22.6625 | 23.2711 | 22.0940 |
| 050240 | 25.2540 | 26.3657 | 26.7620 | 26.0528 |
| 050241 | 27.2198 | 26.3740 | 29.8345 | 27.7426 |
| 050242 | 30.1432 | 31.1576 | 32.0829 | 31.1145 |
| 050243 | 22.9123 | 28.9635 | 26.4627 | 26.1049 |
| 050245 | 24.3969 | 23.8124 | 23.2716 | 23.7873 |
| 050248 | 27.4214 | 26.2015 | 27.6457 | 27.0910 |
| 050251 | 18.4990 | 21.6574 | 23.6360 | 21.1907 |
| 050253 | 20.0658 | 16.0701 | 16.7540 | 17.4281 |
| 050254 | 19.6899 | 19.3126 | 20.1176 | 19.7146 |
| 050256 | 23.5302 | 23.6887 | 23.4835 | 23.5723 |
| 050257 | 19.5923 | 15.2306 | 17.2596 | 17.1813 |
| 050260 | 23.5201 | 23.2421 | 27.4234 | 24.5032 |
| 050261 | 20.4496 | 20.0552 | 20.1040 | 20.2029 |
| 050262 | 29.0054 | 28.8785 | 29.5550 | 29.1532 |
| 050264 | 29.4542 | 32.1312 | 36.0331 | 32.4545 |
| 050267 | 24.7464 | 26.2264 | 26.0401 | 25.6690 |
| 050270 | 23.7260 | 24.0439 | 25.3757 | 24.3521 |
| 050272 | 21.4374 | 22.4247 | 23.0587 | 22.2948 |
| 050274 | 21.1943 | 20.0422 | * | 20.6204 |
| 050276 | 28.5051 | 29.8624 | 33.3302 | 30.5715 |
| 050277 | 22.3125 | 20.0520 | 26.0822 | 22.5131 |
| 050278 | 23.8434 | 24.7787 | 23.9289 | 24.1853 |
| 050279 | 21.0570 | 20.8444 | 21.8949 | 21.2309 |
| 050280 | 24.4267 | 25.2149 | 25.6651 | 25.1337 |
| 050281 | 18.5907 | 19.6888 | 24.2251 | 20.7934 |
| 050282 | 24.4593 | 28.8261 | 25.4428 | 26.2214 |
| 050283 | 27.8763 | 29.7734 | 31.7669 | 30.1598 |
| 050286 | 17.8045 | 16.5708 | 19.4241 | 17.6805 |
| 050289 | 26.7185 | 34.1393 | 30.4750 | 30.2632 |
| 050290 | 26.3745 | 28.6231 | 29.6796 | 28.2631 |
| 050291 | 26.4908 | 30.2748 | 29.4029 | 28.6899 |
| 050292 | 22.4878 | 21.6243 | 20.8410 | 21.6183 |
| 050293 | 19.1761 | 22.2963 | 24.1875 | 21.4642 |
| 050295 | 20.7393 | 21.2892 | 21.7883 | 21.2665 |
| 050296 | 25.3166 | 27.2948 | 28.3906 | 27.0098 |
| 050298 | 20.5181 | 24.4477 | 23.2006 | 22.6781 |
| 050299 | 25.7697 | 26.4543 | 25.5035 | 25.9187 |
| 050300 | 22.7423 | 23.5116 | 25.9228 | 24.1102 |
| 050301 | 26.0355 | 22.5201 | 21.1403 | 23.0323 |
| 050302 | 29.2007 | * | * | 29.2007 |
| 050305 | 32.7082 | 34.5185 | 36.7908 | 34.7340 |
| 050307 | 27.9830 | 17.2147 | * | 21.7503 |
| 050308 | 28.4019 | 29.3803 | 28.9284 | 28.9113 |
| 050309 | 24.4034 | 23.7884 | 25.3515 | 24.5133 |
| 050310 | 20.6181 | * | * | 20.6181 |
| 050312 | 23.7936 | 26.7617 | 26.0015 | 25.5439 |
| 050313 | 23.1009 | 21.7577 | 25.6827 | 23.5594 |
| 050315 | 21.9227 | 24.7086 | 22.7359 | 23.0264 |
| 050317 | 19.4479 | 21.6937 | * | 20.5789 |
| 050320 | 30.6054 | 30.4101 | 32.4809 | 31.1252 |
| 050324 | 26.2735 | 26.6049 | 25.3694 | 26.0738 |
| 050325 | 23.2355 | 24.4862 | 23.6327 | 23.7872 |
| 050327 | 22.8511 | 23.9484 | 25.6450 | 24.1469 |
| 050328 | 23.1889 | * | * | 23.1889 |
| 050329 | 21.4125 | 19.7455 | 21.6984 | 20.9322 |
| 050331 | 25.5252 | 22.2536 | 25.0230 | 24.1261 |
| 050333 | 20.1468 | 19.4589 | 19.1449 | 19.5671 |
| 050334 | 32.0169 | 34.2330 | 34.2557 | 33.5307 |
| 050335 | 20.2013 | 23.0258 | 22.9926 | 22.0827 |
| 050336 | 20.0980 | 20.7979 | 21.3402 | 20.7523 |
| 050342 | 19.3524 | 20.1841 | 20.8255 | 20.1210 |
| 050343 | 17.3394 | 17.2085 | * | 17.2799 |
| 050348 | 20.7505 | 23.8779 | 25.1085 | 23.3219 |
| 050349 | 15.0515 | 14.9754 | 15.0667 | 15.0310 |
| 050350 | 25.0676 | 24.8340 | 26.4161 | 25.4163 |
| 050351 | 24.6936 | 25.4791 | 24.8121 | 24.9948 |
| 050352 | 23.5927 | 26.1380 | 26.4262 | 25.4187 |
| 050353 | 23.2468 | 23.0564 | 23.2699 | 23.1944 |
| 050355 | 17.1597 | 17.2778 | 21.0969 | 18.0157 |
| 050357 | 23.6411 | 22.6545 | 24.5345 | 23.6386 |
| 050359 | 20.4005 | 17.7907 | 21.7548 | 19.8316 |
| 050360 | 31.7608 | 31.3526 | 31.7583 | 31.6236 |
| 050366 | 21.3442 | 23.7528 | 19.6823 | 21.4770 |
| 050367 | 29.4763 | 28.2805 | 30.7328 | 29.5063 |
| 050369 | 24.2604 | 27.0548 | 26.2234 | 25.8174 |
| 050373 | 26.6548 | 26.9776 | 27.8275 | 27.1333 |
| 050376 | 25.3036 | 26.5840 | 28.0990 | 26.5882 |
| 050377 | 25.6401 | 17.1764 | 17.0012 | 20.1035 |
| 050378 | 22.2363 | 25.9810 | 26.9101 | 24.8709 |
| 050379 | 15.4994 | 15.2022 | 18.4278 | 16.2767 |
| 050380 | 30.5790 | 31.4343 | 31.9578 | 31.3600 |
| 050382 | 26.1465 | 26.1398 | 25.9244 | 26.0725 |
| 050385 | 25.9188 | 24.6083 | * | 25.2398 |
| 050388 | 13.7863 | 19.1512 | 22.0122 | 17.5709 |
| 050390 | 22.5668 | 25.0426 | 24.2700 | 23.9349 |
| 050391 | 22.4881 | 18.9266 | 20.0615 | 20.3952 |
| 050392 | 21.9324 | 21.6729 | 22.9430 | 22.1487 |
| 050393 | 23.1387 | 25.6964 | 24.1981 | 24.3082 |
| 050394 | 22.2424 | 23.0604 | 23.1526 | 22.8333 |
| 050396 | 23.6322 | 24.0636 | 25.3729 | 24.3512 |
| 050397 | 20.7698 | 20.2601 | 20.6397 | 20.5453 |
| 050401 | 17.7807 | 20.7473 | 18.4593 | 18.9557 |
| 050404 | 19.2754 | 17.3396 | 15.9839 | 17.4356 |
| 050406 | 16.8931 | 17.3016 | 17.8596 | 17.3407 |
| 050407 | 30.1222 | 29.9642 | 30.8346 | 30.2996 |
| 050410 | 16.4735 | 17.6769 | 19.8508 | 17.8663 |
| 050411 | 32.2364 | 34.8899 | 33.1943 | 33.4145 |
| 050414 | 24.4243 | 24.2060 | 25.9723 | 24.9224 |
| 050417 | 21.8884 | 21.5739 | 23.3005 | 22.2456 |
| 050419 | 23.1162 | 23.7584 | 23.4936 | 23.4646 |
| 050420 | 22.6819 | 22.3166 | 23.5438 | 22.8448 |
| 050423 | 23.3296 | 17.3771 | 21.3552 | 20.6272 |
| 050424 | 23.7788 | 22.8350 | 24.0727 | 23.5641 |
| 050425 | 33.6911 | 32.8364 | 35.3712 | 34.0224 |
| 050426 | 23.7082 | 25.2453 | 29.0120 | 25.8759 |
| 050427 | 20.0698 | 20.1674 | 16.4330 | 18.6499 |
| 050430 | 21.3428 | 23.8788 | 21.2275 | 22.2136 |
| 050432 | 21.4984 | 24.4133 | 24.5630 | 23.4427 |
| 050433 | 16.8035 | 17.4643 | 18.9021 | 17.7004 |
| 050434 | 15.6348 | 19.7591 | * | 17.6624 |
| 050435 | 32.9865 | 25.6676 | 23.3426 | 26.8858 |
| 050436 | 16.3594 | 14.8121 | * | 15.5729 |
| 050438 | 24.0828 | 25.0138 | 23.2583 | 24.1266 |
| 050440 | 21.1100 | 23.5167 | 22.5400 | 22.3553 |
| 050441 | 28.7067 | 28.9804 | 31.8774 | 29.8169 |
| 050443 | 16.4308 | 19.9020 | 17.2875 | 17.7906 |
| 050444 | 24.6741 | 21.4533 | 22.4530 | 22.8550 |
| 050446 | 20.5383 | 20.4908 | 22.3422 | 21.1378 |
| 050447 | 18.4183 | 17.9751 | 18.9851 | 18.4558 |
| 050448 | 20.0757 | 19.7046 | 21.7718 | 20.5035 |
| 050449 | 22.1784 | 23.8001 | 23.4614 | 23.1469 |
| 050454 | 28.6857 | 28.7432 | 30.0792 | 29.2410 |
| 050455 | 19.9209 | 20.1643 | 19.8577 | 19.9840 |
| 050456 | 17.6229 | 20.1254 | 18.1585 | 18.5890 |
| 050457 | 31.2489 | 34.4949 | 32.1910 | 32.6376 |
| 050459 | 37.0914 | * | * | 37.0914 |
| 050464 | 22.3142 | 25.3292 | 25.7710 | 24.4665 |
| 050468 | 23.1701 | 23.3050 | 22.2926 | 22.8998 |
| 050469 | 23.4404 | 23.8759 | 24.5205 | 23.8915 |
| 050470 | 17.0353 | 16.0292 | 16.0805 | 16.3264 |
| 050471 | 24.2887 | 25.6172 | 27.1597 | 25.6415 |
| 050476 | 23.1428 | 22.4754 | 24.0253 | 23.2552 |
| 050477 | 27.7855 | 27.9595 | 27.5819 | 27.7866 |
| 050478 | 23.0530 | 24.5401 | 26.3306 | 24.6133 |
| 050481 | 26.8293 | 28.9722 | 27.7973 | 27.8692 |
| 050482 | 16.9268 | 18.1217 | 16.0114 | 17.0134 |
| 050483 | 21.6038 | 22.7182 | * | 22.1632 |
| 050485 | 23.1933 | 24.1983 | 24.6906 | 24.0174 |
| 050486 | 24.4967 | * | * | 24.4967 |
| 050488 | 32.8620 | 34.6939 | 31.7481 | 33.0979 |
| 050491 | 25.1011 | 26.8703 | 27.4600 | 26.4606 |
| 050492 | 21.4156 | 19.5457 | 20.5030 | 20.4277 |
| 050494 | 25.4078 | 29.2621 | 29.1296 | 27.9125 |
| 050496 | 33.0168 | 32.5168 | 34.9704 | 33.4862 |
| 050497 | * | 13.8110 | 15.4115 | 14.5264 |
| 050498 | 24.8445 | 24.9677 | 26.1716 | 25.3085 |
| 050502 | 22.6253 | 22.3788 | 25.3701 | 23.4214 |
| 050503 | 23.5911 | 24.4069 | 23.3745 | 23.7879 |
| 050506 | 21.2165 | 25.0845 | 25.0333 | 23.8164 |
| 050510 | 33.4617 | 33.3774 | 33.7481 | 33.5309 |
| 050512 | 34.3138 | 35.3581 | 34.4368 | 34.6837 |
| 050515 | 35.0412 | 35.3419 | 33.7321 | 34.6571 |
| 050516 | 25.1850 | 24.7992 | 26.1969 | 25.4171 |
| 050517 | 20.3733 | 20.9550 | 22.0985 | 21.1081 |
| 050522 | 31.7326 | 35.3784 | 36.2127 | 34.2256 |
| 050523 | 28.4235 | 27.0544 | 31.2522 | 28.8864 |
| 050526 | 26.9206 | 23.8099 | 26.4014 | 25.6096 |
| 050528 | 18.6898 | 19.0611 | 18.9155 | 18.8867 |
| 050531 | 20.7332 | 22.7308 | 21.3948 | 21.6689 |
| 050534 | 23.3026 | 24.0700 | 24.0001 | 23.7954 |
| 050535 | 24.2257 | 25.4215 | 26.8511 | 25.4120 |
| 050537 | 22.2073 | 22.2256 | 24.0354 | 22.8159 |
| 050539 | 23.2501 | 20.7129 | 23.3846 | 22.4405 |
| 050541 | 34.6195 | 34.4573 | 36.6149 | 35.2691 |
| 050542 | 17.8537 | 16.0892 | 17.7737 | 17.2018 |
| 050543 | 23.0437 | 22.3994 | 21.6795 | 22.3610 |
| 050545 | 27.5713 | 26.3304 | 31.7280 | 27.9472 |
| 050546 | 27.7557 | 26.1949 | 38.8087 | 28.7303 |
| 050547 | 27.0845 | 26.8305 | 37.7681 | 28.7499 |
| 050548 | 26.5922 | 28.8083 | 29.8516 | 28.2370 |
| 050549 | 27.9098 | 27.2765 | 28.9615 | 28.0769 |
| 050550 | 25.7546 | 24.8048 | 25.6588 | 25.4034 |
| 050551 | 24.0488 | 25.4652 | 24.8084 | 24.7966 |
| 050552 | 22.8731 | 21.5216 | 20.3239 | 21.6775 |
| 050557 | 22.1385 | 21.1243 | 22.2562 | 21.8314 |
| 050559 | 24.6689 | 23.5759 | 24.7866 | 24.3485 |
| 050561 | 33.9268 | 34.5791 | 33.4423 | 33.9701 |
| 050564 | 24.5099 | 23.5922 | 24.2091 | 24.0891 |
| 050565 | 22.8785 | 23.7829 | 20.8349 | 22.3644 |
| 050566 | 18.3297 | 17.4423 | 22.3448 | 19.2949 |
| 050567 | 24.2349 | 24.6454 | 25.0787 | 24.6746 |
| 050568 | 20.5205 | 19.5816 | 20.5376 | 20.2025 |
| 050569 | 24.9453 | 26.5479 | 27.3429 | 26.2484 |
| 050570 | 24.4961 | 25.2294 | 25.8619 | 25.1838 |
| 050571 | 24.3741 | 26.2039 | 24.0154 | 24.8290 |
| 050573 | 25.1398 | 24.9644 | 25.6589 | 25.2612 |
| 050575 | * | 19.5611 | 20.7090 | 20.0979 |
| 050577 | 20.5177 | 25.1549 | 23.5487 | 22.9797 |
| 050578 | 28.9073 | 28.5379 | 28.9009 | 28.7846 |
| 050579 | 30.0694 | 30.4952 | 29.9348 | 30.1803 |
| 050580 | 23.9183 | 25.9004 | 24.6962 | 24.8350 |
| 050581 | 23.5660 | 23.8584 | 24.9807 | 24.1454 |
| 050583 | 23.3609 | 24.3987 | 25.8800 | 24.5448 |
| 050584 | 23.1610 | 21.2366 | 19.5805 | 21.2667 |
| 050585 | 26.4985 | 25.9426 | 24.2824 | 25.5872 |
| 050586 | 23.8402 | 23.4079 | 23.1850 | 23.4570 |
| 050588 | 30.3873 | 25.3094 | 24.5472 | 26.4705 |
| 050589 | 24.3453 | 24.8698 | 23.8880 | 24.3389 |
| 050590 | * | 22.4480 | 24.4797 | 23.4541 |
| 050591 | 22.3224 | 23.9412 | 25.0209 | 23.7207 |
| 050592 | 26.0528 | 21.1745 | 22.1174 | 23.0414 |
| 050594 | 22.7826 | 27.1584 | 27.7002 | 25.6455 |
| 050597 | 23.1789 | 22.8523 | 23.3280 | 23.1176 |
| 050598 | 28.1062 | 24.3597 | 23.9202 | 25.2869 |
| 050599 | 26.3191 | 29.1221 | 26.0892 | 27.1846 |
| 050601 | 32.8704 | 31.8670 | 29.7417 | 31.4201 |
| 050603 | 22.7500 | 23.3390 | 21.7031 | 22.5608 |
| 050604 | 33.3239 | 34.0461 | 35.4034 | 34.3023 |
| 050607 | 24.1052 | * | * | 24.1052 |
| 050608 | 16.1529 | 18.0947 | 18.1664 | 17.4208 |
| 050609 | 31.9340 | 34.9935 | 33.5028 | 33.4973 |
| 050613 | 23.4779 | 23.3835 | 30.2413 | 25.4419 |
| 050615 | 23.7015 | 23.8815 | 27.5682 | 24.9089 |
| 050616 | 22.7960 | 22.7437 | 24.9843 | 23.5101 |
| 050618 | 21.7032 | 21.6509 | 21.4895 | 21.6219 |
| 050623 | 30.3208 | 29.1806 | 27.5832 | 29.0384 |
| 050624 | 22.3419 | 22.7148 | 26.4659 | 23.7251 |
| 050625 | 24.3503 | 26.4849 | 27.5816 | 26.1377 |
| 050630 | 24.0961 | 23.9159 | 24.2120 | 24.0782 |
| 050633 | 21.9790 | 23.1918 | 25.4283 | 23.5401 |
| 050635 | 37.8481 | * | * | 37.8481 |
| 050636 | 20.8349 | 21.2618 | 23.5257 | 21.8335 |
| 050638 | 23.6341 | 18.2859 | 18.2159 | 19.5807 |
| 050641 | 21.3605 | 21.8315 | 17.1258 | 19.7042 |
| 050644 | 23.1229 | 22.3456 | 22.1489 | 22.5048 |
| 050661 | 20.4769 | 19.6780 | * | 20.1699 |
| 050662 | 28.2910 | 26.9606 | 35.0989 | 28.9225 |
| 050663 | 23.7097 | 30.6591 | 24.9110 | 25.8492 |
| 050667 | 24.1064 | 24.9979 | 27.5045 | 25.1663 |
| 050668 | 39.9001 | 42.0974 | 61.7751 | 44.9671 |
| 050670 | 21.8750 | 20.0152 | 24.6101 | 21.9523 |
| 050674 | 36.2361 | 34.7380 | 32.4807 | 34.3308 |
| 050675 | 15.8423 | 15.6794 | * | 15.7602 |
| 050676 | 17.5302 | 18.6672 | 20.2087 | 18.7455 |
| 050677 | 33.7056 | 35.6503 | 33.6070 | 34.3198 |
| 050678 | 22.6591 | 26.8741 | 22.7756 | 23.9129 |
| 050680 | 27.3188 | 28.0584 | 31.4839 | 28.9200 |
| 050682 | 17.9715 | 26.2882 | 17.3566 | 19.6443 |
| 050684 | 21.8067 | 22.3398 | 23.3697 | 22.4849 |
| 050685 | 32.1330 | 31.1725 | 35.1307 | 32.7762 |
| 050686 | 33.2515 | 35.2631 | 33.4420 | 33.9679 |
| 050688 | 29.9990 | 30.6635 | 31.0648 | 30.5922 |
| 050689 | 34.1851 | 30.7295 | 30.9399 | 31.8127 |
| 050690 | 33.8277 | 32.8204 | 34.8112 | 33.8469 |
| 050693 | 33.2977 | 26.8265 | 25.5662 | 28.3155 |
| 050694 | 22.5719 | 23.2293 | 23.5572 | 23.1120 |
| 050695 | 23.5215 | 21.1377 | 24.4301 | 23.0784 |
| 050696 | 26.4103 | 28.0015 | 28.3291 | 27.6235 |
| 050697 | 21.4716 | 21.1566 | 18.2338 | 20.1433 |
| 050699 | 28.4754 | 25.7843 | 17.5296 | 23.1610 |
| 050700 | 28.4522 | * | * | 28.4522 |
| 050701 | 27.6190 | 22.6959 | 24.3055 | 24.7548 |
| 050702 | 12.2518 | * | * | 12.2518 |
| 050704 | 20.7568 | 22.8716 | 22.7618 | 22.3025 |
| 050707 | 27.5065 | 26.2732 | 27.8958 | 27.2979 |
| 050708 | 21.9149 | 22.7821 | 24.8647 | 23.2324 |
| 050709 | 19.4255 | 21.9598 | 19.4977 | 20.2535 |
| 050710 | 26.8095 | 26.9060 | 27.5828 | 27.1479 |
| 050713 | 15.3027 | 17.7259 | 16.8538 | 16.6077 |
| 050714 | * | 28.9314 | 30.1925 | 29.4900 |
| 050715 | 19.1151 | * | * | 19.1151 |
| 050717 | * | 25.9534 | 28.7973 | 27.3346 |
| 050718 | * | 17.6062 | 18.0940 | 17.8064 |
| 050719 | * | 25.5508 | 23.0833 | 23.8495 |
| 050720 | * | * | 25.8677 | 25.8677 |
| 060001 | 20.5908 | 21.3659 | 21.1819 | 21.0411 |
| 060003 | 19.3243 | 19.8023 | 20.4682 | 19.8685 |
| 060004 | 21.7899 | 22.8750 | 21.4496 | 22.0469 |
| 060006 | 17.8613 | 19.3651 | 20.0213 | 19.0568 |
| 060007 | 16.3833 | 17.4682 | 18.2977 | 17.3945 |
| 060008 | 17.0944 | 18.0333 | 18.4590 | 17.8646 |
| 060009 | 21.1795 | 21.4312 | 22.7164 | 21.8027 |
| 060010 | 22.7241 | 24.0872 | 23.6827 | 23.5135 |
| 060011 | 21.9727 | 23.4366 | 22.3458 | 22.5831 |
| 060012 | 19.7746 | 20.1442 | 19.4932 | 19.7974 |
| 060013 | 19.1369 | 22.7346 | 19.1256 | 20.3432 |
| 060014 | 20.5353 | 24.2459 | 24.3210 | 23.0067 |
| 060015 | 23.5675 | 20.9773 | 23.2469 | 22.5866 |
| 060016 | 15.9627 | 16.4707 | 20.2408 | 17.3661 |
| 060018 | 21.8607 | 20.3183 | 21.5083 | 21.2146 |
| 060020 | 17.7250 | 18.3099 | 18.8985 | 18.3187 |
| 060022 | 19.6488 | 21.0558 | 21.0830 | 20.6200 |
| 060023 | 19.6534 | 19.2373 | 21.5475 | 20.1296 |
| 060024 | 22.8347 | 21.9955 | 22.9185 | 22.5887 |
| 060027 | 21.6731 | 20.9846 | 22.0713 | 21.5836 |
| 060028 | 22.2461 | 23.2065 | 23.1792 | 22.8860 |
| 060029 | 21.4111 | 20.8585 | 18.2938 | 20.0752 |
| 060030 | 20.0345 | 20.5002 | 20.3452 | 20.2923 |
| 060031 | 19.3998 | 21.1649 | 22.5067 | 20.9951 |
| 060032 | 22.3702 | 23.4162 | 22.8123 | 22.8765 |
| 060033 | 13.8165 | 15.9085 | 16.0760 | 15.2591 |
| 060034 | 21.4110 | 22.4791 | 23.2816 | 22.4305 |
| 060036 | 19.2386 | 15.0698 | 18.5988 | 17.4095 |
| 060037 | 14.0458 | 15.5611 | 15.4513 | 15.0213 |
| 060038 | 14.3084 | 14.0791 | 14.3249 | 14.2429 |
| 060041 | 14.8299 | 14.8934 | 19.1263 | 15.9980 |
| 060042 | 20.0815 | 19.1892 | 20.8597 | 19.9134 |
| 060043 | 13.0544 | 13.6717 | 13.4443 | 13.3963 |
| 060044 | 22.5286 | 19.7039 | 20.8673 | 21.1240 |
| 060046 | 20.4359 | 19.4567 | 22.2699 | 20.7384 |
| 060047 | 15.1181 | 15.8770 | 17.1534 | 15.9786 |
| 060049 | 20.6427 | 21.7797 | 23.0613 | 21.7878 |
| 060050 | 16.8012 | 18.2238 | 19.0832 | 18.0606 |
| 060052 | 12.5517 | 13.4210 | 14.8729 | 13.6675 |
| 060053 | 14.9399 | 15.9806 | 18.0232 | 16.2596 |
| 060054 | 19.3943 | 22.8985 | 20.4160 | 20.8278 |
| 060056 | 17.0509 | 18.2831 | 18.1263 | 17.9597 |
| 060057 | 23.3804 | 26.4046 | 25.4185 | 25.1123 |
| 060058 | 16.9064 | 15.4856 | 13.8539 | 15.6088 |
| 060060 | 14.8894 | 15.6469 | 15.6018 | 15.4330 |
| 060062 | 14.9354 | 17.2991 | 16.8640 | 16.3901 |
| 060063 | 15.0896 | * | * | 15.0896 |
| 060064 | 20.9349 | 21.2207 | 22.7797 | 21.6636 |
| 060065 | 24.3032 | 21.6305 | 24.5572 | 23.4210 |
| 060066 | 14.0672 | 16.3485 | 17.2537 | 15.7129 |
| 060068 | 19.6355 | * | * | 19.6355 |
| 060070 | 16.5821 | 17.3184 | 18.8960 | 17.6173 |
| 060071 | 16.9545 | 17.5987 | 17.4068 | 17.3254 |
| 060073 | 15.8385 | 15.7860 | 17.0846 | 16.2338 |
| 060075 | 22.8498 | 24.1550 | 23.8724 | 23.6295 |
| 060076 | 19.2861 | 24.8732 | 20.3265 | 21.3796 |
| 060085 | 13.4761 | 13.6277 | 14.3409 | 13.7955 |
| 060087 | 21.0277 | * | * | 21.0277 |
| 060088 | 16.6753 | 25.2786 | 13.7174 | 17.2655 |
| 060090 | 14.5096 | 22.2974 | 16.3760 | 17.6196 |
| 060096 | 23.1232 | 21.9623 | 20.8937 | 21.9261 |
| 060100 | 21.9983 | 23.5986 | 23.9305 | 23.4279 |
| 060103 | 22.3414 | 24.8151 | 23.5083 | 23.4950 |
| 060104 | 22.3008 | 22.2295 | 21.1820 | 21.8472 |
| 060107 | 13.6449 | 14.2698 | 21.9221 | 15.1674 |
| 070001 | 26.5150 | 26.0878 | 26.3596 | 26.3266 |
| 070002 | 25.4570 | 26.2801 | 26.1768 | 25.9680 |
| 070003 | 26.0894 | 25.6949 | 27.5200 | 26.4175 |
| 070004 | 23.2664 | 22.4871 | 24.2567 | 23.3158 |
| 070005 | 25.5739 | 26.6483 | 26.9151 | 26.3676 |
| 070006 | 28.7139 | 27.5674 | 28.6413 | 28.3103 |
| 070007 | 27.1867 | 26.9505 | 26.3313 | 26.8152 |
| 070008 | 26.0269 | 23.0227 | 24.2971 | 24.3585 |
| 070009 | 23.4686 | 24.6201 | 24.1871 | 24.0886 |
| 070010 | 25.9375 | 26.2354 | 29.2194 | 27.0543 |
| 070011 | 23.9603 | 23.3638 | 23.0883 | 23.4486 |
| 070012 | 25.1022 | 23.0321 | 28.8067 | 25.3536 |
| 070015 | 25.3317 | 23.8240 | 28.1204 | 25.7263 |
| 070016 | 26.3005 | 24.9148 | 24.4633 | 25.2035 |
| 070017 | 24.8038 | 26.2923 | 26.0424 | 25.7039 |
| 070018 | 28.8776 | 28.0689 | 30.6864 | 29.1923 |
| 070019 | 24.7025 | 25.7283 | 24.9249 | 25.1145 |
| 070020 | 23.7227 | 23.9987 | 25.9964 | 24.5532 |
| 070021 | 26.5173 | 25.2978 | 26.3043 | 26.0246 |
| 070022 | 25.0845 | 26.5691 | 26.9111 | 26.1557 |
| 070024 | 25.1491 | 25.2983 | 24.8948 | 25.1081 |
| 070025 | 25.4055 | 25.1315 | 25.4345 | 25.3241 |
| 070026 | 18.7892 | * | * | 18.7892 |
| 070027 | 23.6381 | 23.6412 | 26.8450 | 24.6648 |
| 070028 | 24.6913 | 24.6788 | 25.7492 | 25.0300 |
| 070029 | 22.7507 | 22.0080 | 23.9682 | 22.8885 |
| 070030 | 24.9676 | 28.9117 | 22.1578 | 25.5338 |
| 070031 | 21.6565 | 23.4419 | 24.1198 | 23.0342 |
| 070033 | 28.8099 | 30.4214 | 31.4736 | 30.2068 |
| 070034 | 29.1220 | 28.9200 | 29.4916 | 29.1706 |
| 070035 | 23.0574 | 23.0869 | 24.1423 | 23.4347 |
| 070036 | 28.9463 | 28.8400 | 29.9470 | 29.2263 |
| 070039 | 21.7791 | 22.9032 | 22.3356 | 22.3067 |
| 080001 | 25.2849 | 25.4836 | 24.8833 | 25.2209 |
| 080002 | 15.5984 | 19.6011 | 20.1965 | 18.4286 |
| 080003 | 22.3957 | 22.1856 | 23.1275 | 22.5300 |
| 080004 | 19.7725 | 21.9391 | 22.9706 | 21.5842 |
| 080005 | 14.4289 | * | * | 14.4289 |
| 080006 | 22.2632 | 20.0792 | 22.6671 | 21.6173 |
| 080007 | 20.3833 | 19.6213 | 21.3746 | 20.4985 |
| 090001 | 25.8921 | 21.7526 | 21.5751 | 23.1400 |
| 090002 | 19.6997 | 19.4191 | 21.5726 | 20.1912 |
| 090003 | 28.6092 | 22.1090 | 23.1268 | 24.5792 |
| 090004 | 24.4267 | 24.3367 | 25.5054 | 24.7042 |
| 090005 | 24.8766 | 23.8620 | 26.3074 | 24.9846 |
| 090006 | 20.0816 | 20.8675 | 22.0957 | 21.0167 |
| 090007 | 21.6551 | 22.1973 | 29.2840 | 24.7855 |
| 090008 | 21.5972 | 20.2166 | 25.2708 | 22.3042 |
| 090010 | 15.8676 | 24.1287 | 23.6616 | 20.2595 |
| 090011 | 27.3741 | 27.4781 | 26.6349 | 27.1495 |
| 100001 | 17.6948 | 19.5796 | 20.2157 | 19.1458 |
| 100002 | 21.3243 | 20.7136 | 21.0222 | 21.0141 |
| 100004 | 15.2465 | 14.6283 | 15.4149 | 15.0845 |
| 100006 | 20.6302 | 20.1133 | 21.2293 | 20.6802 |
| 100007 | 21.7217 | 21.7242 | 22.1590 | 21.8790 |
| 100008 | 20.7232 | 20.4980 | 20.8381 | 20.6876 |
| 100009 | 24.2947 | 22.6419 | 22.1741 | 22.9648 |
| 100010 | 21.9101 | 21.9078 | 23.0637 | 22.2904 |
| 100012 | 18.5169 | 19.6177 | 20.4659 | 19.5030 |
| 100014 | 19.8352 | 19.8023 | 19.5770 | 19.7276 |
| 100015 | 18.2394 | 18.4779 | 18.0654 | 18.2696 |
| 100017 | 17.7739 | 19.0608 | 19.8655 | 18.9086 |
| 100018 | 20.8392 | 21.0332 | 21.6388 | 21.1816 |
| 100019 | 19.8134 | 22.6152 | 23.5462 | 21.9719 |
| 100020 | 26.1783 | 21.3848 | 20.7816 | 22.5004 |
| 100022 | 25.8853 | 26.4094 | 26.5695 | 26.2778 |
| 100023 | 21.1068 | 19.9739 | 19.1787 | 20.0604 |
| 100024 | 20.7760 | 21.8791 | 22.1332 | 21.6047 |
| 100025 | 19.1219 | 18.7774 | 19.4529 | 19.1169 |
| 100026 | 20.7591 | 20.5641 | 20.9461 | 20.7639 |
| 100027 | 12.9410 | 19.1481 | 14.7916 | 15.3484 |
| 100028 | 19.7491 | 19.3757 | 19.3371 | 19.4791 |
| 100029 | 19.1768 | 20.8745 | 20.8950 | 20.2753 |
| 100030 | 18.8229 | 22.8204 | 20.5952 | 20.6758 |
| 100032 | 19.3165 | 19.8127 | 19.7451 | 19.6185 |
| 100034 | 18.2314 | 17.8743 | 19.5282 | 18.5138 |
| 100035 | 19.5842 | 20.1540 | 23.8117 | 21.2289 |
| 100038 | 24.7851 | 23.3578 | 24.5864 | 24.2183 |
| 100039 | 20.2529 | 21.5297 | 21.7861 | 21.1854 |
| 100040 | 18.6417 | 19.0449 | 18.6321 | 18.7662 |
| 100043 | 17.5215 | 18.7993 | 18.8206 | 18.3605 |
| 100044 | 21.1370 | 21.4764 | 22.7236 | 21.7975 |
| 100045 | 20.7688 | 20.9216 | 21.0228 | 20.9056 |
| 100046 | 21.2094 | 21.6207 | 21.3028 | 21.3728 |
| 100047 | 18.8677 | 20.0114 | 20.6068 | 19.8263 |
| 100048 | 13.5021 | 15.0584 | 15.7790 | 14.8232 |
| 100049 | 18.5598 | 18.8535 | 19.1025 | 18.8421 |
| 100050 | 16.6058 | 17.2377 | 17.9039 | 17.2452 |
| 100051 | 18.8377 | 23.1273 | 17.9453 | 19.6449 |
| 100052 | 16.1855 | 17.9537 | 18.1780 | 17.4312 |
| 100053 | 18.7103 | 20.1724 | 19.6800 | 19.5213 |
| 100054 | 18.1853 | 23.5491 | 21.1518 | 20.9367 |
| 100055 | 17.6226 | 18.0547 | 18.8760 | 18.1971 |
| 100056 | 23.6545 | 25.7863 | 21.8506 | 23.8349 |
| 100057 | 18.7489 | 19.9712 | 19.5319 | 19.4242 |
| 100060 | 22.3904 | 23.2561 | 23.5997 | 23.0802 |
| 100061 | 21.7923 | 22.1133 | 22.9176 | 22.2483 |
| 100062 | 17.9575 | 19.4370 | 21.4424 | 19.6570 |
| 100063 | 16.2324 | 19.2629 | 18.4642 | 17.9066 |
| 100067 | 17.3950 | 18.0877 | 18.4851 | 17.9682 |
| 100068 | 18.6480 | 19.9305 | 19.8308 | 19.4718 |
| 100069 | 16.1393 | 16.8271 | 17.3666 | 16.7757 |
| 100070 | 20.3358 | 18.7408 | 20.0381 | 19.6563 |
| 100071 | 16.4756 | 17.5451 | 17.7234 | 17.2640 |
| 100072 | 19.2223 | 21.0225 | 20.5968 | 20.3580 |
| 100073 | 18.1554 | 21.1898 | 22.2812 | 20.4948 |
| 100075 | 18.0548 | 18.3688 | 19.4480 | 18.6211 |
| 100076 | 16.2469 | 17.8733 | 17.8612 | 17.3644 |
| 100077 | 19.6214 | 22.3438 | 19.0640 | 20.3179 |
| 100078 | 18.2791 | 18.4499 | 19.2891 | 18.6609 |
| 100080 | 21.1603 | 22.1966 | 22.7153 | 22.0462 |
| 100081 | 13.9564 | 14.8313 | 15.4253 | 14.7661 |
| 100082 | 19.8033 | 18.8998 | * | 19.3432 |
| 100084 | 20.4002 | 22.3674 | 22.7009 | 21.8810 |
| 100085 | 21.0802 | 22.1231 | * | 21.5986 |
| 100086 | 21.1625 | 21.6997 | 23.3718 | 22.0734 |
| 100087 | 23.1162 | 23.6090 | 23.6562 | 23.4609 |
| 100088 | 20.0571 | 20.3693 | 20.5566 | 20.3435 |
| 100090 | 17.8768 | 19.1479 | 19.7695 | 18.9939 |
| 100092 | 18.1953 | 17.9216 | 20.1760 | 18.7907 |
| 100093 | 16.6310 | 16.5128 | 16.8422 | 16.6633 |
| 100098 | 19.0319 | 19.2427 | 20.8315 | 19.7124 |
| 100099 | 15.2983 | 15.7823 | 15.7591 | 15.6112 |
| 100102 | 19.3330 | 18.9701 | 19.7673 | 19.3542 |
| 100103 | 18.1019 | 17.2364 | 18.7844 | 18.0201 |
| 100105 | 21.5028 | 21.6604 | 21.8268 | 21.6611 |
| 100106 | 19.3113 | 17.2527 | 17.4958 | 17.9164 |
| 100107 | 18.0142 | 20.1281 | 20.0719 | 19.4041 |
| 100108 | 11.4692 | 19.9593 | 20.1125 | 16.4375 |
| 100109 | 22.1715 | 20.8440 | 20.8370 | 21.2360 |
| 100110 | 19.6439 | 20.8995 | 20.1853 | 20.2509 |
| 100112 | 9.7706 | 25.2570 | 15.2128 | 15.6728 |
| 100113 | 22.2584 | 23.2020 | 21.3489 | 22.1642 |
| 100114 | 23.4501 | 21.6262 | 22.8178 | 22.5825 |
| 100117 | 18.8619 | 20.7624 | 20.6962 | 20.1889 |
| 100118 | 19.7608 | 22.8702 | 20.7323 | 21.1427 |
| 100121 | 19.3435 | * | 18.5842 | 18.9363 |
| 100122 | 18.0551 | 19.8783 | 19.2643 | 19.0686 |
| 100124 | 19.0527 | 17.0713 | 20.4022 | 18.8192 |
| 100125 | 17.3358 | 18.9535 | 19.6097 | 18.6719 |
| 100126 | 18.0943 | 19.5413 | 19.3103 | 18.9490 |
| 100127 | 19.8727 | 19.9860 | 19.2122 | 19.6859 |
| 100128 | 21.3653 | 20.1536 | 22.8826 | 21.4045 |
| 100129 | 18.5723 | 19.1936 | * | 18.8646 |
| 100130 | 19.1052 | 18.6751 | 20.0947 | 19.3019 |
| 100131 | 22.1680 | 23.4373 | 23.1622 | 22.9338 |
| 100132 | 16.8978 | 18.1167 | 18.7863 | 17.9218 |
| 100134 | 13.4711 | 15.1764 | 15.9733 | 14.8260 |
| 100135 | 17.4785 | 18.8253 | 19.1865 | 18.5050 |
| 100137 | 19.0464 | 18.6955 | 19.5562 | 19.1372 |
| 100138 | 11.0135 | 17.1373 | 14.9539 | 13.7935 |
| 100139 | 15.6444 | 15.6514 | 15.2532 | 15.5227 |
| 100140 | 17.3518 | 17.1389 | 19.0584 | 17.8826 |
| 100142 | 18.6812 | 19.6815 | 18.4113 | 18.9199 |
| 100144 | 15.0197 | 12.2877 | * | 13.4059 |
| 100145 | 19.1143 | * | * | 19.1143 |
| 100146 | 17.8692 | 18.1267 | 21.3359 | 19.1001 |
| 100147 | 14.6751 | 14.6616 | 15.2348 | 14.8665 |
| 100150 | 21.0224 | 21.2807 | 21.5057 | 21.2659 |
| 100151 | 19.3990 | 21.6087 | 23.8489 | 21.6478 |
| 100154 | 19.8485 | 20.0015 | 20.4068 | 20.1020 |
| 100156 | 17.1335 | 19.4980 | 18.4779 | 18.3856 |
| 100157 | 21.0324 | 22.6744 | 22.6195 | 22.1032 |
| 100159 | 16.3778 | 10.2793 | 10.7818 | 11.9429 |
| 100160 | 21.6339 | 20.5581 | 23.3121 | 21.8278 |
| 100161 | 21.5025 | 22.2994 | 22.3053 | 22.0508 |
| 100162 | 19.8748 | 20.1411 | 20.3110 | 20.1117 |
| 100165 | 18.5739 | 19.0388 | 22.6622 | 20.3299 |
| 100166 | 20.4228 | 20.0250 | 21.2309 | 20.5491 |
| 100167 | 21.8138 | 23.4075 | 23.2969 | 22.8605 |
| 100168 | 20.1260 | 20.1994 | 20.3167 | 20.2165 |
| 100169 | 20.7778 | 20.9506 | 20.3017 | 20.6703 |
| 100170 | 15.1167 | 18.5088 | 19.3005 | 17.5325 |
| 100172 | 15.1848 | 14.3446 | 14.8826 | 14.8099 |
| 100173 | 17.3416 | 18.5662 | 17.1337 | 17.6572 |
| 100174 | 20.5125 | 26.1826 | 21.9807 | 22.2819 |
| 100175 | 17.8237 | 18.1692 | 20.5442 | 19.0035 |
| 100176 | 24.6978 | 22.8604 | 24.3089 | 23.9493 |
| 100177 | 22.0034 | 24.4296 | 24.4284 | 23.5639 |
| 100179 | 20.9053 | 22.3015 | 23.0849 | 22.0467 |
| 100180 | 18.4754 | 20.2130 | 21.5388 | 20.0049 |
| 100181 | 24.5704 | 23.0800 | 18.9510 | 21.8206 |
| 100183 | 20.8579 | 24.6121 | 23.0654 | 22.6623 |
| 100187 | 20.6938 | 20.2533 | 20.8535 | 20.6013 |
| 100189 | 21.0102 | 21.3147 | 26.5962 | 23.0255 |
| 100191 | 18.4692 | 19.9879 | 21.0647 | 19.7731 |
| 100199 | 23.3713 | 21.7193 | * | 22.5030 |
| 100200 | 22.2575 | 22.4579 | 23.8729 | 22.8861 |
| 100203 | 18.8628 | * | * | 18.8628 |
| 100204 | 20.2049 | 20.8995 | 20.2193 | 20.4418 |
| 100206 | 20.3511 | 19.5710 | 20.1171 | 20.0138 |
| 100207 | 15.9173 | * | * | 15.9173 |
| 100208 | 20.8337 | 21.2117 | 20.7029 | 20.9220 |
| 100209 | 19.7329 | 22.4577 | 23.3903 | 21.8570 |
| 100210 | 19.1799 | 21.3575 | 21.8545 | 20.7662 |
| 100211 | 25.5277 | 20.6427 | 20.7516 | 21.9172 |
| 100212 | 25.3441 | 21.1187 | 21.1263 | 22.2176 |
| 100213 | 19.1238 | 20.6558 | 21.1818 | 20.2975 |
| 100217 | 19.8700 | 20.5909 | 22.7335 | 21.0211 |
| 100220 | 19.9121 | 21.2796 | 21.8246 | 20.9627 |
| 100221 | 22.2517 | 17.3965 | 21.2321 | 20.0812 |
| 100222 | 22.1958 | * | * | 22.1958 |
| 100223 | 18.7580 | 20.6302 | 20.2233 | 19.8755 |
| 100224 | 24.7023 | 20.0251 | 21.8628 | 21.8826 |
| 100225 | 20.6404 | 20.6802 | 21.5059 | 20.9335 |
| 100226 | 24.8641 | 20.6858 | 21.8808 | 22.2342 |
| 100228 | 23.6986 | 21.3168 | 20.8810 | 21.8300 |
| 100229 | 18.2070 | 19.6908 | 18.2350 | 18.7682 |
| 100230 | 20.6018 | 20.5051 | 22.5650 | 21.2357 |
| 100231 | 17.4002 | 17.9226 | 18.7526 | 18.0268 |
| 100232 | 17.3171 | 19.3491 | 19.8002 | 18.8267 |
| 100234 | 21.5763 | 20.9104 | 21.6360 | 21.3290 |
| 100235 | 17.6648 | 17.1622 | * | 17.4262 |
| 100236 | 21.8111 | 20.3766 | 20.6942 | 20.8937 |
| 100237 | 22.9344 | 22.0865 | 23.2408 | 22.7368 |
| 100238 | 17.6310 | 19.6367 | 20.8252 | 19.4032 |
| 100239 | 19.7605 | 21.3193 | 19.4481 | 20.1474 |
| 100240 | 17.9339 | 20.4340 | 21.0606 | 19.8014 |
| 100241 | 13.8344 | 14.7224 | 17.1063 | 15.0865 |
| 100242 | 17.1154 | 17.9260 | 18.6938 | 17.9097 |
| 100243 | 20.3838 | 21.2644 | 20.8041 | 20.8228 |
| 100244 | 17.4124 | 18.6227 | 20.5352 | 18.9148 |
| 100246 | 21.2160 | 19.6376 | 21.9247 | 20.8876 |
| 100248 | 21.5399 | 20.7007 | 21.2988 | 21.1681 |
| 100249 | 19.0243 | 19.2808 | 18.1397 | 18.8067 |
| 100252 | 17.8726 | 17.7778 | 19.8079 | 18.4729 |
| 100253 | 20.6014 | 21.3232 | 22.4778 | 21.5023 |
| 100254 | 20.9080 | 19.6598 | 19.5523 | 19.9896 |
| 100255 | 21.0224 | 25.2119 | 21.0284 | 22.2338 |
| 100256 | 23.5640 | 20.9356 | 21.2786 | 21.7690 |
| 100258 | 21.8764 | 21.3501 | 20.0300 | 21.0257 |
| 100259 | 19.8600 | 20.3815 | 21.1160 | 20.4723 |
| 100260 | 21.2224 | 21.0506 | 24.9183 | 22.3504 |
| 100262 | 19.5874 | 20.0433 | 21.0927 | 20.2558 |
| 100263 | 16.9012 | * | * | 16.9012 |
| 100264 | 17.6085 | 19.1556 | 19.9491 | 18.8967 |
| 100265 | 19.8571 | 18.8301 | 18.2291 | 18.8491 |
| 100266 | 17.7319 | 18.2993 | 19.3623 | 18.4763 |
| 100267 | 17.0986 | 20.1141 | 21.7430 | 19.6266 |
| 100268 | 23.5863 | 23.9249 | 24.0538 | 23.8633 |
| 100269 | 21.2047 | 21.6724 | 22.5114 | 21.8200 |
| 100270 | 19.8576 | 15.1462 | 16.7148 | 17.2012 |
| 100271 | 19.9208 | 20.4824 | 20.8695 | 20.4494 |
| 100275 | 21.3273 | 20.9188 | 21.4904 | 21.2374 |
| 100276 | 21.9797 | 22.3646 | 24.1022 | 22.8308 |
| 100277 | 16.1410 | 16.6255 | 19.7241 | 17.0041 |
| 100279 | 23.0213 | 22.9095 | 22.5879 | 22.8402 |
| 100280 | 16.5851 | 17.3676 | 18.1972 | 17.4129 |
| 100281 | 22.0202 | 22.4392 | 23.0142 | 22.5262 |
| 100282 | 19.7717 | 19.1978 | 18.4884 | 19.1653 |
| 100284 | * | * | 18.9448 | 18.9448 |
| 110001 | 18.0571 | 19.1971 | 20.1150 | 19.1086 |
| 110002 | 17.3674 | 17.1406 | 19.5158 | 18.0122 |
| 110003 | 16.9099 | 18.1168 | 17.1450 | 17.3940 |
| 110004 | 18.9468 | 19.5591 | 19.7733 | 19.4194 |
| 110005 | 19.2639 | 17.7348 | 22.4568 | 20.0888 |
| 110006 | 20.1273 | 20.7820 | 21.0601 | 20.6571 |
| 110007 | 23.4976 | 21.9505 | 25.2523 | 23.5682 |
| 110008 | 18.2642 | 22.0081 | 18.5265 | 19.5622 |
| 110009 | 14.8218 | 16.3069 | 17.4306 | 16.2843 |
| 110010 | 24.5493 | 23.3213 | 23.9104 | 23.9180 |
| 110011 | 18.2846 | 18.6144 | 18.9823 | 18.6368 |
| 110013 | 16.0264 | 16.2811 | 18.9160 | 17.1183 |
| 110014 | 16.1168 | 16.0658 | 18.1787 | 16.7192 |
| 110015 | 19.4769 | 21.2146 | 20.9926 | 20.5614 |
| 110016 | 15.2967 | 22.5321 | 14.2398 | 16.6540 |
| 110017 | 10.5399 | 13.1960 | 22.2537 | 15.3899 |
| 110018 | 21.0415 | 19.6064 | 22.1480 | 20.9298 |
| 110020 | 18.5251 | 18.3147 | 19.4617 | 18.7736 |
| 110023 | 18.6460 | 21.1994 | 22.0546 | 20.5885 |
| 110024 | 19.7923 | 20.7297 | 20.7345 | 20.4144 |
| 110025 | 18.6463 | 19.5749 | 20.4232 | 19.5033 |
| 110026 | 16.1414 | 17.2977 | 16.2484 | 16.5517 |
| 110027 | 14.6834 | 16.0642 | 14.7081 | 15.1696 |
| 110028 | 19.8894 | 20.1547 | 29.1670 | 22.3800 |
| 110029 | 20.0507 | 20.2906 | 21.2150 | 20.5454 |
| 110030 | 17.6785 | 18.8105 | 19.6412 | 18.7203 |
| 110031 | 21.5794 | 19.9482 | 20.0553 | 20.4598 |
| 110032 | 16.1859 | 15.7349 | 18.2014 | 16.6413 |
| 110033 | 21.4143 | 22.1879 | 25.6335 | 22.9577 |
| 110034 | 18.1882 | 19.6055 | 19.5554 | 19.0987 |
| 110035 | 21.1670 | 19.3795 | 22.7950 | 21.1658 |
| 110036 | 24.4181 | 22.2498 | 20.7284 | 22.3301 |
| 110038 | 16.3750 | 17.7060 | 17.7396 | 17.2680 |
| 110039 | 20.7710 | 20.6011 | 20.4998 | 20.6248 |
| 110040 | 16.4043 | 17.0743 | 16.8083 | 16.7529 |
| 110041 | 16.6927 | 18.8035 | 20.2755 | 18.6583 |
| 110042 | 20.6503 | 24.0153 | 25.2331 | 23.2575 |
| 110043 | 17.2175 | 20.1016 | 20.6150 | 19.2219 |
| 110044 | 19.5983 | 16.3624 | 17.2087 | 17.5794 |
| 110045 | 19.9445 | 20.2498 | 21.3049 | 20.4714 |
| 110046 | 19.2327 | 19.7377 | 21.4905 | 20.1167 |
| 110048 | 15.6463 | 16.3148 | 15.6113 | 15.8483 |
| 110049 | 14.2135 | 16.1817 | 16.8639 | 15.7669 |
| 110050 | 18.7516 | 20.7619 | 19.2291 | 19.5578 |
| 110051 | 15.7475 | 17.0070 | 17.2292 | 16.6496 |
| 110052 | 15.0562 | * | * | 15.0562 |
| 110054 | 19.2712 | * | 20.0549 | 19.6625 |
| 110056 | 16.4960 | 15.6202 | 17.7959 | 16.7305 |
| 110059 | 17.6984 | 16.6678 | 16.7990 | 17.0253 |
| 110061 | 13.7196 | 15.0367 | 16.3557 | 15.0889 |
| 110062 | 12.2107 | 18.8019 | 17.0053 | 16.1264 |
| 110063 | 17.9743 | 16.9612 | 18.5071 | 17.7965 |
| 110064 | 18.3368 | 18.9515 | 19.1203 | 18.8163 |
| 110065 | 13.3245 | 15.6771 | 16.3546 | 15.1604 |
| 110066 | 20.6502 | 21.0207 | 22.4189 | 21.3274 |
| 110069 | 18.3519 | 19.3109 | 20.9575 | 19.5384 |
| 110070 | 18.2264 | 21.0227 | 17.3438 | 18.7743 |
| 110071 | 14.8902 | 14.5984 | 18.8321 | 15.8863 |
| 110072 | 12.4303 | 12.7877 | 12.7625 | 12.6652 |
| 110073 | 15.1377 | 15.4261 | 16.4658 | 15.6663 |
| 110074 | 20.7572 | 21.3945 | 22.3769 | 21.5169 |
| 110075 | 17.0067 | 18.5199 | 20.1757 | 18.5793 |
| 110076 | 20.4430 | 21.2867 | 21.9798 | 21.2384 |
| 110078 | 24.7069 | 22.3718 | 24.0893 | 23.6954 |
| 110079 | 20.1385 | 21.0593 | 22.1070 | 21.0913 |
| 110080 | 23.4336 | 18.4768 | 19.1839 | 20.1449 |
| 110082 | 22.0078 | 23.8768 | 24.3140 | 23.4175 |
| 110083 | 21.3578 | 23.1219 | 23.1463 | 22.5746 |
| 110086 | 14.9756 | 18.2815 | 16.6374 | 16.5417 |
| 110087 | 20.5420 | 21.7773 | 22.7069 | 21.7189 |
| 110089 | 18.5761 | 18.5587 | 19.3855 | 18.8318 |
| 110091 | 21.3789 | 19.5114 | 21.5328 | 20.7784 |
| 110092 | 15.0890 | 17.3479 | 16.9725 | 16.4433 |
| 110093 | 14.8049 | * | 16.9827 | 15.7486 |
| 110094 | 13.8658 | 14.5641 | 16.9503 | 15.0650 |
| 110095 | 15.9478 | 16.4670 | 17.1195 | 16.5075 |
| 110096 | 16.3202 | 16.8541 | 17.4157 | 16.8647 |
| 110097 | 15.6164 | 15.5811 | 17.4558 | 16.1121 |
| 110098 | 14.0067 | 16.3532 | 16.0597 | 15.3226 |
| 110100 | 20.3764 | 18.6978 | 19.0764 | 19.3213 |
| 110101 | 11.7278 | 10.8187 | 18.8491 | 12.7872 |
| 110103 | 11.9352 | 13.6842 | 21.1837 | 14.0859 |
| 110104 | 15.3184 | 15.7781 | 15.9431 | 15.6829 |
| 110105 | 16.5196 | 16.8909 | 16.7775 | 16.7306 |
| 110107 | 17.3921 | 19.3609 | 19.3897 | 18.7335 |
| 110108 | 15.1401 | 19.7938 | 25.2161 | 19.3940 |
| 110109 | 16.3703 | 15.9359 | 16.4031 | 16.2270 |
| 110111 | 17.3215 | 18.5108 | 18.3951 | 18.0800 |
| 110112 | 19.1288 | 19.0619 | 19.8986 | 19.3117 |
| 110113 | 15.1896 | 16.8179 | 15.9532 | 15.9721 |
| 110114 | 15.1303 | 14.6888 | 16.4812 | 15.4358 |
| 110115 | 24.8332 | 43.9427 | 22.5049 | 27.8401 |
| 110118 | 15.3992 | 20.5368 | 19.7509 | 18.5122 |
| 110120 | 15.1878 | 15.2589 | 17.7452 | 15.9897 |
| 110121 | 15.5792 | 16.2711 | 19.3643 | 17.0685 |
| 110122 | 18.8497 | 21.1385 | 21.1469 | 20.3688 |
| 110124 | 17.1306 | 17.5732 | 18.3366 | 17.6460 |
| 110125 | 17.3254 | 19.1311 | 18.0090 | 18.1411 |
| 110127 | 13.7612 | 14.6143 | 20.3765 | 16.2641 |
| 110128 | 18.9705 | 18.1845 | 18.0835 | 18.4293 |
| 110129 | 18.1208 | 18.9388 | 19.0001 | 18.6851 |
| 110130 | 13.0779 | 16.0580 | 14.6011 | 14.6559 |
| 110132 | 15.0231 | 16.0419 | 16.3943 | 15.8158 |
| 110134 | 11.5583 | 12.5723 | 19.8639 | 15.1252 |
| 110135 | 17.0834 | 17.4380 | 17.3504 | 17.2967 |
| 110136 | 16.1680 | 18.0639 | 16.9629 | 16.8702 |
| 110140 | 17.8806 | 17.8870 | 17.7915 | 17.8571 |
| 110141 | 12.5051 | 13.2501 | 14.4935 | 13.4024 |
| 110142 | 12.3029 | 14.6144 | 13.9525 | 13.5947 |
| 110143 | 21.6898 | 20.1603 | 22.5926 | 21.5352 |
| 110144 | 17.9766 | 16.8685 | 17.5112 | 17.4397 |
| 110146 | 17.6068 | 16.1316 | 17.1835 | 16.9320 |
| 110149 | 22.2256 | 17.7535 | 32.1975 | 23.0615 |
| 110150 | 18.7724 | 20.2644 | 21.2909 | 20.0962 |
| 110152 | 14.7674 | 15.3996 | 15.1324 | 15.1011 |
| 110153 | 18.6862 | 19.2744 | 20.5068 | 19.4781 |
| 110154 | 14.8067 | 14.9636 | 17.3761 | 15.6408 |
| 110155 | 17.1370 | 15.5306 | 16.5146 | 16.3434 |
| 110156 | 15.3422 | 14.7477 | 16.3876 | 15.4698 |
| 110161 | 20.8657 | 21.7153 | 22.2861 | 21.6563 |
| 110163 | 18.2016 | 20.4202 | 18.6637 | 19.0060 |
| 110164 | 19.4946 | 20.2074 | 21.2160 | 20.2947 |
| 110165 | 18.9974 | 21.2577 | 20.8030 | 20.3401 |
| 110166 | 19.8510 | 20.5882 | 20.5049 | 20.3148 |
| 110168 | 19.8178 | 20.6646 | 21.8058 | 20.8014 |
| 110169 | 18.7189 | 20.6385 | 22.6648 | 20.4216 |
| 110171 | 20.0874 | 23.7893 | 25.5296 | 22.6284 |
| 110172 | 25.4390 | 23.3730 | 23.6803 | 24.1715 |
| 110174 | 14.2978 | 13.7339 | 14.6199 | 14.1905 |
| 110176 | 22.3971 | * | * | 22.3971 |
| 110177 | 19.5888 | 20.7187 | 21.2796 | 20.5272 |
| 110178 | 16.8555 | 18.8306 | * | 17.8083 |
| 110179 | 20.5161 | 22.7841 | 22.0767 | 21.7231 |
| 110181 | 13.7195 | 14.0941 | 12.9798 | 13.6399 |
| 110183 | 21.1797 | 23.3826 | 22.5148 | 22.3473 |
| 110184 | 20.9465 | 22.1970 | 22.1920 | 21.7791 |
| 110185 | 16.2487 | 16.7246 | 17.7925 | 16.9013 |
| 110186 | 17.3398 | 17.4287 | 18.3178 | 17.6984 |
| 110187 | 21.4462 | 20.1154 | 19.8419 | 20.4516 |
| 110188 | 20.0548 | 24.8376 | 23.7032 | 22.6465 |
| 110189 | 18.8627 | 22.2715 | 20.8786 | 20.7023 |
| 110190 | 19.4318 | 18.5728 | 18.3649 | 18.7761 |
| 110191 | 19.1065 | 20.2033 | 21.4033 | 20.2583 |
| 110192 | 20.7660 | 21.4951 | 21.0486 | 21.1064 |
| 110193 | 18.7807 | 20.6380 | 20.7867 | 20.0518 |
| 110194 | 15.0937 | 15.1480 | 14.8115 | 15.0165 |
| 110195 | 10.5227 | 13.9135 | 12.7261 | 12.3146 |
| 110198 | 26.1898 | 24.1999 | 24.8646 | 25.0493 |
| 110200 | 17.2129 | 18.1862 | 17.7744 | 17.7301 |
| 110201 | 19.2438 | 20.4699 | 20.9497 | 20.2248 |
| 110203 | 20.2958 | 26.8148 | 22.7453 | 23.1944 |
| 110204 | 20.5728 | 19.7317 | 30.7342 | 21.7754 |
| 110205 | 26.1154 | 21.1435 | 21.3617 | 22.7145 |
| 110207 | 12.8710 | 12.9727 | 14.7154 | 13.5335 |
| 110208 | 14.8907 | 15.1742 | 15.6161 | 5.1789 |
| 110209 | 20.4640 | 17.9190 | 18.6404 | 18.9942 |
| 110211 | 21.8226 | 20.9372 | 26.9151 | 23.1427 |
| 110212 | 12.6583 | 11.8545 | 14.3790 | 12.8830 |
| 110213 | 13.1976 | 14.3651 | * | 13.7453 |
| 110215 | * | 20.1928 | 18.1539 | 19.0047 |
| 110216 | * | * | 27.1878 | 27.1878 |
| 120001 | 26.7134 | 27.9213 | 29.0427 | 27.8237 |
| 120002 | 24.3780 | 25.0744 | 25.2021 | 24.8896 |
| 120003 | 23.8452 | 25.9059 | 23.9115 | 24.5394 |
| 120004 | 24.0456 | 23.9208 | 24.8632 | 24.2413 |
| 120005 | 20.5380 | 23.3975 | 24.1662 | 22.6197 |
| 120006 | 23.7151 | 25.0895 | 25.8943 | 24.8700 |
| 120007 | 23.2684 | 22.7200 | 22.8772 | 22.9509 |
| 120009 | 19.0216 | 17.4693 | 16.4485 | 17.5600 |
| 120010 | 25.3976 | 25.1480 | 24.1923 | 24.8868 |
| 120011 | 33.5459 | 35.0582 | 37.2759 | 35.3313 |
| 120012 | 22.5219 | 23.1144 | 21.8507 | 22.5391 |
| 120014 | 24.0467 | 22.8866 | 24.1208 | 23.6739 |
| 120015 | 29.0747 | 32.9906 | 42.6465 | 33.1800 |
| 120016 | 29.4104 | 27.9127 | 45.1899 | 31.1230 |
| 120018 | 25.6088 | 24.5031 | 31.1879 | 26.2841 |
| 120019 | 21.9199 | 22.9341 | 25.5659 | 23.4285 |
| 120021 | 19.4236 | 23.4508 | 23.1839 | 21.8865 |
| 120022 | 17.9306 | 21.7868 | 19.2614 | 19.5032 |
| 120024 | 22.2846 | 29.4808 | 32.2514 | 26.8486 |
| 120025 | 19.0197 | 20.1065 | 50.6376 | 21.3455 |
| 120026 | 23.2237 | 26.0787 | 25.1314 | 24.7719 |
| 120027 | 24.5549 | 24.7255 | 24.4535 | 24.5737 |
| 120028 | 23.4873 | 27.5023 | 27.0897 | 25.8902 |
| 130001 | 24.9511 | 18.8471 | 17.6306 | 20.1752 |
| 130002 | 16.1853 | 16.6620 | 16.9867 | 16.6200 |
| 130003 | 19.9499 | 21.7313 | 22.3430 | 21.3583 |
| 130005 | 20.1678 | 20.7169 | 21.2386 | 20.7149 |
| 130006 | 18.8705 | 19.3392 | 20.4614 | 19.5797 |
| 130007 | 19.8442 | 20.8338 | 21.8107 | 20.8426 |
| 130008 | 12.9177 | 12.5506 | 13.6018 | 12.9892 |
| 130009 | 18.2958 | 19.1837 | 15.9701 | 17.7296 |
| 130010 | 21.4325 | 17.6795 | 17.5119 | 18.7875 |
| 130011 | 19.0816 | 20.5031 | 20.1147 | 19.9190 |
| 130012 | 22.6153 | 22.9813 | 24.9976 | 23.5891 |
| 130013 | 19.2170 | 17.4038 | 15.1129 | 17.1523 |
| 130014 | 17.9836 | 18.9769 | 19.2107 | 18.7286 |
| 130015 | 15.2662 | 15.7233 | 18.5913 | 16.3849 |
| 130016 | 16.9987 | 17.3942 | 19.0516 | 17.7864 |
| 130017 | 16.8822 | 17.1710 | 19.6875 | 17.7220 |
| 130018 | 17.9651 | 19.7368 | 19.8425 | 19.2288 |
| 130019 | 17.2317 | 18.6648 | 19.1711 | 18.3322 |
| 130021 | 12.2562 | 12.8588 | 15.6155 | 13.6528 |
| 130022 | 19.5040 | 16.5270 | 18.9127 | 18.2241 |
| 130024 | 18.3789 | 19.3634 | 19.0703 | 18.9600 |
| 130025 | 15.2691 | 17.5213 | 16.4627 | 16.4881 |
| 130026 | 20.5535 | 21.5934 | 21.8106 | 21.3093 |
| 130027 | 20.7044 | 21.4279 | 20.5344 | 20.8883 |
| 130028 | 18.2074 | 19.1093 | 20.9674 | 19.4388 |
| 130029 | 20.3153 | 18.4263 | 18.7694 | 19.1364 |
| 130030 | 18.3981 | 17.8440 | 17.5759 | 17.9347 |
| 130031 | 17.6458 | 16.2397 | 16.7766 | 16.8967 |
| 130034 | 18.8164 | 16.9873 | 18.9483 | 18.2785 |
| 130035 | 20.4708 | 19.3478 | 20.7770 | 20.1943 |
| 130036 | 13.7942 | 13.7933 | 13.6362 | 13.7373 |
| 130037 | 17.7374 | 18.8071 | 18.6856 | 18.3986 |
| 130043 | 16.0686 | 16.5102 | 16.7904 | 16.4511 |
| 130044 | 13.1816 | 17.8160 | 13.4513 | 14.6424 |
| 130045 | 16.4655 | 16.0990 | 19.0208 | 17.0869 |
| 130048 | 15.0924 | 16.0899 | 16.7900 | 15.9311 |
| 130049 | 20.3928 | 20.3129 | 22.4440 | 21.0760 |
| 130054 | 17.7802 | 17.2729 | 17.7085 | 17.5766 |
| 130056 | 15.6551 | 14.6862 | 20.9476 | 16.5492 |
| 130058 | 17.7462 | * | * | 17.7462 |
| 130060 | 20.8508 | 21.8662 | 22.7399 | 21.8288 |
| 130061 | 16.7839 | 15.4006 | 14.7394 | 15.6929 |
| 130062 | 15.1086 | 16.5672 | 19.8157 | 17.1915 |
| 130063 | * | 15.9441 | 18.8024 | 17.8420 |
| 140001 | 15.4448 | 16.3372 | 17.7990 | 16.4814 |
| 140002 | 19.2575 | 19.0248 | 19.9284 | 19.3999 |
| 140003 | 18.0001 | 21.2886 | 17.8595 | 18.9466 |
| 140004 | 17.5200 | 15.7042 | 17.4574 | 16.8965 |
| 140005 | 10.8718 | 11.6127 | 12.3002 | 11.5858 |
| 140007 | 22.4015 | 22.9799 | 23.8585 | 23.0838 |
| 140008 | 21.2844 | 21.6548 | 22.1111 | 21.6838 |
| 140010 | 25.2227 | 31.8207 | 28.5635 | 28.3677 |
| 140011 | 17.2856 | 17.8676 | 18.6164 | 17.9499 |
| 140012 | 19.4406 | 23.0653 | 21.4374 | 21.2652 |
| 140013 | 17.3488 | 18.3060 | 19.6722 | 18.4213 |
| 140014 | 20.7563 | 22.4737 | 21.4042 | 21.5054 |
| 140015 | 15.0232 | 16.6735 | 17.6805 | 16.4314 |
| 140016 | 12.5363 | 13.1278 | 14.4938 | 13.3972 |
| 140018 | 21.4147 | 22.3070 | 22.4132 | 22.0345 |
| 140019 | 15.3435 | 16.6548 | 16.4254 | 16.1654 |
| 140024 | 14.6674 | 16.8271 | 15.3782 | 15.5912 |
| 140025 | 16.9489 | 16.9462 | 18.5135 | 17.4713 |
| 140026 | 15.9557 | 16.6612 | 18.3220 | 16.9446 |
| 140027 | 17.5023 | 18.7553 | 19.2149 | 18.5013 |
| 140029 | 21.0358 | 22.8322 | 26.0833 | 23.2140 |
| 140030 | 22.4414 | 21.9475 | 23.1760 | 22.5308 |
| 140031 | 15.9442 | 19.5731 | 17.6067 | 17.6942 |
| 140032 | 17.3363 | 18.1058 | 19.0383 | 18.1645 |
| 140033 | 22.5583 | 24.1722 | 25.1639 | 23.9291 |
| 140034 | 19.1482 | 19.5278 | 19.8792 | 19.5183 |
| 140035 | 12.9963 | 15.2649 | 15.5040 | 14.5633 |
| 140036 | 17.0419 | 18.5771 | 19.1076 | 18.2935 |
| 140037 | 12.5012 | 13.0764 | 14.1083 | 13.2105 |
| 140038 | 17.6094 | 18.3035 | 18.4948 | 18.1352 |
| 140040 | 16.2462 | 19.9267 | 16.7450 | 17.5895 |
| 140041 | 17.2829 | 17.6582 | 18.5952 | 17.8248 |
| 140042 | 15.6092 | 15.4095 | 15.8892 | 15.6354 |
| 140043 | 18.9464 | 19.4683 | 20.1176 | 19.5022 |
| 140045 | 20.6541 | 15.5807 | 17.7799 | 17.9528 |
| 140046 | 16.4621 | 18.9763 | 18.6371 | 18.0097 |
| 140047 | 16.3298 | 17.1539 | 13.3610 | 15.4382 |
| 140048 | 20.5773 | 24.0913 | 23.9545 | 22.8943 |
| 140049 | 21.5937 | 28.4958 | 26.9483 | 25.7338 |
| 140051 | 20.8455 | 23.8264 | 24.0796 | 22.8956 |
| 140052 | 19.6045 | 19.6409 | 17.9571 | 19.0338 |
| 140053 | 17.8218 | 19.1892 | 19.9620 | 18.9702 |
| 140054 | 26.1497 | 22.1921 | 23.1576 | 23.7695 |
| 140055 | 14.8031 | 16.3404 | 14.3603 | 15.1391 |
| 140058 | 17.2716 | 17.4927 | 18.6861 | 17.8100 |
| 140059 | 15.3934 | 15.0195 | * | 15.1978 |
| 140061 | 15.9612 | 17.3012 | 18.2039 | 17.1185 |
| 140062 | 27.0912 | 28.0877 | 28.5304 | 27.9131 |
| 140063 | 22.3882 | 25.3641 | 29.1453 | 25.1919 |
| 140064 | 19.2549 | 19.1023 | 18.9379 | 19.0960 |
| 140065 | 23.1610 | 24.1128 | 25.3336 | 24.1516 |
| 140066 | 16.1759 | 17.3902 | 13.6491 | 15.5770 |
| 140067 | 18.4031 | 19.3267 | 19.5292 | 19.0846 |
| 140068 | 18.8739 | 19.9691 | 21.6188 | 20.0995 |
| 140069 | 16.1453 | 16.7544 | 17.3879 | 16.7949 |
| 140070 | 19.2995 | 22.9678 | 22.7153 | 21.2244 |
| 140074 | 19.0077 | 19.3504 | 21.6052 | 19.9120 |
| 140075 | 22.5083 | 21.6313 | 21.6434 | 21.9439 |
| 140077 | 16.6447 | 17.5305 | 17.3647 | 17.1709 |
| 140079 | 21.9205 | 23.3020 | 23.6928 | 22.9153 |
| 140080 | 20.9999 | 21.0739 | 22.1968 | 21.3875 |
| 140081 | 15.5103 | 16.2247 | 16.9808 | 16.1897 |
| 140082 | 22.6227 | 23.8960 | 29.7262 | 24.9037 |
| 140083 | 18.1349 | 19.3145 | 21.0330 | 19.4951 |
| 140084 | 20.0133 | 20.9709 | 22.3467 | 21.0939 |
| 140086 | 17.3717 | 18.3803 | 19.1613 | 18.3356 |
| 140087 | 18.3639 | 16.1009 | 17.1147 | 17.1839 |
| 140088 | 24.2568 | 25.2369 | 25.4176 | 24.9650 |
| 140089 | 17.2086 | 17.6366 | 18.3157 | 17.7164 |
| 140090 | 23.5888 | 26.4325 | 26.9364 | 25.3709 |
| 140091 | 20.7039 | 20.9018 | 21.9322 | 21.1441 |
| 140093 | 19.1469 | 18.2899 | 20.1528 | 19.1437 |
| 140094 | 20.6129 | 21.4709 | 21.9383 | 21.3227 |
| 140095 | 21.5376 | 24.0549 | 24.2859 | 23.1400 |
| 140097 | 16.8997 | 17.5081 | 21.1719 | 18.4160 |
| 140100 | 19.0588 | 21.3581 | 23.1399 | 21.1571 |
| 140101 | 26.0894 | 21.5473 | 21.4211 | 22.7744 |
| 140102 | 15.0777 | 17.1500 | 17.5729 | 16.5644 |
| 140103 | 17.8586 | 19.2783 | 18.1303 | 18.4145 |
| 140105 | 20.9068 | 22.6573 | 22.8944 | 22.1275 |
| 140107 | 12.7573 | 13.7533 | 11.8383 | 12.6800 |
| 140108 | 28.6028 | 25.4742 | 26.9971 | 26.9964 |
| 140109 | 15.4724 | 15.7465 | 14.5498 | 15.2467 |
| 140110 | 18.8112 | 19.1822 | 19.2888 | 19.0728 |
| 140112 | 16.2399 | 17.6856 | 17.6974 | 17.1885 |
| 140113 | 17.9151 | 19.0592 | 19.5584 | 18.8265 |
| 140114 | 20.4808 | 21.1639 | 21.0976 | 20.9149 |
| 140115 | 20.0939 | 21.1926 | 21.0433 | 20.7564 |
| 140116 | 21.8290 | 23.1177 | 23.8993 | 22.9520 |
| 140117 | 19.6445 | 21.5671 | 21.4876 | 20.8750 |
| 140118 | 23.0797 | 23.5952 | 24.3260 | 23.6559 |
| 140119 | 26.5042 | 29.1419 | 27.9145 | 27.8197 |
| 140120 | 14.8375 | 18.0743 | 17.9716 | 16.8874 |
| 140121 | 9.5268 | 16.0397 | 16.6993 | 13.2257 |
| 140122 | 23.7473 | 24.6470 | 26.1270 | 24.8110 |
| 140124 | 26.9706 | 27.1906 | 27.9813 | 27.3549 |
| 140125 | 17.0974 | 17.6759 | 16.9516 | 17.2453 |
| 140127 | 19.4259 | 19.8973 | 20.0489 | 19.7765 |
| 140128 | 17.6751 | 19.4955 | 23.1327 | 20.0664 |
| 140129 | 15.2494 | 18.2639 | 20.2868 | 17.8627 |
| 140130 | 23.7682 | 22.2285 | 23.4298 | 23.1296 |
| 140132 | 23.0443 | 23.5475 | 23.3054 | 23.2992 |
| 140133 | 19.9083 | 21.4090 | 21.4166 | 20.8761 |
| 140135 | 17.6927 | 17.8100 | 17.3985 | 17.6268 |
| 140137 | 16.5141 | 16.8969 | 18.6330 | 17.3470 |
| 140138 | 14.5877 | 16.7420 | 17.1968 | 16.2121 |
| 140139 | 16.5794 | 14.0619 | 11.0397 | 13.5138 |
| 140140 | 15.2985 | 17.8243 | 17.6845 | 16.9747 |
| 140141 | 15.1782 | 17.5204 | 19.1097 | 17.2133 |
| 140143 | 18.7616 | 19.1862 | 19.0810 | 19.0186 |
| 140144 | 19.7913 | 21.3245 | 22.2864 | 21.1022 |
| 140145 | 16.6111 | 17.5471 | 18.1788 | 17.4556 |
| 140146 | 23.7400 | 21.9573 | 19.9704 | 21.7285 |
| 140147 | 24.8191 | 16.1336 | 18.8049 | 19.2135 |
| 140148 | 19.5026 | 18.6598 | 18.7730 | 18.9637 |
| 140150 | 27.8485 | 27.3378 | 24.7976 | 26.6536 |
| 140151 | 19.3016 | 21.3896 | 20.0310 | 20.2086 |
| 140152 | 22.4270 | 24.6333 | 25.6011 | 24.1041 |
| 140155 | 17.3131 | 19.9738 | 20.2778 | 19.1103 |
| 140158 | 22.2666 | 22.7639 | 22.7988 | 22.5990 |
| 140160 | 17.8822 | 17.7691 | 17.7921 | 17.8132 |
| 140161 | 19.0448 | 20.0948 | 20.3799 | 19.8258 |
| 140162 | 18.4167 | 19.6464 | 20.3452 | 19.4479 |
| 140164 | 18.6120 | 18.7806 | 18.6589 | 18.6860 |
| 140165 | 15.4186 | 14.9156 | 14.7223 | 15.0080 |
| 140166 | 17.5434 | 17.5496 | 18.3833 | 17.8149 |
| 140167 | 16.5671 | 17.1479 | 17.6525 | 17.1325 |
| 140168 | 16.4638 | 16.6770 | 17.7453 | 16.9752 |
| 140170 | 14.1360 | 16.1621 | 16.4107 | 15.5211 |
| 140171 | 14.7316 | 14.1637 | 15.0237 | 14.6354 |
| 140172 | 20.7982 | 23.8431 | 23.6262 | 22.5610 |
| 140173 | 18.4788 | 15.1487 | 16.3924 | 16.7054 |
| 140174 | 19.9216 | 20.5339 | 35.9320 | 23.2157 |
| 140176 | 21.4129 | 23.2866 | 24.5338 | 23.0397 |
| 140177 | 18.1692 | 18.2648 | 15.0827 | 17.1204 |
| 140179 | 22.6989 | 21.1948 | 21.9859 | 21.9622 |
| 140180 | 23.2536 | 22.4548 | 22.7996 | 22.8262 |
| 140181 | 20.5461 | 20.8709 | 21.9864 | 21.1001 |
| 140182 | 20.7013 | 22.0170 | 28.9515 | 23.2649 |
| 140184 | 14.9763 | 17.8155 | 17.2401 | 16.6194 |
| 140185 | 17.3616 | 17.6514 | 18.2867 | 17.7696 |
| 140186 | 18.9878 | 22.7890 | 23.5034 | 21.7241 |
| 140187 | 17.6910 | 17.9201 | 18.3331 | 17.9863 |
| 140188 | 14.8373 | 15.2479 | 16.1907 | 15.4001 |
| 140189 | 19.0791 | 21.0616 | 20.6627 | 20.2758 |
| 140190 | 15.8770 | 16.3366 | 17.5263 | 16.5534 |
| 140191 | 24.7368 | 25.8835 | 25.2628 | 25.2833 |
| 140193 | 15.5196 | 15.8022 | 17.4057 | 16.2409 |
| 140197 | 17.9828 | 18.6394 | 19.3774 | 18.6752 |
| 140199 | 18.8333 | 18.3507 | 18.0450 | 18.4044 |
| 140200 | 21.6508 | 21.5220 | 21.7680 | 21.6496 |
| 140202 | 22.1800 | 22.1939 | 23.7955 | 22.7597 |
| 140203 | 20.7854 | 19.9194 | 21.0848 | 20.5915 |
| 140205 | 17.2369 | 17.4751 | 20.0784 | 18.0505 |
| 140206 | 20.5096 | 21.3295 | 22.5109 | 21.4570 |
| 140207 | 20.2048 | 21.9779 | 22.3905 | 21.3996 |
| 140208 | 23.9441 | 25.9900 | 26.2527 | 25.3856 |
| 140209 | 17.7889 | 18.1206 | 20.1557 | 18.6405 |
| 140210 | 12.6648 | 15.6899 | 14.8248 | 14.4319 |
| 140211 | 20.9615 | 21.8891 | 22.6265 | 21.8594 |
| 140213 | 26.2041 | 27.0645 | 24.9892 | 26.0871 |
| 140215 | 14.4544 | 15.9949 | 15.2893 | 15.2456 |
| 140217 | 23.3192 | 24.8229 | 25.7329 | 24.5914 |
| 140218 | 15.0750 | 14.9459 | 14.9851 | 15.0038 |
| 140220 | 16.7341 | 17.6370 | 17.8450 | 17.4280 |
| 140223 | 21.4725 | 24.9249 | 24.9017 | 23.6377 |
| 140224 | 22.9945 | 25.8668 | 32.8292 | 26.7133 |
| 140228 | 18.6731 | 19.6988 | 20.1688 | 19.5400 |
| 140230 | 16.5979 | 18.0918 | 18.2983 | 17.6740 |
| 140231 | 21.6062 | 23.9176 | 24.5019 | 23.4404 |
| 140233 | 18.3703 | 19.4542 | 21.2333 | 19.6539 |
| 140234 | 18.7156 | 18.9945 | * | 18.8552 |
| 140236 | 13.1341 | * | 12.9253 | 13.0112 |
| 140239 | 18.8785 | 18.8127 | 20.3745 | 19.3689 |
| 140240 | 24.2141 | 23.6860 | 24.6949 | 24.1989 |
| 140242 | 22.6679 | 24.5428 | 25.2317 | 24.1792 |
| 140245 | 15.5554 | 13.4839 | 14.2481 | 14.3597 |
| 140246 | 12.8238 | 13.4639 | 11.6267 | 12.5798 |
| 140250 | 23.4127 | 25.0876 | 23.6449 | 24.0578 |
| 140251 | 20.5813 | 21.4385 | 21.9435 | 21.3153 |
| 140252 | 24.4856 | 25.2246 | 25.0220 | 24.9139 |
| 140253 | 16.7356 | 18.5511 | 19.5858 | 18.2440 |
| 140258 | 21.1321 | 23.2973 | 25.3622 | 23.2691 |
| 140271 | 15.3606 | 15.5079 | 12.0079 | 14.1590 |
| 140275 | 17.9597 | 20.1699 | 23.8171 | 20.5857 |
| 140276 | 23.7163 | 26.6777 | 25.3134 | 25.2323 |
| 140280 | 18.8420 | 20.2360 | 18.8300 | 19.2649 |
| 140281 | 23.3433 | 24.0192 | 25.2719 | 24.2302 |
| 140285 | 14.7087 | 18.1181 | 18.5916 | 17.2227 |
| 140286 | 19.9500 | 20.3735 | 26.1290 | 22.0885 |
| 140288 | 21.8213 | 25.2327 | 24.4331 | 23.7989 |
| 140289 | 16.4542 | 17.1388 | 18.1747 | 17.3055 |
| 140290 | 21.2384 | 21.1784 | 22.8590 | 21.7763 |
| 140291 | 22.4352 | 25.0911 | 24.9537 | 24.1790 |
| 140292 | 22.7136 | 20.8560 | 21.9950 | 21.8371 |
| 140294 | 17.5226 | 17.7226 | 17.7301 | 17.6645 |
| 140297 | 21.4692 | * | * | 21.4692 |
| 140300 | 23.2560 | 25.3662 | 27.8436 | 25.5898 |
| 150001 | 21.6990 | 22.8109 | 24.0620 | 22.8643 |
| 150002 | 18.7568 | 19.3401 | 20.7651 | 19.6416 |
| 150003 | 19.3117 | 19.7661 | 20.8636 | 19.9824 |
| 150004 | 19.7020 | 20.3685 | 21.2449 | 20.4349 |
| 150005 | 18.9964 | 20.6260 | 21.6806 | 20.4380 |
| 150006 | 20.0433 | 20.8158 | 20.6523 | 20.5130 |
| 150007 | 19.5255 | 20.1826 | 20.6635 | 20.1487 |
| 150008 | 20.9684 | 21.4545 | 21.8457 | 21.4285 |
| 150009 | 18.2168 | 18.7073 | 19.0030 | 18.6289 |
| 150010 | 18.4776 | 21.7125 | 20.5570 | 20.1836 |
| 150011 | 19.1957 | 18.3742 | 18.3275 | 18.6280 |
| 150012 | 20.5193 | 22.4751 | 22.1402 | 21.6785 |
| 150013 | 16.0043 | 17.0352 | 16.9327 | 16.6522 |
| 150014 | 21.2812 | 22.0143 | 21.5168 | 21.6212 |
| 150015 | 22.0452 | 22.5409 | 21.9037 | 22.1546 |
| 150017 | 18.8898 | 18.7664 | 19.5339 | 19.0694 |
| 150018 | 19.5612 | 20.4947 | 21.0496 | 20.3869 |
| 150019 | 15.2892 | 16.6327 | 17.8585 | 16.5672 |
| 150020 | 14.4592 | 15.1120 | 16.6600 | 15.3745 |
| 150021 | 19.0162 | 19.5096 | 21.5944 | 20.0447 |
| 150022 | 17.9206 | 19.1555 | 17.9222 | 18.3309 |
| 150023 | 18.6641 | 18.3598 | 19.3412 | 18.8110 |
| 150024 | 17.8311 | 18.4140 | 19.2295 | 18.4561 |
| 150025 | 18.1490 | 17.7007 | 20.2750 | 18.6347 |
| 150026 | 20.5085 | 18.8417 | 22.4978 | 20.5355 |
| 150027 | 16.4846 | 17.3284 | 18.0335 | 17.2600 |
| 150029 | 21.7414 | 23.0546 | 23.2454 | 22.7440 |
| 150030 | 17.3296 | 17.9992 | 19.2406 | 18.1943 |
| 150031 | 18.0060 | 17.2429 | 18.3463 | 17.8675 |
| 150032 | 20.6391 | * | * | 20.6391 |
| 150033 | 21.6854 | 21.8768 | 22.6741 | 22.0835 |
| 150034 | 21.2868 | 22.1317 | 23.1533 | 22.1845 |
| 150035 | 19.8177 | 20.4477 | 21.2374 | 20.5107 |
| 150036 | 20.3848 | 20.8692 | 21.4567 | 20.9448 |
| 150037 | 17.7868 | 21.7109 | 24.4611 | 21.1306 |
| 150038 | 20.2503 | 21.2193 | 22.0572 | 21.2025 |
| 150039 | 17.4919 | 18.4729 | 19.6215 | 18.5025 |
| 150042 | 17.1241 | 18.1632 | 20.2221 | 18.3947 |
| 150043 | 17.9834 | 19.0120 | 20.1741 | 18.9948 |
| 150044 | 17.6432 | 18.4381 | 19.1309 | 18.4093 |
| 150045 | 17.0395 | 16.8121 | 18.1670 | 17.3563 |
| 150046 | 17.3210 | 17.6342 | 18.2543 | 17.7460 |
| 150047 | 24.8819 | 19.7441 | 22.0145 | 22.1013 |
| 150048 | 16.9573 | 19.3329 | 19.1648 | 18.5048 |
| 150049 | 16.8529 | 17.0141 | 18.6451 | 17.4705 |
| 150050 | 17.1442 | 16.8354 | 17.7354 | 17.2410 |
| 150051 | 18.1990 | 19.0130 | 19.7257 | 18.9710 |
| 150052 | 15.3618 | 15.8590 | 17.3750 | 16.2411 |
| 150053 | 18.7463 | 19.1421 | 18.8632 | 18.9165 |
| 150054 | 17.3296 | 17.3825 | 18.3916 | 17.7528 |
| 150056 | 23.2991 | 22.4087 | 21.5774 | 22.2457 |
| 150057 | 16.8630 | 16.5882 | 16.9736 | 16.8076 |
| 150058 | 20.9537 | 20.8178 | 22.1409 | 21.3058 |
| 150059 | 20.8004 | 21.2535 | 22.7360 | 21.5830 |
| 150060 | 16.0098 | 17.0743 | 18.6159 | 17.2538 |
| 150061 | 17.2141 | 17.3887 | 19.7968 | 18.0770 |
| 150062 | 18.4110 | 20.5415 | 20.8274 | 20.0239 |
| 150063 | 21.0899 | 22.0925 | 22.6525 | 21.9213 |
| 150064 | 17.0309 | 18.1400 | 20.3865 | 18.5718 |
| 150065 | 19.0051 | 19.8913 | 21.2153 | 20.0425 |
| 150066 | 14.5977 | 15.3373 | 19.5313 | 16.4634 |
| 150067 | 17.0829 | 18.2926 | 18.8862 | 18.0821 |
| 150069 | 17.3918 | 21.5310 | 23.3969 | 20.9447 |
| 150070 | 17.1992 | 17.9260 | 18.0827 | 17.7417 |
| 150071 | 14.7306 | 13.4760 | 13.5111 | 13.9122 |
| 150072 | 16.1091 | 16.2054 | 15.0765 | 15.7702 |
| 150073 | 19.0292 | 22.2968 | * | 20.5664 |
| 150074 | 18.8597 | 20.4175 | 20.2305 | 19.8210 |
| 150075 | 14.9786 | 15.5603 | 16.7532 | 15.7414 |
| 150076 | 22.3407 | 22.9382 | 22.6424 | 22.6387 |
| 150077 | 17.5750 | * | * | 17.5750 |
| 150078 | 19.0096 | 19.2718 | 19.9668 | 19.4018 |
| 150079 | 15.4545 | 17.2436 | 18.2051 | 16.9085 |
| 150082 | 17.8796 | 17.5265 | 17.8381 | 17.7489 |
| 150084 | 22.9159 | 23.2506 | 24.3107 | 23.4933 |
| 150086 | 17.3442 | 18.9735 | 18.3838 | 18.2534 |
| 150088 | 19.4475 | 18.9869 | 20.3366 | 19.5726 |
| 150089 | 22.9458 | 23.8791 | 22.1725 | 22.9671 |
| 150090 | 19.0595 | 20.7726 | 21.0945 | 20.2459 |
| 150091 | 19.8912 | 20.4053 | 22.4640 | 20.9087 |
| 150092 | 15.9174 | 16.7434 | 16.9179 | 16.5364 |
| 150094 | 18.3410 | 16.5788 | 17.5244 | 17.5067 |
| 150095 | 17.1187 | 17.1324 | 19.2749 | 17.7838 |
| 150096 | 20.0281 | 23.2764 | 20.8204 | 21.3056 |
| 150097 | 18.3103 | 19.3802 | 19.7751 | 19.1545 |
| 150098 | 14.2953 | 15.0943 | 15.2829 | 14.8856 |
| 150099 | 18.9718 | 22.4229 | * | 20.3545 |
| 150100 | 17.4776 | 18.4148 | 19.8066 | 18.6620 |
| 150101 | 17.5554 | 16.4604 | 20.6209 | 18.1130 |
| 150102 | 11.5034 | 19.7426 | 23.7180 | 17.1422 |
| 150103 | 17.3064 | 18.4781 | 18.7036 | 18.2137 |
| 150104 | 17.2642 | 17.6981 | 20.0765 | 18.3399 |
| 150105 | 19.1709 | 20.0431 | 22.4412 | 20.4692 |
| 150106 | 18.9097 | 16.1510 | 16.8714 | 17.2294 |
| 150109 | 18.2289 | 18.8077 | 19.9066 | 18.9623 |
| 150110 | 18.5752 | 18.6627 | 21.9336 | 19.5289 |
| 150111 | 16.1707 | 18.4556 | 19.2355 | 17.8619 |
| 150112 | 19.8155 | 20.4109 | 20.5253 | 20.2569 |
| 150113 | 19.1988 | 20.3780 | 19.6603 | 19.7455 |
| 150114 | 16.9638 | 19.5183 | 17.9877 | 18.1743 |
| 150115 | 17.0627 | 17.4315 | 18.4844 | 17.6591 |
| 150122 | 19.3545 | 18.7139 | 17.7867 | 18.6097 |
| 150123 | 15.1552 | 14.1105 | 14.0508 | 14.4522 |
| 150124 | 15.0706 | 14.6245 | 15.9487 | 15.2180 |
| 150125 | 20.3198 | 20.6735 | 21.3311 | 20.7806 |
| 150126 | 20.2958 | 21.3697 | 20.6857 | 20.7640 |
| 150127 | 22.8129 | 17.1994 | 17.0052 | 18.8048 |
| 150128 | 19.9205 | 18.5100 | 19.5576 | 19.3346 |
| 150129 | 23.4718 | 24.7711 | 28.6211 | 25.2796 |
| 150130 | 16.4144 | 18.1971 | 18.4846 | 17.6635 |
| 150132 | 19.4805 | 20.1684 | 20.9443 | 20.1836 |
| 150133 | 16.4910 | 17.3966 | 18.4250 | 17.4061 |
| 150134 | 17.0612 | 19.2526 | 19.3632 | 18.5912 |
| 150136 | 19.2819 | 20.1245 | 21.8097 | 20.3987 |
| 150145 | * | 16.6851 | * | 16.6851 |
| 150146 | * | * | 19.0204 | 19.0204 |
| 160001 | 19.0279 | 18.6035 | 19.0085 | 18.8767 |
| 160002 | 15.3724 | 15.9534 | 16.6003 | 15.9668 |
| 160003 | 15.7747 | 16.0862 | 16.2208 | 16.0221 |
| 160005 | 15.2320 | 17.6153 | 17.9405 | 16.9144 |
| 160007 | 15.6638 | 13.2101 | 15.1738 | 14.6237 |
| 160008 | 14.9698 | 15.9742 | 16.6193 | 15.8477 |
| 160009 | 16.0919 | 16.8391 | 17.9886 | 16.9591 |
| 160012 | 16.5409 | 16.4827 | 16.7112 | 16.5761 |
| 160013 | 17.0602 | 18.3996 | 18.6304 | 18.0298 |
| 160014 | 15.0861 | 15.9086 | 16.7146 | 15.8981 |
| 160016 | 18.3710 | 19.6322 | 19.9747 | 19.3376 |
| 160018 | 14.1634 | 14.5946 | 15.6141 | 14.7975 |
| 160020 | 14.4135 | 15.4712 | 15.5384 | 15.1417 |
| 160021 | 15.4860 | 16.5049 | 16.7617 | 16.2368 |
| 160023 | 14.2015 | 15.0665 | 15.0099 | 14.7723 |
| 160024 | 18.9548 | 19.7050 | 19.4764 | 19.3806 |
| 160026 | 18.6624 | 18.8379 | 19.5260 | 19.0040 |
| 160027 | 15.7403 | 16.3477 | 16.9417 | 16.3376 |
| 160028 | 20.5416 | 19.9595 | 21.0000 | 20.4893 |
| 160029 | 20.4003 | 20.4678 | 21.3457 | 20.7382 |
| 160030 | 17.9860 | 19.9508 | 19.6182 | 19.1837 |
| 160031 | 15.2831 | 15.2448 | 16.1267 | 15.5484 |
| 160032 | 16.1820 | 17.3202 | 18.3168 | 17.2888 |
| 160033 | 18.3736 | 18.8673 | 18.8859 | 18.7219 |
| 160034 | 14.5053 | 15.0019 | 16.5957 | 15.3739 |
| 160035 | 15.9199 | 15.2211 | 16.3991 | 15.8029 |
| 160036 | 19.1984 | 17.8849 | 17.4558 | 18.1820 |
| 160037 | 18.3968 | 19.0532 | 19.5045 | 18.9883 |
| 160039 | 17.6272 | 17.4758 | 17.8647 | 17.6551 |
| 160040 | 16.8295 | 18.1949 | 18.0667 | 17.6917 |
| 160041 | 15.4700 | 16.7850 | 17.4435 | 16.5782 |
| 160043 | 15.6261 | 15.6909 | 14.8564 | 15.3356 |
| 160044 | 16.0385 | 16.7439 | 17.8323 | 16.9072 |
| 160045 | 20.1154 | 20.1236 | 20.0611 | 20.1010 |
| 160046 | 14.7672 | 14.5655 | 16.2737 | 15.1831 |
| 160047 | 16.6926 | 18.3593 | 19.0787 | 18.0537 |
| 160048 | 13.1417 | 14.6144 | 15.6856 | 14.5140 |
| 160049 | 13.3614 | 14.5457 | 15.5673 | 14.5017 |
| 160050 | 16.4161 | 17.4912 | 17.7878 | 17.2198 |
| 160051 | 14.2660 | 14.6400 | 16.4261 | 15.1036 |
| 160052 | 17.5509 | 18.0941 | 21.7647 | 19.2313 |
| 160054 | 15.7093 | 16.1753 | 16.1981 | 16.0321 |
| 160055 | 14.0647 | 14.7600 | 15.1674 | 14.6539 |
| 160056 | 15.3758 | 16.1575 | 17.0172 | 16.1537 |
| 160057 | 17.4101 | 18.1776 | 19.1378 | 18.2553 |
| 160058 | 20.3402 | 21.1159 | 22.1061 | 21.1598 |
| 160060 | 15.9527 | 16.0436 | 17.2825 | 16.3968 |
| 160061 | 17.5707 | 17.3215 | 17.0938 | 17.3350 |
| 160062 | 14.4433 | 17.8086 | 17.4388 | 16.4393 |
| 160063 | 16.2960 | 16.8834 | 16.3583 | 16.5061 |
| 160064 | 19.9135 | 20.5496 | 22.2131 | 20.9171 |
| 160065 | 16.5087 | 16.9373 | 17.1043 | 16.8758 |
| 160066 | 16.2651 | 17.1875 | 17.9971 | 17.1716 |
| 160067 | 17.8551 | 17.8514 | 16.7833 | 17.4322 |
| 160068 | 15.8526 | 17.9892 | 19.0572 | 17.5565 |
| 160069 | 18.4857 | 19.7280 | 19.1640 | 19.1095 |
| 160070 | 15.6647 | 16.7017 | 18.4588 | 16.9299 |
| 160072 | 14.1920 | 14.9536 | 14.4141 | 14.5422 |
| 160073 | 15.0526 | 11.8261 | 11.4997 | 12.6736 |
| 160074 | 16.4772 | 19.5092 | 17.9513 | 18.0038 |
| 160075 | 17.8870 | 19.4948 | 18.4613 | 18.6342 |
| 160076 | 17.3086 | 17.9381 | 17.8824 | 17.7060 |
| 160077 | 11.4028 | 12.8826 | 13.6658 | 12.6451 |
| 160079 | 17.7050 | 17.6187 | 18.6333 | 17.9899 |
| 160080 | 17.8143 | 18.6687 | 19.4925 | 18.6704 |
| 160081 | 16.5150 | 17.0052 | 17.4466 | 17.0164 |
| 160082 | 18.7630 | 19.6499 | 19.5322 | 19.3143 |
| 160083 | 18.4078 | 20.6189 | 19.7542 | 19.5937 |
| 160085 | 18.5510 | 18.0063 | 21.2557 | 19.2281 |
| 160086 | 16.4558 | 17.3271 | 17.5308 | 17.0998 |
| 160088 | 17.5331 | 20.2331 | 22.3655 | 19.9346 |
| 160089 | 16.7419 | 16.9538 | 17.3449 | 17.0079 |
| 160090 | 16.6002 | 17.1090 | 17.9614 | 17.2461 |
| 160091 | 12.1893 | 12.8516 | 14.2573 | 13.0755 |
| 160092 | 15.7979 | 15.5011 | 17.0633 | 16.0971 |
| 160093 | 15.9525 | 17.7457 | 18.5675 | 17.5141 |
| 160094 | 16.5609 | 18.7653 | 17.6094 | 17.6731 |
| 160095 | 14.2649 | 15.1895 | 15.2722 | 14.9322 |
| 160097 | 15.2079 | 15.9263 | 16.6790 | 15.9380 |
| 160098 | 15.5385 | 16.3135 | 16.8670 | 16.2509 |
| 160099 | 13.7864 | 13.9053 | 15.0880 | 14.2533 |
| 160101 | 17.8654 | 18.3705 | 18.9788 | 18.3824 |
| 160102 | 18.3631 | 18.8765 | 20.1161 | 19.0875 |
| 160103 | 17.1519 | 17.0973 | 18.2741 | 17.4869 |
| 160104 | 19.7387 | 18.8301 | 17.4829 | 18.7797 |
| 160106 | 16.6624 | 16.9639 | 17.3474 | 16.9910 |
| 160107 | 16.5622 | 18.0634 | 18.0097 | 17.5762 |
| 160108 | 15.4183 | 16.0529 | 16.7779 | 16.0861 |
| 160109 | 16.4885 | 16.5593 | 17.9873 | 16.9740 |
| 160110 | 18.8056 | 19.1420 | 20.6215 | 19.5351 |
| 160111 | 13.1689 | 14.1644 | 14.9965 | 14.0808 |
| 160112 | 16.2829 | 16.8332 | 17.2450 | 16.7911 |
| 160113 | 14.5838 | 14.7097 | 15.4834 | 14.9308 |
| 160114 | 15.5812 | 16.1423 | 16.5006 | 16.0651 |
| 160115 | 15.7566 | 15.8995 | 16.5654 | 16.0764 |
| 160116 | 16.6927 | 16.9534 | 16.6993 | 16.7818 |
| 160117 | 17.2914 | 17.9410 | 18.7615 | 17.9848 |
| 160118 | 15.8351 | 17.2523 | 19.4472 | 17.5046 |
| 160120 | 12.5642 | 10.5992 | 15.6789 | 12.4454 |
| 160122 | 18.5214 | 18.9252 | 18.1469 | 18.5357 |
| 160124 | 17.1642 | 18.0908 | 19.1600 | 18.1198 |
| 160126 | 17.7397 | 17.8142 | 19.4903 | 18.3068 |
| 160129 | 15.8914 | 16.7131 | 17.2112 | 16.5953 |
| 160130 | 15.4477 | 16.0528 | 15.6666 | 15.7242 |
| 160131 | 14.6874 | 15.4898 | 16.0424 | 15.4292 |
| 160134 | 13.3246 | 13.4743 | 15.3012 | 14.0359 |
| 160135 | 16.3294 | 18.2682 | 18.7711 | 17.7744 |
| 160138 | 15.7076 | 16.8699 | 17.1491 | 16.5906 |
| 160140 | 18.7962 | 18.4007 | 18.5630 | 18.5823 |
| 160142 | 16.1372 | 16.2875 | 18.1467 | 16.8318 |
| 160143 | 15.9240 | 16.6154 | 17.4497 | 16.6799 |
| 160145 | 15.1745 | 13.9152 | 16.9092 | 15.2763 |
| 160146 | 16.3532 | 16.6024 | 17.7010 | 16.8728 |
| 160147 | 18.3917 | 17.4880 | 19.4041 | 18.3938 |
| 160151 | 15.7384 | 16.8257 | 17.2177 | 16.5833 |
| 160152 | 15.2179 | 15.6170 | 15.9500 | 15.5914 |
| 160153 | 19.6927 | 20.2316 | 21.2085 | 20.3741 |
| 170001 | 17.4383 | 17.9304 | 17.9218 | 17.7616 |
| 170004 | 13.0635 | 15.0636 | 16.1442 | 14.7434 |
| 170006 | 19.3075 | 17.2192 | 17.5982 | 17.9438 |
| 170008 | 13.9009 | 14.9124 | 16.8412 | 15.1327 |
| 170009 | 19.5867 | 20.7795 | 23.1349 | 21.2143 |
| 170010 | 17.8995 | 18.7384 | 19.4584 | 18.6890 |
| 170012 | 16.7886 | 17.8719 | 18.4432 | 17.7137 |
| 170013 | 17.8949 | 18.6454 | 19.4667 | 18.6963 |
| 170014 | 17.3379 | 17.9349 | 18.4931 | 17.9333 |
| 170015 | 15.8887 | 16.5750 | 17.1302 | 16.5216 |
| 170016 | 19.6393 | 19.2130 | 20.0675 | 19.6307 |
| 170017 | 17.8690 | 17.7958 | 19.5994 | 18.4143 |
| 170018 | 14.2759 | 15.2984 | 15.3237 | 14.9817 |
| 170019 | 16.6611 | 15.2094 | 16.9362 | 16.2597 |
| 170020 | 16.1460 | 17.3400 | 18.1325 | 17.2351 |
| 170022 | 17.9383 | 18.5309 | 19.1888 | 18.5543 |
| 170023 | 19.3585 | 19.1351 | 19.2441 | 19.2444 |
| 170024 | 13.0566 | 13.6803 | 14.3604 | 13.6835 |
| 170025 | 16.3716 | 17.8667 | 18.7182 | 17.6087 |
| 170026 | 13.3122 | 15.0470 | 14.8974 | 14.3412 |
| 170027 | 16.3859 | 17.3604 | 17.8690 | 17.2095 |
| 170030 | 15.2397 | 14.6530 | 15.9282 | 15.2488 |
| 170031 | 13.4670 | 13.9601 | 14.2151 | 13.8715 |
| 170032 | 14.4835 | 15.6093 | 16.3449 | 15.4817 |
| 170033 | 16.0529 | 16.4059 | 19.1952 | 17.1087 |
| 170034 | 14.6349 | 15.8202 | 16.9586 | 15.7633 |
| 170035 | 15.6240 | 18.5885 | 17.0945 | 17.0832 |
| 170036 | 14.1732 | * | * | 14.1732 |
| 170038 | 14.2092 | 14.7776 | 13.8582 | 14.2922 |
| 170039 | 14.2952 | 15.8635 | 17.0774 | 15.7642 |
| 170040 | 20.1419 | 21.6440 | 21.0617 | 20.9374 |
| 170041 | 11.4691 | 11.7566 | 12.4488 | 11.8690 |
| 170044 | 14.7801 | 15.3011 | 17.3254 | 15.8168 |
| 170045 | 12.1066 | 14.0875 | 25.8331 | 16.7874 |
| 170049 | 18.5821 | 19.9415 | 20.7921 | 19.8083 |
| 170051 | 14.1572 | 15.0889 | 16.4851 | 15.2703 |
| 170052 | 14.6176 | 15.0108 | 15.2283 | 14.9500 |
| 170053 | 9.0407 | 16.5102 | 14.6133 | 11.9759 |
| 170054 | 12.7655 | 14.4353 | 14.6354 | 13.9214 |
| 170055 | 14.9875 | 16.9800 | 18.2607 | 16.7698 |
| 170056 | 14.8656 | 17.0442 | 18.3550 | 16.8283 |
| 170057 | 15.0892 | 13.0007 | * | 13.9776 |
| 170058 | 18.3389 | 18.6983 | 19.5415 | 18.8159 |
| 170060 | 17.2271 | 17.3482 | 18.9853 | 17.7512 |
| 170061 | 14.1380 | 15.6527 | 15.0258 | 14.9459 |
| 170063 | 11.3284 | 12.8082 | 14.1185 | 12.6216 |
| 170064 | 12.4183 | * | * | 12.4183 |
| 170066 | 14.4790 | 15.5322 | 16.2891 | 15.4168 |
| 170067 | 12.7846 | 14.7492 | 14.9921 | 14.1535 |
| 170068 | 15.8175 | 15.1790 | 17.0022 | 15.9795 |
| 170070 | 12.8158 | 14.2445 | 14.0627 | 13.7083 |
| 170072 | 13.3379 | 12.6329 | 12.7709 | 12.9159 |
| 170073 | 16.4690 | 17.5368 | 17.7056 | 17.2186 |
| 170074 | 14.4009 | 17.5537 | 17.3699 | 16.4326 |
| 170075 | 11.2598 | 12.4212 | 13.6816 | 12.5950 |
| 170076 | 13.5820 | 14.5866 | 14.6109 | 14.2394 |
| 170077 | 12.7244 | 13.5235 | 13.9104 | 13.3651 |
| 170079 | 14.2859 | 13.5261 | 11.5902 | 13.1470 |
| 170080 | 12.2012 | 12.6014 | 14.8293 | 13.1562 |
| 170081 | 12.5122 | 13.8077 | 14.6823 | 13.7421 |
| 170082 | 12.3902 | 12.8563 | 13.7462 | 12.9854 |
| 170084 | 12.1611 | 12.5410 | 13.0519 | 12.5742 |
| 170085 | 14.5069 | 15.4518 | 17.5422 | 15.9150 |
| 170086 | 19.8496 | 20.4068 | 19.7182 | 19.9991 |
| 170088 | 11.7505 | 13.4542 | 13.4860 | 12.9031 |
| 170089 | 18.0823 | 18.8136 | 15.4860 | 17.4574 |
| 170090 | 11.2747 | 11.9147 | 10.9444 | 11.3947 |
| 170092 | 12.8507 | * | * | 12.8507 |
| 170093 | 12.7780 | 13.5490 | 14.0276 | 13.4193 |
| 170094 | 17.7091 | 20.1985 | 21.2035 | 19.6936 |
| 170095 | 15.7469 | 15.5463 | 15.3532 | 15.5482 |
| 170097 | 15.8504 | 16.4608 | 17.7540 | 16.7203 |
| 170098 | 14.1026 | 15.5259 | 16.6210 | 15.4425 |
| 170099 | 13.5509 | 13.6033 | 14.3370 | 13.8072 |
| 170100 | 14.4700 | * | * | 14.4700 |
| 170101 | 12.8847 | 14.5629 | 18.0143 | 14.7718 |
| 170102 | 13.2434 | 13.6321 | 14.2447 | 13.7065 |
| 170103 | 16.6578 | 17.2844 | 17.9530 | 17.2887 |
| 170104 | 19.7645 | 20.6182 | 21.0049 | 20.4661 |
| 170105 | 15.9290 | 16.5408 | 16.7403 | 16.4083 |
| 170106 | 14.6773 | 18.5479 | 17.7467 | 16.9030 |
| 170109 | 16.9421 | 17.2629 | 16.9782 | 17.0622 |
| 170110 | 15.5549 | 16.9823 | 18.5731 | 17.1658 |
| 170112 | 13.3908 | 14.3855 | 15.4049 | 14.4270 |
| 170113 | 13.3935 | 13.9038 | 14.6486 | 13.9920 |
| 170114 | 14.5116 | 14.4545 | 16.2645 | 15.0138 |
| 170115 | 12.6815 | 12.6997 | 12.9216 | 12.7709 |
| 170116 | 15.7566 | 16.8714 | 18.1830 | 16.9494 |
| 170117 | 15.2818 | 15.7875 | 16.8237 | 15.8968 |
| 170119 | 13.9673 | 15.1990 | 15.2708 | 14.7822 |
| 170120 | 16.2122 | 17.6748 | 17.4917 | 17.1241 |
| 170122 | 20.1266 | 20.0615 | 21.1769 | 20.4366 |
| 170123 | 21.4168 | 23.1697 | 23.6534 | 22.7009 |
| 170124 | 10.2089 | 11.1249 | 15.0596 | 11.8247 |
| 170126 | 12.1268 | 12.8096 | 13.5736 | 12.8129 |
| 170128 | 14.9919 | 14.8891 | 14.1676 | 14.6301 |
| 170131 | 13.0978 | 10.1000 | * | 11.3849 |
| 170133 | 17.1103 | 18.0243 | 18.8119 | 17.9917 |
| 170134 | 14.2252 | 14.1085 | 14.6799 | 14.3402 |
| 170137 | 17.4151 | 17.8290 | 19.3118 | 18.1884 |
| 170139 | 13.3896 | 14.1967 | 14.3001 | 13.9545 |
| 170142 | 17.3234 | * | 17.7134 | 17.5177 |
| 170143 | 15.8802 | 15.6509 | 16.0415 | 15.8575 |
| 170144 | 16.0860 | 19.0929 | 20.4392 | 18.4073 |
| 170145 | 16.7499 | 17.1837 | 19.0142 | 17.6442 |
| 170146 | 19.9725 | 20.9075 | 21.7919 | 20.9132 |
| 170147 | 16.2829 | 22.3017 | 17.6717 | 18.6905 |
| 170148 | 17.2497 | 16.9183 | 19.1942 | 17.6867 |
| 170150 | 15.4283 | 15.5651 | 15.9072 | 15.6422 |
| 170151 | 13.3674 | 13.8934 | 14.3668 | 13.8637 |
| 170152 | 13.6846 | 14.9139 | 15.6423 | 14.7323 |
| 170160 | 13.3087 | 13.7108 | 14.4732 | 13.8369 |
| 170164 | 15.5597 | 16.6542 | 17.4072 | 16.5279 |
| 170166 | 17.5681 | 27.5567 | 12.7507 | 18.3396 |
| 170171 | 13.8059 | 12.5200 | 13.1792 | 13.1761 |
| 170175 | 17.8802 | 19.0232 | 20.1907 | 18.9985 |
| 170176 | 20.3194 | 21.3400 | 23.5043 | 21.7098 |
| 170180 | * | 16.6921 | 8.6352 | 11.8552 |
| 170182 | 14.1971 | 22.2164 | 21.3454 | 19.8791 |
| 170183 | 19.0919 | 20.3505 | 19.5182 | 19.7036 |
| 170184 | 27.0152 | * | * | 27.0152 |
| 180001 | 19.5188 | 17.9906 | 20.4885 | 19.3882 |
| 180002 | 18.1348 | 17.9669 | 17.5798 | 17.8819 |
| 180004 | 15.9921 | 17.2581 | 17.7149 | 16.9654 |
| 180005 | 20.6280 | 21.1390 | 22.4634 | 21.3796 |
| 180006 | 11.2254 | 11.4398 | 10.3400 | 11.0123 |
| 180007 | 17.1997 | 17.6776 | 17.9491 | 17.6005 |
| 180009 | 20.8103 | 21.4730 | 21.0608 | 21.1163 |
| 180010 | 17.5452 | 19.1100 | 19.6311 | 18.7406 |
| 180011 | 16.9311 | 17.1050 | 19.0526 | 17.8588 |
| 180012 | 18.7350 | 18.7223 | 19.0646 | 18.8428 |
| 180013 | 17.4487 | 18.2354 | 19.7418 | 18.5305 |
| 180014 | 20.8033 | 21.4856 | 21.3361 | 21.1759 |
| 180016 | 18.8422 | 19.8892 | 21.1458 | 20.0187 |
| 180017 | 15.1699 | 15.4140 | 15.6583 | 15.4240 |
| 180018 | 18.9020 | 17.1692 | 15.4892 | 17.0584 |
| 180019 | 16.7648 | 17.3970 | 17.8285 | 17.3565 |
| 180020 | 17.7782 | 17.7288 | 18.0111 | 17.8397 |
| 180021 | 15.1627 | 15.4580 | 17.0618 | 15.8957 |
| 180023 | 15.2219 | 15.8803 | 17.4717 | 16.1885 |
| 180024 | 15.3299 | 16.1731 | 16.5040 | 15.9951 |
| 180025 | 17.1688 | 14.1841 | 15.4180 | 15.4826 |
| 180026 | 14.1571 | 14.6804 | 15.0118 | 14.6082 |
| 180027 | 14.8869 | 16.4116 | 17.5286 | 16.2087 |
| 180028 | 19.3519 | 19.5276 | 15.7005 | 18.0068 |
| 180029 | 18.0191 | 17.7729 | 17.7248 | 17.8352 |
| 180030 | 17.0234 | 17.3430 | 17.9543 | 17.4342 |
| 180031 | 13.7862 | 13.9844 | 13.1848 | 13.6178 |
| 180032 | 16.0941 | 16.8318 | 17.2784 | 16.7976 |
| 180033 | 13.7667 | 17.7344 | 15.4131 | 15.5472 |
| 180034 | 17.3158 | 15.3369 | 16.3991 | 16.3000 |
| 180035 | 19.4485 | 20.1305 | 21.3666 | 20.2870 |
| 180036 | 19.1922 | 19.8398 | 20.1860 | 19.7448 |
| 180037 | 18.8053 | 19.9737 | 21.2184 | 19.9797 |
| 180038 | 17.1643 | 17.7626 | 18.5923 | 17.8512 |
| 180040 | 19.4450 | 19.5337 | 21.2229 | 20.0583 |
| 180041 | 15.1703 | 15.0785 | 16.3699 | 15.5655 |
| 180042 | 16.2924 | 16.7691 | 17.1519 | 16.7450 |
| 180043 | 16.6077 | 16.8027 | 14.6526 | 15.9643 |
| 180044 | 17.8196 | 18.5571 | 19.4984 | 18.6534 |
| 180045 | 17.7272 | 17.7130 | 20.8455 | 18.9499 |
| 180046 | 17.9096 | 19.2523 | 21.2080 | 19.4569 |
| 180047 | 15.0354 | 16.2304 | 18.6938 | 16.6027 |
| 180048 | 19.5681 | 18.3442 | 17.7816 | 18.5208 |
| 180049 | 16.0799 | 16.4319 | 16.5459 | 16.3594 |
| 180050 | 18.4753 | 17.8540 | 17.1493 | 17.7884 |
| 180051 | 15.6796 | 16.3960 | 17.5441 | 16.5170 |
| 180053 | 14.6299 | 15.9284 | 15.8994 | 15.5002 |
| 180054 | 16.3875 | 19.4858 | 20.0946 | 18.5771 |
| 180055 | 14.6446 | 15.2663 | 15.8422 | 15.2446 |
| 180056 | 16.6240 | 17.0056 | 17.5881 | 17.0744 |
| 180058 | 14.3562 | 15.9685 | 14.5355 | 14.9226 |
| 180059 | 14.2605 | 13.3955 | 14.7032 | 14.1102 |
| 180060 | 7.2139 | * | * | 7.2139 |
| 180063 | 11.9120 | 13.1036 | 12.4448 | 12.4785 |
| 180064 | 14.4872 | 15.2424 | 15.5066 | 15.0871 |
| 180065 | 20.0286 | 12.0629 | 11.1934 | 13.8815 |
| 180066 | 18.5635 | 19.2981 | 19.8956 | 19.2578 |
| 180067 | 18.5288 | 20.6322 | 20.1712 | 19.7577 |
| 180069 | 17.2956 | 17.7911 | 16.2916 | 17.1149 |
| 180070 | 13.8370 | 13.1923 | 15.9362 | 14.2840 |
| 180072 | 17.8554 | 16.9021 | 17.2347 | 17.3229 |
| 180075 | 15.0701 | * | * | 15.0701 |
| 180078 | 19.1615 | 21.1170 | 21.7116 | 20.6787 |
| 180079 | 13.4072 | 15.1636 | 15.9048 | 14.8197 |
| 180080 | 15.8327 | 16.4989 | 16.6428 | 16.3363 |
| 180087 | 14.9660 | 14.9167 | 15.6089 | 15.1555 |
| 180088 | 22.5349 | 22.0374 | 22.1774 | 22.2484 |
| 180092 | 16.3099 | 18.2405 | 18.3597 | 17.6633 |
| 180093 | 16.8286 | 17.0132 | 17.8492 | 17.2232 |
| 180094 | 12.5074 | 13.5490 | 13.6233 | 13.2263 |
| 180095 | 13.3991 | 13.8021 | 13.9050 | 13.6989 |
| 180099 | 13.6988 | 13.3631 | 13.2991 | 13.4593 |
| 180101 | 19.5644 | 18.4883 | * | 18.9778 |
| 180102 | 17.8751 | 17.9618 | 18.5240 | 18.1008 |
| 180103 | 19.2182 | 19.8965 | 20.3490 | 19.8359 |
| 180104 | 18.8730 | 18.9281 | 19.3922 | 19.0643 |
| 180105 | 14.0811 | 15.2394 | 16.6997 | 15.2994 |
| 180106 | 13.6062 | 14.3505 | 15.2895 | 14.3903 |
| 180108 | 14.6222 | 14.8187 | 14.4740 | 14.6381 |
| 180115 | 17.1079 | 16.7003 | 16.9096 | 16.9026 |
| 180116 | 16.9389 | 18.0392 | 18.6077 | 17.8709 |
| 180117 | 18.3821 | 17.7857 | 23.0192 | 19.6584 |
| 180118 | 12.1533 | 15.8597 | 16.9250 | 14.8270 |
| 180120 | 17.8145 | 16.1591 | 15.3115 | 16.3371 |
| 180121 | 14.5134 | 15.0983 | 20.0494 | 16.3330 |
| 180122 | 16.9678 | 18.5094 | 18.1930 | 17.8754 |
| 180123 | 18.9995 | 21.0613 | 21.1067 | 20.4023 |
| 180124 | 18.4064 | 17.4994 | 18.8487 | 18.2269 |
| 180125 | 19.7341 | 19.6416 | 14.9314 | 17.5744 |
| 180126 | 12.3959 | 12.9228 | 14.3551 | 13.2733 |
| 180127 | 17.3452 | 19.2581 | 17.6365 | 18.0663 |
| 180128 | 17.0508 | 17.6385 | 18.2817 | 17.6802 |
| 180129 | 17.8600 | 16.8378 | 22.3536 | 18.8696 |
| 180130 | 19.0110 | 19.8192 | 20.6450 | 19.8370 |
| 180132 | 17.2657 | 17.7744 | 19.5884 | 18.2006 |
| 180133 | 22.2325 | 21.6794 | 21.7800 | 21.8995 |
| 180134 | 13.6287 | 13.1935 | 14.5387 | 13.7967 |
| 180136 | 17.7146 | 17.3542 | * | 17.5359 |
| 180138 | 18.6149 | 19.3692 | 20.2102 | 19.4170 |
| 180139 | 18.7679 | 18.7198 | 20.5350 | 19.3756 |
| 180140 | 20.3953 | 16.8152 | 15.2719 | 17.3915 |
| 180141 | 20.0075 | 20.9820 | 23.8930 | 21.4590 |
| 180142 | * | * | 20.7510 | 20.7510 |
| 190001 | 17.0159 | 17.6832 | 18.1514 | 17.6263 |
| 190002 | 18.8381 | 19.1924 | 19.8834 | 19.2931 |
| 190003 | 22.1543 | 19.7749 | 19.9121 | 20.4811 |
| 190004 | 17.5385 | 17.7710 | 18.3620 | 17.8959 |
| 190005 | 16.7149 | 17.2422 | 17.5161 | 17.1568 |
| 190006 | 17.7335 | 17.8036 | 17.5911 | 17.7112 |
| 190007 | 13.6014 | 13.8189 | 14.4720 | 13.9833 |
| 190008 | 16.8916 | 18.6664 | 19.2456 | 18.2327 |
| 190009 | 14.2085 | 15.3555 | 15.9731 | 15.1819 |
| 190010 | 17.0192 | 16.2805 | 16.5020 | 16.6088 |
| 190011 | 15.1715 | 15.9534 | 15.6351 | 15.5881 |
| 190013 | 16.5706 | 16.8181 | 15.5019 | 16.2739 |
| 190014 | 17.0170 | 17.0959 | 17.8015 | 17.3107 |
| 190015 | 18.1943 | 18.6266 | 18.9896 | 18.6153 |
| 190017 | 15.7894 | 16.2393 | 17.5381 | 16.5250 |
| 190018 | 16.9761 | 15.0668 | 11.1898 | 14.5841 |
| 190019 | 17.4006 | 18.5257 | 18.3788 | 18.1281 |
| 190020 | 17.3084 | 17.5256 | 17.6840 | 17.5059 |
| 190025 | 16.0738 | 18.6369 | 16.8686 | 17.2271 |
| 190026 | 17.2166 | 18.1622 | 18.5015 | 17.9532 |
| 190027 | 16.1856 | 17.0827 | 17.4761 | 16.9034 |
| 190029 | 17.1103 | 16.5239 | 19.1967 | 17.5497 |
| 190033 | 10.7448 | * | * | 10.7448 |
| 190034 | 16.5066 | 16.8503 | 18.0754 | 17.1513 |
| 190036 | 19.9456 | 20.1780 | 20.0300 | 20.0491 |
| 190037 | 12.0237 | 17.6945 | 19.9878 | 16.0686 |
| 190039 | 17.1687 | 19.4713 | 19.0376 | 18.5119 |
| 190040 | 20.3180 | 21.4634 | 21.7376 | 21.1907 |
| 190041 | 17.8975 | 17.6646 | 17.9535 | 17.8382 |
| 190043 | 12.5660 | 15.5580 | 15.5618 | 14.5094 |
| 190044 | 17.1984 | 17.2892 | 17.4471 | 17.3108 |
| 190045 | 21.6948 | 21.6107 | 21.2853 | 21.5139 |
| 190046 | 19.3538 | 19.7964 | 20.4458 | 19.8736 |
| 190048 | 16.3404 | 16.6683 | 16.8136 | 16.6153 |
| 190049 | 16.4250 | 17.2280 | 17.7417 | 17.1570 |
| 190050 | 15.3771 | 16.1980 | 16.2854 | 15.9545 |
| 190053 | 12.4980 | 13.2159 | 13.0080 | 12.9160 |
| 190054 | 16.4683 | 19.1738 | 18.9059 | 18.1924 |
| 190059 | 15.8443 | 15.6942 | 15.8373 | 15.7915 |
| 190060 | 18.3689 | 14.7186 | 17.8443 | 16.7639 |
| 190064 | 19.9047 | 20.4482 | 18.2466 | 19.4909 |
| 190065 | 19.3856 | 20.9927 | 18.3091 | 19.5174 |
| 190071 | 13.5908 | 14.4827 | 16.4138 | 14.8320 |
| 190077 | 12.8290 | 15.7805 | 16.5536 | 15.0793 |
| 190078 | 13.4990 | 14.8826 | 16.9383 | 14.8793 |
| 190079 | 17.2909 | 17.7120 | 17.9403 | 17.6368 |
| 190081 | 12.0190 | 15.3198 | 14.9707 | 14.2301 |
| 190083 | 16.1374 | 18.8895 | 18.4951 | 17.8399 |
| 190086 | 14.9295 | 15.8694 | 16.5074 | 15.7738 |
| 190088 | 19.6328 | 20.5531 | 19.9362 | 20.0391 |
| 190089 | 12.7879 | 13.0503 | 15.0395 | 13.5823 |
| 190090 | 16.5580 | 16.6664 | 16.2351 | 16.4928 |
| 190092 | 18.0655 | * | * | 18.0655 |
| 190095 | 15.7316 | 16.2287 | 17.3258 | 16.3915 |
| 190098 | 19.2175 | 20.4897 | 21.0847 | 20.2301 |
| 190099 | 18.9255 | 19.9018 | 19.0635 | 19.3257 |
| 190102 | 19.0477 | 20.0300 | 20.7870 | 19.9631 |
| 190103 | 15.5698 | 12.1389 | 14.4158 | 13.8580 |
| 190106 | 17.7468 | 18.5813 | 18.5908 | 18.3281 |
| 190109 | 14.5288 | 15.5767 | 15.8187 | 15.3068 |
| 190110 | 12.9925 | 15.8052 | 15.7313 | 14.8387 |
| 190111 | 20.0376 | 19.7514 | 20.6508 | 20.1574 |
| 190112 | 19.2067 | 21.0232 | 22.0741 | 20.6951 |
| 190113 | 18.9922 | 12.5777 | * | 15.7380 |
| 190114 | 12.9083 | 12.6366 | 13.9209 | 13.1568 |
| 190115 | 20.4914 | 20.2473 | 22.7583 | 21.1252 |
| 190116 | 12.5881 | 15.5481 | 17.3757 | 15.1678 |
| 190118 | 12.9537 | 14.7876 | 16.3776 | 14.7222 |
| 190120 | 13.6938 | 13.9591 | 17.2309 | 14.9846 |
| 190122 | 14.8255 | 15.4793 | 15.3742 | 15.2287 |
| 190124 | 22.3825 | 20.6222 | 20.1206 | 20.9375 |
| 190125 | 18.6287 | 20.4517 | 19.8298 | 19.6458 |
| 190128 | 19.7127 | 20.4688 | 20.8770 | 20.3583 |
| 190130 | 12.4307 | 15.1467 | 14.0379 | 13.8956 |
| 190131 | 19.5984 | 20.7565 | 18.8958 | 19.7536 |
| 190133 | 13.4750 | 13.5383 | 15.1393 | 13.9917 |
| 190134 | 12.6774 | 12.1749 | 12.4507 | 12.4351 |
| 190135 | 21.3511 | 21.6875 | 21.3454 | 21.4650 |
| 190136 | 11.3250 | 12.4091 | 15.1662 | 13.0730 |
| 190138 | 22.7088 | * | * | 22.7088 |
| 190140 | 12.0285 | 14.2256 | 14.6829 | 13.6611 |
| 190142 | 14.9820 | 15.4861 | 16.2280 | 15.5517 |
| 190144 | 16.8360 | 16.2068 | 18.4405 | 17.1561 |
| 190145 | 13.9893 | 15.2345 | 16.2505 | 15.1638 |
| 190146 | 20.0941 | 21.2825 | 21.9607 | 21.1552 |
| 190147 | 14.3219 | 14.4345 | 14.7202 | 14.4910 |
| 190148 | 14.0180 | 16.6337 | 15.5338 | 15.4604 |
| 190149 | 15.1862 | 17.5997 | 16.4722 | 16.4169 |
| 190151 | 11.9190 | 14.7333 | 15.5210 | 14.0028 |
| 190152 | 20.3951 | 22.2070 | 22.0319 | 21.4716 |
| 190155 | 11.0800 | * | * | 11.0800 |
| 190156 | 12.4786 | 15.7478 | 16.0442 | 14.6766 |
| 190158 | 19.6164 | 20.4637 | 20.4078 | 20.1474 |
| 190160 | 18.4746 | 17.1003 | 18.4662 | 18.0078 |
| 190161 | 14.6295 | 15.5737 | 15.9280 | 15.3544 |
| 190162 | 19.5027 | 20.6143 | 20.1962 | 20.0440 |
| 190164 | 16.3328 | 15.1783 | 18.2379 | 16.4778 |
| 190167 | 16.2880 | 16.6681 | 17.7611 | 16.9143 |
| 190170 | 13.5772 | 14.1750 | 14.5222 | 14.0895 |
| 190173 | 19.6362 | 23.6398 | 23.0934 | 22.0602 |
| 190175 | 20.6908 | 19.3625 | 20.4580 | 20.1298 |
| 190176 | 18.8205 | 24.0574 | 22.2316 | 21.4596 |
| 190177 | 20.3177 | 18.6715 | 19.7794 | 19.5846 |
| 190178 | 10.4941 | 11.0657 | 12.0372 | 11.1714 |
| 190182 | 20.0267 | 20.2855 | 20.7102 | 20.3281 |
| 190183 | 16.1064 | 16.7671 | 16.0752 | 16.3134 |
| 190184 | 14.8645 | 17.2044 | 19.8436 | 17.2547 |
| 190185 | 19.3707 | 20.1444 | 20.5852 | 20.0405 |
| 190186 | 16.3586 | 18.7568 | 17.4078 | 17.5306 |
| 190189 | 26.5419 | * | * | 26.5419 |
| 190190 | 18.6656 | 17.4642 | 15.8985 | 17.1134 |
| 190191 | 18.1353 | 20.4975 | 19.6911 | 19.4475 |
| 190196 | 14.8699 | 17.9225 | 18.6138 | 17.2784 |
| 190197 | 17.9166 | 19.5569 | 20.2082 | 19.2721 |
| 190199 | 13.4222 | 16.0637 | 15.3522 | 14.6078 |
| 190200 | 19.4148 | 22.0391 | 21.6852 | 21.0397 |
| 190201 | 19.1432 | 18.7079 | 19.7421 | 19.2055 |
| 190202 | 17.8959 | * | * | 17.8959 |
| 190203 | 21.3096 | 21.7350 | 21.7931 | 21.5975 |
| 190204 | 21.2119 | 21.4624 | 20.5784 | 21.0754 |
| 190205 | 18.1007 | 19.6587 | 19.3737 | 19.0483 |
| 190206 | 20.0648 | 21.7012 | 21.3307 | 21.0222 |
| 190207 | 17.6712 | 20.5082 | 19.0216 | 19.1034 |
| 190208 | 14.6096 | 20.0065 | 16.9641 | 17.1855 |
| 190218 | 18.1627 | 19.7518 | 19.2992 | 19.0335 |
| 190223 | 19.2550 | * | * | 19.2550 |
| 190227 | 12.1086 | * | * | 12.1086 |
| 190231 | 16.8850 | 15.8287 | 17.7247 | 16.7665 |
| 190235 | 18.2702 | * | * | 18.2702 |
| 190236 | 22.1837 | 19.3395 | 21.1982 | 20.9440 |
| 190238 | * | * | 20.6799 | 20.6799 |
| 190239 | * | * | 19.7601 | 19.7601 |
| 190240 | * | * | 14.3579 | 14.3579 |
| 200001 | 17.4890 | 18.0527 | 18.2513 | 17.9448 |
| 200002 | 18.7745 | 19.3629 | 22.3035 | 20.2028 |
| 200003 | 16.7389 | 16.9566 | 18.4141 | 17.3782 |
| 200006 | 19.7984 | 17.6586 | 21.0922 | 19.4856 |
| 200007 | 17.8859 | 18.7992 | 18.1681 | 18.2871 |
| 200008 | 20.5020 | 21.7489 | 21.5556 | 21.2780 |
| 200009 | 20.6433 | 22.2280 | 21.4763 | 21.4574 |
| 200012 | 17.0130 | 18.3484 | 19.1047 | 18.1711 |
| 200013 | 16.4933 | 18.0566 | 17.9378 | 17.5422 |
| 200015 | 20.1117 | * | * | 20.1117 |
| 200016 | 17.6623 | 18.0866 | 17.1187 | 17.6192 |
| 200017 | 19.6462 | 17.2930 | * | 18.7598 |
| 200018 | 17.2422 | 18.5397 | 17.8675 | 17.8479 |
| 200019 | 18.6399 | 19.2348 | 19.9245 | 19.2946 |
| 200020 | 20.5967 | 22.4526 | 22.3355 | 21.8088 |
| 200021 | 19.4052 | 19.9133 | 20.7361 | 19.9988 |
| 200023 | 14.9164 | 16.1707 | 20.2063 | 16.7560 |
| 200024 | 18.6518 | 19.4329 | 20.8336 | 19.6454 |
| 200025 | 19.0659 | 20.2259 | 20.4165 | 19.9282 |
| 200026 | 17.2842 | 18.1194 | 17.9021 | 17.7766 |
| 200027 | 18.2775 | 18.5659 | 19.4220 | 18.7949 |
| 200028 | 16.9306 | 19.5708 | 18.8763 | 18.4290 |
| 200031 | 15.9043 | 16.2217 | 16.1641 | 16.1005 |
| 200032 | 17.9160 | 18.9315 | 19.4613 | 18.7411 |
| 200033 | 21.4031 | 21.8634 | 22.4685 | 21.9155 |
| 200034 | 19.2407 | 20.1519 | 20.4941 | 19.9680 |
| 200037 | 18.2419 | 18.6713 | 20.3015 | 19.1236 |
| 200038 | 19.2147 | 23.3851 | 21.2632 | 21.2824 |
| 200039 | 20.2901 | 19.8589 | 20.1508 | 20.0694 |
| 200040 | 19.2970 | 19.5503 | 18.9580 | 19.2627 |
| 200041 | 17.6559 | 19.3563 | 18.8131 | 18.6006 |
| 200043 | 16.5368 | 16.7224 | 19.4295 | 17.5199 |
| 200050 | 18.0805 | 20.1214 | 20.2014 | 19.5017 |
| 200051 | 19.5925 | 22.1525 | 22.0712 | 21.5149 |
| 200052 | 15.1216 | 17.2099 | 17.6271 | 16.6895 |
| 200055 | 17.1729 | 18.8422 | 18.5983 | 18.1835 |
| 200062 | 16.5139 | 17.2273 | 18.4279 | 17.3769 |
| 200063 | 19.6658 | 19.9331 | 21.2121 | 20.2562 |
| 200066 | 16.3431 | 17.0289 | 17.0570 | 16.8076 |
| 210001 | 18.7266 | 20.4841 | 18.6617 | 19.2372 |
| 210002 | 22.8448 | 19.9219 | 23.5132 | 22.2827 |
| 210003 | 25.3730 | 20.3446 | 26.0447 | 23.6583 |
| 210004 | 23.5884 | 24.2909 | 24.9760 | 24.2880 |
| 210005 | 19.6162 | 21.4929 | 21.3829 | 20.7876 |
| 210006 | 17.7721 | 18.9436 | 19.3682 | 18.7016 |
| 210007 | 21.5415 | 23.1007 | 23.8840 | 22.8043 |
| 210008 | 19.5006 | 21.1768 | 21.2895 | 20.6531 |
| 210009 | 21.8111 | 20.5447 | 20.7479 | 21.0282 |
| 210010 | 14.3783 | 18.7197 | 19.5908 | 17.3758 |
| 210011 | 21.2422 | 21.4862 | 21.4043 | 21.3727 |
| 210012 | 23.4317 | 20.7203 | 21.3977 | 21.7764 |
| 210013 | 18.8455 | 19.7288 | 19.4505 | 19.3405 |
| 210015 | 16.6898 | 16.1912 | 18.7448 | 17.2340 |
| 210016 | 22.1469 | 23.8739 | 26.5193 | 24.0991 |
| 210017 | 17.1747 | 18.8928 | 18.5079 | 18.1448 |
| 210018 | 21.4055 | 22.2135 | 22.8553 | 22.1574 |
| 210019 | 19.0899 | 19.3046 | 20.6025 | 19.6453 |
| 210022 | 21.8160 | 22.6389 | 24.5744 | 23.0098 |
| 210023 | 21.7988 | 23.1950 | 22.9989 | 22.6719 |
| 210024 | 19.5645 | 20.6011 | 24.4280 | 21.4080 |
| 210025 | 19.5704 | 19.5876 | 21.2769 | 20.0208 |
| 210026 | 11.6440 | 12.1348 | 13.8668 | 12.6171 |
| 210027 | 18.4862 | 17.6855 | 17.1060 | 17.7943 |
| 210028 | 18.8623 | 19.6408 | 19.4157 | 19.3091 |
| 210029 | 22.3876 | 21.2167 | 25.4939 | 23.0892 |
| 210030 | 21.0169 | 21.7403 | 20.9574 | 21.2261 |
| 210031 | 15.5873 | 16.2299 | * | 15.9014 |
| 210032 | 18.4983 | 17.7228 | 20.1955 | 18.7972 |
| 210033 | 19.9144 | 20.8053 | 23.7588 | 21.3886 |
| 210034 | 16.1216 | 15.7322 | 19.4144 | 17.1228 |
| 210035 | 20.6092 | 20.2731 | 20.8317 | 20.5720 |
| 210037 | 18.7361 | 18.3072 | 20.5528 | 19.2053 |
| 210038 | 23.2616 | 23.4971 | 24.9762 | 23.8679 |
| 210039 | 20.7291 | 19.9901 | 21.3559 | 20.7067 |
| 210040 | 25.0770 | 21.5014 | 23.4252 | 23.3184 |
| 210043 | 18.5891 | 19.6474 | 22.4000 | 20.0973 |
| 210044 | 22.2438 | 22.5781 | 23.0917 | 22.6329 |
| 210045 | 9.6862 | 11.6086 | 12.1467 | 11.1781 |
| 210048 | 22.3923 | 23.0537 | 24.6921 | 23.3434 |
| 210049 | 17.6697 | 19.0821 | 19.3022 | 18.6991 |
| 210051 | 20.7633 | 22.4335 | 23.6476 | 22.3235 |
| 210054 | 23.5122 | 22.3559 | 23.2730 | 23.0396 |
| 210055 | 20.1012 | 29.2539 | 26.5272 | 25.0062 |
| 210056 | 20.9445 | 19.2662 | 22.9593 | 21.0605 |
| 210057 | 22.5717 | 23.8289 | 26.0076 | 24.0668 |
| 210058 | 21.4976 | 22.0753 | 16.3191 | 20.0884 |
| 210059 | 23.1274 | 22.6766 | 25.6052 | 23.5899 |
| 210060 | * | * | 26.5846 | 26.5846 |
| 210061 | 20.0203 | 17.2240 | 16.1931 | 17.8181 |
| 220001 | 26.3207 | 21.9369 | 22.9064 | 22.9526 |
| 220002 | 22.5808 | 24.1285 | 16.3789 | 20.4063 |
| 220003 | 19.1383 | 16.9246 | 17.9319 | 17.9948 |
| 220004 | 20.0058 | * | * | 20.0058 |
| 220006 | 22.1228 | 22.3085 | 22.6337 | 22.3566 |
| 220008 | 21.8873 | 24.4691 | 22.0796 | 22.7689 |
| 220010 | 21.9226 | 21.8582 | 22.0067 | 21.9297 |
| 220011 | 28.5673 | 26.1827 | 29.5290 | 28.2047 |
| 220012 | 29.5051 | 32.0829 | 31.2303 | 30.9286 |
| 220015 | 21.7813 | 22.5773 | 23.1893 | 22.4843 |
| 220016 | 23.1440 | 23.3750 | 23.0951 | 23.2050 |
| 220017 | 25.2630 | 22.4605 | 25.1568 | 24.2781 |
| 220019 | 19.1264 | 19.5613 | 19.8551 | 19.5190 |
| 220020 | 19.9925 | 21.4152 | 22.4295 | 21.2738 |
| 220021 | 23.6313 | * | * | 23.6313 |
| 220023 | 18.7625 | 16.1885 | * | 18.0910 |
| 220024 | 21.5871 | 21.5363 | 21.9316 | 21.6947 |
| 220025 | 19.9398 | 20.7882 | 22.8593 | 21.1235 |
| 220028 | 22.0721 | 22.8036 | 21.0630 | 21.9530 |
| 220029 | 21.8711 | 23.1509 | 25.6560 | 23.4858 |
| 220030 | 14.5383 | 18.5441 | 18.7429 | 17.2580 |
| 220031 | 28.1584 | 30.2430 | 29.3091 | 29.1415 |
| 220033 | 20.4120 | 20.0695 | 20.3609 | 20.2712 |
| 220035 | 21.9974 | 21.6396 | 23.1892 | 22.2365 |
| 220036 | 24.1570 | 24.6470 | 24.4091 | 24.3977 |
| 220038 | 22.3494 | 22.6518 | 22.3162 | 22.4382 |
| 220041 | 23.1483 | 23.4720 | 27.5034 | 24.5999 |
| 220042 | 25.2852 | 25.0779 | 26.0473 | 25.4181 |
| 220046 | 22.4677 | 22.7068 | 23.3149 | 22.8459 |
| 220049 | 23.0283 | 26.0025 | 27.2689 | 25.4891 |
| 220050 | 20.8345 | 22.0144 | 22.5265 | 21.7871 |
| 220051 | 20.4765 | 21.1033 | 21.7357 | 21.0973 |
| 220052 | 23.1376 | 23.7650 | 23.5225 | 23.4708 |
| 220053 | 21.2679 | 19.1280 | * | 20.2813 |
| 220055 | 21.5706 | 21.3743 | * | 21.4727 |
| 220057 | 23.0010 | 25.3902 | 25.8064 | 24.6606 |
| 220058 | 20.1888 | 19.9369 | 26.8345 | 22.1915 |
| 220060 | 26.1753 | 28.0843 | 28.0794 | 27.4392 |
| 220062 | 20.0560 | 20.4685 | 20.2254 | 20.2505 |
| 220063 | 20.9547 | 20.3951 | 20.8079 | 20.7132 |
| 220064 | 22.1785 | 22.3260 | 22.7497 | 22.4060 |
| 220065 | 20.1974 | 20.1364 | 20.1424 | 20.1584 |
| 220066 | 20.4586 | 20.7826 | 23.4477 | 21.6604 |
| 220067 | 25.7414 | 26.4443 | 27.5405 | 26.5452 |
| 220068 | 6.4548 | * | * | 6.4548 |
| 220070 | 19.7678 | 19.7528 | 20.9128 | 20.1099 |
| 220071 | 24.6508 | 25.6184 | 27.4151 | 25.8715 |
| 220073 | 25.8680 | 25.6025 | 26.1328 | 25.8683 |
| 220074 | 24.0523 | 25.6390 | 24.3057 | 24.7411 |
| 220075 | 21.5418 | 22.8057 | 22.5329 | 22.2794 |
| 220076 | 24.7783 | 22.6668 | 23.2795 | 23.6106 |
| 220077 | 24.8019 | 25.2646 | 26.1545 | 25.3933 |
| 220079 | 21.0090 | 22.6256 | 22.0769 | 21.8560 |
| 220080 | 20.5007 | 21.5238 | 22.1971 | 21.3825 |
| 220081 | 25.3370 | 29.1726 | 29.6682 | 28.0686 |
| 220082 | 20.0175 | 21.6726 | 22.1453 | 21.2140 |
| 220083 | 23.0759 | 23.9156 | 22.5815 | 23.1732 |
| 220084 | 24.6624 | 23.6641 | 25.3761 | 24.5459 |
| 220086 | 30.4649 | 23.8705 | 26.7778 | 26.4452 |
| 220088 | 23.3783 | 22.9067 | 23.4258 | 23.2384 |
| 220089 | 21.7884 | 23.0965 | 25.4106 | 23.3099 |
| 220090 | 21.6353 | 22.0041 | 23.3049 | 22.2774 |
| 220092 | 17.0409 | 18.5239 | 24.7905 | 19.4783 |
| 220094 | 21.9853 | * | * | 21.9853 |
| 220095 | 21.4468 | 21.4831 | 21.7851 | 21.5735 |
| 220098 | 20.8596 | 21.5906 | 23.1547 | 21.8533 |
| 220100 | 25.3484 | 25.7077 | 27.5841 | 26.2007 |
| 220101 | 24.3260 | 25.9204 | 27.0711 | 25.7662 |
| 220104 | 27.5297 | 28.0021 | 28.7258 | 28.0695 |
| 220105 | 21.6873 | 21.4129 | 21.9185 | 21.6684 |
| 220106 | 24.5518 | 25.6577 | 25.9277 | 25.3659 |
| 220107 | 20.2719 | * | * | 20.2719 |
| 220108 | 22.6372 | 21.9115 | 23.4975 | 22.6709 |
| 220110 | 29.1927 | 28.7071 | 29.1648 | 29.0217 |
| 220111 | 23.0475 | 23.8066 | 24.7510 | 23.8707 |
| 220116 | 24.9744 | 26.1662 | 32.0049 | 27.4579 |
| 220118 | 30.5213 | * | * | 30.5213 |
| 220119 | 22.8586 | 23.3216 | 23.8785 | 23.3181 |
| 220123 | 27.3063 | 25.8994 | 32.4678 | 28.6276 |
| 220126 | 20.9557 | 22.5218 | 23.6045 | 22.3000 |
| 220128 | 20.5636 | * | * | 20.5636 |
| 220133 | 35.2747 | 25.4596 | 29.3911 | 30.0324 |
| 220135 | 25.0798 | 25.6522 | 28.3648 | 26.3313 |
| 220153 | 23.8981 | 22.9592 | * | 23.4152 |
| 220154 | 22.1261 | 22.4770 | 21.1563 | 22.0118 |
| 220163 | 27.3527 | 29.1143 | 29.2299 | 28.5578 |
| 220171 | 23.4340 | 24.5553 | 24.9261 | 24.3151 |
| 230001 | 19.2015 | 19.8020 | 20.0438 | 19.6841 |
| 230002 | 21.9058 | 22.7991 | 23.0439 | 22.5920 |
| 230003 | 19.6118 | 19.8420 | 21.2215 | 20.2501 |
| 230004 | 22.0310 | 23.1036 | 20.5005 | 21.8004 |
| 230005 | 19.4040 | 18.5644 | 17.0943 | 18.3438 |
| 230006 | 18.4681 | 19.1041 | 20.4978 | 19.3271 |
| 230007 | 19.4339 | 15.5538 | * | 18.1334 |
| 230012 | 18.6663 | 15.0803 | * | 16.5807 |
| 230013 | 20.6322 | 20.8018 | 22.2211 | 21.1847 |
| 230015 | 20.4264 | 20.1104 | 20.6464 | 20.3967 |
| 230017 | 20.3975 | 22.2822 | 22.9755 | 21.8495 |
| 230019 | 21.3222 | 22.2622 | 23.6674 | 22.4892 |
| 230020 | 21.3206 | 22.1280 | 21.8526 | 21.7774 |
| 230021 | 18.5670 | 18.9636 | 19.8256 | 19.1973 |
| 230022 | 19.7598 | 18.8006 | 21.9129 | 20.1618 |
| 230024 | 27.9551 | 23.7326 | 24.9664 | 25.4314 |
| 230027 | 18.0285 | 14.6950 | 19.6393 | 17.2624 |
| 230029 | 21.0636 | 19.4911 | 22.1782 | 20.9312 |
| 230030 | 17.7040 | 18.3916 | 18.6406 | 18.2548 |
| 230031 | 17.5352 | 19.3162 | 19.9465 | 18.8845 |
| 230032 | 20.6821 | 21.8845 | 24.8930 | 22.4347 |
| 230034 | 17.2302 | 19.0473 | 19.4366 | 18.6363 |
| 230035 | 17.5607 | 17.5109 | 17.7490 | 17.6051 |
| 230036 | 21.7565 | 23.2119 | 23.8398 | 22.9390 |
| 230037 | 19.0688 | 20.4747 | 23.2751 | 20.8659 |
| 230038 | 23.3876 | 23.5251 | 21.9692 | 22.9521 |
| 230040 | 20.3897 | 21.4393 | 20.7841 | 20.8605 |
| 230041 | 19.0278 | 20.3131 | 21.7364 | 20.3273 |
| 230042 | 19.4937 | 22.1043 | 21.3870 | 21.0005 |
| 230046 | 25.9482 | 25.5696 | 25.3206 | 25.6107 |
| 230047 | 20.6379 | 21.5381 | 22.3595 | 21.5205 |
| 230053 | 22.1781 | 25.4968 | 26.8917 | 24.7553 |
| 230054 | 19.5427 | 20.6963 | 20.8014 | 20.3482 |
| 230055 | 19.8381 | 20.7932 | 20.8492 | 20.4732 |
| 230056 | 16.4101 | 16.0766 | 17.8091 | 16.7213 |
| 230058 | 18.2349 | 20.4165 | 21.0303 | 19.9623 |
| 230059 | 19.5098 | 19.9240 | 20.7092 | 20.0517 |
| 230060 | 17.8716 | 19.8021 | 19.8987 | 19.1871 |
| 230062 | 16.2952 | 17.1540 | 18.8039 | 17.3634 |
| 230063 | 20.2211 | 20.4171 | * | 20.3143 |
| 230065 | 21.1507 | 22.3459 | 22.7416 | 22.2057 |
| 230066 | 21.5116 | 22.1768 | 23.0475 | 22.2618 |
| 230069 | 21.7909 | 23.2076 | 24.2470 | 23.0592 |
| 230070 | 20.0645 | 20.2505 | 21.5666 | 20.8098 |
| 230071 | 22.1556 | 22.9052 | 23.1337 | 22.7304 |
| 230072 | 20.4308 | 20.6944 | 20.4456 | 20.5245 |
| 230075 | 19.4316 | 20.0545 | 22.5866 | 20.6203 |
| 230076 | 23.8201 | 24.4547 | 24.7010 | 24.2886 |
| 230077 | 20.3937 | 21.0178 | 20.2823 | 20.5602 |
| 230078 | 16.2486 | 17.5577 | 17.9868 | 17.2435 |
| 230080 | 18.9084 | 19.7687 | 20.2104 | 19.6745 |
| 230081 | 17.9510 | 19.0345 | 19.0199 | 18.6644 |
| 230082 | 17.7417 | 18.2992 | 19.0419 | 18.3501 |
| 230085 | 17.5447 | 20.2096 | 23.4996 | 20.3924 |
| 230086 | 16.9754 | 18.9420 | 20.1730 | 18.6767 |
| 230087 | 15.7694 | 18.9034 | 19.9700 | 18.0112 |
| 230089 | 21.3914 | 23.9100 | 22.6994 | 22.6194 |
| 230092 | 18.9567 | 20.0145 | 20.7738 | 19.9304 |
| 230093 | 20.1928 | 20.4655 | 20.6314 | 20.4325 |
| 230095 | 16.7830 | 17.3313 | 17.6444 | 17.2565 |
| 230096 | 22.5613 | 22.8410 | 22.7785 | 22.7256 |
| 230097 | 20.0960 | 21.2854 | 21.1254 | 20.8481 |
| 230099 | 20.2529 | 21.1933 | 21.7513 | 21.0709 |
| 230100 | 13.1107 | 17.1336 | 17.3842 | 16.0298 |
| 230101 | 18.6098 | 20.0932 | 20.5315 | 19.7445 |
| 230103 | 19.6014 | 22.7696 | 11.3429 | 17.7532 |
| 230104 | 23.4703 | 23.1457 | 24.1238 | 23.5809 |
| 230105 | 20.8765 | 21.5210 | 22.6098 | 21.6727 |
| 230106 | 18.3508 | 20.7997 | 21.6825 | 20.2936 |
| 230107 | 14.6673 | 16.5966 | 17.1386 | 15.9949 |
| 230108 | 17.4231 | 18.8631 | 20.3437 | 18.8600 |
| 230110 | 17.8017 | 18.9825 | 19.7262 | 18.8384 |
| 230113 | 11.1676 | 14.9411 | * | 12.8926 |
| 230115 | 16.4728 | 18.4050 | 19.6281 | 18.1783 |
| 230116 | 16.3563 | 16.5419 | 14.5692 | 15.7763 |
| 230117 | 23.9389 | 25.9318 | 25.6797 | 25.1927 |
| 230118 | 21.7089 | 21.3028 | 20.6797 | 21.2068 |
| 230119 | 23.9568 | 21.1918 | 22.6555 | 22.5908 |
| 230120 | 19.6400 | 18.5264 | 20.3306 | 19.4421 |
| 230121 | 20.0786 | 20.3158 | 21.3342 | 20.5789 |
| 230122 | 18.0903 | 20.9078 | * | 19.5648 |
| 230124 | 18.8938 | 20.3608 | 18.9981 | 19.3961 |
| 230125 | 15.3497 | * | * | 15.3497 |
| 230128 | 23.5787 | 24.9081 | 24.0724 | 24.1436 |
| 230130 | 22.5204 | 23.5170 | 22.1775 | 22.7280 |
| 230132 | 26.1727 | 26.6386 | 26.1946 | 26.3381 |
| 230133 | 17.5688 | 17.6894 | 17.1058 | 17.4473 |
| 230134 | 15.3248 | * | * | 15.3248 |
| 230135 | 22.7401 | 22.5258 | 20.5637 | 22.0738 |
| 230137 | 18.3431 | 19.1813 | * | 18.7522 |
| 230141 | 23.0496 | 22.1299 | 22.4570 | 22.5592 |
| 230142 | 20.1242 | 22.2940 | 23.5621 | 21.8277 |
| 230143 | 16.4468 | 16.3043 | 16.7948 | 16.5112 |
| 230144 | 20.9906 | 22.1108 | 23.4237 | 22.1285 |
| 230145 | 16.5986 | 20.2542 | 19.2638 | 18.8354 |
| 230146 | 18.6293 | 20.5044 | 21.2260 | 20.1486 |
| 230147 | 20.5144 | 21.8496 | 23.2755 | 21.8616 |
| 230149 | 14.1740 | 20.7691 | 18.8005 | 17.7545 |
| 230151 | 20.8884 | 22.1713 | 23.3967 | 22.0865 |
| 230153 | 17.3280 | 19.5633 | 18.7403 | 18.5291 |
| 230154 | 14.5846 | 15.4456 | 15.4362 | 15.1635 |
| 230155 | 16.9857 | 17.2076 | 20.5409 | 18.1875 |
| 230156 | 23.6126 | 24.7587 | 25.6228 | 24.6740 |
| 230157 | 19.7197 | 20.3667 | 17.3571 | 19.2380 |
| 230159 | 18.8426 | 20.0749 | * | 19.3914 |
| 230162 | 17.7689 | 21.4636 | 21.7148 | 20.3064 |
| 230165 | 23.3147 | 23.0106 | 23.8881 | 23.4094 |
| 230167 | 20.3210 | 21.5048 | 22.9745 | 21.5685 |
| 230169 | 22.8606 | 23.0652 | 24.3874 | 23.4345 |
| 230171 | 14.9595 | 13.3863 | 17.1282 | 15.0778 |
| 230172 | 20.2191 | 20.6417 | 21.4675 | 20.7898 |
| 230174 | 20.8542 | 23.0272 | 22.7304 | 22.1820 |
| 230175 | 21.8097 | 16.8909 | * | 19.0428 |
| 230176 | 21.8618 | 22.7772 | 23.8204 | 22.8229 |
| 230178 | 16.0818 | 16.9156 | 17.3030 | 16.7485 |
| 230180 | 15.4837 | 15.8769 | 18.5744 | 16.6297 |
| 230184 | 17.2928 | 19.0604 | 19.7717 | 18.6605 |
| 230186 | * | 19.5337 | 15.7837 | 17.6806 |
| 230188 | 15.5563 | 15.7112 | 16.2975 | 15.8821 |
| 230189 | 15.9089 | 16.6838 | 17.9218 | 16.8493 |
| 230190 | 23.7134 | 26.8196 | 26.4687 | 25.7543 |
| 230191 | 17.1221 | 19.0013 | 18.4861 | 18.1647 |
| 230193 | 20.1805 | 19.7066 | 19.8287 | 19.9318 |
| 230195 | 22.3745 | 21.7775 | 22.9228 | 22.3732 |
| 230197 | 21.6184 | 24.0184 | 24.0854 | 23.1281 |
| 230199 | 18.4012 | 19.4451 | 20.6580 | 19.5586 |
| 230201 | 15.3206 | 17.2141 | 18.0787 | 16.9556 |
| 230204 | 22.9506 | 25.4181 | 23.4966 | 23.9387 |
| 230205 | 13.8861 | 14.3788 | 15.9314 | 14.6555 |
| 230207 | 20.3538 | 20.6375 | 21.2483 | 20.7256 |
| 230208 | 17.1501 | 16.0733 | 16.7454 | 16.6668 |
| 230211 | 17.5087 | 18.6744 | 21.8581 | 19.0214 |
| 230212 | 22.1370 | 23.3021 | 24.2611 | 23.2193 |
| 230213 | 15.3159 | 15.1908 | 15.5469 | 15.3407 |
| 230216 | 19.5921 | 20.3359 | 21.0710 | 20.3422 |
| 230217 | 20.9510 | 21.2707 | 22.2698 | 21.4978 |
| 230219 | 20.7018 | 19.1549 | 20.0442 | 19.9745 |
| 230221 | 21.5000 | * | * | 21.5000 |
| 230222 | 20.8430 | 22.1785 | 21.9711 | 21.6725 |
| 230223 | 21.4990 | 21.1528 | 22.6887 | 21.7715 |
| 230227 | 21.3801 | 23.7259 | 22.3155 | 22.4395 |
| 230230 | 22.5346 | 22.2385 | 22.3097 | 22.3587 |
| 230232 | 12.6373 | * | * | 12.6373 |
| 230235 | 15.9466 | 16.8684 | 17.7197 | 16.8275 |
| 230236 | 23.2178 | 24.3835 | 25.9676 | 24.5556 |
| 230239 | 19.2349 | 18.0942 | 17.8168 | 18.3625 |
| 230241 | 18.8451 | 19.1000 | 20.7297 | 19.5624 |
| 230244 | 21.0758 | 21.7413 | 22.2697 | 21.6892 |
| 230253 | 21.9497 | 20.5945 | 21.0433 | 21.1989 |
| 230254 | 21.2786 | 21.9402 | 22.6335 | 21.9383 |
| 230257 | 20.4721 | 19.6982 | 21.3880 | 20.5021 |
| 230259 | 21.1519 | 22.2393 | 22.3969 | 21.9147 |
| 230264 | 15.1818 | 17.1319 | 17.4864 | 16.5360 |
| 230269 | 22.8138 | 23.3105 | 24.0992 | 23.4229 |
| 230270 | 20.0803 | 22.6187 | 22.5985 | 21.6440 |
| 230273 | 23.4000 | 22.9199 | 22.8715 | 23.0744 |
| 230275 | 17.5975 | 17.7487 | 20.8985 | 18.2554 |
| 230276 | 18.5750 | 21.3722 | 25.8709 | 21.5415 |
| 230277 | 22.5012 | 23.1456 | 23.9771 | 23.2364 |
| 230278 | 16.6645 | 18.2110 | * | 17.3814 |
| 230279 | 16.0437 | 17.6973 | 17.8074 | 17.2147 |
| 230280 | 14.2249 | 15.6654 | 18.3497 | 15.8025 |
| 230283 | * | 27.9480 | 22.5082 | 24.9202 |
| 240001 | 22.8480 | 24.6207 | 25.6936 | 24.3586 |
| 240002 | 23.0240 | 22.7981 | 23.2307 | 23.0178 |
| 240004 | 23.9195 | 25.1908 | 24.4030 | 24.5010 |
| 240005 | 16.9775 | 17.9563 | 20.3193 | 18.3770 |
| 240006 | 27.1133 | 25.1602 | 23.0715 | 24.9568 |
| 240007 | 16.9802 | 17.7625 | 19.0850 | 17.9138 |
| 240008 | 21.8068 | 20.2158 | 23.3783 | 21.6628 |
| 240009 | 16.6910 | 16.8965 | 17.1187 | 16.9211 |
| 240010 | 23.6323 | 23.6477 | 25.4752 | 24.2587 |
| 240011 | 18.9559 | 20.5192 | 21.5875 | 20.3298 |
| 240013 | 18.9705 | 20.3282 | 21.7544 | 20.2656 |
| 240014 | 21.8560 | 23.0025 | 24.2610 | 23.0452 |
| 240016 | 19.8624 | 20.4017 | 22.2011 | 20.8274 |
| 240017 | 17.2325 | 18.3585 | 18.9272 | 18.1627 |
| 240018 | 19.0671 | 20.8501 | 18.4268 | 19.4219 |
| 240019 | 20.9869 | 22.1501 | 23.1477 | 22.1062 |
| 240020 | 19.5727 | 21.1937 | 20.8849 | 20.5389 |
| 240021 | 17.3968 | 18.7515 | 20.1457 | 18.6569 |
| 240022 | 19.1554 | 21.7889 | 21.3234 | 20.7594 |
| 240023 | 20.3923 | 21.5087 | 22.8224 | 21.4999 |
| 240025 | 17.2464 | 18.8345 | 20.0308 | 18.7384 |
| 240027 | 16.2531 | 19.1017 | 16.7758 | 17.3367 |
| 240028 | 19.3781 | 19.7918 | 25.1934 | 21.5071 |
| 240029 | 17.9880 | 21.1329 | 20.0164 | 19.6781 |
| 240030 | 18.4358 | 18.8547 | 20.1653 | 19.1669 |
| 240031 | 18.0652 | 18.1566 | 19.3983 | 18.5009 |
| 240036 | 20.3270 | 22.2460 | 22.1721 | 21.6421 |
| 240037 | 18.4564 | 19.2345 | 20.1195 | 19.3188 |
| 240038 | 26.3539 | 25.3061 | 24.3957 | 25.3169 |
| 240040 | 19.9022 | 20.4813 | 23.1352 | 21.0482 |
| 240041 | 19.2127 | 19.2864 | 21.8655 | 20.0389 |
| 240043 | 17.3064 | 17.7335 | 16.9859 | 17.3013 |
| 240044 | 18.9217 | 18.8411 | 20.3339 | 19.3394 |
| 240045 | 20.9873 | 21.1396 | 24.1557 | 22.0716 |
| 240047 | 21.8576 | 22.6152 | 23.8098 | 22.7467 |
| 240048 | 23.3110 | * | * | 23.3110 |
| 240049 | 22.1345 | * | * | 22.1345 |
| 240050 | 24.5027 | 25.2983 | 21.6499 | 22.6550 |
| 240051 | 18.2287 | 19.9195 | 22.5855 | 20.1307 |
| 240052 | 19.2190 | 20.7749 | * | 19.9948 |
| 240053 | 21.1987 | 22.9611 | 23.8693 | 22.7802 |
| 240056 | 22.2927 | 23.4226 | 23.7139 | 23.1375 |
| 240057 | 23.2377 | 24.2159 | 24.8686 | 24.1392 |
| 240058 | 14.9141 | 14.9697 | 18.4009 | 15.9713 |
| 240059 | 21.9575 | 23.6215 | 23.7808 | 23.1092 |
| 240061 | 25.5581 | 27.2603 | 25.9951 | 26.2655 |
| 240063 | 23.5426 | 23.7866 | 24.4031 | 23.9101 |
| 240064 | 20.7602 | 23.2860 | 22.8578 | 22.2645 |
| 240065 | 12.5547 | 12.7867 | 14.8734 | 13.4307 |
| 240066 | 22.0542 | 23.0698 | 24.1143 | 23.1023 |
| 240069 | 19.1834 | 19.8282 | 21.7991 | 20.2573 |
| 240071 | 19.1913 | 20.2101 | 21.2463 | 20.2337 |
| 240072 | 18.0015 | 21.1824 | 20.9529 | 20.0007 |
| 240073 | 15.6318 | 16.0840 | 17.3559 | 16.3592 |
| 240075 | 21.1934 | 21.2654 | 21.3357 | 21.2661 |
| 240076 | 21.0702 | 21.8795 | 22.3280 | 21.7859 |
| 240077 | 14.9493 | 15.3794 | 20.3445 | 16.8827 |
| 240078 | 22.7122 | 23.9150 | 25.1082 | 23.9382 |
| 240079 | 17.8206 | 18.4338 | 18.8345 | 18.3648 |
| 240080 | 23.7286 | 24.3399 | 25.5619 | 24.7160 |
| 240082 | 18.0272 | 18.3555 | 18.7995 | 18.3952 |
| 240083 | 19.2922 | 19.7637 | 21.0317 | 20.0094 |
| 240084 | 19.6078 | 19.4739 | 21.7421 | 20.2965 |
| 240085 | 18.0214 | 22.5736 | 20.9778 | 20.5540 |
| 240086 | 15.3302 | 16.9392 | 18.1401 | 16.9654 |
| 240087 | 17.0624 | 18.8352 | 21.3323 | 19.0315 |
| 240088 | 21.0202 | 21.6858 | 23.1056 | 21.8928 |
| 240089 | 18.4171 | 20.7239 | 21.1989 | 20.0227 |
| 240090 | 18.0490 | 19.2968 | 19.2166 | 18.8331 |
| 240093 | 18.6788 | 18.7092 | 20.2400 | 19.2268 |
| 240094 | 20.5705 | 20.9446 | 22.0247 | 21.2053 |
| 240096 | 18.3365 | 20.1644 | 21.0417 | 19.7961 |
| 240097 | 23.6230 | 24.2662 | 27.9496 | 25.1295 |
| 240098 | 20.6036 | 21.3467 | 24.2296 | 22.0643 |
| 240099 | 14.3759 | 14.4649 | 15.4964 | 14.7485 |
| 240100 | 19.1921 | 20.8302 | 20.8325 | 20.3051 |
| 240101 | 17.7478 | 19.2120 | 19.9837 | 18.9205 |
| 240102 | 15.5644 | 14.6067 | 16.3659 | 15.5008 |
| 240103 | 16.8805 | 19.1540 | 18.7510 | 18.2532 |
| 240104 | 24.0175 | 23.2178 | 23.5351 | 23.5902 |
| 240105 | 14.7904 | 14.3965 | * | 14.6094 |
| 240106 | 23.7818 | 23.5148 | 23.5005 | 23.6022 |
| 240107 | 19.0299 | 20.3983 | 20.9004 | 20.0558 |
| 240108 | 16.4605 | 15.3547 | 18.2427 | 16.5529 |
| 240109 | 13.1537 | 13.5537 | 16.3216 | 14.2359 |
| 240110 | 17.2834 | 19.4828 | 21.0277 | 19.2199 |
| 240111 | 17.0408 | 17.2100 | 17.8617 | 17.3567 |
| 240112 | 15.3246 | 15.8350 | 16.6244 | 15.9308 |
| 240114 | 15.4919 | 16.2505 | 17.3682 | 16.3794 |
| 240115 | 22.1575 | 23.7765 | 23.8675 | 23.3187 |
| 240116 | 15.1757 | 16.6731 | 18.3520 | 16.6014 |
| 240117 | 17.5676 | 18.0636 | 17.9941 | 17.8845 |
| 240119 | 22.4981 | 20.6126 | 21.8289 | 21.5894 |
| 240121 | 21.3747 | 23.4018 | 22.2266 | 22.3266 |
| 240122 | 18.0396 | 19.1811 | 21.2876 | 19.5090 |
| 240123 | 15.5968 | 16.5098 | 18.3941 | 16.7420 |
| 240124 | 19.0505 | 19.4400 | 20.4728 | 19.6473 |
| 240125 | 13.1505 | 12.3627 | 14.9708 | 13.5694 |
| 240127 | 14.7670 | 15.8966 | 17.9724 | 16.1476 |
| 240128 | 16.0759 | 17.2513 | 16.3608 | 16.5520 |
| 240129 | 15.4226 | 14.4212 | 16.5209 | 15.4258 |
| 240130 | 15.6477 | 14.9399 | 16.4271 | 15.6650 |
| 240132 | 24.4998 | 23.0669 | 23.1452 | 23.5239 |
| 240133 | 18.5216 | 19.2126 | 19.5293 | 19.1081 |
| 240135 | 13.6014 | 14.3069 | 15.7015 | 14.4270 |
| 240137 | 19.1770 | 20.3750 | 21.5073 | 20.3195 |
| 240138 | 13.7359 | 15.2062 | 16.7332 | 15.1922 |
| 240139 | 17.0163 | 20.8053 | 20.5496 | 19.6213 |
| 240141 | 21.9909 | 23.8066 | 23.1009 | 22.9648 |
| 240142 | 20.6139 | 25.2770 | 29.2238 | 24.5024 |
| 240143 | 14.2790 | 16.6172 | 20.4266 | 16.9078 |
| 240144 | 15.8710 | 18.2604 | 21.4469 | 18.2664 |
| 240145 | 14.9997 | 17.2778 | 19.0689 | 17.4197 |
| 240146 | 16.7496 | 16.0652 | 16.5412 | 16.4544 |
| 240148 | 11.3388 | 18.8779 | 19.5204 | 16.6060 |
| 240150 | 12.8255 | 13.8786 | 20.8331 | 15.4453 |
| 240152 | 20.2020 | 21.1678 | 22.4744 | 21.2973 |
| 240153 | 15.6079 | 16.5412 | 19.3336 | 17.0363 |
| 240154 | 17.0625 | 17.5769 | 21.5052 | 18.6158 |
| 240155 | 20.4189 | 19.8762 | 20.9385 | 20.4180 |
| 240157 | 14.6914 | 17.4168 | 13.7309 | 15.3007 |
| 240160 | 16.6034 | 15.9492 | 15.9014 | 16.1454 |
| 240161 | 15.4160 | 15.7996 | 16.8809 | 15.9681 |
| 240162 | 19.0404 | 16.6292 | 19.1542 | 18.1964 |
| 240163 | 17.8714 | 18.8320 | 20.4760 | 18.9698 |
| 240166 | 16.3907 | 17.3233 | 19.4131 | 17.7688 |
| 240169 | 18.6155 | 16.6725 | 16.3958 | 17.2174 |
| 240170 | 17.6501 | 18.8762 | 20.3779 | 18.9004 |
| 240171 | 16.7237 | 17.2886 | 18.5172 | 17.5402 |
| 240172 | 16.0711 | 18.2852 | 20.8606 | 18.2323 |
| 240173 | 16.7411 | 17.2655 | 18.5187 | 17.5027 |
| 240179 | 16.6464 | 17.5116 | 20.4004 | 18.1225 |
| 240184 | 14.3996 | 15.3793 | 16.8917 | 15.4746 |
| 240187 | 17.5154 | 19.9230 | 21.2736 | 19.5789 |
| 240193 | 16.3004 | 17.8226 | 18.4664 | 17.4827 |
| 240196 | 23.2666 | 24.3472 | 25.3479 | 24.3358 |
| 240200 | 14.7295 | 14.3415 | 14.9076 | 14.6539 |
| 240207 | 23.3339 | 24.1127 | 25.2814 | 24.2879 |
| 240210 | 23.8391 | 24.2218 | 24.5664 | 24.2274 |
| 240211 | 20.5548 | 19.7399 | 30.6260 | 22.1746 |
| 250001 | 18.1407 | 18.4233 | 19.2756 | 18.6319 |
| 250002 | 15.6036 | 17.2501 | 18.6938 | 17.1218 |
| 250003 | 15.6560 | 17.6539 | 16.7570 | 16.6622 |
| 250004 | 17.1177 | 17.8868 | 18.3860 | 17.7913 |
| 250005 | 12.0032 | 12.5993 | 12.5834 | 12.3909 |
| 250006 | 15.7036 | 16.9048 | 17.5192 | 16.6995 |
| 250007 | 19.1555 | 19.2913 | 19.7562 | 19.3984 |
| 250008 | 13.3179 | 14.1760 | 15.8506 | 14.4224 |
| 250009 | 16.1847 | 18.5610 | 17.7283 | 17.5396 |
| 250010 | 13.3372 | 13.3905 | 14.6101 | 13.7324 |
| 250012 | 18.4756 | 14.1623 | 16.7579 | 16.4800 |
| 250015 | 11.0747 | 13.5274 | 11.7249 | 11.9737 |
| 250017 | 17.3006 | 17.9410 | 20.5976 | 18.5334 |
| 250018 | 13.4707 | 11.9311 | 13.1687 | 12.7895 |
| 250019 | 17.1501 | 16.7425 | 18.0956 | 17.3536 |
| 250020 | 14.0618 | 13.4476 | 16.2698 | 14.4562 |
| 250021 | 9.0772 | 9.4318 | 10.5844 | 9.6552 |
| 250023 | 13.5440 | 13.9116 | 12.3434 | 13.2963 |
| 250024 | 11.5940 | 12.7127 | 12.9899 | 12.4525 |
| 250025 | 17.8890 | 19.0390 | 20.3625 | 19.2022 |
| 250027 | 12.4241 | 14.9519 | 14.5445 | 13.9032 |
| 250029 | 14.8456 | 16.4834 | 16.0682 | 15.8412 |
| 250030 | 13.6277 | 17.3636 | 26.6173 | 19.2750 |
| 250031 | 18.7663 | 17.9715 | 18.3825 | 18.3676 |
| 250032 | 17.2983 | 17.1339 | 17.5957 | 17.3467 |
| 250033 | 15.7646 | 17.8257 | 15.0941 | 16.2509 |
| 250034 | 18.1269 | 16.6988 | 17.0399 | 17.2230 |
| 250035 | 17.4148 | 15.2353 | 16.8349 | 16.3942 |
| 250036 | 13.7928 | 15.8445 | 16.1913 | 15.3676 |
| 250037 | 10.3212 | 15.4325 | 12.7156 | 12.4979 |
| 250038 | 13.6207 | 16.8454 | 17.7019 | 16.0182 |
| 250039 | 16.5105 | 14.1556 | 15.1409 | 15.2552 |
| 250040 | 15.6367 | 17.3430 | 18.3364 | 17.1495 |
| 250042 | 16.4728 | 16.3867 | 17.6531 | 16.8406 |
| 250043 | 13.6492 | 16.0729 | 16.6500 | 15.4718 |
| 250044 | 16.7462 | 16.1218 | 16.7321 | 16.5323 |
| 250045 | 19.4788 | 22.0839 | 21.8988 | 21.2480 |
| 250047 | 12.0953 | 13.3706 | 14.7461 | 13.3242 |
| 250048 | 15.7073 | 16.8932 | 17.6649 | 16.7793 |
| 250049 | 10.7578 | 11.6715 | 12.1635 | 11.5642 |
| 250050 | 13.9220 | 14.3949 | 15.1159 | 14.4819 |
| 250051 | 9.6017 | 9.3464 | 10.4900 | 9.8032 |
| 250057 | 14.2863 | 15.9237 | 16.1838 | 15.4582 |
| 250058 | 15.4206 | 15.5327 | 15.7197 | 15.5555 |
| 250059 | 14.2997 | 16.2845 | 16.6494 | 15.7755 |
| 250060 | 7.9882 | 13.0301 | 16.1804 | 11.2768 |
| 250061 | 13.9655 | 11.0308 | 11.5108 | 11.9846 |
| 250063 | 14.9743 | 13.2540 | 13.3092 | 13.7869 |
| 250065 | 12.6803 | 12.8853 | 13.6904 | 13.0682 |
| 250066 | 14.3274 | 15.6760 | 16.1742 | 15.4025 |
| 250067 | 15.2871 | 16.4120 | 16.8522 | 16.2039 |
| 250068 | 11.4272 | 13.6768 | 13.4127 | 12.8087 |
| 250069 | 15.7653 | 17.8960 | 16.8980 | 16.8834 |
| 250071 | 11.2079 | 14.3781 | 12.3488 | 12.5425 |
| 250072 | 16.9263 | 18.2218 | 18.9487 | 18.0776 |
| 250076 | * | 10.5098 | * | 10.5098 |
| 250077 | 11.4135 | 12.2564 | 13.7404 | 12.5026 |
| 250078 | 15.4571 | 15.6336 | 15.9739 | 15.6895 |
| 250079 | 19.0587 | 16.2712 | 16.5835 | 17.1998 |
| 250081 | 16.1412 | 17.3325 | 19.0358 | 17.4600 |
| 250082 | 14.0249 | 16.0975 | 17.1427 | 15.7611 |
| 250083 | 9.2019 | 14.2634 | 16.6065 | 13.1746 |
| 250084 | 19.7390 | 17.0189 | 20.6429 | 19.0165 |
| 250085 | 13.8487 | 14.3797 | 15.4477 | 14.5716 |
| 250088 | 16.7514 | 17.8674 | 18.2736 | 17.6409 |
| 250089 | 13.0481 | 13.4238 | 14.3027 | 13.5884 |
| 250093 | 15.0918 | 15.2044 | 16.1506 | 15.4926 |
| 250094 | 17.8539 | 18.0852 | 18.5063 | 18.1422 |
| 250095 | 16.3574 | 17.0039 | 17.4217 | 16.9079 |
| 250096 | 17.0713 | 19.0688 | 19.0584 | 18.3546 |
| 250097 | 18.4099 | 16.9905 | 15.5741 | 16.9320 |
| 250098 | 14.3017 | 13.1341 | 18.3874 | 15.0909 |
| 250099 | 14.4142 | 14.8528 | 15.1265 | 14.8018 |
| 250100 | 16.6033 | 17.1682 | 17.8688 | 17.2128 |
| 250101 | 16.3083 | 18.4685 | 17.7194 | 17.5079 |
| 250102 | 20.0190 | 23.9329 | 18.9348 | 20.8793 |
| 250104 | 17.5421 | 18.2502 | 18.7651 | 18.1832 |
| 250105 | 14.5986 | 14.5401 | 15.5133 | 14.8921 |
| 250107 | 13.6296 | 15.1496 | 15.0737 | 14.6455 |
| 250109 | 14.5496 | 22.1551 | 21.3867 | 18.8951 |
| 250112 | 14.2023 | 15.5610 | 16.3640 | 15.3179 |
| 250117 | 14.5171 | 16.1225 | 16.9787 | 15.9014 |
| 250119 | 12.7379 | 15.2199 | 16.1218 | 14.6728 |
| 250120 | 14.4126 | 15.3433 | 16.7182 | 15.4420 |
| 250122 | 17.7079 | 18.9417 | 19.2990 | 18.6619 |
| 250123 | 17.4068 | 18.8690 | 18.7863 | 18.3698 |
| 250124 | 12.6677 | 13.1823 | 13.2490 | 13.0310 |
| 250125 | 14.4867 | 20.8895 | 21.2660 | 18.4338 |
| 250126 | 14.7083 | 18.2355 | 21.9101 | 17.8900 |
| 250128 | 12.9968 | 14.0048 | 16.1418 | 14.4375 |
| 250131 | 10.2765 | 12.6056 | 12.4557 | 11.6657 |
| 250134 | 17.9755 | 17.0671 | 18.5142 | 17.8554 |
| 250136 | 18.0538 | 18.9689 | 21.3497 | 19.3579 |
| 250138 | 17.5999 | 18.4028 | 20.4550 | 18.6918 |
| 250141 | 17.1247 | 19.0113 | 19.6692 | 18.6505 |
| 250145 | 11.4047 | 10.2507 | 11.2120 | 10.9506 |
| 250146 | 13.2763 | 14.4924 | 14.7781 | 14.1955 |
| 250148 | 14.8234 | 18.0980 | 19.4233 | 17.4956 |
| 250149 | 12.9840 | 12.9569 | 15.2318 | 13.7102 |
| 250150 | * | * | 21.8599 | 21.8599 |
| 260001 | 17.5520 | 18.0971 | 20.1560 | 18.5941 |
| 260002 | 20.5878 | 22.1183 | 21.6597 | 21.4585 |
| 260003 | 14.3537 | 14.6553 | 15.4482 | 14.8108 |
| 260004 | 13.7528 | 13.0133 | 13.7035 | 13.4793 |
| 260005 | 19.7058 | 19.5554 | 23.9681 | 21.0036 |
| 260006 | 18.9408 | 19.7467 | 20.0994 | 19.6144 |
| 260008 | 16.2451 | 13.8495 | 16.8893 | 15.5719 |
| 260009 | 17.9364 | 18.5080 | 18.2863 | 18.2469 |
| 260011 | 18.3378 | 19.1027 | 19.5059 | 18.9819 |
| 260012 | 14.4594 | 14.3645 | 17.1662 | 15.3316 |
| 260013 | 15.5388 | 15.9884 | 16.1825 | 15.8932 |
| 260015 | 21.3327 | 16.5822 | 17.8817 | 18.4578 |
| 260017 | 15.8013 | 16.7916 | 16.9914 | 16.5434 |
| 260018 | 12.2293 | 12.0060 | 12.5301 | 12.2688 |
| 260019 | 23.6727 | 18.6113 | * | 20.6992 |
| 260020 | 21.8585 | 20.5142 | 20.2241 | 20.8205 |
| 260021 | 17.5694 | 22.1017 | 21.6237 | 20.1803 |
| 260022 | 19.3454 | 17.2462 | 17.7772 | 17.8898 |
| 260023 | 15.8235 | 16.4705 | 17.8649 | 16.6827 |
| 260024 | 13.4737 | 15.2356 | 15.7815 | 14.8371 |
| 260025 | 14.9377 | 15.4935 | 17.0965 | 15.8836 |
| 260027 | 21.0084 | 21.2977 | 22.0362 | 21.4252 |
| 260029 | 17.4744 | 19.7484 | 21.1858 | 19.3784 |
| 260030 | 11.2434 | 12.5118 | 11.9215 | 11.8847 |
| 260031 | 18.3039 | 19.4921 | 19.7249 | 19.1438 |
| 260032 | 20.8097 | 20.1988 | 19.6728 | 20.2222 |
| 260034 | 17.8986 | 17.4233 | 20.4902 | 18.5746 |
| 260035 | 12.5886 | 13.1065 | 13.0071 | 12.9052 |
| 260036 | 18.3128 | 16.7430 | 18.8104 | 17.9282 |
| 260039 | 14.1980 | 14.1866 | 14.6644 | 14.3527 |
| 260040 | 15.3853 | 17.3099 | 18.0140 | 16.9033 |
| 260042 | 17.4459 | 18.7567 | 18.7514 | 18.2697 |
| 260044 | 17.1177 | 15.9927 | 15.9206 | 16.3491 |
| 260047 | 17.2768 | 19.0112 | 19.2247 | 18.5386 |
| 260048 | 21.4309 | 20.0885 | 21.0602 | 20.8622 |
| 260050 | 18.7366 | 15.6908 | 16.8520 | 17.0991 |
| 260052 | 17.7502 | 18.0553 | 18.0914 | 17.9657 |
| 260053 | 12.0098 | 15.2236 | 16.5166 | 14.4005 |
| 260054 | 17.3708 | 20.0199 | 20.6242 | 19.2873 |
| 260055 | 13.7961 | 12.0118 | 15.4214 | 13.6790 |
| 260057 | 15.3276 | 17.4636 | 19.7144 | 17.7259 |
| 260059 | 15.7887 | 16.1000 | 17.0546 | 16.3478 |
| 260061 | 15.0099 | 14.7175 | 15.7112 | 15.1405 |
| 260062 | 20.2655 | 20.1477 | 21.3138 | 20.5946 |
| 260063 | 16.8474 | 18.2309 | 18.8973 | 17.9893 |
| 260064 | 16.5033 | 16.5934 | 17.8033 | 16.9429 |
| 260065 | 18.4654 | 19.4382 | 20.0975 | 19.3238 |
| 260066 | 14.4163 | 14.9640 | 15.3460 | 14.8934 |
| 260067 | 12.1588 | 14.2249 | 15.1837 | 13.8617 |
| 260068 | 19.8261 | 20.2418 | 19.4240 | 19.8242 |
| 260070 | 21.6873 | * | 13.9510 | 17.3672 |
| 260073 | 13.0075 | 14.2550 | 15.9182 | 14.4333 |
| 260074 | 15.4480 | 19.0350 | 19.8915 | 18.1123 |
| 260077 | 18.2594 | 18.6473 | 19.4482 | 18.8035 |
| 260078 | 15.4754 | 15.6381 | 14.9463 | 15.3700 |
| 260079 | 14.8281 | 14.2985 | 16.1453 | 15.0169 |
| 260080 | 12.5631 | 13.5384 | 14.6832 | 13.5392 |
| 260081 | 18.9629 | 21.0151 | 20.3053 | 20.0653 |
| 260082 | 15.7880 | 15.9407 | 15.9858 | 15.9090 |
| 260085 | 19.5153 | 20.4669 | 20.7051 | 20.2110 |
| 260086 | 14.8730 | 14.3164 | 15.2927 | 14.8291 |
| 260091 | 19.6081 | 19.9987 | 21.5464 | 20.5925 |
| 260094 | 15.8705 | 18.0085 | 18.5395 | 17.5281 |
| 260095 | 19.7672 | 19.6944 | 20.7292 | 20.0618 |
| 260096 | 21.7176 | 23.0282 | 22.5972 | 22.4661 |
| 260097 | 15.7899 | 16.5582 | 19.0632 | 17.1704 |
| 260100 | 15.7324 | 15.7047 | 16.6523 | 16.0345 |
| 260102 | 16.3653 | 20.1264 | 20.6361 | 18.8983 |
| 260103 | 17.3541 | 18.5957 | 19.7146 | 18.4987 |
| 260104 | 19.1158 | 21.0138 | 20.3176 | 20.0928 |
| 260105 | 20.8006 | 24.7223 | 24.8181 | 23.3052 |
| 260107 | 18.4618 | 19.8422 | 20.4269 | 19.5069 |
| 260108 | 19.2422 | 19.4609 | 20.0034 | 19.5906 |
| 260109 | 13.4400 | 13.9129 | 14.8181 | 14.0725 |
| 260110 | 16.9952 | 17.8375 | 18.3227 | 17.7209 |
| 260113 | 14.8968 | 14.6756 | 16.2223 | 15.2316 |
| 260115 | 17.8971 | 19.2259 | 17.4698 | 18.2033 |
| 260116 | 14.5715 | 16.2774 | 14.9812 | 15.2548 |
| 260119 | 16.2000 | 16.8836 | 17.2942 | 16.7641 |
| 260120 | 17.1269 | 16.3755 | 16.4904 | 16.6414 |
| 260122 | 14.5390 | 14.9697 | 16.0931 | 15.2238 |
| 260123 | 13.9960 | 14.6444 | 14.6822 | 14.4496 |
| 260127 | 15.9481 | 18.3572 | 18.4026 | 17.5109 |
| 260128 | 11.2705 | 13.0481 | 12.6414 | 12.2813 |
| 260129 | 14.6353 | * | * | 14.6353 |
| 260131 | 19.7491 | 17.7686 | 18.4154 | 18.5978 |
| 260134 | 16.5834 | 16.2832 | 17.5127 | 16.7877 |
| 260137 | 15.2169 | 17.9531 | 19.4697 | 17.5188 |
| 260138 | 21.3885 | 22.6491 | 23.2364 | 22.4440 |
| 260141 | 17.9598 | 19.1580 | 19.1893 | 18.7555 |
| 260142 | 16.0299 | 17.1248 | 17.3084 | 16.7937 |
| 260143 | 11.9389 | 12.7867 | 13.9040 | 12.7859 |
| 260147 | 13.6568 | 14.0778 | 14.7769 | 14.1672 |
| 260148 | 10.3383 | 11.8674 | 11.3524 | 11.2072 |
| 260158 | 12.4020 | 12.3005 | 12.7699 | 12.4966 |
| 260159 | 18.2232 | 20.3177 | 19.7951 | 19.3893 |
| 260160 | 16.1922 | 15.8394 | 16.5792 | 16.2009 |
| 260162 | 20.7103 | 19.5655 | 21.4099 | 20.5728 |
| 260163 | 14.8051 | 16.4245 | 15.8593 | 15.6940 |
| 260164 | 14.3089 | 14.9372 | 15.1211 | 14.8191 |
| 260166 | 19.5343 | 20.1025 | 21.1224 | 20.2675 |
| 260172 | 12.4851 | 15.4163 | 16.0772 | 14.6285 |
| 260173 | 11.9777 | 12.8523 | 14.2090 | 13.1471 |
| 260175 | 16.2940 | 16.9023 | 17.5625 | 16.9246 |
| 260176 | 19.5449 | 26.8712 | 21.6044 | 22.7500 |
| 260177 | 20.7457 | 21.2578 | 21.9014 | 21.3180 |
| 260178 | 21.4080 | 19.6638 | 20.2796 | 20.4480 |
| 260179 | 20.7397 | 21.4906 | 22.7185 | 21.6624 |
| 260180 | 18.5398 | 19.5819 | 18.9881 | 19.0361 |
| 260183 | 20.1940 | 20.0712 | 21.3175 | 20.5306 |
| 260186 | 18.0588 | 19.3238 | 19.6026 | 19.0698 |
| 260188 | 18.5772 | 20.6388 | 22.5060 | 20.5016 |
| 260189 | 10.7518 | 11.3004 | 16.4233 | 12.7425 |
| 260190 | 18.1639 | 18.5168 | 19.3419 | 18.6978 |
| 260191 | 19.3386 | 17.9812 | 18.1604 | 18.4767 |
| 260193 | 20.5055 | 21.1588 | 20.2577 | 20.6284 |
| 260195 | 15.9518 | 17.7237 | 19.7068 | 17.8042 |
| 260197 | 16.4605 | 19.2840 | 20.5453 | 18.3884 |
| 260198 | 17.6381 | 11.9751 | 19.7552 | 15.6949 |
| 260200 | 18.8755 | 20.5339 | 20.6888 | 20.0233 |
| 260205 | * | 17.6210 | * | 17.6210 |
| 270002 | 17.1866 | 28.9959 | 19.2387 | 20.5385 |
| 270003 | 22.1299 | 22.0995 | 22.5019 | 22.2424 |
| 270004 | 21.3442 | 19.6292 | 19.4834 | 20.1660 |
| 270006 | 16.1872 | 16.0238 | 17.0715 | 16.3653 |
| 270007 | 13.1679 | 11.3143 | 13.8824 | 12.6774 |
| 270009 | 17.7016 | 17.2292 | 20.8238 | 18.5056 |
| 270011 | 19.8229 | 20.2669 | 21.1653 | 20.3748 |
| 270012 | 22.8770 | 19.7346 | 19.7878 | 20.8557 |
| 270013 | 20.4012 | * | * | 20.4012 |
| 270014 | 18.5595 | 19.0872 | 19.9859 | 19.2205 |
| 270016 | 19.7675 | 19.6717 | 18.6149 | 19.4350 |
| 270017 | 19.5798 | 21.0800 | 20.0152 | 20.2382 |
| 270019 | 12.7812 | 18.1099 | 15.4128 | 15.4635 |
| 270021 | 16.6541 | 17.1787 | 16.9457 | 16.9258 |
| 270023 | 20.3641 | 22.2639 | 22.7181 | 21.7139 |
| 270026 | 15.6381 | 17.5102 | 18.0568 | 17.0775 |
| 270027 | 9.7758 | 13.1392 | 17.2091 | 12.8885 |
| 270028 | 17.2132 | 21.1492 | 19.1177 | 19.1160 |
| 270029 | 17.8852 | 16.5666 | 17.3710 | 17.2639 |
| 270032 | 17.0285 | 17.7393 | 18.7811 | 17.8749 |
| 270033 | 16.4554 | 16.9602 | 18.4876 | 17.2764 |
| 270035 | 17.6482 | 16.8295 | 16.4302 | 16.9974 |
| 270036 | 14.0815 | 14.2537 | 16.8552 | 14.8821 |
| 270039 | 15.3501 | 15.9368 | 19.6796 | 16.7774 |
| 270040 | 19.1901 | 18.8145 | 20.1242 | 19.3585 |
| 270041 | 16.7791 | 19.0327 | 25.8153 | 19.7981 |
| 270044 | 13.4559 | 16.7710 | 17.5137 | 15.8620 |
| 270046 | 17.1048 | * | * | 17.1048 |
| 270048 | 15.8403 | 17.0154 | 18.0666 | 16.8972 |
| 270049 | 21.1670 | 22.2444 | 22.2540 | 21.8899 |
| 270050 | 18.0448 | 16.7110 | 19.9356 | 18.1546 |
| 270051 | 18.9468 | 20.2735 | 20.1950 | 19.8100 |
| 270052 | 14.8042 | 14.4773 | 14.7009 | 14.6552 |
| 270057 | 20.0080 | 21.1317 | 20.6714 | 20.6119 |
| 270058 | 14.0669 | 14.7481 | 16.1412 | 14.9510 |
| 270059 | 15.5957 | 14.7530 | 19.1808 | 16.3576 |
| 270060 | 14.0212 | 15.2727 | 20.4148 | 16.5316 |
| 270063 | 14.2287 | 12.6108 | 15.1049 | 13.8837 |
| 270073 | 15.5281 | 14.4569 | 16.1937 | 15.3359 |
| 270079 | 15.0277 | 15.6873 | 16.7048 | 15.7603 |
| 270080 | 14.0437 | 16.3171 | 15.0705 | 15.0926 |
| 270081 | 15.5207 | 15.6262 | 16.7389 | 15.9424 |
| 270082 | 16.1280 | 17.3443 | 23.1245 | 18.7794 |
| 270083 | 20.8231 | 18.4432 | 17.8554 | 18.9597 |
| 270084 | 16.2075 | 16.6243 | 16.2958 | 16.3734 |
| 280001 | 17.8928 | 17.3541 | 18.1831 | 17.7825 |
| 280003 | 21.9957 | 22.3179 | 23.0213 | 22.4564 |
| 280005 | 18.7477 | 19.2405 | 23.6949 | 20.6104 |
| 280009 | 18.7541 | 19.8145 | 20.9643 | 19.8453 |
| 280010 | 16.5417 | 17.4859 | 20.0462 | 17.5272 |
| 280011 | 13.9627 | 15.8573 | 15.9614 | 15.3328 |
| 280012 | 16.4079 | * | * | 16.4079 |
| 280013 | 22.1767 | 22.8063 | 22.5163 | 22.5039 |
| 280014 | 15.2414 | 15.9596 | 16.8368 | 15.9667 |
| 280015 | 14.6353 | 17.0281 | 16.6939 | 16.1405 |
| 280017 | 14.1897 | 14.2059 | 13.9939 | 14.1278 |
| 280018 | 14.8492 | 15.1328 | 15.4496 | 15.1512 |
| 280020 | 19.3963 | 19.9667 | 21.2467 | 20.2637 |
| 280021 | 16.6949 | 17.1048 | 17.6345 | 17.1389 |
| 280022 | 15.7059 | 16.7179 | 16.8184 | 16.3693 |
| 280023 | 21.2387 | 25.8494 | 22.3433 | 23.0540 |
| 280024 | 13.9115 | 14.2186 | 15.0380 | 14.3613 |
| 280025 | 14.2701 | 15.5850 | 21.4764 | 16.6875 |
| 280026 | 16.0599 | 16.6861 | 16.5851 | 16.4520 |
| 280028 | 15.8871 | 17.3176 | 18.0793 | 17.1201 |
| 280029 | 19.0519 | 23.1292 | 24.4359 | 21.9196 |
| 280030 | 28.7091 | 24.5366 | 24.7723 | 25.8891 |
| 280031 | 13.2242 | 13.5654 | 9.6321 | 12.1542 |
| 280032 | 19.3884 | 18.8964 | 19.1191 | 19.1301 |
| 280033 | 14.9334 | 15.7583 | 17.4745 | 16.1329 |
| 280034 | 15.2821 | * | * | 15.2821 |
| 280035 | 15.3304 | 15.9170 | 16.6872 | 15.8969 |
| 280037 | 16.1684 | 16.7952 | 17.1064 | 16.6926 |
| 280038 | 16.4685 | 17.0878 | 18.2503 | 17.2635 |
| 280039 | 15.1916 | 16.0442 | 16.1587 | 15.8239 |
| 280040 | 18.9717 | 19.5333 | 20.9896 | 19.8846 |
| 280041 | 13.3901 | 16.4083 | 16.5503 | 15.4920 |
| 280042 | 15.3029 | 16.1191 | 16.6239 | 16.0122 |
| 280043 | 15.7858 | 16.6570 | 17.5937 | 16.7160 |
| 280045 | 14.2741 | 16.9048 | 15.7630 | 15.6286 |
| 280046 | 13.7155 | 17.9221 | 17.3214 | 16.1724 |
| 280047 | 18.3743 | 18.3407 | 17.4735 | 18.0424 |
| 280048 | 14.0702 | 15.8723 | 15.8100 | 15.1939 |
| 280049 | 15.6343 | 18.3605 | 18.4365 | 17.4677 |
| 280050 | 15.3413 | 16.6432 | 20.0379 | 17.6064 |
| 280051 | 15.8504 | 15.6336 | 17.1942 | 16.1502 |
| 280052 | 13.6489 | 14.0819 | 14.1201 | 13.9629 |
| 280054 | 17.5819 | 18.7992 | 18.7575 | 18.3765 |
| 280055 | 12.9933 | 13.5667 | 13.8129 | 13.4587 |
| 280056 | 14.0151 | 12.6475 | 15.6135 | 14.0018 |
| 280057 | 15.7623 | 18.0454 | 20.0686 | 17.7576 |
| 280058 | 17.8798 | 19.6752 | 21.4868 | 19.6876 |
| 280060 | 28.6047 | 19.7527 | 20.7022 | 22.2434 |
| 280061 | 17.9511 | 17.1629 | 18.6370 | 17.9240 |
| 280062 | 13.6738 | 14.4896 | 15.6018 | 14.6170 |
| 280064 | 15.5092 | 16.2977 | 16.8330 | 16.2046 |
| 280065 | 18.5327 | 19.2932 | 20.7370 | 19.5513 |
| 280066 | 11.6416 | 11.6621 | 11.7207 | 11.6766 |
| 280068 | 10.1327 | 9.4943 | 10.5987 | 10.0463 |
| 280070 | 13.7353 | 17.7400 | 22.6201 | 17.5276 |
| 280073 | 17.0583 | 17.4244 | 17.7698 | 17.4266 |
| 280074 | 15.2182 | 16.4310 | 17.3143 | 16.2521 |
| 280075 | 13.7875 | 15.5327 | 13.2230 | 14.1041 |
| 280076 | 13.9203 | 14.8469 | 16.7488 | 15.0947 |
| 280077 | 19.0145 | 19.2068 | 20.0148 | 19.4096 |
| 280079 | 9.9132 | 10.4540 | 16.6117 | 11.4307 |
| 280080 | 14.3528 | 15.3308 | 16.9487 | 15.6285 |
| 280081 | 20.9196 | 21.0771 | 20.9606 | 20.9873 |
| 280082 | 13.1250 | 14.3399 | 14.6173 | 14.0723 |
| 280083 | 17.5544 | 18.2992 | 21.5336 | 19.2134 |
| 280084 | 11.6868 | 12.5836 | 13.6536 | 12.6157 |
| 280085 | 21.5793 | 20.4302 | 20.4825 | 20.9817 |
| 280088 | 22.1147 | 20.2961 | * | 21.2560 |
| 280089 | 17.4696 | 18.1668 | 18.9567 | 18.1923 |
| 280090 | 14.7191 | 14.1362 | 15.1274 | 14.6962 |
| 280091 | 15.2184 | 15.8436 | 16.1866 | 15.7538 |
| 280092 | 14.1998 | 14.1945 | 14.7912 | 14.4303 |
| 280094 | 15.8843 | 17.6873 | 16.3474 | 16.6450 |
| 280097 | 14.2990 | 14.1734 | 13.8223 | 14.0824 |
| 280098 | 10.1686 | 13.0029 | 12.5875 | 12.0141 |
| 280101 | 17.4168 | 13.5261 | 16.9973 | 15.7528 |
| 280102 | 12.9367 | 14.0102 | * | 13.4735 |
| 280104 | 13.3842 | 13.2819 | 16.2167 | 14.1456 |
| 280105 | 18.7851 | 18.6575 | 21.0735 | 19.5325 |
| 280106 | 15.5396 | 16.1247 | 16.0679 | 15.9189 |
| 280107 | 13.4553 | 13.3311 | 14.4679 | 13.7065 |
| 280108 | 17.2185 | 17.5625 | 17.1961 | 17.3277 |
| 280109 | 11.0622 | 12.6803 | 12.4408 | 12.0678 |
| 280110 | 12.2950 | 12.7546 | 14.2136 | 13.0914 |
| 280111 | 23.0856 | 21.8773 | 19.6283 | 21.4131 |
| 280114 | 13.5580 | 15.7160 | 17.3076 | 15.4628 |
| 280115 | 16.4282 | 16.7041 | 18.1480 | 17.1049 |
| 280117 | 16.8216 | 17.7276 | 18.8279 | 17.8057 |
| 280118 | 16.9228 | 16.8687 | 18.6524 | 17.4822 |
| 280123 | 20.7732 | 14.0637 | 11.8582 | 15.0281 |
| 280125 | * | 16.1332 | 16.3944 | 16.2644 |
| 290001 | 22.4188 | 22.8226 | 22.7450 | 22.6608 |
| 290002 | 20.9442 | 17.2554 | 16.5419 | 18.3712 |
| 290003 | 25.0066 | 22.8840 | 24.2175 | 23.9864 |
| 290005 | 17.8609 | 19.4888 | 21.9814 | 19.6686 |
| 290006 | 19.8815 | 21.8070 | 22.4063 | 21.4371 |
| 290007 | 29.6864 | 29.7706 | 30.9075 | 30.1389 |
| 290008 | 20.2506 | 20.6190 | 24.1255 | 21.5150 |
| 290009 | 22.7399 | 23.3620 | 23.9373 | 23.3345 |
| 290010 | 14.4800 | 15.6423 | 16.4476 | 15.5219 |
| 290011 | 16.4419 | 20.1564 | 21.1234 | 19.0261 |
| 290012 | 21.5139 | 21.8275 | 25.0430 | 22.8581 |
| 290013 | 17.0883 | 18.2713 | 15.7932 | 17.0224 |
| 290014 | 18.3755 | 18.9743 | 18.7829 | 18.7144 |
| 290015 | 17.8303 | 22.3487 | 19.4504 | 19.7229 |
| 290016 | 12.7869 | 14.3542 | 23.8656 | 16.2244 |
| 290019 | 20.9336 | 21.2509 | 22.2045 | 21.4895 |
| 290020 | 26.1502 | 20.8733 | 21.2380 | 22.7207 |
| 290021 | 21.1250 | 21.5806 | 22.9488 | 21.8726 |
| 290022 | 24.0856 | 24.5468 | 25.5011 | 24.7398 |
| 290027 | 16.4289 | 16.7786 | 13.3769 | 15.4098 |
| 290032 | 22.7882 | 22.8447 | 23.9504 | 23.1730 |
| 290036 | 18.6112 | * | 12.9074 | 15.9259 |
| 290038 | 23.1402 | 20.6753 | 27.7030 | 22.6435 |
| 290039 | 25.8004 | 25.3864 | 25.5024 | 25.5429 |
| 290041 | * | * | 25.9905 | 25.9905 |
| 290042 | * | * | 18.7527 | 18.7527 |
| 290043 | * | * | 27.9053 | 27.9053 |
| 300001 | 21.4192 | 22.0909 | 23.8567 | 22.4761 |
| 300003 | 23.3777 | 22.9111 | 24.1297 | 23.4634 |
| 300005 | 19.9876 | 20.7545 | 22.2858 | 20.9804 |
| 300006 | 18.9331 | 23.7793 | 18.9745 | 20.5179 |
| 300007 | 19.3447 | 20.2372 | 20.6325 | 20.0620 |
| 300008 | 16.4649 | 20.7702 | 19.6149 | 18.9666 |
| 300009 | 20.0057 | 18.0602 | 20.0938 | 19.3221 |
| 300010 | 19.3833 | 19.3940 | 20.2130 | 19.6671 |
| 300011 | 21.2429 | 22.4325 | 23.0279 | 22.1850 |
| 300012 | 23.8859 | 24.5673 | 24.5619 | 24.3251 |
| 300013 | 18.9664 | 19.1247 | 20.1669 | 19.4250 |
| 300014 | 19.7969 | 20.3292 | 20.1774 | 20.0987 |
| 300015 | 19.9308 | 20.4916 | 19.6627 | 20.0406 |
| 300016 | 18.5037 | 21.8659 | 17.8148 | 19.4173 |
| 300017 | 22.3408 | 21.6563 | 22.7191 | 22.2414 |
| 300018 | 20.8947 | 21.2381 | 21.6385 | 21.2565 |
| 300019 | 20.6090 | 20.9753 | 19.6728 | 20.4155 |
| 300020 | 21.9725 | 21.9165 | 22.6627 | 22.2032 |
| 300021 | 17.3477 | 18.6211 | 19.3101 | 18.4253 |
| 300022 | 17.1864 | 18.3507 | 19.1875 | 18.2148 |
| 300023 | 20.3909 | 22.1210 | 22.7649 | 21.7833 |
| 300024 | 17.9460 | 19.9116 | 21.5842 | 19.6334 |
| 300028 | 18.0515 | 17.4075 | 20.0778 | 18.5816 |
| 300029 | 20.8961 | 22.5748 | 22.6013 | 22.0065 |
| 300033 | 19.8506 | 17.1869 | 17.1632 | 17.9333 |
| 300034 | 23.5215 | 25.5182 | 24.4975 | 24.5048 |
| 310001 | 27.5967 | 28.1329 | 27.4730 | 27.7287 |
| 310002 | 27.8735 | 28.3434 | 27.9728 | 28.0592 |
| 310003 | 27.4152 | 29.1096 | 27.5624 | 28.0099 |
| 310005 | 23.0493 | 22.1146 | 22.9712 | 22.6992 |
| 310006 | 21.5557 | 21.5957 | 22.0894 | 21.7417 |
| 310008 | 24.9483 | 23.5084 | 24.7618 | 24.4065 |
| 310009 | 23.1906 | 23.6371 | 21.7094 | 22.8601 |
| 310010 | 21.1064 | 22.5682 | 23.1060 | 22.2131 |
| 310011 | 23.4038 | 23.1977 | 24.2885 | 23.6223 |
| 310012 | 26.3249 | 26.5242 | 26.6772 | 26.5118 |
| 310013 | 22.1062 | 21.2251 | 22.5603 | 21.9726 |
| 310014 | 28.6964 | 27.4614 | 23.1956 | 26.3647 |
| 310015 | 26.7584 | 27.4331 | 27.9684 | 27.3934 |
| 310016 | 26.0518 | 24.3838 | 24.5206 | 24.9705 |
| 310017 | 26.0703 | 25.7902 | 24.5976 | 25.5018 |
| 310018 | 24.5312 | 22.8428 | 22.4779 | 23.3087 |
| 310019 | 23.0888 | 24.0542 | 24.9914 | 24.0619 |
| 310020 | 19.2663 | 24.1848 | 24.4152 | 22.3484 |
| 310021 | 22.6456 | 23.9369 | 25.4393 | 23.9309 |
| 310022 | 20.7276 | 21.2706 | 20.8258 | 20.9386 |
| 310024 | 22.7831 | 24.2353 | 24.9521 | 23.9428 |
| 310025 | 22.8129 | 24.3513 | 24.1812 | 23.7695 |
| 310026 | 23.8726 | 23.5491 | 22.1997 | 23.2228 |
| 310027 | 21.7666 | 21.8846 | 22.5696 | 22.0722 |
| 310028 | 23.5188 | 23.4577 | 23.9428 | 23.6444 |
| 310029 | 23.3801 | 22.6629 | 23.6610 | 23.2308 |
| 310031 | 25.1780 | 26.1567 | 26.6831 | 25.9979 |
| 310032 | 23.3017 | 24.3528 | 24.7404 | 24.1425 |
| 310034 | 21.6851 | 23.2729 | 24.1150 | 22.9962 |
| 310036 | 19.8178 | 20.1905 | 21.7187 | 20.5557 |
| 310037 | 27.4447 | 27.7823 | 28.1289 | 27.7758 |
| 310038 | 25.3832 | 26.7209 | 28.4893 | 26.9013 |
| 310039 | 22.0259 | 22.1754 | 22.7317 | 22.2988 |
| 310040 | 23.9864 | 26.1492 | 26.3573 | 25.4478 |
| 310041 | 23.7829 | 24.8960 | 23.5559 | 24.0709 |
| 310042 | 24.3292 | 23.2472 | 24.7678 | 24.1098 |
| 310043 | 22.0887 | 21.9022 | 21.6128 | 21.8925 |
| 310044 | 20.4309 | 21.6677 | 23.1549 | 21.6891 |
| 310045 | 28.1570 | 28.4854 | 28.9274 | 28.5212 |
| 310047 | 24.5225 | 25.1101 | 26.1921 | 25.2615 |
| 310048 | 23.3295 | 23.6118 | 25.2870 | 24.0821 |
| 310049 | 24.7617 | 24.8299 | 27.0842 | 25.4915 |
| 310050 | 22.5877 | 25.1752 | 24.7988 | 24.2032 |
| 310051 | 25.2762 | 27.1265 | 27.5378 | 26.5967 |
| 310052 | 22.5753 | 22.9326 | 23.3973 | 22.9809 |
| 310054 | 24.7413 | 26.1726 | 27.7376 | 26.1388 |
| 310057 | 20.4484 | 21.1686 | 22.2572 | 21.2802 |
| 310058 | 26.2243 | 26.5308 | 26.3765 | 26.3747 |
| 310060 | 19.1119 | 19.1992 | 20.0997 | 19.4729 |
| 310061 | 20.8023 | 23.2646 | 33.9582 | 25.0082 |
| 310062 | 19.2729 | 22.9073 | * | 21.3672 |
| 310063 | 21.8540 | 21.9045 | 22.1080 | 21.9521 |
| 310064 | 24.2115 | 24.8567 | 25.4822 | 24.8391 |
| 310067 | 22.2740 | 25.0888 | 23.9278 | 23.7333 |
| 310069 | 24.1662 | 23.7531 | 24.2329 | 24.0530 |
| 310070 | 25.0448 | 26.0903 | 28.2220 | 26.3630 |
| 310072 | 22.2231 | 21.7605 | 22.5611 | 22.1704 |
| 310073 | 25.6299 | 28.5149 | 26.2937 | 26.7849 |
| 310074 | 24.4638 | 23.8340 | 22.3588 | 23.6496 |
| 310075 | 26.4606 | 23.3266 | 24.4788 | 24.7522 |
| 310076 | 28.8981 | 30.0797 | 27.9918 | 29.0283 |
| 310077 | 25.0569 | 25.2500 | 26.1251 | 25.4460 |
| 310078 | 23.4788 | 23.8841 | 24.0587 | 23.7967 |
| 310081 | 23.8898 | 22.0762 | 22.4086 | 22.8084 |
| 310083 | 23.6761 | 23.8852 | 24.8204 | 24.1353 |
| 310084 | 24.0915 | 26.6753 | 24.6049 | 25.1157 |
| 310086 | 21.4350 | 22.1674 | 23.1719 | 22.2404 |
| 310087 | 20.8875 | 20.7243 | 21.1215 | 20.9125 |
| 310088 | 22.3419 | 22.3160 | 23.1722 | 22.6064 |
| 310090 | 24.2426 | 23.8284 | 24.8986 | 24.3109 |
| 310091 | 22.0103 | 22.7978 | 23.2969 | 22.6743 |
| 310092 | 22.3446 | 20.5165 | 21.6964 | 21.5200 |
| 310093 | 21.2302 | 22.4291 | 23.7251 | 22.4166 |
| 310096 | 26.3041 | 25.1572 | 24.5759 | 25.3591 |
| 310105 | 24.4851 | 25.5891 | 26.2537 | 25.4282 |
| 310108 | 22.8801 | 22.4756 | 23.8308 | 23.0488 |
| 310110 | 20.1400 | 21.8341 | 23.2146 | 21.7904 |
| 310111 | 21.7218 | 1.1066 | 22.1151 | 21.6430 |
| 310112 | 22.5213 | 23.6701 | 24.7914 | 23.6656 |
| 310113 | 22.9536 | 23.6841 | 23.1961 | 23.2803 |
| 310115 | 20.0667 | 21.7320 | 21.1645 | 20.9731 |
| 310116 | 25.2429 | 22.9812 | 23.6366 | 23.9253 |
| 310118 | 24.5443 | 26.4625 | 26.1315 | 25.6352 |
| 310119 | 29.4809 | 33.6686 | 32.7858 | 31.9394 |
| 310120 | 21.6852 | 23.9681 | 23.3200 | 22.9127 |
| 310121 | 18.7365 | * | * | 18.7365 |
| 320001 | 17.8522 | 19.1150 | 20.6225 | 19.1818 |
| 320002 | 22.4623 | 22.6175 | 23.0983 | 22.7062 |
| 320003 | 15.3484 | 15.9504 | 16.4642 | 15.9014 |
| 320004 | 17.2353 | 18.5824 | 19.6642 | 18.5890 |
| 320005 | 19.8698 | 21.6103 | 21.0411 | 20.8577 |
| 320006 | 18.6472 | 18.9019 | 20.3863 | 19.2674 |
| 320009 | 17.6400 | 18.2883 | 19.3500 | 18.4218 |
| 320011 | 16.5481 | 20.0601 | 18.5222 | 18.4330 |
| 320012 | 15.9972 | 16.4355 | 17.1764 | 16.5374 |
| 320013 | 23.8390 | 22.9573 | 24.5543 | 23.8179 |
| 320014 | 15.9666 | 16.3598 | 16.8412 | 16.4003 |
| 320016 | 18.9296 | 20.5398 | 18.8519 | 19.4293 |
| 320017 | 18.1545 | 18.6388 | 19.4498 | 18.7392 |
| 320018 | 18.1944 | 18.8479 | 19.2336 | 18.7690 |
| 320019 | 19.2600 | 24.4707 | 26.9637 | 23.5577 |
| 320021 | 17.1647 | 17.8705 | 19.0457 | 17.9920 |
| 320022 | 15.8391 | 16.1777 | 18.0606 | 16.7167 |
| 320023 | 16.4170 | 18.0548 | 17.8419 | 17.3761 |
| 320030 | 16.5266 | 16.5495 | 18.6859 | 17.1956 |
| 320031 | 13.9914 | 19.6768 | 25.1715 | 19.2605 |
| 320032 | 18.7536 | 18.8097 | 20.6871 | 19.3668 |
| 320033 | 20.3137 | 25.0777 | 21.0621 | 21.9427 |
| 320035 | 25.7392 | 21.5186 | 15.0612 | 19.2882 |
| 320037 | 17.0846 | 17.0305 | 17.8280 | 17.3203 |
| 320038 | 16.2896 | 16.8117 | 22.2664 | 18.6619 |
| 320046 | 19.0033 | 18.3190 | 18.9607 | 18.7526 |
| 320048 | 19.1705 | 19.9642 | 16.8769 | 18.5918 |
| 320063 | 19.8320 | 18.3237 | 17.9089 | 18.6049 |
| 320065 | 16.1046 | 16.7933 | 18.6525 | 17.1721 |
| 320067 | 57.4818 | 33.8654 | 15.3228 | 25.9798 |
| 320068 | 18.1809 | 17.4785 | 18.5103 | 18.1180 |
| 320069 | 11.3058 | 13.0094 | 14.4212 | 12.8497 |
| 320074 | 18.6545 | 19.3406 | 20.2290 | 19.3600 |
| 320079 | 17.0696 | 18.2828 | 19.8555 | 18.3645 |
| 330001 | 25.2067 | 26.5533 | 27.3996 | 26.4208 |
| 330002 | 26.3926 | 26.5370 | 26.9341 | 26.6121 |
| 330003 | 18.0549 | 19.4102 | 18.9211 | 18.7797 |
| 330004 | 19.9573 | 22.5298 | 20.9501 | 21.1368 |
| 330005 | 24.2795 | 24.8338 | 22.1957 | 23.2739 |
| 330006 | 25.9186 | 25.0576 | 25.8006 | 25.5856 |
| 330007 | 18.7956 | 18.9024 | * | 18.8475 |
| 330008 | 18.0684 | 19.0045 | 19.2341 | 18.7497 |
| 330009 | 30.4220 | 30.6918 | 31.3435 | 30.8056 |
| 330010 | 14.7382 | 17.4512 | 16.6508 | 16.1432 |
| 330011 | 18.0419 | 18.2986 | 18.6748 | 18.3483 |
| 330012 | 31.5135 | 32.7624 | * | 32.1317 |
| 330013 | 19.9929 | 19.0856 | 19.6269 | 19.5703 |
| 330014 | 27.5704 | 32.3370 | 36.8669 | 32.2778 |
| 330016 | 17.4069 | 16.9717 | 16.8016 | 17.0572 |
| 330019 | 32.4515 | 35.9822 | 33.5369 | 34.0043 |
| 330020 | 14.5488 | 15.5527 | 15.1142 | 15.0641 |
| 330023 | 24.2708 | 24.4006 | 25.6512 | 24.7835 |
| 330024 | 33.6175 | 34.1682 | 37.3316 | 34.9189 |
| 330025 | 16.0290 | 16.2033 | 16.8687 | 16.3599 |
| 330027 | 32.4959 | 33.4738 | 35.5255 | 33.7629 |
| 330028 | 27.0752 | 28.2089 | 29.5294 | 28.2349 |
| 330029 | 16.5552 | 18.1567 | 17.0016 | 17.2536 |
| 330030 | 15.0551 | 17.4977 | 19.1085 | 16.8779 |
| 330033 | 16.7497 | 18.5353 | 17.4444 | 17.6068 |
| 330034 | 30.7840 | 31.3997 | 27.7738 | 30.5701 |
| 330036 | 24.3239 | 23.9874 | 25.2820 | 24.5370 |
| 330037 | 16.0026 | 16.1140 | 16.4866 | 16.2081 |
| 330038 | 16.0153 | 16.2549 | 17.3429 | 16.5336 |
| 330039 | 12.4666 | * | * | 12.4666 |
| 330041 | 30.4192 | 24.5215 | 31.4871 | 28.4761 |
| 330043 | 27.6286 | 28.7467 | 27.4661 | 27.9537 |
| 330044 | 18.6969 | 20.0238 | 19.5219 | 19.4106 |
| 330045 | 27.1759 | 28.0758 | 27.9919 | 27.7401 |
| 330046 | 31.9802 | 32.4189 | 35.2703 | 33.1562 |
| 330047 | 17.6895 | 18.1815 | 18.5536 | 18.1416 |
| 330048 | 17.6239 | 17.8787 | 19.1093 | 18.1878 |
| 330049 | 19.3136 | 19.4993 | 20.5731 | 19.7930 |
| 330053 | 15.6659 | 17.4430 | 17.8082 | 16.9823 |
| 330055 | 30.7330 | 36.1109 | 32.8910 | 33.1680 |
| 330056 | 30.2206 | 30.4525 | 30.0945 | 30.2540 |
| 330057 | 18.6891 | 18.7478 | 19.3643 | 18.9410 |
| 330058 | 16.9805 | 17.0014 | 17.7672 | 17.2379 |
| 330059 | 32.2285 | 34.1705 | 34.2426 | 33.4744 |
| 330061 | 25.0674 | 25.7331 | 25.4082 | 25.4024 |
| 330062 | 15.2819 | 17.6067 | 18.1318 | 16.9856 |
| 330064 | 32.8724 | 33.1269 | 33.6447 | 33.2084 |
| 330065 | 18.3686 | 19.8940 | 19.9305 | 19.3468 |
| 330066 | 19.9455 | 19.5611 | 18.8707 | 19.4674 |
| 330067 | 21.2872 | 20.9443 | 22.1065 | 21.4528 |
| 330072 | 29.3096 | 30.8019 | 30.4171 | 30.1659 |
| 330073 | 15.8849 | 16.2898 | 16.4518 | 16.2013 |
| 330074 | 18.1636 | 18.0005 | 17.7308 | 17.9678 |
| 330075 | 17.4266 | 17.2298 | 17.6385 | 17.4324 |
| 330078 | 17.4863 | 16.7949 | 18.7884 | 17.6577 |
| 330079 | 16.7608 | 17.4555 | 18.7622 | 17.6535 |
| 330080 | 26.8766 | 29.2686 | 31.4424 | 29.0970 |
| 330084 | 23.0327 | 18.0435 | 19.3216 | 19.8703 |
| 330085 | 18.7835 | 20.2926 | 20.6203 | 19.8951 |
| 330086 | 30.6954 | 31.2980 | 23.6496 | 28.6407 |
| 330088 | 25.6160 | 25.6626 | 25.7940 | 25.6905 |
| 330090 | 18.6833 | 19.3954 | 19.2112 | 19.0937 |
| 330091 | 18.5334 | 19.0953 | 19.7776 | 19.1249 |
| 330092 | 12.6540 | 14.0671 | 13.3723 | 13.3059 |
| 330094 | 17.7196 | 17.5585 | 18.1582 | 17.8207 |
| 330095 | 18.5502 | 20.1073 | 21.1096 | 19.8197 |
| 330096 | 16.5963 | 17.9641 | 18.5149 | 17.6975 |
| 330097 | 16.9626 | 16.2169 | 16.4433 | 16.5145 |
| 330100 | 28.1060 | 27.0661 | 29.0916 | 28.0415 |
| 330101 | 31.3075 | 32.4105 | 31.5914 | 31.7153 |
| 330102 | 17.5230 | 17.5755 | 19.0058 | 18.0012 |
| 330103 | 16.5212 | 15.7197 | 16.8110 | 16.3435 |
| 330104 | 28.7669 | 31.6471 | 31.2074 | 30.5068 |
| 330106 | 35.8740 | 40.2686 | 35.3775 | 37.0516 |
| 330107 | 28.0780 | 28.5580 | 27.7797 | 28.1411 |
| 330108 | 17.0846 | 17.3605 | 18.0786 | 17.5050 |
| 330111 | 15.2047 | 19.5314 | 15.9321 | 16.7001 |
| 330114 | 18.2390 | 17.3522 | 17.0581 | 17.5626 |
| 330115 | 16.5581 | 17.4430 | 17.4684 | 17.1455 |
| 330116 | 24.2266 | 24.4622 | 14.9610 | 20.6732 |
| 330118 | 20.7550 | 20.6936 | * | 20.7240 |
| 330119 | 34.7478 | 34.8385 | 33.1179 | 34.2290 |
| 330121 | 15.8468 | 16.1052 | 16.3385 | 16.0964 |
| 330122 | 21.2021 | 20.8204 | 20.2417 | 20.7389 |
| 330125 | 19.7456 | 19.8494 | 19.7638 | 19.7865 |
| 330126 | 22.6990 | 23.7938 | 23.8957 | 23.4789 |
| 330127 | 29.3317 | 31.9046 | 30.7356 | 30.6271 |
| 330128 | 27.8693 | 29.0222 | 30.8242 | 29.1534 |
| 330132 | 14.7006 | 15.7633 | 14.3673 | 14.9673 |
| 330133 | 32.3812 | 37.2494 | 35.3576 | 34.8196 |
| 330135 | 18.3346 | 18.7120 | 22.2670 | 19.6717 |
| 330136 | 17.6041 | 18.2422 | 20.1043 | 18.6252 |
| 330140 | 19.5016 | 19.1438 | 19.3615 | 19.3334 |
| 330141 | 25.1371 | 26.4956 | 26.7096 | 26.0966 |
| 330144 | 15.5068 | 14.0566 | 16.2517 | 15.2343 |
| 330148 | 15.0400 | 16.8151 | 16.2782 | 16.0197 |
| 330151 | 13.9700 | 16.0714 | 15.7594 | 15.2313 |
| 330152 | 29.4818 | 30.5409 | 30.8314 | 30.2117 |
| 330153 | 17.4996 | 18.9689 | 18.1776 | 18.1944 |
| 330157 | 20.8239 | 22.0792 | 22.3804 | 21.7687 |
| 330158 | 26.0476 | 25.7569 | 27.1228 | 26.3184 |
| 330159 | 18.0211 | 19.1536 | 19.4998 | 18.8640 |
| 330160 | 30.5678 | 32.7840 | 29.5885 | 30.9340 |
| 330162 | 27.7162 | 27.1166 | 27.6010 | 27.4784 |
| 330163 | 20.4555 | 18.7816 | 20.7456 | 19.9795 |
| 330164 | 19.4831 | 19.8647 | 20.9003 | 20.0827 |
| 330166 | 14.1815 | 15.0954 | 15.4420 | 14.8722 |
| 330167 | 31.1834 | 29.3634 | 30.2346 | 30.2561 |
| 330169 | 33.4462 | 37.2655 | 35.4794 | 35.3665 |
| 330171 | 25.4314 | 25.5307 | 24.8035 | 25.2597 |
| 330175 | 16.6851 | 17.3290 | 18.3116 | 17.4443 |
| 330177 | 14.5378 | 17.2907 | 16.3704 | 16.0830 |
| 330179 | 12.6857 | 13.4999 | 13.8953 | 13.3684 |
| 330180 | 15.5304 | 16.8787 | 17.9877 | 16.7426 |
| 330181 | 32.4718 | 32.5192 | 33.0908 | 32.6900 |
| 330182 | 30.9260 | 32.9371 | 33.6531 | 32.5479 |
| 330183 | 19.9964 | 19.9207 | 20.6164 | 20.1809 |
| 330184 | 27.4859 | 30.0400 | 31.3706 | 29.6316 |
| 330185 | 26.9496 | 25.6112 | 26.8612 | 26.4537 |
| 330188 | 18.7208 | 20.9587 | 18.8000 | 19.4696 |
| 330189 | 17.6585 | 15.1253 | 18.4498 | 16.9610 |
| 330191 | 18.8586 | 18.6206 | 19.0348 | 18.8384 |
| 330193 | 29.8042 | 36.5481 | 30.2260 | 31.8162 |
| 330194 | 35.5748 | 34.6785 | 35.2036 | 35.1664 |
| 330195 | 31.3915 | 33.3254 | 34.8966 | 33.0747 |
| 330196 | 28.4465 | 30.8165 | 30.5799 | 29.9142 |
| 330197 | 16.9990 | 17.6646 | 18.3527 | 17.6922 |
| 330198 | 23.8113 | 24.6038 | 24.8590 | 24.4203 |
| 330199 | 27.6605 | 28.7609 | 30.5409 | 28.9499 |
| 330201 | 30.3293 | 32.1149 | 28.7861 | 30.4144 |
| 330202 | 30.7869 | 31.4435 | 31.2575 | 31.1487 |
| 330203 | 19.2353 | 20.7575 | 25.0345 | 21.5038 |
| 330204 | 29.3662 | 29.4418 | 32.2005 | 30.2707 |
| 330205 | 19.4642 | 20.5793 | 22.3490 | 20.7832 |
| 330208 | 25.8201 | 26.1822 | 26.6682 | 26.2220 |
| 330209 | 24.8834 | 23.9924 | 25.1281 | 24.6749 |
| 330211 | 19.0968 | 19.5064 | 19.5405 | 19.3836 |
| 330212 | 21.1777 | 21.7705 | 24.7681 | 22.5597 |
| 330213 | 18.5066 | 18.7722 | 19.6796 | 18.9552 |
| 330214 | 32.1966 | 36.4447 | 32.4292 | 33.4440 |
| 330215 | 17.5818 | 19.6926 | 17.9863 | 18.3902 |
| 330218 | 21.7072 | 21.4796 | 21.1890 | 21.4557 |
| 330219 | 22.1476 | 23.9908 | 23.4310 | 23.1411 |
| 330221 | 32.2081 | 27.8485 | 33.3796 | 31.2840 |
| 330222 | 17.8140 | 18.3666 | 18.5571 | 18.2482 |
| 330223 | 17.2754 | 17.6199 | 17.8306 | 17.5845 |
| 330224 | 21.9728 | 19.6410 | 20.4309 | 20.7047 |
| 330225 | 25.8043 | 25.5823 | 27.0379 | 26.0910 |
| 330226 | 17.6708 | 16.6711 | 23.1859 | 18.8241 |
| 330229 | 16.2509 | 16.8026 | 17.5326 | 16.8453 |
| 330230 | 28.8625 | 29.7626 | 29.6283 | 29.3810 |
| 330231 | 29.0917 | 30.0923 | 32.7200 | 30.4677 |
| 330232 | 19.5042 | 17.9083 | 19.1787 | 18.8569 |
| 330233 | 33.3008 | 30.9241 | 44.1265 | 35.0751 |
| 330234 | 33.3286 | 35.1777 | 35.0720 | 34.4830 |
| 330235 | 19.4532 | 21.0842 | 19.5880 | 20.0417 |
| 330236 | 30.7017 | 29.5913 | 31.3463 | 30.5397 |
| 330238 | 14.7951 | 15.6245 | 17.3976 | 15.9047 |
| 330239 | 17.2808 | 17.4462 | 18.5079 | 17.7328 |
| 330240 | 30.4765 | 29.7082 | 30.7321 | 30.2841 |
| 330241 | 22.6046 | 24.6076 | 23.8638 | 23.6409 |
| 330242 | 24.7401 | 28.2612 | 27.6384 | 26.8305 |
| 330245 | 17.2803 | 17.6767 | 18.5161 | 17.8488 |
| 330246 | 26.6587 | 28.1090 | 28.1205 | 27.6612 |
| 330247 | 27.6203 | 28.5310 | 27.3937 | 27.8277 |
| 330249 | 16.4818 | 16.2687 | 17.1320 | 16.6304 |
| 330250 | 19.5553 | 19.5823 | 19.9619 | 19.7058 |
| 330252 | 17.0379 | * | * | 17.0379 |
| 330254 | 16.7252 | 18.4057 | 15.9123 | 17.0146 |
| 330258 | 30.4656 | 29.7426 | 31.8910 | 30.6921 |
| 330259 | 25.2526 | 26.2661 | 25.9994 | 25.8364 |
| 330261 | 26.1654 | 25.7244 | 27.9766 | 26.6137 |
| 330263 | 19.6388 | 20.4149 | 18.7378 | 19.6517 |
| 330264 | 23.1359 | 22.8672 | 22.8099 | 22.9301 |
| 330265 | 15.6249 | 18.0193 | 17.6301 | 17.0414 |
| 330267 | 23.5561 | 24.5183 | 24.5939 | 24.2287 |
| 330268 | 14.6249 | 13.0595 | 15.9060 | 14.5364 |
| 330270 | 28.2392 | 34.4254 | 36.0824 | 32.6382 |
| 330273 | 25.8910 | 23.1511 | 26.0565 | 24.9430 |
| 330275 | 17.4223 | 19.0548 | 18.7268 | 18.3387 |
| 330276 | 17.7452 | 18.2870 | 19.0228 | 18.3342 |
| 330277 | 17.1570 | 18.3169 | 19.1761 | 18.2131 |
| 330279 | 19.9079 | 19.5983 | 20.7107 | 20.0436 |
| 330285 | 22.4717 | 23.5264 | 24.0491 | 23.3509 |
| 330286 | 25.0948 | 26.7633 | 27.7762 | 26.5916 |
| 330290 | 32.5792 | 33.5056 | 30.4706 | 32.2470 |
| 330293 | 15.3782 | 16.2158 | 16.9238 | 16.1248 |
| 330304 | 29.3687 | 26.7683 | 27.3562 | 27.8227 |
| 330306 | 27.6214 | 27.3798 | 29.5937 | 28.1525 |
| 330307 | 20.7362 | 21.0673 | 21.7257 | 21.1725 |
| 330308 | 36.8361 | * | * | 36.8361 |
| 330314 | 24.7399 | 24.5444 | 25.9937 | 25.0514 |
| 330316 | 28.7872 | 27.6102 | 27.9543 | 28.1177 |
| 330327 | 16.9724 | 16.4611 | 20.3874 | 17.9258 |
| 330331 | 31.0405 | 31.6216 | 33.1276 | 32.0298 |
| 330332 | 27.1554 | 27.6914 | 25.3689 | 26.7855 |
| 330333 | * | 29.1931 | * | 29.1931 |
| 330336 | 30.1708 | 29.7689 | 29.8294 | 29.9290 |
| 330338 | 23.0077 | 22.4581 | 21.2670 | 22.2755 |
| 330339 | 19.6730 | 20.0111 | 20.1028 | 19.9220 |
| 330340 | 26.9201 | 28.8419 | 28.4129 | 28.0687 |
| 330350 | 30.3754 | 30.8889 | 30.9763 | 30.7427 |
| 330353 | 33.5519 | 32.1984 | 34.2431 | 33.3163 |
| 330357 | 34.7492 | 36.5928 | 34.1846 | 35.2059 |
| 330359 | 29.2920 | * | * | 29.2920 |
| 330372 | 22.5027 | 28.8482 | 33.3771 | 27.5982 |
| 330381 | 29.2438 | 31.0091 | 31.8602 | 30.6612 |
| 330385 | 28.8373 | 35.6722 | 33.2246 | 32.4207 |
| 330386 | 24.6713 | 17.6383 | 20.4231 | 20.5236 |
| 330389 | 32.4234 | 30.2505 | 37.3749 | 32.9392 |
| 330390 | 29.7936 | 31.1577 | 30.8744 | 30.5843 |
| 330393 | 27.9901 | 26.4958 | 27.8352 | 27.4232 |
| 330394 | 18.7724 | 19.2392 | 18.9343 | 18.9816 |
| 330395 | 37.6805 | 32.8749 | 32.7494 | 34.3792 |
| 330396 | 30.7228 | 34.8648 | 30.7961 | 32.1685 |
| 330397 | 31.0043 | 33.9061 | 32.6068 | 32.3768 |
| 330398 | 30.3217 | 28.7707 | 29.2872 | 29.6846 |
| 330399 | 35.5212 | 32.9100 | 33.3012 | 33.9214 |
| 330400 | * | * | 16.2707 | 16.2707 |
| 340001 | 19.0159 | 18.1814 | 19.7093 | 18.9605 |
| 340002 | 18.7790 | 20.8858 | 20.5253 | 20.0921 |
| 340003 | 21.9674 | 20.2540 | 19.5145 | 20.4958 |
| 340004 | 17.8923 | 19.0695 | 20.9863 | 19.3245 |
| 340005 | 14.0941 | 15.8205 | 16.7176 | 15.5039 |
| 340006 | 17.8145 | 16.9818 | 16.5709 | 17.0955 |
| 340007 | 17.1708 | 17.2356 | 18.3399 | 17.5929 |
| 340008 | 18.3769 | 21.2889 | 20.4157 | 20.0279 |
| 340009 | 20.5011 | 20.5023 | 20.9178 | 20.6132 |
| 340010 | 17.6500 | 18.3380 | 19.4302 | 18.4900 |
| 340011 | 14.9215 | 13.6554 | 14.4798 | 14.3110 |
| 340012 | 16.6574 | 18.8701 | 17.5112 | 17.6905 |
| 340013 | 17.4302 | 20.1747 | 19.4613 | 19.0754 |
| 340014 | 19.9203 | 20.5748 | 27.7888 | 22.1408 |
| 340015 | 19.0056 | 20.1562 | 19.4676 | 19.5517 |
| 340016 | 16.3977 | 17.5404 | 18.8958 | 17.5664 |
| 340017 | 19.2203 | 19.4192 | 20.2775 | 19.6581 |
| 340018 | 15.1579 | 14.0930 | 18.1751 | 15.6569 |
| 340019 | 13.5919 | 14.8980 | 15.2887 | 14.5682 |
| 340020 | 16.7515 | 18.6334 | 18.0897 | 17.8512 |
| 340021 | 19.6658 | 19.8020 | 20.5813 | 20.0277 |
| 340022 | 16.7211 | 17.8178 | 18.7714 | 17.7886 |
| 340023 | 17.2054 | 18.5414 | 19.3146 | 18.3540 |
| 340024 | 16.6389 | 17.3824 | 17.9130 | 17.3104 |
| 340025 | 16.8198 | 17.2648 | 18.4628 | 17.5179 |
| 340027 | 17.2971 | 18.0816 | 19.4548 | 18.2602 |
| 340028 | 17.7196 | 18.4787 | 19.9403 | 18.7490 |
| 340030 | 20.0530 | 21.1420 | 22.4709 | 21.2046 |
| 340031 | 12.3895 | 14.6951 | 14.6370 | 13.8761 |
| 340032 | 20.4735 | 20.0049 | 20.7444 | 20.4083 |
| 340035 | 18.0988 | 20.2312 | 18.9930 | 19.1067 |
| 340036 | 16.9674 | 18.2190 | 17.7619 | 17.6323 |
| 340037 | 15.5347 | 16.6576 | 17.5829 | 16.5842 |
| 340038 | 17.0154 | 17.3762 | 18.1493 | 17.5050 |
| 340039 | 20.1470 | 20.5876 | 21.3711 | 20.7125 |
| 340040 | 20.1214 | 20.4282 | 20.7237 | 20.4264 |
| 340041 | 17.7626 | 15.1419 | 15.5873 | 16.0395 |
| 340042 | 16.6300 | 16.9298 | 17.0034 | 16.8680 |
| 340044 | 16.3657 | 18.8687 | 18.0863 | 17.7757 |
| 340045 | 12.4152 | 13.0538 | 13.6182 | 12.9769 |
| 340047 | 19.6050 | 20.0602 | 20.0744 | 19.9132 |
| 340049 | 16.4988 | 19.2050 | 19.5127 | 18.2917 |
| 340050 | 18.5570 | 20.0090 | 19.6726 | 19.4142 |
| 340051 | 18.5953 | 16.5617 | 19.3627 | 18.0980 |
| 340052 | 21.3746 | 22.8173 | 23.2134 | 22.4161 |
| 340053 | 19.4881 | 20.9495 | 19.9915 | 20.1403 |
| 340054 | 14.4722 | 15.5993 | 15.5090 | 15.2167 |
| 340055 | 18.1786 | 19.6056 | 19.4035 | 19.0752 |
| 340060 | 17.9167 | 18.7137 | 19.3410 | 18.6670 |
| 340061 | 20.8474 | 21.5385 | 22.1175 | 21.4855 |
| 340063 | 16.9232 | 17.0249 | 16.7377 | 16.9005 |
| 340064 | 17.2584 | 20.7125 | 18.5069 | 18.8299 |
| 340065 | 18.3212 | 17.5414 | 17.3530 | 17.7394 |
| 340067 | 18.6132 | 19.3785 | 19.7187 | 19.2365 |
| 340068 | 16.7015 | 16.6305 | 17.8065 | 17.0483 |
| 340069 | 19.9948 | 21.0840 | 21.6728 | 20.9166 |
| 340070 | 18.6270 | 19.7796 | 20.6829 | 19.7122 |
| 340071 | 16.3701 | 17.1424 | 18.0767 | 17.2043 |
| 340072 | 15.6014 | 16.7400 | 17.7129 | 16.7307 |
| 340073 | 20.6905 | 21.9761 | 23.5832 | 22.0016 |
| 340075 | 18.2060 | 18.7090 | 20.0081 | 18.9541 |
| 340080 | 16.8453 | 22.2533 | 18.2061 | 19.0642 |
| 340084 | 21.7813 | 17.1532 | 19.0103 | 19.0182 |
| 340085 | 16.2355 | 17.3462 | 18.3179 | 17.3020 |
| 340087 | 16.6987 | 17.3884 | 18.2255 | 17.4652 |
| 340088 | 19.8314 | 21.0226 | 22.2322 | 21.0156 |
| 340089 | 13.8633 | 13.8535 | 15.4760 | 14.4308 |
| 340090 | 17.8457 | 17.0584 | 18.5287 | 17.8139 |
| 340091 | 19.3955 | 20.5923 | 20.3861 | 20.1343 |
| 340093 | 15.1615 | 16.3276 | 16.8903 | 16.0870 |
| 340094 | 15.9568 | 19.0406 | * | 17.4328 |
| 340096 | 17.9764 | 17.8189 | 19.4696 | 18.4348 |
| 340097 | 21.3700 | 18.8412 | 18.2399 | 19.4192 |
| 340098 | 20.1671 | 21.4135 | 21.9578 | 21.2065 |
| 340099 | 15.0888 | 16.8305 | 15.3752 | 15.7269 |
| 340101 | 15.3610 | 13.9994 | 15.6509 | 14.9555 |
| 340104 | 15.8729 | 13.0462 | 11.5169 | 13.4465 |
| 340105 | 18.9007 | 20.2954 | * | 19.5963 |
| 340106 | 18.0769 | 17.7220 | 18.1211 | 17.9704 |
| 340107 | 16.9503 | 18.0205 | 19.3197 | 18.0904 |
| 340109 | 17.9576 | 18.7746 | 19.0532 | 18.6067 |
| 340111 | 14.9247 | 16.3344 | 16.5976 | 15.9665 |
| 340112 | 14.5966 | 14.7562 | 15.5142 | 14.9625 |
| 340113 | 20.8821 | 21.2906 | 21.9883 | 21.3854 |
| 340114 | 20.8195 | 21.2166 | 20.7261 | 20.9197 |
| 340115 | 18.6700 | 19.7578 | 21.7586 | 20.0594 |
| 340116 | 19.4786 | 20.4255 | 20.6800 | 20.2116 |
| 340119 | 16.8537 | 18.8507 | 19.5827 | 18.4595 |
| 340120 | 14.3822 | 15.0410 | 15.8240 | 15.1047 |
| 340121 | 15.9686 | 16.3295 | 17.8771 | 16.7251 |
| 340123 | 16.2227 | 16.9114 | 18.9078 | 17.3848 |
| 340124 | 14.0462 | 15.5779 | 17.4185 | 15.7171 |
| 340125 | 19.6252 | 19.7164 | 20.2748 | 19.8633 |
| 340126 | 17.7214 | 18.8100 | 19.3734 | 18.6747 |
| 340127 | 17.3849 | 19.3925 | 19.3842 | 18.7105 |
| 340129 | 19.7332 | 20.4605 | 20.6521 | 20.2893 |
| 340130 | 19.4430 | 19.7422 | 19.8707 | 19.6940 |
| 340131 | 18.9361 | 19.7908 | 21.3849 | 20.0481 |
| 340132 | 16.9369 | 17.3448 | 17.5711 | 17.3015 |
| 340133 | 14.3501 | 16.4766 | 17.2138 | 16.0568 |
| 340137 | * | 21.0249 | 31.7702 | 23.8273 |
| 340138 | 19.2807 | 20.7618 | * | 20.0092 |
| 340141 | 22.2234 | 21.3754 | 21.4986 | 21.6898 |
| 340142 | 16.0912 | 17.1525 | 18.0766 | 17.1107 |
| 340143 | 20.9509 | 21.3604 | 24.4098 | 22.2423 |
| 340144 | 19.1919 | 20.9113 | 22.9183 | 20.9333 |
| 340145 | 19.1964 | 20.1081 | 19.9233 | 19.7573 |
| 340146 | 13.0119 | 15.9203 | 17.3051 | 15.3284 |
| 340147 | 19.1087 | 19.6827 | 20.5520 | 19.8121 |
| 340148 | 18.4227 | 18.5875 | 18.9912 | 18.6555 |
| 340151 | 16.5671 | 16.7275 | 18.4733 | 17.2579 |
| 340153 | 20.6588 | 20.6420 | 20.7533 | 20.6847 |
| 340155 | 20.4236 | 20.5792 | 23.1021 | 21.3418 |
| 340158 | 17.2565 | 18.1439 | 19.0843 | 18.2232 |
| 340159 | 16.8048 | 17.3893 | 19.0338 | 17.7595 |
| 340160 | 15.5298 | 16.1778 | 16.7170 | 16.1477 |
| 340162 | 16.6362 | 14.3472 | * | 16.3541 |
| 340164 | 19.6820 | 21.2523 | 21.5769 | 20.8240 |
| 340166 | 19.1743 | 20.0434 | 20.8270 | 20.0663 |
| 340168 | 14.7508 | 15.2919 | 15.6071 | 15.2494 |
| 340171 | 20.0495 | 21.5973 | 22.4779 | 21.4041 |
| 340173 | 20.2132 | 19.3353 | 21.0898 | 20.2512 |
| 350001 | 11.7345 | 14.9080 | 16.6551 | 14.4005 |
| 350002 | 17.2834 | 17.5259 | 18.3459 | 17.7122 |
| 350003 | 17.4276 | 18.2470 | 19.2840 | 18.3041 |
| 350004 | 17.9049 | 20.6518 | 23.7016 | 20.6528 |
| 350005 | 16.0259 | 18.3792 | 19.9156 | 18.1833 |
| 350006 | 16.6241 | 18.4107 | 19.0343 | 17.9691 |
| 350007 | 13.2771 | 13.3292 | 13.8824 | 13.4842 |
| 350008 | 21.6983 | 20.4777 | 22.3783 | 21.4889 |
| 350009 | 18.2818 | 19.1611 | 18.3688 | 18.6099 |
| 350010 | 15.2762 | 16.2808 | 16.6272 | 16.0505 |
| 350011 | 18.4931 | 18.2008 | 19.1944 | 18.6474 |
| 350012 | 12.7287 | 15.7033 | 18.2524 | 15.6975 |
| 350013 | 16.6784 | 16.4579 | 17.2596 | 16.7923 |
| 350014 | 15.7906 | 16.8403 | 18.0999 | 16.8354 |
| 350015 | 15.8651 | 16.3397 | 17.1071 | 16.3998 |
| 350016 | 11.6255 | 11.6524 | * | 11.6395 |
| 350017 | 17.7835 | 17.6278 | 17.5124 | 17.6446 |
| 350018 | 13.6366 | 14.4928 | 16.4939 | 14.8276 |
| 350019 | 19.4037 | 19.3063 | 20.1608 | 19.6008 |
| 350021 | 12.6885 | 16.2898 | 17.7123 | 15.5294 |
| 350023 | 12.7952 | 17.9048 | 17.4983 | 16.4355 |
| 350024 | 14.3740 | 14.7529 | 15.4788 | 14.8361 |
| 350025 | 16.2400 | 17.1199 | 15.0469 | 16.0889 |
| 350027 | 17.1177 | 15.0835 | 15.5178 | 15.9200 |
| 350029 | 12.7950 | 13.5219 | 14.6173 | 13.6002 |
| 350030 | 17.3497 | 17.7209 | 18.1131 | 17.7195 |
| 350033 | 14.8953 | 14.9012 | 16.0870 | 15.2715 |
| 350034 | 18.3180 | 18.7245 | 19.6445 | 18.8742 |
| 350035 | 10.1561 | 10.4570 | 11.7675 | 10.7676 |
| 350038 | 18.7357 | 17.6666 | 19.6854 | 18.6648 |
| 350039 | 17.3128 | 17.0361 | 16.6278 | 17.0024 |
| 350041 | 14.6772 | 14.6680 | 19.1341 | 15.9095 |
| 350042 | 16.7544 | 16.7402 | 19.3309 | 17.4345 |
| 350043 | 17.1573 | 16.8876 | 16.7433 | 16.9224 |
| 350044 | 10.5296 | 10.2154 | 11.0601 | 10.5801 |
| 350047 | 17.9270 | 14.4628 | 18.0094 | 16.8202 |
| 350049 | 14.5330 | 14.8019 | 18.1993 | 15.6280 |
| 350050 | 10.5733 | 11.4921 | 12.2183 | 11.3924 |
| 350051 | 17.5323 | 17.7279 | 17.0653 | 17.4458 |
| 350053 | 13.9379 | 14.6398 | 15.9160 | 14.8075 |
| 350055 | 12.3722 | 14.5691 | 15.7916 | 14.3152 |
| 350056 | 14.7382 | 14.8293 | 15.0995 | 14.8885 |
| 350058 | 14.3484 | 15.9378 | 16.7034 | 15.7009 |
| 350060 | 9.5962 | 10.3666 | 10.3076 | 10.0926 |
| 350061 | 14.5894 | 15.7269 | 18.8790 | 16.4237 |
| 360001 | 17.3933 | 17.0791 | 19.6655 | 18.0423 |
| 360002 | 17.3955 | 18.0139 | 18.2613 | 17.9462 |
| 360003 | 22.0351 | 22.7471 | 22.7521 | 22.5117 |
| 360006 | 22.0906 | 21.8048 | 22.4436 | 22.1137 |
| 360007 | 17.0955 | 18.0941 | 14.8213 | 16.6387 |
| 360008 | 17.8185 | 18.5439 | 18.7961 | 18.3915 |
| 360009 | 17.5328 | 18.9322 | 18.9935 | 18.4667 |
| 360010 | 18.0886 | 19.2288 | 19.1852 | 18.8325 |
| 360011 | 18.9491 | 19.3835 | 21.3659 | 19.9105 |
| 360012 | 19.2221 | 19.9881 | 20.0525 | 19.7649 |
| 360013 | 20.8112 | 20.6021 | 21.3690 | 20.9190 |
| 360014 | 19.8844 | 20.2390 | 20.7419 | 20.2907 |
| 360016 | 18.7709 | 17.8065 | 21.2505 | 19.1632 |
| 360017 | 22.4972 | 21.7543 | 22.2740 | 22.1696 |
| 360018 | 21.3436 | 23.5219 | 24.6686 | 23.0168 |
| 360019 | 20.1726 | 18.7147 | 20.6480 | 19.8139 |
| 360020 | 22.9512 | 21.7806 | 22.1751 | 22.3268 |
| 360024 | 18.5412 | 19.8508 | 20.1352 | 19.5008 |
| 360025 | 19.2918 | 20.3638 | 20.2531 | 19.9763 |
| 360026 | 17.0378 | 18.2222 | 17.9523 | 17.7450 |
| 360027 | 20.3568 | 21.0406 | 21.7650 | 21.0544 |
| 360028 | 17.2681 | 17.0177 | 18.7174 | 17.5937 |
| 360029 | 18.2193 | 18.7622 | 19.2928 | 18.7626 |
| 360030 | 15.3535 | 17.5748 | 17.6058 | 16.8173 |
| 360031 | 19.8987 | 19.3858 | 21.0687 | 20.1028 |
| 360032 | 17.9274 | 18.6559 | 19.8020 | 18.7667 |
| 360034 | 15.5649 | 14.9534 | 17.9594 | 16.1258 |
| 360035 | 20.3358 | 20.5557 | 21.0674 | 20.6574 |
| 360036 | 19.1835 | 20.2107 | 20.9916 | 20.1250 |
| 360037 | 22.5240 | 23.5094 | 23.1674 | 23.0445 |
| 360038 | 19.8921 | 21.2467 | 19.9415 | 20.3576 |
| 360039 | 17.4033 | 18.7791 | 19.0013 | 18.5872 |
| 360040 | 18.1238 | 18.1618 | 18.7425 | 18.3503 |
| 360041 | 18.4244 | 19.5744 | 19.7968 | 19.2697 |
| 360042 | 16.1187 | 17.4306 | 17.1952 | 16.9328 |
| 360044 | 16.7925 | 17.0612 | 17.6882 | 17.1993 |
| 360045 | 21.1814 | 22.1471 | 22.4018 | 21.8209 |
| 360046 | 19.3198 | 20.4755 | 20.4607 | 20.0909 |
| 360047 | 15.3399 | 17.1871 | 15.2922 | 15.8884 |
| 360048 | 21.1719 | 22.5857 | 22.4890 | 22.0646 |
| 360049 | 18.8084 | 20.4564 | 20.8393 | 20.0008 |
| 360050 | 12.8888 | 12.9873 | 15.0568 | 13.6080 |
| 360051 | 20.9461 | 20.8338 | 20.8757 | 20.8844 |
| 360052 | 20.0182 | 19.6233 | 18.7931 | 19.5088 |
| 360054 | 16.1875 | 17.2574 | 17.4911 | 16.9860 |
| 360055 | 23.2671 | 21.5585 | 21.4112 | 22.0925 |
| 360056 | 18.7606 | 19.0474 | 20.6968 | 19.5385 |
| 360057 | 13.8094 | 15.0146 | 15.8569 | 14.8518 |
| 360058 | 17.9178 | 18.6992 | 19.3306 | 18.6392 |
| 360059 | 21.9689 | 20.5618 | 19.9304 | 20.8679 |
| 360062 | 20.3111 | 20.7588 | 21.9195 | 20.9548 |
| 360063 | 22.7866 | 18.4512 | 17.5108 | 19.4998 |
| 360064 | 20.6416 | 20.4846 | 20.0615 | 20.4087 |
| 360065 | 19.4531 | 20.0532 | 19.6199 | 19.7128 |
| 360066 | 20.0285 | 21.6015 | 22.8175 | 21.4937 |
| 360067 | 14.5687 | 15.3157 | 14.2745 | 14.7189 |
| 360068 | 21.2199 | 21.2789 | 22.6227 | 21.7164 |
| 360069 | 17.8329 | 16.6982 | 14.6597 | 16.2292 |
| 360070 | 17.5300 | 17.3758 | 18.8406 | 17.9171 |
| 360071 | 23.8013 | 17.9756 | 19.0302 | 20.2494 |
| 360072 | 17.9697 | 18.1467 | 19.0166 | 18.3995 |
| 360074 | 18.2614 | 20.8275 | 18.5889 | 19.1849 |
| 360075 | 18.4733 | 22.4523 | 26.0663 | 21.4074 |
| 360076 | 19.5864 | 20.0700 | 20.3317 | 20.0010 |
| 360077 | 20.8202 | 21.1053 | 21.5517 | 21.1550 |
| 360078 | 20.7940 | 21.4392 | 22.6490 | 21.6280 |
| 360079 | 22.0033 | 22.1096 | 21.6644 | 21.9274 |
| 360080 | 16.6414 | 17.3892 | 17.6369 | 17.2080 |
| 360081 | 19.6354 | 21.7342 | 20.4614 | 20.6451 |
| 360082 | 22.8585 | 22.9460 | 20.7610 | 22.1460 |
| 360083 | 18.4635 | * | * | 18.4635 |
| 360084 | 20.0914 | 20.4894 | 22.0492 | 20.8664 |
| 360085 | 21.6670 | 21.9051 | 21.5151 | 21.7121 |
| 360086 | 17.0389 | 19.5378 | 19.3701 | 18.5836 |
| 360087 | 20.0395 | 20.1684 | 20.7969 | 20.3249 |
| 360088 | 22.3121 | 24.0097 | 24.0822 | 23.4637 |
| 360089 | 20.5610 | 18.3881 | 18.1941 | 19.0415 |
| 360090 | 20.3955 | 21.0376 | 20.8971 | 20.7887 |
| 360091 | 21.0335 | 21.3126 | 21.8447 | 21.4132 |
| 360092 | 15.9095 | 20.4534 | 21.5073 | 18.9727 |
| 360093 | 18.5744 | 19.3292 | 19.0261 | 18.9905 |
| 360094 | 18.3105 | 18.8780 | 20.1227 | 19.0848 |
| 360095 | 18.7079 | 20.4149 | 19.8521 | 19.6643 |
| 360096 | 17.1617 | 18.2215 | 19.6726 | 18.3160 |
| 360098 | 18.3361 | 19.5314 | 19.8178 | 19.2371 |
| 360099 | 18.5523 | 18.5855 | 19.6241 | 18.9389 |
| 360100 | 17.6554 | 17.8989 | 18.0442 | 17.8625 |
| 360101 | 22.3121 | 21.3914 | 20.2635 | 21.3487 |
| 360102 | 19.7700 | 19.4345 | 18.5367 | 19.2837 |
| 360103 | 22.6228 | * | * | 22.6228 |
| 360106 | 16.1843 | 18.9752 | 19.1778 | 18.1964 |
| 360107 | 18.6195 | 19.7599 | 22.1359 | 20.1794 |
| 360108 | 16.5076 | 17.5832 | 20.0681 | 18.0497 |
| 360109 | 19.5162 | 20.1032 | 19.9237 | 19.8530 |
| 360112 | 22.5676 | 22.5589 | 24.6335 | 23.2167 |
| 360113 | 22.4584 | 24.2654 | 20.8154 | 22.4061 |
| 360114 | 16.3288 | 17.8761 | 18.7509 | 17.6758 |
| 360115 | 18.1859 | 18.8059 | 20.7652 | 19.2888 |
| 360116 | 18.0835 | 18.8882 | 18.8319 | 18.6000 |
| 360118 | 18.6098 | 19.3732 | 19.9141 | 19.3196 |
| 360121 | 21.0979 | 22.1093 | 22.2175 | 21.8088 |
| 360123 | 19.1313 | 20.3236 | 20.9792 | 20.1480 |
| 360125 | 18.1756 | 19.0774 | 20.5508 | 19.2432 |
| 360126 | 20.4558 | 19.0036 | 24.5387 | 21.1181 |
| 360127 | 16.9228 | 17.5882 | 16.5559 | 16.9955 |
| 360128 | 15.5823 | 16.1243 | 17.0515 | 16.2361 |
| 360129 | 15.5241 | 15.5002 | 16.6114 | 15.8783 |
| 360130 | 15.3356 | 17.2009 | 18.4539 | 16.9275 |
| 360131 | 18.2897 | 19.2241 | 18.4688 | 18.6543 |
| 360132 | 18.2733 | 19.9171 | 21.3493 | 19.8413 |
| 360133 | 19.0349 | 19.4316 | 20.2857 | 19.5509 |
| 360134 | 20.2383 | 20.6876 | 20.9564 | 20.6143 |
| 360136 | 17.8473 | 17.7827 | 18.2194 | 17.9464 |
| 360137 | 20.2581 | 20.1756 | 22.3648 | 20.9095 |
| 360140 | 19.1263 | 20.2791 | 21.2881 | 20.2299 |
| 360141 | 22.8496 | 23.0016 | 23.5343 | 23.1176 |
| 360142 | 17.3154 | 17.0059 | 18.3188 | 17.5468 |
| 360143 | 20.4378 | 20.1989 | 21.0336 | 20.5552 |
| 360144 | 21.9159 | 23.2191 | 20.9033 | 21.9858 |
| 360145 | 19.3907 | 19.6413 | 20.0513 | 19.6956 |
| 360147 | 16.5898 | 16.6616 | 17.6779 | 16.9779 |
| 360148 | 18.8914 | 19.2816 | 19.1393 | 19.1100 |
| 360149 | 18.7891 | 19.9808 | * | 19.3785 |
| 360150 | 20.6253 | 21.1327 | 22.3620 | 21.3641 |
| 360151 | 17.4863 | 16.6019 | 19.2788 | 17.7101 |
| 360152 | 21.9978 | 20.8328 | 21.6005 | 21.4611 |
| 360153 | 14.8948 | 15.4132 | 16.7399 | 15.6460 |
| 360154 | 13.7761 | 14.3270 | 14.3593 | 14.1608 |
| 360155 | 20.8977 | 22.5347 | 22.2112 | 21.8776 |
| 360156 | 17.9155 | 17.8787 | 18.9095 | 18.2225 |
| 360159 | 20.7119 | 20.2841 | 21.5695 | 20.8609 |
| 360161 | 19.4122 | 19.1983 | 20.6160 | 19.7228 |
| 360162 | 18.6084 | * | * | 18.6084 |
| 360163 | 20.3821 | 20.7275 | 21.2689 | 20.8164 |
| 360164 | 16.1643 | * | * | 16.1643 |
| 360165 | 19.4831 | 18.2571 | 18.2417 | 18.6524 |
| 360166 | 16.9778 | 18.7321 | * | 17.8568 |
| 360170 | 17.1779 | 16.4653 | 20.4407 | 17.9153 |
| 360172 | 18.4690 | 18.6720 | 19.8909 | 19.1486 |
| 360174 | 19.0887 | 19.9725 | 20.5399 | 20.0142 |
| 360175 | 20.4133 | 21.1685 | 21.5450 | 21.0739 |
| 360176 | 15.4730 | 15.9430 | 16.6228 | 16.0305 |
| 360177 | 19.4122 | 18.7898 | 18.9576 | 19.0368 |
| 360178 | 17.3985 | 18.8704 | 16.7962 | 17.7254 |
| 360179 | 19.1417 | 21.1309 | 20.7069 | 20.2966 |
| 360180 | 22.0949 | 21.3826 | 21.0146 | 21.4888 |
| 360184 | 19.3502 | 19.1224 | * | 19.2391 |
| 360185 | 18.6697 | 18.7291 | 19.4858 | 18.9599 |
| 360186 | 20.8579 | 18.3246 | 20.7572 | 19.9570 |
| 360187 | 18.0209 | 18.5109 | 19.6535 | 18.7427 |
| 360188 | 17.5327 | 17.1044 | 18.3057 | 17.6838 |
| 360189 | 17.3713 | 17.8981 | 18.5940 | 17.9373 |
| 360192 | 20.9980 | 21.6365 | 22.7846 | 21.8042 |
| 360193 | 17.6874 | * | * | 17.6874 |
| 360194 | 17.6890 | 17.1884 | 17.6140 | 17.4968 |
| 360195 | 19.0173 | 19.9302 | 20.5828 | 19.8368 |
| 360197 | 19.4250 | 20.0603 | 20.5062 | 19.9981 |
| 360200 | 17.7583 | 16.2306 | 17.9623 | 17.3129 |
| 360203 | 15.6212 | 16.3181 | 15.9609 | 15.9716 |
| 360204 | 19.3543 | 22.2494 | * | 20.5754 |
| 360210 | 20.2809 | 20.9955 | 21.8629 | 21.0428 |
| 360211 | 19.5762 | 19.9895 | 20.6081 | 20.0860 |
| 360212 | 20.2288 | 21.1123 | 20.6987 | 20.6781 |
| 360213 | 18.3253 | 19.4765 | 19.0584 | 18.9547 |
| 360218 | 18.4140 | 18.9469 | 18.8204 | 18.7231 |
| 360230 | 21.4385 | 21.9763 | 20.8042 | 21.3850 |
| 360231 | 13.5586 | 12.9588 | 14.4168 | 13.6102 |
| 360234 | 22.4324 | 23.2588 | 20.6131 | 22.0967 |
| 360236 | 19.4881 | 17.8426 | 21.4628 | 19.5088 |
| 360239 | 19.8584 | 20.1854 | 19.2375 | 19.7767 |
| 360241 | 22.0795 | 23.5318 | 25.3741 | 23.5406 |
| 360243 | 13.5835 | 14.8694 | * | 14.2018 |
| 360244 | 10.5518 | * | * | 10.5518 |
| 360245 | 15.0579 | 16.4622 | 15.9782 | 15.8310 |
| 360247 | 18.1116 | 16.3092 | 17.0776 | 17.0967 |
| 360248 | 21.6499 | * | * | 21.6499 |
| 360249 | * | * | 25.4331 | 25.4331 |
| 370001 | 21.2714 | 22.5214 | 24.1929 | 22.6419 |
| 370002 | 14.0847 | 14.7315 | 15.4333 | 14.7194 |
| 370004 | 16.7671 | 19.3236 | 18.5233 | 18.1546 |
| 370005 | 17.3817 | 15.1654 | 15.3881 | 15.9167 |
| 370006 | 12.9493 | 16.6484 | 16.4995 | 15.3118 |
| 370007 | 17.1535 | 15.2905 | 15.8312 | 16.0498 |
| 370008 | 17.3048 | 16.6566 | 17.5553 | 17.1688 |
| 370011 | 14.6397 | 14.9701 | 15.6178 | 15.0345 |
| 370012 | 10.8003 | 11.7265 | 12.4942 | 11.6228 |
| 370013 | 18.0385 | 19.3398 | 18.9584 | 18.7911 |
| 370014 | 19.6543 | 20.6512 | 20.2858 | 20.2276 |
| 370015 | 17.8247 | 17.0319 | 20.8765 | 18.5256 |
| 370016 | 16.6401 | 19.1191 | 19.1613 | 18.3470 |
| 370017 | 12.9837 | 12.6400 | 13.6531 | 13.1239 |
| 370018 | 14.2438 | 18.5107 | 17.7054 | 16.6955 |
| 370019 | 16.8801 | 14.2277 | 14.6216 | 15.1546 |
| 370020 | 13.4787 | 14.3798 | 15.1035 | 14.3356 |
| 370021 | 11.2639 | 12.0474 | 12.9030 | 12.0738 |
| 370022 | 17.9015 | 17.2344 | 17.3724 | 17.4872 |
| 370023 | 16.8215 | 17.7630 | 17.5148 | 17.3665 |
| 370025 | 16.3970 | 17.4988 | 18.4815 | 17.4661 |
| 370026 | 16.8991 | 18.3371 | 18.0412 | 17.7563 |
| 370028 | 19.7118 | 18.4445 | 21.1292 | 19.7322 |
| 370029 | 13.8930 | 16.4924 | 18.2580 | 16.0663 |
| 370030 | 15.4736 | 16.3269 | 16.5803 | 16.1058 |
| 370032 | 16.6432 | 18.2821 | 18.1538 | 17.7030 |
| 370033 | 12.3910 | 13.5216 | 11.3210 | 12.4595 |
| 370034 | 14.5101 | 15.6386 | 15.6288 | 15.2811 |
| 370035 | 18.9629 | 25.5764 | * | 21.9610 |
| 370036 | 11.4593 | 12.4026 | 12.4070 | 12.0833 |
| 370037 | 17.7491 | 16.7012 | 18.9556 | 17.7764 |
| 370038 | 12.8135 | 13.3084 | 13.0210 | 13.0660 |
| 370039 | 16.2661 | 15.5206 | 19.4498 | 17.0406 |
| 370040 | 14.2582 | 14.4672 | 15.5109 | 14.7638 |
| 370041 | 17.4123 | 16.7356 | 16.2316 | 16.8488 |
| 370042 | 14.6146 | 14.9175 | 15.2764 | 14.9764 |
| 370043 | 16.0764 | 15.9534 | 17.0892 | 16.3549 |
| 370045 | 12.4352 | 10.1994 | 11.3560 | 11.2236 |
| 370046 | 18.1499 | 18.8334 | * | 18.4831 |
| 370047 | 15.6716 | 16.7554 | 17.8769 | 16.7444 |
| 370048 | 17.4356 | 18.2150 | 15.6803 | 17.1206 |
| 370049 | 19.8397 | 20.7176 | 19.4868 | 19.9892 |
| 370051 | 12.1816 | 11.6736 | 12.5171 | 12.1083 |
| 370054 | 16.5598 | 16.9049 | 18.0787 | 17.1343 |
| 370056 | 18.8774 | 18.4558 | 18.1432 | 18.4804 |
| 370057 | 14.6564 | 16.7261 | 15.1228 | 15.5054 |
| 370059 | 16.4578 | 18.1386 | 18.3314 | 17.6259 |
| 370060 | 15.1169 | 16.5403 | 19.3051 | 16.8157 |
| 370063 | 17.0645 | 14.4132 | 16.7342 | 16.0603 |
| 370064 | 8.7499 | 10.9676 | 11.9954 | 10.6741 |
| 370065 | 16.5638 | 16.6898 | 18.1349 | 17.1281 |
| 370071 | 14.9472 | 16.1439 | 16.4567 | 15.8354 |
| 370072 | 14.6497 | 14.4742 | 13.6519 | 14.2760 |
| 370076 | 12.8568 | 13.5694 | 14.3555 | 13.5818 |
| 370077 | 17.6236 | * | * | 17.6236 |
| 370078 | 17.2370 | 18.4086 | 19.2412 | 18.2505 |
| 370079 | 13.5976 | 16.6861 | 16.9201 | 15.7005 |
| 370080 | 14.3445 | 13.9239 | 14.7323 | 14.3058 |
| 370082 | 13.5434 | 13.9634 | 15.0669 | 14.1855 |
| 370083 | 11.4905 | 13.1519 | 13.1810 | 12.6268 |
| 370084 | 21.7484 | 22.0545 | 13.1197 | 17.8063 |
| 370085 | 11.8844 | 11.2842 | 48.1271 | 14.9179 |
| 370086 | 13.5646 | 15.4404 | 11.1900 | 13.1933 |
| 370089 | 14.4968 | 16.0966 | 17.2638 | 15.9758 |
| 370091 | 17.5839 | 19.1698 | 20.1822 | 18.9743 |
| 370092 | 14.6757 | 14.9802 | 15.7678 | 15.1529 |
| 370093 | 18.5747 | 18.4600 | 19.7008 | 19.0469 |
| 370094 | 18.3796 | 18.0002 | 19.5462 | 18.6588 |
| 370095 | 14.1319 | 12.6383 | 13.4202 | 13.3755 |
| 370097 | 23.3116 | 22.9714 | 23.2056 | 23.1716 |
| 370099 | 16.2649 | 15.4549 | 19.4646 | 16.8783 |
| 370100 | 17.1036 | 14.0168 | 18.8274 | 16.6764 |
| 370103 | 15.8967 | 19.2353 | 18.2685 | 17.7516 |
| 370105 | 17.6811 | 21.3352 | 20.7890 | 19.9853 |
| 370106 | 18.6238 | 18.5485 | 20.3651 | 19.1398 |
| 370108 | 12.2379 | 12.3279 | 12.7470 | 12.4421 |
| 370112 | 15.2488 | 14.8539 | 15.3039 | 15.1287 |
| 370113 | 16.2043 | 16.1046 | 17.6107 | 16.6143 |
| 370114 | 15.9801 | 16.5268 | 17.8941 | 16.8136 |
| 370121 | 19.5506 | 22.5611 | 21.3099 | 21.1472 |
| 370122 | 12.1514 | 15.0645 | 15.4375 | 13.9736 |
| 370123 | 16.3609 | 18.9159 | 19.0313 | 18.0343 |
| 370125 | 13.5453 | 15.6284 | 13.9436 | 14.3107 |
| 370126 | 18.2447 | 23.9654 | 15.8020 | 19.1824 |
| 370131 | 16.2403 | 17.5689 | 15.7261 | 16.4650 |
| 370133 | 10.0169 | 10.9575 | 12.9545 | 11.1921 |
| 370138 | 15.9372 | 16.4005 | 17.5551 | 16.6500 |
| 370139 | 13.3023 | 14.8612 | 14.9964 | 14.3624 |
| 370140 | 15.2265 | 16.0721 | 17.1393 | 16.1657 |
| 370141 | 12.1420 | 18.4101 | 20.7798 | 16.3574 |
| 370146 | 12.5581 | 12.6402 | 13.0399 | 12.7467 |
| 370148 | 16.4147 | 20.6458 | 20.6612 | 19.2220 |
| 370149 | 16.7218 | 16.1850 | 17.0929 | 16.6647 |
| 370153 | 15.3218 | 17.8352 | 16.4669 | 16.5507 |
| 370154 | 15.9128 | 15.5127 | 15.6093 | 15.6789 |
| 370156 | 13.6363 | 13.9255 | 14.5696 | 14.0273 |
| 370158 | 15.0865 | 15.6917 | 15.6994 | 15.4906 |
| 370159 | 17.8319 | 28.0536 | 21.1267 | 21.7006 |
| 370163 | 14.5609 | 17.6361 | 20.4217 | 17.2893 |
| 370165 | 13.2174 | 13.0910 | 13.0375 | 13.1156 |
| 370166 | 17.8154 | 17.2849 | 21.0797 | 18.6456 |
| 370169 | 9.4807 | 12.5243 | 12.7138 | 11.5273 |
| 370176 | 16.0355 | 15.9476 | 18.9951 | 16.9629 |
| 370177 | 11.8757 | 11.2536 | 14.6481 | 12.5743 |
| 370178 | 11.6384 | 10.5726 | 11.6200 | 11.2422 |
| 370179 | 19.2677 | 17.2829 | 21.3002 | 18.9651 |
| 370183 | 7.6164 | 10.2945 | 16.9318 | 11.0088 |
| 370186 | 13.3454 | 13.6192 | 15.4533 | 14.1321 |
| 370190 | 13.7032 | 14.1397 | 19.3570 | 15.3737 |
| 370192 | 16.7402 | 18.4614 | 19.6967 | 18.2866 |
| 370197 | 21.5718 | * | * | 21.5718 |
| 370198 | * | 21.3136 | * | 21.3136 |
| 370200 | * | * | 22.5299 | 22.5299 |
| 380001 | 22.0255 | 20.3127 | 26.4822 | 22.5494 |
| 380002 | 19.4764 | 24.0241 | 21.9185 | 21.9840 |
| 380003 | 24.7434 | 21.7826 | 20.9007 | 22.2865 |
| 380004 | 23.1432 | 23.1451 | 23.3609 | 23.2208 |
| 380005 | 23.2415 | 24.0838 | 25.0750 | 24.1485 |
| 380006 | 20.5375 | 21.2731 | 21.3520 | 21.0653 |
| 380007 | 24.2933 | 25.2995 | 32.2678 | 27.0282 |
| 380008 | 21.1888 | 20.7063 | 22.3004 | 21.4082 |
| 380009 | 25.1702 | 23.8104 | 24.3851 | 24.4234 |
| 380010 | 19.7477 | 23.7488 | 22.7276 | 21.8451 |
| 380011 | 21.1353 | 21.1151 | 20.3357 | 20.8683 |
| 380013 | 20.1038 | 18.6818 | 19.8180 | 19.5721 |
| 380014 | 23.4819 | 24.6574 | 25.9828 | 24.7413 |
| 380017 | 23.8231 | 26.0578 | 25.3954 | 25.0552 |
| 380018 | 22.0776 | 22.3525 | 22.9822 | 22.4971 |
| 380019 | 20.7700 | 22.1215 | 20.8176 | 21.2209 |
| 380020 | 21.3556 | 20.1464 | 22.9568 | 21.5448 |
| 380021 | 20.6358 | 21.1590 | 23.8499 | 21.8371 |
| 380022 | 21.6110 | 22.6408 | 24.5974 | 22.8841 |
| 380023 | 19.2357 | 20.5462 | 21.3831 | 20.3976 |
| 380025 | 24.6738 | 26.3652 | 26.9346 | 25.9824 |
| 380026 | 19.2663 | 20.4706 | 20.6972 | 20.1525 |
| 380027 | 20.1576 | 20.8647 | 21.5490 | 20.8958 |
| 380029 | 18.5699 | 19.4246 | 20.1471 | 19.4015 |
| 380031 | 22.8346 | 23.3181 | 20.3396 | 22.1492 |
| 380033 | 23.2881 | 25.2454 | 27.1343 | 25.1500 |
| 380035 | 21.6533 | 22.4099 | 23.9719 | 22.6232 |
| 380036 | 19.3269 | 27.1587 | 27.2157 | 23.8613 |
| 380037 | 21.2347 | 21.9158 | 22.1774 | 21.7911 |
| 380038 | 25.5750 | 26.0869 | 26.7759 | 26.1419 |
| 380039 | 22.1235 | 23.1746 | 22.8048 | 22.6937 |
| 380040 | 21.6378 | 26.2717 | 22.5477 | 23.4095 |
| 380042 | 19.8096 | 21.1176 | 24.4172 | 21.7244 |
| 380047 | 21.9511 | 23.0718 | 24.2524 | 23.1258 |
| 380048 | 18.3847 | 17.5885 | 18.3005 | 18.0671 |
| 380050 | 18.2486 | 20.3934 | 20.3205 | 19.6254 |
| 380051 | 21.2358 | 22.3568 | 22.3207 | 21.9927 |
| 380052 | 17.8741 | 19.4570 | 18.6299 | 18.6300 |
| 380055 | 21.2459 | * | * | 21.2459 |
| 380056 | 17.1600 | 19.5185 | 18.4961 | 18.3892 |
| 380060 | 23.2923 | 24.2670 | 24.2059 | 23.9182 |
| 380061 | 22.5983 | 22.3736 | 22.8781 | 22.6217 |
| 380062 | 18.5229 | 20.7716 | 18.2148 | 19.1910 |
| 380063 | 19.3566 | 20.4077 | * | 19.9113 |
| 380064 | 19.8719 | 19.9826 | 22.9160 | 20.8404 |
| 380065 | 22.1706 | 26.1404 | 22.9608 | 23.6770 |
| 380066 | 20.4189 | 22.0349 | 23.2794 | 21.9793 |
| 380068 | 22.7573 | 22.3178 | * | 22.5559 |
| 380069 | 19.5793 | 19.8300 | 20.4882 | 19.9809 |
| 380070 | 24.7116 | 27.2541 | 27.7790 | 26.6130 |
| 380071 | 20.4707 | 22.6386 | 25.1808 | 22.8743 |
| 380072 | 16.3169 | 19.1553 | 19.4346 | 18.3236 |
| 380075 | 22.1703 | 22.3625 | 22.4139 | 22.3203 |
| 380078 | 19.1035 | 20.2507 | 21.0903 | 20.1439 |
| 380081 | 20.5902 | 20.9882 | 20.4082 | 20.6790 |
| 380082 | 22.5856 | 22.2275 | 22.9606 | 22.5990 |
| 380083 | 21.8096 | 21.3859 | 21.7431 | 21.6440 |
| 380084 | 23.6412 | 24.2844 | 27.1689 | 24.9815 |
| 380087 | 14.0976 | 16.5309 | 17.0380 | 15.8783 |
| 380088 | 19.5204 | 21.5225 | 19.5346 | 20.1728 |
| 380089 | 23.7413 | 19.5255 | 25.2908 | 23.0572 |
| 380090 | 27.0867 | 29.2702 | 24.9351 | 26.9453 |
| 380091 | 22.8333 | 27.5560 | 25.3062 | 25.1774 |
| 390001 | 18.6384 | 19.2989 | 19.6732 | 19.2277 |
| 390002 | 18.0787 | 21.8353 | 19.7833 | 19.8184 |
| 390003 | 17.2435 | 17.1371 | 18.1025 | 17.4798 |
| 390004 | 18.8899 | 19.2277 | 20.3204 | 19.4755 |
| 390005 | 16.4459 | 17.3506 | 16.9472 | 16.9256 |
| 390006 | 19.6012 | 20.2959 | 21.1786 | 20.3254 |
| 390007 | 21.4093 | 21.7506 | 21.3839 | 21.5152 |
| 390008 | 16.7440 | 17.8297 | 18.2743 | 17.6097 |
| 390009 | 20.1181 | 20.6507 | 20.6241 | 20.4567 |
| 390010 | 17.2315 | 17.5127 | 17.3335 | 17.3583 |
| 390011 | 18.0683 | 18.1717 | 18.3257 | 18.1941 |
| 390012 | 20.0227 | 20.6523 | 21.0610 | 20.5672 |
| 390013 | 19.3300 | 19.2698 | 19.6562 | 19.4200 |
| 390015 | 12.9372 | 13.1337 | 13.7352 | 13.2647 |
| 390016 | 17.0679 | 16.9892 | 17.1133 | 17.0565 |
| 390017 | 16.2170 | 16.7493 | 18.6113 | 17.1752 |
| 390018 | 19.1241 | 21.3626 | 19.0279 | 19.8558 |
| 390019 | 16.3965 | 16.7848 | 17.7258 | 16.9784 |
| 390022 | 22.8967 | 21.5064 | 24.8468 | 23.0587 |
| 390023 | 19.5639 | 21.8270 | 22.1044 | 21.4167 |
| 390024 | 25.0359 | 24.9437 | 25.4606 | 25.1433 |
| 390025 | 15.7111 | 15.6155 | 15.5523 | 15.6287 |
| 390026 | 22.7645 | 22.3902 | 22.9718 | 22.7143 |
| 390027 | 27.6893 | 26.8878 | 29.5940 | 28.0411 |
| 390028 | 20.1087 | 22.7700 | 23.6571 | 22.0510 |
| 390029 | 19.6883 | 21.5729 | 21.2661 | 20.8012 |
| 390030 | 18.3978 | 17.9580 | 18.6887 | 18.3432 |
| 390031 | 19.5175 | 19.2755 | 18.8162 | 19.2068 |
| 390032 | 18.1492 | 17.8041 | 21.5105 | 19.0439 |
| 390035 | 18.5146 | 20.2029 | 22.3591 | 20.2740 |
| 390036 | 18.8657 | 19.9880 | 19.7671 | 19.5278 |
| 390037 | 22.2359 | 21.0616 | 20.4263 | 21.2243 |
| 390039 | 16.5438 | 17.1046 | 17.5300 | 17.0475 |
| 390040 | 15.1211 | 15.9612 | 16.6876 | 15.9078 |
| 390041 | 19.5760 | 19.8080 | 20.4397 | 19.9243 |
| 390042 | 21.1276 | 22.7693 | 22.5775 | 22.1662 |
| 390043 | 16.3561 | 17.2607 | 17.4764 | 17.0230 |
| 390044 | 19.5419 | 20.2813 | 20.9831 | 20.2788 |
| 390045 | 18.4591 | 18.5574 | 19.4677 | 18.8305 |
| 390046 | 20.4608 | 20.7303 | 21.7445 | 20.9727 |
| 390047 | 24.5824 | 27.6661 | 26.9709 | 26.2900 |
| 390048 | 18.3801 | 19.0920 | 19.7992 | 19.0527 |
| 390049 | 21.1318 | 21.1217 | 22.1586 | 21.4802 |
| 390050 | 20.9240 | 22.8808 | 22.2639 | 22.0253 |
| 390051 | 26.0485 | 25.7910 | 28.1385 | 26.5675 |
| 390052 | 17.0988 | 20.9306 | 20.1195 | 19.3733 |
| 390054 | 17.4382 | 17.8852 | 18.4975 | 17.9431 |
| 390055 | 25.8961 | 24.2211 | 23.4017 | 24.4911 |
| 390056 | 17.1692 | 17.7858 | 19.3901 | 18.0977 |
| 390057 | 19.7459 | 20.2059 | 20.2395 | 20.0600 |
| 390058 | 19.2543 | 19.7379 | 20.3520 | 19.7916 |
| 390060 | 13.6276 | * | * | 13.6276 |
| 390061 | 20.4819 | 21.2392 | 23.8722 | 21.8310 |
| 390062 | 16.4505 | 16.6721 | 17.3750 | 16.8291 |
| 390063 | 19.6373 | 20.0125 | 19.4965 | 19.7211 |
| 390065 | 20.0001 | 19.9361 | 20.0473 | 19.9948 |
| 390066 | 18.7064 | 19.8539 | 18.9296 | 19.1567 |
| 390067 | 20.6515 | 20.9688 | 20.8162 | 20.8116 |
| 390068 | 17.5524 | 18.3158 | 19.1109 | 18.3267 |
| 390069 | 19.2858 | 19.6466 | * | 19.4555 |
| 390070 | 20.1862 | 16.1988 | 21.8549 | 19.3957 |
| 390071 | 16.2298 | 15.7165 | 16.0100 | 15.9856 |
| 390072 | 15.5565 | 16.3133 | 16.9232 | 16.2264 |
| 390073 | 20.6859 | 20.5581 | 21.2623 | 20.8422 |
| 390074 | 16.5971 | 18.4806 | 18.3093 | 17.7465 |
| 390075 | 17.2676 | 17.9840 | 18.7695 | 17.9105 |
| 390076 | 21.4307 | 20.2475 | 21.3290 | 20.9889 |
| 390078 | 18.2328 | 19.2089 | 19.0156 | 18.8052 |
| 390079 | 18.1969 | 18.3312 | 18.9269 | 18.4731 |
| 390080 | 19.5180 | 18.8028 | 21.4707 | 19.8661 |
| 390081 | 23.9922 | 24.8351 | 24.7461 | 24.5194 |
| 390083 | 20.5919 | * | * | 20.5919 |
| 390084 | 16.3463 | 16.4026 | 20.2529 | 17.4556 |
| 390086 | 17.2481 | 18.5265 | 18.3563 | 18.0522 |
| 390088 | 23.4941 | 23.6173 | 23.9506 | 23.6668 |
| 390090 | 20.6463 | 21.6437 | 21.3759 | 21.2068 |
| 390091 | 18.3746 | 18.1569 | 18.3770 | 18.3019 |
| 390093 | 16.6336 | 17.7171 | 18.4442 | 17.6019 |
| 390095 | 13.0459 | 16.3357 | 16.6930 | 15.2335 |
| 390096 | 19.3118 | 19.1171 | 22.4382 | 20.4516 |
| 390097 | 21.4115 | 23.5963 | 25.2845 | 23.2449 |
| 390100 | 20.3014 | 20.7859 | 20.9263 | 20.6729 |
| 390101 | 17.0534 | 17.9499 | 18.5039 | 17.8169 |
| 390102 | 19.4924 | 19.0461 | 21.5496 | 20.0293 |
| 390103 | 17.7054 | 18.4312 | 18.8667 | 18.3176 |
| 390104 | 15.9605 | 15.9008 | 16.3255 | 16.0548 |
| 390106 | 16.2783 | 16.6666 | 16.8439 | 16.6044 |
| 390107 | 19.1793 | 19.5178 | 20.9841 | 19.9123 |
| 390108 | 21.2872 | 21.0899 | 21.3142 | 21.2288 |
| 390109 | 14.6645 | 16.4597 | 16.5299 | 15.8639 |
| 390110 | 21.3191 | 21.5282 | 21.6464 | 21.5043 |
| 390111 | 28.7875 | 27.5193 | 33.3971 | 29.8383 |
| 390112 | 14.0439 | 14.9427 | 15.0065 | 14.6808 |
| 390113 | 17.9377 | 19.1945 | 19.3634 | 18.8262 |
| 390114 | 22.9698 | 19.6295 | 20.9533 | 21.1250 |
| 390115 | 24.7244 | 23.3461 | 21.4287 | 23.0792 |
| 390116 | 20.6016 | 21.4877 | 21.3671 | 21.1457 |
| 390117 | 16.9036 | 17.9393 | 18.0769 | 17.6425 |
| 390118 | 16.8962 | 18.3440 | 18.9507 | 18.0638 |
| 390119 | 18.5935 | 18.2951 | 18.8815 | 18.5863 |
| 390121 | 18.6422 | 20.8780 | 19.1315 | 19.5644 |
| 390122 | 17.4645 | 17.1902 | 17.7734 | 17.4764 |
| 390123 | 20.8412 | 20.8344 | 21.3974 | 21.0254 |
| 390125 | 15.9356 | 16.7983 | 17.5446 | 16.7393 |
| 390126 | 20.9383 | 20.6498 | * | 20.8020 |
| 390127 | 21.8849 | 21.7724 | 22.4555 | 22.0398 |
| 390128 | 19.4132 | 19.6792 | 19.3165 | 19.4699 |
| 390130 | 17.3253 | 17.7049 | 18.3695 | 17.7936 |
| 390131 | 16.8349 | 16.0986 | 19.2096 | 17.3202 |
| 390132 | 20.5528 | 21.1931 | 22.8414 | 21.4849 |
| 390133 | 24.6131 | 23.3489 | 24.7561 | 24.1960 |
| 390135 | 21.2497 | 21.5782 | 22.1905 | 21.6491 |
| 390136 | 17.6128 | 16.9737 | 20.6286 | 18.3801 |
| 390137 | 16.5598 | 17.5687 | 18.5397 | 17.5480 |
| 390138 | 18.8601 | 19.6212 | 20.6936 | 19.7394 |
| 390139 | 22.9351 | 24.4515 | 23.9757 | 23.7712 |
| 390142 | 26.7954 | 26.8086 | 28.8877 | 27.5656 |
| 390145 | 20.3393 | 20.3731 | 20.4228 | 20.3787 |
| 390146 | 17.7020 | 18.7922 | 18.6505 | 18.3503 |
| 390147 | 21.1085 | 20.9651 | 21.2492 | 21.1067 |
| 390150 | 19.6575 | 20.7294 | 20.3155 | 20.2474 |
| 390151 | 20.5084 | 21.6000 | 22.5206 | 21.5535 |
| 390152 | 19.1525 | 20.3353 | 19.4017 | 19.6203 |
| 390153 | 23.1183 | 23.7013 | 22.9707 | 23.2621 |
| 390154 | 15.8478 | 17.4036 | 16.7052 | 16.6538 |
| 390156 | 21.1629 | 21.8498 | 22.6398 | 21.8660 |
| 390157 | 19.8268 | 19.6578 | 19.1783 | 19.5633 |
| 390158 | 21.6045 | * | * | 21.6045 |
| 390160 | 20.7676 | 21.4810 | 19.4463 | 20.4967 |
| 390161 | 12.3743 | 16.4799 | * | 14.3389 |
| 390162 | 21.0228 | 21.4095 | 21.9188 | 21.4386 |
| 390163 | 15.6227 | 16.8013 | 17.7564 | 16.7297 |
| 390164 | 21.5890 | 24.6765 | 24.9750 | 23.5327 |
| 390166 | 19.9612 | 19.0405 | 19.7978 | 19.5957 |
| 390167 | 22.9136 | 19.8973 | * | 21.3982 |
| 390168 | 18.9936 | 18.7400 | 18.8863 | 18.8736 |
| 390169 | 18.9878 | 20.2382 | 22.0547 | 20.4487 |
| 390170 | 22.9877 | 26.5891 | 24.7973 | 24.6450 |
| 390173 | 17.8568 | 18.5370 | 18.6613 | 18.3502 |
| 390174 | 25.2407 | 25.4189 | 25.3307 | 25.3310 |
| 390176 | 17.3577 | 17.8740 | 20.8368 | 18.6587 |
| 390178 | 17.7036 | 16.6993 | 17.0534 | 17.1490 |
| 390179 | 21.4093 | 21.6901 | 21.8593 | 21.6579 |
| 390180 | 25.1191 | 25.7074 | 26.5541 | 25.8271 |
| 390181 | 17.0860 | 19.4654 | 19.3832 | 18.6237 |
| 390183 | 19.0834 | 17.8306 | 17.9848 | 18.2942 |
| 390184 | 20.7489 | 20.8060 | 20.9349 | 20.8256 |
| 390185 | 17.6516 | 18.8798 | 20.3877 | 18.9752 |
| 390189 | 18.6668 | 20.0889 | 20.3338 | 19.6907 |
| 390191 | 16.1993 | 16.3240 | 17.2270 | 16.5760 |
| 390192 | 16.3696 | 17.4537 | 17.6597 | 17.1476 |
| 390193 | 16.4663 | 16.7874 | 18.1209 | 17.0634 |
| 390194 | 20.1547 | 20.7953 | 21.2689 | 20.7092 |
| 390195 | 23.6920 | 24.6855 | 24.1793 | 24.1876 |
| 390197 | 18.9857 | 19.2690 | 20.7998 | 19.6927 |
| 390198 | 15.4508 | 15.9721 | 15.8833 | 15.7671 |
| 390199 | 16.6644 | 17.0515 | 17.3865 | 17.0306 |
| 390200 | 13.5898 | 15.1399 | 15.4012 | 14.7971 |
| 390201 | 20.5011 | 20.6296 | 20.3533 | 20.4916 |
| 390203 | 21.1895 | 20.9432 | 21.4989 | 21.2088 |
| 390204 | 20.8483 | 20.1779 | 22.9616 | 21.3067 |
| 390206 | 18.5746 | 18.4027 | * | 18.4910 |
| 390209 | 16.9558 | 17.4792 | 18.7059 | 17.7155 |
| 390211 | 17.9132 | 17.8638 | 18.4213 | 18.0846 |
| 390213 | 17.4453 | 18.8555 | 19.1553 | 18.5312 |
| 390215 | 21.4291 | 20.7084 | 21.2032 | 21.1048 |
| 390217 | 19.2926 | 19.1406 | 19.9837 | 19.4647 |
| 390219 | 21.6295 | 18.8292 | 19.6226 | 19.9600 |
| 390220 | 18.5178 | 18.7178 | 17.7916 | 18.3301 |
| 390222 | 20.9080 | 21.5739 | 22.1548 | 21.5483 |
| 390223 | 22.6498 | 23.6482 | 22.1775 | 22.7892 |
| 390224 | 15.9058 | 15.3015 | 13.7518 | 14.9518 |
| 390225 | 18.1752 | 18.6125 | 18.7290 | 18.5053 |
| 390226 | 23.1638 | 21.8268 | 21.8481 | 22.2835 |
| 390228 | 19.8129 | 19.4083 | 19.8180 | 19.6802 |
| 390231 | 24.4852 | 22.7544 | 19.4798 | 21.9903 |
| 390233 | 18.7707 | 19.4887 | 20.2309 | 19.5042 |
| 390235 | 24.6044 | 25.0857 | 21.4200 | 24.0078 |
| 390236 | 17.0339 | 16.2397 | 17.8735 | 17.0494 |
| 390237 | 21.7479 | 19.5230 | 22.3011 | 21.1430 |
| 390238 | * | 17.8211 | 17.1055 | 17.4821 |
| 390242 | 18.0943 | * | * | 18.0943 |
| 390244 | 14.4133 | 15.4611 | 15.6402 | 15.1810 |
| 390245 | 20.1544 | 26.0194 | 24.5076 | 23.4886 |
| 390246 | 17.9214 | 18.9733 | 25.0556 | 20.2904 |
| 390247 | 20.6671 | 20.9526 | 21.2151 | 20.8919 |
| 390249 | 10.7336 | 12.7920 | 13.1657 | 12.2298 |
| 390256 | 23.7828 | 20.9469 | 22.2773 | 22.2601 |
| 390258 | 21.3629 | 21.9207 | 22.6852 | 21.9998 |
| 390260 | 21.1917 | 21.9509 | 21.5982 | 21.5728 |
| 390262 | 18.6684 | 18.2379 | * | 18.4504 |
| 390263 | 20.0939 | 20.6855 | 20.3796 | 20.3890 |
| 390265 | 19.5089 | 20.3580 | 20.4950 | 20.1207 |
| 390266 | 16.2372 | 17.1666 | 17.1966 | 16.8552 |
| 390267 | 20.5125 | 21.2974 | 19.2665 | 20.4773 |
| 390268 | 21.0161 | 21.3486 | 22.0909 | 21.4791 |
| 390270 | 17.8280 | 19.0925 | 19.2074 | 18.7055 |
| 390277 | 27.0983 | * | * | 27.0983 |
| 390278 | 19.2019 | 18.2865 | 17.7176 | 18.4620 |
| 390279 | 13.6992 | 14.3241 | 14.8655 | 14.2998 |
| 390283 | * | * | 22.5490 | 22.5490 |
| 390284 | * | * | 34.3904 | 34.3904 |
| 400001 | 9.8615 | 9.9463 | 10.5757 | 10.1359 |
| 400002 | 9.3063 | 10.1417 | 13.0494 | 10.8249 |
| 400003 | 9.9865 | 10.8821 | 12.4078 | 11.0633 |
| 400004 | 8.4811 | 8.9864 | 8.5648 | 8.6695 |
| 400005 | 7.8494 | 9.5632 | 7.7432 | 8.3858 |
| 400006 | 10.5281 | 10.3444 | 10.1048 | 10.3288 |
| 400007 | 7.8637 | 6.4490 | 8.0174 | 7.3754 |
| 400009 | 8.3727 | 8.4207 | 8.8650 | 8.5497 |
| 400010 | 11.6642 | 10.6518 | 10.8011 | 10.9779 |
| 400011 | 5.6825 | 7.4979 | 8.5426 | 7.2512 |
| 400012 | 7.8134 | 8.2412 | 8.4728 | 8.1883 |
| 400013 | 8.2066 | 8.4579 | 9.2624 | 8.6839 |
| 400014 | 9.5354 | 9.5235 | 9.4798 | 9.5126 |
| 400015 | 10.3326 | 10.9505 | 14.4076 | 11.3577 |
| 400016 | 12.0743 | 13.2756 | 13.3922 | 12.9125 |
| 400017 | 8.5675 | 8.6421 | 9.2577 | 8.8024 |
| 400018 | 9.4534 | 10.4557 | 10.6208 | 10.1978 |
| 400019 | 10.1512 | 10.4332 | 10.8940 | 10.5307 |
| 400021 | 9.9121 | 10.6988 | 12.1434 | 10.9538 |
| 400022 | 11.1204 | 11.5861 | 12.2199 | 11.6336 |
| 400024 | 7.5594 | 7.8984 | 9.2409 | 8.1615 |
| 400026 | 7.1236 | 5.6454 | 5.8335 | 6.1312 |
| 400027 | 8.4862 | 9.5899 | * | 9.0120 |
| 400028 | 8.3991 | 8.8597 | 9.1794 | 8.7817 |
| 400031 | 9.7826 | 8.2660 | * | 8.9857 |
| 400032 | 9.7291 | 10.5498 | 10.0448 | 10.1074 |
| 400044 | 11.7484 | 11.9704 | 11.9486 | 11.8844 |
| 400048 | 8.9224 | 9.1701 | 15.1405 | 10.3604 |
| 400061 | 12.2770 | 12.4493 | 13.0988 | 12.5813 |
| 400079 | 7.0830 | * | 9.7203 | 8.1082 |
| 400087 | 10.3972 | 9.5097 | 9.8534 | 9.8687 |
| 400094 | 7.8208 | 8.9116 | 7.9187 | 8.1829 |
| 400098 | 7.2098 | 9.3308 | 9.7791 | 8.8630 |
| 400102 | 7.7288 | 9.8536 | 9.9903 | 9.1668 |
| 400103 | 10.7316 | 11.2069 | 11.5359 | 11.1167 |
| 400104 | 9.9416 | 11.0672 | 10.7292 | 10.5214 |
| 400105 | 10.1726 | 9.3049 | 9.0556 | 9.5335 |
| 400106 | 8.5143 | 9.3123 | 9.2187 | 9.0108 |
| 400109 | 10.1786 | 10.9826 | 11.8760 | 11.0486 |
| 400110 | 10.5250 | 10.3326 | 10.5277 | 10.4760 |
| 400111 | 9.5600 | 9.5583 | 10.9665 | 10.1021 |
| 400112 | 12.8478 | 10.1755 | 10.8694 | 11.2941 |
| 400113 | 9.4835 | 9.2238 | 8.3168 | 9.0068 |
| 400114 | 6.4076 | 9.0496 | 7.0510 | 7.4630 |
| 400115 | 9.1311 | 9.8244 | 8.5487 | 9.1780 |
| 400117 | 10.0381 | 10.2295 | 10.8756 | 10.3823 |
| 400118 | 8.6964 | 9.4398 | 11.4051 | 9.9004 |
| 400120 | 9.7425 | 9.5274 | 10.6584 | 9.9956 |
| 400121 | 7.1061 | 7.8052 | 9.8322 | 8.2686 |
| 400122 | 8.4806 | 8.1911 | 7.6413 | 8.0571 |
| 400123 | 9.0217 | 7.8099 | 10.2367 | 9.0130 |
| 400124 | 11.4839 | 12.0999 | 12.2452 | 11.9729 |
| 400125 | * | * | 10.2056 | 10.2056 |
| 410001 | 22.5322 | 23.2808 | 23.1738 | 23.0006 |
| 410004 | 22.3212 | 22.4801 | 21.0638 | 22.0103 |
| 410005 | 21.2407 | 23.1444 | 22.7170 | 22.3365 |
| 410006 | 21.9798 | 23.3968 | 23.8700 | 23.0621 |
| 410007 | 20.9489 | 22.1452 | 23.1325 | 22.1106 |
| 410008 | 22.6133 | 23.0662 | 24.9726 | 23.5244 |
| 410009 | 24.0769 | 24.4899 | 24.3895 | 24.3200 |
| 410010 | 27.1426 | 26.9813 | 28.4589 | 27.5328 |
| 410011 | 24.3676 | 25.2926 | 26.1183 | 25.2512 |
| 410012 | 21.3337 | 24.5811 | 24.1695 | 23.4018 |
| 410013 | 25.0050 | 24.5122 | 24.8800 | 24.7951 |
| 420002 | 20.2049 | 19.4845 | 20.7804 | 20.1513 |
| 420004 | 19.4079 | 19.7968 | 20.9588 | 20.0732 |
| 420005 | 15.9906 | 17.3510 | 17.9694 | 17.1171 |
| 420006 | 18.2374 | 18.3439 | 19.1760 | 18.5687 |
| 420007 | 17.5783 | 18.2096 | 18.6456 | 18.1319 |
| 420009 | 17.2515 | 18.5456 | 19.9586 | 18.6114 |
| 420010 | 17.9141 | 17.1184 | 18.0252 | 17.6914 |
| 420011 | 14.9944 | 16.5664 | 18.0970 | 16.4913 |
| 420014 | 16.7219 | 16.6065 | 18.0519 | 17.0894 |
| 420015 | 17.1802 | 18.8411 | 20.1164 | 18.5841 |
| 420016 | 18.1451 | 15.6241 | 15.5485 | 16.2939 |
| 420018 | 19.7285 | 19.7367 | 21.8775 | 20.3791 |
| 420019 | 15.5521 | 16.9990 | 17.1726 | 16.5419 |
| 420020 | 17.9011 | 20.9449 | 20.3193 | 19.6942 |
| 420023 | 20.9663 | 19.4855 | 20.4053 | 20.2598 |
| 420026 | 21.8968 | 20.3476 | 21.8749 | 21.3678 |
| 420027 | 18.0774 | 18.8457 | 19.2594 | 18.7307 |
| 420029 | 18.3557 | * | * | 18.3557 |
| 420030 | 17.8215 | 19.1453 | 20.6448 | 19.3038 |
| 420031 | 13.0718 | 14.1855 | 8.2516 | 11.1227 |
| 420033 | 21.0863 | 21.7279 | 23.1303 | 21.9705 |
| 420036 | 19.7421 | 17.6136 | 21.3222 | 19.4565 |
| 420037 | 21.9603 | 21.7908 | 22.7099 | 22.1669 |
| 420038 | 16.1498 | 17.6726 | 18.6568 | 17.4393 |
| 420039 | 16.9646 | 15.8385 | 18.3017 | 17.0260 |
| 420042 | 14.6567 | * | * | 14.6567 |
| 420043 | 18.3607 | 19.4521 | 19.7570 | 19.1785 |
| 420048 | 18.0286 | 18.4367 | 18.8070 | 18.4223 |
| 420049 | 19.2340 | 17.5854 | 19.4049 | 18.7208 |
| 420051 | 18.2518 | 19.5001 | 19.1555 | 18.9941 |
| 420053 | 16.5452 | 16.9599 | 18.1657 | 17.1887 |
| 420054 | 16.5474 | 18.2702 | 20.2574 | 18.3229 |
| 420055 | 16.1823 | 19.2048 | 16.8717 | 17.3777 |
| 420056 | 15.5966 | 14.8695 | 15.1835 | 15.1636 |
| 420057 | 14.5006 | 15.9849 | 20.5266 | 17.2252 |
| 420059 | 19.1303 | 15.8160 | 17.1483 | 17.3325 |
| 420061 | 16.1310 | 16.5555 | 17.3543 | 16.6881 |
| 420062 | 18.9513 | 17.8205 | 21.7469 | 19.4924 |
| 420064 | 15.4531 | 16.7227 | 16.0794 | 16.0985 |
| 420065 | 19.0645 | 19.6902 | 19.9435 | 19.5673 |
| 420066 | 15.5001 | 15.1804 | 18.0042 | 16.2261 |
| 420067 | 18.3106 | 18.8610 | 19.7824 | 19.0239 |
| 420068 | 17.2144 | 18.5030 | 18.5481 | 18.0958 |
| 420069 | 16.3189 | 17.0788 | 18.1298 | 17.2134 |
| 420070 | 17.4486 | 18.0057 | 17.3876 | 17.6174 |
| 420071 | 18.2878 | 19.4482 | 20.3902 | 19.3836 |
| 420072 | 12.6013 | 13.8550 | 15.0158 | 13.8117 |
| 420073 | 19.2011 | 19.1604 | 19.9986 | 19.4566 |
| 420074 | 13.8038 | 16.9292 | 18.0967 | 16.2019 |
| 420075 | 16.2946 | 14.2931 | 12.8158 | 14.3372 |
| 420078 | 20.6818 | 20.7317 | 21.9082 | 21.1259 |
| 420079 | 18.7710 | 20.8639 | 21.0874 | 20.2636 |
| 420080 | 24.8321 | 22.3443 | 21.9968 | 22.9897 |
| 420081 | 20.4211 | * | * | 20.4211 |
| 420082 | 18.8848 | 20.4653 | 21.7210 | 20.3535 |
| 420083 | 23.3425 | 20.1472 | 22.6376 | 21.9902 |
| 420085 | 18.5502 | 19.9603 | 21.6791 | 20.1188 |
| 420086 | 19.3054 | 25.7179 | 20.2878 | 21.4636 |
| 420087 | 18.4016 | 19.1403 | 19.8388 | 19.1412 |
| 420088 | 17.9063 | 17.1938 | 19.9919 | 18.3046 |
| 420089 | 21.6608 | 20.2537 | 20.5360 | 20.7623 |
| 420091 | 18.5723 | 18.8687 | 20.3092 | 19.2195 |
| 420093 | 16.7734 | 17.4689 | 18.3902 | 17.5654 |
| 420094 | 32.6768 | * | * | 32.6768 |
| 430004 | 17.8435 | 18.5438 | 19.6344 | 18.6310 |
| 430005 | 15.8449 | 16.3059 | 16.4560 | 16.2068 |
| 430007 | 14.0586 | 14.1078 | 14.6331 | 14.2620 |
| 430008 | 16.7640 | 17.6640 | 18.1323 | 17.5240 |
| 430010 | 16.1093 | 17.1766 | 19.8191 | 17.5891 |
| 430011 | 16.4234 | 16.9848 | 17.4750 | 16.9703 |
| 430012 | 17.7809 | 17.2775 | 17.6997 | 17.5855 |
| 430013 | 17.2424 | 18.1338 | 18.4817 | 17.9391 |
| 430014 | 18.4417 | 16.8925 | 20.2387 | 18.3922 |
| 430015 | 16.4123 | 18.0019 | 18.2875 | 17.5236 |
| 430016 | 18.9715 | 19.4759 | 20.8850 | 19.7559 |
| 430018 | 14.9100 | 14.8854 | 16.2244 | 15.3323 |
| 430022 | 12.9532 | 13.4905 | 14.5118 | 13.6222 |
| 430023 | 11.6383 | 12.2331 | 16.2164 | 13.2302 |
| 430024 | 13.9942 | 15.4709 | 16.1801 | 15.3449 |
| 430026 | 10.8532 | * | * | 10.8532 |
| 430027 | 18.6367 | 19.1461 | 20.2591 | 19.2968 |
| 430028 | 16.7185 | 18.2312 | 17.1577 | 17.3522 |
| 430029 | 15.1010 | 16.6500 | 17.6986 | 16.5066 |
| 430031 | 12.4631 | 13.1258 | 12.4660 | 12.6792 |
| 430033 | 14.6423 | 15.3003 | 17.3652 | 15.6688 |
| 430034 | 12.8513 | 15.4064 | 14.2491 | 14.1740 |
| 430036 | 13.7807 | 13.6967 | 15.6258 | 14.3461 |
| 430037 | 15.9545 | 16.5368 | 18.1293 | 16.8632 |
| 430038 | 11.9419 | 13.7167 | 18.4078 | 14.2118 |
| 430040 | 13.3722 | 13.6745 | 14.4509 | 13.8057 |
| 430041 | 12.6235 | 13.1936 | 14.8816 | 13.4964 |
| 430043 | 13.4288 | 13.6908 | 14.9949 | 14.0204 |
| 430044 | 16.4488 | 18.4970 | 21.0823 | 18.5195 |
| 430047 | 15.6227 | 17.4956 | 17.9823 | 16.9377 |
| 430048 | 17.2589 | 18.3524 | 18.7602 | 18.0996 |
| 430049 | 14.4354 | 15.5381 | 15.2237 | 15.0640 |
| 430051 | 17.2139 | 17.0574 | 18.8070 | 17.6987 |
| 430054 | 13.5011 | 14.7251 | 14.8003 | 14.3524 |
| 430056 | 11.4117 | 11.7627 | 10.3697 | 11.1792 |
| 430057 | 15.1516 | 15.4390 | 17.2805 | 15.9601 |
| 430060 | 8.6409 | 9.0358 | 10.0176 | 9.2343 |
| 430062 | 10.8879 | * | * | 10.8879 |
| 430064 | 12.7394 | 14.4367 | 14.2184 | 13.7779 |
| 430065 | 12.7660 | * | * | 12.7660 |
| 430066 | 13.4380 | 14.3557 | 15.6660 | 14.4524 |
| 430073 | 14.9784 | 16.1133 | 15.3776 | 15.4839 |
| 430076 | 12.2452 | 12.7608 | 13.9883 | 12.9521 |
| 430077 | 17.7126 | 19.3012 | 19.8558 | 18.9586 |
| 430079 | 12.9780 | 13.6836 | 14.1815 | 13.5924 |
| 430087 | 10.4491 | * | * | 10.4491 |
| 430089 | 17.0065 | 17.8908 | 17.9790 | 17.6658 |
| 430090 | * | 21.5239 | 21.5974 | 21.5592 |
| 430091 | * | 19.2146 | 18.1567 | 18.5152 |
| 430092 | * | * | 21.3807 | 21.3807 |
| 430093 | * | * | 19.5013 | 19.5013 |
| 440001 | 15.3134 | 14.8713 | 15.5897 | 15.2550 |
| 440002 | 18.5411 | 19.1498 | 20.3740 | 19.3756 |
| 440003 | 17.4736 | 18.3658 | 19.3042 | 18.3967 |
| 440006 | 20.6559 | 19.6021 | 21.4055 | 20.5221 |
| 440007 | 7.7632 | 12.1230 | 14.8959 | 11.0241 |
| 440008 | 15.4701 | 17.2848 | 18.8994 | 17.1822 |
| 440009 | 15.4558 | 17.8424 | 17.4831 | 16.9676 |
| 440010 | 13.5118 | 19.9829 | 16.3283 | 16.4644 |
| 440011 | 17.1591 | 17.6948 | 18.3375 | 17.7161 |
| 440012 | 19.0606 | 15.9837 | 19.5739 | 18.2503 |
| 440014 | 14.6093 | 15.9195 | 16.1143 | 15.5705 |
| 440015 | 21.0884 | 18.2632 | 22.0659 | 20.4116 |
| 440016 | 14.9409 | 15.4097 | 16.2964 | 15.5583 |
| 440017 | 21.1258 | 19.6215 | 20.4563 | 20.3835 |
| 440018 | 18.2080 | 16.4115 | 17.4995 | 17.3550 |
| 440019 | 28.2242 | 20.0416 | 21.5402 | 22.7883 |
| 440020 | 15.5889 | 18.1154 | 17.8879 | 17.2181 |
| 440022 | 19.0214 | 15.8459 | * | 17.5909 |
| 440023 | 14.1410 | 15.4721 | 16.7837 | 15.4038 |
| 440024 | 18.1028 | 18.4432 | 18.4046 | 18.3183 |
| 440025 | 15.2826 | 15.8784 | 16.3140 | 15.8395 |
| 440026 | 22.9174 | 23.0550 | 23.2566 | 23.0549 |
| 440029 | 18.5183 | 19.4326 | 20.7050 | 19.5797 |
| 440030 | 15.5718 | 16.2941 | 16.9925 | 16.3267 |
| 440031 | 14.3023 | 15.5432 | 17.0211 | 15.6197 |
| 440032 | 13.5996 | 13.9775 | 13.8140 | 13.7931 |
| 440033 | 14.0409 | 14.5304 | 13.7328 | 14.1227 |
| 440034 | 17.9315 | 19.5470 | 20.0309 | 19.2030 |
| 440035 | 18.1578 | 18.9026 | 19.3034 | 18.7862 |
| 440039 | 19.3747 | 19.9439 | 21.6536 | 20.3424 |
| 440040 | 17.4965 | 16.3740 | 16.9275 | 16.9214 |
| 440041 | 13.6279 | 14.6621 | 14.9545 | 14.4249 |
| 440046 | 16.8798 | 18.1654 | 19.3229 | 18.0984 |
| 440047 | 17.0037 | 16.6646 | 17.8092 | 17.1528 |
| 440048 | 18.1449 | 19.4498 | 21.4993 | 19.5981 |
| 440049 | 16.7066 | 17.9292 | 18.7967 | 17.8439 |
| 440050 | 16.7627 | 19.1328 | 18.2511 | 18.0098 |
| 440051 | 14.9074 | 13.1901 | 16.0421 | 14.6532 |
| 440052 | 16.2693 | 16.6541 | 19.8075 | 17.4207 |
| 440053 | 17.6873 | 18.5515 | 19.6494 | 18.6583 |
| 440054 | 12.3134 | 13.8716 | 13.3967 | 13.1942 |
| 440056 | 14.2534 | 15.9821 | 16.2742 | 15.4778 |
| 440057 | 12.7190 | 12.7925 | 13.7257 | 13.0446 |
| 440058 | 18.7381 | 18.8118 | 19.1878 | 18.9185 |
| 440059 | 17.5274 | 18.5418 | 19.6018 | 18.6049 |
| 440060 | 15.8599 | 18.0586 | 19.7916 | 17.7309 |
| 440061 | 16.8442 | 14.9708 | 22.5525 | 17.8114 |
| 440063 | 18.2923 | 19.3222 | 19.8371 | 19.1661 |
| 440064 | 17.6154 | 17.7652 | 18.9809 | 18.1133 |
| 440065 | 18.6943 | 18.5825 | 18.8296 | 18.7013 |
| 440067 | 22.0655 | 16.2811 | 17.2397 | 18.2348 |
| 440068 | 17.4513 | 19.4695 | 19.3668 | 18.7087 |
| 440070 | 15.0440 | 13.7035 | 14.0437 | 14.2715 |
| 440071 | 16.2691 | 17.0186 | 19.7836 | 17.5412 |
| 440072 | 16.7675 | 17.5995 | 19.1522 | 17.8026 |
| 440073 | 18.5576 | 19.1714 | 19.5554 | 19.1079 |
| 440078 | 13.0916 | 15.0849 | 16.0188 | 14.6728 |
| 440081 | 17.9702 | 18.3587 | 19.3454 | 18.5764 |
| 440082 | 23.0805 | 22.2857 | 22.6855 | 22.6613 |
| 440083 | 35.0978 | 14.8525 | 13.7423 | 17.4998 |
| 440084 | 13.3678 | 13.4378 | 13.7731 | 13.5305 |
| 440091 | 19.7250 | 19.6114 | 20.1065 | 19.8343 |
| 440100 | 13.9487 | 13.8437 | 14.7113 | 14.1637 |
| 440102 | 13.9575 | 14.3510 | 14.5500 | 14.2949 |
| 440103 | 19.2083 | 20.3052 | 18.6990 | 19.3857 |
| 440104 | 22.3883 | 22.4403 | 22.6754 | 22.4883 |
| 440105 | 16.0338 | 16.7131 | 17.1172 | 16.6050 |
| 440109 | 14.2491 | 16.0446 | 17.7443 | 15.8919 |
| 440110 | 15.9174 | 21.1716 | 17.4816 | 17.9016 |
| 440111 | 21.0682 | 23.2425 | 23.2254 | 22.5309 |
| 440114 | 13.6095 | 14.4997 | 15.0036 | 14.3318 |
| 440115 | 12.9668 | 17.4514 | 18.5457 | 16.2205 |
| 440120 | 18.2993 | 17.2384 | 16.3115 | 17.2831 |
| 440125 | 16.1067 | 15.6588 | 19.4115 | 17.0424 |
| 440130 | 16.6750 | 17.8223 | 17.4857 | 17.3264 |
| 440131 | 14.6752 | 15.5048 | 16.1214 | 15.4186 |
| 440132 | 15.9069 | 16.6553 | 16.8871 | 16.4950 |
| 440133 | 21.5116 | 21.5313 | 23.0891 | 22.0182 |
| 440135 | 20.9029 | 19.2010 | 22.2005 | 20.8180 |
| 440137 | 14.6966 | 14.5632 | 15.0070 | 14.7511 |
| 440141 | 12.4774 | 13.5308 | 15.9429 | 13.7977 |
| 440142 | 13.0059 | 15.7287 | 16.8855 | 15.0859 |
| 440143 | 17.8429 | 17.7821 | 18.2061 | 17.9416 |
| 440144 | 16.6666 | 17.6415 | 18.3859 | 17.5674 |
| 440145 | 13.6577 | 17.0608 | 18.3948 | 16.1716 |
| 440147 | 22.0069 | 21.4304 | 26.1464 | 23.0399 |
| 440148 | 17.6438 | 19.2435 | 19.4598 | 18.7842 |
| 440149 | 17.1496 | 16.6923 | 18.4281 | 17.4374 |
| 440150 | 13.0775 | 20.1411 | 20.3006 | 17.2935 |
| 440151 | 15.4250 | 17.4248 | 18.3928 | 17.0781 |
| 440152 | 17.8399 | 21.0287 | 22.7664 | 20.2196 |
| 440153 | 16.0954 | 16.7769 | 16.5716 | 16.4916 |
| 440156 | 19.6117 | 29.5557 | 21.7577 | 23.1575 |
| 440157 | 11.3982 | 16.9265 | 18.4249 | 15.5384 |
| 440159 | 17.6237 | 17.7158 | 20.9371 | 18.4872 |
| 440161 | 20.7643 | 21.8013 | 22.8816 | 21.7855 |
| 440162 | 14.4121 | 14.7637 | 15.5534 | 14.8623 |
| 440166 | 18.1413 | 19.6684 | 19.2159 | 18.9985 |
| 440168 | 15.9513 | 18.6535 | 19.1509 | 17.9995 |
| 440173 | 18.4683 | 18.6402 | 19.1812 | 18.7699 |
| 440174 | 17.0080 | 17.3294 | 18.0865 | 17.4583 |
| 440175 | 17.6107 | 20.0802 | 18.5186 | 18.7356 |
| 440176 | 18.7529 | 18.0294 | 19.2208 | 18.6470 |
| 440180 | 17.3412 | 19.7773 | 20.2184 | 19.1376 |
| 440181 | 11.8471 | 16.4878 | 17.7709 | 15.0662 |
| 440182 | 20.3202 | 17.7487 | 19.7094 | 19.1341 |
| 440183 | 19.4374 | 22.7067 | 21.3465 | 21.1277 |
| 440184 | 18.0603 | 17.2037 | 16.8880 | 17.4646 |
| 440185 | 18.7286 | 19.3870 | 21.2188 | 19.7784 |
| 440186 | 18.5312 | 19.3948 | 19.7983 | 19.2465 |
| 440187 | 16.2530 | 18.9713 | 17.5872 | 17.6013 |
| 440189 | 16.1906 | * | 18.5252 | 17.4309 |
| 440192 | 19.9669 | 19.0839 | 19.1705 | 19.3968 |
| 440193 | 18.3952 | 19.0811 | 18.6999 | 18.7380 |
| 440194 | 20.3343 | 19.8682 | 22.4562 | 20.9277 |
| 440197 | 23.1080 | 21.9618 | 21.8503 | 22.2548 |
| 440200 | 16.0619 | 17.9575 | 19.8078 | 18.0280 |
| 440203 | 16.6132 | 18.3400 | 16.2861 | 17.0710 |
| 440206 | 15.5462 | 16.4429 | * | 16.0270 |
| 440209 | 14.7466 | * | * | 14.7466 |
| 440210 | 12.3292 | 11.0218 | 11.9815 | 11.7402 |
| 440211 | * | 14.8972 | * | 14.8972 |
| 440212 | * | 17.0685 | * | 17.0685 |
| 440213 | * | 19.5760 | * | 19.5760 |
| 440214 | * | * | 28.0285 | 28.0285 |
| 440215 | * | * | 22.2928 | 22.2928 |
| 450002 | 19.9195 | 21.3749 | 21.4836 | 20.9147 |
| 450004 | 15.2751 | 16.6723 | 16.7850 | 16.2360 |
| 450005 | 15.5888 | 18.3600 | 16.6396 | 16.8103 |
| 450007 | 15.7536 | 16.9681 | 19.1910 | 17.3218 |
| 450008 | 15.7458 | 17.0832 | 17.6582 | 16.7901 |
| 450010 | 16.0790 | 16.5001 | 17.6677 | 17.0234 |
| 450011 | 18.0137 | 17.1942 | 20.8102 | 18.6782 |
| 450014 | 18.2173 | 17.9495 | 17.5815 | 17.9004 |
| 450015 | 18.4400 | 18.9895 | 21.6773 | 19.6131 |
| 450016 | 17.3054 | 18.4463 | 18.3456 | 18.0337 |
| 450018 | 20.4133 | 21.4788 | 23.2293 | 21.6061 |
| 450020 | 16.9661 | 17.8415 | 19.1153 | 18.0122 |
| 450021 | 22.6910 | 23.0843 | 23.3630 | 23.0474 |
| 450023 | 16.6408 | 16.0831 | 17.6360 | 16.7896 |
| 450024 | 16.5604 | 17.3518 | 18.5985 | 17.4846 |
| 450025 | 16.4396 | 17.0004 | * | 16.7280 |
| 450028 | 18.4287 | 18.8764 | 19.1658 | 18.8489 |
| 450029 | 17.6909 | 17.4716 | 17.7425 | 17.6360 |
| 450031 | 20.8992 | 22.2222 | 29.6945 | 23.8280 |
| 450032 | 15.2404 | 17.3317 | 14.6530 | 15.6504 |
| 450033 | 20.8634 | 19.7437 | 21.0222 | 20.5422 |
| 450034 | 18.9068 | 19.6721 | 18.8823 | 19.1560 |
| 450035 | 16.8132 | 20.0951 | 20.3599 | 19.0234 |
| 450037 | 18.6549 | 19.5411 | 19.9140 | 19.3829 |
| 450039 | 22.0811 | 19.8143 | 19.7176 | 20.5536 |
| 450040 | 17.5179 | 16.8534 | 19.6370 | 18.0669 |
| 450042 | 17.5906 | 19.8921 | 18.8357 | 18.7392 |
| 450044 | 21.0399 | 24.7961 | 21.0909 | 22.1921 |
| 450046 | 17.0917 | 18.6536 | 17.3631 | 17.6586 |
| 450047 | 13.9022 | 13.4486 | 16.9028 | 14.6102 |
| 450050 | 13.0037 | 14.7669 | 17.7209 | 15.0293 |
| 450051 | 20.0763 | 21.0236 | 21.1008 | 20.7301 |
| 450052 | 13.5278 | 13.8881 | 15.5890 | 14.3570 |
| 450053 | 17.3139 | 17.0467 | 17.2781 | 17.2160 |
| 450054 | 21.9835 | 22.8960 | 15.9388 | 20.5562 |
| 450055 | 14.8119 | 15.0433 | 15.8526 | 15.2415 |
| 450056 | 20.0008 | 21.8436 | 21.8605 | 21.2529 |
| 450058 | 16.9832 | 18.0967 | 18.6172 | 17.9075 |
| 450059 | 14.2072 | 15.2168 | 19.8240 | 16.2886 |
| 450063 | 13.8126 | 14.3815 | 12.7211 | 13.5914 |
| 450064 | 16.4165 | 17.4093 | 19.7682 | 17.8341 |
| 450065 | 19.6087 | 21.4934 | 23.3797 | 21.3723 |
| 450068 | 22.6924 | 22.8998 | 23.3495 | 22.9910 |
| 450072 | 17.3794 | 19.0111 | 18.0307 | 18.1442 |
| 450073 | 16.6168 | 17.1002 | 16.5942 | 16.7690 |
| 450078 | 13.4875 | 11.7265 | 13.2820 | 12.8188 |
| 450079 | 19.4899 | 21.0518 | 20.6483 | 20.4464 |
| 450080 | 16.3147 | 17.4553 | 18.6212 | 17.4805 |
| 450081 | 16.1653 | 16.3448 | 17.5737 | 16.7023 |
| 450082 | 13.2952 | 16.1585 | 16.8677 | 15.5279 |
| 450083 | 20.1830 | 21.5884 | 23.3754 | 21.7298 |
| 450085 | 14.2167 | 18.3602 | 20.0085 | 17.2728 |
| 450087 | 21.4764 | 22.0273 | 21.9320 | 21.8111 |
| 450090 | 13.9101 | 15.0939 | 15.5796 | 14.8590 |
| 450092 | 15.7316 | 16.8260 | 17.9520 | 16.8805 |
| 450094 | 19.4249 | 21.3158 | 23.2863 | 21.3961 |
| 450096 | 16.6300 | 17.8813 | 18.6802 | 17.7158 |
| 450097 | 18.2740 | 19.5723 | 19.7187 | 19.2252 |
| 450098 | 15.4796 | 20.5754 | 19.0454 | 18.3431 |
| 450099 | 22.8834 | 19.2258 | 20.4181 | 20.6312 |
| 450101 | 16.9628 | 17.1330 | 17.7928 | 17.2860 |
| 450102 | 18.8465 | 18.6707 | 19.8793 | 19.1269 |
| 450104 | 15.9781 | 16.6744 | 17.0821 | 16.5911 |
| 450107 | 20.7359 | 25.1986 | 24.1094 | 23.2223 |
| 450108 | 16.1451 | 15.6324 | 15.2797 | 15.6413 |
| 450109 | 12.7654 | 13.8127 | 10.5973 | 12.1326 |
| 450110 | 21.4421 | 19.5821 | * | 20.4354 |
| 450111 | 19.2749 | 19.6350 | 21.4908 | 20.1993 |
| 450112 | 14.7610 | 16.0441 | 18.1026 | 16.3114 |
| 450113 | 18.5356 | 20.9777 | 20.8306 | 19.9901 |
| 450118 | 15.8317 | 17.9053 | * | 16.9195 |
| 450119 | 18.3166 | 20.2853 | 20.2030 | 19.6520 |
| 450121 | 18.2278 | 20.4641 | 21.9198 | 20.1751 |
| 450123 | 19.1912 | 15.7618 | 14.1755 | 16.0237 |
| 450124 | 21.0925 | 22.7480 | 22.5208 | 22.1327 |
| 450126 | 17.4512 | 21.7233 | 21.4789 | 19.9557 |
| 450128 | 15.8881 | 18.2184 | 18.1446 | 17.4552 |
| 450130 | 17.8722 | 20.4156 | 18.9211 | 19.0565 |
| 450131 | 17.6163 | 19.2589 | 17.4168 | 18.0711 |
| 450132 | 18.0745 | 18.1713 | 21.8089 | 19.3784 |
| 450133 | 19.9259 | 23.6366 | 26.0763 | 23.0339 |
| 450135 | 20.8065 | 21.0306 | 20.4068 | 20.7284 |
| 450137 | 23.9555 | 22.4590 | 23.4346 | 23.2829 |
| 450140 | 18.0743 | 20.2280 | 17.3370 | 18.5682 |
| 450143 | 14.4623 | 14.5270 | 15.0871 | 14.7298 |
| 450144 | 16.3037 | 18.1121 | 17.4309 | 17.3356 |
| 450145 | 14.8441 | 15.6078 | 16.1895 | 15.5356 |
| 450146 | 14.2041 | 17.8572 | 15.5030 | 15.8115 |
| 450147 | 18.0664 | 18.9363 | 19.0477 | 18.6958 |
| 450148 | 22.0269 | 18.6758 | 20.4923 | 20.3406 |
| 450149 | 24.0005 | 19.7521 | 21.7219 | 21.7182 |
| 450150 | 15.2061 | 16.3719 | 17.8612 | 16.4235 |
| 450151 | 14.8373 | 15.2906 | 16.4209 | 15.5098 |
| 450152 | 17.3780 | 18.0061 | 17.7265 | 17.7015 |
| 450153 | 19.9447 | 19.4419 | 18.6514 | 19.3436 |
| 450154 | 13.1810 | 13.8731 | 13.9119 | 13.6623 |
| 450155 | 23.7678 | 11.5841 | 13.3456 | 14.7760 |
| 450157 | 14.6623 | 15.6371 | 15.3083 | 15.2158 |
| 450160 | 8.7503 | 16.6533 | 10.6852 | 11.1452 |
| 450162 | 22.1981 | 20.9560 | 21.9218 | 21.6852 |
| 450163 | 16.9811 | 17.5403 | 17.8028 | 17.4591 |
| 450164 | 20.0368 | 16.9741 | 17.7180 | 18.0843 |
| 450165 | 15.1561 | 13.9218 | 17.3283 | 15.3582 |
| 450166 | 10.2801 | 11.4772 | 11.0541 | 10.9545 |
| 450169 | 15.8793 | 13.1990 | * | 14.1674 |
| 450170 | 14.8131 | 14.2997 | 14.3234 | 14.4821 |
| 450176 | 16.3031 | 16.9674 | 17.2576 | 16.8653 |
| 450177 | 14.7280 | 14.9241 | 15.2419 | 14.9812 |
| 450178 | 16.7550 | 17.8508 | 16.0280 | 16.8828 |
| 450181 | 14.0192 | 15.5622 | 18.6936 | 16.1716 |
| 450184 | 19.9674 | 21.1263 | 20.0821 | 20.3949 |
| 450185 | 13.0632 | 14.0714 | 11.5228 | 12.7662 |
| 450187 | 17.5702 | 16.6945 | 18.5053 | 17.5863 |
| 450188 | 13.7757 | 14.3938 | 15.1954 | 14.4624 |
| 450191 | 18.8023 | 20.1222 | 20.9512 | 19.9757 |
| 450192 | 19.3352 | 20.3795 | 21.2497 | 20.3207 |
| 450193 | 22.7325 | 23.1963 | 23.1639 | 23.0345 |
| 450194 | 19.1466 | 20.5187 | 20.7745 | 20.1569 |
| 450196 | 16.4929 | 17.1955 | 17.8993 | 17.1933 |
| 450200 | 17.3756 | 18.7387 | 19.2228 | 18.4203 |
| 450201 | 17.0548 | 16.9908 | 17.1463 | 17.0668 |
| 450203 | 18.6552 | 20.6712 | 19.3978 | 19.6025 |
| 450209 | 18.6566 | 19.0811 | 20.0140 | 19.2218 |
| 450210 | 14.2317 | 13.9758 | 16.3470 | 14.7958 |
| 450211 | 17.1433 | 17.9857 | 18.8114 | 17.9863 |
| 450213 | 18.4472 | 17.7631 | 19.0651 | 18.4304 |
| 450214 | 17.2465 | 19.0475 | 20.5070 | 18.8579 |
| 450217 | 11.6893 | 12.8457 | 12.7647 | 12.4509 |
| 450219 | 15.4207 | 15.3976 | 17.6884 | 16.1962 |
| 450221 | 16.9935 | 16.3700 | 15.2120 | 16.1091 |
| 450222 | 18.4542 | 20.3129 | 19.8967 | 19.5439 |
| 450224 | 22.8300 | 24.9046 | 20.1579 | 22.3861 |
| 450229 | 16.4116 | 16.4503 | 16.7853 | 16.5551 |
| 450231 | 17.7045 | 19.1564 | 19.1746 | 18.9853 |
| 450234 | 13.3012 | 16.1945 | 16.3003 | 15.4055 |
| 450235 | 13.4177 | 15.2332 | 16.3115 | 15.0648 |
| 450236 | 15.6774 | 16.6703 | 16.4957 | 16.3054 |
| 450237 | 17.3984 | 20.7930 | 19.0325 | 19.0438 |
| 450239 | 13.6376 | 17.1308 | 17.8401 | 16.0311 |
| 450241 | 14.8674 | 12.5675 | 16.4240 | 14.4148 |
| 450243 | 12.3626 | 11.9099 | 13.6416 | 12.6485 |
| 450246 | 17.9702 | 16.5478 | 16.7959 | 17.0548 |
| 450249 | 11.6279 | 12.0302 | 11.7658 | 11.8055 |
| 450250 | 14.9133 | 10.2844 | 13.6787 | 12.3052 |
| 450253 | 15.3542 | 12.2402 | 13.2177 | 13.4392 |
| 450258 | 13.2334 | 16.0466 | 16.7337 | 15.4196 |
| 450259 | 17.8488 | * | * | 17.8488 |
| 450264 | 13.8879 | 13.8929 | 14.5956 | 14.1447 |
| 450269 | 14.9334 | 12.3594 | 12.7717 | 13.2360 |
| 450270 | 12.7018 | 12.8381 | 14.4792 | 13.2703 |
| 450271 | 15.4998 | 16.6319 | 16.7831 | 16.3572 |
| 450272 | 17.9514 | 19.9331 | 18.4344 | 18.7713 |
| 450276 | 12.7053 | 13.1155 | 14.0745 | 13.3159 |
| 450278 | 13.7894 | 14.8291 | 15.2950 | 14.5985 |
| 450280 | 19.4926 | 22.2984 | 22.2936 | 21.3667 |
| 450283 | 13.8916 | 14.5664 | 15.1950 | 14.5306 |
| 450286 | 12.1212 | * | * | 12.1212 |
| 450288 | 15.9878 | 16.2502 | 18.8935 | 16.9454 |
| 450289 | 18.3478 | 20.3104 | 20.3460 | 19.6703 |
| 450292 | 19.5050 | 16.9693 | 20.5335 | 18.8754 |
| 450293 | 14.4281 | 16.0132 | 16.2721 | 15.6074 |
| 450296 | 20.6628 | 21.6000 | 22.3430 | 21.5410 |
| 450299 | 17.9678 | 21.5672 | * | 19.7778 |
| 450303 | 12.6720 | 12.4582 | 12.8996 | 12.6812 |
| 450306 | 13.3165 | 13.8216 | 14.2047 | 13.8205 |
| 450307 | 16.6779 | 16.4622 | 17.0691 | 16.7424 |
| 450309 | 16.2055 | 13.1480 | 13.3771 | 14.0877 |
| 450315 | 20.8043 | 22.8140 | 21.4684 | 21.6913 |
| 450320 | 19.6331 | 20.0946 | 20.6596 | 20.1159 |
| 450321 | 13.3932 | 13.1752 | 14.7344 | 13.7774 |
| 450322 | 12.4570 | 22.7667 | 29.1884 | 20.6852 |
| 450324 | 17.8697 | 17.7886 | 19.1692 | 18.2493 |
| 450327 | 16.0935 | 11.7511 | 13.3639 | 13.4001 |
| 450330 | 18.4163 | 18.9425 | 19.8066 | 19.0827 |
| 450334 | 12.2721 | 12.8051 | 13.8392 | 12.9835 |
| 450337 | 17.4208 | 17.1073 | 25.5708 | 18.8965 |
| 450340 | 15.8519 | 17.6914 | * | 16.7663 |
| 450341 | 19.1828 | 18.9429 | * | 19.0666 |
| 450346 | 17.1038 | 17.5367 | 18.9475 | 17.8083 |
| 450347 | 17.6908 | 17.1099 | 19.3475 | 18.0306 |
| 450348 | 12.9414 | 13.9535 | 13.3585 | 13.4272 |
| 450351 | 15.9772 | 18.4116 | 19.3159 | 17.9591 |
| 450352 | 17.8528 | 18.7480 | 20.1871 | 18.9532 |
| 450353 | 15.0020 | 17.7539 | 16.0003 | 16.2513 |
| 450355 | 14.3182 | 11.9473 | 11.8933 | 12.5966 |
| 450358 | 21.2812 | 22.3235 | 23.0206 | 22.2174 |
| 450362 | 15.3536 | 15.8847 | 18.1983 | 16.4730 |
| 450369 | 15.1854 | 15.2233 | 15.3122 | 15.2420 |
| 450370 | 15.4368 | 12.6061 | 16.1369 | 14.6391 |
| 450371 | 11.8996 | 24.6339 | 16.0236 | 16.3341 |
| 450372 | 19.8589 | 20.0924 | 22.0746 | 20.6261 |
| 450373 | 17.5998 | 17.4183 | 17.9554 | 17.6614 |
| 450374 | 12.8264 | 13.6099 | 15.1750 | 13.8338 |
| 450378 | 23.1598 | 23.5789 | 23.4599 | 23.4221 |
| 450379 | 20.2756 | 22.7632 | 22.8756 | 21.9542 |
| 450381 | 15.6215 | 16.4166 | 16.7112 | 16.2538 |
| 450388 | 17.5561 | 19.2499 | 19.7408 | 18.8527 |
| 450389 | 18.1478 | 18.1797 | 18.8448 | 18.4036 |
| 450393 | 18.7387 | 20.2784 | 22.4992 | 20.3300 |
| 450395 | 16.6754 | 18.3768 | 18.0024 | 17.6923 |
| 450399 | 16.3066 | 15.7845 | 15.3491 | 15.8113 |
| 450400 | 14.0761 | 19.5379 | 18.6668 | 17.2665 |
| 450403 | 21.3691 | 20.1989 | 22.8430 | 21.4973 |
| 450411 | 14.0463 | 14.4832 | 15.1121 | 14.5493 |
| 450417 | 13.8517 | 13.4983 | 15.3591 | 14.2291 |
| 450418 | 20.5847 | 21.9161 | 21.9690 | 21.5007 |
| 450419 | 21.8196 | 20.6325 | 23.2551 | 21.9114 |
| 450422 | 24.5309 | 26.4848 | 28.0257 | 26.2815 |
| 450423 | 19.4352 | 22.7132 | * | 20.9607 |
| 450424 | 17.5658 | 18.9741 | 18.7895 | 18.4852 |
| 450429 | 11.3811 | 13.8723 | * | 12.4654 |
| 450431 | 16.2696 | 19.6304 | 22.0361 | 19.0606 |
| 450438 | 16.5461 | 19.5028 | 15.4553 | 17.0919 |
| 450446 | 21.9685 | 13.0986 | 20.7592 | 18.0346 |
| 450447 | 16.6124 | 18.0376 | 18.0377 | 17.5317 |
| 450451 | 19.6424 | 18.8948 | 18.2988 | 18.9126 |
| 450457 | 19.7689 | 24.7880 | 19.6569 | 21.1382 |
| 450460 | 14.2156 | 15.1765 | 14.6523 | 14.6666 |
| 450462 | 20.1347 | 22.6212 | 22.1144 | 21.6206 |
| 450464 | 13.4714 | 13.2931 | 15.5908 | 14.0563 |
| 450465 | 15.2203 | 15.5650 | 15.4731 | 15.4326 |
| 450467 | 15.6034 | 10.6184 | 17.0004 | 13.7745 |
| 450469 | 22.1012 | 19.6269 | 22.1930 | 21.2351 |
| 450473 | 14.1895 | 19.9761 | 19.7148 | 17.9827 |
| 450475 | 16.2489 | 16.3404 | 16.9269 | 16.5089 |
| 450484 | 19.5869 | 16.8131 | 18.9825 | 18.4097 |
| 450488 | 18.6813 | 19.3457 | 19.2173 | 19.0899 |
| 450489 | 14.5747 | 9.9326 | 16.3584 | 13.1235 |
| 450497 | 11.9242 | 15.0886 | 16.2997 | 14.3957 |
| 450498 | 12.0249 | 13.8551 | 14.4713 | 13.5076 |
| 450508 | 19.8722 | 18.8069 | 19.0991 | 19.2442 |
| 450514 | 22.2791 | 21.3243 | 20.0144 | 21.2387 |
| 450517 | 12.8702 | 27.8815 | 14.3191 | 16.6822 |
| 450518 | 19.0112 | 19.8116 | 21.4873 | 20.0415 |
| 450523 | 20.2589 | 20.0792 | 21.0393 | 20.4436 |
| 450530 | 22.9101 | 22.8623 | 21.1634 | 22.2676 |
| 450534 | 24.0835 | 19.9376 | 20.1520 | 21.2600 |
| 450535 | 21.2659 | 19.6645 | 21.0513 | 20.6461 |
| 450537 | 21.7432 | 20.8438 | 20.1161 | 20.8690 |
| 450538 | 19.6864 | * | * | 19.6864 |
| 450539 | 14.2536 | 16.4921 | 18.7559 | 16.5056 |
| 450544 | 19.3848 | 23.9283 | 23.6652 | 21.9211 |
| 450545 | 16.9674 | 19.5558 | 20.2823 | 18.9428 |
| 450547 | 13.8074 | 14.8248 | 18.1524 | 15.7208 |
| 450551 | 13.9069 | 16.9439 | 16.6237 | 15.8128 |
| 450558 | 20.0164 | 22.2574 | 20.7404 | 21.0120 |
| 450559 | 13.4572 | * | * | 13.4572 |
| 450561 | 16.8162 | * | * | 16.8162 |
| 450563 | 30.3744 | 19.9218 | 22.0708 | 22.9095 |
| 450565 | 16.4545 | 16.2652 | 17.3803 | 16.7063 |
| 450570 | 17.7135 | 18.9532 | 19.0336 | 18.5591 |
| 450571 | 16.9705 | 17.5598 | 18.2784 | 17.6264 |
| 450573 | 15.6698 | 12.2502 | 17.3518 | 14.9746 |
| 450574 | 14.2411 | 14.5965 | 14.6128 | 14.4845 |
| 450575 | 19.0613 | 19.3925 | 22.5621 | 20.3955 |
| 450578 | 16.8731 | 15.4783 | 18.0925 | 16.7620 |
| 450580 | 15.3581 | 15.8321 | 16.7374 | 16.0231 |
| 450583 | 15.5040 | 15.6580 | 14.4411 | 15.1895 |
| 450584 | 13.3747 | 14.2321 | 14.6735 | 14.1004 |
| 450586 | 12.8439 | 14.3773 | 13.8248 | 13.7154 |
| 450587 | 17.1124 | 17.0230 | 18.0219 | 17.3661 |
| 450591 | 17.9151 | 17.8981 | 17.7795 | 17.8608 |
| 450596 | 14.8232 | 22.5420 | 21.6729 | 19.1117 |
| 450597 | 16.1797 | 17.0776 | 17.6179 | 16.9806 |
| 450603 | 12.7682 | 11.6442 | 23.5572 | 15.3844 |
| 450604 | 15.4790 | 16.4535 | 17.6582 | 16.5641 |
| 450605 | 20.1541 | 21.1400 | 19.4580 | 20.2362 |
| 450609 | 10.7323 | 15.9753 | 17.0986 | 14.6244 |
| 450610 | 16.7464 | 18.9924 | 21.5191 | 19.2633 |
| 450614 | 13.8304 | 17.9853 | 16.5754 | 15.9153 |
| 450615 | 14.7457 | 14.8562 | 15.2956 | 14.9778 |
| 450617 | 19.5381 | 20.3387 | 20.8919 | 20.3006 |
| 450620 | 13.7063 | 15.8380 | 16.0987 | 15.2421 |
| 450623 | 21.8275 | 22.1950 | 23.1270 | 22.3514 |
| 450626 | 19.7896 | 18.1673 | 18.4349 | 18.7617 |
| 450628 | 16.8345 | 20.5611 | 18.6093 | 18.6475 |
| 450630 | 19.1904 | 21.6876 | 20.9605 | 20.5728 |
| 450631 | 17.5555 | 20.0417 | 21.6736 | 19.4992 |
| 450632 | 12.7295 | 11.7587 | 13.9147 | 12.7814 |
| 450633 | 20.7209 | 19.5183 | 19.4949 | 19.8926 |
| 450634 | 20.2932 | 23.5333 | 22.9877 | 22.3295 |
| 450638 | 19.6968 | 23.1437 | 22.1704 | 21.6228 |
| 450639 | 20.3050 | 23.1936 | 21.6421 | 21.6608 |
| 450641 | 13.5049 | 16.5125 | 15.7578 | 15.1652 |
| 450643 | 17.4268 | 18.7054 | 16.8152 | 17.6481 |
| 450644 | 20.7904 | 23.6587 | 22.7721 | 22.2903 |
| 450646 | 19.9866 | 19.8274 | 19.1433 | 19.6406 |
| 450647 | 22.4196 | 24.7981 | 24.2763 | 23.8588 |
| 450648 | 14.7541 | 14.8488 | 15.0305 | 14.8793 |
| 450649 | 15.8156 | 16.4496 | 16.6577 | 16.3245 |
| 450651 | 20.7304 | 22.7664 | 22.7112 | 22.1063 |
| 450652 | 16.6461 | 13.4389 | 17.2445 | 15.4912 |
| 450653 | 19.2847 | 18.1834 | 19.2349 | 18.8580 |
| 450654 | 13.8833 | 14.5258 | 14.5423 | 14.3223 |
| 450656 | 18.7328 | 17.6723 | 18.2606 | 18.1968 |
| 450658 | 15.1477 | 16.2657 | 17.2630 | 16.2787 |
| 450659 | 20.5609 | 22.2550 | 23.0108 | 21.9106 |
| 450661 | 20.2196 | 19.7160 | 18.9071 | 19.5857 |
| 450662 | 18.6797 | 18.2284 | 19.3152 | 18.7697 |
| 450665 | 15.4395 | 15.2015 | 16.1319 | 15.5906 |
| 450666 | 19.3456 | 20.3248 | 20.2549 | 19.9584 |
| 450668 | 18.7218 | 20.6965 | 21.0972 | 20.1590 |
| 450669 | 22.2832 | 21.7632 | 21.6746 | 21.8862 |
| 450670 | 18.2030 | 16.8893 | 20.2632 | 18.5133 |
| 450672 | 21.2079 | 21.8559 | 21.4927 | 21.5115 |
| 450673 | 13.8444 | 13.9620 | 13.7005 | 13.8283 |
| 450674 | 20.6151 | 22.2796 | 22.2426 | 21.7353 |
| 450675 | 23.2587 | 22.4961 | 21.4479 | 22.2858 |
| 450677 | 18.7905 | 22.6839 | 20.6556 | 20.7200 |
| 450678 | 20.7453 | 23.2617 | 24.1301 | 22.6596 |
| 450683 | 21.1748 | 20.9143 | 22.8699 | 21.6172 |
| 450684 | 22.8552 | 19.7005 | 21.9962 | 21.3850 |
| 450686 | 15.0122 | 16.5661 | 16.4632 | 15.9861 |
| 450688 | 20.8988 | 19.6250 | 20.1831 | 20.2348 |
| 450690 | 22.4118 | 21.6578 | 22.4707 | 22.1725 |
| 450694 | 18.4917 | 17.4758 | 18.1872 | 18.0283 |
| 450696 | 17.5701 | 24.9636 | * | 21.1885 |
| 450697 | 15.9259 | 18.8405 | 19.4949 | 18.0008 |
| 450698 | 14.3983 | 14.6680 | 15.4750 | 14.8475 |
| 450700 | 15.1153 | 14.6421 | 15.9050 | 15.2506 |
| 450702 | 21.0157 | 20.8223 | 21.3739 | 21.0706 |
| 450703 | 18.8029 | * | * | 18.8029 |
| 450704 | 21.6236 | 20.9821 | 20.7987 | 21.1724 |
| 450705 | 22.3175 | 30.0116 | 22.1809 | 24.2035 |
| 450706 | 21.3777 | 21.2072 | 22.0884 | 21.5769 |
| 450709 | 19.7741 | 20.8889 | 22.1490 | 21.0078 |
| 450711 | 18.2350 | 19.8126 | 19.8581 | 19.3268 |
| 450712 | 16.8942 | 13.6240 | 15.9298 | 15.4007 |
| 450713 | 23.6009 | 20.8065 | 22.6986 | 22.2836 |
| 450715 | 19.7719 | 22.0413 | 22.5988 | 21.5504 |
| 450716 | 19.9871 | 20.5544 | 20.9074 | 20.4812 |
| 450717 | 19.4546 | 20.7192 | 20.6551 | 20.2618 |
| 450718 | 19.0679 | 19.6886 | 22.1765 | 20.3069 |
| 450723 | 19.7044 | 19.7563 | 20.8213 | 20.1083 |
| 450724 | 20.0667 | 20.3235 | 20.3706 | 20.2569 |
| 450725 | 19.5572 | * | * | 19.5572 |
| 450727 | 17.7508 | 13.5458 | 17.9172 | 16.1802 |
| 450728 | 12.9277 | 17.5284 | 19.8879 | 16.6493 |
| 450730 | 20.9129 | 22.0819 | 23.0054 | 22.0459 |
| 450733 | 20.3718 | 20.7693 | 20.2199 | 20.4645 |
| 450735 | 8.0014 | 13.8767 | * | 10.0108 |
| 450742 | 20.7775 | 22.7655 | 21.8392 | 21.8145 |
| 450743 | 15.9493 | 18.8937 | 19.6015 | 18.1561 |
| 450746 | 20.7534 | 12.7904 | 30.2657 | 19.9075 |
| 450747 | 17.3842 | 19.2585 | 20.3914 | 18.9599 |
| 450749 | 12.9542 | 16.2130 | 19.1678 | 16.2656 |
| 450750 | 14.7207 | 14.6914 | 13.8098 | 14.4310 |
| 450751 | 22.2491 | 21.2198 | 19.9995 | 21.3756 |
| 450754 | 14.8896 | 16.0860 | 16.7145 | 15.9455 |
| 450755 | 14.7070 | 17.9904 | 19.8743 | 17.5601 |
| 450757 | 13.9636 | 13.8675 | 14.9434 | 14.2422 |
| 450758 | 18.6513 | 21.8669 | 19.0221 | 19.8347 |
| 450760 | 18.0690 | 17.4852 | 19.2225 | 18.2582 |
| 450761 | 11.1444 | 13.6152 | 15.7681 | 13.3382 |
| 450763 | 17.5603 | 18.2123 | 18.6092 | 18.1083 |
| 450766 | 21.8103 | 22.4348 | 23.3879 | 22.5926 |
| 450769 | 13.6183 | 14.5858 | 18.4163 | 15.2554 |
| 450770 | 16.8250 | 16.5458 | 19.0183 | 17.4436 |
| 450771 | 21.5814 | 22.4542 | 21.8268 | 21.9636 |
| 450774 | 16.5198 | 17.9964 | 16.2948 | 16.9482 |
| 450775 | 19.9651 | 19.8897 | 21.3504 | 20.4169 |
| 450776 | 10.1953 | 15.7750 | 14.1720 | 13.1591 |
| 450777 | 19.5923 | 21.0682 | 19.0380 | 19.9747 |
| 450779 | 22.9697 | 21.4546 | 21.6642 | 21.8768 |
| 450780 | 15.2800 | 19.1498 | 19.0914 | 17.6291 |
| 450785 | 18.5475 | 18.4976 | * | 18.5211 |
| 450788 | 20.9806 | 19.1463 | 19.6469 | 19.7295 |
| 450794 | 18.3981 | 18.2229 | * | 18.3485 |
| 450795 | 14.1682 | 16.6494 | 22.5753 | 17.9737 |
| 450796 | 17.4472 | 16.5362 | 19.2059 | 17.6627 |
| 450797 | 18.5901 | 15.9188 | 16.4923 | 16.8594 |
| 450798 | 9.2165 | 9.4634 | * | 9.3327 |
| 450801 | 16.6095 | 17.5669 | 17.9548 | 17.3668 |
| 450802 | 18.9018 | 19.9168 | 17.1435 | 18.5477 |
| 450803 | 16.2047 | 18.3767 | 21.6653 | 19.3492 |
| 450804 | 20.2223 | 19.4846 | 19.0893 | 19.5891 |
| 450807 | 13.2256 | 11.3192 | 13.4306 | 12.5547 |
| 450808 | 45.4728 | 16.9915 | 17.4917 | 21.1577 |
| 450809 | 19.0266 | 20.0202 | 19.7899 | 19.6416 |
| 450811 | 18.3847 | 19.0961 | 19.9168 | 19.1389 |
| 450812 | 20.7383 | * | * | 20.7383 |
| 450813 | * | 15.9166 | 14.5392 | 15.1549 |
| 450815 | * | * | 21.2741 | 21.2741 |
| 450819 | * | * | 16.5521 | 16.5521 |
| 450820 | * | * | 26.8348 | 26.8348 |
| 450822 | * | * | 22.8556 | 22.8556 |
| 460001 | 20.6336 | 21.7996 | 22.2735 | 21.5846 |
| 460003 | 20.5958 | 20.0452 | 22.6289 | 21.0329 |
| 460004 | 20.8196 | 21.3744 | 21.7234 | 21.3231 |
| 460005 | 17.5818 | 19.7069 | 22.5252 | 19.8732 |
| 460006 | 19.6485 | 20.6252 | 21.0700 | 20.4918 |
| 460007 | 20.5677 | 20.8026 | 21.1922 | 20.8840 |
| 460008 | 21.0338 | 18.8661 | 19.1153 | 19.6864 |
| 460009 | 21.1084 | 21.9016 | 22.5295 | 21.8515 |
| 460010 | 21.2473 | 21.9830 | 22.4948 | 21.9354 |
| 460011 | 16.7114 | 18.8660 | 19.7674 | 18.3702 |
| 460013 | 20.3331 | 20.7326 | 20.1936 | 20.4306 |
| 460014 | 19.5465 | 18.3865 | 18.5370 | 18.7488 |
| 460015 | 20.0987 | 20.6593 | 21.0470 | 20.6197 |
| 460016 | 18.0791 | 18.2408 | 21.9105 | 19.2998 |
| 460017 | 26.0310 | 17.7103 | 18.9929 | 19.9984 |
| 460018 | 16.8566 | 17.6235 | 17.0063 | 17.1606 |
| 460019 | 17.3683 | 16.2671 | 17.8690 | 17.1417 |
| 460020 | 17.0271 | 17.3467 | 17.2663 | 17.2239 |
| 460021 | 20.2613 | 21.0470 | 21.5174 | 20.9913 |
| 460022 | 18.2100 | 20.1534 | 21.3614 | 19.7210 |
| 460023 | 21.3321 | 22.3535 | 22.9265 | 22.2381 |
| 460024 | 13.0279 | * | * | 13.0279 |
| 460025 | 12.5083 | 19.4247 | 17.3494 | 16.5301 |
| 460026 | 17.3431 | 19.9241 | 20.2576 | 19.0202 |
| 460027 | 20.8331 | 21.8868 | 22.2955 | 21.6637 |
| 460029 | 17.2501 | 20.5154 | 20.8366 | 19.2190 |
| 460030 | 17.2196 | 17.6071 | 17.1383 | 17.3160 |
| 460032 | 19.5474 | 21.1006 | 21.4832 | 20.7171 |
| 460033 | 15.7233 | 19.5372 | 19.2664 | 18.1972 |
| 460035 | 14.2802 | 16.0021 | 16.1685 | 15.4874 |
| 460036 | 22.3788 | 23.5893 | 23.4573 | 23.1384 |
| 460037 | 18.7665 | 18.6850 | 17.7399 | 18.3920 |
| 460039 | 24.4781 | 24.9134 | 24.4808 | 24.6217 |
| 460041 | 21.6926 | 21.0623 | 20.2035 | 20.9715 |
| 460042 | 17.8455 | 18.8814 | 19.5662 | 18.7473 |
| 460043 | 23.8970 | 24.4779 | 23.2819 | 23.8380 |
| 460044 | 20.6897 | 21.4696 | 21.8485 | 21.3516 |
| 460046 | 17.1085 | 18.2224 | * | 17.6742 |
| 460047 | 21.3843 | 23.0433 | 22.7524 | 22.4777 |
| 460049 | 18.8206 | 19.6483 | 20.8283 | 19.8892 |
| 460050 | 26.2485 | * | * | 26.2485 |
| 460051 | 20.9797 | 19.4761 | 22.1758 | 20.8643 |
| 460052 | * | * | 19.8961 | 19.8961 |
| 470001 | 19.6108 | 20.2299 | 21.3817 | 20.4021 |
| 470003 | 22.5949 | 23.6949 | 22.0563 | 22.7712 |
| 470004 | 18.0952 | 16.8842 | 18.1879 | 17.7051 |
| 470005 | 21.5151 | 21.9191 | 23.1808 | 22.1962 |
| 470006 | 18.3898 | 17.8699 | 20.2829 | 18.8123 |
| 470008 | 19.4136 | 19.6069 | 20.1969 | 19.7378 |
| 470010 | 19.4652 | 20.2961 | 21.0616 | 20.2790 |
| 470011 | 21.2014 | 21.7675 | 22.2415 | 21.7386 |
| 470012 | 18.5162 | 18.5339 | 18.9444 | 18.6579 |
| 470015 | 19.2552 | 19.5366 | 20.2125 | 19.6399 |
| 470018 | 20.4161 | 21.5426 | 21.2406 | 21.0610 |
| 470020 | 18.9884 | 20.6643 | 21.5688 | 20.4558 |
| 470023 | 20.6391 | 20.4511 | 21.7139 | 20.9439 |
| 470024 | 20.4087 | 20.8510 | 21.9807 | 21.0777 |
| 490001 | 24.7604 | 21.9755 | 20.0570 | 22.0422 |
| 490002 | 12.9871 | 15.2287 | 15.7365 | 14.6222 |
| 490003 | 18.0034 | 19.1040 | 20.3237 | 19.1299 |
| 490004 | 18.7731 | 19.2126 | 19.7074 | 19.2382 |
| 490005 | 16.9087 | 20.5517 | 21.3318 | 19.6257 |
| 490006 | 15.2276 | 15.9537 | 12.3253 | 14.5928 |
| 490007 | 18.4330 | 18.7740 | 19.8938 | 19.0586 |
| 490009 | 22.9513 | 23.9344 | 23.7659 | 23.5499 |
| 490010 | 18.5780 | 21.7424 | * | 19.9381 |
| 490011 | 18.7508 | 18.6071 | 19.8042 | 19.0282 |
| 490012 | 13.7788 | 15.9973 | 15.2965 | 15.0022 |
| 490013 | 16.9324 | 17.3318 | 18.2396 | 17.5085 |
| 490014 | 24.5557 | 25.8315 | 23.5266 | 24.6242 |
| 490015 | 19.3608 | 19.6363 | 20.0667 | 19.6821 |
| 490017 | 17.3152 | 18.4361 | 19.3854 | 18.3964 |
| 490018 | 17.9433 | 18.3435 | 18.5508 | 18.2858 |
| 490019 | 17.5309 | 19.6178 | 21.0124 | 19.4215 |
| 490020 | 17.6655 | 18.5691 | 19.3424 | 18.5533 |
| 490021 | 19.4490 | 19.3945 | 20.0496 | 19.6794 |
| 490022 | 20.7223 | 21.2183 | 22.3380 | 21.4351 |
| 490023 | 18.9587 | 20.6694 | 21.5683 | 20.4224 |
| 490024 | 16.8904 | 17.7221 | 18.4314 | 17.8400 |
| 490027 | 14.4234 | 16.2761 | 16.7556 | 15.8360 |
| 490030 | 10.5029 | 9.1789 | 8.6446 | 9.5559 |
| 490031 | 15.8213 | 14.9539 | 16.0003 | 15.5875 |
| 490032 | 21.5592 | 22.4262 | 21.4037 | 21.7854 |
| 490033 | 18.3265 | 21.1723 | 19.2908 | 19.5511 |
| 490037 | 15.9704 | 16.3759 | 17.0113 | 16.4399 |
| 490038 | 15.7099 | 21.0218 | 17.6324 | 17.9048 |
| 490040 | 22.5237 | 22.7061 | 24.1266 | 23.1321 |
| 490041 | 16.5542 | 18.3589 | 18.7987 | 17.8901 |
| 490042 | 15.2717 | 16.4666 | 17.0972 | 16.2668 |
| 490043 | 20.6775 | 22.1574 | 22.1068 | 21.7221 |
| 490044 | 17.6282 | 18.3137 | 19.7842 | 18.6148 |
| 490045 | 19.6325 | 20.5468 | 20.5558 | 20.2593 |
| 490046 | 18.6112 | 18.4825 | 19.9102 | 19.0232 |
| 490047 | 17.1631 | 25.0438 | 18.7614 | 19.8637 |
| 490048 | 17.8907 | 18.4361 | 19.5417 | 18.6005 |
| 490050 | 22.7129 | 23.0729 | 23.3668 | 23.0530 |
| 490052 | 16.9363 | 16.8600 | 16.4787 | 16.7609 |
| 490053 | 15.6883 | 15.6996 | 16.8410 | 16.1062 |
| 490054 | 15.5516 | 15.4734 | 19.5780 | 16.7024 |
| 490057 | 19.0668 | 19.9210 | 20.3160 | 19.7770 |
| 490059 | 20.3744 | 20.8662 | 21.4801 | 20.8999 |
| 490060 | 19.2006 | 17.6308 | 18.5917 | 18.4363 |
| 490063 | 28.2527 | 28.6536 | 26.1930 | 27.6341 |
| 490066 | 16.5024 | 20.6972 | 19.8352 | 18.9146 |
| 490067 | 17.1922 | 17.0195 | 17.8487 | 17.3549 |
| 490069 | 15.6986 | 17.3297 | 20.7582 | 17.8379 |
| 490071 | 19.4701 | 21.8879 | 23.3511 | 21.4480 |
| 490073 | 26.1420 | 20.7960 | 26.0957 | 24.1488 |
| 490074 | 19.3417 | * | * | 19.3417 |
| 490075 | 19.1906 | 18.6983 | 19.2156 | 19.0267 |
| 490077 | 19.7866 | 21.3670 | 22.6504 | 21.2469 |
| 490079 | 16.4379 | 17.0815 | 17.7016 | 17.0749 |
| 490083 | 16.6406 | * | * | 16.6406 |
| 490084 | 16.3846 | 16.7834 | 18.0555 | 17.0646 |
| 490085 | 16.3979 | 17.4584 | 17.6158 | 17.1539 |
| 490088 | 15.5982 | 16.4362 | 17.9141 | 16.6068 |
| 490089 | 15.8618 | 17.7692 | 18.2290 | 17.2642 |
| 490090 | 16.2785 | 17.0199 | 17.5799 | 16.9734 |
| 490091 | 19.9949 | 20.8734 | 25.0272 | 21.8088 |
| 490092 | 15.6893 | 16.9533 | 16.4360 | 16.3528 |
| 490093 | 16.4767 | 17.3711 | 17.8275 | 17.2502 |
| 490094 | 16.7880 | 18.9204 | 22.3033 | 19.3562 |
| 490095 | 18.2495 | * | * | 18.2495 |
| 490097 | 15.8586 | 15.5780 | 16.9518 | 16.0789 |
| 490098 | 14.6971 | 15.1403 | 16.0488 | 15.2544 |
| 490099 | 16.8667 | 17.9665 | 18.3985 | 17.7293 |
| 490100 | 17.2189 | 22.5010 | * | 19.8823 |
| 490101 | 25.0907 | 24.7616 | 23.5553 | 24.4275 |
| 490104 | 28.4910 | 25.6889 | 40.2529 | 29.2590 |
| 490105 | 18.2461 | 18.5765 | 21.4428 | 19.2491 |
| 490106 | 16.9117 | 17.6596 | 26.3821 | 18.9838 |
| 490107 | 22.4054 | 23.5240 | 22.9283 | 22.9660 |
| 490108 | 19.7478 | 20.2112 | 24.1232 | 21.0559 |
| 490109 | 21.1589 | 23.6620 | 25.9475 | 23.4402 |
| 490110 | 15.8408 | 16.5131 | 18.1561 | 16.8181 |
| 490111 | 17.3453 | 17.1768 | 17.8510 | 17.4580 |
| 490112 | 20.5239 | 21.4532 | 22.1162 | 21.3613 |
| 490113 | 23.0840 | 23.2235 | 23.9043 | 23.4071 |
| 490114 | 16.9083 | 17.3047 | 18.0359 | 17.4375 |
| 490115 | 17.1023 | 16.5203 | 16.8537 | 16.8239 |
| 490116 | 16.4436 | 16.6170 | 17.2040 | 16.7676 |
| 490117 | 13.8429 | 14.0104 | 14.7944 | 14.2244 |
| 490118 | 20.8707 | 21.4674 | 23.2022 | 21.8304 |
| 490119 | 17.8686 | 17.9147 | 18.6046 | 18.1353 |
| 490120 | 19.9810 | 19.3707 | 20.5777 | 19.9742 |
| 490122 | 23.9695 | 23.8801 | 23.8198 | 23.8925 |
| 490123 | 16.8505 | 17.7461 | 19.3056 | 18.0001 |
| 490124 | 19.3616 | 22.0884 | 21.3818 | 20.8857 |
| 490126 | 18.2276 | 18.6844 | 20.4294 | 19.0254 |
| 490127 | 14.4815 | 16.0516 | 16.5993 | 15.6547 |
| 490129 | 27.4701 | 22.5885 | 28.6868 | 25.1130 |
| 490130 | 16.2779 | 16.4322 | 17.6943 | 16.7915 |
| 490132 | 17.0204 | 18.6570 | 18.4671 | 18.0649 |
| 500001 | 21.3476 | 22.1896 | 24.4829 | 22.6367 |
| 500002 | 21.0375 | 21.6332 | 19.8476 | 20.7811 |
| 500003 | 24.3055 | 24.2814 | 24.4333 | 24.3392 |
| 500005 | 23.4808 | 22.3955 | 24.3870 | 23.3703 |
| 500007 | 22.4269 | 26.0599 | 21.9911 | 23.4148 |
| 500008 | 24.1930 | 25.3064 | 26.1737 | 25.2130 |
| 500011 | 25.1836 | 24.0162 | 24.6554 | 24.5938 |
| 500012 | 22.2815 | 20.7032 | 24.2799 | 22.3541 |
| 500014 | 23.9276 | 24.3419 | 24.0990 | 24.1249 |
| 500015 | 23.2435 | 23.9297 | 24.9923 | 24.0554 |
| 500016 | 23.9034 | 24.3938 | 24.9439 | 24.4287 |
| 500019 | 22.3668 | 22.4213 | 23.2054 | 22.6470 |
| 500021 | 24.4622 | 25.9198 | 27.6490 | 25.9957 |
| 500023 | 27.1892 | 26.6535 | 27.1025 | 26.9568 |
| 500024 | 24.0453 | 23.7472 | 26.6452 | 24.7736 |
| 500025 | 23.9557 | 26.4810 | 24.4825 | 24.9695 |
| 500026 | 23.3491 | 23.8005 | 26.9884 | 24.7238 |
| 500027 | 25.0529 | 22.2158 | 25.1125 | 24.0804 |
| 500028 | 18.8588 | 19.2675 | 18.9556 | 19.0337 |
| 500029 | 16.8083 | 17.9237 | 18.5042 | 17.7373 |
| 500030 | 24.1321 | 24.9039 | 26.3828 | 25.1714 |
| 500031 | 23.3659 | 29.2707 | 23.6099 | 25.1784 |
| 500033 | 21.3906 | 22.3527 | 22.5462 | 22.1428 |
| 500036 | 21.8950 | 22.1096 | 23.6333 | 22.5254 |
| 500037 | 19.6803 | 20.7139 | 21.4059 | 20.6062 |
| 500039 | 23.3211 | 23.8918 | 24.0007 | 23.7403 |
| 500041 | 24.8556 | 23.9608 | 25.4376 | 24.7549 |
| 500042 | 22.1286 | 22.9125 | * | 22.5386 |
| 500043 | 20.2509 | 20.9459 | 22.0466 | 21.0230 |
| 500044 | 23.1128 | 23.3364 | 24.2212 | 23.5535 |
| 500045 | 22.0982 | 20.8881 | 24.0526 | 22.2906 |
| 500048 | 19.3029 | 22.1906 | 20.3207 | 20.5960 |
| 500049 | 22.9534 | 24.0489 | 24.5997 | 23.8657 |
| 500050 | 20.9445 | 22.0065 | 22.6563 | 21.9092 |
| 500051 | 24.4769 | 24.8203 | 25.9447 | 25.1087 |
| 500053 | 22.0515 | 23.9397 | 22.8399 | 22.9429 |
| 500054 | 22.9024 | 22.8829 | 23.8089 | 23.1889 |
| 500055 | 22.8769 | 23.7446 | 23.8622 | 23.5097 |
| 500057 | 18.0424 | 18.2737 | 19.0479 | 18.4516 |
| 500058 | 23.3984 | 24.7882 | 24.1106 | 24.0962 |
| 500059 | 22.5412 | 23.3506 | 26.6270 | 24.1016 |
| 500060 | 23.5360 | 25.0233 | 28.3655 | 25.4628 |
| 500061 | 20.3957 | 21.7013 | 20.8624 | 20.9851 |
| 500062 | 19.4607 | 18.6329 | 19.0557 | 19.0333 |
| 500064 | 24.5283 | 25.5748 | 26.7000 | 25.6273 |
| 500065 | 21.4254 | 21.9308 | 23.5671 | 22.3106 |
| 500068 | 18.6960 | 19.6574 | 19.2638 | 19.2003 |
| 500069 | 20.6262 | 21.3592 | 21.4542 | 21.1522 |
| 500071 | 19.3810 | 19.1906 | 19.1428 | 19.2439 |
| 500072 | 24.4599 | 25.3928 | 25.2001 | 25.0228 |
| 500073 | 21.4303 | 21.2469 | 21.7698 | 21.4835 |
| 500074 | 18.6506 | 18.9679 | 19.5981 | 19.0849 |
| 500077 | 23.2056 | 22.8536 | 23.9410 | 23.3357 |
| 500079 | 22.9809 | 24.2036 | 23.1041 | 23.4248 |
| 500080 | 13.8000 | 15.6630 | 18.3883 | 15.5897 |
| 500084 | 22.2169 | 23.4032 | 24.4044 | 23.3798 |
| 500085 | 28.6121 | 21.4403 | 20.4517 | 22.7948 |
| 500086 | 22.3132 | 23.3288 | 22.8829 | 22.8469 |
| 500088 | 23.6988 | 23.2701 | 25.2478 | 24.0737 |
| 500089 | 17.9399 | 18.7080 | 19.7166 | 18.7736 |
| 500090 | 16.3297 | 16.1576 | 20.4429 | 17.2562 |
| 500092 | 17.2881 | 16.7913 | 19.2028 | 17.7527 |
| 500094 | 18.1080 | 18.5835 | 15.7866 | 17.6577 |
| 500096 | 20.9580 | 21.0151 | 23.3564 | 21.7716 |
| 500097 | 20.8010 | 19.7706 | 20.8774 | 20.4568 |
| 500098 | 12.9935 | 16.3511 | 15.2040 | 14.9340 |
| 500101 | 19.4498 | 19.7337 | 15.8000 | 18.3994 |
| 500102 | 20.3321 | 20.9389 | 21.8963 | 21.0615 |
| 500104 | 22.5849 | 22.8154 | 24.9389 | 23.3843 |
| 500106 | 18.7087 | 18.6041 | 19.1465 | 18.7914 |
| 500107 | 17.2987 | 18.1201 | 17.9489 | 17.8064 |
| 500108 | 27.2126 | 26.2939 | 28.6229 | 27.3944 |
| 500110 | 21.4053 | 21.4553 | 22.9775 | 21.9505 |
| 500118 | 22.9245 | 23.8397 | 24.8034 | 23.8697 |
| 500119 | 21.5704 | 22.4373 | 22.1192 | 22.0436 |
| 500122 | 21.9135 | 22.4268 | 23.5264 | 22.6230 |
| 500123 | 19.5855 | 20.3181 | 19.6646 | 19.8819 |
| 500124 | 24.1473 | 23.2836 | 23.7742 | 23.7287 |
| 500125 | 16.6272 | 15.1112 | 14.7910 | 15.5165 |
| 500129 | 23.5952 | 26.1575 | 25.4685 | 25.1115 |
| 500132 | 19.3567 | 15.6717 | 23.1822 | 19.3937 |
| 500134 | 20.9570 | 17.7457 | 17.2430 | 18.5700 |
| 500139 | 20.8816 | 22.2297 | 22.3053 | 21.8379 |
| 500141 | 22.9358 | 23.8838 | 29.9695 | 25.5485 |
| 500143 | 17.6031 | 18.0343 | 18.2570 | 17.9797 |
| 500146 | 17.8558 | 21.6003 | * | 19.6218 |
| 510001 | 17.8282 | 19.1492 | 20.0429 | 18.9855 |
| 510002 | 17.3409 | 20.1527 | 17.6392 | 18.3009 |
| 510005 | 14.4330 | 14.2503 | 13.8621 | 14.1872 |
| 510006 | 17.8821 | 18.7313 | 19.9609 | 18.8717 |
| 510007 | 20.2483 | 21.2729 | 21.6761 | 21.0848 |
| 510008 | 17.3653 | 18.3296 | 19.0513 | 18.2388 |
| 510012 | 16.5037 | 15.8390 | 15.6089 | 15.9887 |
| 510013 | 16.6194 | 17.8527 | 19.5798 | 17.9628 |
| 510015 | 14.7904 | 14.9039 | 16.7311 | 15.5193 |
| 510016 | 12.0276 | * | * | 12.0276 |
| 510018 | 16.4757 | 18.5269 | 18.5358 | 17.8403 |
| 510020 | 12.6472 | 13.1837 | 14.1211 | 13.3435 |
| 510022 | 19.8375 | 20.1763 | 21.5770 | 20.5146 |
| 510023 | 15.9417 | 16.0129 | 16.7777 | 16.2444 |
| 510024 | 18.7982 | 19.0941 | 18.7461 | 18.8794 |
| 510026 | 13.4586 | 13.6888 | 13.7952 | 13.6491 |
| 510027 | 17.5759 | 17.2900 | 18.5945 | 17.8135 |
| 510028 | 20.7306 | 20.0628 | 19.9208 | 20.2198 |
| 510029 | 17.0519 | 17.7124 | 18.4668 | 17.7625 |
| 510030 | 18.3137 | 17.4198 | 17.7603 | 17.8189 |
| 510031 | 18.4887 | 28.6673 | 18.6341 | 21.0020 |
| 510033 | 18.8061 | 18.4082 | 18.4718 | 18.5670 |
| 510035 | 18.6471 | 16.5007 | 18.3164 | 17.7425 |
| 510036 | 13.1995 | 13.4559 | 13.8786 | 13.5021 |
| 510038 | 14.3433 | 15.8132 | 15.5576 | 15.2710 |
| 510039 | 16.0555 | 16.9398 | 17.1461 | 16.7060 |
| 510043 | 14.2872 | 14.0662 | 13.1308 | 13.8129 |
| 510046 | 17.7320 | 17.3821 | 18.5896 | 17.9120 |
| 510047 | 19.1202 | 19.8963 | 20.8101 | 19.9042 |
| 510048 | 20.3734 | 21.0407 | 17.1647 | 19.5052 |
| 510050 | 16.5681 | 16.9136 | 18.4036 | 17.3154 |
| 510053 | 15.5856 | 16.1036 | 17.5798 | 16.4010 |
| 510055 | 22.8376 | 23.7248 | 24.2133 | 23.6043 |
| 510058 | 17.9786 | 18.4156 | 18.4501 | 18.2860 |
| 510059 | 16.7732 | 16.5854 | 16.1044 | 16.5068 |
| 510060 | 15.6581 | 17.5594 | * | 16.5969 |
| 510061 | 14.2227 | 13.8204 | 14.1968 | 14.0767 |
| 510062 | 17.6276 | 19.3881 | 18.1588 | 18.4173 |
| 510065 | 14.5882 | * | * | 14.5882 |
| 510066 | 12.7164 | 12.2943 | * | 12.5091 |
| 510067 | 18.1079 | 16.7161 | 17.3067 | 17.3634 |
| 510068 | 16.2864 | 18.7938 | 23.0452 | 19.1223 |
| 510070 | 16.3616 | 18.5146 | 18.7091 | 17.9505 |
| 510071 | 16.2390 | 17.2148 | 18.0278 | 17.1797 |
| 510072 | 17.6579 | 15.6262 | 15.9257 | 16.4174 |
| 510077 | 16.4111 | 18.0668 | 18.2947 | 17.6316 |
| 510080 | 14.7966 | 17.4485 | 16.3453 | 16.1690 |
| 510081 | 13.0020 | 13.6359 | 11.9701 | 12.8648 |
| 510082 | 13.6905 | 17.4538 | 13.5946 | 14.7307 |
| 510084 | 12.4820 | 17.2395 | 13.5339 | 14.4076 |
| 510085 | 18.6367 | 17.5624 | 18.6227 | 18.2581 |
| 510086 | 13.7937 | 13.4763 | 14.2241 | 13.8304 |
| 510088 | * | * | 14.8854 | 14.8854 |
| 520002 | 18.3521 | 19.7447 | 19.6755 | 19.2773 |
| 520003 | 16.4334 | 17.1248 | 18.7956 | 17.5028 |
| 520004 | 18.1744 | 19.6512 | 20.4591 | 19.4206 |
| 520006 | 20.4446 | 21.5313 | 21.4884 | 21.1400 |
| 520007 | 13.1087 | 16.2001 | 18.4629 | 16.0134 |
| 520008 | 22.8024 | 22.8024 | 24.9395 | 23.5372 |
| 520009 | 18.5094 | 18.6002 | 21.4638 | 19.4842 |
| 520010 | 20.3447 | 22.7703 | 22.3311 | 21.8215 |
| 520011 | 20.3797 | 20.7410 | 21.5223 | 20.8830 |
| 520013 | 21.6289 | 20.3965 | 20.5944 | 20.8585 |
| 520014 | 16.3989 | 17.1646 | 18.0841 | 17.1764 |
| 520015 | 18.3185 | 18.6078 | 19.7672 | 18.9031 |
| 520016 | 13.2889 | 17.3018 | 18.4320 | 16.1862 |
| 520017 | 19.3179 | 19.6008 | 19.4780 | 19.4685 |
| 520018 | 18.6441 | 21.1941 | 21.5279 | 20.5280 |
| 520019 | 18.3143 | 19.5440 | 20.9164 | 19.5698 |
| 520021 | 20.0355 | 21.3471 | 21.9531 | 21.1390 |
| 520024 | 14.6107 | 14.0175 | 14.4750 | 14.3609 |
| 520025 | 18.1086 | 18.2430 | 20.3838 | 18.8661 |
| 520026 | 19.8131 | 21.5453 | 20.8546 | 20.7335 |
| 520027 | 18.9085 | 19.9324 | 21.5868 | 20.1744 |
| 520028 | 19.1370 | 21.2852 | 22.5941 | 20.9020 |
| 520029 | 16.7520 | 19.5750 | 21.4197 | 19.2161 |
| 520030 | 20.0043 | 20.5039 | 21.6311 | 20.7089 |
| 520031 | 18.7066 | 20.4814 | 20.9875 | 19.9520 |
| 520032 | 17.9007 | 19.5697 | 21.1069 | 19.5434 |
| 520033 | 18.8906 | 19.2954 | 20.2520 | 19.4725 |
| 520034 | 16.6858 | 17.1282 | 20.4307 | 18.0336 |
| 520035 | 17.0997 | 18.9452 | 18.7135 | 18.2608 |
| 520037 | 20.0516 | 20.6686 | 21.6017 | 20.7624 |
| 520038 | 17.7074 | 19.6294 | 20.6130 | 19.3169 |
| 520039 | 19.5990 | 20.7641 | 23.3687 | 21.1069 |
| 520040 | 20.7420 | 20.4677 | 21.2023 | 20.8002 |
| 520041 | 15.3666 | 17.1959 | 18.4117 | 16.9517 |
| 520042 | 17.6577 | 18.5843 | 19.5466 | 18.6338 |
| 520044 | 17.7932 | 18.4014 | 19.1877 | 18.4535 |
| 520045 | 19.6736 | 20.5917 | 21.2427 | 20.5162 |
| 520047 | 17.8702 | 18.3048 | 20.3487 | 18.7633 |
| 520048 | 19.1712 | 20.6583 | 19.8926 | 19.9142 |
| 520049 | 19.5727 | 20.3559 | 20.1667 | 20.0444 |
| 520051 | 19.7416 | 21.6497 | 24.0460 | 21.7205 |
| 520053 | 16.4887 | 17.3945 | 18.0851 | 17.3336 |
| 520054 | 15.9873 | 15.1747 | 16.8363 | 15.9586 |
| 520057 | 18.3186 | 19.0872 | 19.8492 | 19.0812 |
| 520058 | 18.1264 | 19.7283 | 21.2500 | 19.7133 |
| 520059 | 19.8530 | 20.9913 | 21.5796 | 20.8254 |
| 520060 | 17.1675 | 17.9258 | 18.8232 | 17.9582 |
| 520062 | 17.8000 | 19.1482 | 19.7038 | 18.8681 |
| 520063 | 20.7744 | 19.6136 | 20.5262 | 20.3055 |
| 520064 | 21.4586 | 22.7423 | 22.0917 | 22.0917 |
| 520066 | 22.4419 | 22.8837 | 24.0087 | 23.0580 |
| 520068 | 18.0798 | 18.9943 | 19.6855 | 18.9053 |
| 520069 | 17.9133 | 20.2934 | 20.1770 | 19.3716 |
| 520070 | 17.8192 | 18.5938 | 19.4261 | 18.6155 |
| 520071 | 18.7861 | 18.7304 | 19.9866 | 19.1576 |
| 520074 | 18.6923 | 20.4601 | 20.9007 | 20.0036 |
| 520075 | 19.0891 | 19.8457 | 20.7301 | 19.8876 |
| 520076 | 16.5072 | 17.6088 | 19.5878 | 17.8567 |
| 520077 | 15.5427 | 17.7830 | 18.7119 | 17.3266 |
| 520078 | 20.5559 | 21.3380 | 21.7545 | 21.2404 |
| 520082 | 16.7417 | 17.7405 | * | 17.1848 |
| 520083 | 22.5715 | 23.8849 | 23.5787 | 23.3411 |
| 520084 | 18.9475 | 20.8427 | 23.5446 | 21.0737 |
| 520087 | 19.3942 | 20.3624 | 20.7821 | 20.1850 |
| 520088 | 20.1529 | 20.6312 | 21.8931 | 20.8632 |
| 520089 | 20.6110 | 21.5456 | 22.1055 | 21.4053 |
| 520090 | 18.0026 | 18.9343 | 20.3645 | 19.1272 |
| 520091 | 20.0693 | 20.9927 | 20.9440 | 20.6686 |
| 520092 | 17.5577 | 17.6500 | 18.6248 | 17.9402 |
| 520094 | 19.7791 | 20.3611 | 20.6179 | 20.2438 |
| 520095 | 18.5066 | 20.3269 | 18.6425 | 19.1370 |
| 520096 | 19.2980 | 19.7757 | 20.6668 | 19.9365 |
| 520097 | 19.6470 | 20.2354 | 20.8016 | 20.2268 |
| 520098 | 20.0289 | 22.3348 | 23.4707 | 21.9054 |
| 520100 | 18.3788 | 18.3832 | 19.4788 | 18.7419 |
| 520101 | 17.8453 | 19.5186 | 19.9875 | 19.1542 |
| 520102 | 19.8354 | 20.1898 | 21.0138 | 20.3351 |
| 520103 | 21.2324 | 19.4809 | 20.1092 | 20.2137 |
| 520107 | 20.5441 | 20.3747 | 21.7907 | 20.8828 |
| 520109 | 18.6322 | 19.1303 | 19.7609 | 19.1753 |
| 520110 | 20.0319 | 20.4494 | 21.0055 | 20.5065 |
| 520111 | 17.2388 | 17.7834 | 17.7673 | 17.6163 |
| 520112 | 18.1827 | 19.1797 | 18.9577 | 18.7858 |
| 520113 | 20.5925 | 21.1485 | 21.8852 | 21.2341 |
| 520114 | 17.3799 | 16.6616 | 17.8476 | 17.2735 |
| 520115 | 17.3755 | 18.2980 | 19.2248 | 18.2555 |
| 520116 | 18.5698 | 19.8509 | 20.6922 | 19.7165 |
| 520117 | 17.4242 | 18.5414 | 18.3963 | 18.1365 |
| 520118 | 12.4422 | 14.2326 | 14.8626 | 13.8369 |
| 520120 | 15.6205 | 18.7437 | * | 17.3887 |
| 520121 | 17.5851 | 19.7305 | 20.8492 | 19.5992 |
| 520122 | 16.7552 | 16.2436 | 16.9335 | 16.6326 |
| 520123 | 17.4135 | 17.3980 | 17.7986 | 17.5610 |
| 520124 | 16.3902 | 17.2619 | 17.9205 | 17.1864 |
| 520130 | 15.1639 | 15.6845 | 16.6873 | 15.8395 |
| 520131 | 18.8043 | 18.7295 | 20.2591 | 19.2549 |
| 520132 | 17.2759 | 15.6379 | 18.1630 | 16.9564 |
| 520134 | 17.6094 | 18.0953 | 18.8150 | 18.1846 |
| 520135 | 14.4748 | 15.8246 | 17.3476 | 15.9083 |
| 520136 | 19.9935 | 19.8480 | 20.9050 | 20.2727 |
| 520138 | 20.8922 | 21.2260 | 22.5599 | 21.5577 |
| 520139 | 21.2797 | 20.9988 | 21.4042 | 21.2251 |
| 520140 | 21.4175 | 21.5207 | 22.3671 | 21.7731 |
| 520141 | 16.9543 | * | * | 16.9543 |
| 520142 | 17.7003 | 20.5858 | 21.9432 | 19.9586 |
| 520144 | 16.6231 | 18.5701 | 19.9120 | 18.4107 |
| 520145 | 17.2356 | 18.2654 | 18.7958 | 18.1015 |
| 520146 | 15.7318 | 17.9585 | 18.2370 | 17.3448 |
| 520148 | 16.9293 | 17.2421 | 19.1502 | 17.8057 |
| 520149 | 13.3032 | 14.1901 | 12.8928 | 13.4360 |
| 520151 | 18.0771 | 17.3267 | 18.7070 | 18.0230 |
| 520152 | 21.3333 | 19.5858 | 22.5980 | 21.0747 |
| 520153 | 15.4467 | 15.9753 | 17.0863 | 16.1441 |
| 520154 | 17.9229 | 18.5403 | 19.5994 | 18.6875 |
| 520156 | 19.8396 | 21.3377 | 20.9638 | 20.7243 |
| 520157 | 17.2784 | 17.1974 | 19.6008 | 18.0185 |
| 520159 | 18.7423 | 18.6760 | 17.7649 | 18.3871 |
| 520160 | 18.8444 | 19.4173 | 20.5154 | 19.5953 |
| 520161 | 18.5742 | 19.4905 | 20.1102 | 19.4069 |
| 520170 | 22.5033 | 21.5233 | 21.9857 | 21.9871 |
| 520171 | 15.7316 | 17.4560 | 18.0785 | 17.1053 |
| 520173 | 20.1410 | 21.3016 | 20.9209 | 20.7812 |
| 520177 | 21.7609 | 22.7221 | 24.0139 | 22.8278 |
| 520178 | 17.0411 | 18.6936 | 20.9010 | 18.7748 |
| 520188 | * | 13.9135 | * | 13.9135 |
| 530002 | 17.5888 | 19.3273 | 21.0560 | 19.3920 |
| 530003 | 15.7813 | 16.2139 | 15.9523 | 15.9820 |
| 530004 | 16.1862 | 15.0497 | 13.3788 | 14.7758 |
| 530005 | 15.1487 | 13.3529 | 15.3255 | 14.5529 |
| 530006 | 19.3403 | 18.5894 | 19.1305 | 19.0082 |
| 530007 | 18.0601 | 18.5161 | 17.7897 | 18.1450 |
| 530008 | 22.9625 | 18.8349 | 19.0113 | 20.0471 |
| 530009 | 19.4478 | 22.5009 | 21.7795 | 21.2113 |
| 530010 | 18.9317 | 21.6092 | 13.9536 | 17.6719 |
| 530011 | 17.4412 | 18.7354 | 19.4606 | 18.5542 |
| 530012 | 19.4829 | 18.9923 | 21.1854 | 19.8564 |
| 530014 | 17.3158 | 18.0869 | 18.4900 | 17.9675 |
| 530015 | 22.6465 | 22.4568 | 23.4040 | 22.8118 |
| 530016 | 17.7084 | 18.1562 | 19.3205 | 18.4153 |
| 530017 | 13.7131 | 16.3478 | 17.7736 | 15.9421 |
| 530018 | 17.8699 | 18.3783 | 19.5986 | 18.6254 |
| 530019 | 16.7630 | 18.5430 | 20.1097 | 18.3351 |
| 530022 | 17.8781 | 18.5002 | 19.6136 | 18.7082 |
| 530023 | 20.7527 | 20.1948 | 20.0677 | 20.3449 |
| 530025 | 20.3200 | 21.2598 | 22.0300 | 21.1974 |
| 530026 | 18.9175 | 17.0118 | 19.8969 | 18.4992 |
| 530027 | 29.7722 | 18.1664 | 25.5067 | 22.9705 |
| 530029 | 17.7993 | 16.5092 | 19.3361 | 17.7626 |
| 530031 | 13.3775 | 18.3322 | 20.1734 | 17.2600 |
| 530032 | 20.2143 | 21.0361 | 20.0132 | 20.4281 |
| *Asterisk denotes wage data not available for the provider that year. | ||||
| **The 3-year average hourly wage is weighted by salaries and hours. | ||||
| Urban Area | FY 2002 Average Hourly Wage | 3-Year Average Hourly Wage |
|---|---|---|
| Abilene, TX | 17.7691 | 17.6806 |
| Aguadilla, PR | 10.4485 | 9.2769 |
| Akron, OH | 22.0323 | 21.5752 |
| Albany, GA | 23.7363 | 22.4591 |
| Albany-Schenectady-Troy, NY | 18.9628 | 18.7015 |
| Albuquerque, NM | 21.7519 | 19.8583 |
| Alexandria, LA | 17.9113 | 17.4211 |
| Allentown-Bethlehem-Easton, PA | 22.4824 | 21.9015 |
| Altoona, PA | 20.3592 | 20.1685 |
| Amarillo, TX | 19.4329 | 18.7074 |
| Anchorage, AK | 28.0436 | 27.7208 |
| Ann Arbor, MI | 24.7586 | 24.5264 |
| Anniston, AL | 18.4627 | 18.1432 |
| Appleton-Oshkosh-Neenah, WI | 20.6158 | 19.7313 |
| Arecibo, PR | 10.3287 | 10.1229 |
| Asheville, NC | 20.5253 | 19.9864 |
| Athens, GA | 21.9578 | 21.2433 |
| Atlanta, GA | 22.4386 | 21.9090 |
| Atlantic-Cape May, NJ | 25.1942 | 24.4875 |
| Auburn-Opelika, AL | 18.3605 | 17.4403 |
| Augusta-Aiken, GA-SC | 22.2437 | 20.3470 |
| Austin-San Marcos, TX | 21.4095 | 20.5134 |
| Bakersfield, CA | 21.2373 | 20.8780 |
| Baltimore, MD | 21.9879 | 21.1182 |
| Bangor, ME | 21.4017 | 20.8620 |
| Barnstable-Yarmouth, MA | 30.3987 | 29.5566 |
| Baton Rouge, LA | 18.1796 | 18.6154 |
| Beaumont-Port Arthur, TX | 18.8344 | 18.7128 |
| Bellingham, WA | 26.3828 | 25.1714 |
| Benton Harbor, MI | 19.8256 | 18.8187 |
| Bergen-Passaic, NJ | 26.0785 | 25.7821 |
| Billings, MT | 20.8647 | 20.9984 |
| Biloxi-Gulfport-Pascagoula, MS | 18.8292 | 17.8351 |
| Binghamton, NY | 18.8434 | 18.7661 |
| Birmingham, AL | 19.6498 | 19.0252 |
| Bismarck, ND | 17.8118 | 16.9730 |
| Bloomington,IN | 19.7257 | 18.9710 |
| Bloomington-Normal, IL | 20.1643 | 19.6505 |
| Boise City, ID | 20.1899 | 19.6753 |
| Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH | 25.1952 | 24.5070 |
| Boulder-Longmont, CO | 21.8607 | 21.3813 |
| Brazoria, TX | 18.3149 | 18.3834 |
| Bremerton, WA | 24.0007 | 23.7403 |
| Brownsville-Harlingen-San Benito, TX | 20.1061 | 19.5499 |
| Bryan-College Station, TX | 20.8102 | 18.8209 |
| Buffalo-Niagara Falls, NY | 21.1015 | 20.7620 |
| Burlington, VT | 22.0478 | 22.5833 |
| Caguas, PR | 10.4833 | 10.0219 |
| Canton-Massillon, OH | 19.9801 | 19.0700 |
| Casper, WY | 21.1855 | 19.8564 |
| Cedar Rapids, IA | 19.4080 | 19.1733 |
| Champaign-Urbana, IL | 20.7605 | 20.0368 |
| Charleston-North Charleston, SC | 20.5383 | 19.7662 |
| Charleston, WV | 20.6672 | 20.0125 |
| Charlotte-Gastonia-Rock Hill, NC-SC | 20.8279 | 20.4253 |
| Charlottesville, VA | 23.5721 | 23.1481 |
| Chattanooga, TN-GA | 20.9025 | 20.9736 |
| Cheyenne, WY | 18.4900 | 17.9675 |
| Chicago, IL | 24.6432 | 23.9647 |
| Chico-Paradise, CA | 21.9881 | 21.8619 |
| Cincinnati, OH-KY-IN | 21.1338 | 20.5246 |
| Clarksville-Hopkinsville, TN-KY | 18.5997 | 17.8563 |
| Cleveland-Lorain-Elyria, OH | 21.0982 | 20.8296 |
| Colorado Springs, CO | 21.7395 | 20.8047 |
| Columbia, MO | 19.3787 | 19.2453 |
| Columbia, SC | 21.1766 | 20.5897 |
| Columbus, GA-AL | 18.8304 | 18.5114 |
| Columbus, OH | 21.3384 | 21.0849 |
| Corpus Christi, TX | 18.6084 | 18.6824 |
| Corvallis, OR | 25.9828 | 24.7413 |
| Cumberland, MD-WV | 18.5294 | 18.4566 |
| Dallas, TX | 22.1658 | 21.3656 |
| Danville, VA | 19.2156 | 19.0267 |
| Davenport-Moline-Rock Island, IA-IL | 19.2716 | 19.0340 |
| Dayton-Springfield, OH | 20.5800 | 20.3849 |
| Daytona Beach, FL | 20.0167 | 19.7043 |
| Decatur, AL | 19.5764 | 18.8565 |
| Decatur, IL | 17.8196 | 17.7118 |
| Denver, CO | 23.0415 | 22.2645 |
| Des Moines, IA | 19.5864 | 19.3257 |
| Detroit, MI | 23.3966 | 22.7762 |
| Dothan, AL | 17.7316 | 17.1772 |
| Dover, DE | 22.9706 | 21.5842 |
| Dubuque, IA | 19.0053 | 18.6795 |
| Duluth-Superior, MN-WI | 22.9429 | 22.1011 |
| Dutchess County, NY | 23.4959 | 22.7248 |
| Eau Claire, WI | 19.8536 | 19.3107 |
| El Paso, TX | 20.5588 | 19.9419 |
| Elkhart-Goshen, IN | 21.5029 | 20.4359 |
| Elmira, NY | 18.7740 | 18.4812 |
| Enid, OK | 18.6448 | 18.0515 |
| Erie, PA | 19.4447 | 19.3682 |
| Eugene-Springfield, OR | 25.5919 | 23.9337 |
| Evansville, Henderson, IN-KY | 18.9936 | 18.1304 |
| Fargo-Moorhead, ND-MN | 20.6740 | 19.3632 |
| Fayetteville, NC | 20.1393 | 19.0183 |
| Fayetteville-Springdale-Rogers, AR | 18.8407 | 17.4532 |
| Flagstaff, AZ-UT | 23.5500 | 22.9479 |
| Flint, MI | 24.3455 | 24.0039 |
| Florence, AL | 17.5023 | 16.9533 |
| Florence, SC | 19.4593 | 18.9517 |
| Fort Collins-Loveland, CO | 22.4100 | 22.4773 |
| Fort Lauderdale, FL | 22.9622 | 22.1804 |
| Fort Myers-Cape Coral, FL | 20.9121 | 19.9782 |
| Fort Pierce-Port St. Lucie, FL | 22.7860 | 21.5773 |
| Fort Smith, AR-OK | 17.9648 | 17.3902 |
| Fort Walton Beach, FL | 20.0841 | 19.8202 |
| Fort Wayne, IN | 20.5313 | 19.5510 |
| Fort Worth-Arlington, TX | 20.9570 | 20.8452 |
| Fresno, CA | 22.2730 | 22.0075 |
| Gadsden, AL | 19.6146 | 18.7634 |
| Gainesville, FL | 21.1521 | 21.4897 |
| Galveston-Texas City, TX | 23.0087 | 21.6646 |
| Gary, IN | 21.2620 | 20.5771 |
| Glens Falls, NY | 18.5967 | 18.3428 |
| Goldsboro, NC | 19.4302 | 18.4900 |
| Grand Forks, ND-MN | 20.2317 | 19.5346 |
| Grand Junction, CO | 21.3486 | 20.1879 |
| Grand Rapids-Muskegon-Holland, MI | 22.4166 | 22.0645 |
| Great Falls, MT | 19.7878 | 20.7979 |
| Greeley, CO | 21.1820 | 21.0411 |
| Green Bay, WI | 20.5432 | 19.9981 |
| Greensboro-Winston-Salem-High Point, NC | 21.2803 | 20.0780 |
| Greenville, NC | 20.7237 | 20.4264 |
| Greenville-Spartanburg-Anderson, SC | 20.5626 | 19.8772 |
| Hagerstown, MD | 18.6617 | 19.2372 |
| Hamilton-Middletown, OH | 20.7196 | 19.8132 |
| Harrisburg-Lebanon-Carlisle, PA | 21.0273 | 20.8140 |
| Hartford, CT | 25.7288 | 25.0922 |
| Hattiesburg, MS | 16.6793 | 16.3839 |
| Hickory-Morganton-Lenoir, NC | 20.8978 | 19.9473 |
| Honolulu, HI | 25.7427 | 25.2694 |
| Houma, LA | 17.7919 | 17.3205 |
| Houston, TX | 21.4873 | 20.8626 |
| Huntington-Ashland, WV-KY-OH | 21.4522 | 21.2133 |
| Huntsville, AL | 19.8172 | 19.3336 |
| Indianapolis, IN | 21.6359 | 21.2238 |
| Iowa City, IA | 21.9959 | 21.1012 |
| Jackson, MI | 20.6529 | 19.7626 |
| Jackson, MS | 18.9422 | 18.6455 |
| Jackson, TN | 20.1078 | 19.1864 |
| Jacksonville, FL | 20.5769 | 19.8750 |
| Jacksonville, NC | 17.0034 | 16.8680 |
| Jamestown, NY | 17.9583 | 17.1876 |
| Janesville-Beloit, WI | 21.7281 | 20.9886 |
| Jersey City, NJ | 24.9369 | 24.8965 |
| Johnson City-Kingsport-Bristol, TN-VA | 19.2235 | 18.6571 |
| Johnstown, PA | 19.4611 | 18.9954 |
| Jonesboro, AR | 18.7961 | 16.9923 |
| Joplin, MO | 19.4696 | 17.8013 |
| Kalamazoo-Battlecreek, MI | 23.7355 | 22.5300 |
| Kankakee, IL | 22.0627 | 20.5487 |
| Kansas City, KS-MO | 21.2753 | 20.5840 |
| Kenosha, WI | 21.3454 | 20.4490 |
| Killeen-Temple, TX | 16.2682 | 19.9750 |
| Knoxville, TN | 19.8337 | 19.1504 |
| Kokomo, IN | 20.3602 | 19.9881 |
| La Crosse, WI-MN | 20.6365 | 19.8718 |
| Lafayette, LA | 19.0613 | 18.3994 |
| Lafayette, IN | 20.3481 | 19.3998 |
| Lake Charles, LA | 17.3224 | 16.7485 |
| Lakeland-Winter Haven, FL | 20.2272 | 19.6704 |
| Lancaster, PA | 20.7395 | 20.1687 |
| Lansing-East Lansing, MI | 21.5357 | 21.4297 |
| Laredo, TX | 17.5103 | 17.6390 |
| Las Cruces, NM | 19.2336 | 18.7690 |
| Las Vegas, NV-AZ | 24.9460 | 24.1211 |
| 1 Lawrence, KS | 17.6233 | |
| Lawton, OK | 19.3702 | 19.7127 |
| Lewiston-Auburn, ME | 20.7185 | 19.7537 |
| Lexington, KY | 19.6123 | 18.9899 |
| Lima, OH | 21.1268 | 20.0862 |
| Lincoln, NE | 22.6963 | 21.4133 |
| Little Rock-North Little Rock, AR | 19.9791 | 19.2054 |
| Longview-Marshall, TX | 19.1225 | 19.0256 |
| Los Angeles-Long Beach, CA | 26.6548 | 26.0962 |
| Louisville, KY-IN | 21.2596 | 20.4841 |
| Lubbock, TX | 18.8491 | 18.6166 |
| Lynchburg, VA | 20.3083 | 19.4241 |
| Macon, GA | 19.9824 | 19.2057 |
| Madison, WI | 23.0613 | 21.9843 |
| Mansfield, OH | 19.4276 | 18.7455 |
| Mayaguez, PR | 10.8433 | 10.2295 |
| McAllen-Edinburg-Mission, TX | 18.6914 | 18.1962 |
| Medford-Ashland, OR | 23.0097 | 22.6022 |
| Melbourne-Titusville-Palm Bay, FL | 22.1149 | 20.9722 |
| Memphis, TN-AR-MS | 20.0303 | 18.8000 |
| Merced, CA | 22.1904 | 21.6193 |
| Miami, FL | 22.1977 | 21.9246 |
| Middlesex-Somerset-Hunterdon, NJ | 25.5879 | 24.3992 |
| Milwaukee-Waukesha, WI | 22.2459 | 21.4514 |
| Minneapolis-St. Paul, MN-WI | 24.3849 | 23.8437 |
| Missoula, MT | 20.8911 | 20.0992 |
| Mobile, AL | 18.0301 | 17.7727 |
| Modesto, CA | 24.1386 | 22.6578 |
| Monmouth-Ocean, NJ | 24.2514 | 24.2156 |
| Monroe, LA | 18.2960 | 18.0030 |
| Montgomery, AL | 16.4170 | 16.4651 |
| Muncie, IN | 22.1725 | 22.9671 |
| Myrtle Beach, SC | 19.5681 | 18.6951 |
| Naples, FL | 21.6388 | 21.1816 |
| Nashville, TN | 21.7612 | 20.8163 |
| Nassau-Suffolk, NY | 30.4363 | 30.1896 |
| New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT | 27.3029 | 26.7357 |
| New London-Norwich, CT | 25.7135 | 26.0913 |
| New Orleans, LA | 20.1579 | 19.8724 |
| New York, NY | 32.1854 | 31.5830 |
| Newark, NJ | 25.9290 | 25.4360 |
| Newburgh, NY-PA | 24.7917 | 23.8549 |
| Norfolk-Virginia Beach-Newport News, VA-NC | 19.1397 | 18.4429 |
| Oakland, CA | 34.1768 | 32.8934 |
| Ocala, FL | 21.3185 | 20.6236 |
| Odessa-Midland, TX | 22.5425 | 20.4491 |
| Oklahoma City, OK | 19.3952 | 18.9190 |
| Olympia, WA | 25.3219 | 23.8950 |
| Omaha, NE-IA | 21.6670 | 21.5315 |
| Orange County, CA | 24.8160 | 24.7793 |
| Orlando, FL | 21.5114 | 21.0699 |
| Owensboro, KY | 18.5923 | 17.8512 |
| Panama City, FL | 20.2145 | 19.7652 |
| Parkersburg-Marietta, WV-OH | 18.1448 | 17.9931 |
| Pensacola, FL | 18.6539 | 18.1053 |
| Peoria-Pekin, IL | 19.5717 | 18.6727 |
| Philadelphia, PA-NJ | 24.4217 | 23.9480 |
| Phoenix-Mesa, AZ | 21.5030 | 20.8692 |
| Pine Bluff, AR | 17.6144 | 16.9553 |
| Pittsburgh, PA | 21.3283 | 20.9676 |
| Pittsfield, MA | 22.9287 | 22.3291 |
| Pocatello, ID | 21.0779 | 19.9570 |
| Ponce, PR | 11.6402 | 11.0089 |
| Portland, ME | 21.0314 | 20.7690 |
| Portland-Vancouver, OR-WA | 24.7891 | 23.9331 |
| Providence-Warwick, RI | 24.1057 | 23.4709 |
| Provo-Orem, UT | 21.9597 | 21.5577 |
| Pueblo, CO | 19.1954 | 19.0481 |
| Punta Gorda, FL | 20.1130 | 20.3995 |
| Racine, WI | 20.8222 | 20.1696 |
| Raleigh-Durham-Chapel Hill, NC | 21.9030 | 21.0278 |
| Rapid City, SD | 19.7860 | 18.9541 |
| Reading, PA | 21.3801 | 20.4191 |
| Redding, CA | 24.8864 | 24.7297 |
| Reno, NV | 23.2497 | 22.9230 |
| Richland-Kennewick-Pasco, WA | 24.4507 | 24.4034 |
| Richmond-Petersburg, VA | 21.5917 | 20.8973 |
| Riverside-San Bernardino, CA | 24.7903 | 24.3425 |
| Roanoke, VA | 18.6747 | 18.3527 |
| Rochester, MN | 25.5712 | 24.8162 |
| Rochester, NY | 20.8521 | 20.0838 |
| Rockford, IL | 20.5343 | 19.4475 |
| Rocky Mount, NC | 20.3213 | 19.3679 |
| Sacramento, CA | 26.3945 | 26.1465 |
| Saginaw-Bay City-Midland, MI | 21.3941 | 20.6362 |
| St. Cloud, MN | 21.9780 | 21.3047 |
| 1 St. Joseph, MO | 19.3531 | |
| St. Louis, MO-IL | 19.9244 | 19.5996 |
| Salem, OR | 22.3342 | 21.8859 |
| Salinas, CA | 32.7598 | 31.8419 |
| Salt Lake City-Ogden, UT | 22.0030 | 21.4144 |
| San Angelo, TX | 18.2784 | 17.4362 |
| San Antonio, TX | 19.1516 | 18.4593 |
| San Diego, CA | 25.1307 | 25.3474 |
| San Francisco, CA | 31.5450 | 30.6851 |
| San Jose, CA | 31.6633 | 30.0720 |
| San Juan-Bayamon, PR | 10.6229 | 10.2284 |
| San Luis Obispo-Atascadero-Paso Robles, CA | 24.5182 | 23.3041 |
| Santa Barbara-Santa Maria-Lompoc, CA | 24.0983 | 23.3594 |
| Santa Cruz-Watsonville, CA | 31.1654 | 30.4145 |
| Santa Fe, NM | 22.7435 | 22.5866 |
| Santa Rosa, CA | 29.0793 | 28.0256 |
| Sarasota-Bradenton, FL | 22.5102 | 21.6154 |
| Savannah, GA | 20.6199 | 20.9278 |
| Scranton-Wilkes Barre-Hazleton, PA | 19.3713 | 18.4721 |
| Seattle-Bellevue-Everett, WA | 25.3458 | 24.3975 |
| Sharon, PA | 17.6824 | 17.4957 |
| Sheboygan, WI | 18.7992 | 18.1442 |
| Sherman-Denison, TX | 20.9115 | 19.8213 |
| Shreveport-Bossier City, LA | 20.1898 | 19.4576 |
| Sioux City, IA-NE | 19.5588 | 18.6963 |
| Sioux Falls, SD | 20.3884 | 19.3356 |
| South Bend, IN | 22.2935 | 21.5894 |
| Spokane, WA | 23.7995 | 23.1813 |
| Springfield, IL | 19.3559 | 18.8869 |
| Springfield, MO | 19.1121 | 18.1563 |
| Springfield, MA | 24.2745 | 23.3313 |
| State College, PA | 20.3757 | 19.7984 |
| Steubenville-Weirton, OH-WV | 19.2689 | 18.6797 |
| Stockton-Lodi, CA | 24.1271 | 23.2304 |
| Sumter, SC | 17.3876 | 17.6174 |
| Syracuse, NY | 21.4641 | 20.7071 |
| Tacoma, WA | 25.9158 | 25.1530 |
| Tallahassee, FL | 19.0232 | 18.5413 |
| Tampa-St. Petersburg-Clearwater, FL | 19.9114 | 19.5352 |
| Terre Haute, IN | 19.0337 | 18.4440 |
| Texarkana, AR-Texarkana, TX | 18.5780 | 17.9809 |
| Toledo, OH | 21.8824 | 21.3504 |
| Topeka, KS | 19.8816 | 19.8271 |
| Trenton, NJ | 23.2382 | 22.2118 |
| Tucson, AZ | 20.0050 | 19.2367 |
| Tulsa, OK | 19.8607 | 18.4406 |
| Tuscaloosa, AL | 18.2284 | 17.6510 |
| Tyler, TX | 21.5091 | 20.6026 |
| Utica-Rome, NY | 18.5820 | 18.2679 |
| Vallejo-Fairfield-Napa, CA | 30.2552 | 28.8147 |
| Ventura, CA | 24.5276 | 24.2700 |
| Victoria, TX | 18.5790 | 18.0303 |
| Vineland-Millville-Bridgeton, NJ | 23.2940 | 22.8113 |
| Visalia-Tulare-Porterville, CA | 21.4790 | 21.4191 |
| Waco, TX | 18.1355 | 17.7707 |
| Washington, DC-MD-VA-WV | 24.4550 | 23.7621 |
| Waterloo-Cedar Falls, IA | 17.9383 | 18.0820 |
| Wausau, WI | 21.6311 | 20.7089 |
| West Palm Beach-Boca Raton, FL | 21.8130 | 21.3673 |
| Wheeling, OH-WV | 17.8134 | 16.9419 |
| Wichita, KS | 21.4307 | 20.6976 |
| Wichita Falls, TX | 17.5498 | 16.8374 |
| Williamsport, PA | 19.2494 | 18.4198 |
| Wilmington-Newark, DE-MD | 24.2660 | 24.1627 |
| Wilmington, NC | 20.9901 | 20.6684 |
| Yakima, WA | 23.5754 | 22.3174 |
| Yolo, CA | 21.6430 | 21.4983 |
| York, PA | 21.0635 | 20.3115 |
| Youngstown-Warren, OH | 21.3343 | 21.0926 |
| Yuba City, CA | 23.1110 | 23.0076 |
| Yuma, AZ | 20.0535 | 20.5870 |
| 1 The MSA is empty for FY 2002. The hospital(s) in the MSA received rural status under Section 401 of the Balanced Budget Refinement Act of 1999 (P.L. 106-113). The MSA is assigned the statewide rural wage index (see Table 4B). | ||
| Nonurban Area | FY 2002 Average Hourly Wage | 3-Year Average Hourly Wage |
|---|---|---|
| Alabama | 16.3730 | 16.1146 |
| Alaska | 26.4636 | 26.3425 |
| Arizona | 19.3673 | 18.5370 |
| Arkansas | 16.7079 | 16.0831 |
| California | 21.5497 | 21.3758 |
| Colorado | 19.6575 | 19.2833 |
| Connecticut | 26.9422 | 26.2306 |
| Delaware | 21.3930 | 20.2349 |
| Florida | 19.6192 | 19.3651 |
| Georgia | 18.5057 | 17.9168 |
| Hawaii | 24.7906 | 23.8356 |
| Idaho | 19.4497 | 18.9015 |
| Illinois | 17.9658 | 17.5928 |
| Indiana | 19.4553 | 18.6527 |
| Iowa | 18.1754 | 17.4857 |
| Kansas | 17.4286 | 16.6018 |
| Kentucky | 17.7644 | 17.3603 |
| Louisiana | 16.9467 | 16.4424 |
| Maine | 19.4557 | 18.9537 |
| Maryland | 19.7644 | 18.9527 |
| Massachusetts | 25.5523 | 24.6681 |
| Michigan | 20.0792 | 19.4470 |
| Minnesota | 20.1570 | 19.2809 |
| Mississippi | 16.7955 | 16.1984 |
| Missouri | 17.6049 | 16.9330 |
| Montana | 19.3090 | 18.6615 |
| Nebraska | 18.1647 | 17.6040 |
| Nevada | 21.6995 | 20.3605 |
| New Hampshire | 21.8156 | 21.4054 |
| New Jersey1 | ||
| New Mexico | 19.3566 | 18.5498 |
| New York | 19.0675 | 18.6183 |
| North Carolina | 19.0403 | 18.3332 |
| North Dakota | 17.5784 | 16.8515 |
| Ohio | 19.3379 | 18.8488 |
| Oklahoma | 16.8803 | 16.1856 |
| Oregon | 22.3705 | 21.7851 |
| Pennsylvania | 19.2018 | 18.6374 |
| Puerto Rico | 10.7076 | 9.6394 |
| Rhode Island1 | ||
| South Carolina | 18.9889 | 18.2492 |
| South Dakota | 17.5369 | 16.6639 |
| Tennessee | 17.6873 | 16.9880 |
| Texas | 17.2050 | 16.4636 |
| Utah | 20.1916 | 19.5942 |
| Vermont | 21.1189 | 20.4055 |
| Virginia | 18.3851 | 17.6464 |
| Washington | 22.7769 | 22.5424 |
| West Virginia | 17.9971 | 17.6684 |
| Wisconsin | 20.2251 | 19.3721 |
| Wyoming | 19.5145 | 19.1625 |
| 1 All counties within the State are classified as urban. | ||
| Urban Area (Constituent Counties) | Wage Index | GAF |
|---|---|---|
| 0040Abilene, TX | 0.7983 | 0.8570 |
| Taylor, TX | ||
| 00602 Aguadilla, PR | 0.4832 | 0.6077 |
| Aguada, PR | ||
| Aguadilla, PR | ||
| Moca, PR | ||
| 0080Akron, OH | 0.9876 | 0.9915 |
| Portage, OH | ||
| Summit, OH | ||
| 0120Albany, GA | 1.0640 | 1.0434 |
| Dougherty, GA | ||
| Lee, GA | ||
| 01602 Albany-Schenectady-Troy, NY | 0.8547 | 0.8981 |
| Albany, NY | ||
| Montgomery, NY | ||
| Rensselaer, NY | ||
| Saratoga, NY | ||
| Schenectady, NY | ||
| Schoharie, NY | ||
| 0200Albuquerque, NM | 0.9750 | 0.9828 |
| Bernalillo, NM | ||
| Sandoval, NM | ||
| Valencia, NM | ||
| 0220Alexandria, LA | 0.8059 | 0.8626 |
| Rapides, LA | ||
| 0240Allentown-Bethlehem-Easton, PA | 1.0077 | 1.0053 |
| Carbon, PA | ||
| Lehigh, PA | ||
| Northampton, PA | ||
| 0280Altoona, PA | 0.9126 | 0.9393 |
| Blair, PA | ||
| 0320Amarillo, TX | 0.8711 | 0.9098 |
| Potter, TX | ||
| Randall, TX | ||
| 0380Anchorage, AK | 1.2696 | 1.1776 |
| Anchorage, AK | ||
| 0440Ann Arbor, MI | 1.1098 | 1.0739 |
| Lenawee, MI | ||
| Livingston, MI | ||
| Washtenaw, MI | ||
| 0450Anniston, AL | 0.8276 | 0.8785 |
| Calhoun, AL | ||
| 0460Appleton-Oshkosh-Neenah, WI | 0.9241 | 0.9474 |
| Calumet, WI | ||
| Outagamie, WI | ||
| Winnebago, WI | ||
| 04702 Arecibo, PR | 0.4832 | 0.6077 |
| Arecibo, PR | ||
| Camuy, PR | ||
| Hatillo, PR | ||
| 0480Asheville, NC | 0.9200 | 0.9445 |
| Buncombe, NC | ||
| Madison, NC | ||
| 0500Athens, GA | 0.9842 | 0.9892 |
| Clarke, GA | ||
| Madison, GA | ||
| Oconee, GA | ||
| 05201 Atlanta, GA | 1.0058 | 1.0040 |
| Barrow, GA | ||
| Bartow, GA | ||
| Carroll, GA | ||
| Cherokee, GA | ||
| Clayton, GA | ||
| Cobb, GA | ||
| Coweta, GA | ||
| DeKalb, GA | ||
| Douglas, GA | ||
| Fayette, GA | ||
| Forsyth, GA | ||
| Fulton, GA | ||
| Gwinnett, GA | ||
| Henry, GA | ||
| Newton, GA | ||
| Paulding, GA | ||
| Pickens, GA | ||
| Rockdale, GA | ||
| Spalding, GA | ||
| Walton, GA | ||
| 0560Atlantic-Cape May, NJ | 1.1293 | 1.0868 |
| Atlantic, NJ | ||
| Cape May, NJ | ||
| 0580Auburn-Opelika, AL | 0.8230 | 0.8751 |
| Lee, AL | ||
| 0600Augusta-Aiken, GA-SC | 0.9970 | 0.9979 |
| Columbia, GA | ||
| McDuffie, GA | ||
| Richmond, GA | ||
| Aiken, SC | ||
| Edgefield, SC | ||
| 06401 Austin-San Marcos, TX | 0.9597 | 0.9722 |
| Bastrop, TX | ||
| Caldwell, TX | ||
| Hays, TX | ||
| Travis, TX | ||
| Williamson, TX | ||
| 06802 Bakersfield, CA | 0.9659 | 0.9765 |
| Kern, CA | ||
| 07201 Baltimore, MD | 0.9856 | 0.9901 |
| Anne Arundel, MD | ||
| Baltimore, MD | ||
| Baltimore City, MD | ||
| Carroll, MD | ||
| Harford, MD | ||
| Howard, MD | ||
| Queen Anne's, MD | ||
| 0733Bangor, ME | 0.9593 | 0.9719 |
| Penobscot, ME | ||
| 0743Barnstable-Yarmouth, MA | 1.3626 | 1.2360 |
| Barnstable, MA | ||
| 0760Baton Rouge, LA | 0.8149 | 0.8692 |
| Ascension, LA | ||
| East Baton Rouge, LA | ||
| Livingston, LA | ||
| West Baton Rouge, LA | ||
| 0840Beaumont-Port Arthur, TX | 0.8442 | 0.8905 |
| Hardin, TX | ||
| Jefferson, TX | ||
| Orange, TX | ||
| 0860Bellingham, WA | 1.1826 | 1.1217 |
| Whatcom, WA | ||
| 08702 Benton Harbor, MI | 0.9000 | 0.9304 |
| Berrien, MI | ||
| 08751 Bergen-Passaic, NJ | 1.1808 | 1.1205 |
| Bergen, NJ | ||
| Passaic, NJ | ||
| 0880Billings, MT | 0.9352 | 0.9552 |
| Yellowstone, MT | ||
| 0920Biloxi-Gulfport-Pascagoula, MS | 0.8440 | 0.8903 |
| Hancock, MS | ||
| Harrison, MS | ||
| Jackson, MS | ||
| 09602 Binghamton, NY | 0.8547 | 0.8981 |
| Broome, NY | ||
| Tioga, NY | ||
| 1000Birmingham, AL | 0.8808 | 0.9168 |
| Blount, AL | ||
| Jefferson, AL | ||
| St. Clair, AL | ||
| Shelby, AL | ||
| 1010Bismarck, ND | 0.7984 | 0.8571 |
| Burleigh, ND | ||
| Morton, ND | ||
| 1020Bloomington, IN | 0.8842 | 0.9192 |
| Monroe, IN | ||
| 1040Bloomington-Normal, IL | 0.9038 | 0.9331 |
| McLean, IL | ||
| 1080Boise City, ID | 0.9050 | 0.9339 |
| Ada, ID | ||
| Canyon, ID | ||
| 11231 2 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH (MA Hospitals) | 1.1454 | 1.0974 |
| Bristol, MA | ||
| Essex, MA | ||
| Middlesex, MA | ||
| Norfolk, MA | ||
| Plymouth, MA | ||
| Suffolk, MA | ||
| Worcester, MA | ||
| Hillsborough, NH | ||
| Merrimack, NH | ||
| Rockingham, NH | ||
| Strafford, NH | ||
| 11231 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH (NH Hospitals) | 1.1293 | 1.0868 |
| Bristol, MA | ||
| Essex, MA | ||
| Middlesex, MA | ||
| Norfolk, MA | ||
| Plymouth, MA | ||
| Suffolk, MA | ||
| Worcester, MA | ||
| Hillsborough, NH | ||
| Merrimack, NH | ||
| Rockingham, NH | ||
| Strafford, NH | ||
| 1125Boulder-Longmont, CO | 0.9799 | 0.9862 |
| Boulder, CO | ||
| 1145Brazoria, TX | 0.8209 | 0.8736 |
| Brazoria, TX | ||
| 1150Bremerton, WA | 1.0758 | 1.0513 |
| Kitsap, WA | ||
| 1240Brownsville-Harlingen-San Benito, TX | 0.9012 | 0.9312 |
| Cameron, TX | ||
| 1260Bryan-College Station, TX | 0.9328 | 0.9535 |
| Brazos, TX | ||
| 12801 Buffalo-Niagara Falls, NY | 0.9459 | 0.9626 |
| Erie, NY | ||
| Niagara, NY | ||
| 1303Burlington, VT | 0.9883 | 0.9920 |
| Chittenden, VT | ||
| Franklin, VT | ||
| Grand Isle, VT | ||
| 13102 Caguas, PR | 0.4832 | 0.6077 |
| Caguas, PR | ||
| Cayey, PR | ||
| Cidra, PR | ||
| Gurabo, PR | ||
| San Lorenzo, PR | ||
| 1320Canton-Massillon, OH | 0.8956 | 0.9273 |
| Carroll, OH | ||
| Stark, OH | ||
| 1350Casper, WY | 0.9496 | 0.9652 |
| Natrona, WY | ||
| 1360Cedar Rapids, IA | 0.8699 | 0.9090 |
| Linn, IA | ||
| 1400Champaign-Urbana, IL | 0.9306 | 0.9519 |
| Champaign, IL | ||
| 1440Charleston-North Charleston, SC | 0.9206 | 0.9449 |
| Berkeley, SC | ||
| Charleston, SC | ||
| Dorchester, SC | ||
| 1480Charleston, WV | 0.9264 | 0.9490 |
| Kanawha, WV | ||
| Putnam, WV | ||
| 15201 Charlotte-Gastonia-Rock Hill, NC-SC | 0.9407 | 0.9590 |
| Cabarrus, NC | ||
| Gaston, NC | ||
| Lincoln, NC | ||
| Mecklenburg, NC | ||
| Rowan, NC | ||
| Stanly, NC | ||
| Union, NC | ||
| York, SC | ||
| 1540Charlottesville, VA | 1.0566 | 1.0384 |
| Albemarle, VA | ||
| Charlottesville City, VA | ||
| Fluvanna, VA | ||
| Greene, VA | ||
| 1560Chattanooga, TN-GA | 0.9369 | 0.9563 |
| Catoosa, GA | ||
| Dade, GA | ||
| Walker, GA | ||
| Hamilton, TN | ||
| Marion, TN | ||
| 15802 Cheyenne, WY | 0.8747 | 0.9124 |
| Laramie, WY | ||
| 16001 Chicago, IL | 1.1046 | 1.0705 |
| Cook, IL | ||
| DeKalb, IL | ||
| DuPage, IL | ||
| Grundy, IL | ||
| Kane, IL | ||
| Kendall, IL | ||
| Lake, IL | ||
| McHenry, IL | ||
| Will, IL | ||
| 1620Chico-Paradise, CA | 0.9856 | 0.9901 |
| Butte, CA | ||
| 16401 Cincinnati, OH-KY-IN | 0.9473 | 0.9636 |
| Dearborn, IN | ||
| Ohio, IN | ||
| Boone, KY | ||
| Campbell, KY | ||
| Gallatin, KY | ||
| Grant, KY | ||
| Kenton, KY | ||
| Pendleton, KY | ||
| Brown, OH | ||
| Clermont, OH | ||
| Hamilton, OH | ||
| Warren, OH | ||
| 1660Clarksville-Hopkinsville, TN-KY | 0.8393 | 0.8869 |
| Christian, KY | ||
| Montgomery, TN | ||
| 16801 Cleveland-Lorain-Elyria, OH | 0.9457 | 0.9625 |
| Ashtabula, OH | ||
| Cuyahoga, OH | ||
| Geauga, OH | ||
| Lake, OH | ||
| Lorain, OH | ||
| Medina, OH | ||
| 1720Colorado Springs, CO | 0.9744 | 0.9824 |
| El Paso, CO | ||
| 1740Columbia, MO | 0.8686 | 0.9080 |
| Boone, MO | ||
| 1760Columbia, SC | 0.9492 | 0.9649 |
| Lexington, SC | ||
| Richland, SC | ||
| 1800Columbus, GA-AL | ||
| Russell, AL | 0.8440 | 0.8903 |
| Chattahoochee, GA | ||
| Harris, GA | ||
| Muscogee, GA | ||
| 18401 Columbus, OH | 0.9565 | 0.9700 |
| Delaware, OH | ||
| Fairfield, OH | ||
| Franklin, OH | ||
| Licking, OH | ||
| Madison, OH | ||
| Pickaway, OH | ||
| 1880Corpus Christi, TX | 0.8341 | 0.8832 |
| Nueces, TX | ||
| San Patricio, TX | ||
| 1890Corvallis, OR | 1.1646 | 1.1100 |
| Benton, OR | ||
| 19002 Cumberland, MD-WV (MD Hospitals) | 0.8859 | 0.9204 |
| Allegany, MD | ||
| Mineral, WV | ||
| 1900Cumberland, MD-WV (WV Hospital) | 0.8306 | 0.8806 |
| Allegany, MD | ||
| Mineral, WV | ||
| 19201 Dallas, TX | 0.9936 | 0.9956 |
| Collin, TX | ||
| Dallas, TX | ||
| Denton, TX | ||
| Ellis, TX | ||
| Henderson, TX | ||
| Hunt, TX | ||
| Kaufman, TX | ||
| Rockwall, TX | ||
| 1950Danville, VA | 0.8613 | 0.9028 |
| Danville City, VA | ||
| Pittsylvania, VA | ||
| 1960Davenport-Moline-Rock Island, IA-IL | 0.8638 | 0.9046 |
| Scott, IA | ||
| Henry, IL | ||
| Rock Island, IL | ||
| 2000Dayton-Springfield, OH | 0.9225 | 0.9463 |
| Clark, OH | ||
| Greene, OH | ||
| Miami, OH | ||
| Montgomery, OH | ||
| 2020Daytona Beach, FL | 0.8972 | 0.9284 |
| Flagler, FL | ||
| Volusia, FL | ||
| 2030Decatur, AL | 0.8775 | 0.9144 |
| Lawrence, AL | ||
| Morgan, AL | ||
| 20402 Decatur, IL | 0.8053 | 0.8622 |
| Macon, IL | ||
| 20801 Denver, CO | 1.0328 | 1.0223 |
| Adams, CO | ||
| Arapahoe, CO | ||
| Denver, CO | ||
| Douglas, CO | ||
| Jefferson, CO | ||
| 2120Des Moines, IA | 0.8779 | 0.9147 |
| Dallas, IA | ||
| Polk, IA | ||
| Warren, IA | ||
| 21601 Detroit, MI | 1.0487 | 1.0331 |
| Lapeer, MI | ||
| Macomb, MI | ||
| Monroe, MI | ||
| Oakland, MI | ||
| St. Clair, MI | ||
| Wayne, MI | ||
| 2180Dothan, AL | 0.7988 | 0.8574 |
| Dale, AL | ||
| Houston, AL | ||
| 2190Dover, DE | 1.0296 | 1.0202 |
| Kent, DE | ||
| 2200Dubuque, IA | 0.8519 | 0.8960 |
| Dubuque, IA | ||
| 2240Duluth-Superior, MN-WI | 1.0284 | 1.0194 |
| St. Louis, MN | ||
| Douglas, WI | ||
| 2281Dutchess County, NY | 1.0532 | 1.0361 |
| Dutchess, NY | ||
| 22902 Eau Claire, WI | 0.9068 | 0.9352 |
| Chippewa, WI | ||
| Eau Claire, WI | ||
| 2320El Paso, TX | 0.9215 | 0.9456 |
| El Paso, TX | ||
| 2330Elkhart-Goshen, IN | 0.9638 | 0.9751 |
| Elkhart, IN | ||
| 23352 Elmira, NY | 0.8547 | 0.8981 |
| Chemung, NY | ||
| 2340Enid, OK | 0.8357 | 0.8843 |
| Garfield, OK | ||
| 2360Erie, PA | 0.8716 | 0.9102 |
| Erie, PA | ||
| 2400Eugene-Springfield, OR | 1.1471 | 1.0985 |
| Lane, OR | ||
| 24402 Evansville-Henderson, IN-KY (IN Hospitals) | 0.8721 | 0.9105 |
| Posey, IN | ||
| Vanderburgh, IN | ||
| Warrick, IN | ||
| Henderson, KY | ||
| 2440Evansville-Henderson, IN-KY (KY Hospitals) | 0.8514 | 0.8957 |
| Posey, IN | ||
| Vanderburgh, IN | ||
| Warrick, IN | ||
| Henderson, KY | ||
| 2520Fargo-Moorhead, ND-MN | 0.9267 | 0.9492 |
| Clay, MN | ||
| Cass, ND | ||
| 2560Fayetteville, NC | 0.9027 | 0.9323 |
| Cumberland, NC | ||
| 2580Fayetteville-Springdale-Rogers, AR | 0.8445 | 0.8907 |
| Benton, AR | ||
| Washington, AR | ||
| 2620Flagstaff, AZ-UT | 1.0556 | 1.0377 |
| Coconino, AZ | ||
| Kane, UT | ||
| 2640Flint, MI | 1.0913 | 1.0617 |
| Genesee, MI | ||
| 2650Florence, AL | 0.7889 | 0.8501 |
| Colbert, AL | ||
| Lauderdale, AL | ||
| 2655Florence, SC | 0.8722 | 0.9106 |
| Florence, SC | ||
| 2670Fort Collins-Loveland, CO | 1.0045 | 1.0031 |
| Larimer, CO | ||
| 26801 Ft. Lauderdale, FL | 1.0784 | 1.0530 |
| Broward, FL | ||
| 2700Fort Myers-Cape Coral, FL | 0.9374 | 0.9567 |
| Lee, FL | ||
| 2710Fort Pierce-Port St. Lucie, FL | 1.0214 | 1.0146 |
| Martin, FL | ||
| St. Lucie, FL | ||
| 2720Fort Smith, AR-OK | 0.8053 | 0.8622 |
| Crawford, AR | ||
| Sebastian, AR | ||
| Sequoyah, OK | ||
| 2750Fort Walton Beach, FL | 0.9002 | 0.9305 |
| Okaloosa, FL | ||
| 2760Fort Wayne, IN | 0.9203 | 0.9447 |
| Adams, IN | ||
| Allen, IN | ||
| De Kalb, IN | ||
| Huntington, IN | ||
| Wells, IN | ||
| Whitley, IN | ||
| 28001 Fort Worth-Arlington, TX | 0.9394 | 0.9581 |
| Hood, TX | ||
| Johnson, TX | ||
| Parker, TX | ||
| Tarrant, TX | ||
| 2840Fresno, CA | 0.9984 | 0.9989 |
| Fresno, CA | ||
| Madera, CA | ||
| 2880Gadsden, AL | 0.8792 | 0.9156 |
| Etowah, AL | ||
| 2900Gainesville, FL | 0.9481 | 0.9642 |
| Alachua, FL | ||
| 2920Galveston-Texas City, TX | 1.0313 | 1.0213 |
| Galveston, TX | ||
| 2960Gary, IN | 0.9530 | 0.9676 |
| Lake, IN | ||
| Porter, IN | ||
| 29752 Glens Falls, NY | 0.8547 | 0.8981 |
| Warren, NY | ||
| Washington, NY | ||
| 2980Goldsboro, NC | 0.8709 | 0.9097 |
| Wayne, NC | ||
| 2985Grand Forks, ND-MN | 0.9119 | 0.9388 |
| Polk, MN | ||
| Grand Forks, ND | ||
| 2995Grand Junction, CO | 0.9774 | 0.9845 |
| Mesa, CO | ||
| 30001 Grand Rapids-Muskegon-Holland, MI | 1.0048 | 1.0033 |
| Allegan, MI | ||
| Kent, MI | ||
| Muskegon, MI | ||
| Ottawa, MI | ||
| 3040Great Falls, MT | 0.9195 | 0.9441 |
| Cascade, MT | ||
| 3060Greeley, CO | 0.9495 | 0.9651 |
| Weld, CO | ||
| 3080Green Bay, WI | 0.9357 | 0.9555 |
| Brown, WI | ||
| 31201 Greensboro-Winston-Salem-High Point, NC | 0.9539 | 0.9682 |
| Alamance, NC | ||
| Davidson, NC | ||
| Davie, NC | ||
| Forsyth, NC | ||
| Guilford, NC | ||
| Randolph, NC | ||
| Stokes, NC | ||
| Yadkin, NC | ||
| 3150Greenville, NC | 0.9289 | 0.9507 |
| Pitt, NC | ||
| 3160Greenville-Spartanburg-Anderson, SC | 0.9217 | 0.9457 |
| Anderson, SC | ||
| Cherokee, SC | ||
| Greenville, SC | ||
| Pickens, SC | ||
| Spartanburg, SC | ||
| 31802 Hagerstown, MD | 0.8859 | 0.9204 |
| Washington, MD | ||
| 3200Hamilton-Middletown, OH | 0.9287 | 0.9506 |
| Butler, OH | ||
| 3240Harrisburg-Lebanon-Carlisle, PA | 0.9425 | 0.9603 |
| Cumberland, PA | ||
| Dauphin, PA | ||
| Lebanon, PA | ||
| Perry, PA | ||
| 32831 2 Hartford, CT | 1.2077 | 1.1380 |
| Hartford, CT | ||
| Litchfield, CT | ||
| Middlesex, CT | ||
| Tolland, CT | ||
| 32852 Hattiesburg, MS | 0.7528 | 0.8233 |
| Forrest, MS | ||
| Lamar, MS | ||
| 3290Hickory-Morganton-Lenoir, NC | 0.9367 | 0.9562 |
| Alexander, NC | ||
| Burke, NC | ||
| Caldwell, NC | ||
| Catawba, NC | ||
| 3320Honolulu, HI | 1.1544 | 1.1033 |
| Honolulu, HI | ||
| 3350Houma, LA | 0.7975 | 0.8565 |
| Lafourche, LA | ||
| Terrebonne, LA | ||
| 33601 Houston, TX | 0.9631 | 0.9746 |
| Chambers, TX | ||
| Fort Bend, TX | ||
| Harris, TX | ||
| Liberty, TX | ||
| Montgomery, TX | ||
| Waller, TX | ||
| 3400Huntington-Ashland, WV-KY-OH | 0.9616 | 0.9735 |
| Boyd, KY | ||
| Carter, KY | ||
| Greenup, KY | ||
| Lawrence, OH | ||
| Cabell, WV | ||
| Wayne, WV | ||
| 3440Huntsville, AL | 0.8883 | 0.9221 |
| Limestone, AL | ||
| Madison, AL | ||
| 34801 Indianapolis, IN | 0.9698 | 0.9792 |
| Boone, IN | ||
| Hamilton, IN | ||
| Hancock, IN | ||
| Hendricks, IN | ||
| Johnson, IN | ||
| Madison, IN | ||
| Marion, IN | ||
| Morgan, IN | ||
| Shelby, IN | ||
| 3500Iowa City, IA | 0.9859 | 0.9903 |
| Johnson, IA | ||
| 3520Jackson, MI | 0.9257 | 0.9485 |
| Jackson, MI | ||
| 3560Jackson, MS | 0.8491 | 0.8940 |
| Hinds, MS | ||
| Madison, MS | ||
| Rankin, MS | ||
| 3580Jackson, TN | 0.9013 | 0.9313 |
| Madison, TN | ||
| Chester, TN | ||
| 36001 Jacksonville, FL | 0.9223 | 0.9461 |
| Clay, FL | ||
| Duval, FL | ||
| Nassau, FL | ||
| St. Johns, FL | ||
| 36052 Jacksonville, NC | 0.8535 | 0.8972 |
| Onslow, NC | ||
| 36102 Jamestown, NY | 0.8547 | 0.8981 |
| Chautauqua, NY | ||
| 3620Janesville-Beloit, WI | 0.9739 | 0.9821 |
| Rock, WI | ||
| 3640Jersey City, NJ | 1.1178 | 1.0792 |
| Hudson, NJ | ||
| 3660Johnson City-Kingsport-Bristol, TN-VA | 0.8617 | 0.9031 |
| Carter, TN | ||
| Hawkins, TN | ||
| Sullivan, TN | ||
| Unicoi, TN | ||
| Washington, TN | ||
| Bristol City, VA | ||
| Scott, VA | ||
| Washington, VA | ||
| 3680Johnstown, PA | 0.8723 | 0.9107 |
| Cambria, PA | ||
| Somerset, PA | ||
| 3700Jonesboro, AR | 0.8425 | 0.8893 |
| Craighead, AR | ||
| 3710Joplin, MO | 0.8727 | 0.9110 |
| Jasper, MO | ||
| Newton, MO | ||
| 3720Kalamazoo-Battlecreek, MI | 1.0639 | 1.0433 |
| Calhoun, MI | ||
| Kalamazoo, MI | ||
| Van Buren, MI | ||
| 3740Kankakee, IL | 0.9889 | 0.9924 |
| Kankakee, IL | ||
| 37601 Kansas City, KS-MO | 0.9536 | 0.9680 |
| Johnson, KS | ||
| Leavenworth, KS | ||
| Miami, KS | ||
| Wyandotte, KS | ||
| Cass, MO | ||
| Clay, MO | ||
| Clinton, MO | ||
| Jackson, MO | ||
| Lafayette, MO | ||
| Platte, MO | ||
| Ray, MO | ||
| 3800Kenosha, WI | 0.9568 | 0.9702 |
| Kenosha, WI | ||
| 38102 Killeen-Temple, TX | 0.7714 | 0.8372 |
| Bell, TX | ||
| Coryell, TX | ||
| 3840Knoxville, TN | 0.8890 | 0.9226 |
| Anderson, TN | ||
| Blount, TN | ||
| Knox, TN | ||
| Loudon, TN | ||
| Sevier, TN | ||
| Union, TN | ||
| 3850Kokomo, IN | 0.9184 | 0.9434 |
| Howard, IN | ||
| Tipton, IN | ||
| 3870La Crosse, WI-MN | 0.9250 | 0.9480 |
| Houston, MN | ||
| La Crosse, WI | ||
| 3880Lafayette, LA | 0.8544 | 0.8978 |
| Acadia, LA | ||
| Lafayette, LA | ||
| St. Landry, LA | ||
| St. Martin, LA | ||
| 3920Lafayette, IN | 0.9121 | 0.9389 |
| Clinton, IN | ||
| Tippecanoe, IN | ||
| 3960Lake Charles, LA | 0.7765 | 0.8409 |
| Calcasieu, LA | ||
| 3980Lakeland-Winter Haven, FL | 0.9067 | 0.9351 |
| Polk, FL | ||
| 4000Lancaster, PA | 0.9296 | 0.9512 |
| Lancaster, PA | ||
| 4040Lansing-East Lansing, MI | 0.9653 | 0.9761 |
| Clinton, MI | ||
| Eaton, MI | ||
| Ingham, MI | ||
| 4080Laredo, TX | 0.7849 | 0.8472 |
| Webb, TX | ||
| 41002 Las Cruces, NM | 0.8676 | 0.9073 |
| Dona Ana, NM | ||
| 41201 Las Vegas, NV-AZ | 1.1182 | 1.0795 |
| Mohave, AZ | ||
| Clark, NV | ||
| Nye, NV | ||
| 4150Lawrence, KS | 0.7812 | 0.8444 |
| Douglas, KS | ||
| 4200Lawton, OK | 0.8682 | 0.9078 |
| Comanche, OK | ||
| 4243Lewiston-Auburn, ME | 0.9287 | 0.9506 |
| Androscoggin, ME | ||
| 4280Lexington, KY | 0.8791 | 0.9155 |
| Bourbon, KY | ||
| Clark, KY | ||
| Fayette, KY | ||
| Jessamine, KY | ||
| Madison, KY | ||
| Scott, KY | ||
| Woodford, KY | ||
| 4320Lima, OH | 0.9470 | 0.9634 |
| Allen, OH | ||
| Auglaize, OH | ||
| 4360Lincoln, NE | 1.0173 | 1.0118 |
| Lancaster, NE | ||
| 4400Little Rock-North Little Rock, AR | 0.8955 | 0.9272 |
| Faulkner, AR | ||
| Lonoke, AR | ||
| Pulaski, AR | ||
| Saline, AR | ||
| 4420Longview-Marshall, TX | 0.8571 | 0.8998 |
| Gregg, TX | ||
| Harrison, TX | ||
| Upshur, TX | ||
| 44801 Los Angeles-Long Beach, CA | 1.1961 | 1.1305 |
| Los Angeles, CA | ||
| 45201 Louisville, KY-IN | 0.9529 | 0.9675 |
| Clark, IN | ||
| Floyd, IN | ||
| Harrison, IN | ||
| Scott, IN | ||
| Bullitt, KY | ||
| Jefferson, KY | ||
| Oldham, KY | ||
| 4600Lubbock, TX | 0.8463 | 0.8920 |
| Lubbock, TX | ||
| 4640Lynchburg, VA | 0.9103 | 0.9377 |
| Amherst, VA | ||
| Bedford, VA | ||
| Bedford City, VA | ||
| Campbell, VA | ||
| Lynchburg City, VA | ||
| 4680Macon, GA | 0.8971 | 0.9283 |
| Bibb, GA | ||
| Houston, GA | ||
| Jones, GA | ||
| Peach, GA | ||
| Twiggs, GA | ||
| 4720Madison, WI | 1.0367 | 1.0250 |
| Dane, WI | ||
| 4800Mansfield, OH | 0.8726 | 0.9109 |
| Crawford, OH | ||
| Richland, OH | ||
| 4840Mayaguez, PR | 0.4860 | 0.6101 |
| Anasco, PR | ||
| Cabo Rojo, PR | ||
| Hormigueros, PR | ||
| Mayaguez, PR | ||
| Sabana Grande, PR | ||
| San German, PR | ||
| 4880McAllen-Edinburg-Mission, TX | 0.8378 | 0.8859 |
| Hidalgo, TX | ||
| 4890Medford-Ashland, OR | 1.0314 | 1.0214 |
| Jackson, OR | ||
| 4900Melbourne-Titusville-Palm Bay, FL | 0.9913 | 0.9940 |
| Brevard, Fl | ||
| 49201 Memphis, TN-AR-MS | 0.8978 | 0.9288 |
| Crittenden, AR | ||
| DeSoto, MS | ||
| Fayette, TN | ||
| Shelby, TN | ||
| Tipton, TN | ||
| 4940Merced, CA | 0.9947 | 0.9964 |
| Merced, CA | ||
| 50001 Miami, FL | 0.9950 | 0.9966 |
| Dade, FL | ||
| 50151 Middlesex-Somerset-Hunterdon, NJ | 1.1469 | 1.0984 |
| Hunterdon, NJ | ||
| Middlesex, NJ | ||
| Somerset, NJ | ||
| 50801 Milwaukee-Waukesha, WI | 0.9971 | 0.9980 |
| Milwaukee, WI | ||
| Ozaukee, WI | ||
| Washington, WI | ||
| Waukesha, WI | ||
| 51201 Minneapolis-St. Paul, MN-WI | 1.0930 | 1.0628 |
| Anoka, MN | ||
| Carver, MN | ||
| Chisago, MN | ||
| Dakota, MN | ||
| Hennepin, MN | ||
| Isanti, MN | ||
| Ramsey, MN | ||
| Scott, MN | ||
| Sherburne, MN | ||
| Washington, MN | ||
| Wright, MN | ||
| Pierce, WI | ||
| St. Croix, WI | ||
| 5140Missoula, MT | 0.9364 | 0.9560 |
| Missoula, MT | ||
| 5160Mobile, AL | 0.8084 | 0.8645 |
| Baldwin, AL | ||
| Mobile, AL | ||
| 5170Modesto, CA | 1.0820 | 1.0555 |
| Stanislaus, CA | ||
| 51901 Monmouth-Ocean, NJ | 1.1257 | 1.0845 |
| Monmouth, NJ | ||
| Ocean, NJ | ||
| 5200Monroe, LA | 0.8201 | 0.8730 |
| Ouachita, LA | ||
| 52402 Montgomery, AL | 0.7400 | 0.8137 |
| Autauga, AL | ||
| Elmore, AL | ||
| Montgomery, AL | ||
| 5280Muncie, IN | 0.9939 | 0.9958 |
| Delaware, IN | ||
| 5330Myrtle Beach, SC | 0.8771 | 0.9141 |
| Horry, SC | ||
| 5345Naples, FL | 0.9699 | 0.9793 |
| Collier, FL | ||
| 53601 Nashville, TN | 0.9754 | 0.9831 |
| Cheatham, TN | ||
| Davidson, TN | ||
| Dickson, TN | ||
| Robertson, TN | ||
| Rutherford TN | ||
| Sumner, TN | ||
| Williamson, TN | ||
| Wilson, TN | ||
| 53801 Nassau-Suffolk, NY | 1.3643 | 1.2370 |
| Nassau, NY | ||
| Suffolk, NY | ||
| 54831 New Haven-Bridgeport-Stamford-Waterbury- | 1.2294 | 1.1519 |
| Danbury, CT | ||
| Fairfield, CT | ||
| New Haven, CT | ||
| 55232 New London-Norwich, CT | 1.2077 | 1.1380 |
| New London, CT | ||
| 55601 New Orleans, LA | 0.9036 | 0.9329 |
| Jefferson, LA | ||
| Orleans, LA | ||
| Plaquemines, LA | ||
| St. Bernard, LA | ||
| St. Charles, LA | ||
| St. James, LA | ||
| St. John The Baptist, LA | ||
| St. Tammany, LA | ||
| 56001 New York, NY | 1.4427 | 1.2853 |
| Bronx, NY | ||
| Kings, NY | ||
| New York, NY | ||
| Putnam, NY | ||
| Queens, NY | ||
| Richmond, NY | ||
| Rockland, NY | ||
| Westchester, NY | ||
| 56401 Newark, NJ | 1.1622 | 1.1084 |
| Essex, NJ | ||
| Morris, NJ | ||
| Sussex, NJ | ||
| Union, NJ | ||
| Warren, NJ | ||
| 5660Newburgh, NY-PA | 1.1113 | 1.0749 |
| Orange, NY | ||
| Pike, PA | ||
| 57201 Norfolk-Virginia Beach-Newport News, VA-NC | 0.8579 | 0.9004 |
| Currituck, NC | ||
| Chesapeake City, VA | ||
| Gloucester, VA | ||
| Hampton City, VA | ||
| Isle of Wight, VA | ||
| James City, VA | ||
| Mathews, VA | ||
| Newport News City, VA | ||
| Norfolk City, VA | ||
| Poquoson City, VA | ||
| Portsmouth City, VA | ||
| Suffolk City, VA | ||
| Virginia Beach City VA | ||
| Williamsburg City, VA | ||
| York, VA | ||
| 57751 Oakland, CA | 1.5319 | 1.3392 |
| Alameda, CA | ||
| Contra Costa, CA | ||
| 5790Ocala, FL | 0.9556 | 0.9694 |
| Marion, FL | ||
| 5800Odessa-Midland, TX | 1.0104 | 1.0071 |
| Ector, TX | ||
| Midland, TX | ||
| 58801 Oklahoma City, OK | 0.8694 | 0.9086 |
| Canadian, OK | ||
| Cleveland, OK | ||
| Logan, OK | ||
| McClain, OK | ||
| Oklahoma, OK | ||
| Pottawatomie, OK | ||
| 5910Olympia, WA | 1.1350 | 1.0906 |
| Thurston, WA | ||
| 5920Omaha, NE-IA | 0.9712 | 0.9802 |
| Pottawattamie, IA | ||
| Cass, NE | ||
| Douglas, NE | ||
| Sarpy, NE | ||
| Washington, NE | ||
| 59451 Orange County, CA | 1.1246 | 1.0837 |
| Orange, CA | ||
| 59601 Orlando, FL | 0.9642 | 0.9753 |
| Lake, FL | ||
| Orange, FL | ||
| Osceola, FL | ||
| Seminole, FL | ||
| 5990Owensboro, KY | 0.8334 | 0.8827 |
| Daviess, KY | ||
| 6015Panama City, FL | 0.9061 | 0.9347 |
| Bay, FL | ||
| 6020Parkersburg-Marietta, WV-OH (WV Hospitals) | 0.8133 | 0.8680 |
| Washington, OH | ||
| Wood, WV | ||
| 60202 Parkersburg-Marietta, WV-OH (OH Hospitals) | 0.8668 | 0.9067 |
| Washington, OH | ||
| Wood, WV | ||
| 60802 Pensacola, FL | 0.8794 | 0.9158 |
| Escambia, FL | ||
| Santa Rosa, FL | ||
| 6120Peoria-Pekin, IL | 0.8773 | 0.9143 |
| Peoria, IL | ||
| Tazewell, IL | ||
| Woodford, IL | ||
| 61601 Philadelphia, PA-NJ | 1.0947 | 1.0639 |
| Burlington, NJ | ||
| Camden, NJ | ||
| Gloucester, NJ | ||
| Salem, NJ | ||
| Bucks, PA | ||
| Chester, PA | ||
| Delaware, PA | ||
| Montgomery, PA | ||
| Philadelphia, PA | ||
| 62001 Phoenix-Mesa, AZ | 0.9638 | 0.9751 |
| Maricopa, AZ | ||
| Pinal, AZ | ||
| 6240Pine Bluff, AR | 0.7895 | 0.8506 |
| Jefferson, AR | ||
| 62801 Pittsburgh, PA | 0.9560 | 0.9697 |
| Allegheny, PA | ||
| Beaver, PA | ||
| Butler, PA | ||
| Fayette, PA | ||
| Washington, PA | ||
| Westmoreland, PA | ||
| 63232 Pittsfield, MA | 1.1454 | 1.0974 |
| Berkshire, MA | ||
| 6340Pocatello, ID | 0.9448 | 0.9619 |
| Bannock, ID | ||
| 6360Ponce, PR | 0.5218 | 0.6405 |
| Guayanilla, PR | ||
| Juana Diaz, PR | ||
| Penuelas, PR | ||
| Ponce, PR | ||
| Villalba, PR | ||
| Yauco, PR | ||
| 6403Portland, ME | 0.9427 | 0.9604 |
| Cumberland, ME | ||
| Sagadahoc, ME | ||
| York, ME | ||
| 64401 Portland-Vancouver, OR-WA | 1.1150 | 1.0774 |
| Clackamas, OR | ||
| Columbia, OR | ||
| Multnomah, OR | ||
| Washington, OR | ||
| Yamhill, OR | ||
| Clark, WA | ||
| 64831 Providence-Warwick-Pawtucket, RI | 1.0805 | 1.0545 |
| Bristol, RI | ||
| Kent, RI | ||
| Newport, RI | ||
| Providence, RI | ||
| Washington, RI | ||
| 6520Provo-Orem, UT | 0.9843 | 0.9892 |
| Utah, UT | ||
| 65602 Pueblo, CO | 0.8811 | 0.9170 |
| Pueblo, CO | ||
| 6580Punta Gorda, FL | 0.9015 | 0.9315 |
| Charlotte, FL | ||
| 6600Racine, WI | 0.9333 | 0.9538 |
| Racine, WI | ||
| 66401 Raleigh-Durham-Chapel Hill, NC | 0.9818 | 0.9875 |
| Chatham, NC | ||
| Durham, NC | ||
| Franklin, NC | ||
| Johnston, NC | ||
| Orange, NC | ||
| Wake, NC | ||
| 6660Rapid City, SD | 0.8869 | 0.9211 |
| Pennington, SD | ||
| 6680Reading, PA | 0.9583 | 0.9713 |
| Berks, PA | ||
| 6690Redding, CA | 1.1155 | 1.0777 |
| Shasta, CA | ||
| 6720Reno, NV | 1.0421 | 1.0286 |
| Washoe, NV | ||
| 6740Richland-Kennewick-Pasco, WA | 1.0960 | 1.0648 |
| Benton, WA | ||
| Franklin, WA | ||
| 6760Richmond-Petersburg, VA | 0.9678 | 0.9778 |
| Charles City County, VA | ||
| Chesterfield, VA | ||
| Colonial Heights City, VA | ||
| Dinwiddie, VA | ||
| Goochland, VA | ||
| Hanover, VA | ||
| Henrico, VA | ||
| Hopewell City, VA | ||
| New Kent, VA | ||
| Petersburg City, VA | ||
| Powhatan, VA | ||
| Prince George, VA | ||
| Richmond City, VA | ||
| 67801 Riverside-San Bernardino, CA | 1.1112 | 1.0749 |
| Riverside, CA | ||
| San Bernardino, CA | ||
| 6800Roanoke, VA | 0.8371 | 0.8854 |
| Botetourt, VA | ||
| Roanoke, VA | ||
| Roanoke City, VA | ||
| Salem City, VA | ||
| 6820Rochester, MN | 1.1462 | 1.0979 |
| Olmsted, MN | ||
| 68401 Rochester, NY | 0.9347 | 0.9548 |
| Genesee, NY | ||
| Livingston, NY | ||
| Monroe, NY | ||
| Ontario, NY | ||
| Orleans, NY | ||
| Wayne, NY | ||
| 6880Rockford, IL | 0.9204 | 0.9448 |
| Boone, IL | ||
| Ogle, IL | ||
| Winnebago, IL | ||
| 6895Rocky Mount, NC | 0.9109 | 0.9381 |
| Edgecombe, NC | ||
| Nash, NC | ||
| 69201 Sacramento, CA | 1.1831 | 1.1220 |
| El Dorado, CA | ||
| Placer, CA | ||
| Sacramento, CA | ||
| 6960Saginaw-Bay City-Midland, MI | 0.9590 | 0.9717 |
| Bay, MI | ||
| Midland, MI | ||
| Saginaw, MI | ||
| 6980St. Cloud, MN | 0.9919 | 0.9944 |
| Benton, MN | ||
| Stearns, MN | ||
| 7000St. Joseph, MO | 0.7899 | 0.8509 |
| Andrew, MO | ||
| Buchanan, MO | ||
| 70401 St. Louis, MO-IL | 0.8931 | 0.9255 |
| Clinton, IL | ||
| Jersey, IL | ||
| Madison, IL | ||
| Monroe, IL | ||
| St. Clair, IL | ||
| Franklin, MO | ||
| Jefferson, MO | ||
| Lincoln, MO | ||
| St. Charles, MO | ||
| St. Louis, MO | ||
| St. Louis City, MO | ||
| Warren, MO | ||
| 70802 Salem, OR | 1.0033 | 1.0023 |
| Marion, OR | ||
| Polk, OR | ||
| 7120Salinas, CA | 1.4684 | 1.3009 |
| Monterey, CA | ||
| 71601Salt Lake City-Ogden, UT | 0.9863 | 0.9906 |
| Davis, UT | ||
| Salt Lake, UT | ||
| Weber, UT | ||
| 7200San Angelo, TX | 0.8193 | 0.8724 |
| Tom Green, TX | ||
| 72401 San Antonio, TX | 0.8584 | 0.9007 |
| Bexar, TX | ||
| Comal, TX | ||
| Guadalupe, TX | ||
| Wilson, TX | ||
| 73201 San Diego, CA | 1.1265 | 1.0850 |
| San Diego, CA | ||
| 73601 San Francisco, CA | 1.4140 | 1.2677 |
| Marin, CA | ||
| San Francisco, CA | ||
| San Mateo, CA | ||
| 74001 San Jose, CA | 1.4193 | 1.2710 |
| Santa Clara, CA | ||
| 74401 2 San Juan-Bayamon, PR | 0.4832 | 0.6077 |
| Aguas Buenas, PR | ||
| Barceloneta, PR | ||
| Bayamon, PR | ||
| Canovanas, PR | ||
| Carolina, PR | ||
| Catano, PR | ||
| Ceiba, PR | ||
| Comerio, PR | ||
| Corozal, PR | ||
| Dorado, PR | ||
| Fajardo, PR | ||
| Florida, PR | ||
| Guaynabo, PR | ||
| Humacao, PR | ||
| Juncos, PR | ||
| Los Piedras, PR | ||
| Loiza, PR | ||
| Luguillo, PR | ||
| Manati, PR | ||
| Morovis, PR | ||
| Naguabo, PR | ||
| Naranjito, PR | ||
| Rio Grande, PR | ||
| San Juan, PR | ||
| Toa Alta, PR | ||
| Toa Baja, PR | ||
| Trujillo Alto, PR | ||
| Vega Alta, PR | ||
| Vega Baja, PR | ||
| Yabucoa, PR | ||
| 7460San Luis Obispo-Atascadero-Paso Robles, CA | 1.0990 | 1.0668 |
| San Luis Obispo, CA | ||
| 7480Santa Barbara-Santa Maria-Lompoc, CA | 1.0802 | 1.0543 |
| Santa Barbara, CA | ||
| 7485Santa Cruz-Watsonville, CA | 1.3970 | 1.2573 |
| Santa Cruz, CA | ||
| 7490Santa Fe, NM | 1.0194 | 1.0132 |
| Los Alamos, NM | ||
| Santa Fe, NM | ||
| 7500 Santa Rosa, CA | 1.3034 | 1.1990 |
| Sonoma, CA | ||
| 7510Sarasota-Bradenton, FL | 1.0090 | 1.0062 |
| Manatee, FL | ||
| Sarasota, FL | ||
| 7520Savannah, GA | 0.9243 | 0.9475 |
| Bryan, GA | ||
| Chatham, GA | ||
| Effingham, GA | ||
| 7560Scranton--Wilkes-Barre--Hazleton, PA | 0.8683 | 0.9078 |
| Columbia, PA | ||
| Lackawanna, PA | ||
| Luzerne, PA | ||
| Wyoming, PA | ||
| 76001 Seattle-Bellevue-Everett, WA | 1.1361 | 1.0913 |
| Island, WA | ||
| King, WA | ||
| Snohomish, WA | ||
| 76102 Sharon, PA | 0.8607 | 0.9024 |
| Mercer, PA | ||
| 76202 Sheboygan, WI | 0.9068 | 0.9352 |
| Sheboygan, WI | ||
| 7640Sherman-Denison, TX | 0.9373 | 0.9566 |
| Grayson, TX | ||
| 7680 Shreveport-Bossier City, LA | 0.9050 | 0.9339 |
| Bossier, LA | ||
| Caddo, LA | ||
| Webster, LA | ||
| 7720Sioux City, IA-NE | 0.8767 | 0.9138 |
| Woodbury, IA | ||
| Dakota, NE | ||
| 7760Sioux Falls, SD | 0.9139 | 0.9402 |
| Lincoln, SD | ||
| Minnehaha, SD | ||
| 7800South Bend, IN | 0.9993 | 0.9995 |
| St. Joseph, IN | ||
| 7840Spokane, WA | 1.0668 | 1.0453 |
| Spokane, WA | ||
| 7880Springfield, IL | 0.8676 | 0.9073 |
| Menard, IL | ||
| Sangamon, IL | ||
| 7920Springfield, MO | 0.8567 | 0.8995 |
| Christian, MO | ||
| Greene, MO | ||
| Webster, MO | ||
| 80032 Springfield, MA | 1.1454 | 1.0974 |
| Hampden, MA | ||
| Hampshire, MA | ||
| 8050State College, PA | 0.9133 | 0.9398 |
| Centre, PA | ||
| 80802 Steubenville-Weirton, OH-WV (OH Hospitals) | 0.8668 | 0.9067 |
| Jefferson, OH | ||
| Brooke, WV | ||
| Hancock, WV | ||
| 8080Steubenville-Weirton, OH-WV (WV Hospitals) | 0.8637 | 0.9045 |
| Jefferson, OH | ||
| Brooke, WV | ||
| Hancock, WV | ||
| 8120Stockton-Lodi, CA | 1.0988 | 1.0666 |
| San Joaquin, CA | ||
| 81402 Sumter, SC | 0.8512 | 0.8955 |
| Sumter, SC | ||
| 8160Syracuse, NY | 0.9621 | 0.9739 |
| Cayuga, NY | ||
| Madison, NY | ||
| Onondaga, NY | ||
| Oswego, NY | ||
| 8200Tacoma, WA | 1.1616 | 1.1080 |
| Pierce, WA | ||
| 82402 Tallahassee, FL | 0.8794 | 0.9158 |
| Gadsden, FL | ||
| Leon, FL | ||
| 82801 Tampa-St. Petersburg-Clearwater, FL | 0.8925 | 0.9251 |
| Hernando, FL | ||
| Hillsborough, FL | ||
| Pasco, FL | ||
| Pinellas, FL | ||
| 83202 Terre Haute, IN | 0.8721 | 0.9105 |
| Clay, IN | ||
| Vermillion, IN | ||
| Vigo, IN | ||
| 8360Texarkana,AR-Texarkana, TX | 0.8327 | 0.8822 |
| Miller, AR | ||
| Bowie, TX | ||
| 8400Toledo, OH | 0.9809 | 0.9869 |
| Fulton, OH | ||
| Lucas, OH | ||
| Wood, OH | ||
| 8440Topeka, KS | 0.8912 | 0.9242 |
| Shawnee, KS | ||
| 8480 Trenton, NJ | 1.0416 | 1.0283 |
| Mercer, NJ | ||
| 8520Tucson, AZ | 0.8976 | 0.9287 |
| Pima, AZ | ||
| 8560Tulsa, OK | 0.8902 | 0.9234 |
| Creek, OK | ||
| Osage, OK | ||
| Rogers, OK | ||
| Tulsa, OK | ||
| Wagoner, OK | ||
| 8600Tuscaloosa, AL | 0.8171 | 0.8708 |
| Tuscaloosa, AL | ||
| 8640Tyler, TX | 0.9641 | 0.9753 |
| Smith, TX | ||
| 86802 Utica-Rome, NY | 0.8547 | 0.8981 |
| Herkimer, NY | ||
| Oneida, NY | ||
| 8720Vallejo-Fairfield-Napa, CA | 1.3562 | 1.2320 |
| Napa, CA | ||
| Solano, CA | ||
| 8735Ventura, CA | 1.0994 | 1.0670 |
| Ventura, CA | ||
| 8750Victoria, TX | 0.8328 | 0.8822 |
| Victoria, TX | ||
| 8760Vineland-Millville-Bridgeton, NJ | 1.0441 | 1.0300 |
| Cumberland, NJ | ||
| 87802 Visalia-Tulare-Porterville, CA | 0.9659 | 0.9765 |
| Tulare, CA | ||
| 8800Waco, TX | 0.8150 | 0.8693 |
| McLennan, TX | ||
| 88401 Washington, DC-MD-VA-WV | 1.0962 | 1.0649 |
| District of Columbia, DC | ||
| Calvert, MD | ||
| Charles, MD | ||
| Frederick, MD | ||
| Montgomery, MD | ||
| Prince Georges, MD | ||
| Alexandria City, VA | ||
| Arlington, VA | ||
| Clarke, VA | ||
| Culpeper, VA | ||
| Fairfax, VA | ||
| Fairfax City, VA | ||
| Falls Church City, VA | ||
| Fauquier, VA | ||
| Fredericksburg City, VA | ||
| King George, VA | ||
| Loudoun, VA | ||
| Manassas City, VA | ||
| Manassas Park City, VA | ||
| Prince William, VA | ||
| Spotsylvania, VA | ||
| Stafford, VA | ||
| Warren, VA | ||
| Berkeley, WV | ||
| Jefferson, WV | ||
| 8920Waterloo-Cedar Falls, IA | 0.8677 | 0.9074 |
| Black Hawk, IA | ||
| 8940Wausau, WI | 0.9696 | 0.9791 |
| Marathon, WI | ||
| 89601 West Palm Beach-Boca Raton, FL | 0.9777 | 0.9847 |
| Palm Beach, FL | ||
| 90002 Wheeling, WV-OH (WV Hospitals) | 0.8067 | 0.8632 |
| Belmont, OH | ||
| Marshall, WV | ||
| Ohio, WV | ||
| 90002 Wheeling, WV-OH (OH Hospitals) | 0.8668 | 0.9067 |
| Belmont, OH | ||
| Marshall, WV | ||
| Ohio, WV | ||
| 9040Wichita, KS | 0.9606 | 0.9728 |
| Butler, KS | ||
| Harvey, KS | ||
| Sedgwick, KS | ||
| 9080Wichita Falls, TX | 0.7946 | 0.8543 |
| Archer, TX | ||
| Wichita, TX | ||
| 9140Williamsport, PA | 0.8628 | 0.9039 |
| Lycoming, PA | ||
| 9160Wilmington-Newark, DE-MD | 1.0877 | 1.0593 |
| New Castle, DE | ||
| Cecil, MD | ||
| 9200Wilmington, NC | 0.9409 | 0.9591 |
| New Hanover, NC | ||
| Brunswick, NC | ||
| 9260Yakima, WA | 1.0567 | 1.0385 |
| Yakima, WA | ||
| 9270Yolo, CA | 0.9701 | 0.9794 |
| Yolo, CA | ||
| 9280York, PA | 0.9441 | 0.9614 |
| York, PA | ||
| 9320Youngstown-Warren, OH | 0.9563 | 0.9699 |
| Columbiana, OH | ||
| Mahoning, OH | ||
| Trumbull, OH | ||
| 9340Yuba City, CA | 1.0359 | 1.0244 |
| Sutter, CA | ||
| Yuba, CA | ||
| 9360Yuma, AZ | 0.8989 | 0.9296 |
| Yuma, AZ | ||
| 1 Large Urban Area | ||
| 2 Hospitals geographically located in the area are assigned the statewide rural wage index for FY 2002. | ||
| Nonurban Area | Wage Index | GAF |
|---|---|---|
| Alabama | 0.7400 | 0.8137 |
| Alaska | 1.1862 | 1.1240 |
| Arizona | 0.8681 | 0.9077 |
| Arkansas | 0.7489 | 0.8204 |
| California | 0.9659 | 0.9765 |
| Colorado | 0.8811 | 0.9170 |
| Connecticut | 1.2077 | 1.1380 |
| Delaware | 0.9589 | 0.9717 |
| Florida | 0.8794 | 0.9158 |
| Georgia | 0.8295 | 0.8798 |
| Hawaii | 1.1112 | 1.0749 |
| Idaho | 0.8718 | 0.9103 |
| Illinois | 0.8053 | 0.8622 |
| Indiana | 0.8721 | 0.9105 |
| Iowa | 0.8147 | 0.8691 |
| Kansas | 0.7812 | 0.8444 |
| Kentucky | 0.7963 | 0.8556 |
| Louisiana | 0.7692 | 0.8355 |
| Maine | 0.8721 | 0.9105 |
| Maryland | 0.8859 | 0.9204 |
| Massachusetts | 1.1454 | 1.0974 |
| Michigan | 0.9000 | 0.9304 |
| Minnesota | 0.9035 | 0.9329 |
| Mississippi | 0.7528 | 0.8233 |
| Missouri | 0.7899 | 0.8509 |
| Montana | 0.8655 | 0.9058 |
| Nebraska | 0.8142 | 0.8687 |
| Nevada | 0.9727 | 0.9812 |
| New Hampshire | 0.9779 | 0.9848 |
| New Jersey1 | ||
| New Mexico | 0.8676 | 0.9073 |
| New York | 0.8547 | 0.8981 |
| North Carolina | 0.8535 | 0.8972 |
| North Dakota | 0.7879 | 0.8494 |
| Ohio | 0.8668 | 0.9067 |
| Oklahoma | 0.7566 | 0.8261 |
| Oregon | 1.0038 | 1.0026 |
| Pennsylvania | 0.8607 | 0.9024 |
| Puerto Rico | 0.4832 | 0.6077 |
| Rhode Island1 | ||
| South Carolina | 0.8512 | 0.8955 |
| South Dakota | 0.7861 | 0.8481 |
| Tennessee | 0.7928 | 0.8530 |
| Texas | 0.7714 | 0.8372 |
| Utah | 0.9051 | 0.9340 |
| Vermont | 0.9608 | 0.9730 |
| Virginia | 0.8241 | 0.8759 |
| Washington | 1.0209 | 1.0143 |
| West Virginia | 0.8067 | 0.8632 |
| Wisconsin | 0.9068 | 0.9352 |
| Wyoming | 0.8747 | 0.9124 |
| 1 All counties within the State are classified as urban. | ||
| Area | Wage Index | GAF |
|---|---|---|
| Abilene, TX | 0.7983 | 0.8570 |
| Akron, OH | 0.9876 | 0.9915 |
| Albany, GA | 1.0640 | 1.0434 |
| Albuquerque, NM | 0.9750 | 0.9828 |
| Alexandria, LA | 0.8059 | 0.8626 |
| Allentown-Bethlehem-Easton, PA | 1.0077 | 1.0053 |
| Altoona, PA | 0.9126 | 0.9393 |
| Amarillo, TX | 0.8502 | 0.8948 |
| Anchorage, AK | 1.2696 | 1.1776 |
| Ann Arbor, MI | 1.1098 | 1.0739 |
| Anniston, AL | 0.7841 | 0.8466 |
| Asheville, NC | 0.9200 | 0.9445 |
| Athens, GA | 0.9706 | 0.9798 |
| Atlanta, GA | 1.0058 | 1.0040 |
| Augusta-Aiken, GA-SC | 0.9970 | 0.9979 |
| Austin-San Marcos, TX | 0.9597 | 0.9722 |
| Barnstable-Yarmouth, MA | 1.3423 | 1.2234 |
| Baton Rouge, LA | 0.8149 | 0.8692 |
| Bellingham, WA | 1.1296 | 1.0870 |
| Benton Harbor, MI | 0.9000 | 0.9304 |
| Bergen-Passaic, NJ | 1.1808 | 1.1205 |
| Billings, MT | 0.9352 | 0.9552 |
| Biloxi-Gulfport-Pascagoula, MS | 0.8105 | 0.8660 |
| Binghamton, NY | 0.8607 | 0.9024 |
| Birmingham, AL | 0.8808 | 0.9168 |
| Bismarck, ND | 0.7984 | 0.8571 |
| Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH | 1.1293 | 1.0868 |
| Burlington, VT (VT Hospitals) | 0.9608 | 0.9730 |
| Burlington, VT (NY Hospitals) | 0.9606 | 0.9728 |
| Caguas, PR | 0.4832 | 0.6077 |
| Casper, WY | 0.9346 | 0.9547 |
| Champaign-Urbana, IL | 0.9140 | 0.9403 |
| Charleston-North Charleston, SC | 0.9206 | 0.9449 |
| Charleston, WV | 0.8902 | 0.9234 |
| Charlotte-Gastonia-Rock Hill, NC-SC | 0.9407 | 0.9590 |
| Chattanooga, TN-GA | 0.9181 | 0.9432 |
| Chicago, IL | 1.0917 | 1.0619 |
| Cincinnati, OH-KY-IN | 0.9473 | 0.9636 |
| Clarksville-Hopkinsville, TN-KY | 0.8393 | 0.8869 |
| Cleveland-Lorain-Elyria, OH | 0.9457 | 0.9625 |
| Columbia, MO | 0.8686 | 0.9080 |
| Columbia, SC | 0.9168 | 0.9422 |
| Columbus, GA-AL | 0.8440 | 0.8903 |
| Columbus, OH | 0.9565 | 0.9700 |
| Corpus Christi, TX | 0.8238 | 0.8757 |
| Dallas, TX | 0.9936 | 0.9956 |
| Davenport-Moline-Rock Island, IA-IL | 0.8538 | 0.8974 |
| Dayton-Springfield, OH | 0.9225 | 0.9463 |
| Denver, CO | 1.0328 | 1.0223 |
| Des Moines, IA | 0.8779 | 0.9147 |
| Dothan, AL | 0.7988 | 0.8574 |
| Dover, DE | 1.0003 | 1.0002 |
| Duluth-Superior, MN-WI | 1.0284 | 1.0194 |
| Eau Claire, WI | 0.9068 | 0.9352 |
| Elkhart-Goshen, IN | 0.9517 | 0.9667 |
| Erie, PA | 0.8716 | 0.9102 |
| Eugene-Springfield, OR | 1.1006 | 1.0678 |
| Fargo-Moorhead, ND-MN | 0.9166 | 0.9421 |
| Fayetteville, NC | 0.8869 | 0.9211 |
| Flagstaff, AZ-UT | 1.0105 | 1.0072 |
| Flint, MI | 1.0810 | 1.0548 |
| Florence, AL | 0.7889 | 0.8501 |
| Florence, SC | 0.8722 | 0.9106 |
| Fort Collins-Loveland, CO | 1.0045 | 1.0031 |
| Ft. Lauderdale, FL | 1.0784 | 1.0530 |
| Fort Pierce-Port St. Lucie, FL | 1.0114 | 1.0078 |
| Fort Smith, AR-OK | 0.7857 | 0.8478 |
| Fort Walton Beach, FL | 0.8828 | 0.9182 |
| Fort Wayne, IN | 0.9203 | 0.9447 |
| Forth Worth-Arlington, TX | 0.9394 | 0.9581 |
| Gadsden, AL | 0.8386 | 0.8864 |
| Gainesville, FL | 0.9481 | 0.9642 |
| Grand Forks, ND-MN | 0.9119 | 0.9388 |
| Grand Junction, CO | 0.9774 | 0.9845 |
| Grand Rapids-Muskegon-Holland, MI | 0.9939 | 0.9958 |
| Great Falls, MT | 0.9195 | 0.9441 |
| Greeley, CO | 0.9495 | 0.9651 |
| Green Bay, WI | 0.9357 | 0.9555 |
| Greensboro-Winston-Salem-High Point, NC | 0.9395 | 0.9582 |
| Greenville, NC | 0.9289 | 0.9507 |
| Greenville-Spartanburg-Anderson, SC | 0.9217 | 0.9457 |
| Harrisburg-Lebanon-Carlisle, PA | 0.9425 | 0.9603 |
| Hartford, CT | 1.1571 | 1.1051 |
| Hattiesburg, MS | 0.7528 | 0.8233 |
| Hickory-Morganton-Lenoir, NC | 0.9367 | 0.9562 |
| Honolulu, HI | 1.1544 | 1.1033 |
| Houston, TX | 0.9631 | 0.9746 |
| Huntington-Ashland, WV-KY-OH | 0.9238 | 0.9472 |
| Huntsville, AL | 0.8696 | 0.9088 |
| Indianapolis, IN | 0.9698 | 0.9792 |
| Iowa City, IA | 0.9708 | 0.9799 |
| Jackson, MS | 0.8491 | 0.8940 |
| Jackson, TN | 0.8843 | 0.9192 |
| Jacksonville, FL | 0.9223 | 0.9461 |
| Johnson City-Kingsport-Bristol, TN-VA | 0.8617 | 0.9031 |
| Jonesboro, AR | 0.8115 | 0.8667 |
| Joplin, MO | 0.8528 | 0.8967 |
| Kalamazoo-Battlecreek, MI | 1.0471 | 1.0320 |
| Kansas City, KS-MO | 0.9536 | 0.9680 |
| Knoxville, TN | 0.8890 | 0.9226 |
| Kokomo, IN | 0.9184 | 0.9434 |
| Lafayette, LA | 0.8395 | 0.8871 |
| Lansing-East Lansing, MI | 0.9653 | 0.9761 |
| Las Vegas, NV-AZ | 1.1182 | 1.0795 |
| Lawton, OK | 0.8281 | 0.8788 |
| Lexington, KY | 0.8641 | 0.9048 |
| Lima, OH | 0.9470 | 0.9634 |
| Lincoln, NE | 0.9843 | 0.9892 |
| Little Rock-North Little Rock, AR | 0.8800 | 0.9162 |
| Longview-Marshall, TX | 0.8571 | 0.8998 |
| Los Angeles-Long Beach, CA | 1.1961 | 1.1305 |
| Louisville, KY-IN | 0.9416 | 0.9596 |
| Lubbock, TX | 0.8463 | 0.8920 |
| Lynchburg, VA | 0.8795 | 0.9158 |
| Macon, GA | 0.8971 | 0.9283 |
| Madison, WI | 1.0367 | 1.0250 |
| Mansfield, OH | 0.8726 | 0.9109 |
| Medford-Ashland, OR | 1.0033 | 1.0023 |
| Memphis, TN-AR-MS | 0.8793 | 0.9157 |
| Miami, FL | 0.9950 | 0.9966 |
| Milwaukee-Waukesha, WI | 0.9865 | 0.9907 |
| Minneapolis-St. Paul, MN-WI | 1.0930 | 1.0628 |
| Missoula, MT | 0.9177 | 0.9429 |
| Mobile, AL | 0.8084 | 0.8645 |
| Modesto, CA | 1.0820 | 1.0555 |
| Monmouth-Ocean, NJ | 1.1257 | 1.0845 |
| Monroe, LA | 0.8097 | 0.8654 |
| Montgomery, AL | 0.7400 | 0.8137 |
| Myrtle Beach, SC | 0.8577 | 0.9002 |
| Nashville, TN | 0.9552 | 0.9691 |
| New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT | 1.2294 | 1.1519 |
| New London-Norwich, CT | 1.1526 | 1.1021 |
| New Orleans, LA | 0.9036 | 0.9329 |
| New York, NY | 1.4287 | 1.2767 |
| Newark, NJ | 1.1622 | 1.1084 |
| Newburgh, NY-PA | 1.0797 | 1.0539 |
| Oakland, CA | 1.5319 | 1.3392 |
| Odessa-Midland, TX | 0.9495 | 0.9651 |
| Oklahoma City, OK | 0.8694 | 0.9086 |
| Omaha, NE-IA | 0.9712 | 0.9802 |
| Orange County, CA | 1.1246 | 1.0837 |
| Orlando, FL | 0.9642 | 0.9753 |
| Peoria-Pekin, IL | 0.8773 | 0.9143 |
| Philadelphia, PA-NJ | 1.0947 | 1.0639 |
| Pine Bluff, AR | 0.7895 | 0.8506 |
| Pittsburgh, PA | 0.9419 | 0.9598 |
| Pittsfield, MA | 0.9904 | 0.9934 |
| Pocatello, ID | 0.9159 | 0.9416 |
| Portland, ME | 0.9427 | 0.9604 |
| Portland-Vancouver, OR-WA | 1.1150 | 1.0774 |
| Provo-Orem, UT | 0.9843 | 0.9892 |
| Raleigh-Durham-Chapel Hill, NC | 0.9818 | 0.9875 |
| Rapid City, SD | 0.8869 | 0.9211 |
| Reading, PA | 0.9216 | 0.9456 |
| Redding, CA | 1.1155 | 1.0777 |
| Reno, NV | 1.0421 | 1.0286 |
| Richland-Kennewick-Pasco, WA | 1.0356 | 1.0242 |
| Richmond-Petersburg, VA | 0.9678 | 0.9778 |
| Roanoke, VA | 0.8371 | 0.8854 |
| Rochester, MN | 1.1462 | 1.0979 |
| Rockford, IL | 0.9042 | 0.9334 |
| Sacramento, CA | 1.1831 | 1.1220 |
| Saginaw-Bay City-Midland, MI | 0.9590 | 0.9717 |
| St. Cloud, MN | 0.9919 | 0.9944 |
| St. Joseph, MO | 0.8121 | 0.8672 |
| St. Louis, MO-IL | 0.8931 | 0.9255 |
| Salinas, CA | 1.4570 | 1.2940 |
| Salt Lake City-Ogden, UT | 0.9863 | 0.9906 |
| San Diego, CA | 1.1265 | 1.0850 |
| Santa Fe, NM | 0.9765 | 0.9838 |
| Santa Rosa, CA | 1.2631 | 1.1734 |
| Sarasota-Bradenton, FL | 1.0090 | 1.0062 |
| Savannah, GA | 0.9243 | 0.9475 |
| Seattle-Bellevue-Everett, WA | 1.1361 | 1.0913 |
| Sherman-Denison, TX | 0.9003 | 0.9306 |
| Shreveport-Bossier City, LA | 0.9050 | 0.9339 |
| Sioux City, IA-NE | 0.8767 | 0.9138 |
| Sioux Falls, SD | 0.8939 | 0.9261 |
| South Bend, IN | 0.9993 | 0.9995 |
| Spokane, WA | 1.0668 | 1.0453 |
| Springfield, IL | 0.8571 | 0.8998 |
| Springfield, MO | 0.8357 | 0.8843 |
| Stockton-Lodi, CA | 1.0988 | 1.0666 |
| Syracuse, NY | 0.9621 | 0.9739 |
| Tampa-St. Petersburg-Clearwater, FL | 0.8925 | 0.9251 |
| Texarkana,AR-Texarkana, TX | 0.8327 | 0.8822 |
| Toledo, OH | 0.9809 | 0.9869 |
| Topeka, KS | 0.8749 | 0.9125 |
| Tucson, AZ | 0.8976 | 0.9287 |
| Tulsa, OK | 0.8760 | 0.9133 |
| Tuscaloosa, AL | 0.8171 | 0.8708 |
| Tyler, TX | 0.9359 | 0.9556 |
| Victoria, TX | 0.8328 | 0.8822 |
| Waco, TX | 0.8150 | 0.8693 |
| Washington, DC-MD-VA-WV | 1.0854 | 1.0577 |
| Waterloo-Cedar Falls, IA | 0.8677 | 0.9074 |
| Wausau, WI | 0.9558 | 0.9695 |
| West Palm Beach-Boca Raton, FL | 0.9777 | 0.9847 |
| Wichita, KS | 0.9237 | 0.9471 |
| Wichita Falls, TX | 0.7946 | 0.8543 |
| Wilmington-Newark, DE-MD | 1.0877 | 1.0593 |
| Rural Alabama | 0.7528 | 0.8233 |
| Rural Florida | 0.8794 | 0.9158 |
| Rural Illinois (IA Hospitals) | 0.8147 | 0.8691 |
| Rural Illinois (MO Hospitals) | 0.8053 | 0.8622 |
| Rural Kentucky | 0.7963 | 0.8556 |
| Rural Louisiana | 0.7692 | 0.8355 |
| Rural Minnesota | 0.9035 | 0.9329 |
| Rural Missouri | 0.7899 | 0.8509 |
| Rural Montana | 0.8655 | 0.9058 |
| Rural Nebraska | 0.8142 | 0.8687 |
| Rural Nevada | 0.9161 | 0.9418 |
| Rural Oregon | 1.0038 | 1.0026 |
| Rural Texas | 0.7714 | 0.8372 |
| Rural Washington | 1.0209 | 1.0143 |
| Rural Wisconsin | 0.9068 | 0.9352 |
| Rural Wyoming | 0.8747 | 0.9124 |
| Area | Wage Index | GAF | Wage Index- Reclass. Hospitals | GAF- Reclass. Hospitals |
|---|---|---|---|---|
| 1 Aguadilla, PR | 1.0025 | 1.0017 | ||
| 1 Arecibo, PR | 1.0025 | 1.0017 | ||
| 1 Caguas, PR | 1.0025 | 1.0017 | 1.0025 | 1.0017 |
| Mayaguez, PR | 1.0084 | 1.0057 | ||
| Ponce, PR | 1.0825 | 1.0558 | ||
| 1 San Juan-Bayamon, PR | 1.0025 | 1.0017 | ||
| Rural Puerto Rico | 1.0025 | 1.0017 | ||
| 1 Hospitals geographically located in the area are assigned the Rural Puerto Rico wage index for FY 2002. | ||||
| Urban Area (Constituent Counties) | Wage Index |
|---|---|
| 0040Abilene, TX | 0.7965 |
| Taylor, TX | |
| 0060Aguadilla, PR | 0.4683 |
| Aguada, PR | |
| Aguadilla, PR | |
| Moca, PR | |
| 0080Akron, OH | 0.9876 |
| Portage, OH | |
| Summit, OH | |
| 0120Albany, GA | 1.0640 |
| Dougherty, GA | |
| Lee, GA | |
| 0160Albany-Schenectady-Troy, NY | 0.8500 |
| Albany, NY | |
| Montgomery, NY | |
| Rensselaer, NY | |
| Saratoga, NY | |
| Schenectady, NY | |
| Schoharie, NY | |
| 0200Albuquerque, NM | 0.9750 |
| Bernalillo, NM | |
| Sandoval, NM | |
| Valencia, NM | |
| 0220Alexandria, LA | 0.8029 |
| Rapides, LA | |
| 0240Allentown-Bethlehem-Easton, PA | 1.0077 |
| Carbon, PA | |
| Lehigh, PA | |
| Northampton, PA | |
| 0280Altoona, PA | 0.9126 |
| Blair, PA | |
| 0320Amarillo, TX - | 0.8711 |
| Potter, TX | |
| Randall, TX | |
| 0380Anchorage, AK | 1.2570 |
| Anchorage, AK | |
| 0440Ann Arbor, MI | 1.1098 |
| Lenawee, MI | |
| Livingston, MI | |
| Washtenaw, MI | |
| 0450Anniston, AL | 0.8276 |
| Calhoun, AL | |
| 0460Appleton-Oshkosh-Neenah, WI | 0.9241 |
| Calumet, WI | |
| Outagamie, WI | |
| Winnebago, WI | |
| 0470Arecibo, PR | 0.4630 |
| Arecibo, PR | |
| Camuy, PR | |
| Hatillo, PR | |
| 0480Asheville, NC | 0.9200 |
| Buncombe, NC | |
| Madison, NC | |
| 0500Athens, GA | 0.9842 |
| Clarke, GA | |
| Madison, GA | |
| Oconee, GA | |
| 0520Atlanta, GA | 1.0058 |
| Barrow, GA | |
| Bartow, GA | |
| Carroll, GA | |
| Cherokee, GA | |
| Clayton, GA | |
| Cobb, GA | |
| Coweta, GA | |
| DeKalb, GA | |
| Douglas, GA | |
| Fayette, GA | |
| Forsyth, GA | |
| Fulton, GA | |
| Gwinnett, GA | |
| Henry, GA | |
| Newton, GA | |
| Paulding, GA | |
| Pickens, GA | |
| Rockdale, GA | |
| Spalding, GA | |
| Walton, GA | |
| 0560Atlantic-Cape May, NJ | 1.1293 |
| Atlantic, NJ | |
| Cape May, NJ | |
| 0580Auburn-Opelika, AL | 0.8230 |
| Lee, AL | |
| 0600Augusta-Aiken, GA-SC | 0.9970 |
| Columbia, GA | |
| McDuffie, GA | |
| Richmond, GA | |
| Aiken, SC | |
| Edgefield, SC | |
| 0640Austin-San Marcos, TX | 0.9597 |
| Bastrop, TX | |
| Caldwell, TX | |
| Hays, TX | |
| Travis, TX | |
| Williamson, TX | |
| 0680Bakersfield, CA | 0.9470 |
| Kern, CA | |
| 0720Baltimore, MD | 0.9856 |
| Anne Arundel, MD | |
| Baltimore, MD | |
| Baltimore City, MD | |
| Carroll, MD | |
| Harford, MD | |
| Howard, MD | |
| Queen Anne's, MD | |
| 0733Bangor, ME | 0.9593 |
| Penobscot, ME | |
| 0743Barnstable-Yarmouth, MA | 1.3626 |
| Barnstable, MA | |
| 0760Baton Rouge, LA | 0.8149 |
| Ascension, LA | |
| East Baton Rouge, LA | |
| Livingston, LA | |
| West Baton Rouge, LA | |
| 0840Beaumont-Port Arthur, TX | 0.8442 |
| Hardin, TX | |
| Jefferson, TX | |
| Orange, TX | |
| 0860Bellingham, WA | 1.1826 |
| Whatcom, WA | |
| 0870Benton Harbor, MI | 0.8810 |
| Berrien, MI | |
| 0875Bergen-Passaic, NJ | 1.1689 |
| Bergen, NJ | |
| Passaic, NJ | |
| 0880Billings, MT | 0.9352 |
| Yellowstone, MT | |
| 0920Biloxi-Gulfport-Pascagoula, MS | 0.8440 |
| Hancock, MS | |
| Harrison, MS | |
| Jackson, MS | |
| 0960Binghamton, NY | 0.8446 |
| Broome, NY | |
| Tioga, NY | |
| 1000Birmingham, AL | 0.8808 |
| Blount, AL | |
| Jefferson, AL | |
| St. Clair, AL | |
| Shelby, AL | |
| 1010Bismarck, ND | 0.7984 |
| Burleigh, ND | |
| Morton, ND | |
| 1020Bloomington, IN | 0.8842 |
| Monroe, IN | |
| 1040Bloomington-Normal, IL | 0.9038 |
| McLean, IL | |
| 1080Boise City, ID | 0.9050 |
| Ada, ID | |
| Canyon, ID | |
| 1123Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH (NH Hospitals) | 1.1289 |
| Bristol, MA | |
| Essex, MA | |
| Middlesex, MA | |
| Norfolk, MA | |
| Plymouth, MA | |
| Suffolk, MA | |
| Worcester, MA | |
| Hillsborough, NH | |
| Merrimack, NH | |
| Rockingham, NH | |
| Strafford, NH | |
| 1125Boulder-Longmont, CO | 0.9799 |
| Boulder, CO | |
| 1145 Brazoria, TX | 0.8209 |
| Brazoria, TX | |
| 1150Bremerton, WA | 1.0758 |
| Kitsap, WA | |
| 1240Brownsville-Harlingen-San Benito, TX | 0.9012 |
| Cameron, TX | |
| 1260Bryan-College Station, TX | 0.9328 |
| Brazos, TX | |
| 1280Buffalo-Niagara Falls, NY | 0.9459 |
| Erie, NY | |
| Niagara, NY | |
| 1303Burlington, VT | 0.9883 |
| Chittenden, VT | |
| Franklin, VT | |
| Grand Isle, VT | |
| 1310Caguas, PR | 0.4699 |
| Caguas, PR | |
| Cayey, PR | |
| Cidra, PR | |
| Gurabo, PR | |
| San Lorenzo, PR | |
| 1320Canton-Massillon, OH | 0.8956 |
| Carroll, OH | |
| Stark, OH | |
| 1350Casper, WY | 0.9496 |
| Natrona, WY | |
| 1360Cedar Rapids, IA | 0.8699 |
| Linn, IA | |
| 1400Champaign-Urbana, IL | 0.9306 |
| Champaign, IL | |
| 1440Charleston-North Charleston, SC | 0.9206 |
| Berkeley, SC | |
| Charleston, SC | |
| Dorchester, SC | |
| 1480Charleston, WV | 0.9264 |
| Kanawha, WV | |
| Putnam, WV | |
| 1520Charlotte-Gastonia-Rock Hill, NC-SC | 0.9348 |
| Cabarrus, NC | |
| Gaston, NC | |
| Lincoln, NC | |
| Mecklenburg, NC | |
| Rowan, NC | |
| Stanly, NC | |
| Union, NC | |
| York, SC | |
| 1540Charlottesville, VA | 1.0566 |
| Albemarle, VA | |
| Charlottesville City, VA | |
| Fluvanna, VA | |
| Greene, VA | |
| 1560Chattanooga, TN-GA | 0.9369 |
| Catoosa, GA | |
| Dade, GA | |
| Walker, GA | |
| Hamilton, TN | |
| Marion, TN | |
| 1580Cheyenne, WY | 0.8288 |
| Laramie, WY | |
| 1600Chicago, IL | 1.1046 |
| Cook, IL | |
| DeKalb, IL | |
| DuPage, IL | |
| Grundy, IL | |
| Kane, IL | |
| Kendall, IL | |
| Lake, IL | |
| McHenry, IL | |
| Will, IL | |
| 1620Chico-Paradise, CA | 0.9856 |
| Butte, CA | |
| 1640Cincinnati, OH-KY-IN | 0.9473 |
| Dearborn, IN | |
| Ohio, IN | |
| Boone, KY | |
| Campbell, KY | |
| Gallatin, KY | |
| Grant, KY | |
| Kenton, KY | |
| Pendleton, KY | |
| Brown, OH | |
| Clermont, OH | |
| Hamilton, OH | |
| Warren, OH | |
| 1660Clarksville-Hopkinsville, TN-KY | 0.8337 |
| Christian, KY | |
| Montgomery, TN | |
| 1680Cleveland-Lorain-Elyria, OH | 0.9457 |
| Ashtabula, OH | |
| Cuyahoga, OH | |
| Geauga, OH | |
| Lake, OH | |
| Lorain, OH | |
| Medina, OH | |
| 1720Colorado Springs, CO | 0.9744 |
| El Paso, CO | |
| 1740Columbia, MO | 0.8686 |
| Boone, MO | |
| 1760Columbia, SC | 0.9492 |
| Lexington, SC | |
| Richland, SC | |
| 1800Columbus, GA-AL-Russell, AL | 0.8440 |
| Chattahoochee, GA | |
| Harris, GA | |
| Muscogee, GA | |
| 1840Columbus, OH | 0.9565 |
| Delaware, OH | |
| Fairfield, OH | |
| Franklin, OH | |
| Licking, OH | |
| Madison, OH | |
| Pickaway, OH | |
| 1880Corpus Christi, TX | 0.8341 |
| Nueces, TX | |
| San Patricio, TX | |
| 1890Corvallis, OR | 1.1646 |
| Benton, OR | |
| 1900Cumberland, MD-WV (WV Hospital) | 0.8306 |
| Allegany, MD | |
| Mineral, WV | |
| 1920Dallas, TX | 0.9936 |
| Collin, TX | |
| Dallas, TX | |
| Denton, TX | |
| Ellis, TX | |
| Henderson, TX | |
| Hunt, TX | |
| Kaufman, TX | |
| Rockwall, TX | |
| 1950Danville, VA | 0.8613 |
| Danville City, VA | |
| Pittsylvania, VA | |
| 1960Davenport-Moline-Rock Island, IA-IL | 0.8638 |
| Scott, IA | |
| Henry, IL | |
| Rock Island, IL | |
| 2000Dayton-Springfield, OH | 0.9225 |
| Clark, OH | |
| Greene, OH | |
| Miami, OH | |
| Montgomery, OH | |
| 2020Daytona Beach, FL | 0.8982 |
| Flagler, FL | |
| Volusia, FL | |
| 2030Decatur, AL | 0.8775 |
| Lawrence, AL | |
| Morgan, AL | |
| 2040Decatur, IL | 0.7987 |
| Macon, IL | |
| 2080Denver, CO | 1.0328 |
| Adams, CO | |
| Arapahoe, CO | |
| Denver, CO | |
| Douglas, CO | |
| Jefferson, CO | |
| 2120Des Moines, IA | 0.8779 |
| Dallas, IA | |
| Polk, IA | |
| Warren, IA | |
| 2160Detroit, MI | 1.0487 |
| Lapeer, MI | |
| Macomb, MI | |
| Monroe, MI | |
| Oakland, MI | |
| St. Clair, MI | |
| Wayne, MI | |
| 2180Dothan, AL | 0.7948 |
| Dale, AL | |
| Houston, AL | |
| 2190Dover, DE | 1.0296 |
| Kent, DE | |
| 2200Dubuque, IA | 0.8519 |
| Dubuque, IA | |
| 2240Duluth-Superior, MN-WI | 1.0284 |
| St. Louis, MN | |
| Douglas, WI | |
| 2281Dutchess County, NY | 1.0532 |
| Dutchess, NY | |
| 2290Eau Claire, WI | 0.8832 |
| Chippewa, WI | |
| Eau Claire, WI | |
| 2320El Paso, TX | 0.9215 |
| El Paso, TX | |
| 2330Elkhart-Goshen, IN | 0.9638 |
| Elkhart, IN | |
| 2335Elmira, NY | 0.8415 |
| Chemung, NY | |
| 2340Enid, OK | 0.8357 |
| Garfield, OK | |
| 2360Erie, PA | 0.8716 |
| Erie, PA | |
| 2400Eugene-Springfield, OR | 1.1471 |
| Lane, OR | |
| 2440Evansville-Henderson, IN-KY (IN Hospitals) | 0.8514 |
| Posey, IN | |
| Vanderburgh, IN | |
| Warrick, IN | |
| Henderson, KY | |
| 2520Fargo-Moorhead, ND-MN | 0.9267 |
| Clay, MN | |
| Cass, ND | |
| 2560Fayetteville, NC | 0.9027 |
| Cumberland, NC | |
| 2580Fayetteville-Springdale-Rogers, AR | 0.8445 |
| Benton, AR | |
| Washington, AR | |
| 2620Flagstaff, AZ-UT | 1.0556 |
| Coconino, AZ | |
| Kane, UT | |
| 2640Flint, MI | 1.0913 |
| Genesee, MI | |
| 2650Florence, AL | 0.7845 |
| Colbert, AL | |
| Lauderdale, AL | |
| 2655Florence, SC | 0.8722 |
| Florence, SC | |
| 2670Fort Collins-Loveland, CO | 1.0045 |
| Larimer, CO | |
| 2680Ft. Lauderdale, FL | 1.0293 |
| Broward, FL | |
| 2700Fort Myers-Cape Coral, FL | 0.9374 |
| Lee, FL | |
| 2710Fort Pierce-Port St. Lucie, FL | 1.0214 |
| Martin, FL | |
| St. Lucie, FL | |
| 2720Fort Smith, AR-OK | 0.8053 |
| Crawford, AR | |
| Sebastian, AR | |
| Sequoyah, OK | |
| 2750Fort Walton Beach, FL | 0.9002 |
| Okaloosa, FL | |
| 2760Fort Wayne, IN | 0.9203 |
| Adams, IN | |
| Allen, IN | |
| De Kalb, IN | |
| Huntington, IN | |
| Wells, IN | |
| Whitley, IN | |
| 2800Forth Worth-Arlington, TX | 0.9394 |
| Hood, TX | |
| Johnson, TX | |
| Parker, TX | |
| Tarrant, TX | |
| 2840Fresno, CA | 0.9887 |
| Fresno, CA | |
| Madera, CA | |
| 2880Gadsden, AL | |
| Etowah, AL | 0.8792 |
| 2900Gainesville, FL | 0.9481 |
| Alachua, FL | |
| 2920Galveston-Texas City, TX | 1.0313 |
| Galveston, TX | |
| 2960Gary, IN | 0.9530 |
| Lake, IN | |
| Porter, IN | |
| 2975Glens Falls, NY | 0.8336 |
| Warren, NY | |
| Washington, NY | |
| 2980Goldsboro, NC | 0.8709 |
| Wayne, NC | |
| 2985Grand Forks, ND-MN | 0.9069 |
| Polk, MN | |
| Grand Forks, ND | |
| 2995Grand Junction, CO | 0.9569 |
| Mesa, CO | |
| 3000Grand Rapids-Muskegon-Holland, MI | 1.0048 |
| Allegan, MI | |
| Kent, MI | |
| Muskegon, MI | |
| Ottawa, MI | |
| 3040Great Falls, MT | 0.8870 |
| Cascade, MT | |
| 3060Greeley, CO | 0.9495 |
| Weld, CO | |
| 3080Green Bay, WI | 0.9208 |
| Brown, WI | |
| 3120Greensboro-Winston-Salem-High Point, NC | 0.9539 |
| Alamance, NC | |
| Davidson, NC | |
| Davie, NC | |
| Forsyth, NC | |
| Guilford, NC | |
| Randolph, NC | |
| Stokes, NC | |
| Yadkin, NC | |
| 3150Greenville, NC | 0.9289 |
| Pitt, NC | |
| 3160Greenville-Spartanburg-Anderson, SC | 0.9217 |
| Anderson, SC | |
| Cherokee, SC | |
| Greenville, SC | |
| Pickens, SC | |
| Spartanburg, SC | |
| 3180Hagerstown, MD | 0.8365 |
| Washington, MD | |
| 3200Hamilton-Middletown, OH | 0.9287 |
| Butler, OH | |
| 3240Harrisburg-Lebanon-Carlisle, PA | 0.9425 |
| Cumberland, PA | |
| Dauphin, PA | |
| Lebanon, PA | |
| Perry, PA | |
| 3283Hartford, CT | 1.1533 |
| Hartford, CT | |
| Litchfield, CT | |
| Middlesex, CT | |
| Tolland, CT | |
| 32852 Hattiesburg, MS | 0.7476 |
| Forrest, MS | |
| Lamar, MS | |
| 3290Hickory-Morganton-Lenoir, NC | 0.9367 |
| Alexander, NC | |
| Burke, NC | |
| Caldwell, NC | |
| Catawba, NC | |
| 3320Honolulu, HI | 1.1539 |
| Honolulu, HI | |
| 3350Houma, LA | 0.7951 |
| Lafourche, LA | |
| Terrebonne, LA | |
| 3360Houston, TX | 0.9631 |
| Chambers, TX | |
| Fort Bend, TX | |
| Harris, TX | |
| Liberty, TX | |
| Montgomery, TX | |
| Waller, TX | |
| 3400Huntington-Ashland, WV-KY-OH | 0.9616 |
| Boyd, KY | |
| Carter, KY | |
| Greenup, KY | |
| Lawrence, OH | |
| Cabell, WV | |
| Wayne, WV | |
| 3440Huntsville, AL | 0.8883 |
| Limestone, AL | |
| Madison, AL | |
| 3480Indianapolis, IN | 0.9698 |
| Boone, IN | |
| Hamilton, IN | |
| Hancock, IN | |
| Hendricks, IN | |
| Johnson, IN | |
| Madison, IN | |
| Marion, IN | |
| Morgan, IN | |
| Shelby, IN | |
| 3500Iowa City, IA | 0.9859 |
| Johnson, IA | |
| 3520Jackson, MI | 0.9257 |
| Jackson, MI | |
| 3560Jackson, MS | 0.8491 |
| Hinds, MS | |
| Madison, MS | |
| Rankin, MS | |
| 3580Jackson, TN | 0.9013 |
| Madison, TN | |
| Chester, TN | |
| 3600Jacksonville, FL | 0.9223 |
| Clay, FL | |
| Duval, FL | |
| Nassau, FL | |
| St. Johns, FL | |
| 3605Jacksonville, NC | 0.7622 |
| Onslow, NC | |
| 3610Jamestown, NY | 0.8050 |
| Chautauqua, NY | |
| 3620Janesville-Beloit, WI | 0.9739 |
| Rock, WI | |
| 3640Jersey City, NJ | 1.1178 |
| Hudson, NJ | |
| 3660Johnson City-Kingsport-Bristol, TN-VA | 0.8617 |
| Carter, TN | |
| Hawkins, TN | |
| Sullivan, TN | |
| Unicoi, TN | |
| Washington, TN | |
| Bristol City, VA | |
| Scott, VA | |
| Washington, VA | |
| 3680Johnstown, PA | 0.8723 |
| Cambria, PA | |
| Somerset, PA | |
| 3700Jonesboro, AR | 0.8425 |
| Craighead, AR | |
| 3710Joplin, MO | 0.8727 |
| Jasper, MO | |
| Newton, MO | |
| 3720Kalamazoo-Battlecreek, MI | 1.0639 |
| Calhoun, MI | |
| Kalamazoo, MI | |
| Van Buren, MI | |
| 3740Kankakee, IL | 0.9889 |
| Kankakee, IL | |
| 3760Kansas City, KS-MO | 0.9536 |
| Johnson, KS | |
| Leavenworth, KS | |
| Miami, KS | |
| Wyandotte, KS | |
| Cass, MO | |
| Clay, MO | |
| Clinton, MO | |
| Jackson, MO | |
| Lafayette, MO | |
| Platte, MO | |
| Ray, MO | |
| 3800Kenosha, WI | 0.9568 |
| Kenosha, WI | |
| 3810Killeen-Temple, TX | 0.7292 |
| Bell, TX | |
| Coryell, TX | |
| 3840Knoxville, TN | 0.8890 |
| Anderson, TN | |
| Blount, TN | |
| Knox, TN | |
| Loudon, TN | |
| Sevier, TN | |
| Union, TN | |
| 3850Kokomo, IN | 0.9126 |
| Howard, IN | |
| Tipton, IN | |
| 3870La Crosse, WI-MN | 0.9250 |
| Houston, MN | |
| La Crosse, WI | |
| 3880Lafayette, LA | 0.8526 |
| Acadia, LA | |
| Lafayette, LA | |
| St. Landry, LA | |
| St. Martin, LA | |
| 3920Lafayette, IN | 0.9121 |
| Clinton, IN | |
| Tippecanoe, IN | |
| 3960Lake Charles, LA | 0.7765 |
| Calcasieu, LA | |
| 3980Lakeland-Winter Haven, FL | 0.9067 |
| Polk, FL | |
| 4000Lancaster, PA | 0.9296 |
| Lancaster, PA | |
| 4040Lansing-East Lansing, MI | 0.9653 |
| Clinton, MI | |
| Eaton, MI | |
| Ingham, MI | |
| 4080Laredo, TX | 0.7849 |
| Webb, TX | |
| 4100Las Cruces, NM | 0.8621 |
| Dona Ana, NM | |
| 4120Las Vegas, NV-AZ | 1.1182 |
| Mohave, AZ | |
| Clark, NV | |
| Nye, NV | |
| 4150Lawrence, KS | 0.8656 |
| Douglas, KS | |
| 4200Lawton, OK | 0.8682 |
| Comanche, OK | |
| 4243Lewiston-Auburn, ME | 0.9287 |
| Androscoggin, ME | |
| 4280Lexington, KY | 0.8791 |
| Bourbon, KY | |
| Clark, KY | |
| Fayette, KY | |
| Jessamine, KY | |
| Madison, KY | |
| Scott, KY | |
| Woodford, KY | |
| 4320Lima, OH | 0.9470 |
| Allen, OH | |
| Auglaize, OH | |
| 4360Lincoln, NE | 1.0173 |
| Lancaster, NE | |
| 4400Little Rock-North Little Rock, AR | 0.8955 |
| Faulkner, AR | |
| Lonoke, AR | |
| Pulaski, AR | |
| Saline, AR | |
| 4420Longview-Marshall, TX | 0.8571 |
| Gregg, TX | |
| Harrison, TX | |
| Upshur, TX | |
| 4480Los Angeles-Long Beach, CA | 1.1948 |
| Los Angeles, CA | |
| 45201 Louisville, KY-IN | 0.9529 |
| Clark, IN | |
| Floyd, IN | |
| Harrison, IN | |
| Scott, IN | |
| Bullitt, KY | |
| Jefferson, KY | |
| Oldham, KY | |
| 4600Lubbock, TX | 0.8449 |
| Lubbock, TX | |
| 4640Lynchburg, VA | 0.9103 |
| Amherst, VA | |
| Bedford, VA | |
| Bedford City, VA | |
| Campbell, VA | |
| Lynchburg City, VA | |
| 4680Macon, GA | 0.8957 |
| Bibb, GA | |
| Houston, GA | |
| Jones, GA | |
| Peach, GA | |
| Twiggs, GA | |
| 4720Madison, WI | 1.0337 |
| Dane, WI | |
| 4800Mansfield, OH | 0.8708 |
| Crawford, OH | |
| Richland, OH | |
| 4840Mayaguez, PR | 0.4860 |
| Anasco, PR | |
| Cabo Rojo, PR | |
| Hormigueros, PR | |
| Mayaguez, PR | |
| Sabana Grande, PR | |
| San German, PR | |
| 4880McAllen-Edinburg-Mission, TX | 0.8378 |
| Hidalgo, TX | |
| 4890 Medford-Ashland, OR | 1.0314 |
| Jackson, OR | |
| 4900Melbourne-Titusville-Palm Bay, FL | 0.9913 |
| Brevard, Fl | |
| 4920Memphis, TN-AR-MS | 0.8978 |
| Crittenden, AR | |
| DeSoto, MS | |
| Fayette, TN | |
| Shelby, TN | |
| Tipton, TN | |
| 4940Merced, CA | 0.9757 |
| Merced, CA | |
| 5000Miami, FL | 0.9950 |
| Dade, FL | |
| 5015Middlesex-Somerset-Hunterdon, NJ | 1.1469 |
| Hunterdon, NJ | |
| Middlesex, NJ | |
| Somerset, NJ | |
| 5080Milwaukee-Waukesha, WI | 0.9971 |
| Milwaukee, WI | |
| Ozaukee, WI | |
| Washington, WI | |
| Waukesha, WI | |
| 5120Minneapolis-St. Paul, MN-WI | 1.0930 |
| Anoka, MN | |
| Carver, MN | |
| Chisago, MN | |
| Dakota, MN | |
| Hennepin, MN | |
| Isanti, MN | |
| Ramsey, MN | |
| Scott, MN | |
| Sherburne, MN | |
| Washington, MN | |
| Wright, MN | |
| Pierce, WI | |
| St. Croix, WI | |
| 5140Missoula, MT | 0.9364 |
| Missoula, MT | |
| 5160Mobile, AL | 0.8082 |
| Baldwin, AL | |
| Mobile, AL | |
| 5170Modesto, CA | 1.0820 |
| Stanislaus, CA | |
| 5190Monmouth-Ocean, NJ | 1.0872 |
| Monmouth, NJ | |
| Ocean, NJ | |
| 5200Monroe, LA | 0.8201 |
| Ouachita, LA | |
| 5240Montgomery, AL | 0.7359 |
| Autauga, AL | |
| Elmore, AL | |
| Montgomery, AL | |
| 5280Muncie, IN | 0.9939 |
| Delaware, IN | |
| 5330Myrtle Beach, SC | 0.8771 |
| Horry, SC | |
| 5345Naples, FL | 0.9699 |
| Collier, FL | |
| 5360Nashville, TN | 0.9754 |
| Cheatham, TN | |
| Davidson, TN | |
| Dickson, TN | |
| Robertson, TN | |
| Rutherford TN | |
| Sumner, TN | |
| Williamson, TN | |
| Wilson, TN | |
| 5380Nassau-Suffolk, NY | 1.3643 |
| Nassau, NY | |
| Suffolk, NY | |
| 5483New Haven-Bridgeport-Stamford-Waterbury- | 1.2238 |
| Danbury, CT | |
| Fairfield, CT | |
| New Haven, CT | |
| 5523New London-Norwich, CT | 1.1526 |
| New London, CT | |
| 5560New Orleans, LA | 0.9036 |
| Jefferson, LA | |
| Orleans, LA | |
| Plaquemines, LA | |
| St. Bernard, LA | |
| St. Charles, LA | |
| St. James, LA | |
| St. John The Baptist, LA | |
| St. Tammany, LA | |
| 5600New York, NY | 1.4427 |
| Bronx, NY | |
| Kings, NY | |
| New York, NY | |
| Putnam, NY | |
| Queens, NY | |
| Richmond, NY | |
| Rockland, NY | |
| Westchester, NY | |
| 5640Newark, NJ | 1.1622 |
| Essex, NJ | |
| Morris, NJ | |
| Sussex, NJ | |
| Union, NJ | |
| Warren, NJ | |
| 5660Newburgh, NY-PA | 1.1113 |
| Orange, NY | |
| Pike, PA | |
| 5720Norfolk-Virginia Beach-Newport News, VA-NC | 0.8579 |
| Currituck, NC | |
| Chesapeake City, VA | |
| Gloucester, VA | |
| Hampton City, VA | |
| Isle of Wight, VA | |
| James City, VA | |
| Mathews, VA | |
| Newport News City, VA | |
| Norfolk City, VA | |
| Poquoson City, VA | |
| Portsmouth City, VA | |
| Suffolk City, VA | |
| Virginia Beach City VA | |
| Williamsburg City, VA | |
| York, VA | |
| 5775Oakland, CA | 1.5319 |
| Alameda, CA | |
| Contra Costa, CA | |
| 5790Ocala, FL | 0.9556 |
| Marion, FL | |
| 5800Odessa-Midland, TX | 1.0104 |
| Ector, TX | |
| Midland, TX | |
| 5880Oklahoma City, OK | 0.8694 |
| Canadian, OK | |
| Cleveland, OK | |
| Logan, OK | |
| McClain, OK | |
| Oklahoma, OK | |
| Pottawatomie, OK | |
| 5910 Olympia, WA | 1.1350 |
| Thurston, WA | |
| 5920Omaha, NE-IA | 0.9712 |
| Pottawattamie, IA | |
| Cass, NE | |
| Douglas, NE | |
| Sarpy, NE | |
| Washington, NE | |
| 5945Orange County, CA | 1.1123 |
| Orange, CA | |
| 5960Orlando, FL | 0.9642 |
| Lake, FL | |
| Orange, FL | |
| Osceola, FL | |
| Seminole, FL | |
| 5990Owensboro, KY | 0.8334 |
| Daviess, KY | |
| 6015 Panama City, FL | 0.9061 |
| Bay, FL | |
| 6020Parkersburg-Marietta, WV-OH | 0.8133 |
| Washington, OH | |
| Wood, WV | |
| 6080Pensacola, FL | 0.8329 |
| Escambia, FL | |
| Santa Rosa, FL | |
| 6120Peoria-Pekin, IL | 0.8773 |
| Peoria, IL | |
| Tazewell, IL | |
| Woodford, IL | |
| 6160Philadelphia, PA-NJ | 1.0947 |
| Burlington, NJ | |
| Camden, NJ | |
| Gloucester, NJ | |
| Salem, NJ | |
| Bucks, PA | |
| Chester, PA | |
| Delaware, PA | |
| Montgomery, PA | |
| Philadelphia, PA | |
| 6200Phoenix-Mesa, AZ | 0.9638 |
| Maricopa, AZ | |
| Pinal, AZ | |
| 6240Pine Bluff, AR | 0.7895 |
| Jefferson, AR | |
| 6280Pittsburgh, PA | 0.9560 |
| Allegheny, PA | |
| Beaver, PA | |
| Butler, PA | |
| Fayette, PA | |
| Washington, PA | |
| Westmoreland, PA | |
| 6323Pittsfield, MA | 1.0278 |
| Berkshire, MA | |
| 6340Pocatello, ID | 0.9448 |
| Bannock, ID | |
| 6360Ponce, PR | 0.5218 |
| Guayanilla, PR | |
| Juana Diaz, PR | |
| Penuelas, PR | |
| Ponce, PR | |
| Villalba, PR | |
| Yauco, PR | |
| 6403Portland, ME | 0.9427 |
| Cumberland, ME | |
| Sagadahoc, ME | |
| York, ME | |
| 6440Portland-Vancouver, OR-WA | 1.1111 |
| Clackamas, OR | |
| Columbia, OR | |
| Multnomah, OR | |
| Washington, OR | |
| Yamhill, OR | |
| Clark, WA | |
| 6483Providence-Warwick-Pawtucket, RI | 1.0805 |
| Bristol, RI | |
| Kent, RI | |
| Newport, RI | |
| Providence, RI | |
| Washington, RI | |
| 6520Provo-Orem, UT | 0.9843 |
| Utah, UT | |
| 6560Pueblo, CO | 0.8604 |
| Pueblo, CO | |
| 6580Punta Gorda, FL | 0.9015 |
| Charlotte, FL | |
| 6600Racine, WI | 0.9333 |
| Racine, WI | |
| 6640Raleigh-Durham-Chapel Hill, NC | 0.9818 |
| Chatham, NC | |
| Durham, NC | |
| Franklin, NC | |
| Johnston, NC | |
| Orange, NC | |
| Wake, NC | |
| 6660Rapid City, SD | 0.8869 |
| Pennington, SD | |
| 6680Reading, PA | 0.9583 |
| Berks, PA | |
| 6690Redding, CA | 1.1155 |
| Shasta, CA | |
| 6720Reno, NV | 1.0440 |
| Washoe, NV | |
| 6740Richland-Kennewick-Pasco, WA | 1.0960 |
| Benton, WA | |
| Franklin, WA | |
| 6760Richmond-Petersburg, VA | 0.9678 |
| Charles City County, VA | |
| Chesterfield, VA | |
| Colonial Heights City, VA | |
| Dinwiddie, VA | |
| Goochland, VA | |
| Hanover, VA | |
| Henrico, VA | |
| Hopewell City, VA | |
| New Kent, VA | |
| Petersburg City, VA | |
| Powhatan, VA | |
| Prince George, VA | |
| Richmond City, VA | |
| 6780Riverside-San Bernardino, CA | 1.1111 |
| Riverside, CA | |
| San Bernardino, CA | |
| 6800Roanoke, VA | 0.8371 |
| Botetourt, VA | |
| Roanoke, VA | |
| Roanoke City, VA | |
| Salem City, VA | |
| 6820Rochester, MN | 1.1462 |
| Olmsted, MN | |
| 6840Rochester, NY | 0.9347 |
| Genesee, NY | |
| Livingston, NY | |
| Monroe, NY | |
| Ontario, NY | |
| Orleans, NY | |
| Wayne, NY | |
| 6880Rockford, IL | 0.9204 |
| Boone, IL | |
| Ogle, IL | |
| Winnebago, IL | |
| 6895Rocky Mount, NC | 0.9109 |
| Edgecombe, NC | |
| Nash, NC | |
| 6920Sacramento, CA | 1.1831 |
| El Dorado, CA | |
| Placer, CA | |
| Sacramento, CA | |
| 6960Saginaw-Bay City-Midland, MI | 0.9590 |
| Bay, MI | |
| Midland, MI | |
| Saginaw, MI | |
| 6980St. Cloud, MN | 0.9851 |
| Benton, MN | |
| Stearns, MN | |
| 7000St. Joseph, MO | 0.9009 |
| Andrew, MO | |
| Buchanan, MO | |
| 7040St. Louis, MO-IL | 0.8931 |
| Clinton, IL | |
| Jersey, IL | |
| Madison, IL | |
| Monroe, IL | |
| St. Clair, IL | |
| Franklin, MO | |
| Jefferson, MO | |
| Lincoln, MO | |
| St. Charles, MO | |
| St. Louis, MO | |
| St. Louis City, MO | |
| Warren, MO | |
| 7080Salem, OR | 1.0011 |
| Marion, OR | |
| Polk, OR | |
| 7120Salinas, CA | 1.4684 |
| Monterey, CA | |
| 7160Salt Lake City-Ogden, UT | 0.9863 |
| Davis, UT | |
| Salt Lake, UT | |
| Weber, UT | |
| 7200San Angelo, TX | 0.8193 |
| Tom Green, TX | |
| 7240San Antonio, TX | 0.8584 |
| Bexar, TX | |
| Comal, TX | |
| Guadalupe, TX | |
| Wilson, TX | |
| 7320San Diego, CA | 1.1265 |
| San Diego, CA | |
| 7360San Francisco, CA | 1.4140 |
| Marin, CA | |
| San Francisco, CA | |
| San Mateo, CA | |
| 7400San Jose, CA | 1.4193 |
| Santa Clara, CA | |
| 7440San Juan-Bayamon, PR | 0.4762 |
| Aguas Buenas, PR | |
| Barceloneta, PR | |
| Bayamon, PR | |
| Canovanas, PR | |
| Carolina, PR | |
| Catano, PR | |
| Ceiba, PR | |
| Comerio, PR | |
| Corozal, PR | |
| Dorado, PR | |
| Fajardo, PR | |
| Florida, PR | |
| Guaynabo, PR | |
| Humacao, PR | |
| Juncos, PR | |
| Los Piedras, PR | |
| Loiza, PR | |
| Luguillo, PR | |
| Manati, PR | |
| Morovis, PR | |
| Naguabo, PR | |
| Naranjito, PR | |
| Rio Grande, PR | |
| San Juan, PR | |
| Toa Alta, PR | |
| Toa Baja, PR | |
| Trujillo Alto, PR | |
| Vega Alta, PR | |
| Vega Baja, PR | |
| Yabucoa, PR | |
| 7460San Luis Obispo-Atascadero-Paso Robles, CA | 1.0990 |
| San Luis Obispo, CA | |
| 7480Santa Barbara-Santa Maria-Lompoc, CA | 1.0802 |
| Santa Barbara, CA | |
| 7485Santa Cruz-Watsonville, CA | 1.3970 |
| Santa Cruz, CA | |
| 7490Santa Fe, NM | 1.0194 |
| Los Alamos, NM | |
| Santa Fe, NM | |
| 7500 Santa Rosa, CA | 1.3034 |
| Sonoma, CA | |
| 7510Sarasota-Bradenton, FL | 1.0090 |
| Manatee, FL | |
| Sarasota, FL | |
| 7520Savannah, GA | 0.9243 |
| Bryan, GA | |
| Chatham, GA | |
| Effingham, GA | |
| 7560Scranton--Wilkes-Barre--Hazleton, PA | 0.8683 |
| Columbia, PA | |
| Lackawanna, PA | |
| Luzerne, PA | |
| Wyoming, PA | |
| 7600Seattle-Bellevue-Everett, WA | 1.1361 |
| Island, WA | |
| King, WA | |
| Snohomish, WA | |
| 7610Sharon, PA | 0.7926 |
| Mercer, PA | |
| 7620Sheboygan, WI | 0.8427 |
| Sheboygan, WI | |
| 7640Sherman-Denison, TX | 0.9373 |
| Grayson, TX | |
| 7680 Shreveport-Bossier City, LA | 0.9050 |
| Bossier, LA | |
| Caddo, LA | |
| Webster, LA | |
| 7720Sioux City, IA-NE | 0.8767 |
| Woodbury, IA | |
| Dakota, NE | |
| 7760Sioux Falls, SD | 0.9139 |
| Lincoln, SD | |
| Minnehaha, SD | |
| 7800South Bend, IN | 0.9993 |
| St. Joseph, IN | |
| 7840Spokane, WA | 1.0668 |
| Spokane, WA | |
| 7880Springfield, IL | 0.8676 |
| Menard, IL | |
| Sangamon, IL | |
| 7920Springfield, MO | 0.8567 |
| Christian, MO | |
| Greene, MO | |
| Webster, MO | |
| 8003Springfield, MA | 1.0881 |
| Hampden, MA | |
| Hampshire, MA | |
| 8050State College, PA | 0.9133 |
| Centre, PA | |
| 8080Steubenville-Weirton, OH-WV (WV Hospitals) | 0.8637 |
| Jefferson, OH | |
| Brooke, WV | |
| Hancock, WV | |
| 8120Stockton-Lodi, CA | 1.0815 |
| San Joaquin, CA | |
| 8140Sumter, SC | 0.7794 |
| Sumter, SC | |
| 8160Syracuse, NY | 0.9621 |
| Cayuga, NY | |
| Madison, NY | |
| Onondaga, NY | |
| Oswego, NY | |
| 8200Tacoma, WA | 1.1616 |
| Pierce, WA | |
| 8240Tallahassee, FL | 0.8527 |
| Gadsden, FL | |
| Leon, FL | |
| 8280Tampa-St. Petersburg-Clearwater, FL | 0.8925 |
| Hernando, FL | |
| Hillsborough, FL | |
| Pasco, FL | |
| Pinellas, FL | |
| 8320Terre Haute, IN | 0.8532 |
| Clay, IN | |
| Vermillion, IN | |
| Vigo, IN | |
| 8360Texarkana,AR-Texarkana, TX | 0.8327 |
| Miller, AR | |
| Bowie, TX | |
| 8400Toledo, OH | 0.9809 |
| Fulton, OH | |
| Lucas, OH | |
| Wood, OH | |
| 8440Topeka, KS | 0.8912 |
| Shawnee, KS | |
| 8480 Trenton, NJ | 1.0416 |
| Mercer, NJ | |
| 8520Tucson, AZ | 0.8967 |
| Pima, AZ | |
| 8560Tulsa, OK | 0.8902 |
| Creek, OK | |
| Osage, OK | |
| Rogers, OK | |
| Tulsa, OK | |
| Wagoner, OK | |
| 8600Tuscaloosa, AL | 0.8171 |
| Tuscaloosa, AL | |
| 8640Tyler, TX | 0.9641 |
| Smith, TX | |
| 8680Utica-Rome, NY | 0.8329 |
| Herkimer, NY | |
| Oneida, NY | |
| 8720Vallejo-Fairfield-Napa, CA | 1.3562 |
| Napa, CA | |
| Solano, CA | |
| 8735Ventura, CA | 1.0994 |
| Ventura, CA | |
| 8750Victoria, TX | 0.8328 |
| Victoria, TX | |
| 8760Vineland-Millville-Bridgeton, NJ | 1.0441 |
| Cumberland, NJ | |
| 8780Visalia-Tulare-Porterville, CA | 0.9610 |
| Tulare, CA | |
| 8800Waco, TX | 0.8129 |
| McLennan, TX | |
| 8840Washington, DC-MD-VA-WV | 1.0962 |
| District of Columbia, DC | |
| Calvert, MD | |
| Charles, MD | |
| Frederick, MD | |
| Montgomery, MD | |
| Prince Georges, MD | |
| Alexandria City, VA | |
| Arlington, VA | |
| Clarke, VA | |
| Culpeper, VA | |
| Fairfax, VA | |
| Fairfax City, VA | |
| Falls Church City, VA | |
| Fauquier, VA | |
| Fredericksburg City, VA | |
| King George, VA | |
| Loudoun, VA | |
| Manassas City, VA | |
| Manassas Park City, VA | |
| Prince William, VA | |
| Spotsylvania, VA | |
| Stafford, VA | |
| Warren, VABerkeley, WV | |
| Jefferson, WV | |
| 8920Waterloo-Cedar Falls, IA | 0.8041 |
| Black Hawk, IA | |
| 8940Wausau, WI | 0.9696 |
| Marathon, WI | |
| 8960West Palm Beach-Boca Raton, FL | 0.9777 |
| Palm Beach, FL | |
| 9000Wheeling, WV-OH | 0.7985 |
| Belmont, OH | |
| Marshall, WV | |
| Ohio, WV | |
| 9040Wichita, KS | 0.9606 |
| Butler, KS | |
| Harvey, KS | |
| Sedgwick, KS | |
| 9080Wichita Falls, TX | 0.7867 |
| Archer, TX | |
| Wichita, TX | |
| 9140Williamsport, PA | 0.8521 |
| Lycoming, PA | |
| 9160Wilmington-Newark, DE-MD | 1.0877 |
| New Castle, DE | |
| Cecil, MD | |
| 9200Wilmington, NC | 0.9409 |
| New Hanover, NC | |
| Brunswick, NC | |
| 9260Yakima, WA | 1.0567 |
| Yakima, WA | |
| 9270Yolo, CA | 0.9701 |
| Yolo, CA | |
| 9280York, PA | 0.9441 |
| York, PA | |
| 9320Youngstown-Warren, OH | 0.9563 |
| Columbiana, OH | |
| Mahoning, OH | |
| Trumbull, OH | |
| 9340Yuba City, CA | 1.0359 |
| Sutter, CA | |
| Yuba, CA | |
| 9360Yuma, AZ | 0.8989 |
| Yuma, AZ |
| Nonurban Area | Wage Index |
|---|---|
| Alabama | 0.7339 |
| Alaska | 1.1862 |
| Arizona | 0.8681 |
| Arkansas | 0.7489 |
| California | 0.9772 |
| Colorado | 0.8811 |
| Connecticut | 1.2077 |
| Delaware | 0.9589 |
| Florida | 0.8812 |
| Georgia | 0.8295 |
| Hawaii | 1.1112 |
| Idaho | 0.8718 |
| Illinois | 0.8053 |
| Indiana | 0.8721 |
| Iowa | 0.8147 |
| Kansas | 0.7769 |
| Kentucky | 0.7963 |
| Louisiana | 0.7601 |
| Maine | 0.8721 |
| Maryland | 0.8859 |
| Massachusetts | 1.1454 |
| Michigan | 0.9010 |
| Minnesota | 0.9035 |
| Mississippi | 0.7528 |
| Missouri | 0.7778 |
| Montana | 0.8655 |
| Nebraska | 0.8142 |
| Nevada | 0.9673 |
| New Hampshire | 0.9803 |
| New Jersey1 | |
| New Mexico | 0.8676 |
| New York | 0.8547 |
| North Carolina | 0.8539 |
| North Dakota | 0.7879 |
| Ohio | 0.8668 |
| Oklahoma | 0.7566 |
| Oregon | 1.0027 |
| Pennsylvania | 0.8617 |
| Puerto Rico | 0.4800 |
| Rhode Island1 | |
| South Carolina | 0.8512 |
| South Dakota | 0.7861 |
| Tennessee | 0.7928 |
| Texas | 0.7712 |
| Utah | 0.9051 |
| Vermont | 0.9466 |
| Virginia | 0.8241 |
| Washington | 1.0209 |
| West Virginia | 0.8067 |
| Wisconsin | 0.9079 |
| Wyoming | 0.8747 |
| 1 All counties within the State are classified as urban. | |
----------
* Medicare data have been supplemented by data from 19 states for low volume DRGs.** DRGs 469 and 470 contain cases which could not be assigned to valid DRGs.Note: Geometric mean is used only to determine payment for transfer cases.Note: Arithmetic mean is presented for informational purposes only.Note: Relative weights are based on Medicare patient data and may not be appropriate for other patients.
| DRG | MDC | Type | DRG title | Relative weights | Geometric mean LOS | Arithmetic mean LOS |
|---|---|---|---|---|---|---|
| 1 | 01 | SURG | CRANIOTOMY AGE 17 EXCEPT FOR TRAUMA | 3.2713 | 7.6 | 10.2 |
| 2 | 01 | SURG | CRANIOTOMY FOR TRAUMA AGE 17 | 3.3874 | 8.8 | 11.1 |
| 3 | 01 | SURG | *CRANIOTOMY AGE 0-17 | 1.9594 | 12.7 | 12.7 |
| 4 | 01 | SURG | SPINAL PROCEDURES | 2.4148 | 5.5 | 8.1 |
| 5 | 01 | SURG | EXTRACRANIAL VASCULAR PROCEDURES | 1.3628 | 2.3 | 3.2 |
| 6 | 01 | SURG | CARPAL TUNNEL RELEASE | .7230 | 2.1 | 3.0 |
| 7 | 01 | SURG | PERIPH CRANIAL NERVE OTHER NERV SYST PROC W CC | 2.6285 | 8.3 | 11.1 |
| 8 | 01 | SURG | PERIPH CRANIAL NERVE OTHER NERV SYST PROC W/O CC | 1.3953 | 2.0 | 2.9 |
| 9 | 01 | MED | SPINAL DISORDERS INJURIES | 1.3350 | 5.2 | 6.9 |
| 10 | 01 | MED | NERVOUS SYSTEM NEOPLASMS W CC | 1.2690 | 5.5 | 7.2 |
| 11 | 01 | MED | NERVOUS SYSTEM NEOPLASMS W/O CC | .8471 | 3.3 | 4.3 |
| 12 | 01 | MED | DEGENERATIVE NERVOUS SYSTEM DISORDERS | .9020 | 4.9 | 6.3 |
| 13 | 01 | MED | MULTIPLE SCLEROSIS CEREBELLAR ATAXIA | .8129 | 4.5 | 5.5 |
| 14 | 01 | MED | SPECIFIC CEREBROVASCULAR DISORDERS EXCEPT TIA | 1.1655 | 4.8 | 6.1 |
| 15 | 01 | MED | TRANSIENT ISCHEMIC ATTACK PRECEREBRAL OCCLUSIONS | .7349 | 3.0 | 3.7 |
| 16 | 01 | MED | NONSPECIFIC CEREBROVASCULAR DISORDERS W CC | 1.1867 | 5.1 | 6.5 |
| 17 | 01 | MED | NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC | .6689 | 2.7 | 3.4 |
| 18 | 01 | MED | CRANIAL PERIPHERAL NERVE DISORDERS W CC | .9744 | 4.6 | 5.8 |
| 19 | 01 | MED | CRANIAL PERIPHERAL NERVE DISORDERS W/O CC | .6756 | 3.0 | 3.8 |
| 20 | 01 | MED | NERVOUS SYSTEM INFECTION EXCEPT VIRAL MENINGITIS | 2.7764 | 9.0 | 11.4 |
| 21 | 01 | MED | VIRAL MENINGITIS | 1.4573 | 5.5 | 7.1 |
| 22 | 01 | MED | HYPERTENSIVE ENCEPHALOPATHY | 1.0037 | 4.0 | 5.1 |
| 23 | 01 | MED | NONTRAUMATIC STUPOR COMA | .8069 | 3.4 | 4.4 |
| 24 | 01 | MED | SEIZURE HEADACHE AGE 17 W CC | 1.0172 | 4.0 | 5.3 |
| 25 | 01 | MED | SEIZURE HEADACHE AGE 17 W/O CC | .5947 | 2.7 | 3.3 |
| 26 | 01 | MED | SEIZURE HEADACHE AGE 0-17 | .5981 | 2.4 | 3.0 |
| 27 | 01 | MED | TRAUMATIC STUPOR COMA, COMA 1 HR | 1.3514 | 3.7 | 5.6 |
| 28 | 01 | MED | TRAUMATIC STUPOR COMA, COMA 1 HR AGE 17 W CC | 1.3609 | 5.2 | 6.8 |
| 29 | 01 | MED | TRAUMATIC STUPOR COMA, COMA 1 HR AGE 17 W/O CC | .6956 | 3.0 | 3.8 |
| 30 | 01 | MED | *TRAUMATIC STUPOR COMA, COMA 1 HR AGE 0-17 | .3314 | 2.0 | 2.0 |
| 31 | 01 | MED | CONCUSSION AGE 17 W CC | .9165 | 3.5 | 4.8 |
| 32 | 01 | MED | CONCUSSION AGE 17 W/O CC | .5230 | 2.0 | 2.6 |
| 33 | 01 | MED | *CONCUSSION AGE 0-17 | .2082 | 1.6 | 1.6 |
| 34 | 01 | MED | OTHER DISORDERS OF NERVOUS SYSTEM W CC | 1.0074 | 4.2 | 5.4 |
| 35 | 01 | MED | OTHER DISORDERS OF NERVOUS SYSTEM W/O CC | .5885 | 2.7 | 3.5 |
| 36 | 02 | SURG | RETINAL PROCEDURES | .6615 | 1.2 | 1.5 |
| 37 | 02 | SURG | ORBITAL PROCEDURES | 1.1300 | 2.9 | 4.3 |
| 38 | 02 | SURG | PRIMARY IRIS PROCEDURES | .4751 | 2.0 | 2.6 |
| 39 | 02 | SURG | LENS PROCEDURES WITH OR WITHOUT VITRECTOMY | .5986 | 1.5 | 1.9 |
| 40 | 02 | SURG | EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 17 | .8264 | 2.4 | 3.6 |
| 41 | 02 | SURG | *EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 0-17 | .3374 | 1.6 | 1.6 |
| 42 | 02 | SURG | INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS LENS | .6302 | 1.6 | 2.3 |
| 43 | 02 | MED | HYPHEMA | .4578 | 2.8 | 3.3 |
| 44 | 02 | MED | ACUTE MAJOR EYE INFECTIONS | .6554 | 4.3 | 5.2 |
| 45 | 02 | MED | NEUROLOGICAL EYE DISORDERS | .6760 | 2.7 | 3.3 |
| 46 | 02 | MED | OTHER DISORDERS OF THE EYE AGE 17 W CC | .7962 | 3.9 | 5.0 |
| 47 | 02 | MED | OTHER DISORDERS OF THE EYE AGE 17 W/O CC | .5043 | 2.7 | 3.4 |
| 48 | 02 | MED | *OTHER DISORDERS OF THE EYE AGE 0-17 | .2972 | 2.9 | 2.9 |
| 49 | 03 | SURG | MAJOR HEAD NECK PROCEDURES | 1.7649 | 3.8 | 5.1 |
| 50 | 03 | SURG | SIALOADENECTOMY | .8158 | 1.5 | 1.9 |
| 51 | 03 | SURG | SALIVARY GLAND PROCEDURES EXCEPT SIALOADENECTOMY | .7895 | 1.8 | 2.7 |
| 52 | 03 | SURG | CLEFT LIP PALATE REPAIR | .7590 | 1.5 | 1.9 |
| 53 | 03 | SURG | SINUS MASTOID PROCEDURES AGE 17 | 1.1773 | 2.3 | 3.7 |
| 54 | 03 | SURG | *SINUS MASTOID PROCEDURES AGE 0-17 | .4817 | 3.2 | 3.2 |
| 55 | 03 | SURG | MISCELLANEOUS EAR, NOSE, MOUTH THROAT PROCEDURES | .8483 | 1.8 | 2.7 |
| 56 | 03 | SURG | RHINOPLASTY | .8787 | 2.0 | 2.7 |
| 57 | 03 | SURG | TA PROC, EXCEPT TONSILLECTOMY /OR ADENOIDECTOMY ONLY, AGE 17 | 1.2004 | 2.8 | 4.3 |
| 58 | 03 | SURG | *TA PROC, EXCEPT TONSILLECTOMY /OR ADENOIDECTOMY ONLY, AGE 0-17 | .2735 | 1.5 | 1.5 |
| 59 | 03 | SURG | TONSILLECTOMY /OR ADENOIDECTOMY ONLY, AGE 17 | .8276 | 1.9 | 2.8 |
| 60 | 03 | SURG | *TONSILLECTOMY /OR ADENOIDECTOMY ONLY, AGE 0-17 | .2083 | 1.5 | 1.5 |
| 61 | 03 | SURG | MYRINGOTOMY W TUBE INSERTION AGE 17 | 1.3541 | 3.3 | 5.7 |
| 62 | 03 | SURG | *MYRINGOTOMY W TUBE INSERTION AGE 0-17 | .2950 | 1.3 | 1.3 |
| 63 | 03 | SURG | OTHER EAR, NOSE, MOUTH THROAT O.R. PROCEDURES | 1.3718 | 3.3 | 4.7 |
| 64 | 03 | MED | EAR, NOSE, MOUTH THROAT MALIGNANCY | 1.2319 | 4.8 | 6.8 |
| 65 | 03 | MED | DYSEQUILIBRIUM | .5326 | 2.4 | 2.9 |
| 66 | 03 | MED | EPISTAXIS | .5536 | 2.6 | 3.3 |
| 67 | 03 | MED | EPIGLOTTITIS | .7514 | 3.0 | 3.7 |
| 68 | 03 | MED | OTITIS MEDIA URI AGE 17 W CC | .6665 | 3.6 | 4.3 |
| 69 | 03 | MED | OTITIS MEDIA URI AGE 17 W/O CC | .4948 | 2.8 | 3.4 |
| 70 | 03 | MED | OTITIS MEDIA URI AGE 0-17 | .4575 | 2.5 | 3.0 |
| 71 | 03 | MED | LARYNGOTRACHEITIS | .6685 | 3.1 | 4.0 |
| 72 | 03 | MED | NASAL TRAUMA DEFORMITY | .6699 | 2.9 | 3.7 |
| 73 | 03 | MED | OTHER EAR, NOSE, MOUTH THROAT DIAGNOSES AGE 17 | .7993 | 3.6 | 4.7 |
| 74 | 03 | MED | *OTHER EAR, NOSE, MOUTH THROAT DIAGNOSES AGE 0-17 | .3352 | 2.1 | 2.1 |
| 75 | 04 | SURG | MAJOR CHEST PROCEDURES | 3.2096 | 8.8 | 10.8 |
| 76 | 04 | SURG | OTHER RESP SYSTEM O.R. PROCEDURES W CC | 3.0129 | 10.1 | 12.7 |
| 77 | 04 | SURG | OTHER RESP SYSTEM O.R. PROCEDURES W/O CC | 1.2416 | 4.1 | 5.5 |
| 78 | 04 | MED | PULMONARY EMBOLISM | 1.3295 | 6.3 | 7.2 |
| 79 | 04 | MED | RESPIRATORY INFECTIONS INFLAMMATIONS AGE 17 W CC | 1.7094 | 7.6 | 9.3 |
| 80 | 04 | MED | RESPIRATORY INFECTIONS INFLAMMATIONS AGE 17 W/O CC | .9215 | 5.0 | 6.0 |
| 81 | 04 | MED | *RESPIRATORY INFECTIONS INFLAMMATIONS AGE 0-17 | 1.5177 | 6.1 | 6.1 |
| 82 | 04 | MED | RESPIRATORY NEOPLASMS | 1.4316 | 6.0 | 7.6 |
| 83 | 04 | MED | MAJOR CHEST TRAUMA W CC | .9803 | 4.8 | 5.9 |
| 84 | 04 | MED | MAJOR CHEST TRAUMA W/O CC | .5454 | 2.8 | 3.5 |
| 85 | 04 | MED | PLEURAL EFFUSION W CC | 1.2483 | 5.5 | 6.9 |
| 86 | 04 | MED | PLEURAL EFFUSION W/O CC | .6769 | 3.0 | 3.8 |
| 87 | 04 | MED | PULMONARY EDEMA RESPIRATORY FAILURE | 1.4282 | 5.5 | 6.9 |
| 88 | 04 | MED | CHRONIC OBSTRUCTIVE PULMONARY DISEASE | .9127 | 4.5 | 5.4 |
| 89 | 04 | MED | SIMPLE PNEUMONIA PLEURISY AGE 17 W CC | 1.0601 | 5.3 | 6.3 |
| 90 | 04 | MED | SIMPLE PNEUMONIA PLEURISY AGE 17 W/O CC | .6344 | 3.7 | 4.3 |
| 91 | 04 | MED | SIMPLE PNEUMONIA PLEURISY AGE 0-17 | .7937 | 3.8 | 4.7 |
| 92 | 04 | MED | INTERSTITIAL LUNG DISEASE W CC | 1.2296 | 5.6 | 6.8 |
| 93 | 04 | MED | INTERSTITIAL LUNG DISEASE W/O CC | .7443 | 3.5 | 4.3 |
| 94 | 04 | MED | PNEUMOTHORAX W CC | 1.2024 | 5.4 | 6.9 |
| 95 | 04 | MED | PNEUMOTHORAX W/O CC | .5817 | 3.2 | 3.9 |
| 96 | 04 | MED | BRONCHITIS ASTHMA AGE 17 W CC | .7604 | 4.1 | 4.9 |
| 97 | 04 | MED | BRONCHITIS ASTHMA AGE 17 W/O CC | .5636 | 3.2 | 3.8 |
| 98 | 04 | MED | BRONCHITIS ASTHMA AGE 0-17 | .7496 | 3.1 | 4.6 |
| 99 | 04 | MED | RESPIRATORY SIGNS SYMPTOMS W CC | .6964 | 2.6 | 3.3 |
| 100 | 04 | MED | RESPIRATORY SIGNS SYMPTOMS W/O CC | .5186 | 1.8 | 2.2 |
| 101 | 04 | MED | OTHER RESPIRATORY SYSTEM DIAGNOSES W CC | .8604 | 3.6 | 4.7 |
| 102 | 04 | MED | OTHER RESPIRATORY SYSTEM DIAGNOSES W/O CC | .5207 | 2.1 | 2.7 |
| 103 | PRE | SURG | HEART TRANSPLANT | 20.2413 | 39.2 | 58.5 |
| 104 | 05 | SURG | CARDIAC VALVE OTH MAJOR CARDIOTHORACIC PROC W CARD CATH | 7.8411 | 13.2 | 15.3 |
| 105 | 05 | SURG | CARDIAC VALVE OTH MAJOR CARDIOTHORACIC PROC W/O CARD CATH | 5.6796 | 8.8 | 10.4 |
| 106 | 05 | SURG | CORONARY BYPASS W PTCA | 7.4396 | 10.7 | 12.3 |
| 107 | 05 | SURG | CORONARY BYPASS W CARDIAC CATH | 5.3125 | 9.7 | 10.9 |
| 108 | 05 | SURG | OTHER CARDIOTHORACIC PROCEDURES | 5.5325 | 9.2 | 11.2 |
| 109 | 05 | SURG | CORONARY BYPASS W/O PTCA OR CARDIAC CATH | 3.9017 | 7.0 | 8.0 |
| 110 | 05 | SURG | MAJOR CARDIOVASCULAR PROCEDURES W CC | 4.1576 | 8.1 | 10.3 |
| 111 | 05 | SURG | MAJOR CARDIOVASCULAR PROCEDURES W/O CC | 2.2865 | 4.3 | 5.1 |
| 112 | 05 | SURG | NO LONGER VALID | .0000 | .0 | .0 |
| 113 | 05 | SURG | AMPUTATION FOR CIRC SYSTEM DISORDERS EXCEPT UPPER LIMB TOE | 2.6714 | 9.8 | 12.9 |
| 114 | 05 | SURG | UPPER LIMB TOE AMPUTATION FOR CIRC SYSTEM DISORDERS | 1.6809 | 7.3 | 9.4 |
| 115 | 05 | SURG | PRM CARD PACEM IMPL W AMI,HRT FAIL OR SHK,OR AICD LEAD OR GN | 3.3822 | 7.2 | 9.2 |
| 116 | 05 | SURG | OTHER PERMANENT CARDIAC PACEMAKER IMPLANT | 2.2648 | 3.6 | 4.9 |
| 117 | 05 | SURG | CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT | 1.3351 | 2.8 | 4.5 |
| 118 | 05 | SURG | CARDIAC PACEMAKER DEVICE REPLACEMENT | 1.4339 | 1.8 | 2.7 |
| 119 | 05 | SURG | VEIN LIGATION STRIPPING | 1.3578 | 3.3 | 5.3 |
| 120 | 05 | SURG | OTHER CIRCULATORY SYSTEM O.R. PROCEDURES | 2.3552 | 6.7 | 9.9 |
| 121 | 05 | MED | CIRCULATORY DISORDERS W AMI MAJOR COMP, DISCHARGED ALIVE | 1.5787 | 5.6 | 6.9 |
| 122 | 05 | MED | CIRCULATORY DISORDERS W AMI W/O MAJOR COMP, DISCHARGED ALIVE | 1.0241 | 3.2 | 3.9 |
| 123 | 05 | MED | CIRCULATORY DISORDERS W AMI, EXPIRED | 1.5883 | 3.2 | 5.0 |
| 124 | 05 | MED | CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH COMPLEX DIAG | 1.4072 | 3.6 | 4.6 |
| 125 | 05 | MED | CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG | 1.0406 | 2.2 | 2.8 |
| 126 | 05 | MED | ACUTE SUBACUTE ENDOCARDITIS | 2.6836 | 10.5 | 13.0 |
| 127 | 05 | MED | HEART FAILURE SHOCK | 1.0103 | 4.5 | 5.6 |
| 128 | 05 | MED | DEEP VEIN THROMBOPHLEBITIS | .7320 | 5.2 | 5.9 |
| 129 | 05 | MED | CARDIAC ARREST, UNEXPLAINED | 1.0209 | 1.7 | 2.8 |
| 130 | 05 | MED | PERIPHERAL VASCULAR DISORDERS W CC | .9379 | 5.0 | 6.1 |
| 131 | 05 | MED | PERIPHERAL VASCULAR DISORDERS W/O CC | .5725 | 3.8 | 4.5 |
| 132 | 05 | MED | ATHEROSCLEROSIS W CC | .6473 | 2.5 | 3.1 |
| 133 | 05 | MED | ATHEROSCLEROSIS W/O CC | .5558 | 1.9 | 2.3 |
| 134 | 05 | MED | HYPERTENSION | .5814 | 2.7 | 3.4 |
| 135 | 05 | MED | CARDIAC CONGENITAL VALVULAR DISORDERS AGE 17 W CC | .9128 | 3.7 | 4.8 |
| 136 | 05 | MED | CARDIAC CONGENITAL VALVULAR DISORDERS AGE 17 W/O CC | .5643 | 2.2 | 2.8 |
| 137 | 05 | MED | *CARDIAC CONGENITAL VALVULAR DISORDERS AGE 0-17 | .8177 | 3.3 | 3.3 |
| 138 | 05 | MED | CARDIAC ARRHYTHMIA CONDUCTION DISORDERS W CC | .8222 | 3.3 | 4.2 |
| 139 | 05 | MED | CARDIAC ARRHYTHMIA CONDUCTION DISORDERS W/O CC | .4961 | 2.1 | 2.5 |
| 140 | 05 | MED | ANGINA PECTORIS | .5335 | 2.2 | 2.7 |
| 141 | 05 | MED | SYNCOPE COLLAPSE W CC | .7241 | 3.0 | 3.8 |
| 142 | 05 | MED | SYNCOPE COLLAPSE W/O CC | .5395 | 2.2 | 2.7 |
| 143 | 05 | MED | CHEST PAIN | .5191 | 1.7 | 2.1 |
| 144 | 05 | MED | OTHER CIRCULATORY SYSTEM DIAGNOSES W CC | 1.2015 | 4.3 | 5.8 |
| 145 | 05 | MED | OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC | .5899 | 2.2 | 2.8 |
| 146 | 06 | SURG | RECTAL RESECTION W CC | 2.7764 | 9.6 | 10.9 |
| 147 | 06 | SURG | RECTAL RESECTION W/O CC | 1.5993 | 6.2 | 6.7 |
| 148 | 06 | SURG | MAJOR SMALL LARGE BOWEL PROCEDURES W CC | 3.5332 | 11.1 | 13.1 |
| 149 | 06 | SURG | MAJOR SMALL LARGE BOWEL PROCEDURES W/O CC | 1.5063 | 6.2 | 6.7 |
| 150 | 06 | SURG | PERITONEAL ADHESIOLYSIS W CC | 2.9483 | 10.5 | 12.2 |
| 151 | 06 | SURG | PERITONEAL ADHESIOLYSIS W/O CC | 1.3451 | 5.3 | 6.3 |
| 152 | 06 | SURG | MINOR SMALL LARGE BOWEL PROCEDURES W CC | 1.9477 | 7.4 | 8.7 |
| 153 | 06 | SURG | MINOR SMALL LARGE BOWEL PROCEDURES W/O CC | 1.1642 | 5.1 | 5.6 |
| 154 | 06 | SURG | STOMACH, ESOPHAGEAL DUODENAL PROCEDURES AGE 17 W CC | 4.3519 | 11.9 | 14.7 |
| 155 | 06 | SURG | STOMACH, ESOPHAGEAL DUODENAL PROCEDURES AGE 17 W/O CC | 1.3273 | 3.4 | 4.5 |
| 156 | 06 | SURG | *STOMACH, ESOPHAGEAL DUODENAL PROCEDURES AGE 0-17 | .8421 | 6.0 | 6.0 |
| 157 | 06 | SURG | ANAL STOMAL PROCEDURES W CC | 1.2599 | 4.4 | 5.9 |
| 158 | 06 | SURG | ANAL STOMAL PROCEDURES W/O CC | .6209 | 2.0 | 2.5 |
| 159 | 06 | SURG | HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL AGE 17 W CC | 1.3618 | 4.2 | 5.4 |
| 160 | 06 | SURG | HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL AGE 17 W/O CC | .7655 | 2.2 | 2.7 |
| 161 | 06 | SURG | INGUINAL FEMORAL HERNIA PROCEDURES AGE 17 W CC | 1.1375 | 3.2 | 4.5 |
| 162 | 06 | SURG | INGUINAL FEMORAL HERNIA PROCEDURES AGE 17 W/O CC | .6121 | 1.6 | 1.9 |
| 163 | 06 | SURG | *HERNIA PROCEDURES AGE 0-17 | .6909 | 2.1 | 2.1 |
| 164 | 06 | SURG | APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC | 2.3960 | 7.8 | 9.0 |
| 165 | 06 | SURG | APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC | 1.2904 | 4.5 | 5.0 |
| 166 | 06 | SURG | APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC | 1.4934 | 4.2 | 5.4 |
| 167 | 06 | SURG | APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC | .8753 | 2.2 | 2.6 |
| 168 | 03 | SURG | MOUTH PROCEDURES W CC | 1.2982 | 3.6 | 5.2 |
| 169 | 03 | SURG | MOUTH PROCEDURES W/O CC | .6964 | 1.8 | 2.3 |
| 170 | 06 | SURG | OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC | 3.0540 | 9.4 | 12.5 |
| 171 | 06 | SURG | OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC | 1.1716 | 3.8 | 4.8 |
| 172 | 06 | MED | DIGESTIVE MALIGNANCY W CC | 1.3985 | 5.9 | 7.6 |
| 173 | 06 | MED | DIGESTIVE MALIGNANCY W/O CC | .6933 | 3.0 | 3.9 |
| 174 | 06 | MED | G.I. HEMORRHAGE W CC | .9896 | 4.1 | 5.1 |
| 175 | 06 | MED | G.I. HEMORRHAGE W/O CC | .5419 | 2.6 | 3.0 |
| 176 | 06 | MED | COMPLICATED PEPTIC ULCER | 1.0888 | 4.4 | 5.6 |
| 177 | 06 | MED | UNCOMPLICATED PEPTIC ULCER W CC | .8910 | 3.9 | 4.8 |
| 178 | 06 | MED | UNCOMPLICATED PEPTIC ULCER W/O CC | .6408 | 2.7 | 3.2 |
| 179 | 06 | MED | INFLAMMATORY BOWEL DISEASE | 1.0868 | 5.1 | 6.4 |
| 180 | 06 | MED | G.I. OBSTRUCTION W CC | .9565 | 4.6 | 5.7 |
| 181 | 06 | MED | G.I. OBSTRUCTION W/O CC | .5237 | 3.0 | 3.5 |
| 182 | 06 | MED | ESOPHAGITIS, GASTROENT MISC DIGEST DISORDERS AGE 17 W CC | .7940 | 3.6 | 4.6 |
| 183 | 06 | MED | ESOPHAGITIS, GASTROENT MISC DIGEST DISORDERS AGE 17 W/O CC | .5568 | 2.4 | 3.0 |
| 184 | 06 | MED | ESOPHAGITIS, GASTROENT MISC DIGEST DISORDERS AGE 0-17 | .4141 | 2.5 | 3.0 |
| 185 | 03 | MED | DENTAL ORAL DIS EXCEPT EXTRACTIONS RESTORATIONS, AGE 17 | .8660 | 3.6 | 4.8 |
| 186 | 03 | MED | *DENTAL ORAL DIS EXCEPT EXTRACTIONS RESTORATIONS, AGE 0-17 | .3210 | 2.9 | 2.9 |
| 187 | 03 | MED | DENTAL EXTRACTIONS RESTORATIONS | .7868 | 3.2 | 4.2 |
| 188 | 06 | MED | OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 17 W CC | 1.1250 | 4.6 | 6.0 |
| 189 | 06 | MED | OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 17 W/O CC | .5776 | 2.5 | 3.3 |
| 190 | 06 | MED | OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 0-17 | 1.1897 | 4.5 | 7.4 |
| 191 | 07 | SURG | PANCREAS, LIVER SHUNT PROCEDURES W CC | 4.6199 | 12.2 | 15.5 |
| 192 | 07 | SURG | PANCREAS, LIVER SHUNT PROCEDURES W/O CC | 1.8255 | 6.0 | 7.1 |
| 193 | 07 | SURG | BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC | 3.5085 | 11.6 | 13.6 |
| 194 | 07 | SURG | BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC | 1.7294 | 6.3 | 7.3 |
| 195 | 07 | SURG | CHOLECYSTECTOMY W C.D.E. W CC | 3.0863 | 9.4 | 10.9 |
| 196 | 07 | SURG | CHOLECYSTECTOMY W C.D.E. W/O CC | 1.6111 | 5.3 | 6.0 |
| 197 | 07 | SURG | CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC | 2.5748 | 8.1 | 9.6 |
| 198 | 07 | SURG | CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC | 1.2062 | 4.2 | 4.7 |
| 199 | 07 | SURG | HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY | 2.5070 | 8.4 | 10.9 |
| 200 | 07 | SURG | HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY | 3.1811 | 8.5 | 12.0 |
| 201 | 07 | SURG | OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES | 3.7986 | 12.3 | 15.6 |
| 202 | 07 | MED | CIRRHOSIS ALCOHOLIC HEPATITIS | 1.3291 | 5.5 | 7.0 |
| 203 | 07 | MED | MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS | 1.3627 | 5.7 | 7.3 |
| 204 | 07 | MED | DISORDERS OF PANCREAS EXCEPT MALIGNANCY | 1.2047 | 4.9 | 6.2 |
| 205 | 07 | MED | DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC | 1.2207 | 5.2 | 6.7 |
| 206 | 07 | MED | DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC | .7302 | 3.2 | 4.1 |
| 207 | 07 | MED | DISORDERS OF THE BILIARY TRACT W CC | 1.1120 | 4.3 | 5.5 |
| 208 | 07 | MED | DISORDERS OF THE BILIARY TRACT W/O CC | .6380 | 2.4 | 3.0 |
| 209 | 08 | SURG | MAJOR JOINT LIMB REATTACHMENT PROCEDURES OF LOWER EXTREMITY | 1.9917 | 4.6 | 5.1 |
| 210 | 08 | SURG | HIP FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 17 W CC | 1.7503 | 6.1 | 6.9 |
| 211 | 08 | SURG | HIP FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 17 W/O CC | 1.2236 | 4.6 | 5.0 |
| 212 | 08 | SURG | *HIP FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 0-17 | .8457 | 11.1 | 11.1 |
| 213 | 08 | SURG | AMPUTATION FOR MUSCULOSKELETAL SYSTEM CONN TISSUE DISORDERS | 1.9437 | 7.7 | 10.0 |
| 214 | 08 | SURG | NO LONGER VALID | .0000 | .0 | .0 |
| 215 | 08 | SURG | NO LONGER VALID | .0000 | .0 | .0 |
| 216 | 08 | SURG | BIOPSIES OF MUSCULOSKELETAL SYSTEM CONNECTIVE TISSUE | 2.3172 | 8.5 | 10.9 |
| 217 | 08 | SURG | WND DEBRID SKN GRFT EXCEPT HAND,FOR MUSCSKELET CONN TISS DIS | 3.2005 | 11.0 | 15.2 |
| 218 | 08 | SURG | LOWER EXTREM HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE 17 W CC | 1.5499 | 4.7 | 5.8 |
| 219 | 08 | SURG | LOWER EXTREM HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE 17 W/O CC | .9950 | 2.8 | 3.3 |
| 220 | 08 | SURG | *LOWER EXTREM HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE 0-17 | .5834 | 5.3 | 5.3 |
| 221 | 08 | SURG | NO LONGER VALID | .0000 | .0 | .0 |
| 222 | 08 | SURG | NO LONGER VALID | .0000 | .0 | .0 |
| 223 | 08 | SURG | MAJOR SHOULDER/ELBOW PROC, OR OTHER UPPER EXTREMITY PROC W CC | .9723 | 2.1 | 2.9 |
| 224 | 08 | SURG | SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC, W/O CC | .7697 | 1.6 | 1.9 |
| 225 | 08 | SURG | FOOT PROCEDURES | 1.1164 | 3.8 | 5.3 |
| 226 | 08 | SURG | SOFT TISSUE PROCEDURES W CC | 1.5902 | 5.2 | 7.3 |
| 227 | 08 | SURG | SOFT TISSUE PROCEDURES W/O CC | .7922 | 2.1 | 2.7 |
| 228 | 08 | SURG | MAJOR THUMB OR JOINT PROC,OR OTH HAND OR WRIST PROC W CC | 1.0906 | 2.7 | 4.0 |
| 229 | 08 | SURG | HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC | .7142 | 1.9 | 2.5 |
| 230 | 08 | SURG | LOCAL EXCISION REMOVAL OF INT FIX DEVICES OF HIP FEMUR | 1.3598 | 3.9 | 5.8 |
| 231 | 08 | SURG | LOCAL EXCISION REMOVAL OF INT FIX DEVICES EXCEPT HIP FEMUR | 1.4340 | 3.6 | 5.4 |
| 232 | 08 | SURG | ARTHROSCOPY | .9532 | 1.8 | 2.9 |
| 233 | 08 | SURG | OTHER MUSCULOSKELET SYS CONN TISS O.R. PROC W CC | 2.0945 | 6.3 | 8.4 |
| 234 | 08 | SURG | OTHER MUSCULOSKELET SYS CONN TISS O.R. PROC W/O CC | 1.2097 | 2.7 | 3.6 |
| 235 | 08 | MED | FRACTURES OF FEMUR | .7632 | 4.1 | 5.5 |
| 236 | 08 | MED | FRACTURES OF HIP PELVIS | .6889 | 3.9 | 4.9 |
| 237 | 08 | MED | SPRAINS, STRAINS, DISLOCATIONS OF HIP, PELVIS THIGH | .5325 | 3.0 | 3.6 |
| 238 | 08 | MED | OSTEOMYELITIS | 1.4154 | 7.4 | 9.4 |
| 239 | 08 | MED | PATHOLOGICAL FRACTURES MUSCULOSKELETAL CONN TISS MALIGNANCY | 1.0032 | 5.4 | 6.7 |
| 240 | 08 | MED | CONNECTIVE TISSUE DISORDERS W CC | 1.3692 | 5.6 | 7.3 |
| 241 | 08 | MED | CONNECTIVE TISSUE DISORDERS W/O CC | .6315 | 3.3 | 4.0 |
| 242 | 08 | MED | SEPTIC ARTHRITIS | 1.0953 | 5.7 | 7.2 |
| 243 | 08 | MED | MEDICAL BACK PROBLEMS | .7304 | 4.0 | 4.9 |
| 244 | 08 | MED | BONE DISEASES SPECIFIC ARTHROPATHIES W CC | .7152 | 4.1 | 5.1 |
| 245 | 08 | MED | BONE DISEASES SPECIFIC ARTHROPATHIES W/O CC | .4665 | 2.9 | 3.6 |
| 246 | 08 | MED | NON-SPECIFIC ARTHROPATHIES | .5717 | 3.2 | 4.1 |
| 247 | 08 | MED | SIGNS SYMPTOMS OF MUSCULOSKELETAL SYSTEM CONN TISSUE | .5587 | 2.8 | 3.6 |
| 248 | 08 | MED | TENDONITIS, MYOSITIS BURSITIS | .8160 | 4.1 | 5.1 |
| 249 | 08 | MED | AFTERCARE, MUSCULOSKELETAL SYSTEM CONNECTIVE TISSUE | .6784 | 2.7 | 3.9 |
| 250 | 08 | MED | FX, SPRN, STRN DISL OF FOREARM, HAND, FOOT AGE 17 W CC | .6809 | 3.5 | 4.3 |
| 251 | 08 | MED | FX, SPRN, STRN DISL OF FOREARM, HAND, FOOT AGE 17 W/O CC | .4582 | 2.4 | 2.9 |
| 252 | 08 | MED | *FX, SPRN, STRN DISL OF FOREARM, HAND, FOOT AGE 0-17 | .2533 | 1.8 | 1.8 |
| 253 | 08 | MED | FX, SPRN, STRN DISL OF UPARM,LOWLEG EX FOOT AGE 17 W CC | .7397 | 4.0 | 5.0 |
| 254 | 08 | MED | FX, SPRN, STRN DISL OF UPARM,LOWLEG EX FOOT AGE 17 W/O CC | .4294 | 2.8 | 3.3 |
| 255 | 08 | MED | *FX, SPRN, STRN DISL OF UPARM,LOWLEG EX FOOT AGE 0-17 | .2951 | 2.9 | 2.9 |
| 256 | 08 | MED | OTHER MUSCULOSKELETAL SYSTEM CONNECTIVE TISSUE DIAGNOSES | .8152 | 4.2 | 5.4 |
| 257 | 09 | SURG | TOTAL MASTECTOMY FOR MALIGNANCY W CC | .8783 | 2.2 | 2.8 |
| 258 | 09 | SURG | TOTAL MASTECTOMY FOR MALIGNANCY W/O CC | .6954 | 1.7 | 1.9 |
| 259 | 09 | SURG | SUBTOTAL MASTECTOMY FOR MALIGNANCY W CC | .8763 | 1.8 | 2.7 |
| 260 | 09 | SURG | SUBTOTAL MASTECTOMY FOR MALIGNANCY W/O CC | .6435 | 1.3 | 1.4 |
| 261 | 09 | SURG | BREAST PROC FOR NON-MALIGNANCY EXCEPT BIOPSY LOCAL EXCISION | .9240 | 1.7 | 2.3 |
| 262 | 09 | SURG | BREAST BIOPSY LOCAL EXCISION FOR NON-MALIGNANCY | .8487 | 3.0 | 4.3 |
| 263 | 09 | SURG | SKIN GRAFT /OR DEBRID FOR SKN ULCER OR CELLULITIS W CC | 2.0570 | 9.1 | 12.3 |
| 264 | 09 | SURG | SKIN GRAFT /OR DEBRID FOR SKN ULCER OR CELLULITIS W/O CC | 1.1079 | 5.6 | 7.3 |
| 265 | 09 | SURG | SKIN GRAFT /OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W CC | 1.6795 | 5.2 | 7.6 |
| 266 | 09 | SURG | SKIN GRAFT /OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC | .8414 | 2.4 | 3.4 |
| 267 | 09 | SURG | PERIANAL PILONIDAL PROCEDURES | .9406 | 3.3 | 4.5 |
| 268 | 09 | SURG | SKIN, SUBCUTANEOUS TISSUE BREAST PLASTIC PROCEDURES | 1.2368 | 2.5 | 3.7 |
| 269 | 09 | SURG | OTHER SKIN, SUBCUT TISS BREAST PROC W CC | 1.7731 | 6.9 | 9.2 |
| 270 | 09 | SURG | OTHER SKIN, SUBCUT TISS BREAST PROC W/O CC | .7806 | 2.5 | 3.6 |
| 271 | 09 | MED | SKIN ULCERS | 1.0365 | 6.2 | 7.7 |
| 272 | 09 | MED | MAJOR SKIN DISORDERS W CC | 1.0248 | 5.2 | 6.7 |
| 273 | 09 | MED | MAJOR SKIN DISORDERS W/O CC | .5638 | 3.4 | 4.2 |
| 274 | 09 | MED | MALIGNANT BREAST DISORDERS W CC | 1.1927 | 5.5 | 7.3 |
| 275 | 09 | MED | MALIGNANT BREAST DISORDERS W/O CC | .6647 | 3.1 | 4.6 |
| 276 | 09 | MED | NON-MALIGANT BREAST DISORDERS | .7033 | 4.0 | 5.0 |
| 277 | 09 | MED | CELLULITIS AGE 17 W CC | .8534 | 5.1 | 6.1 |
| 278 | 09 | MED | CELLULITIS AGE 17 W/O CC | .5487 | 3.8 | 4.5 |
| 279 | 09 | MED | *CELLULITIS AGE 0-17 | .6632 | 4.2 | 4.2 |
| 280 | 09 | MED | TRAUMA TO THE SKIN, SUBCUT TISS BREAST AGE 17 W CC | .6941 | 3.5 | 4.4 |
| 281 | 09 | MED | TRAUMA TO THE SKIN, SUBCUT TISS BREAST AGE 17 W/O CC | .4593 | 2.5 | 3.1 |
| 282 | 09 | MED | *TRAUMA TO THE SKIN, SUBCUT TISS BREAST AGE 0-17 | .2565 | 2.2 | 2.2 |
| 283 | 09 | MED | MINOR SKIN DISORDERS W CC | .7152 | 3.8 | 4.9 |
| 284 | 09 | MED | MINOR SKIN DISORDERS W/O CC | .4204 | 2.5 | 3.2 |
| 285 | 10 | SURG | AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT, METABOL DISORDERS | 2.1297 | 9.1 | 11.4 |
| 286 | 10 | SURG | ADRENAL PITUITARY PROCEDURES | 2.2343 | 5.3 | 6.9 |
| 287 | 10 | SURG | SKIN GRAFTS WOUND DEBRID FOR ENDOC, NUTRIT METAB DISORDERS | 1.9569 | 8.9 | 11.7 |
| 288 | 10 | SURG | O.R. PROCEDURES FOR OBESITY | 2.1590 | 4.9 | 6.0 |
| 289 | 10 | SURG | PARATHYROID PROCEDURES | .9573 | 1.9 | 3.0 |
| 290 | 10 | SURG | THYROID PROCEDURES | .8862 | 1.7 | 2.3 |
| 291 | 10 | SURG | THYROGLOSSAL PROCEDURES | .5964 | 1.5 | 1.8 |
| 292 | 10 | SURG | OTHER ENDOCRINE, NUTRIT METAB O.R. PROC W CC | 2.6892 | 8.8 | 11.6 |
| 293 | 10 | SURG | OTHER ENDOCRINE, NUTRIT METAB O.R. PROC W/O CC | 1.3059 | 4.3 | 5.9 |
| 294 | 10 | MED | DIABETES AGE 35 | .7608 | 3.8 | 4.9 |
| 295 | 10 | MED | DIABETES AGE 0-35 | .7457 | 3.1 | 3.9 |
| 296 | 10 | MED | NUTRITIONAL MISC METABOLIC DISORDERS AGE 17 W CC | .8615 | 4.3 | 5.5 |
| 297 | 10 | MED | NUTRITIONAL MISC METABOLIC DISORDERS AGE 17 W/O CC | .5047 | 2.9 | 3.5 |
| 298 | 10 | MED | NUTRITIONAL MISC METABOLIC DISORDERS AGE 0-17 | .4155 | 2.3 | 3.0 |
| 299 | 10 | MED | INBORN ERRORS OF METABOLISM | .9223 | 4.4 | 5.7 |
| 300 | 10 | MED | ENDOCRINE DISORDERS W CC | 1.1243 | 5.3 | 6.6 |
| 301 | 10 | MED | ENDOCRINE DISORDERS W/O CC | .6078 | 3.0 | 3.8 |
| 302 | 11 | SURG | KIDNEY TRANSPLANT | 3.3278 | 7.9 | 9.3 |
| 303 | 11 | SURG | KIDNEY,URETER MAJOR BLADDER PROCEDURES FOR NEOPLASM | 2.4884 | 7.5 | 9.0 |
| 304 | 11 | SURG | KIDNEY,URETER MAJOR BLADDER PROC FOR NON-NEOPL W CC | 2.4618 | 7.4 | 9.7 |
| 305 | 11 | SURG | KIDNEY,URETER MAJOR BLADDER PROC FOR NON-NEOPL W/O CC | 1.1502 | 3.1 | 3.8 |
| 306 | 11 | SURG | PROSTATECTOMY W CC | 1.2988 | 4.3 | 6.2 |
| 307 | 11 | SURG | PROSTATECTOMY W/O CC | .6050 | 1.9 | 2.2 |
| 308 | 11 | SURG | MINOR BLADDER PROCEDURES W CC | 1.6896 | 4.8 | 6.9 |
| 309 | 11 | SURG | MINOR BLADDER PROCEDURES W/O CC | .8936 | 1.8 | 2.3 |
| 310 | 11 | SURG | TRANSURETHRAL PROCEDURES W CC | 1.1366 | 3.3 | 4.7 |
| 311 | 11 | SURG | TRANSURETHRAL PROCEDURES W/O CC | .5957 | 1.5 | 1.8 |
| 312 | 11 | SURG | URETHRAL PROCEDURES, AGE 17 W CC | 1.0782 | 3.3 | 4.8 |
| 313 | 11 | SURG | URETHRAL PROCEDURES, AGE 17 W/O CC | .6584 | 1.8 | 2.3 |
| 314 | 11 | SURG | *URETHRAL PROCEDURES, AGE 0-17 | .4944 | 2.3 | 2.3 |
| 315 | 11 | SURG | OTHER KIDNEY URINARY TRACT O.R. PROCEDURES | 2.1550 | 4.8 | 8.3 |
| 316 | 11 | MED | RENAL FAILURE | 1.3745 | 5.6 | 7.3 |
| 317 | 11 | MED | ADMIT FOR RENAL DIALYSIS | .6130 | 2.0 | 2.9 |
| 318 | 11 | MED | KIDNEY URINARY TRACT NEOPLASMS W CC | 1.1723 | 5.1 | 6.6 |
| 319 | 11 | MED | KIDNEY URINARY TRACT NEOPLASMS W/O CC | .5852 | 2.1 | 2.8 |
| 320 | 11 | MED | KIDNEY URINARY TRACT INFECTIONS AGE 17 W CC | .8593 | 4.6 | 5.6 |
| 321 | 11 | MED | KIDNEY URINARY TRACT INFECTIONS AGE 17 W/O CC | .5560 | 3.3 | 3.9 |
| 322 | 11 | MED | KIDNEY URINARY TRACT INFECTIONS AGE 0-17 | .5267 | 3.6 | 4.3 |
| 323 | 11 | MED | URINARY STONES W CC, /OR ESW LITHOTRIPSY | .7970 | 2.5 | 3.3 |
| 324 | 11 | MED | URINARY STONES W/O CC | .4422 | 1.6 | 1.9 |
| 325 | 11 | MED | KIDNEY URINARY TRACT SIGNS SYMPTOMS AGE 17 W CC | .6336 | 3.1 | 4.0 |
| 326 | 11 | MED | KIDNEY URINARY TRACT SIGNS SYMPTOMS AGE 17 W/O CC | .4120 | 2.1 | 2.7 |
| 327 | 11 | MED | KIDNEY URINARY TRACT SIGNS SYMPTOMS AGE 0-17 | .3697 | 2.8 | 3.2 |
| 328 | 11 | MED | URETHRAL STRICTURE AGE 17 W CC | .7268 | 2.9 | 3.9 |
| 329 | 11 | MED | URETHRAL STRICTURE AGE 17 W/O CC | .4458 | 1.6 | 2.0 |
| 330 | 11 | MED | *URETHRAL STRICTURE AGE 0-17 | .3185 | 1.6 | 1.6 |
| 331 | 11 | MED | OTHER KIDNEY URINARY TRACT DIAGNOSES AGE 17 W CC | 1.0640 | 4.6 | 6.0 |
| 332 | 11 | MED | OTHER KIDNEY URINARY TRACT DIAGNOSES AGE 17 W/O CC | .6056 | 2.6 | 3.4 |
| 333 | 11 | MED | OTHER KIDNEY URINARY TRACT DIAGNOSES AGE 0-17 | .7907 | 3.9 | 5.3 |
| 334 | 12 | SURG | MAJOR MALE PELVIC PROCEDURES W CC | 1.5177 | 4.3 | 5.0 |
| 335 | 12 | SURG | MAJOR MALE PELVIC PROCEDURES W/O CC | 1.1047 | 3.1 | 3.3 |
| 336 | 12 | SURG | TRANSURETHRAL PROSTATECTOMY W CC | .8630 | 2.8 | 3.6 |
| 337 | 12 | SURG | TRANSURETHRAL PROSTATECTOMY W/O CC | .5861 | 1.9 | 2.1 |
| 338 | 12 | SURG | TESTES PROCEDURES, FOR MALIGNANCY | 1.2191 | 3.7 | 5.6 |
| 339 | 12 | SURG | TESTES PROCEDURES, NON-MALIGNANCY AGE 17 | 1.1555 | 3.3 | 5.0 |
| 340 | 12 | SURG | *TESTES PROCEDURES, NON-MALIGNANCY AGE 0-17 | .2830 | 2.4 | 2.4 |
| 341 | 12 | SURG | PENIS PROCEDURES | 1.1306 | 2.0 | 3.0 |
| 342 | 12 | SURG | CIRCUMCISION AGE 17 | .7852 | 2.5 | 3.3 |
| 343 | 12 | SURG | *CIRCUMCISION AGE 0-17 | .1538 | 1.7 | 1.7 |
| 344 | 12 | SURG | OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY | 1.1741 | 1.6 | 2.4 |
| 345 | 12 | SURG | OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY | .9149 | 2.7 | 4.0 |
| 346 | 12 | MED | MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W CC | 1.0304 | 4.9 | 6.4 |
| 347 | 12 | MED | MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W/O CC | .5660 | 2.3 | 3.0 |
| 348 | 12 | MED | BENIGN PROSTATIC HYPERTROPHY W CC | .6998 | 3.4 | 4.4 |
| 349 | 12 | MED | BENIGN PROSTATIC HYPERTROPHY W/O CC | .4128 | 2.0 | 2.5 |
| 350 | 12 | MED | INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM | .7164 | 3.8 | 4.6 |
| 351 | 12 | MED | *STERILIZATION, MALE | .2360 | 1.3 | 1.3 |
| 352 | 12 | MED | OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES | .6868 | 3.0 | 4.2 |
| 353 | 13 | SURG | PELVIC EVISCERATION, RADICAL HYSTERECTOMY RADICAL VULVECTOMY | 1.8493 | 5.4 | 6.8 |
| 354 | 13 | SURG | UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC | 1.5317 | 5.1 | 6.1 |
| 355 | 13 | SURG | UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC | .9033 | 3.1 | 3.3 |
| 356 | 13 | SURG | FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES | .7440 | 2.0 | 2.3 |
| 357 | 13 | SURG | UTERINE ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY | 2.4380 | 7.5 | 9.2 |
| 358 | 13 | SURG | UTERINE ADNEXA PROC FOR NON-MALIGNANCY W CC | 1.1902 | 3.7 | 4.4 |
| 359 | 13 | SURG | UTERINE ADNEXA PROC FOR NON-MALIGNANCY W/O CC | .8165 | 2.6 | 2.8 |
| 360 | 13 | SURG | VAGINA, CERVIX VULVA PROCEDURES | .8520 | 2.4 | 2.9 |
| 361 | 13 | SURG | LAPAROSCOPY INCISIONAL TUBAL INTERRUPTION | 1.0964 | 2.1 | 3.0 |
| 362 | 13 | SURG | *ENDOSCOPIC TUBAL INTERRUPTION | .3017 | 1.4 | 1.4 |
| 363 | 13 | SURG | DC, CONIZATION RADIO-IMPLANT, FOR MALIGNANCY | .8158 | 2.6 | 3.6 |
| 364 | 13 | SURG | DC, CONIZATION EXCEPT FOR MALIGNANCY | .8170 | 2.9 | 4.1 |
| 365 | 13 | SURG | OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES | 2.0008 | 5.8 | 8.1 |
| 366 | 13 | MED | MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC | 1.2699 | 5.6 | 7.4 |
| 367 | 13 | MED | MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC | .5767 | 2.4 | 3.2 |
| 368 | 13 | MED | INFECTIONS, FEMALE REPRODUCTIVE SYSTEM | 1.1355 | 5.6 | 7.0 |
| 369 | 13 | MED | MENSTRUAL OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS | .5581 | 2.5 | 3.4 |
| 370 | 14 | SURG | CESAREAN SECTION W CC | 1.0572 | 4.7 | 6.1 |
| 371 | 14 | SURG | CESAREAN SECTION W/O CC | .6845 | 3.3 | 3.7 |
| 372 | 14 | MED | VAGINAL DELIVERY W COMPLICATING DIAGNOSES | .5550 | 2.7 | 3.3 |
| 373 | 14 | MED | VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES | .3774 | 2.0 | 2.3 |
| 374 | 14 | SURG | VAGINAL DELIVERY W STERILIZATION /OR DC | .6835 | 2.5 | 3.1 |
| 375 | 14 | SURG | VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL /OR DC | .5759 | 2.1 | 2.3 |
| 376 | 14 | MED | POSTPARTUM POST ABORTION DIAGNOSES W/O O.R. PROCEDURE | .4963 | 2.5 | 3.2 |
| 377 | 14 | SURG | POSTPARTUM POST ABORTION DIAGNOSES W O.R. PROCEDURE | 1.6892 | 3.8 | 5.6 |
| 378 | 14 | MED | ECTOPIC PREGNANCY | .8017 | 2.0 | 2.4 |
| 379 | 14 | MED | THREATENED ABORTION | .4521 | 2.4 | 3.6 |
| 380 | 14 | MED | ABORTION W/O DC | .4201 | 1.6 | 2.1 |
| 381 | 14 | SURG | ABORTION W DC, ASPIRATION CURETTAGE OR HYSTEROTOMY | .6628 | 1.8 | 2.5 |
| 382 | 14 | MED | FALSE LABOR | .1599 | 1.2 | 1.3 |
| 383 | 14 | MED | OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS | .4915 | 2.8 | 3.8 |
| 384 | 14 | MED | OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS | .3626 | 1.6 | 2.1 |
| 385 | 15 | MED | *NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY | 1.3743 | 1.8 | 1.8 |
| 386 | 15 | MED | *EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE | 4.5319 | 17.9 | 17.9 |
| 387 | 15 | MED | *PREMATURITY W MAJOR PROBLEMS | 3.0952 | 13.3 | 13.3 |
| 388 | 15 | MED | *PREMATURITY W/O MAJOR PROBLEMS | 1.8676 | 8.6 | 8.6 |
| 389 | 15 | MED | FULL TERM NEONATE W MAJOR PROBLEMS | 3.1794 | 9.3 | 16.0 |
| 390 | 15 | MED | NEONATE W OTHER SIGNIFICANT PROBLEMS | 1.1253 | 3.5 | 4.3 |
| 391 | 15 | MED | *NORMAL NEWBORN | .1524 | 3.1 | 3.1 |
| 392 | 16 | SURG | SPLENECTOMY AGE 17 | 3.3892 | 8.3 | 10.8 |
| 393 | 16 | SURG | *SPLENECTOMY AGE 0-17 | 1.3462 | 9.1 | 9.1 |
| 394 | 16 | SURG | OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS | 1.8231 | 5.1 | 8.1 |
| 395 | 16 | MED | RED BLOOD CELL DISORDERS AGE 17 | .8192 | 3.5 | 4.7 |
| 396 | 16 | MED | RED BLOOD CELL DISORDERS AGE 0-17 | 1.0407 | 3.9 | 5.0 |
| 397 | 16 | MED | COAGULATION DISORDERS | 1.2671 | 4.2 | 5.6 |
| 398 | 16 | MED | RETICULOENDOTHELIAL IMMUNITY DISORDERS W CC | 1.3082 | 5.1 | 6.4 |
| 399 | 16 | MED | RETICULOENDOTHELIAL IMMUNITY DISORDERS W/O CC | .6675 | 3.0 | 3.7 |
| 400 | 17 | SURG | LYMPHOMA LEUKEMIA W MAJOR O.R. PROCEDURE | 2.9346 | 7.4 | 10.5 |
| 401 | 17 | SURG | LYMPHOMA NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC | 2.9905 | 9.9 | 12.8 |
| 402 | 17 | SURG | LYMPHOMA NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC | 1.1594 | 3.1 | 4.4 |
| 403 | 17 | MED | LYMPHOMA NON-ACUTE LEUKEMIA W CC | 1.8579 | 6.8 | 9.1 |
| 404 | 17 | MED | LYMPHOMA NON-ACUTE LEUKEMIA W/O CC | .8718 | 3.4 | 4.6 |
| 405 | 17 | MED | *ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 0-17 | 1.9086 | 4.9 | 4.9 |
| 406 | 17 | SURG | MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W CC | 2.9939 | 8.4 | 11.1 |
| 407 | 17 | SURG | MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W/O CC | 1.2426 | 3.8 | 4.7 |
| 408 | 17 | SURG | MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R.PROC | 2.2144 | 6.0 | 9.2 |
| 409 | 17 | MED | RADIOTHERAPY | 1.1575 | 4.9 | 6.3 |
| 410 | 17 | MED | CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS | .9991 | 3.3 | 4.1 |
| 411 | 17 | MED | HISTORY OF MALIGNANCY W/O ENDOSCOPY | .4481 | 1.8 | 2.3 |
| 412 | 17 | MED | HISTORY OF MALIGNANCY W ENDOSCOPY | .5958 | 1.9 | 2.4 |
| 413 | 17 | MED | OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC | 1.3894 | 6.1 | 7.8 |
| 414 | 17 | MED | OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC | .7418 | 3.5 | 4.6 |
| 415 | 18 | SURG | O.R. PROCEDURE FOR INFECTIOUS PARASITIC DISEASES | 3.9067 | 12.6 | 16.3 |
| 416 | 18 | MED | SEPTICEMIA AGE 17 | 1.6226 | 6.4 | 8.1 |
| 417 | 18 | MED | SEPTICEMIA AGE 0-17 | .8915 | 4.4 | 5.4 |
| 418 | 18 | MED | POSTOPERATIVE POST-TRAUMATIC INFECTIONS | 1.0493 | 5.3 | 6.6 |
| 419 | 18 | MED | FEVER OF UNKNOWN ORIGIN AGE 17 W CC | .8618 | 4.0 | 5.0 |
| 420 | 18 | MED | FEVER OF UNKNOWN ORIGIN AGE 17 W/O CC | .6112 | 3.0 | 3.6 |
| 421 | 18 | MED | VIRAL ILLNESS AGE 17 | .6640 | 3.2 | 3.9 |
| 422 | 18 | MED | VIRAL ILLNESS FEVER OF UNKNOWN ORIGIN AGE 0-17 | .4757 | 2.6 | 3.1 |
| 423 | 18 | MED | OTHER INFECTIOUS PARASITIC DISEASES DIAGNOSES | 1.8365 | 6.7 | 9.0 |
| 424 | 19 | SURG | O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS | 2.4518 | 10.9 | 15.9 |
| 425 | 19 | MED | ACUTE ADJUSTMENT REACTION PSYCHOSOCIAL DYSFUNCTION | .6789 | 3.2 | 4.2 |
| 426 | 19 | MED | DEPRESSIVE NEUROSES | .5261 | 3.5 | 4.7 |
| 427 | 19 | MED | NEUROSES EXCEPT DEPRESSIVE | .5348 | 3.5 | 5.0 |
| 428 | 19 | MED | DISORDERS OF PERSONALITY IMPULSE CONTROL | .7242 | 5.0 | 7.8 |
| 429 | 19 | MED | ORGANIC DISTURBANCES MENTAL RETARDATION | .8367 | 5.2 | 6.9 |
| 430 | 19 | MED | PSYCHOSES | .7676 | 6.7 | 8.9 |
| 431 | 19 | MED | CHILDHOOD MENTAL DISORDERS | .6416 | 5.1 | 7.1 |
| 432 | 19 | MED | OTHER MENTAL DISORDER DIAGNOSES | .7100 | 3.4 | 5.1 |
| 433 | 20 | MED | ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA | .2888 | 2.3 | 3.2 |
| 434 | 20 | MED | NO LONGER VALID | .0000 | .0 | .0 |
| 435 | 20 | MED | NO LONGER VALID | .0000 | .0 | .0 |
| 436 | 20 | MED | NO LONGER VALID | .0000 | .0 | .0 |
| 437 | 20 | MED | NO LONGER VALID | .0000 | .0 | .0 |
| 438 | 20 | NO LONGER VALID | .0000 | .0 | .0 | |
| 439 | 21 | SURG | SKIN GRAFTS FOR INJURIES | 1.9332 | 6.7 | 9.5 |
| 440 | 21 | SURG | WOUND DEBRIDEMENTS FOR INJURIES | 2.0806 | 7.2 | 10.3 |
| 441 | 21 | SURG | HAND PROCEDURES FOR INJURIES | .9295 | 2.3 | 3.3 |
| 442 | 21 | SURG | OTHER O.R. PROCEDURES FOR INJURIES W CC | 2.5304 | 6.8 | 9.6 |
| 443 | 21 | SURG | OTHER O.R. PROCEDURES FOR INJURIES W/O CC | .9920 | 2.7 | 3.6 |
| 444 | 21 | MED | TRAUMATIC INJURY AGE 17 W CC | .7277 | 3.4 | 4.4 |
| 445 | 21 | MED | TRAUMATIC INJURY AGE 17 W/O CC | .4716 | 2.4 | 3.0 |
| 446 | 21 | MED | *TRAUMATIC INJURY AGE 0-17 | .2959 | 2.4 | 2.4 |
| 447 | 21 | MED | ALLERGIC REACTIONS AGE 17 | .4825 | 1.8 | 2.5 |
| 448 | 21 | MED | *ALLERGIC REACTIONS AGE 0-17 | .0973 | 2.9 | 2.9 |
| 449 | 21 | MED | POISONING TOXIC EFFECTS OF DRUGS AGE 17 W CC | .8309 | 2.8 | 4.0 |
| 450 | 21 | MED | POISONING TOXIC EFFECTS OF DRUGS AGE 17 W/O CC | .4139 | 1.6 | 2.0 |
| 451 | 21 | MED | *POISONING TOXIC EFFECTS OF DRUGS AGE 0-17 | .2627 | 2.1 | 2.1 |
| 452 | 21 | MED | COMPLICATIONS OF TREATMENT W CC | 1.0122 | 3.8 | 5.2 |
| 453 | 21 | MED | COMPLICATIONS OF TREATMENT W/O CC | .4980 | 2.2 | 2.8 |
| 454 | 21 | MED | OTHER INJURY, POISONING TOXIC EFFECT DIAG W CC | .8692 | 3.4 | 4.9 |
| 455 | 21 | MED | OTHER INJURY, POISONING TOXIC EFFECT DIAG W/O CC | .4630 | 1.9 | 2.6 |
| 456 | 22 | NO LONGER VALID | .0000 | .0 | .0 | |
| 457 | 22 | MED | NO LONGER VALID | .0000 | .0 | .0 |
| 458 | 22 | SURG | NO LONGER VALID | .0000 | .0 | .0 |
| 459 | 22 | SURG | NO LONGER VALID | .0000 | .0 | .0 |
| 460 | 22 | MED | NO LONGER VALID | .0000 | .0 | .0 |
| 461 | 23 | SURG | O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES | 1.1963 | 2.5 | 4.6 |
| 462 | 23 | MED | REHABILITATION | 1.2125 | 10.4 | 12.3 |
| 463 | 23 | MED | SIGNS SYMPTOMS W CC | .6800 | 3.4 | 4.3 |
| 464 | 23 | MED | SIGNS SYMPTOMS W/O CC | .4628 | 2.5 | 3.1 |
| 465 | 23 | MED | AFTERCARE W HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS | .5445 | 2.1 | 3.1 |
| 466 | 23 | MED | AFTERCARE W/O HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS | .6416 | 2.3 | 3.8 |
| 467 | 23 | MED | OTHER FACTORS INFLUENCING HEALTH STATUS | .4585 | 2.1 | 3.1 |
| 468 | EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS | 3.8756 | 11.4 | 14.7 | ||
| 469 | **PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS | .0000 | .0 | .0 | ||
| 470 | **UNGROUPABLE | .0000 | .0 | .0 | ||
| 471 | 08 | SURG | BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY | 3.0067 | 5.0 | 5.7 |
| 472 | 22 | SURG | NO LONGER VALID | .0000 | .0 | .0 |
| 473 | 17 | SURG | ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 17 | 3.9324 | 9.8 | 15.1 |
| 474 | 04 | SURG | NO LONGER VALID | .0000 | .0 | .0 |
| 475 | 04 | MED | RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT | 3.9253 | 10.0 | 12.7 |
| 476 | SURG | PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS | 2.2915 | 10.0 | 12.3 | |
| 477 | SURG | NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS | 1.9568 | 6.7 | 9.3 | |
| 478 | 05 | SURG | OTHER VASCULAR PROCEDURES W CC | 2.4161 | 5.9 | 8.2 |
| 479 | 05 | SURG | OTHER VASCULAR PROCEDURES W/O CC | 1.3900 | 2.8 | 3.6 |
| 480 | PRE | SURG | LIVER TRANSPLANT | 10.9812 | 18.1 | 23.9 |
| 481 | PRE | SURG | BONE MARROW TRANSPLANT | 8.0438 | 23.6 | 25.8 |
| 482 | PRE | SURG | TRACHEOSTOMY FOR FACE,MOUTH NECK DIAGNOSES | 3.8583 | 11.4 | 14.3 |
| 483 | PRE | SURG | TRACHEOSTOMY EXCEPT FOR FACE,MOUTH NECK DIAGNOSES | 15.4629 | 34.2 | 41.5 |
| 484 | 24 | SURG | CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA | 5.2963 | 11.7 | 14.9 |
| 485 | 24 | SURG | LIMB REATTACHMENT, HIP AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TRA | 3.1724 | 8.5 | 10.5 |
| 486 | 24 | SURG | OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA | 5.2888 | 11.0 | 14.3 |
| 487 | 24 | MED | OTHER MULTIPLE SIGNIFICANT TRAUMA | 1.9585 | 6.3 | 8.2 |
| 488 | 25 | SURG | HIV W EXTENSIVE O.R. PROCEDURE | 5.1965 | 14.9 | 19.7 |
| 489 | 25 | MED | HIV W MAJOR RELATED CONDITION | 1.8948 | 7.0 | 9.4 |
| 490 | 25 | MED | HIV W OR W/O OTHER RELATED CONDITION | 1.0584 | 4.3 | 5.8 |
| 491 | 08 | SURG | MAJOR JOINT LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITY | 1.6353 | 3.0 | 3.5 |
| 492 | 17 | MED | CHEMOTHERAPY W ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS | 4.8886 | 13.6 | 19.0 |
| 493 | 07 | SURG | LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC | 1.8411 | 4.9 | 6.3 |
| 494 | 07 | SURG | LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC | .9754 | 1.9 | 2.4 |
| 495 | PRE | SURG | LUNG TRANSPLANT | 8.8252 | 13.8 | 16.2 |
| 496 | 08 | SURG | COMBINED ANTERIOR/POSTERIOR SPINAL FUSION | 5.7281 | 8.6 | 10.5 |
| 497 | 08 | SURG | SPINAL FUSION EXCEPT CERVICAL W CC | 3.2324 | 5.8 | 6.9 |
| 498 | 08 | SURG | SPINAL FUSION EXCEPT CERVICAL W/O CC | 2.3026 | 3.9 | 4.3 |
| 499 | 08 | SURG | BACK NECK PROCEDURES EXCEPT SPINAL FUSION W CC | 1.4507 | 3.8 | 5.0 |
| 500 | 08 | SURG | BACK NECK PROCEDURES EXCEPT SPINAL FUSION W/O CC | .9385 | 2.2 | 2.6 |
| 501 | 08 | SURG | KNEE PROCEDURES W PDX OF INFECTION W CC | 2.7485 | 9.8 | 11.9 |
| 502 | 08 | SURG | KNEE PROCEDURES W PDX OF INFECTION W/O CC | 1.5544 | 5.9 | 6.9 |
| 503 | 08 | SURG | KNEE PROCEDURES W/O PDX OF INFECTION | 1.2291 | 3.3 | 4.2 |
| 504 | 22 | SURG | EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT | 14.1729 | 28.8 | 34.7 |
| 505 | 22 | MED | EXTENSIVE 3RD DEGREE BURNS W/O SKIN GRAFT | 1.4994 | 2.0 | 3.4 |
| 506 | 22 | SURG | FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA | 4.9233 | 15.7 | 19.9 |
| 507 | 22 | SURG | FULL THICKNESS BURN W SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA | 1.8583 | 7.3 | 9.3 |
| 508 | 22 | MED | FULL THICKNESS BURN W/O SKIN GRFT OR INHAL INJ W CC OR SIG TRAUMA | 1.2967 | 6.1 | 8.3 |
| 509 | 22 | MED | FULL THICKNESS BURN W/O SKIN GRFT OR INH INJ W/O CC OR SIG TRAUMA | .7265 | 3.7 | 4.9 |
| 510 | 22 | MED | NON-EXTENSIVE BURNS W CC OR SIGNIFICANT TRAUMA | 1.3681 | 5.8 | 8.0 |
| 511 | 22 | MED | NON-EXTENSIVE BURNS W/O CC OR SIGNIFICANT TRAUMA | .7656 | 3.6 | 5.2 |
| 512 | PRE | SURG | SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT | 5.7813 | 12.7 | 14.9 |
| 513 | PRE | SURG | PANCREAS TRANSPLANT | 5.8400 | 9.7 | 11.1 |
| 514 | 05 | SURG | CARDIAC DEFIBRILLATOR IMPLANT W CARDIAC CATH | 6.3663 | 6.7 | 8.8 |
| 515 | 05 | SURG | CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH | 4.9905 | 4.2 | 6.7 |
| 516 | 05 | SURG | PERCUTANEOUS CARDIOVASC PROC W AMI | 2.7475 | 4.1 | 5.0 |
| 517 | 05 | SURG | PERC CARDIO PROC W CORONARY ARTERY STENT W/O AMI | 2.1379 | 1.9 | 2.7 |
| 518 | 05 | SURG | PERC CARDIO PROC W/O CORONARY ARTERY STENT OR AMI | 1.6989 | 2.5 | 3.7 |
| 519 | 08 | SURG | CERVICAL SPINAL FUSION W CC | 2.3249 | 3.8 | 5.6 |
| 520 | 08 | SURG | CERVICAL SPINAL FUSION W/O CC | 1.4195 | 1.7 | 2.2 |
| 521 | 20 | MED | ALCOHOL/DRUG ABUSE OR DEPENDENCE W CC | .7355 | 5.0 | 6.4 |
| 522 | 20 | MED | ALC/DRUG ABUSE OR DEPEND W REHABILITATION THERAPY W/O CC | .6249 | 8.6 | 10.4 |
| 523 | 20 | MED | ALC/DRUG ABUSE OR DEPEND W/O REHABILITATION THERAPY W/O CC | .3997 | 3.5 | 4.3 |
| *Medicare data have been supplemented by data from 19 states for low volume DRGs. | ||||||
| **DRGs 469 and 470 contain cases which could not be assigned to valid DRGs. | ||||||
| Note: Geometric mean is used only to determine payment for transfer cases. | ||||||
| Note: Arithmetic mean is presented for informational purposes only. | ||||||
| Note: Relative weights are based on Medicare patient data and may not be appropriate for other patients. | ||||||
| Diagnosis Code | Description | CC | MDC | DRG |
|---|---|---|---|---|
| 256.31 | Premature menopause | N | 13 | 358, 359, 369 |
| 256.39 | Other ovarian failure | N | 13 | 358, 359, 369 |
| 277.7 | Dysmetabolic Syndrome X | N | 10 | 299 |
| 464.00 | Acute laryngitis, without mention of obstruction | N | 3 pre | 68, 69, 70 482 |
| 464.01 | Acute laryngitis, with obstruction | N | 3 pre | 68, 69, 70 482 |
| 464.50 | Unspecified supraglottis, without mention of obstruction | N | 3 pre | 68, 69, 70 482 |
| 464.51 | Unspecified supraglottis, with obstruction | N | 3 pre | 68, 69, 70 482 |
| 521.00 | Unspecified dental caries | N | 3 pre | 185, 186, 187 482 |
| 521.01 | Dental caries limited to enamel | N | 3 pre | 185, 186, 187 482 |
| 521.02 | Dental caries extending into dentine | N | 3 pre | 185, 186, 187 482 |
| 521.03 | Dental caries extending into pulp | N | 3 pre | 185, 186, 187 482 |
| 521.04 | Arrested dental caries | N | 3 pre | 185, 186, 187 482 |
| 521.05 | Odontoclasia | N | 3 pre | 185, 186, 187 482 |
| 521.09 | Other dental caries | N | 3 pre | 185, 186, 187 482 |
| 525.10 | Unspecified acquired absence of teeth | N | 3 pre | 185, 186, 187 482 |
| 525.11 | Loss of teeth due to trauma | N | 3 pre | 185, 186, 187 482 |
| 525.12 | Loss of teeth due to periodontal disease | N | 3 pre | 185, 186, 187 482 |
| 525.13 | Loss of teeth due to caries | N | 3 pre | 185, 186, 187 482 |
| 525.19 | Other loss of teeth | N | 3 pre | 185, 186, 187 482 |
| 530.12 | Acute esophagitis | N | 6 | 182, 183, 184 |
| 564.00 | Unspecified constipation | N | 6 | 182, 183, 184 |
| 564.01 | Slow transit constipation | N | 6 | 182, 183, 184 |
| 564.02 | Outlet dysfunction constipation | N | 6 | 182, 183, 184 |
| 564.09 | Other constipation | N | 6 | 182, 183, 184 |
| 602.3 | Dysplasia of prostate | N | 12 | 352 |
| 608.82 | Hematospermia | N | 12 | 352 |
| 608.87 | Retrograde ejaculation | N | 12 | 352 |
| 692.76 | Sunburn of second degree | N | 9 | 283, 284 |
| 692.77 | Sunburn of third degree | N | 9 | 283, 284 |
| 718.70 | Developmental dislocation of joint, site unspecified | N | 8 | 256 |
| 718.71 | Developmental dislocation of joint, shoulder region | N | 8 | 256 |
| 718.72 | Developmental dislocation of joint, upper arm | N | 8 | 256 |
| 718.73 | Developmental dislocation of joint, forearm | N | 8 | 256 |
| 718.74 | Developmental dislocation of joint, hand | N | 8 | 256 |
| 718.75 | Developmental dislocation of joint, pelvic region and thigh | N | 8 | 256 |
| 718.76 | Developmental dislocation of joint, lower leg | N | 8 | 256 |
| 718.77 | Developmental dislocation of joint, ankle and foot | N | 8 | 256 |
| 718.78 | Developmental dislocation of joint, other specified sites | N | 8 | 256 |
| 718.79 | Developmental dislocation of joint, multiple sites | N | 8 | 256 |
| 733.93 | Stress fracture of tibia or fibula | Y | 8 | 239 |
| 733.94 | Stress fracture of the metatarsals | Y | 8 | 239 |
| 733.95 | Stress fracture of other bone | Y | 8 | 239 |
| 772.10 | Intraventricular hemorrhage, unspecified grade | Y | 15 | 387, 389 |
| 772.11 | Intraventricular hemorrhage, Grade I | Y | 15 | 387, 389 |
| 772.12 | Intraventricular hemorrhage, Grade II | Y | 15 | 387, 389 |
| 772.13 | Intraventricular hemorrhage, Grade III | Y | 15 | 387, 389 |
| 772.14 | Intraventricular hemorrhage, Grade IV | Y | 15 | 387, 389 |
| 779.7 | Perventricular leukomalacia | Y | 15 | 387, 389 |
| 793.80 | Unspecified abnormal mammogram | N | 9 | 276 |
| 793.81 | Mammographic microcalcification | N | 9 | 276 |
| 793.89 | Other abnormal findings on radiological examination breast | N | 9 | 276 |
| 840.7 | Superior glenoid labrum lesions (SLAP) | N | 8 24 | 253, 254, 255 487 |
| 997.71 | Vascular complications of mesenteric artery | Y | 6 15 | 188, 189, 190 387, 389 |
| 997.72 | Vascular complications of renal artery | Y | 11 15 | 331, 332, 333 387, 389 |
| 997.79 | Vascular complications of other vessels | Y | 5 15 | 130, 131 387, 389 |
| V10.53 | Personal history of malignant neoplasm, renal pelvis | N | 17 | 411, 412 |
| V45.84 | Dental restoration status | N | 23 | 467 |
| V49.82 | Dental sealant status | N | 23 | 467 |
| V83.01 | Asymptomatic hemophilia A carrier | N | 23 | 467 |
| V83.02 | Symptomatic hemophilia A carrier | N | 23 | 467 |
| Procedure Code | Description | OR | MDC | DRG |
|---|---|---|---|---|
| 37.28 | Intracardiac echocardiography | N | ||
| 44.32 | Percutaneous [endoscopic] gastrojejunostomy | Y | 6 7 10 17 | 154-156 201 288 400, 406, 407 |
| 67.51 | Transabdominal cerclage of cervix | Y | 13 14 21 24 | 360 372, 373 442, 443 486 |
| 67.59 | Other repair of internal cervical os | Y | 13 14 21 24 | 360 372, 373 442, 443 486 |
| 75.38 | Fetal pulse oximetry | N | ||
| 81.30 | Refusion of spine, not otherwise specified | Y | 1 8 21 24 | 4 497, 498 442, 443 486 |
| 81.31 | Refusion of Atlas-axis spine | Y | 1 8 21 24 | 4 497, 498 442, 443 486 |
| 81.32 | Refusion of other cervical spine, anterior technique | Y | 1 8 21 24 | 4 496, 519, 520 442, 443 486 |
| 81.33 | Refusion of other cervical spine, posterior technique | Y | 1 8 21 24 | 4 496, 519, 520 442, 443 486 |
| 81.34 | Refusion of dorsal and dorsolumbar spine, anterior technique | Y | 1 8 21 24 | 4 496, 497, 498 442, 443 486 |
| 81.35 | Refusion of dorsal and dorsolumbar spine, posterior technique | Y | 1 8 21 24 | 4 496, 497, 498 442, 443 486 |
| 81.36 | Refusion of lumbar and lumbosacral spine, anterior technique | Y | 1 8 21 24 | 4 496, 497, 498 442, 443 486 |
| 81.37 | Refusion of lumbar and lumbosacral spine, lateral transverse process technique | Y | 1 8 21 24 | 4 496, 497, 498 442, 443 486 |
| 81.38 | Refusion of lumbar and lumbosacral spine, posterior technique | Y | 1 8 21 24 | 4 496, 497, 498 442, 443 486 |
| 81.39 | Refusion of spine, not elsewhere classified | Y | 1 8 21 24 | 4 497, 498 442, 443 486 |
| 97.44 | Nonoperative removal of heart assist system | N |
| Diagnosis Code | Description | CC | MDC | DRG |
|---|---|---|---|---|
| 256.3 | Other ovarian failure | N | 13 | 358, 359, 369 |
| 464.0 | Acute laryngitis | N | 3 pre | 68, 69, 70 482 |
| 521.0 | Dental caries | N | 3 pre | 185, 186, 187 482 |
| 525.1 | Loss of teeth due to accident, extraction, or local periodontal disease | N | 3 pre | 185, 186, 187 482 |
| 564.0 | Constipation | N | 6 | 182, 183, 184 |
| 772.1 | Intraventricular hemorrhage | Y | 15 | 387, 389 |
| 793.8 | Nonspecific abnormal findings on radiological and other examinations of body structure, breast | N | 9 | 276 |
| Procedure Code | Description | OR | MDC | DRG |
|---|---|---|---|---|
| 67.5 | Repair of internal cervical os | Y | 13 14 21 24 | 360 372, 373 442, 443 486 |
| 81.09 | Refusion of spine, any level or technique | Y | 1 8 21 24 | 4 497, 498 442, 443 486 |
| Diagnosis Code | Description | CC | MDC | DRG |
|---|---|---|---|---|
| 411.81 | Acute coronary occlusion without myocardial infarction | Y | 5 | 124, 140 |
| 493.00 | Extrinsic asthma without mention of status asthmaticus or acute exacerbation or unspecified | N | 4 | 96, 97, 98 |
| 493.10 | Intrinsic asthma without mention of status asthmaticus or acute exacerbation or unspecified | N | 4 | 96, 97, 98 |
| 493.20 | Chronic obstructive asthma without mention of status asthmaticus or acute exacerbation or unspecified | Y | 4 | 88 |
| 493.90 | Asthma, unspecified without mention of status asthmaticus or acute exacerbation or unspecified | N | 4 | 96, 97, 98 |
| V70.7 | Examination of participant in clinical trial | N | 23 | 467 |
| Procedure Code | Description | OR | MDC | DRG |
|---|---|---|---|---|
| 75.34 | Other fetal monitoring | N |
| *25631 | 80600 | 82010 | 80637 | 80606 | 82021 | 77212 | 77210 |
| 2580 | 80601 | 82011 | 80638 | 80607 | 82022 | 77213 | 77211 |
| 2581 | 80602 | 82012 | 80639 | 80608 | 82030 | 77214 | 77212 |
| 2588 | 80603 | 82013 | 8064 | 80609 | 82031 | 7797 | 77213 |
| 2589 | 80604 | 82019 | 8065 | 80610 | 82032 | *7729 | 77214 |
| *25639 | 80605 | 82020 | 80660 | 80611 | 8208 | 77210 | 7797 |
| 2580 | 80606 | 82021 | 80661 | 80612 | 8209 | 77211 | *7769 |
| 2581 | 80607 | 82022 | 80662 | 80613 | 82100 | 77212 | 77210 |
| 2588 | 80608 | 82030 | 80669 | 80614 | 82101 | 77213 | 77211 |
| 2589 | 80609 | 82031 | 80670 | 80615 | 82110 | 77214 | 77212 |
| *6023 | 80610 | 82032 | 80671 | 80616 | 82111 | 7797 | 77213 |
| 5960 | 80611 | 8208 | 80672 | 80617 | *7720 | *7760 | 77214 |
| 5996 | 80612 | 8209 | 80679 | 80618 | 77210 | 77210 | 7797 |
| 6010 | 80613 | 82100 | 8068 | 80619 | 77211 | 77211 | *7797 |
| 6012 | 80614 | 82101 | 8069 | 80620 | 77212 | 77212 | 7722 |
| 6013 | 80615 | 82110 | 8080 | 80621 | 77213 | 77213 | 7797 |
| 6021 | 80616 | 82111 | 8082 | 80622 | 77214 | 77214 | *7798 |
| 78820 | 80617 | *73394 | 8083 | 80623 | 7797 | 7797 | 77210 |
| 78829 | 80618 | 73310 | 80843 | 80624 | *77210 | *7761 | 77211 |
| *60887 | 80619 | 73311 | 80849 | 80625 | 77210 | 77210 | 77212 |
| 5970 | 80620 | 73312 | 80851 | 80626 | 77211 | 77211 | 77213 |
| 5994 | 80621 | 73313 | 80852 | 80627 | 77212 | 77212 | 77214 |
| *73310 | 80622 | 73314 | 80853 | 80628 | 77213 | 77213 | 7797 |
| 73393 | 80623 | 73315 | 80859 | 80629 | 77214 | 77214 | *9972 |
| 73394 | 80624 | 73316 | 8088 | 80630 | 7722 | 7797 | 99771 |
| 73395 | 80625 | 73319 | 8089 | 80631 | 7797 | *7762 | 99772 |
| *73311 | 80626 | 73393 | 82000 | 80632 | *77211 | 77210 | 99779 |
| 73393 | 80627 | 73394 | 82001 | 80633 | 77210 | 77211 | *99771 |
| 73394 | 80628 | 73395 | 82002 | 80634 | 77211 | 77212 | 53640 |
| 73395 | 80629 | 8058 | 82003 | 80635 | 77212 | 77213 | 53641 |
| *73312 | 80630 | 8059 | 82009 | 80636 | 77213 | 77214 | 53642 |
| 73393 | 80631 | 80600 | 82010 | 80637 | 77214 | 7797 | 53649 |
| 73394 | 80632 | 80601 | 82011 | 80638 | 7722 | *7763 | 56962 |
| 73395 | 80633 | 80602 | 82012 | 80639 | 7797 | 77210 | 9974 |
| *73313 | 80634 | 80603 | 82013 | 8064 | *77212 | 77211 | 99771 |
| 73393 | 80635 | 80604 | 82019 | 8065 | 77210 | 77212 | 99772 |
| 73394 | 80636 | 80605 | 82020 | 80660 | 77211 | 77213 | 99779 |
| 73395 | 80637 | 80606 | 82021 | 80661 | 77212 | 77214 | *99772 |
| *73314 | 80638 | 80607 | 82022 | 80662 | 77213 | 7797 | 9975 |
| 73393 | 80639 | 80608 | 82030 | 80669 | 77214 | *7764 | 99771 |
| 73394 | 8064 | 80609 | 82031 | 80670 | 7722 | 77210 | 99772 |
| 73395 | 8065 | 80610 | 82032 | 80671 | 7797 | 77211 | 99779 |
| *73315 | 80660 | 80611 | 8208 | 80672 | *77213 | 77212 | *99779 |
| 73393 | 80661 | 80612 | 8209 | 80679 | 77210 | 77213 | 9972 |
| 73394 | 80662 | 80613 | 82100 | 8068 | 77211 | 77214 | 99771 |
| 73395 | 80669 | 80614 | 82101 | 8069 | 77212 | 7797 | 99772 |
| *73316 | 80670 | 80615 | 82110 | 8080 | 77213 | *7765 | 99779 |
| 73393 | 80671 | 80616 | 82111 | 8082 | 77214 | 77210 | *99791 |
| 73394 | 80672 | 80617 | *73395 | 8083 | 7722 | 77211 | 99771 |
| 73395 | 80679 | 80618 | 73310 | 80843 | 7797 | 77212 | 99772 |
| *73319 | 8068 | 80619 | 73311 | 80849 | *77214 | 77213 | 99779 |
| 73393 | 8069 | 80620 | 73312 | 80851 | 77210 | 77214 | *99799 |
| 73394 | 8080 | 80621 | 73313 | 80852 | 77211 | 7797 | 99771 |
| 73395 | 8082 | 80622 | 73314 | 80853 | 77212 | *7766 | 99772 |
| *73393 | 8083 | 80623 | 73315 | 80859 | 77213 | 77210 | 99779 |
| 73310 | 80843 | 80624 | 73316 | 8088 | 77214 | 77211 | *99881 |
| 73311 | 80849 | 80625 | 73319 | 8089 | 7722 | 77212 | 99771 |
| 73312 | 80851 | 80626 | 73393 | 82000 | 7797 | 77213 | 99772 |
| 73313 | 80852 | 80627 | 73394 | 82001 | *7722 | 77214 | 99779 |
| 73314 | 80853 | 80628 | 73395 | 82002 | 77210 | 7797 | *99883 |
| 73315 | 80859 | 80629 | 8058 | 82003 | 77211 | *7767 | 99771 |
| 73316 | 8088 | 80630 | 8059 | 82009 | 77212 | 77210 | 99772 |
| 73319 | 8089 | 80631 | 80600 | 82010 | 77213 | 77211 | 99779 |
| 73393 | 82000 | 80632 | 80601 | 82011 | 77214 | 77212 | *99889 |
| 73394 | 82001 | 80633 | 80602 | 82012 | 7797 | 77213 | 99771 |
| 73395 | 82002 | 80634 | 80603 | 82013 | *7728 | 77214 | 99772 |
| 8058 | 82003 | 80635 | 80604 | 82019 | 77210 | 7797 | 99779 |
| 8059 | 82009 | 80636 | 80605 | 82020 | 77211 | *7768 | *9989 |
| 99771 | |||||||
| 99772 | |||||||
| 99779 |
| *2563 | |||||||
| 2580 | |||||||
| 2581 | |||||||
| 2588 | |||||||
| 2589 | |||||||
| *7720 | |||||||
| 7721 | |||||||
| *7721 | |||||||
| 7721 | |||||||
| 7722 | |||||||
| *7722 | |||||||
| 7721 | |||||||
| *7728 | |||||||
| 7721 | |||||||
| *7729 | |||||||
| 7721 | |||||||
| *7760 | |||||||
| 7721 | |||||||
| *7761 | |||||||
| 7721 | |||||||
| *7762 | |||||||
| 7721 | |||||||
| *7763 | |||||||
| 7721 | |||||||
| *7764 | |||||||
| 7721 | |||||||
| *7765 | |||||||
| 7721 | |||||||
| *7766 | |||||||
| 7721 | |||||||
| *7767 | |||||||
| 7721 | |||||||
| *7768 | |||||||
| 7721 | |||||||
| *7769 | |||||||
| 7721 | |||||||
| *7798 | |||||||
| 7721 |
| DRG | Number discharges | Arithmetic mean LOS | 10th percentile | 25th percentile | 50th percentile | 75th percentile | 90th percentile |
|---|---|---|---|---|---|---|---|
| 1 | 34040 | 9.0038 | 2 | 3 | 6 | 12 | 19 |
| 2 | 6862 | 9.9787 | 3 | 5 | 8 | 12 | 20 |
| 3 | 2 | 43.5000 | 35 | 35 | 52 | 52 | 52 |
| 4 | 6110 | 7.1570 | 1 | 2 | 5 | 9 | 15 |
| 5 | 93853 | 3.1665 | 1 | 1 | 2 | 3 | 7 |
| 6 | 365 | 2.9671 | 1 | 1 | 2 | 4 | 6 |
| 7 | 13063 | 9.8610 | 2 | 4 | 7 | 12 | 20 |
| 8 | 3725 | 2.8969 | 1 | 1 | 2 | 4 | 7 |
| 9 | 1632 | 6.3192 | 1 | 3 | 5 | 8 | 13 |
| 10 | 17754 | 6.5545 | 2 | 3 | 5 | 8 | 13 |
| 11 | 3157 | 4.0744 | 1 | 2 | 3 | 5 | 8 |
| 12 | 47063 | 5.9088 | 2 | 3 | 4 | 7 | 11 |
| 13 | 6504 | 5.1948 | 2 | 3 | 4 | 6 | 9 |
| 14 | 321622 | 5.8761 | 2 | 3 | 5 | 7 | 11 |
| 15 | 146291 | 3.5528 | 1 | 2 | 3 | 4 | 7 |
| 16 | 11235 | 6.0446 | 2 | 3 | 5 | 7 | 12 |
| 17 | 3532 | 3.3061 | 1 | 2 | 3 | 4 | 6 |
| 18 | 26608 | 5.4190 | 2 | 3 | 4 | 7 | 10 |
| 19 | 8346 | 3.6416 | 1 | 2 | 3 | 5 | 7 |
| 20 | 5680 | 10.1768 | 3 | 5 | 8 | 13 | 20 |
| 21 | 1324 | 6.5249 | 2 | 3 | 5 | 8 | 13 |
| 22 | 2560 | 4.8176 | 1 | 2 | 4 | 6 | 9 |
| 23 | 9553 | 4.1807 | 1 | 2 | 3 | 5 | 8 |
| 24 | 53313 | 4.9825 | 1 | 2 | 4 | 6 | 10 |
| 25 | 25528 | 3.2186 | 1 | 2 | 3 | 4 | 6 |
| 26 | 33 | 2.9091 | 1 | 1 | 2 | 4 | 6 |
| 27 | 3519 | 5.0673 | 1 | 1 | 3 | 6 | 11 |
| 28 | 11477 | 6.2222 | 1 | 3 | 5 | 8 | 13 |
| 29 | 4545 | 3.5982 | 1 | 2 | 3 | 5 | 7 |
| 30 | 1 | 1.0000 | 1 | 1 | 1 | 1 | 1 |
| 31 | 3576 | 4.4855 | 1 | 2 | 3 | 5 | 8 |
| 32 | 1770 | 2.5644 | 1 | 1 | 2 | 3 | 5 |
| 33 | 1 | 1.0000 | 1 | 1 | 1 | 1 | 1 |
| 34 | 20753 | 5.0757 | 1 | 2 | 4 | 6 | 10 |
| 35 | 5893 | 3.3743 | 1 | 2 | 3 | 4 | 6 |
| 36 | 3217 | 1.4719 | 1 | 1 | 1 | 1 | 2 |
| 37 | 1465 | 4.0348 | 1 | 1 | 2 | 5 | 9 |
| 38 | 102 | 2.6569 | 1 | 1 | 2 | 3 | 5 |
| 39 | 918 | 1.9379 | 1 | 1 | 1 | 2 | 4 |
| 40 | 1561 | 3.4209 | 1 | 1 | 2 | 4 | 7 |
| 42 | 2235 | 2.2859 | 1 | 1 | 1 | 3 | 5 |
| 43 | 85 | 3.1882 | 1 | 2 | 3 | 4 | 6 |
| 44 | 1244 | 4.9518 | 2 | 3 | 4 | 6 | 9 |
| 45 | 2464 | 3.1717 | 1 | 2 | 3 | 4 | 6 |
| 46 | 3102 | 4.6518 | 1 | 2 | 4 | 6 | 9 |
| 47 | 1284 | 3.2749 | 1 | 1 | 3 | 4 | 6 |
| 49 | 2266 | 4.8010 | 1 | 2 | 3 | 6 | 9 |
| 50 | 2507 | 1.9418 | 1 | 1 | 1 | 2 | 3 |
| 51 | 205 | 2.6927 | 1 | 1 | 1 | 2 | 6 |
| 52 | 224 | 1.9196 | 1 | 1 | 1 | 2 | 3 |
| 53 | 2509 | 3.5787 | 1 | 1 | 2 | 4 | 8 |
| 54 | 2 | 1.5000 | 1 | 1 | 2 | 2 | 2 |
| 55 | 1519 | 2.7340 | 1 | 1 | 1 | 3 | 6 |
| 56 | 517 | 2.7389 | 1 | 1 | 2 | 3 | 5 |
| 57 | 712 | 4.0478 | 1 | 1 | 2 | 5 | 9 |
| 59 | 107 | 2.7850 | 1 | 1 | 2 | 3 | 5 |
| 60 | 2 | 3.5000 | 2 | 2 | 5 | 5 | 5 |
| 61 | 234 | 5.1624 | 1 | 1 | 2 | 6 | 13 |
| 62 | 3 | 1.3333 | 1 | 1 | 1 | 2 | 2 |
| 63 | 2955 | 4.3993 | 1 | 2 | 3 | 5 | 9 |
| 64 | 3070 | 6.1642 | 1 | 2 | 4 | 8 | 13 |
| 65 | 34702 | 2.8444 | 1 | 1 | 2 | 4 | 5 |
| 66 | 7035 | 3.1599 | 1 | 1 | 2 | 4 | 6 |
| 67 | 501 | 3.5768 | 1 | 2 | 3 | 4 | 7 |
| 68 | 16708 | 4.1241 | 1 | 2 | 3 | 5 | 7 |
| 69 | 5417 | 3.2845 | 1 | 2 | 3 | 4 | 6 |
| 70 | 24 | 2.9167 | 1 | 2 | 2 | 4 | 5 |
| 71 | 82 | 3.8049 | 1 | 2 | 3 | 4 | 7 |
| 72 | 893 | 3.5566 | 1 | 2 | 3 | 4 | 6 |
| 73 | 6690 | 4.3988 | 1 | 2 | 3 | 6 | 9 |
| 75 | 39476 | 9.9112 | 3 | 5 | 7 | 12 | 19 |
| 76 | 39399 | 11.3188 | 3 | 5 | 9 | 14 | 21 |
| 77 | 2358 | 4.9165 | 1 | 2 | 4 | 7 | 10 |
| 78 | 32319 | 6.7837 | 3 | 4 | 6 | 8 | 11 |
| 79 | 170615 | 8.4963 | 3 | 4 | 7 | 11 | 16 |
| 80 | 8981 | 5.6562 | 2 | 3 | 5 | 7 | 10 |
| 81 | 4 | 18.2500 | 3 | 3 | 4 | 8 | 58 |
| 82 | 62447 | 6.9403 | 2 | 3 | 5 | 9 | 14 |
| 83 | 6598 | 5.5518 | 2 | 3 | 4 | 7 | 10 |
| 84 | 1539 | 3.3197 | 1 | 2 | 3 | 4 | 6 |
| 85 | 20738 | 6.3135 | 2 | 3 | 5 | 8 | 12 |
| 86 | 2115 | 3.6648 | 1 | 2 | 3 | 5 | 7 |
| 87 | 60486 | 6.2986 | 1 | 3 | 5 | 8 | 12 |
| 88 | 395676 | 5.1294 | 2 | 3 | 4 | 6 | 9 |
| 89 | 529122 | 5.9478 | 2 | 3 | 5 | 7 | 11 |
| 90 | 53985 | 4.1475 | 2 | 3 | 4 | 5 | 7 |
| 91 | 57 | 4.4561 | 2 | 2 | 3 | 5 | 9 |
| 92 | 13873 | 6.3521 | 2 | 3 | 5 | 8 | 12 |
| 93 | 1692 | 4.0969 | 1 | 2 | 3 | 5 | 7 |
| 94 | 12158 | 6.3088 | 2 | 3 | 5 | 8 | 12 |
| 95 | 1621 | 3.7224 | 1 | 2 | 3 | 5 | 7 |
| 96 | 62414 | 4.6281 | 2 | 3 | 4 | 6 | 8 |
| 97 | 31618 | 3.6509 | 1 | 2 | 3 | 5 | 7 |
| 98 | 17 | 4.3529 | 1 | 2 | 3 | 4 | 6 |
| 99 | 19205 | 3.2061 | 1 | 1 | 2 | 4 | 6 |
| 100 | 7656 | 2.1813 | 1 | 1 | 2 | 3 | 4 |
| 101 | 20236 | 4.3987 | 1 | 2 | 3 | 5 | 9 |
| 102 | 5196 | 2.6522 | 1 | 1 | 2 | 3 | 5 |
| 103 | 494 | 47.2510 | 9 | 13 | 25 | 61 | 102 |
| 104 | 37017 | 11.3083 | 3 | 6 | 9 | 14 | 22 |
| 105 | 29991 | 9.2831 | 4 | 5 | 7 | 11 | 17 |
| 106 | 3425 | 11.4923 | 5 | 7 | 10 | 14 | 20 |
| 107 | 88610 | 10.3724 | 5 | 7 | 9 | 12 | 17 |
| 108 | 6099 | 10.2140 | 3 | 5 | 8 | 13 | 19 |
| 109 | 60766 | 7.6912 | 4 | 5 | 6 | 9 | 12 |
| 110 | 53054 | 9.2130 | 2 | 5 | 7 | 11 | 18 |
| 111 | 8563 | 4.7507 | 1 | 2 | 5 | 6 | 8 |
| 112 | 56110 | 3.6750 | 1 | 1 | 2 | 5 | 8 |
| 113 | 42570 | 12.2362 | 3 | 6 | 9 | 15 | 24 |
| 114 | 8788 | 8.4208 | 2 | 4 | 7 | 11 | 16 |
| 115 | 14447 | 8.1481 | 1 | 4 | 7 | 11 | 16 |
| 116 | 333539 | 3.6045 | 1 | 1 | 2 | 5 | 8 |
| 117 | 3750 | 4.1997 | 1 | 1 | 2 | 5 | 9 |
| 118 | 7731 | 2.6831 | 1 | 1 | 1 | 3 | 6 |
| 119 | 1315 | 4.8783 | 1 | 1 | 3 | 6 | 12 |
| 120 | 36315 | 8.1402 | 1 | 2 | 5 | 11 | 18 |
| 121 | 163108 | 6.3828 | 2 | 3 | 5 | 8 | 12 |
| 122 | 79700 | 3.6981 | 1 | 2 | 3 | 5 | 7 |
| 123 | 40952 | 4.5870 | 1 | 1 | 3 | 6 | 11 |
| 124 | 133892 | 4.3434 | 1 | 2 | 3 | 5 | 8 |
| 125 | 80872 | 2.7656 | 1 | 1 | 2 | 4 | 5 |
| 126 | 5210 | 11.7196 | 3 | 6 | 9 | 15 | 22 |
| 127 | 683001 | 5.2764 | 2 | 3 | 4 | 7 | 10 |
| 128 | 9485 | 5.6128 | 2 | 4 | 5 | 7 | 9 |
| 129 | 4174 | 2.7513 | 1 | 1 | 1 | 3 | 6 |
| 130 | 87705 | 5.6725 | 2 | 3 | 5 | 7 | 10 |
| 131 | 27378 | 4.2134 | 1 | 2 | 4 | 6 | 7 |
| 132 | 148681 | 3.0010 | 1 | 1 | 2 | 4 | 6 |
| 133 | 8355 | 2.3246 | 1 | 1 | 2 | 3 | 4 |
| 134 | 36411 | 3.2406 | 1 | 2 | 3 | 4 | 6 |
| 135 | 7338 | 4.5492 | 1 | 2 | 3 | 6 | 9 |
| 136 | 1233 | 2.7178 | 1 | 1 | 2 | 3 | 5 |
| 138 | 195523 | 3.9935 | 1 | 2 | 3 | 5 | 8 |
| 139 | 82943 | 2.5030 | 1 | 1 | 2 | 3 | 5 |
| 140 | 70338 | 2.6538 | 1 | 1 | 2 | 3 | 5 |
| 141 | 91110 | 3.6692 | 1 | 2 | 3 | 5 | 7 |
| 142 | 45981 | 2.6476 | 1 | 1 | 2 | 3 | 5 |
| 143 | 205686 | 2.1259 | 1 | 1 | 2 | 3 | 4 |
| 144 | 82529 | 5.3248 | 1 | 2 | 4 | 7 | 11 |
| 145 | 7242 | 2.7331 | 1 | 1 | 2 | 3 | 5 |
| 146 | 10755 | 10.3134 | 5 | 7 | 9 | 12 | 17 |
| 147 | 2637 | 6.4137 | 3 | 5 | 6 | 8 | 9 |
| 148 | 129971 | 12.2043 | 5 | 7 | 10 | 15 | 22 |
| 149 | 18528 | 6.5116 | 4 | 5 | 6 | 8 | 9 |
| 150 | 19921 | 11.2798 | 4 | 7 | 10 | 14 | 20 |
| 151 | 4858 | 5.8121 | 2 | 3 | 5 | 8 | 10 |
| 152 | 4399 | 8.1444 | 3 | 5 | 7 | 9 | 14 |
| 153 | 2100 | 5.3838 | 3 | 4 | 5 | 7 | 8 |
| 154 | 28871 | 13.1708 | 4 | 7 | 10 | 16 | 25 |
| 155 | 6655 | 4.2026 | 1 | 2 | 3 | 6 | 8 |
| 156 | 4 | 7.5000 | 1 | 1 | 5 | 6 | 18 |
| 157 | 7956 | 5.3910 | 1 | 2 | 4 | 7 | 11 |
| 158 | 4670 | 2.5362 | 1 | 1 | 2 | 3 | 5 |
| 159 | 16448 | 4.9962 | 1 | 2 | 4 | 6 | 10 |
| 160 | 11726 | 2.6594 | 1 | 1 | 2 | 3 | 5 |
| 161 | 11205 | 4.2062 | 1 | 1 | 3 | 5 | 9 |
| 162 | 7214 | 1.9211 | 1 | 1 | 1 | 2 | 4 |
| 163 | 7 | 3.5714 | 1 | 1 | 2 | 3 | 4 |
| 164 | 4857 | 8.4293 | 4 | 5 | 7 | 10 | 15 |
| 165 | 2086 | 4.7895 | 2 | 3 | 5 | 6 | 8 |
| 166 | 3559 | 5.0441 | 2 | 2 | 4 | 6 | 10 |
| 167 | 3316 | 2.6001 | 1 | 2 | 2 | 3 | 5 |
| 168 | 1235 | 4.9247 | 1 | 2 | 3 | 6 | 10 |
| 169 | 813 | 2.3395 | 1 | 1 | 2 | 3 | 5 |
| 170 | 11057 | 11.1942 | 2 | 5 | 8 | 14 | 22 |
| 171 | 1274 | 4.6201 | 1 | 2 | 4 | 6 | 9 |
| 172 | 30682 | 6.9445 | 2 | 3 | 5 | 9 | 14 |
| 173 | 2707 | 3.6679 | 1 | 1 | 3 | 5 | 7 |
| 174 | 242054 | 4.7970 | 2 | 3 | 4 | 6 | 9 |
| 175 | 32431 | 2.9309 | 1 | 2 | 3 | 4 | 5 |
| 176 | 15194 | 5.2285 | 2 | 3 | 4 | 6 | 10 |
| 177 | 9272 | 4.5310 | 2 | 2 | 4 | 6 | 8 |
| 178 | 3619 | 3.0683 | 1 | 2 | 3 | 4 | 6 |
| 179 | 12384 | 5.9738 | 2 | 3 | 5 | 7 | 11 |
| 180 | 86181 | 5.3581 | 2 | 3 | 4 | 7 | 10 |
| 181 | 26423 | 3.4153 | 1 | 2 | 3 | 4 | 6 |
| 182 | 234742 | 4.3758 | 1 | 2 | 3 | 5 | 8 |
| 183 | 81065 | 2.9320 | 1 | 1 | 2 | 4 | 5 |
| 184 | 78 | 2.9487 | 1 | 2 | 2 | 4 | 6 |
| 185 | 4769 | 4.5280 | 1 | 2 | 3 | 6 | 9 |
| 186 | 3 | 9.3333 | 1 | 1 | 9 | 18 | 18 |
| 187 | 443 | 4.0045 | 1 | 2 | 3 | 5 | 8 |
| 188 | 76140 | 5.5645 | 1 | 2 | 4 | 7 | 11 |
| 189 | 12060 | 3.1404 | 1 | 1 | 2 | 4 | 6 |
| 190 | 51 | 6.9608 | 2 | 3 | 4 | 5 | 8 |
| 191 | 8964 | 13.8146 | 4 | 6 | 10 | 17 | 27 |
| 192 | 1122 | 6.5294 | 2 | 4 | 6 | 8 | 11 |
| 193 | 5303 | 12.5218 | 5 | 7 | 10 | 16 | 22 |
| 194 | 721 | 6.7906 | 2 | 4 | 6 | 8 | 12 |
| 195 | 4350 | 10.1616 | 4 | 6 | 9 | 12 | 17 |
| 196 | 1166 | 5.7196 | 2 | 4 | 5 | 7 | 10 |
| 197 | 18895 | 8.9383 | 3 | 5 | 7 | 11 | 16 |
| 198 | 5786 | 4.5380 | 2 | 3 | 4 | 6 | 8 |
| 199 | 1725 | 9.6614 | 2 | 4 | 7 | 13 | 21 |
| 200 | 1081 | 10.3478 | 1 | 3 | 7 | 13 | 23 |
| 201 | 1413 | 13.7594 | 3 | 6 | 11 | 17 | 27 |
| 202 | 26168 | 6.4060 | 2 | 3 | 5 | 8 | 13 |
| 203 | 29251 | 6.6384 | 2 | 3 | 5 | 9 | 13 |
| 204 | 57757 | 5.7995 | 2 | 3 | 4 | 7 | 11 |
| 205 | 23128 | 6.1790 | 2 | 3 | 5 | 8 | 12 |
| 206 | 1970 | 3.8959 | 1 | 2 | 3 | 5 | 7 |
| 207 | 31072 | 5.0836 | 1 | 2 | 4 | 6 | 10 |
| 208 | 10149 | 2.8924 | 1 | 1 | 2 | 4 | 6 |
| 209 | 345519 | 5.0794 | 3 | 3 | 4 | 6 | 8 |
| 210 | 121933 | 6.8207 | 3 | 4 | 6 | 8 | 11 |
| 211 | 31780 | 4.9358 | 3 | 4 | 4 | 6 | 7 |
| 212 | 8 | 10.5000 | 1 | 1 | 4 | 9 | 29 |
| 213 | 9241 | 9.0019 | 2 | 4 | 7 | 11 | 18 |
| 216 | 6008 | 9.6949 | 2 | 4 | 8 | 12 | 20 |
| 217 | 16558 | 13.2636 | 3 | 5 | 9 | 16 | 28 |
| 218 | 21625 | 5.4332 | 2 | 3 | 4 | 7 | 10 |
| 219 | 19714 | 3.2188 | 1 | 2 | 3 | 4 | 6 |
| 220 | 6 | 4.0000 | 1 | 1 | 3 | 7 | 7 |
| 223 | 13397 | 2.8551 | 1 | 1 | 2 | 3 | 6 |
| 224 | 11274 | 1.9346 | 1 | 1 | 2 | 2 | 3 |
| 225 | 5805 | 4.8558 | 1 | 2 | 3 | 6 | 11 |
| 226 | 5235 | 6.5958 | 1 | 2 | 4 | 8 | 14 |
| 227 | 4703 | 2.7053 | 1 | 1 | 2 | 3 | 5 |
| 228 | 2373 | 3.7981 | 1 | 1 | 2 | 5 | 8 |
| 229 | 1119 | 2.4781 | 1 | 1 | 2 | 3 | 5 |
| 230 | 2401 | 5.2603 | 1 | 2 | 3 | 6 | 11 |
| 231 | 12308 | 4.9551 | 1 | 2 | 3 | 6 | 10 |
| 232 | 811 | 2.8792 | 1 | 1 | 1 | 3 | 7 |
| 233 | 5175 | 7.5314 | 2 | 3 | 6 | 10 | 15 |
| 234 | 3204 | 3.4263 | 1 | 1 | 3 | 4 | 7 |
| 235 | 5095 | 5.1460 | 1 | 2 | 4 | 6 | 9 |
| 236 | 38644 | 4.8192 | 1 | 3 | 4 | 6 | 9 |
| 237 | 1698 | 3.4953 | 1 | 2 | 3 | 4 | 6 |
| 238 | 8028 | 8.5896 | 3 | 4 | 6 | 10 | 16 |
| 239 | 49412 | 6.2190 | 2 | 3 | 5 | 8 | 12 |
| 240 | 11462 | 6.6902 | 2 | 3 | 5 | 8 | 13 |
| 241 | 3138 | 3.8368 | 1 | 2 | 3 | 5 | 7 |
| 242 | 2455 | 6.6550 | 2 | 3 | 5 | 8 | 13 |
| 243 | 88444 | 4.6699 | 1 | 2 | 4 | 6 | 9 |
| 244 | 12282 | 4.8026 | 1 | 2 | 4 | 6 | 9 |
| 245 | 5158 | 3.4420 | 1 | 2 | 3 | 4 | 6 |
| 246 | 1402 | 3.8759 | 1 | 2 | 3 | 5 | 7 |
| 247 | 16979 | 3.4022 | 1 | 1 | 3 | 4 | 7 |
| 248 | 10612 | 4.8149 | 1 | 2 | 4 | 6 | 9 |
| 249 | 11655 | 3.6913 | 1 | 1 | 2 | 4 | 8 |
| 250 | 3495 | 4.1021 | 1 | 2 | 3 | 5 | 7 |
| 251 | 2432 | 2.8647 | 1 | 1 | 2 | 4 | 5 |
| 253 | 19997 | 4.7768 | 1 | 3 | 4 | 6 | 9 |
| 254 | 10514 | 3.1844 | 1 | 2 | 3 | 4 | 6 |
| 255 | 1 | 3.0000 | 3 | 3 | 3 | 3 | 3 |
| 256 | 6110 | 5.0566 | 1 | 2 | 4 | 6 | 10 |
| 257 | 16468 | 2.7380 | 1 | 1 | 2 | 3 | 5 |
| 258 | 16096 | 1.9335 | 1 | 1 | 2 | 2 | 3 |
| 259 | 3805 | 2.6915 | 1 | 1 | 1 | 2 | 6 |
| 260 | 4920 | 1.4191 | 1 | 1 | 1 | 2 | 2 |
| 261 | 1871 | 2.2720 | 1 | 1 | 1 | 3 | 5 |
| 262 | 615 | 4.0065 | 1 | 1 | 3 | 5 | 8 |
| 263 | 23616 | 11.6630 | 3 | 5 | 8 | 14 | 23 |
| 264 | 4081 | 7.0034 | 2 | 3 | 5 | 8 | 14 |
| 265 | 3785 | 6.7974 | 1 | 2 | 4 | 8 | 14 |
| 266 | 2669 | 3.2345 | 1 | 1 | 2 | 4 | 7 |
| 267 | 233 | 4.2060 | 1 | 1 | 3 | 6 | 9 |
| 268 | 910 | 3.5824 | 1 | 1 | 2 | 4 | 7 |
| 269 | 8868 | 8.2049 | 2 | 3 | 6 | 10 | 17 |
| 270 | 2661 | 3.4540 | 1 | 1 | 2 | 4 | 7 |
| 271 | 20588 | 7.1370 | 2 | 4 | 6 | 9 | 13 |
| 272 | 5506 | 6.1593 | 2 | 3 | 5 | 8 | 12 |
| 273 | 1290 | 4.0233 | 1 | 2 | 3 | 5 | 8 |
| 274 | 2357 | 6.5965 | 1 | 3 | 5 | 8 | 13 |
| 275 | 249 | 4.3373 | 1 | 1 | 3 | 5 | 9 |
| 276 | 1183 | 4.7101 | 1 | 2 | 4 | 6 | 8 |
| 277 | 88891 | 5.7267 | 2 | 3 | 5 | 7 | 10 |
| 278 | 30673 | 4.3084 | 2 | 3 | 4 | 5 | 8 |
| 279 | 3 | 2.3333 | 1 | 1 | 2 | 4 | 4 |
| 280 | 15826 | 4.1974 | 1 | 2 | 3 | 5 | 8 |
| 281 | 7203 | 3.0314 | 1 | 1 | 3 | 4 | 6 |
| 282 | 3 | 1.6667 | 1 | 1 | 2 | 2 | 2 |
| 283 | 5701 | 4.5869 | 1 | 2 | 4 | 6 | 9 |
| 284 | 1863 | 3.0934 | 1 | 1 | 2 | 4 | 6 |
| 285 | 6259 | 10.2903 | 3 | 5 | 8 | 13 | 20 |
| 286 | 2081 | 6.4248 | 2 | 3 | 5 | 7 | 13 |
| 287 | 5745 | 10.5220 | 3 | 5 | 7 | 12 | 21 |
| 288 | 2705 | 5.7360 | 2 | 3 | 4 | 6 | 9 |
| 289 | 4801 | 3.0165 | 1 | 1 | 2 | 3 | 7 |
| 290 | 8818 | 2.3115 | 1 | 1 | 2 | 2 | 4 |
| 291 | 66 | 1.8333 | 1 | 1 | 1 | 2 | 3 |
| 292 | 5044 | 10.2399 | 2 | 4 | 8 | 13 | 20 |
| 293 | 385 | 5.3714 | 1 | 2 | 4 | 7 | 11 |
| 294 | 88615 | 4.6095 | 1 | 2 | 4 | 6 | 9 |
| 295 | 3318 | 3.7372 | 1 | 2 | 3 | 5 | 7 |
| 296 | 240055 | 5.1602 | 2 | 2 | 4 | 6 | 10 |
| 297 | 44040 | 3.4064 | 1 | 2 | 3 | 4 | 6 |
| 298 | 95 | 2.9158 | 1 | 1 | 2 | 4 | 5 |
| 299 | 1192 | 5.3079 | 1 | 2 | 4 | 7 | 11 |
| 300 | 16118 | 6.1471 | 2 | 3 | 5 | 8 | 12 |
| 301 | 3221 | 3.6107 | 1 | 2 | 3 | 4 | 7 |
| 302 | 8256 | 9.0922 | 4 | 5 | 7 | 10 | 16 |
| 303 | 19568 | 8.4192 | 4 | 5 | 7 | 10 | 15 |
| 304 | 11902 | 8.7432 | 2 | 4 | 6 | 11 | 18 |
| 305 | 3011 | 3.6430 | 1 | 2 | 3 | 5 | 7 |
| 306 | 7368 | 5.6221 | 1 | 2 | 3 | 8 | 13 |
| 307 | 2096 | 2.2457 | 1 | 1 | 2 | 3 | 4 |
| 308 | 7520 | 6.2090 | 1 | 2 | 4 | 8 | 14 |
| 309 | 4120 | 2.2998 | 1 | 1 | 2 | 3 | 4 |
| 310 | 24033 | 4.4040 | 1 | 1 | 3 | 6 | 10 |
| 311 | 8027 | 1.8343 | 1 | 1 | 1 | 2 | 3 |
| 312 | 1499 | 4.4957 | 1 | 1 | 3 | 6 | 10 |
| 313 | 594 | 2.3300 | 1 | 1 | 1 | 3 | 5 |
| 314 | 1 | 3.0000 | 3 | 3 | 3 | 3 | 3 |
| 315 | 30085 | 6.9945 | 1 | 1 | 4 | 9 | 16 |
| 316 | 105482 | 6.6227 | 2 | 3 | 5 | 8 | 13 |
| 317 | 1536 | 2.8561 | 1 | 1 | 2 | 3 | 6 |
| 318 | 5627 | 6.0105 | 1 | 3 | 5 | 8 | 12 |
| 319 | 428 | 2.7477 | 1 | 1 | 2 | 3 | 6 |
| 320 | 188146 | 5.3180 | 2 | 3 | 4 | 6 | 10 |
| 321 | 30418 | 3.7849 | 1 | 2 | 3 | 5 | 7 |
| 322 | 61 | 4.1475 | 2 | 2 | 3 | 5 | 8 |
| 323 | 17410 | 3.2221 | 1 | 1 | 2 | 4 | 7 |
| 324 | 7562 | 1.8803 | 1 | 1 | 1 | 2 | 3 |
| 325 | 8239 | 3.8229 | 1 | 2 | 3 | 5 | 7 |
| 326 | 2705 | 2.6699 | 1 | 1 | 2 | 3 | 5 |
| 327 | 11 | 3.0909 | 1 | 1 | 3 | 4 | 5 |
| 328 | 668 | 3.6722 | 1 | 1 | 3 | 5 | 8 |
| 329 | 76 | 2.0000 | 1 | 1 | 1 | 2 | 4 |
| 331 | 46575 | 5.5475 | 1 | 3 | 4 | 7 | 11 |
| 332 | 4939 | 3.2909 | 1 | 1 | 2 | 4 | 7 |
| 333 | 290 | 4.9828 | 1 | 2 | 3 | 6 | 10 |
| 334 | 10491 | 4.8593 | 2 | 3 | 4 | 6 | 8 |
| 335 | 11916 | 3.3087 | 2 | 2 | 3 | 4 | 5 |
| 336 | 37713 | 3.4950 | 1 | 2 | 2 | 4 | 7 |
| 337 | 30390 | 2.1186 | 1 | 1 | 2 | 3 | 3 |
| 338 | 1232 | 5.1080 | 1 | 2 | 3 | 7 | 11 |
| 339 | 1628 | 4.6161 | 1 | 1 | 3 | 6 | 11 |
| 340 | 1 | 1.0000 | 1 | 1 | 1 | 1 | 1 |
| 341 | 3766 | 3.0316 | 1 | 1 | 2 | 3 | 6 |
| 342 | 675 | 3.2207 | 1 | 2 | 2 | 4 | 6 |
| 344 | 3519 | 2.3743 | 1 | 1 | 1 | 2 | 5 |
| 345 | 1280 | 3.7914 | 1 | 1 | 2 | 4 | 8 |
| 346 | 4489 | 5.9082 | 1 | 3 | 4 | 7 | 12 |
| 347 | 366 | 2.9372 | 1 | 1 | 2 | 4 | 6 |
| 348 | 3077 | 4.1677 | 1 | 2 | 3 | 5 | 8 |
| 349 | 626 | 2.5335 | 1 | 1 | 2 | 3 | 5 |
| 350 | 6325 | 4.4024 | 1 | 2 | 4 | 5 | 8 |
| 352 | 766 | 3.9621 | 1 | 2 | 3 | 5 | 8 |
| 353 | 2557 | 6.4490 | 2 | 3 | 5 | 7 | 12 |
| 354 | 7609 | 5.8406 | 3 | 3 | 4 | 7 | 11 |
| 355 | 5530 | 3.2790 | 2 | 3 | 3 | 4 | 5 |
| 356 | 25303 | 2.2920 | 1 | 1 | 2 | 3 | 4 |
| 357 | 5580 | 8.4925 | 3 | 4 | 7 | 10 | 16 |
| 358 | 20491 | 4.3133 | 2 | 3 | 3 | 5 | 7 |
| 359 | 30146 | 2.7284 | 2 | 2 | 3 | 3 | 4 |
| 360 | 16032 | 2.8550 | 1 | 2 | 2 | 3 | 5 |
| 361 | 386 | 2.9948 | 1 | 1 | 2 | 3 | 5 |
| 363 | 2875 | 3.4650 | 1 | 2 | 2 | 3 | 7 |
| 364 | 1667 | 3.8410 | 1 | 1 | 3 | 5 | 8 |
| 365 | 1737 | 7.2239 | 1 | 3 | 5 | 9 | 16 |
| 366 | 4468 | 6.7258 | 1 | 3 | 5 | 8 | 14 |
| 367 | 584 | 3.1284 | 1 | 1 | 2 | 4 | 6 |
| 368 | 3136 | 6.4716 | 2 | 3 | 5 | 8 | 12 |
| 369 | 3180 | 3.2500 | 1 | 1 | 2 | 4 | 7 |
| 370 | 1151 | 5.9079 | 3 | 3 | 4 | 5 | 10 |
| 371 | 1368 | 3.6447 | 2 | 3 | 3 | 4 | 5 |
| 372 | 964 | 3.2811 | 1 | 2 | 2 | 3 | 5 |
| 373 | 3920 | 2.2487 | 1 | 2 | 2 | 3 | 3 |
| 374 | 130 | 3.0846 | 1 | 2 | 2 | 3 | 4 |
| 375 | 11 | 2.2727 | 1 | 2 | 2 | 2 | 4 |
| 376 | 249 | 3.0843 | 1 | 2 | 2 | 4 | 6 |
| 377 | 51 | 5.0392 | 1 | 1 | 4 | 6 | 12 |
| 378 | 158 | 2.4177 | 1 | 1 | 2 | 3 | 4 |
| 379 | 344 | 3.4506 | 1 | 1 | 2 | 4 | 6 |
| 380 | 60 | 2.0833 | 1 | 1 | 1 | 2 | 5 |
| 381 | 154 | 2.5065 | 1 | 1 | 1 | 3 | 5 |
| 382 | 45 | 1.2889 | 1 | 1 | 1 | 1 | 2 |
| 383 | 1746 | 3.6174 | 1 | 1 | 2 | 4 | 8 |
| 384 | 121 | 2.1488 | 1 | 1 | 1 | 2 | 4 |
| 385 | 1 | 1.0000 | 1 | 1 | 1 | 1 | 1 |
| 389 | 16 | 13.5000 | 1 | 3 | 6 | 11 | 24 |
| 390 | 14 | 4.0000 | 1 | 2 | 3 | 6 | 7 |
| 391 | 1 | 4.0000 | 4 | 4 | 4 | 4 | 4 |
| 392 | 2349 | 9.6841 | 3 | 4 | 7 | 12 | 20 |
| 394 | 1891 | 7.1364 | 1 | 2 | 4 | 8 | 16 |
| 395 | 87679 | 4.4004 | 1 | 2 | 3 | 6 | 9 |
| 396 | 15 | 4.6667 | 1 | 2 | 4 | 6 | 7 |
| 397 | 17705 | 5.1893 | 1 | 2 | 4 | 7 | 10 |
| 398 | 17713 | 5.9510 | 2 | 3 | 5 | 7 | 11 |
| 399 | 1727 | 3.5634 | 1 | 2 | 3 | 5 | 7 |
| 400 | 6492 | 9.1288 | 1 | 3 | 6 | 12 | 20 |
| 401 | 5625 | 11.2775 | 2 | 5 | 9 | 15 | 23 |
| 402 | 1500 | 4.0933 | 1 | 1 | 3 | 6 | 9 |
| 403 | 32010 | 8.0846 | 2 | 3 | 6 | 10 | 17 |
| 404 | 4672 | 4.2609 | 1 | 2 | 3 | 6 | 9 |
| 406 | 2526 | 9.9224 | 3 | 4 | 7 | 12 | 21 |
| 407 | 722 | 4.4252 | 1 | 2 | 4 | 5 | 8 |
| 408 | 2193 | 8.0228 | 1 | 2 | 5 | 10 | 18 |
| 409 | 2831 | 5.9325 | 2 | 3 | 4 | 6 | 12 |
| 410 | 33654 | 3.9062 | 1 | 2 | 4 | 5 | 6 |
| 411 | 13 | 2.3077 | 1 | 1 | 2 | 2 | 5 |
| 412 | 30 | 2.4000 | 1 | 1 | 2 | 3 | 4 |
| 413 | 6478 | 7.0869 | 2 | 3 | 5 | 9 | 14 |
| 414 | 780 | 4.2885 | 1 | 2 | 3 | 5 | 9 |
| 415 | 39078 | 14.3458 | 4 | 6 | 11 | 18 | 28 |
| 416 | 184735 | 7.3935 | 2 | 4 | 6 | 9 | 14 |
| 417 | 18 | 5.0000 | 1 | 2 | 4 | 7 | 9 |
| 418 | 23028 | 6.1229 | 2 | 3 | 5 | 7 | 12 |
| 419 | 15460 | 4.7254 | 2 | 2 | 4 | 6 | 9 |
| 420 | 3116 | 3.4881 | 1 | 2 | 3 | 4 | 6 |
| 421 | 11535 | 3.7877 | 1 | 2 | 3 | 5 | 7 |
| 422 | 83 | 3.0482 | 1 | 2 | 3 | 4 | 6 |
| 423 | 7539 | 8.1108 | 2 | 3 | 6 | 10 | 16 |
| 424 | 1308 | 13.6338 | 2 | 5 | 9 | 16 | 26 |
| 425 | 15852 | 3.9953 | 1 | 2 | 3 | 5 | 8 |
| 426 | 4552 | 4.4512 | 1 | 2 | 3 | 5 | 9 |
| 427 | 1669 | 4.6207 | 1 | 2 | 3 | 6 | 9 |
| 428 | 854 | 6.9859 | 1 | 2 | 4 | 8 | 14 |
| 429 | 26786 | 6.3438 | 2 | 3 | 5 | 7 | 12 |
| 430 | 59892 | 8.0207 | 2 | 3 | 6 | 10 | 16 |
| 431 | 319 | 6.4326 | 1 | 3 | 5 | 7 | 12 |
| 432 | 475 | 4.7684 | 1 | 2 | 3 | 5 | 9 |
| 433 | 5522 | 3.0996 | 1 | 1 | 2 | 4 | 6 |
| 434 | 23062 | 5.0233 | 1 | 2 | 4 | 6 | 9 |
| 435 | 15012 | 4.1096 | 1 | 2 | 3 | 5 | 7 |
| 436 | 3158 | 12.8322 | 4 | 7 | 11 | 18 | 27 |
| 437 | 8588 | 8.6778 | 3 | 5 | 8 | 11 | 15 |
| 439 | 1356 | 8.3857 | 1 | 3 | 5 | 10 | 18 |
| 440 | 5191 | 9.0326 | 2 | 3 | 6 | 11 | 20 |
| 441 | 604 | 3.2235 | 1 | 1 | 2 | 4 | 7 |
| 442 | 15588 | 8.4766 | 1 | 3 | 6 | 10 | 18 |
| 443 | 3738 | 3.4315 | 1 | 1 | 3 | 4 | 7 |
| 444 | 5303 | 4.1495 | 1 | 2 | 3 | 5 | 8 |
| 445 | 2450 | 2.8857 | 1 | 1 | 2 | 4 | 5 |
| 447 | 5497 | 2.4708 | 1 | 1 | 2 | 3 | 5 |
| 449 | 28365 | 3.7491 | 1 | 1 | 3 | 5 | 8 |
| 450 | 6935 | 1.9981 | 1 | 1 | 1 | 2 | 4 |
| 451 | 3 | 1.3333 | 1 | 1 | 1 | 2 | 2 |
| 452 | 22930 | 4.8560 | 1 | 2 | 3 | 6 | 10 |
| 453 | 5095 | 2.7978 | 1 | 1 | 2 | 3 | 5 |
| 454 | 4001 | 4.5431 | 1 | 2 | 3 | 5 | 9 |
| 455 | 939 | 2.5751 | 1 | 1 | 2 | 3 | 5 |
| 461 | 3677 | 4.3723 | 1 | 1 | 2 | 5 | 11 |
| 462 | 13083 | 11.2728 | 4 | 6 | 10 | 14 | 21 |
| 463 | 22068 | 4.1282 | 1 | 2 | 3 | 5 | 8 |
| 464 | 6542 | 3.0011 | 1 | 1 | 2 | 4 | 6 |
| 465 | 248 | 3.0202 | 1 | 1 | 2 | 4 | 6 |
| 466 | 1741 | 3.7030 | 1 | 1 | 2 | 4 | 8 |
| 467 | 1137 | 3.0633 | 1 | 1 | 2 | 3 | 6 |
| 468 | 59766 | 12.9438 | 3 | 6 | 10 | 17 | 26 |
| 471 | 11720 | 5.5506 | 3 | 4 | 4 | 6 | 9 |
| 473 | 7663 | 12.5910 | 1 | 3 | 7 | 18 | 32 |
| 475 | 107894 | 11.2229 | 2 | 5 | 9 | 15 | 22 |
| 476 | 4142 | 10.8841 | 2 | 5 | 9 | 14 | 21 |
| 477 | 25336 | 8.1162 | 1 | 3 | 6 | 11 | 17 |
| 478 | 108852 | 7.3022 | 1 | 3 | 5 | 9 | 15 |
| 479 | 24100 | 3.4573 | 1 | 1 | 3 | 4 | 7 |
| 480 | 562 | 20.9609 | 7 | 9 | 14 | 25 | 44 |
| 481 | 383 | 24.1253 | 10 | 18 | 22 | 27 | 39 |
| 482 | 5733 | 12.9843 | 4 | 7 | 10 | 15 | 25 |
| 483 | 42784 | 39.4479 | 14 | 22 | 33 | 49 | 71 |
| 484 | 331 | 13.0091 | 2 | 6 | 10 | 17 | 26 |
| 485 | 2959 | 9.7080 | 4 | 5 | 7 | 11 | 18 |
| 486 | 2017 | 12.4408 | 1 | 5 | 10 | 16 | 25 |
| 487 | 3506 | 7.3945 | 1 | 3 | 6 | 10 | 15 |
| 488 | 784 | 16.9031 | 3 | 7 | 12 | 22 | 36 |
| 489 | 14140 | 8.4372 | 2 | 3 | 6 | 10 | 17 |
| 490 | 5449 | 5.3577 | 1 | 2 | 4 | 6 | 11 |
| 491 | 12291 | 3.4475 | 2 | 2 | 3 | 4 | 6 |
| 492 | 2698 | 15.6675 | 3 | 5 | 8 | 25 | 34 |
| 493 | 55279 | 5.7576 | 1 | 3 | 5 | 7 | 11 |
| 494 | 30109 | 2.4447 | 1 | 1 | 2 | 3 | 5 |
| 495 | 159 | 15.0503 | 7 | 9 | 12 | 17 | 26 |
| 496 | 1475 | 9.7349 | 4 | 5 | 7 | 12 | 19 |
| 497 | 22725 | 6.1720 | 2 | 3 | 5 | 7 | 12 |
| 498 | 21513 | 3.3043 | 1 | 2 | 3 | 4 | 6 |
| 499 | 31077 | 4.7330 | 1 | 2 | 3 | 6 | 9 |
| 500 | 44660 | 2.6198 | 1 | 1 | 2 | 3 | 5 |
| 501 | 2200 | 10.9600 | 4 | 6 | 8 | 13 | 21 |
| 502 | 585 | 6.5692 | 3 | 4 | 5 | 8 | 11 |
| 503 | 5631 | 4.0012 | 1 | 2 | 3 | 5 | 7 |
| 504 | 118 | 30.5169 | 9 | 15 | 24 | 41 | 55 |
| 505 | 145 | 3.3517 | 1 | 1 | 1 | 3 | 7 |
| 506 | 931 | 17.4071 | 4 | 8 | 14 | 22 | 36 |
| 507 | 293 | 8.3379 | 2 | 4 | 7 | 11 | 18 |
| 508 | 671 | 7.4918 | 2 | 3 | 5 | 9 | 15 |
| 509 | 177 | 4.5367 | 1 | 2 | 4 | 6 | 9 |
| 510 | 1650 | 7.2358 | 2 | 3 | 5 | 9 | 15 |
| 511 | 608 | 4.8158 | 1 | 2 | 3 | 6 | 11 |
| 11079177 |
| DRG | Number discharges | Arithmetic mean LOS | 10th percentile | 25th percentile | 50th percentile | 75th percentile | 90th percentile |
|---|---|---|---|---|---|---|---|
| 1 | 34040 | 9.0038 | 2 | 3 | 6 | 12 | 19 |
| 2 | 6862 | 9.9787 | 3 | 5 | 8 | 12 | 20 |
| 3 | 2 | 43.5000 | 35 | 35 | 52 | 52 | 52 |
| 4 | 6120 | 7.1526 | 1 | 2 | 5 | 9 | 15 |
| 5 | 93853 | 3.1665 | 1 | 1 | 2 | 3 | 7 |
| 6 | 365 | 2.9671 | 1 | 1 | 2 | 4 | 6 |
| 7 | 13283 | 9.8362 | 2 | 4 | 7 | 12 | 20 |
| 8 | 3821 | 2.9089 | 1 | 1 | 2 | 4 | 7 |
| 9 | 1631 | 6.3194 | 1 | 3 | 5 | 8 | 13 |
| 10 | 17754 | 6.5545 | 2 | 3 | 5 | 8 | 13 |
| 11 | 3157 | 4.0744 | 1 | 2 | 3 | 5 | 8 |
| 12 | 47063 | 5.9088 | 2 | 3 | 4 | 7 | 11 |
| 13 | 6504 | 5.1948 | 2 | 3 | 4 | 6 | 9 |
| 14 | 321622 | 5.8761 | 2 | 3 | 5 | 7 | 11 |
| 15 | 146291 | 3.5528 | 1 | 2 | 3 | 4 | 7 |
| 16 | 11235 | 6.0446 | 2 | 3 | 5 | 7 | 12 |
| 17 | 3532 | 3.3061 | 1 | 2 | 3 | 4 | 6 |
| 18 | 26608 | 5.4190 | 2 | 3 | 4 | 7 | 10 |
| 19 | 8346 | 3.6416 | 1 | 2 | 3 | 5 | 7 |
| 20 | 5680 | 10.1768 | 3 | 5 | 8 | 13 | 20 |
| 21 | 1324 | 6.5249 | 2 | 3 | 5 | 8 | 13 |
| 22 | 2560 | 4.8176 | 1 | 2 | 4 | 6 | 9 |
| 23 | 9553 | 4.1807 | 1 | 2 | 3 | 5 | 8 |
| 24 | 53313 | 4.9825 | 1 | 2 | 4 | 6 | 10 |
| 25 | 25528 | 3.2186 | 1 | 2 | 3 | 4 | 6 |
| 26 | 33 | 2.9091 | 1 | 1 | 2 | 4 | 6 |
| 27 | 3519 | 5.0673 | 1 | 1 | 3 | 6 | 11 |
| 28 | 11477 | 6.2222 | 1 | 3 | 5 | 8 | 13 |
| 29 | 4545 | 3.5982 | 1 | 2 | 3 | 5 | 7 |
| 30 | 1 | 1.0000 | 1 | 1 | 1 | 1 | 1 |
| 31 | 3576 | 4.4855 | 1 | 2 | 3 | 5 | 8 |
| 32 | 1770 | 2.5644 | 1 | 1 | 2 | 3 | 5 |
| 33 | 1 | 1.0000 | 1 | 1 | 1 | 1 | 1 |
| 34 | 20751 | 5.0759 | 1 | 2 | 4 | 6 | 10 |
| 35 | 5893 | 3.3743 | 1 | 2 | 3 | 4 | 6 |
| 36 | 3217 | 1.4719 | 1 | 1 | 1 | 1 | 2 |
| 37 | 1465 | 4.0348 | 1 | 1 | 2 | 5 | 9 |
| 38 | 102 | 2.6569 | 1 | 1 | 2 | 3 | 5 |
| 39 | 918 | 1.9379 | 1 | 1 | 1 | 2 | 4 |
| 40 | 1561 | 3.4209 | 1 | 1 | 2 | 4 | 7 |
| 42 | 2235 | 2.2859 | 1 | 1 | 1 | 3 | 5 |
| 43 | 85 | 3.1882 | 1 | 2 | 3 | 4 | 6 |
| 44 | 1244 | 4.9518 | 2 | 3 | 4 | 6 | 9 |
| 45 | 2464 | 3.1717 | 1 | 2 | 3 | 4 | 6 |
| 46 | 3102 | 4.6518 | 1 | 2 | 4 | 6 | 9 |
| 47 | 1284 | 3.2749 | 1 | 1 | 3 | 4 | 6 |
| 49 | 2266 | 4.8010 | 1 | 2 | 3 | 6 | 9 |
| 50 | 2507 | 1.9418 | 1 | 1 | 1 | 2 | 3 |
| 51 | 205 | 2.6927 | 1 | 1 | 1 | 2 | 6 |
| 52 | 224 | 1.9196 | 1 | 1 | 1 | 2 | 3 |
| 53 | 2512 | 3.5760 | 1 | 1 | 2 | 4 | 8 |
| 54 | 2 | 1.5000 | 1 | 1 | 2 | 2 | 2 |
| 55 | 1521 | 2.7331 | 1 | 1 | 1 | 3 | 6 |
| 56 | 517 | 2.7389 | 1 | 1 | 2 | 3 | 5 |
| 57 | 712 | 4.0478 | 1 | 1 | 2 | 5 | 9 |
| 59 | 107 | 2.7850 | 1 | 1 | 2 | 3 | 5 |
| 60 | 2 | 3.5000 | 2 | 2 | 5 | 5 | 5 |
| 61 | 234 | 5.1624 | 1 | 1 | 2 | 6 | 13 |
| 62 | 3 | 1.3333 | 1 | 1 | 1 | 2 | 2 |
| 63 | 3039 | 4.4399 | 1 | 2 | 3 | 5 | 9 |
| 64 | 3070 | 6.1642 | 1 | 2 | 4 | 8 | 13 |
| 65 | 34702 | 2.8444 | 1 | 1 | 2 | 4 | 5 |
| 66 | 7035 | 3.1599 | 1 | 1 | 2 | 4 | 6 |
| 67 | 501 | 3.5768 | 1 | 2 | 3 | 4 | 7 |
| 68 | 16804 | 4.1202 | 1 | 2 | 3 | 5 | 7 |
| 69 | 5465 | 3.2767 | 1 | 2 | 3 | 4 | 6 |
| 70 | 24 | 2.9167 | 1 | 2 | 2 | 4 | 5 |
| 71 | 82 | 3.8049 | 1 | 2 | 3 | 4 | 7 |
| 72 | 893 | 3.5566 | 1 | 2 | 3 | 4 | 6 |
| 73 | 6690 | 4.3988 | 1 | 2 | 3 | 6 | 9 |
| 75 | 39476 | 9.9112 | 3 | 5 | 7 | 12 | 19 |
| 76 | 40377 | 11.4074 | 3 | 5 | 9 | 14 | 22 |
| 77 | 2406 | 5.0000 | 1 | 2 | 4 | 7 | 10 |
| 78 | 32319 | 6.7837 | 3 | 4 | 6 | 8 | 11 |
| 79 | 170615 | 8.4963 | 3 | 4 | 7 | 11 | 16 |
| 80 | 8981 | 5.6562 | 2 | 3 | 5 | 7 | 10 |
| 81 | 4 | 18.2500 | 3 | 3 | 4 | 8 | 58 |
| 82 | 62447 | 6.9403 | 2 | 3 | 5 | 9 | 14 |
| 83 | 6598 | 5.5518 | 2 | 3 | 4 | 7 | 10 |
| 84 | 1539 | 3.3197 | 1 | 2 | 3 | 4 | 6 |
| 85 | 20738 | 6.3135 | 2 | 3 | 5 | 8 | 12 |
| 86 | 2115 | 3.6648 | 1 | 2 | 3 | 5 | 7 |
| 87 | 60486 | 6.2986 | 1 | 3 | 5 | 8 | 12 |
| 88 | 395676 | 5.1294 | 2 | 3 | 4 | 6 | 9 |
| 89 | 529122 | 5.9478 | 2 | 3 | 5 | 7 | 11 |
| 90 | 53985 | 4.1475 | 2 | 3 | 4 | 5 | 7 |
| 91 | 57 | 4.4561 | 2 | 2 | 3 | 5 | 9 |
| 92 | 13873 | 6.3521 | 2 | 3 | 5 | 8 | 12 |
| 93 | 1692 | 4.0969 | 1 | 2 | 3 | 5 | 7 |
| 94 | 12158 | 6.3088 | 2 | 3 | 5 | 8 | 12 |
| 95 | 1621 | 3.7224 | 1 | 2 | 3 | 5 | 7 |
| 96 | 62414 | 4.6281 | 2 | 3 | 4 | 6 | 8 |
| 97 | 31618 | 3.6509 | 1 | 2 | 3 | 5 | 7 |
| 98 | 17 | 4.3529 | 1 | 2 | 3 | 4 | 6 |
| 99 | 19205 | 3.2061 | 1 | 1 | 2 | 4 | 6 |
| 100 | 7656 | 2.1813 | 1 | 1 | 2 | 3 | 4 |
| 101 | 20236 | 4.3987 | 1 | 2 | 3 | 5 | 9 |
| 102 | 5196 | 2.6522 | 1 | 1 | 2 | 3 | 5 |
| 103 | 494 | 47.2510 | 9 | 13 | 25 | 61 | 102 |
| 104 | 19992 | 14.2362 | 6 | 8 | 12 | 17 | 25 |
| 105 | 26203 | 9.7712 | 4 | 6 | 8 | 11 | 17 |
| 106 | 3425 | 11.4923 | 5 | 7 | 10 | 14 | 20 |
| 107 | 88610 | 10.3724 | 5 | 7 | 9 | 12 | 17 |
| 108 | 6099 | 10.2140 | 3 | 5 | 8 | 13 | 19 |
| 109 | 60766 | 7.6912 | 4 | 5 | 6 | 9 | 12 |
| 110 | 53054 | 9.2130 | 2 | 5 | 7 | 11 | 18 |
| 111 | 8563 | 4.7507 | 1 | 2 | 5 | 6 | 8 |
| 113 | 42570 | 12.2362 | 3 | 6 | 9 | 15 | 24 |
| 114 | 8788 | 8.4208 | 2 | 4 | 7 | 11 | 16 |
| 115 | 14447 | 8.1481 | 1 | 4 | 7 | 11 | 16 |
| 116 | 101326 | 4.5123 | 1 | 2 | 3 | 6 | 9 |
| 117 | 3750 | 4.1997 | 1 | 1 | 2 | 5 | 9 |
| 118 | 7731 | 2.6831 | 1 | 1 | 1 | 3 | 6 |
| 119 | 1315 | 4.8783 | 1 | 1 | 3 | 6 | 12 |
| 120 | 37900 | 8.5509 | 1 | 2 | 6 | 11 | 19 |
| 121 | 163108 | 6.3828 | 2 | 3 | 5 | 8 | 12 |
| 122 | 79700 | 3.6981 | 1 | 2 | 3 | 5 | 7 |
| 123 | 40952 | 4.5870 | 1 | 1 | 3 | 6 | 11 |
| 124 | 133892 | 4.3434 | 1 | 2 | 3 | 5 | 8 |
| 125 | 80872 | 2.7656 | 1 | 1 | 2 | 4 | 5 |
| 126 | 5210 | 11.7196 | 3 | 6 | 9 | 15 | 22 |
| 127 | 683001 | 5.2764 | 2 | 3 | 4 | 7 | 10 |
| 128 | 9485 | 5.6128 | 2 | 4 | 5 | 7 | 9 |
| 129 | 4174 | 2.7513 | 1 | 1 | 1 | 3 | 6 |
| 130 | 87705 | 5.6725 | 2 | 3 | 5 | 7 | 10 |
| 131 | 27378 | 4.2134 | 1 | 2 | 4 | 6 | 7 |
| 132 | 148681 | 3.0010 | 1 | 1 | 2 | 4 | 6 |
| 133 | 8355 | 2.3246 | 1 | 1 | 2 | 3 | 4 |
| 134 | 36411 | 3.2406 | 1 | 2 | 3 | 4 | 6 |
| 135 | 7338 | 4.5492 | 1 | 2 | 3 | 6 | 9 |
| 136 | 1233 | 2.7178 | 1 | 1 | 2 | 3 | 5 |
| 138 | 195523 | 3.9935 | 1 | 2 | 3 | 5 | 8 |
| 139 | 82943 | 2.5030 | 1 | 1 | 2 | 3 | 5 |
| 140 | 70338 | 2.6538 | 1 | 1 | 2 | 3 | 5 |
| 141 | 91110 | 3.6692 | 1 | 2 | 3 | 5 | 7 |
| 142 | 45981 | 2.6476 | 1 | 1 | 2 | 3 | 5 |
| 143 | 205686 | 2.1259 | 1 | 1 | 2 | 3 | 4 |
| 144 | 82529 | 5.3248 | 1 | 2 | 4 | 7 | 11 |
| 145 | 7242 | 2.7331 | 1 | 1 | 2 | 3 | 5 |
| 146 | 10755 | 10.3134 | 5 | 7 | 9 | 12 | 17 |
| 147 | 2637 | 6.4137 | 3 | 5 | 6 | 8 | 9 |
| 148 | 130066 | 12.2031 | 5 | 7 | 10 | 15 | 22 |
| 149 | 18560 | 6.5100 | 4 | 5 | 6 | 8 | 9 |
| 150 | 19923 | 11.2795 | 4 | 7 | 10 | 14 | 20 |
| 151 | 4860 | 5.8123 | 2 | 3 | 5 | 8 | 10 |
| 152 | 4399 | 8.1444 | 3 | 5 | 7 | 9 | 14 |
| 153 | 2100 | 5.3838 | 3 | 4 | 5 | 7 | 8 |
| 154 | 28872 | 13.1709 | 4 | 7 | 10 | 16 | 25 |
| 155 | 6655 | 4.2026 | 1 | 2 | 3 | 6 | 8 |
| 156 | 4 | 7.5000 | 1 | 1 | 5 | 6 | 18 |
| 157 | 7963 | 5.3929 | 1 | 2 | 4 | 7 | 11 |
| 158 | 4671 | 2.5359 | 1 | 1 | 2 | 3 | 5 |
| 159 | 16456 | 4.9981 | 1 | 2 | 4 | 6 | 10 |
| 160 | 11727 | 2.6592 | 1 | 1 | 2 | 3 | 5 |
| 161 | 11208 | 4.2057 | 1 | 1 | 3 | 5 | 9 |
| 162 | 7217 | 1.9216 | 1 | 1 | 1 | 2 | 4 |
| 163 | 7 | 3.5714 | 1 | 1 | 2 | 3 | 4 |
| 164 | 4857 | 8.4293 | 4 | 5 | 7 | 10 | 15 |
| 165 | 2086 | 4.7895 | 2 | 3 | 5 | 6 | 8 |
| 166 | 3559 | 5.0441 | 2 | 2 | 4 | 6 | 10 |
| 167 | 3316 | 2.6001 | 1 | 2 | 2 | 3 | 5 |
| 168 | 1361 | 4.7649 | 1 | 2 | 3 | 6 | 10 |
| 169 | 843 | 2.3238 | 1 | 1 | 2 | 3 | 5 |
| 170 | 12291 | 10.9867 | 2 | 4 | 8 | 14 | 22 |
| 171 | 1408 | 4.5014 | 1 | 2 | 4 | 6 | 9 |
| 172 | 30682 | 6.9445 | 2 | 3 | 5 | 9 | 14 |
| 173 | 2707 | 3.6679 | 1 | 1 | 3 | 5 | 7 |
| 174 | 242053 | 4.7969 | 2 | 3 | 4 | 6 | 9 |
| 175 | 32431 | 2.9309 | 1 | 2 | 3 | 4 | 5 |
| 176 | 15194 | 5.2285 | 2 | 3 | 4 | 6 | 10 |
| 177 | 9272 | 4.5310 | 2 | 2 | 4 | 6 | 8 |
| 178 | 3619 | 3.0683 | 1 | 2 | 3 | 4 | 6 |
| 179 | 12384 | 5.9738 | 2 | 3 | 5 | 7 | 11 |
| 180 | 86181 | 5.3581 | 2 | 3 | 4 | 7 | 10 |
| 181 | 26423 | 3.4153 | 1 | 2 | 3 | 4 | 6 |
| 182 | 245515 | 4.3381 | 1 | 2 | 3 | 5 | 8 |
| 183 | 84480 | 2.9129 | 1 | 1 | 2 | 4 | 5 |
| 184 | 80 | 2.9500 | 1 | 2 | 2 | 4 | 6 |
| 185 | 4826 | 4.5089 | 1 | 2 | 3 | 6 | 9 |
| 186 | 3 | 9.3333 | 1 | 1 | 9 | 18 | 18 |
| 187 | 683 | 3.9253 | 1 | 1 | 3 | 5 | 8 |
| 188 | 76140 | 5.5645 | 1 | 2 | 4 | 7 | 11 |
| 189 | 12060 | 3.1404 | 1 | 1 | 2 | 4 | 6 |
| 190 | 51 | 6.9608 | 2 | 3 | 4 | 5 | 8 |
| 191 | 8941 | 13.8186 | 4 | 6 | 10 | 17 | 27 |
| 192 | 1122 | 6.5294 | 2 | 4 | 6 | 8 | 11 |
| 193 | 5303 | 12.5218 | 5 | 7 | 10 | 16 | 22 |
| 194 | 721 | 6.7906 | 2 | 4 | 6 | 8 | 12 |
| 195 | 4350 | 10.1616 | 4 | 6 | 9 | 12 | 17 |
| 196 | 1166 | 5.7196 | 2 | 4 | 5 | 7 | 10 |
| 197 | 18895 | 8.9383 | 3 | 5 | 7 | 11 | 16 |
| 198 | 5786 | 4.5380 | 2 | 3 | 4 | 6 | 8 |
| 199 | 1725 | 9.6614 | 2 | 4 | 7 | 13 | 21 |
| 200 | 1081 | 10.3478 | 1 | 3 | 7 | 13 | 23 |
| 201 | 1431 | 13.7393 | 3 | 6 | 11 | 17 | 27 |
| 202 | 26168 | 6.4060 | 2 | 3 | 5 | 8 | 13 |
| 203 | 29251 | 6.6384 | 2 | 3 | 5 | 9 | 13 |
| 204 | 57757 | 5.7995 | 2 | 3 | 4 | 7 | 11 |
| 205 | 23128 | 6.1790 | 2 | 3 | 5 | 8 | 12 |
| 206 | 1970 | 3.8959 | 1 | 2 | 3 | 5 | 7 |
| 207 | 31072 | 5.0836 | 1 | 2 | 4 | 6 | 10 |
| 208 | 10149 | 2.8924 | 1 | 1 | 2 | 4 | 6 |
| 209 | 345519 | 5.0794 | 3 | 3 | 4 | 6 | 8 |
| 210 | 121933 | 6.8207 | 3 | 4 | 6 | 8 | 11 |
| 211 | 31780 | 4.9358 | 3 | 4 | 4 | 6 | 7 |
| 212 | 8 | 10.5000 | 1 | 1 | 4 | 9 | 29 |
| 213 | 9241 | 9.0019 | 2 | 4 | 7 | 11 | 18 |
| 216 | 6008 | 9.6949 | 2 | 4 | 8 | 12 | 20 |
| 217 | 16558 | 13.2636 | 3 | 5 | 9 | 16 | 28 |
| 218 | 21621 | 5.4328 | 2 | 3 | 4 | 7 | 10 |
| 219 | 19714 | 3.2188 | 1 | 2 | 3 | 4 | 6 |
| 220 | 6 | 4.0000 | 1 | 1 | 3 | 7 | 7 |
| 223 | 13397 | 2.8551 | 1 | 1 | 2 | 3 | 6 |
| 224 | 11274 | 1.9346 | 1 | 1 | 2 | 2 | 3 |
| 225 | 5805 | 4.8558 | 1 | 2 | 3 | 6 | 11 |
| 226 | 5230 | 6.5887 | 1 | 2 | 4 | 8 | 14 |
| 227 | 4702 | 2.7052 | 1 | 1 | 2 | 3 | 5 |
| 228 | 2373 | 3.7981 | 1 | 1 | 2 | 5 | 8 |
| 229 | 1118 | 2.4785 | 1 | 1 | 2 | 3 | 5 |
| 230 | 2395 | 5.2551 | 1 | 2 | 3 | 6 | 11 |
| 231 | 11467 | 4.9383 | 1 | 2 | 3 | 6 | 11 |
| 232 | 811 | 2.8792 | 1 | 1 | 1 | 3 | 7 |
| 233 | 5159 | 7.5251 | 1 | 3 | 6 | 10 | 15 |
| 234 | 3186 | 3.4203 | 1 | 1 | 3 | 4 | 7 |
| 235 | 5095 | 5.1460 | 1 | 2 | 4 | 6 | 9 |
| 236 | 38644 | 4.8192 | 1 | 3 | 4 | 6 | 9 |
| 237 | 1698 | 3.4953 | 1 | 2 | 3 | 4 | 6 |
| 238 | 8028 | 8.5896 | 3 | 4 | 6 | 10 | 16 |
| 239 | 49410 | 6.2190 | 2 | 3 | 5 | 8 | 12 |
| 240 | 11462 | 6.6902 | 2 | 3 | 5 | 8 | 13 |
| 241 | 3138 | 3.8368 | 1 | 2 | 3 | 5 | 7 |
| 242 | 2455 | 6.6550 | 2 | 3 | 5 | 8 | 13 |
| 243 | 88325 | 4.6695 | 1 | 2 | 4 | 6 | 9 |
| 244 | 12281 | 4.8027 | 1 | 2 | 4 | 6 | 9 |
| 245 | 5158 | 3.4420 | 1 | 2 | 3 | 4 | 6 |
| 246 | 1402 | 3.8759 | 1 | 2 | 3 | 5 | 7 |
| 247 | 16979 | 3.4022 | 1 | 1 | 3 | 4 | 7 |
| 248 | 10612 | 4.8149 | 1 | 2 | 4 | 6 | 9 |
| 249 | 11431 | 3.6726 | 1 | 1 | 2 | 4 | 8 |
| 250 | 3495 | 4.1021 | 1 | 2 | 3 | 5 | 7 |
| 251 | 2432 | 2.8647 | 1 | 1 | 2 | 4 | 5 |
| 253 | 19997 | 4.7768 | 1 | 3 | 4 | 6 | 9 |
| 254 | 10514 | 3.1844 | 1 | 2 | 3 | 4 | 6 |
| 255 | 1 | 3.0000 | 3 | 3 | 3 | 3 | 3 |
| 256 | 6097 | 5.0576 | 1 | 2 | 4 | 6 | 10 |
| 257 | 16468 | 2.7380 | 1 | 1 | 2 | 3 | 5 |
| 258 | 16096 | 1.9335 | 1 | 1 | 2 | 2 | 3 |
| 259 | 3805 | 2.6915 | 1 | 1 | 1 | 2 | 6 |
| 260 | 4920 | 1.4191 | 1 | 1 | 1 | 2 | 2 |
| 261 | 1875 | 2.2704 | 1 | 1 | 1 | 3 | 5 |
| 262 | 622 | 3.9807 | 1 | 1 | 3 | 5 | 8 |
| 263 | 23616 | 11.6630 | 3 | 5 | 8 | 14 | 23 |
| 264 | 4081 | 7.0034 | 2 | 3 | 5 | 8 | 14 |
| 265 | 3785 | 6.7974 | 1 | 2 | 4 | 8 | 14 |
| 266 | 2669 | 3.2345 | 1 | 1 | 2 | 4 | 7 |
| 267 | 233 | 4.2060 | 1 | 1 | 3 | 6 | 9 |
| 268 | 910 | 3.5824 | 1 | 1 | 2 | 4 | 7 |
| 269 | 8868 | 8.2049 | 2 | 3 | 6 | 10 | 17 |
| 270 | 2662 | 3.4530 | 1 | 1 | 2 | 4 | 7 |
| 271 | 20588 | 7.1370 | 2 | 4 | 6 | 9 | 13 |
| 272 | 5506 | 6.1593 | 2 | 3 | 5 | 8 | 12 |
| 273 | 1290 | 4.0233 | 1 | 2 | 3 | 5 | 8 |
| 274 | 2357 | 6.5965 | 1 | 3 | 5 | 8 | 13 |
| 275 | 249 | 4.3373 | 1 | 1 | 3 | 5 | 9 |
| 276 | 1189 | 4.7258 | 1 | 2 | 4 | 6 | 8 |
| 277 | 88891 | 5.7267 | 2 | 3 | 5 | 7 | 10 |
| 278 | 30673 | 4.3084 | 2 | 3 | 4 | 5 | 8 |
| 279 | 3 | 2.3333 | 1 | 1 | 2 | 4 | 4 |
| 280 | 15826 | 4.1974 | 1 | 2 | 3 | 5 | 8 |
| 281 | 7203 | 3.0314 | 1 | 1 | 3 | 4 | 6 |
| 282 | 3 | 1.6667 | 1 | 1 | 2 | 2 | 2 |
| 283 | 5701 | 4.5869 | 1 | 2 | 4 | 6 | 9 |
| 284 | 1863 | 3.0934 | 1 | 1 | 2 | 4 | 6 |
| 285 | 6259 | 10.2903 | 3 | 5 | 8 | 13 | 20 |
| 286 | 2081 | 6.4248 | 2 | 3 | 5 | 7 | 13 |
| 287 | 5745 | 10.5220 | 3 | 5 | 7 | 12 | 21 |
| 288 | 2705 | 5.7360 | 2 | 3 | 4 | 6 | 9 |
| 289 | 4801 | 3.0165 | 1 | 1 | 2 | 3 | 7 |
| 290 | 8818 | 2.3115 | 1 | 1 | 2 | 2 | 4 |
| 291 | 66 | 1.8333 | 1 | 1 | 1 | 2 | 3 |
| 292 | 4994 | 10.2367 | 2 | 4 | 8 | 13 | 20 |
| 293 | 385 | 5.3714 | 1 | 2 | 4 | 7 | 11 |
| 294 | 88615 | 4.6095 | 1 | 2 | 4 | 6 | 9 |
| 295 | 3318 | 3.7372 | 1 | 2 | 3 | 5 | 7 |
| 296 | 240050 | 5.1602 | 2 | 2 | 4 | 6 | 10 |
| 297 | 44040 | 3.4064 | 1 | 2 | 3 | 4 | 6 |
| 298 | 95 | 2.9158 | 1 | 1 | 2 | 4 | 5 |
| 299 | 1192 | 5.3079 | 1 | 2 | 4 | 7 | 11 |
| 300 | 16118 | 6.1471 | 2 | 3 | 5 | 8 | 12 |
| 301 | 3221 | 3.6107 | 1 | 2 | 3 | 4 | 7 |
| 302 | 7924 | 8.8892 | 4 | 5 | 7 | 10 | 15 |
| 303 | 19568 | 8.4192 | 4 | 5 | 7 | 10 | 15 |
| 304 | 11900 | 8.7432 | 2 | 4 | 6 | 11 | 18 |
| 305 | 3011 | 3.6430 | 1 | 2 | 3 | 5 | 7 |
| 306 | 7368 | 5.6221 | 1 | 2 | 3 | 8 | 13 |
| 307 | 2096 | 2.2457 | 1 | 1 | 2 | 3 | 4 |
| 308 | 7520 | 6.2090 | 1 | 2 | 4 | 8 | 14 |
| 309 | 4120 | 2.2998 | 1 | 1 | 2 | 3 | 4 |
| 310 | 24033 | 4.4040 | 1 | 1 | 3 | 6 | 10 |
| 311 | 8027 | 1.8343 | 1 | 1 | 1 | 2 | 3 |
| 312 | 1499 | 4.4957 | 1 | 1 | 3 | 6 | 10 |
| 313 | 594 | 2.3300 | 1 | 1 | 1 | 3 | 5 |
| 314 | 1 | 3.0000 | 3 | 3 | 3 | 3 | 3 |
| 315 | 30492 | 7.1080 | 1 | 1 | 4 | 9 | 16 |
| 316 | 105482 | 6.6227 | 2 | 3 | 5 | 8 | 13 |
| 317 | 1536 | 2.8561 | 1 | 1 | 2 | 3 | 6 |
| 318 | 5627 | 6.0105 | 1 | 3 | 5 | 8 | 12 |
| 319 | 428 | 2.7477 | 1 | 1 | 2 | 3 | 6 |
| 320 | 188146 | 5.3180 | 2 | 3 | 4 | 6 | 10 |
| 321 | 30418 | 3.7849 | 1 | 2 | 3 | 5 | 7 |
| 322 | 61 | 4.1475 | 2 | 2 | 3 | 5 | 8 |
| 323 | 17410 | 3.2221 | 1 | 1 | 2 | 4 | 7 |
| 324 | 7562 | 1.8803 | 1 | 1 | 1 | 2 | 3 |
| 325 | 8239 | 3.8229 | 1 | 2 | 3 | 5 | 7 |
| 326 | 2705 | 2.6699 | 1 | 1 | 2 | 3 | 5 |
| 327 | 11 | 3.0909 | 1 | 1 | 3 | 4 | 5 |
| 328 | 668 | 3.6722 | 1 | 1 | 3 | 5 | 8 |
| 329 | 76 | 2.0000 | 1 | 1 | 1 | 2 | 4 |
| 331 | 46575 | 5.5475 | 1 | 3 | 4 | 7 | 11 |
| 332 | 4939 | 3.2909 | 1 | 1 | 2 | 4 | 7 |
| 333 | 290 | 4.9828 | 1 | 2 | 3 | 6 | 10 |
| 334 | 10491 | 4.8593 | 2 | 3 | 4 | 6 | 8 |
| 335 | 11916 | 3.3087 | 2 | 2 | 3 | 4 | 5 |
| 336 | 37713 | 3.4950 | 1 | 2 | 2 | 4 | 7 |
| 337 | 30390 | 2.1186 | 1 | 1 | 2 | 3 | 3 |
| 338 | 1232 | 5.1080 | 1 | 2 | 3 | 7 | 11 |
| 339 | 1628 | 4.6161 | 1 | 1 | 3 | 6 | 11 |
| 340 | 1 | 1.0000 | 1 | 1 | 1 | 1 | 1 |
| 341 | 3766 | 3.0316 | 1 | 1 | 2 | 3 | 6 |
| 342 | 675 | 3.2207 | 1 | 2 | 2 | 4 | 6 |
| 344 | 3519 | 2.3743 | 1 | 1 | 1 | 2 | 5 |
| 345 | 1280 | 3.7914 | 1 | 1 | 2 | 4 | 8 |
| 346 | 4489 | 5.9082 | 1 | 3 | 4 | 7 | 12 |
| 347 | 366 | 2.9372 | 1 | 1 | 2 | 4 | 6 |
| 348 | 3077 | 4.1677 | 1 | 2 | 3 | 5 | 8 |
| 349 | 626 | 2.5335 | 1 | 1 | 2 | 3 | 5 |
| 350 | 6325 | 4.4024 | 1 | 2 | 4 | 5 | 8 |
| 352 | 766 | 3.9621 | 1 | 2 | 3 | 5 | 8 |
| 353 | 2557 | 6.4490 | 2 | 3 | 5 | 7 | 12 |
| 354 | 7609 | 5.8406 | 3 | 3 | 4 | 7 | 11 |
| 355 | 5530 | 3.2790 | 2 | 3 | 3 | 4 | 5 |
| 356 | 25303 | 2.2920 | 1 | 1 | 2 | 3 | 4 |
| 357 | 5580 | 8.4925 | 3 | 4 | 7 | 10 | 16 |
| 358 | 20492 | 4.3132 | 2 | 3 | 3 | 5 | 7 |
| 359 | 30149 | 2.7284 | 2 | 2 | 3 | 3 | 4 |
| 360 | 16035 | 2.8549 | 1 | 2 | 2 | 3 | 5 |
| 361 | 386 | 2.9948 | 1 | 1 | 2 | 3 | 5 |
| 363 | 2875 | 3.4650 | 1 | 2 | 2 | 3 | 7 |
| 364 | 1666 | 3.8427 | 1 | 1 | 3 | 5 | 8 |
| 365 | 1737 | 7.2239 | 1 | 3 | 5 | 9 | 16 |
| 366 | 4468 | 6.7258 | 1 | 3 | 5 | 8 | 14 |
| 367 | 584 | 3.1284 | 1 | 1 | 2 | 4 | 6 |
| 368 | 3136 | 6.4716 | 2 | 3 | 5 | 8 | 12 |
| 369 | 3178 | 3.2498 | 1 | 1 | 2 | 4 | 7 |
| 370 | 1151 | 5.9079 | 3 | 3 | 4 | 5 | 10 |
| 371 | 1368 | 3.6447 | 2 | 3 | 3 | 4 | 5 |
| 372 | 964 | 3.2811 | 1 | 2 | 2 | 3 | 5 |
| 373 | 3920 | 2.2487 | 1 | 2 | 2 | 3 | 3 |
| 374 | 130 | 3.0846 | 1 | 2 | 2 | 3 | 4 |
| 375 | 11 | 2.2727 | 1 | 2 | 2 | 2 | 4 |
| 376 | 249 | 3.0843 | 1 | 2 | 2 | 4 | 6 |
| 377 | 51 | 5.0392 | 1 | 1 | 4 | 6 | 12 |
| 378 | 158 | 2.4177 | 1 | 1 | 2 | 3 | 4 |
| 379 | 344 | 3.4506 | 1 | 1 | 2 | 4 | 6 |
| 380 | 60 | 2.0833 | 1 | 1 | 1 | 2 | 5 |
| 381 | 154 | 2.5065 | 1 | 1 | 1 | 3 | 5 |
| 382 | 45 | 1.2889 | 1 | 1 | 1 | 1 | 2 |
| 383 | 1746 | 3.6174 | 1 | 1 | 2 | 4 | 8 |
| 384 | 121 | 2.1488 | 1 | 1 | 1 | 2 | 4 |
| 385 | 1 | 1.0000 | 1 | 1 | 1 | 1 | 1 |
| 389 | 16 | 13.5000 | 1 | 3 | 6 | 11 | 24 |
| 390 | 14 | 4.0000 | 1 | 2 | 3 | 6 | 7 |
| 391 | 1 | 4.0000 | 4 | 4 | 4 | 4 | 4 |
| 392 | 2349 | 9.6841 | 3 | 4 | 7 | 12 | 20 |
| 394 | 1891 | 7.1364 | 1 | 2 | 4 | 8 | 16 |
| 395 | 87678 | 4.4004 | 1 | 2 | 3 | 6 | 9 |
| 396 | 15 | 4.6667 | 1 | 2 | 4 | 6 | 7 |
| 397 | 17705 | 5.1893 | 1 | 2 | 4 | 7 | 10 |
| 398 | 17713 | 5.9510 | 2 | 3 | 5 | 7 | 11 |
| 399 | 1727 | 3.5634 | 1 | 2 | 3 | 5 | 7 |
| 400 | 6490 | 9.1307 | 1 | 3 | 6 | 12 | 20 |
| 401 | 5622 | 11.2782 | 2 | 5 | 9 | 15 | 23 |
| 402 | 1500 | 4.0933 | 1 | 1 | 3 | 6 | 9 |
| 403 | 31997 | 8.0849 | 2 | 3 | 6 | 10 | 17 |
| 404 | 4670 | 4.2621 | 1 | 2 | 3 | 6 | 9 |
| 406 | 2527 | 9.9201 | 3 | 4 | 7 | 12 | 21 |
| 407 | 723 | 4.4219 | 1 | 2 | 4 | 5 | 8 |
| 408 | 2196 | 8.0255 | 1 | 2 | 5 | 10 | 18 |
| 409 | 2831 | 5.9325 | 2 | 3 | 4 | 6 | 12 |
| 410 | 33654 | 3.9062 | 1 | 2 | 4 | 5 | 6 |
| 411 | 13 | 2.3077 | 1 | 1 | 2 | 2 | 5 |
| 412 | 30 | 2.4000 | 1 | 1 | 2 | 3 | 4 |
| 413 | 6491 | 7.0875 | 2 | 3 | 5 | 9 | 14 |
| 414 | 782 | 4.2813 | 1 | 2 | 3 | 5 | 9 |
| 415 | 39080 | 14.3464 | 4 | 6 | 11 | 18 | 28 |
| 416 | 184735 | 7.3935 | 2 | 4 | 6 | 9 | 14 |
| 417 | 18 | 5.0000 | 1 | 2 | 4 | 7 | 9 |
| 418 | 23026 | 6.1212 | 2 | 3 | 5 | 7 | 11 |
| 419 | 15460 | 4.7254 | 2 | 2 | 4 | 6 | 9 |
| 420 | 3116 | 3.4881 | 1 | 2 | 3 | 4 | 6 |
| 421 | 11535 | 3.7877 | 1 | 2 | 3 | 5 | 7 |
| 422 | 83 | 3.0482 | 1 | 2 | 3 | 4 | 6 |
| 423 | 7539 | 8.1108 | 2 | 3 | 6 | 10 | 16 |
| 424 | 1308 | 13.6338 | 2 | 5 | 9 | 16 | 26 |
| 425 | 15852 | 3.9953 | 1 | 2 | 3 | 5 | 8 |
| 426 | 4552 | 4.4512 | 1 | 2 | 3 | 5 | 9 |
| 427 | 1669 | 4.6207 | 1 | 2 | 3 | 6 | 9 |
| 428 | 854 | 6.9859 | 1 | 2 | 4 | 8 | 14 |
| 429 | 26786 | 6.3438 | 2 | 3 | 5 | 7 | 12 |
| 430 | 59892 | 8.0207 | 2 | 3 | 6 | 10 | 16 |
| 431 | 319 | 6.4326 | 1 | 3 | 5 | 7 | 12 |
| 432 | 475 | 4.7684 | 1 | 2 | 3 | 5 | 9 |
| 433 | 5522 | 3.0996 | 1 | 1 | 2 | 4 | 6 |
| 439 | 1356 | 8.3857 | 1 | 3 | 5 | 10 | 18 |
| 440 | 5191 | 9.0326 | 2 | 3 | 6 | 11 | 20 |
| 441 | 604 | 3.2235 | 1 | 1 | 2 | 4 | 7 |
| 442 | 15588 | 8.4766 | 1 | 3 | 6 | 10 | 18 |
| 443 | 3743 | 3.4320 | 1 | 1 | 3 | 4 | 7 |
| 444 | 5303 | 4.1495 | 1 | 2 | 3 | 5 | 8 |
| 445 | 2450 | 2.8857 | 1 | 1 | 2 | 4 | 5 |
| 447 | 5497 | 2.4708 | 1 | 1 | 2 | 3 | 5 |
| 449 | 28365 | 3.7491 | 1 | 1 | 3 | 5 | 8 |
| 450 | 6934 | 1.9980 | 1 | 1 | 1 | 2 | 4 |
| 451 | 3 | 1.3333 | 1 | 1 | 1 | 2 | 2 |
| 452 | 22930 | 4.8560 | 1 | 2 | 3 | 6 | 10 |
| 453 | 5091 | 2.7969 | 1 | 1 | 2 | 3 | 5 |
| 454 | 4001 | 4.5431 | 1 | 2 | 3 | 5 | 9 |
| 455 | 939 | 2.5751 | 1 | 1 | 2 | 3 | 5 |
| 461 | 3676 | 4.3708 | 1 | 1 | 2 | 5 | 11 |
| 462 | 13083 | 11.2728 | 4 | 6 | 10 | 14 | 21 |
| 463 | 22068 | 4.1282 | 1 | 2 | 3 | 5 | 8 |
| 464 | 6542 | 3.0011 | 1 | 1 | 2 | 4 | 6 |
| 465 | 248 | 3.0202 | 1 | 1 | 2 | 4 | 6 |
| 466 | 1741 | 3.7030 | 1 | 1 | 2 | 4 | 8 |
| 467 | 1137 | 3.0633 | 1 | 1 | 2 | 3 | 6 |
| 468 | 55027 | 12.8995 | 3 | 6 | 10 | 16 | 26 |
| 471 | 11720 | 5.5506 | 3 | 4 | 4 | 6 | 9 |
| 473 | 7663 | 12.5910 | 1 | 3 | 7 | 18 | 32 |
| 475 | 107894 | 11.2229 | 2 | 5 | 9 | 15 | 22 |
| 476 | 4151 | 10.8829 | 2 | 5 | 9 | 14 | 21 |
| 477 | 25363 | 8.1252 | 1 | 3 | 6 | 11 | 17 |
| 478 | 108182 | 7.2900 | 1 | 3 | 5 | 9 | 15 |
| 479 | 24051 | 3.4569 | 1 | 1 | 3 | 4 | 7 |
| 480 | 562 | 20.9609 | 7 | 9 | 14 | 25 | 44 |
| 481 | 383 | 24.1253 | 10 | 18 | 22 | 27 | 39 |
| 482 | 5737 | 12.9796 | 4 | 7 | 10 | 15 | 25 |
| 483 | 42789 | 39.4482 | 14 | 22 | 33 | 49 | 71 |
| 484 | 331 | 13.0091 | 2 | 6 | 10 | 17 | 26 |
| 485 | 2959 | 9.7080 | 4 | 5 | 7 | 11 | 18 |
| 486 | 2017 | 12.4408 | 1 | 5 | 10 | 16 | 25 |
| 487 | 3506 | 7.3945 | 1 | 3 | 6 | 10 | 15 |
| 488 | 784 | 16.9031 | 3 | 7 | 12 | 22 | 36 |
| 489 | 14140 | 8.4372 | 2 | 3 | 6 | 10 | 17 |
| 490 | 5454 | 5.3577 | 1 | 2 | 4 | 6 | 11 |
| 491 | 12291 | 3.4475 | 2 | 2 | 3 | 4 | 6 |
| 492 | 2698 | 15.6675 | 3 | 5 | 8 | 25 | 34 |
| 493 | 55279 | 5.7576 | 1 | 3 | 5 | 7 | 11 |
| 494 | 30109 | 2.4447 | 1 | 1 | 2 | 3 | 5 |
| 495 | 159 | 15.0503 | 7 | 9 | 12 | 17 | 26 |
| 496 | 1504 | 9.7088 | 4 | 5 | 7 | 12 | 19 |
| 497 | 17585 | 6.5739 | 3 | 4 | 5 | 7 | 11 |
| 498 | 12931 | 4.1718 | 2 | 3 | 4 | 5 | 6 |
| 499 | 30519 | 4.7011 | 1 | 2 | 3 | 6 | 9 |
| 500 | 44330 | 2.6104 | 1 | 1 | 2 | 3 | 5 |
| 501 | 2200 | 10.9600 | 4 | 6 | 8 | 13 | 21 |
| 502 | 585 | 6.5692 | 3 | 4 | 5 | 8 | 11 |
| 503 | 5630 | 4.0014 | 1 | 2 | 3 | 5 | 7 |
| 504 | 118 | 30.5169 | 9 | 15 | 24 | 41 | 55 |
| 505 | 145 | 3.3517 | 1 | 1 | 1 | 3 | 7 |
| 506 | 931 | 17.4071 | 4 | 8 | 14 | 22 | 36 |
| 507 | 293 | 8.3379 | 2 | 4 | 7 | 11 | 18 |
| 508 | 671 | 7.4918 | 2 | 3 | 5 | 9 | 15 |
| 509 | 177 | 4.5367 | 1 | 2 | 4 | 6 | 9 |
| 510 | 1650 | 7.2358 | 2 | 3 | 5 | 9 | 15 |
| 511 | 608 | 4.8158 | 1 | 2 | 3 | 6 | 11 |
| 512 | 340 | 13.8971 | 7 | 8 | 11 | 16 | 25 |
| 513 | 115 | 10.6000 | 6 | 7 | 8 | 11 | 19 |
| 514 | 17025 | 7.8702 | 2 | 3 | 6 | 10 | 16 |
| 515 | 3788 | 5.9060 | 1 | 1 | 4 | 8 | 13 |
| 516 | 68886 | 4.7702 | 2 | 3 | 4 | 6 | 9 |
| 517 | 171423 | 2.6737 | 1 | 1 | 2 | 3 | 6 |
| 518 | 48733 | 3.5023 | 1 | 1 | 2 | 4 | 8 |
| 519 | 6359 | 5.1030 | 1 | 2 | 3 | 6 | 12 |
| 520 | 9489 | 2.1653 | 1 | 1 | 2 | 3 | 4 |
| 521 | 28014 | 5.9437 | 2 | 3 | 4 | 7 | 12 |
| 522 | 6852 | 9.4658 | 3 | 5 | 8 | 12 | 20 |
| 523 | 14954 | 4.0942 | 1 | 2 | 3 | 5 | 7 |
| 11094323 |
| State | Urban | Rural |
|---|---|---|
| ALABAMA | 0.343 | 0.410 |
| ALASKA | 0.417 | 0.697 |
| ARIZONA | 0.355 | 0.493 |
| ARKANSAS | 0.466 | 0.445 |
| CALIFORNIA | 0.339 | 0.432 |
| COLORADO | 0.422 | 0.577 |
| CONNECTICUT | 0.497 | 0.506 |
| DELAWARE | 0.511 | 0.450 |
| DISTRICT OF COLUMBIA | 0.421 | |
| FLORIDA | 0.351 | 0.370 |
| GEORGIA | 0.461 | 0.469 |
| HAWAII | 0.412 | 0.549 |
| IDAHO | 0.541 | 0.561 |
| ILLINOIS | 0.404 | 0.501 |
| INDIANA | 0.524 | 0.533 |
| IOWA | 0.486 | 0.613 |
| KANSAS | 0.415 | 0.637 |
| KENTUCKY | 0.479 | 0.492 |
| LOUISIANA | 0.401 | 0.491 |
| MAINE | 0.614 | 0.540 |
| MARYLAND | 0.759 | 0.819 |
| MASSACHUSETTS | 0.511 | 0.571 |
| MICHIGAN | 0.459 | 0.563 |
| MINNESOTA | 0.493 | 0.592 |
| MISSISSIPPI | 0.452 | 0.446 |
| MISSOURI | 0.404 | 0.475 |
| MONTANA | 0.537 | 0.588 |
| NEBRASKA | 0.448 | 0.610 |
| NEVADA | 0.306 | 0.503 |
| NEW HAMPSHIRE | 0.549 | 0.585 |
| NEW JERSEY | 0.394 | |
| NEW MEXICO | 0.466 | 0.491 |
| NEW YORK | 0.524 | 0.607 |
| NORTH CAROLINA | 0.517 | 0.463 |
| NORTH DAKOTA | 0.620 | 0.655 |
| OHIO | 0.500 | 0.568 |
| OKLAHOMA | 0.409 | 0.492 |
| OREGON | 0.614 | 0.598 |
| PENNSYLVANIA | 0.398 | 0.526 |
| PUERTO RICO | 0.486 | 0.584 |
| RHODE ISLAND | 0.510 | |
| SOUTH CAROLINA | 0.440 | 0.463 |
| SOUTH DAKOTA | 0.529 | 0.640 |
| TENNESSEE | 0.438 | 0.453 |
| TEXAS | 0.401 | 0.493 |
| UTAH | 0.497 | 0.582 |
| VERMONT | 0.572 | 0.599 |
| VIRGINIA | 0.459 | 0.496 |
| WASHINGTON | 0.582 | 0.639 |
| WEST VIRGINIA | 0.568 | 0.527 |
| WISCONSIN | 0.524 | 0.613 |
| WYOMING | 0.523 | 0.717 |
| State | Ratio |
|---|---|
| ALABAMA | 0.044 |
| ALASKA | 0.058 |
| ARIZONA | 0.038 |
| ARKANSAS | 0.049 |
| CALIFORNIA | 0.034 |
| COLORADO | 0.045 |
| CONNECTICUT | 0.036 |
| DELAWARE | 0.051 |
| DISTRICT OF COLUMBIA | 0.035 |
| FLORIDA | 0.043 |
| GEORGIA | 0.051 |
| HAWAII | 0.038 |
| IDAHO | 0.046 |
| ILLINOIS | 0.040 |
| INDIANA | 0.056 |
| IOWA | 0.049 |
| KANSAS | 0.050 |
| KENTUCKY | 0.046 |
| LOUISIANA | 0.047 |
| MAINE | 0.040 |
| MARYLAND | 0.013 |
| MASSACHUSETTS | 0.053 |
| MICHIGAN | 0.044 |
| MINNESOTA | 0.047 |
| MISSISSIPPI | 0.044 |
| MISSOURI | 0.044 |
| MONTANA | 0.053 |
| NEBRASKA | 0.054 |
| NEVADA | 0.030 |
| NEW HAMPSHIRE | 0.061 |
| NEW JERSEY | 0.036 |
| NEW MEXICO | 0.045 |
| NEW YORK | 0.051 |
| NORTH CAROLINA | 0.046 |
| NORTH DAKOTA | 0.074 |
| OHIO | 0.047 |
| OKLAHOMA | 0.046 |
| OREGON | 0.046 |
| PENNSYLVANIA | 0.039 |
| PUERTO RICO | 0.045 |
| RHODE ISLAND | 0.029 |
| SOUTH CAROLINA | 0.046 |
| SOUTH DAKOTA | 0.059 |
| TENNESSEE | 0.048 |
| TEXAS | 0.046 |
| UTAH | 0.047 |
| VERMONT | 0.052 |
| VIRGINIA | 0.055 |
| WASHINGTON | 0.063 |
| WEST VIRGINIA | 0.045 |
| WISCONSIN | 0.051 |
| WYOMING | 0.065 |
Appendix A-Regulatory Impact Analysis
I. Introduction
We generally prepare a regulatory flexibility analysis that is consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601 through 612), unless we certify that a final rule would not have a significant economic impact on a substantial number of small entities. For purposes of the RFA, we consider all hospitals to be small entities. We estimate the total impact of these changes for FY 2002 payments compared to FY 2001 payments to be approximately a $1.9 billion increase. As such, this final rule is a major rule as defined in 5 U.S.C. 804(2). Therefore, we have prepared an impact analysis for this final rule.
Also, section 1102(b) of the Act requires us to prepare a regulatory impact analysis for any final rule that may have a significant impact on the operations of a substantial number of small rural hospitals. Such an analysis must conform to the provisions of section 603 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital with fewer than 100 beds that is located outside of a Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA). Section 601(g) of the Social Security Amendments of 1983 (Public Law 98-21) designated hospitals in certain New England counties as belonging to the adjacent NECMA. Thus, for purposes of the hospital inpatient prospective payment systems, we classify these hospitals as urban hospitals.
It is clear that the changes being made in this document would affect both a substantial number of small rural hospitals as well as other classes of hospitals, and the effects on some may be significant. Therefore, the discussion below, in combination with the rest of this final rule, constitutes a combined regulatory impact analysis and regulatory flexibility analysis.
We have reviewed this final rule under the threshold criteria of Executive Order 13132, Federalism, and have determined that the final rule will not have any negative impact on the rights, roles, and responsibilities of State, local, or tribal governments.
Section 202 of the Unfunded Mandate Reform Act of 1995 (Public Law 104-4) also requires that agencies assess anticipated costs and benefits before issuing any final rule that has been preceded by a final rule that may result in an expenditure in any one year by State, local, or tribal governments, in the aggregate, or by the private sector, of $110 million. This final rule would not mandate any requirements for State, local, or tribal governments.
In accordance with the provisions of Executive Order 12866, this final rule was reviewed by the Office of Management and Budget.
II. Changes in the Final Rule
Since we published the proposed rule, the market basket estimates for hospitals subject to the inpatient prospective payment system and hospitals and units excluded from the system have both risen by 0.2 percentage points. As a result, the updates are 0.2 percentage points higher than the updates reflected in the impact analysis for the proposed rule. With the exception of these changes, we are generally implementing the policy and statutory provisions discussed in the proposed rule.
III. Impact Analysis for CMS-1131-F and CMS-1178-F
As noted previously, this final rule contains provisions implemented in two interim final rules with comment periods. The first, published August 1, 2000 (65 FR 47026), implemented, or conformed the regulations to, certain statutory provisions relating to Medicare payments to hospitals for inpatient services that were contained in Public Law 106-113. The second, published June 13, 2001 (66 FR 32172), implemented, or conformed the regulations to, certain statutory provisions relating to Medicare payments to hospitals for inpatient services that were contained in Public Law 106-554.
As described in the preamble to this final rule, with the exception of minor changes to the process for receiving, reviewing, and approving new Medicare-dependent small rural hospitals (MDHs), we are not changing the policies described in those interim final rules with comment period. Therefore, the reader should refer to the impact analyses contained in those interim final rules for a discussion of the impacts of these changes. For the impact analysis in the August 1, 2000 interim final rule, the reader should refer to page 47043. For the impact analysis in the June 13, 2001 interim final rule, the reader should refer to page 32184.
IV. Limitations of Our Analysis
As has been the case in our previously published regulatory impact analyses, the following quantitative analysis presents the projected effects of our proposed policy changes, including statutory changes effective for FY 2002, on various hospital groups. We estimate the effects of individual policy changes by estimating payments per case while holding all other payment policies constant. We use the best data available, but we do not attempt to predict behavioral responses to our policy changes, and we do not make adjustments for future changes in such variables as admissions, lengths of stay, or case-mix. We received two comments on the impact analysis for our May 4, 2001 proposed rule.
Comment: One commenter, who was unable to reconcile the standardized amounts for FY 2002 proposed in the May 4, 2001 Federal Register with the standardized amounts published for FY 2001 (65 FR 47126 and 66 FR 32176), expressed concern with the level of detail provided by the impact analysis and requested a breakdown of the changes reflected in Column 8 of Table 1. The commenter also requested that we release the complete data so that hospitals could evaluate all the proposed FY 2002 policy changes on their own.
Response: As we stated in the proposed rule, column 8 compares our estimate of payments per case, incorporating all changes reflected in this final rule for FY 2002 (including statutory changes), to our estimate of payments per case in FY 2001. It includes the effects of the 2.75 percent update to the standardized amounts and the hospital-specific rates for MDHs and SCHs. It also reflects the 1.1 percentage point difference between the projected percentage of outlier payments in FY 2001 (5.1 percent of total DRG payments) and the current estimate of the percentage of actual outlier payments in FY 2001 (6.2 percent), as described in the introduction to this Appendix and the Addendum to this final rule. Additionally, there are differences resulting from the increased number of hospitals receiving DSH payments under Section 211 of Public Law 106-554 and from the increase in SCH rebasing to a 1996 blended rate. There are also interactive effects among the various factors comprising the payment system that we are not able to isolate. For these reasons, the values in column 7 may not equal the sum of the changes in columns 5 and 6, plus the other impacts that we are able to identify. Since we explain the update for FY 2002 in section II. of the Addendum of this final rule, and since the impact of those changes are the same for all types of hospitals, we do not believe it is necessary to isolate that change in a separate impact column. Also, we would like to note that all of the data used by us in the impact analysis are available to the public. Our impact file is posted on our website following the publication of each proposed and final rule. For information on obtaining the MedPAR file, the Provider-Specific File, and the cost report files on which all of our analysis is based, we refer the reader to section VIII. of this final rule.
Comment: One commenter noted that, in the proposed rule, the budget neutrality factor in footnote 6 of Table 1 was printed as 0.992394 while the same factor was printed as 0.992493 on page 22872 and asked which factor was correct.
Response: Footnote 6 to Table 1 in the proposed rule contained a typographical error. The budget neutrality factor used in the proposed rule was 0.992493 and was printed correctly on page 22872 of the proposed rule.
V. Hospitals Included in and Excluded From the Prospective Payment System
The prospective payment systems for hospital inpatient operating and capital-related costs encompass nearly all general, short-term, acute care hospitals that participate in the Medicare program. There were 48 Indian Health Service hospitals in our database, which we excluded from the analysis due to the special characteristics of the prospective payment method for these hospitals. We also exclude critical access hospitals (CAHs) from our analysis, due to the special characteristics of these hospitals. Among other short-term, acute care hospitals, only the 68 such hospitals in Maryland remain excluded from the prospective payment system under the waiver at section 1814(b)(3) of the Act. Thus, as of July 2001, we have included 4,795 hospitals in our analysis. This represents about 80 percent of all Medicare-participating hospitals. The majority of this impact analysis focuses on this set of hospitals.
The remaining 20 percent are specialty hospitals that are excluded from the prospective payment system and continue to be paid on the basis of their reasonable costs (subject to a rate-of-increase ceiling on their inpatient operating costs per discharge). These hospitals include psychiatric, rehabilitation, long-term care, children's, and cancer hospitals. The impacts of our final policy changes on these hospitals are discussed below.
VI. Impact on Excluded Hospitals and Units
As of July 2001, there were 1,064 specialty hospitals excluded from the prospective payment system and instead paid on a reasonable cost basis subject to the rate-of-increase ceiling under § 413.40. Broken down by specialty, there were 507 psychiatric, 210 rehabilitation, 260 long-term care, 77 children's, and 10 cancer hospitals. In addition, there were 1,446 psychiatric units and 926 rehabilitation units in hospitals otherwise subject to the prospective payment system. These excluded units are also paid in accordance with § 413.40. Under § 413.40(a)(2)(i)(A), the rate-of-increase ceiling is not applicable to the 68 specialty hospitals and units in Maryland that are paid in accordance with the waiver at section 1814(b)(3) of the Act.
As required by section 1886(b)(3)(B) of the Act, the update factor applicable to the rate-of-increase limit for excluded hospitals and units for FY 2002 would be between 0.8 and 3.3 percent, or 0 percent, depending on the hospital's or unit's costs in relation to its limit for the most recent cost reporting period for which information is available.
The impact on excluded hospitals and units of the update in the rate-of-increase limit depends on the cumulative cost increases experienced by each excluded hospital or unit since its applicable base period. For excluded hospitals and units that have maintained their cost increases at a level below the percentage increases in the rate-of-increase limits since their base period, the major effect will be on the level of incentive payments these hospitals and units receive. Conversely, for excluded hospitals and units with per-case cost increases above the cumulative update in their rate-of-increase limits, the major effect will be the amount of excess costs that would not be reimbursed.
We note that, under § 413.40(d)(3), an excluded hospital or unit whose costs exceed 110 percent of its rate-of-increase limit receives its rate-of-increase limit plus 50 percent of the difference between its reasonable costs and 110 percent of the limit, not to exceed 110 percent of its limit. In addition, under the various provisions set forth in § 413.40, certain excluded hospitals and units can obtain payment adjustments for justifiable increases in operating costs that exceed the limit. At the same time, however, by generally limiting payment increases, we continue to provide an incentive for excluded hospitals and units to restrain the growth in their spending for patient services.
VII. Graduate Medical Education Impact
A. National Average Per Resident Amount (PRA)
As discussed in detail in section IV.H.2. of this proposed rule, we proposed to implement section 511 of Public Law 106-554, which increased the floor of the locality-adjusted national average (PRA for the purposes of computing direct GME payments for cost reporting periods beginning during FY 2002. The national average PRA payment methodology, as provided in section 311 of Public Law 106-113, establishes a "floor" and "ceiling" based on a locality-adjusted, updated national average PRA for cost reporting periods beginning on or after October 1, 2000 and before October 1, 2005. Section 511 of Public Law 106-554 increased the floor from 70 percent to equal 85 percent of a locality-adjusted national average PRA for FY 2002.
For this final rule, we have calculated an estimated impact of this policy on teaching hospitals' PRAs for FY 2002, making assumptions about update factors and geographic adjustment factors (GAF) for each hospital. Generally, using FY 1997 data, we calculated a floor based on 70 percent of the national average PRA and a floor based on 85 percent of the national average PRA. We then determined the amount of direct GME payments that would have been paid had the floor remained at 70 percent of the national average PRA. Next, we determined the amount of direct GME payments that would be paid with the floor increased to equal 85 percent of the national average PRA. We subtracted the difference between the two and inflated the difference to FY 2002 to determine the impact of this provision.
The figures we used in this impact, except for the FY 1997 weighted PRA of $68,464, are estimations and are for demonstrative purposes only. Hospitals must use the methodology stated in section IV.H. of this final rule to revise (if appropriate) their individual PRAs.
In calculating this impact, we used Medicare cost report data for all cost reports ending in FY 1997. We excluded hospitals that file manual cost reports because we did not have access to their Medicare utilization data. We also excluded all teaching hospitals in Maryland, because these hospitals are paid on a Medicare waiver outside of the prospective payment system, and those hospitals' PRAs do not determine their level of direct GME payments. For hospitals that had two cost reporting periods ending in FY 1997, we used the later of the two periods. A total of 1,231 teaching hospitals were included in the analysis.
Using the FY 1997 weighted average PRA of $68,464, we determined an 85 percent floor of $58,194 for FY 1997. We then determined that, for cost reporting periods ending in FY 1997, approximately 562 hospitals had PRAs that were below $58,194 (336 hospitals of these hospitals had PRAs that were below the 70-percent floor, and 226 hospitals had PRAs that were above the 70-percent floor but below the 85-percent floor). The estimated total cost to the Medicare program in FY 2002 of replacing the PRAs of the 562 hospitals with the 85-percent floor is $105.3 million.
B. Closed Training Programs or Hospitals That Close Their Training Programs
As discussed in IV.H.5, of the preamble of this final rule, we are allowing a hospital to receive a temporary adjustment to its FTE cap to reflect residents added because of the closure of another hospital's GME program if the hospital that closed its program agrees to temporarily reduce its FTE cap. We have calculated an estimated impact on the Medicare program for FY 2002 as a result of this policy. We used the best available cost report data from the FY 1997 HCRIS in our analysis.
We estimate that approximately 5 to 10 programs, each with an average of 25 residents, close each year without advance warning, displacing the residents before they complete their training. Therefore, the number of residents displaced each year could be between 125 and 250. We estimated the impact of this change based on direct GME and IME payment amounts in FY 1997 to determine a total GME amount and updated the total with the CPI-U for FY 2002. At most, the estimated impact for this provision for FY 2002 is moving payments of between $10 and $20 million among different hospitals. This would result from redirecting these payments from the hospital that closed its program to the hospital(s) that takes on the residents.
VIII. Quantitative Impact Analysis of the Final Policy Changes Under the Prospective Payment System for Operating Costs
A. Basis and Methodology of Estimates
In this final rule, we are announcing policy changes and payment rate updates for the prospective payment systems for operating and capital-related costs. We have prepared separate impact analyses of the final changes to each system. This section deals with changes to the operating prospective payment system.
The data used in developing the quantitative analyses presented below are taken from the March 2001 update of the FY 2000 MedPAR file and the most current Provider Specific File that is used for payment purposes. Although the analyses of the changes to the operating prospective payment system do not incorporate cost data, the most recently available hospital cost report data were used to categorize hospitals. Our analysis has several qualifications. First, we do not make adjustments for behavioral changes that hospitals may adopt in response to these final policy changes. Second, due to the interdependent nature of the prospective payment system, it is very difficult to precisely quantify the impact associated with each final change. Third, we draw upon various sources for the data used to categorize hospitals in the tables. In some cases, particularly the number of beds, there is a fair degree of variation in the data from different sources. We have attempted to construct these variables with the best available sources overall. For individual hospitals, however, some miscategorizations are possible.
Using cases from the March, 2001 update of the FY 2000 MedPAR file, we simulated payments under the operating prospective payment system given various combinations of payment parameters. Any short-term, acute care hospitals not paid under the general prospective payment systems (Indian Health Service hospitals and hospitals in Maryland) are excluded from the simulations. Payments under the capital prospective payment system, or payments for costs other than inpatient operating costs, are not analyzed here. Estimated payment impacts of FY 2002 policy changes to the capital prospective payment system are discussed in section IX. of this Appendix.
The changes discussed separately below are the following:
• The effects of the annual reclassification of diagnoses and procedures and the recalibration of the diagnosis-related group (DRG) relative weights required by section 1886(d)(4)(C) of the Act.
• The effects of changes in hospitals' wage index values reflecting wage data from hospitals' cost reporting periods beginning during FY 1998, compared to the FY 1997 wage data.
• The effects of our final policy to increase the accuracy of the wage index calculation by changing the overhead allocation method used so that the salaries and hours of lower-wage, overhead employees and the overhead wage-related costs associated with the excluded areas of the hospital are more accurately removed when calculating the overhead costs attributable to wages.
• The effects of our final policy to include the contract labor costs of laboratories and pharmacies from Worksheet S-3 Part II Lines 9.01 and 9.02 in the wage index calculation.
• The combined effects of our changes to the wage index data and calculations and the changes in the DRG recalibration.
• The effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB) that will be effective in FY 2002.
• The effects of our new policy to hold-harmless other hospitals in an urban area where certain hospitals are reclassified elsewhere by including the wage data of reclassified hospitals in their geographic area as well as the area to which they are reclassified.
• The total change in payments based on FY 2002 policies relative to payments based on FY 2001 policies.
To illustrate the impacts of the FY 2002 final changes, our analysis begins with a FY 2002 baseline simulation model using: the FY 2001 DRG GROUPER (version 18.0); the FY 2001 wage index; and no MGCRB reclassifications. Outlier payments are set at 5.1 percent of total DRG plus outlier payments.
Each final and statutory policy change is then added incrementally to this baseline model, finally arriving at an FY 2002 model incorporating all of the changes. This allows us to isolate the effects of each change.
Our final comparison illustrates the percent change in payments per case from FY 2001 to FY 2002. Five factors have significant impacts here. The first is the update to the standardized amounts. In accordance with section 1886(d)(3)(A)(iv) of the Act, as amended by section 301 of Public Law 106-554, we updated the large urban and the other areas average standardized amounts for FY 2002 using the most recently forecasted hospital market basket increase for FY 2002 of 3.3 percent minus 0.55 percentage points (for an update of 2.75 percent). Under section 1886(b)(3) of the Act, the updates to the hospital-specific amounts for sole community hospitals (SCHs) and for MDHs are equal to the market basket increase of 3.3 percent minus 0.55 percentage points (for an update of 2.75 percent).
A second significant factor that impacts changes in hospitals' payments per case from FY 2001 to FY 2002 is the change in MGCRB status from one year to the next. That is, hospitals reclassified in FY 2001 that are no longer reclassified in FY 2002 may have a negative payment impact going from FY 2001 to FY 2002; conversely, hospitals not reclassified in FY 2001 that are reclassified in FY 2002 may have a positive impact. In some cases, these impacts can be quite substantial, so if a relatively small number of hospitals in a particular category lose their reclassification status, the percentage change in payments for the category may be below the national mean. This effect may be alleviated somewhat by section 304(a) of Public Law 106-554, which provided that reclassifications for purposes of the wage index are for a 3 year period.
A third significant factor is that we currently estimate that actual outlier payments during FY 2001 will be 6.2 percent of actual total DRG payments. When the FY 2001 final rule was published, we projected FY 2001 outlier payments would be 5.1 percent of total DRG plus outlier payments; the standardized amounts were offset correspondingly. The effects of the higher than expected outlier payments during FY 2001 (as discussed in the Addendum to this final rule) are reflected in the analyses below comparing our current estimates of FY 2001 payments per case to estimated FY 2002 payments per case.
Fourth, section 213 of Public Law 106-554 provided that all SCHs may receive payment on the basis of their costs per case during their cost reporting period that began during 1996. For FY 2002, eligible SCHs that are rebased receive a hospital-specific rate comprised of the greater of 50-percent of the higher of their FY 1982 or FY 1987 hospital-specific rate or 50-percent of the federal rate, and 50-percent of their FY 1996 hospital-specific rate.
Fifth, sections 302 and 303 of Public Law 106-554 affect payments for indirect medical education (IME) and disproportionate share hospitals (DSH), respectively. These sections increased IME and DSH payments during FY 2001 (effective with discharges on or after April 1, 2001). For FY 2002, section 302 established IME payments at the same level as FY 2001 (6.5 percent), and section 303 established DSH payments at the adjustment the hospital would otherwise receive minus 3 percent.
Table I demonstrates the results of our analysis. The table categorizes hospitals by various geographic and special payment consideration groups to illustrate the varying impacts on different types of hospitals. The top row of the table shows the overall impact on the 4,795 hospitals included in the analysis. This number is 93 fewer hospitals than were included in the impact analysis in the FY 2001 final rule (65 FR 47191).
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 2,704 hospitals located in urban areas (MSAs or NECMAs) included in our analysis. Among these, there are 1,561 hospitals located in large urban areas (populations over 1 million), and 1,143 hospitals in other urban areas (populations of 1 million or fewer). In addition, there are 2,091 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 2002 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) are 2,746, 1,632, 1,114, and 2,049, respectively.
The next three groupings examine the impacts of the final changes on hospitals grouped by whether or not they have residency programs (teaching hospitals that receive an IME adjustment) or receive DSH payments, or some combination of these two adjustments. There are 3,668 non-teaching hospitals in our analysis, 890 teaching hospitals with fewer than 100 residents, and 237 teaching hospitals with 100 or more residents.
In the DSH categories, hospitals are grouped according to their DSH payment status, and whether they are considered urban or rural after MGCRB reclassifications. Hospitals in the rural DSH categories, therefore, represent hospitals that were not reclassified for purposes of the standardized amount or for purposes of the DSH adjustment. (They may, however, have been reclassified for purposes of the wage index.) We note that section 211 of Public Law 106-554 reduced the qualifying DSH threshold to 15 percent for all hospitals (this threshold previously applied to urban hospitals with 100 or more beds and rural hospitals with 500 or more beds). Consequently, many more hospitals qualify for DSH. In the FY 2001 final rule, there were 3,070 hospitals that did not receive a DSH adjustment (65 FR 47192). In Table I, the number of hospitals that did not receive a DSH adjustment declines to 1,879. The number of urban hospitals with fewer than 100 beds receiving DSH increases from 72 prior to section 211 to 316 after its implementation. Among rural hospitals with fewer than 100 beds, 103 received DSH prior to section 211; for FY 2002 that number increases to 454.
The next category groups hospitals considered urban after geographic reclassification, in terms of whether they receive the IME adjustment, the DSH adjustment, both, or neither.
The next five rows examine the impacts of the final changes on rural hospitals by special payment groups (SCHs, rural referral centers (RRCs), and MDHs), as well as rural hospitals not receiving a special payment designation. The RRCs (165), SCHs (680), MDHs (329), and SCH and RRCs (70) shown here were not reclassified for purposes of the standardized amount. There are 15 RRCs, 1 MDH, 4 SCHs, and 1 SCH and RRC that will be reclassified as urban for the standardized amount in FY 2002 and, therefore, are not included in these rows.
The next two groupings are based on type of ownership and the hospital's Medicare utilization expressed as a percent of total patient days. These data are taken primarily from the FY 1999 Medicare cost report files, if available (otherwise FY 1998 data are used). Data needed to determine ownership status or Medicare utilization percentages were unavailable for 52 and 78 hospitals, respectively. For the most part, these appear to be new hospitals, without cost reports on file for FY 1999.
The next series of groupings concern the geographic reclassification status of hospitals. The first grouping displays all hospitals that were reclassified by the MGCRB for FY 2002. The next two groupings separate the hospitals in the first group by urban and rural status. The final row in Table I contains hospitals located in rural counties but deemed to be urban under section 1886(d)(8)(B) of the Act.
| Num. of hosps.1 | DRG re- calib.2 | New wage data3 | New overhead alloc.4 | Include contract labor5 | DRG WI changes6 | MCGRB reclassi- fication7 | Reclassi- fication hold- harmless policy8 | All FY 2002 changes9 | |
|---|---|---|---|---|---|---|---|---|---|
| (0) | (1) | (2) | (3) | (4) | (5) | (6) | (7) | (8) | |
| By Geographic Location | |||||||||
| All hospitals | 4,795 | 0.3 | 0.2 | -0.1 | -0.1 | 0.0 | -0.2 | 0.2 | 2.1 |
| Urban hospitals | 2,704 | 0.3 | 0.2 | -0.1 | -0.1 | 0.0 | -0.7 | 0.2 | 1.9 |
| Large urban areas(populations over 1 million) | 1,561 | 0.4 | 0.0 | -0.1 | -0.1 | -0.1 | -0.8 | 0.3 | 1.8 |
| Other urban areas (populations of 1 million or fewer) | 1,143 | 0.2 | 0.5 | -0.2 | -0.1 | 0.2 | -0.5 | 0.1 | 2.0 |
| Rural hospitals | 2,091 | 0.0 | 0.0 | 0.2 | 0.2 | -0.2 | 2.6 | 0.0 | 3.4 |
| Bed Size (Urban): | |||||||||
| 0-99 beds | 695 | -0.1 | 0.1 | 0.1 | 0.1 | 0.0 | -0.8 | 0.2 | 2.6 |
| 100-199 beds | 948 | 0.3 | -0.1 | 0.2 | 0.2 | 0.0 | -0.7 | 0.3 | 2.1 |
| 200-299 beds | 529 | 0.3 | 0.2 | 0.0 | 0.0 | 0.1 | -0.7 | 0.3 | 2.0 |
| 300-499 beds | 383 | 0.3 | 0.4 | -0.3 | -0.2 | 0.0 | -0.7 | 0.2 | 1.8 |
| 500 or more beds | 149 | 0.5 | 0.4 | -0.4 | -0.4 | 0.0 | -0.6 | 0.1 | 1.6 |
| Bed Size (Rural): | |||||||||
| 0-49 beds | 1,226 | -0.2 | 0.1 | 0.2 | 0.1 | -0.3 | 0.3 | 0.0 | 3.4 |
| 50-99 beds | 520 | -0.1 | 0.0 | 0.2 | 0.1 | -0.3 | 1.0 | 0.0 | 3.5 |
| 100-149 beds | 203 | 0.0 | 0.0 | 0.3 | 0.2 | -0.1 | 3.3 | 0.1 | 3.4 |
| 150-199 beds | 75 | 0.1 | -0.2 | 0.2 | 0.2 | -0.2 | 5.2 | 0.0 | 3.6 |
| 200 or more beds | 67 | 0.1 | -0.1 | 0.1 | 0.1 | -0.2 | 4.8 | 0.0 | 3.3 |
| Urban by Region: | |||||||||
| New England | 138 | 0.3 | 1.6 | -0.3 | -0.2 | 1.2 | -0.3 | 0.2 | 3.0 |
| Middle Atlantic | 416 | 0.4 | -0.5 | 0.0 | 0.1 | -0.4 | -0.7 | 0.6 | 1.3 |
| South Atlantic | 393 | 0.4 | 0.5 | -0.1 | -0.1 | 0.4 | -0.8 | 0.3 | 2.4 |
| East North Central | 459 | 0.2 | 0.1 | -0.2 | -0.2 | -0.3 | -0.5 | 0.1 | 1.7 |
| East South Central | 160 | 0.3 | 1.0 | -0.1 | -0.1 | 0.8 | -0.7 | 0.0 | 3.0 |
| West North Central | 187 | 0.2 | 0.4 | -0.3 | -0.3 | -0.1 | -0.7 | 0.0 | 1.7 |
| West South Central | 340 | 0.3 | -0.2 | -0.2 | -0.1 | -0.4 | -0.7 | 0.0 | 1.3 |
| Mountain | 136 | 0.2 | 0.8 | -0.3 | -0.3 | 0.3 | -0.7 | 0.0 | 2.2 |
| Pacific | 429 | 0.5 | 0.0 | 0.1 | 0.1 | 0.1 | -0.8 | 0.3 | 1.9 |
| Puerto Rico | 46 | 0.1 | 2.1 | -0.8 | -0.9 | 1.1 | -0.8 | 0.2 | 3.3 |
| Rural by Region: | |||||||||
| New England | 50 | 0.0 | 0.0 | 0.1 | 0.1 | -0.3 | 2.9 | 0.0 | 3.7 |
| Middle Atlantic | 75 | 0.1 | 0.1 | 0.1 | 0.1 | -0.1 | 2.3 | 0.0 | 3.2 |
| South Atlantic | 269 | 0.1 | -0.1 | 0.2 | 0.2 | -0.2 | 2.9 | 0.0 | 3.6 |
| East North Central | 276 | -0.2 | 0.0 | 0.1 | 0.2 | -0.4 | 2.2 | 0.0 | 2.9 |
| East South Central | 263 | 0.0 | -0.1 | 0.2 | 0.2 | -0.2 | 3.2 | 0.0 | 3.7 |
| West North Central | 481 | -0.3 | 0.3 | 0.2 | 0.1 | -0.1 | 1.8 | 0.0 | 2.6 |
| West South Central | 333 | 0.0 | 0.3 | 0.2 | 0.2 | 0.1 | 3.6 | 0.0 | 4.8 |
| Mountain | 195 | 0.0 | -0.1 | 0.2 | 0.1 | -0.3 | 1.7 | 0.0 | 3.0 |
| Pacific | 144 | 0.1 | -0.9 | 0.2 | 0.2 | -0.9 | 2.3 | 0.0 | 2.8 |
| Puerto Rico | 5 | -0.3 | 6.1 | 0.2 | 0.1 | 5.6 | -0.7 | 0.2 | 9.9 |
| By Payment Classification: | |||||||||
| Urban hospitals | 2,746 | 0.3 | 0.2 | -0.1 | -0.1 | 0.0 | -0.6 | 0.2 | 1.9 |
| Large urban hospitals (populations over 1million) | 1,632 | 0.4 | 0.0 | -0.1 | -0.1 | -0.1 | -0.7 | 0.3 | 1.9 |
| Other urban hospitals (populations of 1 millionor fewer) | 1,114 | 0.2 | 0.5 | -0.2 | -0.1 | 0.2 | -0.5 | 0.1 | 2.0 |
| Rural hospitals | 2,049 | 0.0 | 0.0 | 0.2 | 0.2 | -0.2 | 2.4 | 0.0 | 3.4 |
| Teaching Status: | |||||||||
| Non-teaching | 3,668 | 0.1 | 0.0 | 0.2 | 0.2 | 0.0 | 0.2 | 0.2 | 2.4 |
| Fewer than 100 Residents | 890 | 0.2 | 0.4 | -0.2 | -0.1 | 0.1 | -0.6 | 0.2 | 2.0 |
| 100 or more Residents | 237 | 0.6 | 0.3 | -0.5 | -0.4 | 0.0 | -0.5 | 0.1 | 1.7 |
| Urban DSH: | |||||||||
| Non DSH | 1,879 | 0.1 | 0.2 | -0.1 | -0.1 | -0.1 | -0.1 | 0.2 | 1.9 |
| 100 or more beds | 1,379 | 0.4 | 0.2 | -0.1 | -0.1 | 0.1 | -0.7 | 0.2 | 1.9 |
| Less than 100 beds | 316 | 0.1 | -0.1 | 0.3 | 0.3 | 0.0 | -0.7 | 0.2 | 4.0 |
| Rural DSH: | |||||||||
| Sole Community (SCH) | 545 | 0.0 | 0.0 | 0.1 | 0.1 | -0.3 | 0.3 | 0.0 | 3.1 |
| Referral Center (RRC) | 152 | 0.2 | -0.1 | 0.2 | 0.2 | -0.1 | 5.2 | 0.0 | 3.8 |
| Other Rural: | |||||||||
| 100 or more beds | 70 | 0.0 | 0.1 | 0.3 | 0.3 | 0.1 | 1.5 | 0.1 | 3.7 |
| Less than 100 beds | 454 | -0.1 | -0.1 | 0.2 | 0.2 | -0.4 | 0.6 | 0.0 | 4.5 |
| Urban teaching and DSH: | |||||||||
| Both teaching and DSH | 758 | 0.5 | 0.3 | -0.3 | -0.2 | 0.1 | -0.7 | 0.2 | 1.9 |
| Teaching and no DSH | 298 | 0.2 | 0.4 | -0.3 | -0.3 | -0.1 | -0.5 | 0.3 | 1.8 |
| No teaching and DSH | 937 | 0.3 | 0.0 | 0.2 | 0.2 | 0.1 | -0.6 | 0.2 | 2.2 |
| No teaching and no DSH | 753 | 0.1 | -0.1 | 0.1 | 0.1 | -0.1 | -0.6 | 0.2 | 1.8 |
| Rural Hospital Types: | |||||||||
| Non-special status | 805 | -0.2 | 0.0 | 0.3 | 0.2 | -0.2 | 0.9 | 0.0 | 3.8 |
| RRC | 165 | 0.1 | -0.1 | 0.2 | 0.2 | -0.1 | 6.3 | 0.1 | 3.7 |
| SCH | 680 | 0.0 | 0.0 | 0.1 | 0.1 | -0.3 | 0.3 | 0.0 | 2.7 |
| Medicare-dependent hospitals (MDH) | 329 | -0.2 | 0.2 | 0.1 | 0.1 | -0.2 | 0.4 | 0.0 | 3.6 |
| SCH and RRC | 70 | 0.0 | 0.0 | 0.1 | 0.1 | -0.3 | 2.1 | 0.0 | 2.9 |
| Type of Ownership: | |||||||||
| Voluntary | 2,765 | 0.3 | 0.1 | -0.1 | -0.1 | -0.1 | -0.3 | 0.2 | 2.0 |
| Proprietary | 717 | 0.3 | 0.1 | 0.0 | 0.0 | 0.1 | 0.0 | 0.1 | 2.4 |
| Government | 1,261 | 0.3 | 0.4 | -0.1 | 0.0 | 0.3 | 0.0 | 0.0 | 0.0 |
| Unknown | 52 | -0.4 | 0.6 | 0.1 | 0.1 | -0.1 | -1.8 | 1.0 | 1.6 |
| Medicare Utilization as a Percent of Inpatient Days: | |||||||||
| 0-25 | 396 | 0.7 | 0.2 | 0.0 | 0.0 | 0.5 | -0.4 | 0.2 | 2.5 |
| 25-50 | 1,886 | 0.4 | 0.2 | -0.2 | -0.2 | 0.0 | -0.6 | 0.2 | 1.9 |
| 50-65 | 1,843 | 0.1 | 0.2 | 0.0 | 0.0 | 0.0 | 0.1 | 0.2 | 2.4 |
| Over 65 | 592 | 0.1 | -0.2 | 0.2 | 0.2 | -0.1 | 0.3 | 0.2 | 2.2 |
| Unknown | 78 | 0.3 | -0.3 | -0.1 | 0.0 | -0.6 | 0.8 | 0.2 | 0.7 |
| Hospitals Reclassified by the Medicare Geographic Classification Review Board: FY 2002 Reclassifications: | |||||||||
| All Reclassified Hospitals | 628 | 0.2 | 0.2 | 0.0 | 0.0 | 0.0 | 5.0 | 0.1 | 3.3 |
| Standardized Amount Only | 74 | 0.1 | -0.4 | 0.3 | 0.4 | -0.3 | 2.2 | 0.4 | 3.8 |
| Wage Index Only | 391 | 0.2 | 0.0 | 0.0 | 0.0 | -0.1 | 5.5 | 0.1 | 2.8 |
| Both | 58 | 0.2 | 0.3 | 0.1 | 0.1 | 0.1 | 5.1 | 0.0 | 0.6 |
| All Nonreclassified Hospitals | 4,246 | 0.3 | 0.2 | -0.1 | 0.1 | 0.0 | 0.8 | 0.2 | 2.1 |
| All Reclassified UrbanHospitals | 117 | 0.4 | 0.7 | -0.3 | -0.3 | 0.2 | 4.2 | 0.1 | 2.6 |
| Standardized Amount Only | 14 | 0.2 | -0.3 | 0.5 | 0.5 | -0.1 | 0.4 | 0.3 | 2.6 |
| Wage Index Only | 83 | 0.4 | 0.7 | -0.5 | -0.4 | 0.2 | 4.5 | 0.1 | 2.4 |
| Both | 20 | 0.2 | 0.7 | 0.2 | 0.3 | 0.8 | 4.7 | 0.5 | 3.5 |
| Urban Nonreclassified Hospitals | 2,549 | 0.3 | 0.2 | -0.1 | -0.1 | 0.0 | -1.0 | 0.2 | 1.8 |
| Reclassified Rural Hospitals | 511 | 0.1 | 0.0 | 0.2 | 0.2 | -0.2 | 5.5 | 0.0 | 3.7 |
| Standardized Amount Only | 16 | 0.0 | -0.1 | 0.2 | 0.2 | -0.3 | 3.8 | 0.0 | 2.3 |
| Wage Index Only | 472 | 0.1 | 0.0 | 0.2 | 0.2 | -0.2 | 5.3 | 0.0 | 3.7 |
| Both | 23 | 0.0 | 0.2 | 0.1 | 0.1 | -0.1 | 9.3 | 0.0 | 4.0 |
| Rural Nonreclassified Hospitals | 1,577 | -0.1 | 0.0 | 0.2 | 0.1 | -0.3 | -0.6 | 0.0 | 3.0 |
| Other Reclassified Hospitals (Section 1886(D)(8)(B)) | 41 | 0.1 | 0.6 | 0.1 | 0.1 | 0.4 | 0.8 | -0.7 | 4.2 |
| 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 2000, and hospital cost report data are from reporting periods beginning in FY 1999 and FY 1998. | |||||||||
| 2 This column displays the payment impact of the recalibration of the DRG weights based on FY 2000 MedPAR data and the DRG reclassification changes, in accordance with section 1886(d)(4)(C) of the Act. | |||||||||
| 3 This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1998 cost reports. | |||||||||
| 4 This column displays the impact of removing the salaries and hours of lower-wage, overhead employees and the overhead wage-related costs associated with the excluded areas of the hospital from the wage index calculation. | |||||||||
| 5 This column displays the impact of including contract pharmacy and contract laboratory costs and hours in the wage index calculation. | |||||||||
| 6 This column displays the combined impact of the reclassification and recalibration of the DRGs, the updated and revised wage data used to calculate the wage index, the revised overhead allocation, the laboratory and pharmacy contract labor costs, and the budget neutrality adjustment factor for these two changes, in accordance with sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of the Act. Thus, it represents the combined impacts shown in columns 1, 2, 3, and 4, and the FY 2002 budget neutrality factor of .995821. | |||||||||
| 7 Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate the FY 2002 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2002. Reclassification for prior years has no bearing on the payment impacts shown here. | |||||||||
| 8 Shown here are the effects of our policy to hold-harmless other hospitals in an urban area where certain hospitals are reclassified elsewhere by including the wage data of reclassified hospitals in their geographic area as well as the area to which they are reclassified. | |||||||||
| 9 This column shows changes in payments from FY 2001 to FY 2002. It incorporates all of the changes displayed in columns 5, 6, and 7 (the changes displayed in columns 1, 2, 3, and 4 are included in column 5). It also displays the impact of the FY 2002 update, changes in hospitals' reclassification status in FY 2002 compared to FY 2001, and the difference in outlier payments from FY 2001 to FY 2002. It also reflects section 213 of Public law 106-554, which permitted all SCHs to rebase for a 1996 hospital-specific rate. The sum of these columns may be different from the percentage changes shown here due to rounding and interactive effects. | |||||||||
B. Impact of the Final Changes to the DRG Reclassifications and Recalibration of Relative Weights (Column 1)
In column 1 of Table I, we present the combined effects of the DRG reclassifications and recalibration, as discussed in section II. of the preamble to this final rule. Section 1886(d)(4)(C)(i) of the Act requires us to annually make appropriate classification changes and to recalibrate the DRG weights in order to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources.
We compared aggregate payments using the FY 2001 DRG relative weights (GROUPER version 18) to aggregate payments using the final FY 2002 DRG relative weights (GROUPER version 19). Overall payments increase 0.3 percent due to the DRG reclassification and recalibration. We note that, consistent with section 1886(d)(4)(C)(iii) of the Act, we have applied a budget neutrality factor to ensure that the overall payment impact of the DRG (and wage index) changes is budget neutral. This budget neutrality factor of 0.995821 is applied to payments in Column 5.
We estimate that the DRG changes effective with this final rule would result in higher payments to urban hospitals (0.3 percent) and would have a 0 percent impact on payments to rural hospitals. The changes also would result in higher payments to larger hospitals than to smaller hospitals. This impact is consistent for both urban and rural bed size groups.
This distributional impact likely results from the final changes to major diagnostic category (MDC) 5 "Diseases and Disorders of the Circulatory System." As described in section II. of the preamble of this final rule, we are removing cardiac defibrillator cases from DRGs 104 and 105, and creating two new DRGs for these cases. In addition, we are revising the basis of the DRG assignment for cases involving percutaneous transluminal coronary angioplasty based on whether the patient experienced an acute myocardial infarction. Because MDC 5 is a high volume category, refining the categorizations of these cases has a noticeable overall payment impact.
C. Impact of Updating the Wage Data and the Final Changes to the Wage Index Calculation (Columns 2, 3 4)
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 final wage index for FY 2002 is based on data submitted for hospital cost reporting periods beginning on or after October 1, 1997 and before October 1, 1998. As with column 1, the impact of the new data on hospital payments is isolated in column 2 by holding the other payment parameters constant in the two simulations. That is, column 2 shows the percentage changes in payments when going from a model using the FY 2001 wage index (based on FY 1997 wage data before geographic reclassifications to a model using the FY 2002 prereclassification wage index based on FY 1998 wage data).
The wage data collected on the FY 1998 cost reports are similar to the data used in the calculation of the FY 2001 wage index. For a thorough discussion of the data used to calculate the wage index, see section III.B. of the preamble of this final rule. The July 30, 1999 final rule (64 FR 41505) indicated that we would phase-out costs related to GME and certified registered nurse anesthestists (CRNA) from the calculation of the wage index over a 5-year period, beginning in FY 2000. The FY 2001 wage index was based on a blend of 60 percent of an average hourly wage including these costs, and 40 percent of an average hourly wage excluding these costs. For FY 2002, the wage index is based on a blend of 40 percent of an average hourly wage including these costs, and 60 percent of an average hourly wage excluding these costs. This change is reflected in column 2.
The results indicate that the new wage data are estimated to provide a 0.2 percent increase for hospital payments overall (prior to applying the budget neutrality factor, see column 5). In some cases, the results shown in this final rule may be very different from the impacts shown in the proposed rule. This is due to the large number of data revisions submitted by hospitals after the proposed wage index was calculated. Approximately 30 percent of hospitals submitted revisions in the interim.
Rural hospitals are generally estimated to experience a negligible impact from the new wage data, although rural hospitals in Puerto Rico experience a 6.1 percent increase, likely due to the 13 percent increase in the value of five providers' FY 2002 wage index compared to the wage index for those same providers for FY 2001. Additionally, rural hospitals in West North Central and West South Central experience estimated wage index-driven increases of more than 0.3 percent. Meanwhile, hospitals in the Pacific census division experience a 0.9 percent decrease.
Urban hospitals as a group are estimated to benefit positively from the updated wage data. The other urban hospitals appear to experience a 0.5 percent increase and estimated payments to urban hospitals overall showed an increase of 0.2 percent. Among urban census divisions, Puerto Rico experiences a 2.1 percent increase, the New England division experiences a 1.6 percent increase, East South Central experiences a 1.0 percent increase, and Middle Atlantic a 0.5 percent decrease.
Columns 3 and 4, respectively, show that the final change to the overhead calculation and the policy to include contract labor costs in the wage index discussed in detail in section III.C. of the preamble of this final rule both appear to benefit rural hospitals and small hospitals. Urban hospitals as a group are impacted by a 0.1 percent decrease to their payments from each change. Rural hospitals are expected to receive an estimated 0.2 percent increase in payments due to this policy change.
The following chart compares the shifts in wage index values for labor market areas for FY 2001 relative to FY 2002. This chart demonstrates the impact of the final changes for the FY 2002 wage index relative to the FY 2001 wage index. The majority of labor market areas (335) experience less than a 5-percent change. A total of 28 labor market areas experience an increase of more than 5 percent, with 2 having an increase greater than 10 percent. A total of 11 areas experience decreases of more than 5-percent. Of those, 1 declines by more than 10 percent.
| Percentage change in area wage index values | Number of labor market areas | FY 2001 | FY 2002 |
|---|---|---|---|
| Increase more than 10 percent | 1 | 2 | |
| Increase more than 5 percent and less than 10 percent | 20 | 26 | |
| Increase or decrease less than 5 percent | 339 | 335 | |
| Decrease more than 5 percent and less than 10 percent | 14 | 10 | |
| Decrease more than 10 percent | 1 | 1 |
Among urban hospitals, 129 would experience an increase of between 5 and 10 percent, and 3 experience an increase of more than 10 percent. A total of 18 rural hospitals have increases greater than 5 percent, with 5 increasing greater than 10 percent. On the negative side, 29 urban hospitals have decreases in their wage index values of at least 5 percent but less than 10 percent. Four urban hospitals have decreases in their wage index values greater than 10 percent. There are no rural hospitals with decreases in their wage index values greater than 5 percent. The following chart shows the projected impact for urban and rural hospitals.
| Percentage change in area wage index values | Number of hospitals | Urban | Rural |
|---|---|---|---|
| Increase more than 10 percent | 3 | 5 | |
| Increase more than 5 percent and less than 10 percent | 129 | 13 | |
| Increase or decrease less than 5 percent | 2,531 | 2,166 | |
| Decrease more than 5 percent and less than 10 percent | 29 | 0 | |
| Decrease more than 10 percent | 4 | 0 |
D. Combined Impact of DRG and Wage Index Changes- Including Budget Neutrality Adjustment (Column 5)
The impact of DRG reclassifications and recalibration on aggregate payments is required by section 1886(d)(4)(C)(iii) of the Act to be budget neutral. In addition, section 1886(d)(3)(E) of the Act specifies that any updates or adjustments to the wage index are to be budget neutral. As noted in the Addendum to this final rule, we compared simulated aggregate payments using the FY 2001 DRG relative weights and wage index to simulated aggregate payments using the final FY 2002 DRG relative weights and wage index. Based on this comparison, we computed a wage and recalibration budget neutrality factor of 0.995821. In Table I, the combined overall impacts of the effects of both the DRG reclassifications and recalibration and the updated wage index are shown in column 5. The 0.0 percent impact for all hospitals demonstrates that these changes, in combination with the budget neutrality factor, are budget neutral.
For the most part, the changes in this column are the sum of the changes in columns 1, 2, 3 and 4, minus approximately 0.4 percent attributable to the budget neutrality factor. There may be some variation of plus or minus 0.1 percent due to rounding.
E. Impact of MGCRB Reclassifications (Columns 6 7)
Our impact analysis to this point has assumed hospitals are paid on the basis of their actual geographic location (with the exception of ongoing policies that provide that certain hospitals receive payments on bases other than where they are geographically located, such as hospitals in rural counties that are deemed urban under section 1886(d)(8)(B) of the Act). The changes in column 5 reflect the per case payment impact of moving from this baseline to a simulation incorporating the MGCRB decisions for FY 2002. As noted below, these decisions may affect hospitals' standardized amount and wage index area assignments. The changes in column 7 reflect the postreclassified wage index values resulting from including the wage data for a reclassified hospital in both the area to which it is reclassified and the area where the hospital is physically located.
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 the other area's standardized amount, wage index value, or both.
The final FY 2002 wage index values incorporate all of the MGCRB's reclassification decisions for FY 2002. The wage index values also reflect any decisions made by the CMS Administrator through the appeals and review process for MGCRB decisions.
The overall effect of geographic reclassification is required by section 1886(d)(8)(D) of the Act to be budget neutral. Therefore, we applied an adjustment of 0.990675 to ensure that the effects of reclassification are budget neutral. (See section II.A.4.b. of the Addendum to this final rule.) This results in a larger budget neutrality offset than the FY 2001 factor of 0.993187. This larger offset is accounted for by the extension of wage index reclassifications for 3 years as a result of section 304 of Public Law 106-554, and our final policy to hold-harmless the calculation of urban areas' wage indexes for reclassifications out of the area (see column 7). We have identified 162 hospitals that were reclassified for FY 2001, but not FY 2002, that will nonetheless continue to be reclassified due to section 304 of Public Law 106-554.
As a group, rural hospitals benefit from geographic reclassification. Their payments rise 2.6 percent in column 6. Payments to urban hospitals decline 0.7 percent. Hospitals in other urban areas see a decrease in payments of 0.5 percent, while large urban hospitals lose 0.8 percent. Among urban hospital groups (that is, bed size, census division, and special payment status), payments generally decline.
A positive impact is evident among most of the rural hospital groups. The largest increases are in the West South Central, East South Central, New England and the South Atlantic regions. These regions receive increases of 3.6, 3.2, and 2.9 and 2.9, respectively. The rural census division for the Puerto Rico region appears to receive an estimated decrease in payments of 0.7 percent.
Among all the hospitals that were reclassified for FY 2002, the MGCRB changes are estimated to provide a 5.0 percent increase in payments. Urban hospitals reclassified for FY 2002 are anticipated to receive an increase of 4.2 percent, while rural reclassified hospitals are expected to benefit from the MGCRB changes with a 5.5 percent increase in payments. Overall, among hospitals that were reclassified for purposes of the standardized amount only, a payment increase of 2.2 percent is expected, while those reclassified for purposes of the wage index only show a 5.5 percent increase in payments. Payments to urban hospitals that did not reclassify are expected to decrease by 1.0 percent due to the budget neutrality of MGCRB changes. Those hospitals located in rural counties but deemed to be urban under section 1886(d)(8)(B) of the Act are expected to receive an increase in payments of 0.1 percent.
Column 7 shows the impacts of our final policy to include the wage data for a reclassified hospital in both the area to which it is reclassified and the area where the hospital is physically located. This change affects overall payments by 0.2 percent, partially accounting for the larger budget neutrality factor compared to FY 2001. The payment impacts are generally largest in urban hospital groups, with the largest impact, 0.6 percent, experienced by urban hospitals in the Middle Atlantic census division.
F. All Changes (Column 8)
Column 8 compares our estimate of payments per case, incorporating all changes reflected in this final rule for FY 2002 (including statutory changes), to our estimate of payments per case in FY 2001. It includes the effects of the 2.75 percent update to the standardized amounts and the hospital-specific rates for MDHs and SCHs. It also reflects the 1.1 percentage point difference between the projected percentage of outlier payments in FY 2001 (5.1 percent of total DRG payments) and the current estimate of the percentage of actual outlier payments in FY 2001 (6.2 percent), as described in the introduction to this Appendix and the Addendum to this final rule.
We also note that section 211 of Public Law 106-554 changed the criteria for hospitals to qualify for DSH payment status. Since more hospitals are now eligible to receive DSH payments for the full FY 2002, as opposed to for just the second 6 months of FY 2001, DSH payments to providers in FY 2002 would increase and this change is also captured in column 8.
Section 213 of Public Law 106-554 provided that all SCHs may elect to receive payment on the basis of their costs per case during their cost reporting period that began during 1996. For FY 2002, eligible SCHs that rebase receive a hospital-specific rate comprised of 50 percent of the higher of their FY 1982 or FY 1987 hospital-specific rate or their Federal rate, and 50 percent of their 1996 hospital-specific rate. The impact of this provision is modeled in column 8 as well.
There might also be interactive effects among the various factors comprising the payment system that we are not able to isolate. For these reasons, the values in column 8 may not equal the sum of the changes in columns 5, 6, and 7, plus the other impacts that we are able to identify.
Hospitals in urban areas experience a 1.9 percent increase in payments per case compared to FY 2001. The net 0.5 percent negative impact due to reclassification (columns 6 and 7) is offset by a similar negative impact for FY 2001 of 0.4 percent (65 FR 47196). Hospitals in rural areas, meanwhile, experience a 3.4 percent payment increase. This is primarily due to the change in the DSH threshold to 15 percent for all hospitals enacted by section 211 of Public Law 106-554 effective for discharges on or after April 1, 2001, and the positive effect of the reclassification changes (2.6 percent increase).
The impact of lowering the DSH threshold is demonstrated in Column 8, although we would note that the estimated FY 2001 payments do reflect 6 months of payments to hospitals affected by this change. The impacts are seen in the rows displaying urban hospitals with fewer than 100 beds receiving DSH (4.0 percent increase), and all rural DSH categories.
Among urban census divisions, payments increased between 1.3 and 3.3 percent between FY 2001 and FY 2002. The rural census division experiencing the smallest increase in payments was the West North Central region (2.6 percent). The largest increases by rural hospitals is in Puerto Rico, where payments appear to increase by 9.9 percent, and West South Central, where payments appear to increase by 4.8 percent. All 5 of the rural Puerto Rico hospitals experienced an increase of greater than 10 percent in their wage index values (comparison of FY 2001 and FY 2002). Rural New England, East South Central, and South Atlantic regions also benefited with 3.7, 3.7, and 3.6 percent respectively.
Among special categories of rural hospitals, those hospitals receiving payment under the hospital-specific methodology (SCHs, MDHs, and SCH/RRCs) experience payment increases of 2.7 percent, 3.6 percent, and 2.9 percent, respectively. This outcome is primarily related to the fact that hospitals receiving payments under the hospital-specific methodology are not eligible for outlier payments. Therefore, these hospitals do not experience negative payment impacts from the decline in outlier payments from FY 2001 to FY 2002 (from 6.2 percent of total DRG plus outlier payments to 5.1 percent) as do hospitals paid based on the national standardized amounts.
Among hospitals that were reclassified for FY 2002, hospitals overall are estimated to receive a 3.3 percent increase in payments. Urban hospitals reclassified for FY 2002 are anticipated to receive an increase of 2.6 percent, while rural reclassified hospitals are expected to benefit from reclassification with a 3.7 percent increase in payments. Overall, among hospitals reclassified for purposes of the standardized amount only, a payment increase of 3.8 percent is expected, while those hospitals reclassified for purposes of the wage index only show an expected 2.8 percent increase in payments. Those hospitals located in rural counties but deemed to be urban under section 1886(d)(8)(B) of the Act are expected to receive an increase in payments of 4.2 percent.
| Num. of hosp. | Average FY 2001 payment per case1 | Average FY 2002 payment per case1 | All FY 2002 changes | |
|---|---|---|---|---|
| (1) | (2) | (3) | (4) | |
| By Geographic Location | 4,795 | 6,994 | 7,141 | 2.1 |
| All hospitals | ||||
| Urban hospitals | 2,704 | 7,559 | 7,703 | 1.9 |
| Large urban areas (populations over 1 million) | ||||
| Other urban areas (populations of 1 million of fewer) | 1,143 | 6,853 | 6,989 | 2.0 |
| Rural hospitals | 2,091 | 4,808 | 4,972 | 3.4 |
| Bed Size (Urban) | 695 | 5,110 | 5,246 | 2.6 |
| 0-99 beds | ||||
| 100-199 beds | 948 | 6,313 | 6,444 | 2.1 |
| 200-299 beds | 529 | 7,218 | 7,364 | 2.0 |
| 300-499 beds | 383 | 8,139 | 8,283 | 1.8 |
| 500 or more beds | 149 | 9,875 | 10,035 | 1.6 |
| Bed Size (Rural) | 1,226 | 3,984 | 4,118 | 3.4 |
| 0-49 beds | ||||
| 50-99 beds | 520 | 4,526 | 4,683 | 3.5 |
| 100-149 beds | 203 | 4,858 | 5,022 | 3.4 |
| 150-199 beds | 75 | 5,336 | 5,529 | 3.6 |
| 200 or more beds | 67 | 6,188 | 6,392 | 3.3 |
| Urban by Region | 138 | 8,014 | 8,254 | 3.0 |
| New England | ||||
| Middle Atlantic | 416 | 8,600 | 8,713 | 1.3 |
| South Atlantic | 393 | 7,169 | 7,338 | 2.4 |
| East North Central | 459 | 7,215 | 7,335 | 1.7 |
| East South Central | 160 | 6,776 | 6,976 | 3.0 |
| West North Central | 187 | 7,342 | 7,470 | 1.7 |
| West South Central | 340 | 6,998 | 7,090 | 1.3 |
| Mountain | 136 | 7,308 | 7,467 | 2.2 |
| Pacific | 429 | 8,939 | 9,109 | 1.9 |
| Puerto Rico | 46 | 3,207 | 3,312 | 3.3 |
| Rural by Region | 50 | 5,740 | 5,950 | 3.7 |
| New England | ||||
| Middle Atlantic | 75 | 5,114 | 5,277 | 3.2 |
| South Atlantic | 269 | 4,950 | 51,128 | 3.6 |
| East North Central | 276 | 4,813 | 4,951 | 2.9 |
| East South Central | 263 | 4,423 | 4,587 | 3.7 |
| West North Central | 481 | 4,714 | 4,839 | 2.6 |
| West South Central | 333 | 4,249 | 4,452 | 4.8 |
| Mountain | 195 | 5,168 | 5,321 | 3.0 |
| Pacific | 144 | 6,090 | 6,263 | 2.8 |
| Puerto Rico | 5 | 2,521 | 2,771 | 9.9 |
| By Payment Classification: Urban hospitals | 2,746 | 7,538 | 7,682 | 1.9 |
| Large urban hospitals (populations over 1 million) | 1,632 | 8,026 | 8,175 | 1.9 |
| Other urban hospitals (populations of 1 million or fewer) | 1,114 | 6,870 | 7,006 | 2.0 |
| Rural hospitals | 2,049 | 4,791 | 4,954 | 3.4 |
| Teaching Status | 3,668 | 5,638 | 5,775 | 2.4 |
| Non-teaching | ||||
| Fewer than 100 Residents | 890 | 7,327 | 7,473 | 2.0 |
| 100 or more Residents | 237 | 11,280 | 11,473 | 1.7 |
| Urban DSH | 1,879 | 6,356 | 6,479 | 1.9 |
| Non DSH | ||||
| 100 or more beds | 1,379 | 8,152 | 8,307 | 1.9 |
| Less than 100 beds | 316 | 4,973 | 5,173 | 4.0 |
| Rural DSH | 545 | 4,650 | 4,796 | 3.1 |
| Sole Community (SCH) | ||||
| Referral Center (RRC) | 152 | 5,542 | 5,754 | 3.8 |
| Other Rural | 70 | 4,320 | 4,479 | 3.7 |
| 100 or more beds | ||||
| Less than 100 beds | 454 | 3,937 | 4,115 | 4.5 |
| Urban teaching and DSH: | ||||
| Both teaching and DSH | 758 | 9,081 | 9,250 | 1.9 |
| Teaching and no DSH | 298 | 7,577 | 7,715 | 1.8 |
| No teaching and DSH | 937 | 6,343 | 6,481 | 2.2 |
| No teaching and no DSH | 753 | 5,895 | 6,002 | 1.8 |
| Rural Hospital Types | ||||
| Non-special status | 805 | 4,048 | 4,204 | 3.8 |
| RRC | 165 | 5,433 | 5,636 | 3.7 |
| SCH | 680 | 4,884 | 5,017 | 2.7 |
| Medicare-dependent hospitals (MDH) | 329 | 3,852 | 3,991 | 3.6 |
| SCH and RRC | 70 | 5,902 | 6,073 | 2.9 |
| Type of Ownership: Voluntary | 2,341 | 7,149 | 7,295 | 2.1 |
| Proprietary | 645 | 6,641 | 6,773 | 2.0 |
| Government | 962 | 6,259 | 6,437 | 2.8 |
| Unknown | 847 | 7,151 | 7,293 | 2.0 |
| Medicare Utilization as a Percent of Inpatient Days: | ||||
| 0-25 | 396 | 9,564 | 9,807 | 2.5 |
| 25-50 | 1,886 | 8,045 | 8,195 | 1.9 |
| 50-65 | 1,843 | 6,040 | 6,184 | 2.4 |
| Over 65 | 592 | 5,422 | 5,543 | 2.2 |
| Unknown | 78 | 10,360 | 10,433 | 0.7 |
| Hospitals Reclassified by the Medicare Geographic Classification Review Board: FY 2002 Reclassifications: | ||||
| All Reclassified Hospitals | 628 | 6,234 | 6,438 | 3.3 |
| Standardized Amount Only | 74 | 5,210 | 5,409 | 3.8 |
| Wage Index Only | 391 | 6,103 | 6,270 | 2.8 |
| Both | 58 | 6,876 | 6,919 | 0.6 |
| All Nonreclassified Hospitals | 4,246 | 7,122 | 7,269 | 2.1 |
| All Reclassified Urban Hospitals | 117 | 8,365 | 8,578 | 2.6 |
| Standardized Amount Only | 14 | 5,990 | 6,143 | 2.6 |
| Wage Index Only | 83 | 9,072 | 9,294 | 2.4 |
| Both | 20 | 6,064 | 6,276 | 3.5 |
| Urban Nonreclassified Hospitals | 2,549 | 7,539 | 7,678 | 1.8 |
| All Reclassified Rural Hospitals | 511 | 5,383 | 5,584 | 3.7 |
| Standardized Amount Only | 16 | 5,183 | 5,302 | 2.3 |
| Wage Index Only | 472 | 5,387 | 5,589 | 3.7 |
| Both | 23 | 5,381 | 5,597 | 4.0 |
| Rural Nonreclassified Hospitals | 1,577 | 4,271 | 4,399 | 3.0 |
| Other Reclassified Hospitals (Section 1886(D)(8)(B)) | 41 | 4,838 | 5,043 | 4.2 |
| 1 These payment amounts per case do not reflect any estimates of annual case-mix increase. | ||||
Table II presents the projected impact of the final changes for FY 2002 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 2001 with the average estimated per case payments for FY 2002, as calculated under our models. Thus, this table presents, in terms of the average dollar amounts paid per discharge, the combined effects of the changes presented in Table I. The percentage changes shown in the last column of Table II equal the percentage changes in average payments from column 8 of Table I.
IX. Impact for Critical Access Hospitals (CAHs)
There are approximately 365 facilities that qualify as CAHs. These CAHs are paid based on reasonable costs for their services to inpatients and outpatients. We examined several parts of the final rule, as discussed in detail in section VI.B. of the preamble, for their potential impact on CAHs.
A. Exclusion of CAHs From Payment Window Requirements
In this final rule, we are clarifying the policy that CAHs are not subject to the payment window provisions of section 1886(a)(3) of the Act. Existing regulations do not require application of these provisions to CAHs, and we are not aware of specific situations in which they are now being applied. Consequently, we do not expect any increase or decrease in Medicare spending based on this clarification.
B. Availability of CRNA Pass-Through for CAHs
Under existing § 412.113(c), CRNA pass-through payment is available only to hospitals that either qualified for the pass-through of costs of anesthesia services furnished in calendar year 1989, or met certain conditions, including having employed or contracted with a qualified nonphysician anesthetist as of January 1, 1988, to perform anesthesia services. In this final rule, we are specifying that certain CAHs that meet the pass-through criteria would qualify for pass-through payments. Under the existing criterion, we believe the only facilities that could qualify for the pass-through as CAHs are those that would have qualified for the pass-through if they had elected to continue participating in Medicare as hospitals rather than converting to CAH status. We do not expect any increase or decrease in Medicare spending based on the final change in the regulations.
C. Payment for Emergency Room On-Call Physicians
In accordance with the amendments made by section 204 of Public Law 106-544, in this final rule, we are specifying that we will recognize as allowable costs, amounts for reasonable compensation and related costs for emergency room physicians who are on call but who are not present on the premises of a CAH. We expect that at least some CAHs will elect to compensate emergency room physicians for being on call and that, as a result, Medicare spending for CAH services will increase. However, we do not have information to develop a reliable estimate of how many CAHs will make this election, or how much physician compensation costs they will incur for on call time.
D. Treatment of Ambulance Services Furnished by Certain CAHs
In accordance with the provisions of section 205 of Public Law 106-554, we are amending the existing CAH regulations to provide for payment to CAHs for the reasonable costs of ambulance services furnished by a CAH or an entity owned or operated by the CAH if certain statutory requirements are met. We expect that at least some CAHs or entities owned or operated by CAHs will be able to qualify for payment for their ambulance services. To the extent that CAHs or CAH owned or operated entities furnish these services under the conditions specified in the law, ambulance services will be paid for at higher rates than would otherwise apply. As a result, Medicare spending for ambulance services will increase. However, we do not have sufficient information or data to develop a reliable estimate of how many CAHs or entities will qualify or the dollar amount of ambulance service costs they will incur.
E. Qualified Practitioners for Preanesthesia and Postanesthesia Evaluations in CAHs
As discussed in section VI.B. of this final rule, in an effort to eliminate or minimize potential issues relating to beneficiary access to medical services in rural areas, we are allowing CRNAs who administer the anesthesia to conduct the preanesthesia and postanesthesia evaluations in a CAH. As with any licensed independent health care provider, the final change will not permit CRNAs to practice beyond his or her licensed scope of practice.
We believe that this policy will increase flexibility of providers in furnishing medical services in rural areas. However, we do not have information or data to develop a reliable estimate of how many CRNAs would be used to conduct preanesthesia and postanesthesia evaluations in CAHs or what the associated costs would be.
X. Impact of Changes in the Capital Prospective Payment System
A. General Considerations
We now have cost report data for the 8th year of the capital prospective payment system (cost reports beginning in FY 1999) available through the March 2001 update of the HCRIS. We also have updated information on the projected aggregate amount of obligated capital approved by the fiscal intermediaries. However, our impact analysis of payment changes for capital-related costs is still limited by the lack of hospital-specific data on several items. These are the hospital's projected new capital costs for each year, its projected old capital costs for each year, and the actual amounts of obligated capital that will be put in use for patient care and recognized as Medicare old capital costs in each year. The lack of this information affects our impact analysis in the following ways:
• Major investment in hospital capital assets (for example, in building and major fixed equipment) occurs at irregular intervals. As a result, there can be significant variation in the growth rates of Medicare capital-related costs per case among hospitals. We do not have the necessary hospital-specific budget data to project the hospital capital growth rate for individual hospitals.
• Our policy of recognizing certain obligated capital as old capital makes it difficult to project future capital-related costs for individual hospitals. Under § 412.302(c), a hospital is required to notify its intermediary that it has obligated capital by the later of October 1, 1992, or 90 days after the beginning of the hospital's first cost reporting period under the capital prospective payment system. The intermediary must then notify the hospital of its determination whether the criteria for recognition of obligated capital have been met by the later of the end of the hospital's first cost reporting period subject to the capital prospective payment system or 9 months after the receipt of the hospital's notification. The amount that is recognized as old capital is limited to the lesser of the actual allowable costs when the asset is put in use for patient care or the estimated costs of the capital expenditure at the time it was obligated. We have substantial information regarding fiscal intermediary determinations of projected aggregate obligated capital amounts. However, we still do not know when these projects will actually be put into use for patient care, the actual amount that will be recognized as obligated capital when the project is put into use, or the Medicare share of the recognized costs. Therefore, we do not know actual obligated capital commitments for purposes of the FY 2002 capital cost projections. In Appendix B of this final rule, we discuss the assumptions and computations that we employ to generate the amount of obligated capital commitments for use in the FY 2002 capital cost projections.
In Table III of this section, we present the redistributive effects that are expected to occur between "hold-harmless" hospitals and "fully prospective" hospitals in FY 2002. In addition, we have integrated sufficient hospital-specific information into our actuarial model to project the impact of the FY 2002 capital payment policies by the standard prospective payment system hospital groupings. While we now have actual information on the effects of the transition payment methodology and interim payments under the capital prospective payment system and cost report data for most hospitals, we still need to randomly generate numbers for the change in old capital costs, new capital costs for each year, and obligated amounts that will be put in use for patient care services and recognized as old capital each year. We continue to be unable to predict accurately FY 2002 capital costs for individual hospitals, but with the most recent data on hospitals' experience under the capital prospective payment system, there is adequate information to estimate the aggregate impact on most hospital groupings.
B. Projected Impact Based on the FY 2002 Actuarial Model
1. Assumptions
In this impact analysis, we model dynamically the impact of the capital prospective payment system from FY 2001 to FY 2002 using a capital cost model. The FY 2002 model, as described in Appendix B of this final rule, integrates actual data from individual hospitals with randomly generated capital cost amounts. We have capital cost data from cost reports beginning in FY 1989 through FY 1999 as reported on the March 2001 update of HCRIS, interim payment data for hospitals already receiving capital prospective payments through PRICER, and data reported by the intermediaries that include the hospital-specific rate determinations that have been made through April 1, 2001 in the provider-specific file. We used these data to determine the FY 2002 capital rates. However, we do not have individual hospital data on old capital changes, new capital formation, and actual obligated capital costs. We have data on costs for capital in use in FY 1999, and we age that capital by a formula described in Appendix B. Therefore, we need to randomly generate only new capital acquisitions for any year after FY 1999. All Federal rate payment parameters are assigned to the applicable hospital. We will continue to pay regular exceptions during cost reporting periods beginning before October 1, 2001 but ending in FY 2002. However, in FY 2003 and later, payments will no longer be made under the regular exceptions provision; hence, we will no longer require the actuarial model described in Appendix B of this final rule.
For purposes of this impact analysis, the FY 2002 actuarial model includes the following assumptions:
• Medicare inpatient capital costs per discharge will change at the following rates during these periods:
| Fiscal year | Percentage change |
|---|---|
| 2000 | 1.39 |
| 2001 | 1.37 |
| 2002 | 2.58 |
• We estimate that the Medicare case-mix index will decrease by 0.9 percent in FY 2001 and will increase by 1.0 percent in FY 2002.
• The Federal capital rate and the hospital-specific rate were 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. The FY 2002 update is 1.3 percent (see section IV. of the Addendum to this final rule).
2. Results
We have used the actuarial model to estimate the change in payment for capital-related costs from FY 2001 to FY 2002. Table III shows the effect of the capital prospective payment system on low capital cost hospitals and high capital cost hospitals. We consider a hospital to be a low capital cost hospital if, based on a comparison of its initial hospital-specific rate and the applicable Federal rate, it will be paid under the fully prospective payment methodology. A high capital cost hospital is a hospital that, based on its initial hospital-specific rate and the applicable Federal rate, will be paid under the hold-harmless payment methodology. We are no longer displaying a column for the hospital-specific payments in Table III since, beginning with FY 2001, the transition blend percentage for fully prospective hospitals is 100 percent of the Federal rate and zero percent of the hospital-specific rate, and all hospitals (except "new" hospitals under § 412.324(b)) are paid based on 100 percent of the Federal rate for FY 2002. Based on our actuarial model, the breakdown of hospitals is as follows:
| Type of hospital | Percent of hospitals | Percent of discharges | Percent of capital costs | Percent of capital payments |
|---|---|---|---|---|
| Low Cost Hospital | 66 | 62 | 57 | 61 |
| High Cost Hospital | 34 | 38 | 43 | 39 |
A low capital cost hospital may request to have its hospital-specific rate redetermined based on old capital costs in the current year, through the later of the hospital's cost reporting period beginning in FY 1994 or the first cost reporting period beginning after obligated capital comes into use (within the limits established in § 412.302(c) for putting obligated capital into use for patient care). If the redetermined hospital-specific rate is greater than the adjusted Federal rate, these hospitals will be paid under the hold-harmless payment methodology. Regardless of whether the hospital became a hold-harmless payment hospital as a result of a redetermination, we continue to show these hospitals as low capital cost hospitals in Table III.
Assuming no behavioral changes in capital expenditures, Table III displays the percentage change in payments from FY 2001 to FY 2002 using the above described actuarial model. With the Federal rate, we estimate aggregate Medicare capital payments will increase by 4.27 percent in FY 2002. This increase is noticeably somewhat lower than last year's (5.48 percent) due in part to the fact that because the transition period ends after FY 2001, there is no longer an increase in the Federal blend percentage, which increased from 90 to 100 percent from FY 2000 to FY 2001, for fully prospective hospitals.
| Number of hospitals | Discharges | Adjusted federal payment | Average federal percent | Hold harmless payment | Exceptions payment | Total payment | Percent change over FY 2001 | |
|---|---|---|---|---|---|---|---|---|
| FY 2001 Payments per Discharge: | ||||||||
| Low Cost Hospitals | 3,127 | 6,769,127 | $620.00 | 99.66 | $2.99 | $5.30 | $628.28 | |
| Fully Prospective | 2,942 | 6,276,252 | 621.64 | 100.00 | 4.89 | 626.53 | ||
| 100% Federal Rate | 169 | 456,256 | 617.75 | 100.00 | 6.16 | 623.91 | ||
| Hold Harmless | 16 | 36,620 | 366.68 | 48.18 | 552.28 | 64.01 | 982.96 | |
| High Cost Hospitals | 1,580 | 4,165,866 | 632.93 | 98.07 | 16.77 | 9.18 | 658.87 | |
| 100% Federal Rate | 1,408 | 3,837,475 | 644.77 | 100.00 | 7.11 | 651.88 | ||
| Hold Harmless | 172 | 328,391 | 494.55 | 75.83 | 212.71 | 33.31 | 740.57 | |
| Total Hospitals | 4,707 | 10,934,994 | 624.92 | 99.04 | 8.24 | 6.77 | 639.94 | |
| FY 2002 Payments per Discharge: | ||||||||
| Low Cost Hospitals | 3,127 | 6,877,112 | 643.74 | 100.00 | 2.85 | 646.59 | 2.91 | |
| Fully Prospective | 2,942 | 6,376,366 | 643.23 | 100.00 | 2.92 | 646.14 | 3.13 | |
| 100% Federal Rate | 185 | 500,747 | 650.23 | 100.00 | 2.07 | 652.29 | 4.55 | |
| High Cost Hospitals | 1,580 | 4,232,640 | 667.73 | 100.00 | 5.55 | 673.28 | 2.19 | |
| 100% Federal Rate | 1,580 | 4,232,640 | 667.73 | 100.00 | 5.55 | 673.28 | 3.28 | |
| Total Hospitals | 4,707 | 11,109,753 | 652.88 | 100.00 | 3.88 | 656.76 | 2.63 |
We project that low capital cost hospitals paid under the fully prospective payment methodology will experience an average increase in payments per case of 2.91 percent, and high capital cost hospitals will experience an average increase of 2.19 percent. These results are due to the fact that there is no longer an increase in the Federal blend percentage with the conclusion of the capital transition period in FY 2001 for fully prospective hospitals. Beginning FY 2002, all hospitals (except "new" hospitals under § 412.324(b)) are paid based on 100 percent of the Federal rate for FY 2002.
For hospitals paid under the fully prospective payment methodology, the Federal rate payment percentage remains at 100 percent from FY 2001 (the last year of the transition period) and since they no longer receive payments based on the hospital-specific rate. The Federal rate payment percentage in FY 2001 for hospitals paid under the hold-harmless payment methodology is based on the hospital's ratio of new capital costs to total capital costs. The average Federal rate payment percentage for high cost hospitals receiving a hold-harmless payment for old capital in FY 2001 will increase from 75.83 percent to 100 percent since the transition period will have ended. All hold-harmless hospitals (except "new" hospitals under § 413.324(b)) will be paid based on 100 percent of the Federal rate in FY 2002. We estimate that high cost hospitals (paid based on 100 percent of the Federal rate) will receive a decrease in exceptions payments from $7.11 per discharge in FY 2001 to $5.55 per discharge in FY 2002. This is primarily due to the expiration of the regular exceptions provision in FY 2002.
We are no longer presenting the average hospital-specific rate payment per discharge in Table III because, beginning with FY 2001, the transition blend percentage for fully prospective hospitals is 100 percent of the Federal rate and zero percent of the hospital-specific rate, and all hospitals (except "new" hospitals under § 412.324(b)) will be paid based on 100 percent of the Federal rate for FY 2002.
As stated previously, we will continue to pay regular exceptions for cost reporting periods beginning before October 1, 2001, but ending in FY 2002. However, in FY 2003 and later, regular exception payments will no longer be made under the regular exceptions provision but eligible hospitals could receive special exception payments under § 412.348(g).
We estimate that regular exceptions payments will decrease from 1.06 percent of total capital payments in FY 2001 to 0.59 percent of payments in FY 2002. These results are primarily due to the expiration of the regular exceptions after FY 2001 and the limited nature of the special exceptions policy in FY 2002. The projected distribution of the exception payments is shown in the chart below:
| Type of hospital | Number of hospitals | Percent of exceptions payments |
|---|---|---|
| Low Capital Cost | 104 | 46 |
| High Capital Cost | 112 | 54 |
| Total | 216 | 100 |
In the past we presented a cross-sectional summary of hospital groupings by the capital prospective payment transition period methodology generated by our actuarial model (Appendix B). We are no longer including such a comparison since all hospitals (except "new" hospitals under § 412.324(b)) will be paid based on 100 percent of the Federal rate in FY 2002 with the conclusion of the 10-year capital transition period.
C. Cross-Sectional Analysis of Changes in Aggregate Payments
We used our FY 2002 actuarial model to estimate the potential impact of our changes for FY 2002 on total capital payments per case, using a universe of 4,707 hospitals. The individual hospital payment parameters are taken from the best available data, including: the April 1, 2001 update to the provider-specific file, cost report data, and audit information supplied by intermediaries. In Table IV, we present the results of the cross-sectional analysis using the results of our actuarial model and the aggregate impact of the FY 2002 payment policies. As we explain in Appendix B of this final rule, we were not able to use 88 of the 4,795 hospitals in our database due to insufficient (missing or unusable) data. Consequently, the payment methodology distribution is based on 4,707 hospitals. These data should be fully representative of the payment methodologies that will be applicable to hospitals. Columns 3 and 4 show estimates of payments per case under our model for FY 2001 and FY 2002, respectively. Column 5 shows the total percentage change in payments from FY 2001 to FY 2002. Column 6 presents the percentage change in payments that can be attributed to Federal rate changes alone.
Federal rate changes represented in Column 6 include the 2.28 percent increase in the Federal rate, a 1.0 percent increase in case mix, changes in the adjustments to the Federal rate (for example, the effect of the new hospital wage index on the geographic adjustment factor), and reclassifications by the MGCRB. Column 5 includes the effects of the Federal rate changes represented in Column 6. Column 5 also reflects the effects of all other changes, including the change for all hold-harmless hospitals being paid based on 100 percent of the Federal rate, and changes in exception payments. The comparisons are provided by: (1) geographic location, (2) region, and (3) payment classification.
The simulation results show that, on average, capital payments per case can be expected to increase 2.6 percent in FY 2002. The results show that the effect of the Federal rate change alone is to increase payments by 3.4 percent. In addition to the increase attributable to the Federal rate change, a 0.8 percent decrease is attributable to the effects of all other changes.
Our comparison by geographic location shows an overall increase in payments to hospitals in all areas. This comparison also shows that urban and rural hospitals will experience slightly different rates of increase in capital payments per case (2.7 percent and 2.0 percent, respectively). This difference is due to the lower rate of decrease for urban hospitals relative to rural hospitals (0.7 percent and 1.4 percent, respectively) from the effect of all other changes. Urban hospitals will gain the same as rural hospitals (3.4 percent) from the effects of Federal rate changes alone.
Most regions are estimated to receive increases in total capital payments per case, partly due to the fact that payments to all hospitals (except "new" hospitals under § 412.324(b)) will be based on 100 percent of the Federal rate in FY 2002. Changes by region vary from a minimum increase of 0.7 percent (Mountain rural region) to a maximum increase of 3.5 percent (East North Central region).
By type of ownership, voluntary hospitals are projected to have the largest rate of increase of total payment changes (2.8 percent, a 3.4 percent increase due to the Federal rate changes, and a 0.6 percent decrease from the effects of all other changes). Similarly, payments to government hospitals will increase 2.2 percent (a 3.4 percent increase due to Federal rate changes, and a 1.2 percent decrease from the effects of all other changes), while payments to proprietary hospitals will increase 0.9 percent (a 3.3 percent increase due to Federal rate changes, and a 2.4 percent decrease from the effects of all other changes). This 2.4 percent decrease from all other changes is primarily due to the estimated decrease in exceptions payments and the change for all hold-harmless hospitals being paid based on 100 percent of the Federal rate.
Section 1886(d)(10) of the Act established the MGCRB. Hospitals may apply for reclassification for purposes of the standardized amount, wage index, or both and for purposes of DSH for FYs 1999 through 2001. Although the Federal capital rate is not affected, a hospital's geographic classification for purposes of the operating standardized amount does affect a hospital's capital payments as a result of the large urban adjustment factor and the disproportionate share adjustment for urban hospitals with 100 or more beds. Reclassification for wage index purposes also affects the geographic adjustment factor, since that factor is constructed from the hospital wage index.
To present the effects of the hospitals being reclassified for FY 2002 compared to the effects of reclassification for FY 2001, we show the average payment percentage increase for hospitals reclassified in each fiscal year and in total. For FY 2002 reclassifications, we indicate those hospitals reclassified for standardized amount purposes only, for wage index purposes only, and for both purposes. The reclassified groups are compared to all other nonreclassified hospitals. These categories are further identified by urban and rural designation.
Hospitals reclassified for FY 2002 as a whole are projected to experience a 2.5 percent increase in payments (a 3.4 percent increase attributable to Federal rate changes and a 0.9 percent decrease attributable to the effects of all other changes). Payments to nonreclassified hospitals will increase slightly more (2.6 percent) than reclassified hospitals (2.5 percent) overall. Payments to nonreclassified hospitals will increase the same as reclassified hospitals from the Federal rate changes (3.4 percent), and they will lose slightly less from the effects of all other changes (0.8 percent compared to 0.9 percent, respectively).
| Number of hospitals | Average FY 2001 payments/case | Average FY 2002 payments/case | All charges | Portion attributable to federal rate change | |
|---|---|---|---|---|---|
| By Geographic Location: | |||||
| All hospitals | 4,707 | 640 | 657 | 2.6 | 3.4 |
| Large urban areas (populations over 1 million) | 1,518 | 742 | 763 | 2.9 | 3.4 |
| Other urban areas (populations of 1 million fewer) | 1,110 | 629 | 645 | 2.5 | 3.4 |
| Rural areas | 2,079 | 433 | 442 | 2.0 | 3.4 |
| Urban hospitals | 2,628 | 693 | 712 | 2.7 | 3.4 |
| 0-99 beds | 638 | 504 | 501 | -0.6 | 3.2 |
| 100-199 beds | 932 | 591 | 604 | 2.3 | 3.3 |
| 200-299 beds | 527 | 662 | 681 | 2.9 | 3.4 |
| 300-499 beds | 382 | 734 | 757 | 3.2 | 3.4 |
| 500 or more beds | 149 | 890 | 917 | 3.0 | 3.4 |
| Rural hospitals | 2,079 | 433 | 442 | 2.0 | 3.4 |
| 0-49 beds | 1,218 | 364 | 371 | 1.7 | 3.3 |
| 50-99 beds | 516 | 406 | 414 | 1.9 | 3.3 |
| 100-149 beds | 203 | 443 | 450 | 1.8 | 3.4 |
| 150-199 beds | 75 | 482 | 494 | 2.4 | 3.3 |
| 200 or more beds | 67 | 541 | 553 | 2.2 | 3.4 |
| By Region: | |||||
| Urban by Region | 2,628 | 693 | 712 | 2.7 | 3.4 |
| New England | 137 | 733 | 757 | 3.4 | 3.5 |
| Middle Atlantic | 406 | 776 | 797 | 2.6 | 3.3 |
| South Atlantic | 391 | 665 | 682 | 2.5 | 3.4 |
| East North Central | 445 | 666 | 690 | 3.5 | 3.4 |
| East South Central | 156 | 628 | 643 | 2.4 | 3.4 |
| West North Central | 179 | 687 | 708 | 3.0 | 3.4 |
| West South Central | 319 | 659 | 668 | 1.4 | 3.3 |
| Mountain | 126 | 681 | 690 | 1.3 | 3.4 |
| Pacific | 423 | 783 | 808 | 3.3 | 3.4 |
| Puerto Rico | 46 | 290 | 299 | 3.1 | 3.1 |
| Rural by Region | 2,079 | 433 | 442 | 2.0 | 3.4 |
| New England | 50 | 519 | 530 | 2.1 | 3.4 |
| Middle Atlantic | 74 | 453 | 467 | 3.1 | 3.4 |
| South Atlantic | 269 | 449 | 455 | 1.2 | 3.3 |
| East North Central | 276 | 441 | 452 | 2.4 | 3.4 |
| East South Central | 260 | 403 | 412 | 2.2 | 3.4 |
| West North Central | 479 | 421 | 430 | 2.3 | 3.4 |
| West South Central | 327 | 388 | 393 | 1.4 | 3.3 |
| Mountain | 195 | 458 | 461 | 0.7 | 3.2 |
| Pacific | 144 | 513 | 528 | 3.0 | 3.4 |
| By Payment Classification: | |||||
| All hospitals | 4,707 | 640 | 657 | 2.6 | 3.4 |
| Large urban areas (populations over 1 million) | 1,589 | 735 | 756 | 2.8 | 3.4 |
| Other urban areas (populations of 1 million or fewer) | 1,081 | 631 | 647 | 2.5 | 3.4 |
| Rural areas | 2,037 | 431 | 440 | 2.1 | 3.4 |
| Teaching Status: | |||||
| Non-teaching | 3,582 | 526 | 536 | 2.0 | 3.4 |
| Fewer than 100 Residents | 888 | 668 | 689 | 3.1 | 3.4 |
| 100 or more Residents | 237 | 996 | 1,027 | 3.1 | 3.4 |
| Urban DSH: | |||||
| 100 or more beds | 1,374 | 729 | 750 | 2.8 | 3.4 |
| Less than 100 beds | 309 | 483 | 486 | 0.5 | 3.2 |
| Rural DSH: | |||||
| Sole Community (SCH/EACH) | 545 | 395 | 395 | 0.1 | 3.2 |
| Referral Center (RRC/EACH) | 152 | 495 | 505 | 1.9 | 3.4 |
| Other Rural: | |||||
| 100 or more beds | 70 | 407 | 418 | 2.6 | 3.3 |
| Less than 100 beds | 449 | 366 | 378 | 3.0 | 3.4 |
| Urban teaching and no DSH: | |||||
| Both teaching and DSH | 757 | 805 | 829 | 3.0 | 3.4 |
| Teaching and no DSH | 297 | 712 | 737 | 3.4 | 3.4 |
| No teaching and DSH | 926 | 583 | 596 | 2.2 | 3.3 |
| No teaching and no DSH | 690 | 577 | 587 | 1.7 | 3.4 |
| Rural Hospital Types: | |||||
| Non special status hospitals | 794 | 381 | 392 | 3.1 | 3.4 |
| RRC/EACH | 165 | 498 | 513 | 3.0 | 3.4 |
| SCH/EACH | 680 | 417 | 418 | 0.2 | 3.2 |
| Medicare-dependent hospitals (MDH) | 328 | 353 | 363 | 2.8 | 3.4 |
| SCH, RRC and EACH | 70 | 500 | 503 | 0.6 | 3.3 |
| Hospitals Reclassified by the Medicare Geographic Classification Review Board: | |||||
| Reclassification Status During FY01 and FY02: | |||||
| Reclassified During Both FY01 and FY02 | 475 | 560 | 573 | 2.4 | 3.4 |
| Reclassified During FY02 Only | 152 | 558 | 573 | 2.7 | 3.4 |
| Reclassified During FY01 Only | 51 | 489 | 504 | 3.0 | 3.4 |
| FY02 Reclassifications: | |||||
| All Reclassified Hospitals | 627 | 559 | 573 | 2.5 | 3.4 |
| All Nonclassified Hospitals | 4,159 | 652 | 670 | 2.6 | 3.4 |
| All Urban Reclassified Hospitals | 117 | 742 | 765 | 3.1 | 3.4 |
| Urban nonreclassified Hospitals | 2,473 | 692 | 711 | 2.7 | 3.4 |
| All Reclassified Rural Hospitals | 510 | 486 | 496 | 2.1 | 3.4 |
| Rural Nonreclassified Hospitals | 1,566 | 384 | 391 | 1.8 | 3.3 |
| Other Reclassified Hospitals (Section 1886(D)(8)(B)) | 41 | 439 | 452 | 3.0 | 3.4 |
| Type of Ownership: | |||||
| Voluntary | 2,327 | 654 | 672 | 2.8 | 3.4 |
| Proprietary | 627 | 632 | 637 | 0.9 | 3.3 |
| Government | 954 | 558 | 570 | 2.2 | 3.4 |
| Medicare Utilization as a Percent of Inpatient Days: | |||||
| 0-25 | 390 | 831 | 854 | 2.7 | 3.4 |
| 25-50 | 1,873 | 729 | 750 | 3.0 | 3.4 |
| 50-65 | 1,832 | 561 | 576 | 2.6 | 3.4 |
| Over 65 | 585 | 514 | 516 | 0.3 | 3.3 |
Appendix B:
Technical Appendix on the Capital Cost Model and Required Adjustments
Under section 1886(g)(1)(A) of the Act, we set capital prospective payment rates for FY 1992 through FY 1995 so that aggregate prospective payments for capital costs were projected to be 10 percent lower than the amount that would have been payable on a reasonable cost basis for capital-related costs in that year. To implement this requirement, we developed the capital acquisition model to determine the budget neutrality adjustment factor. Even though the budget neutrality requirement expired effective with FY 1996, we must continue to determine the recalibration and geographic reclassification budget neutrality adjustment factor and the reduction in the Federal and hospital-specific rates for exceptions payments. To determine these factors, we must continue to project capital costs and payments.
We will continue to pay regular exceptions for cost reporting periods beginning before October 1, 2001 but ending in FY 2002. In FY 2003 and later, no payments will be made under the regular exceptions policy; hence, we will not compute a budget neutrality factor for regular exceptions in FY 2003 and later. As described in section V.D. of the preamble of this final rule, the budget neutrality adjustment for special exceptions will be based on historical costs. Consequently, there will be no need to estimate capital costs with the capital acquisition model. We will not publish this appendix after this final rule for the FY 2002 capital rates.
We used the capital acquisition model from the start of prospective payments for capital costs through FY 1997. We now have 8 years of cost reports under the capital prospective payment system. For FY 1998, we developed a new capital cost model to replace the capital acquisition model. This revised model makes use of the data from these cost reports.
The following cost reports are used in the capital cost model for this proposed rule: the March 31, 2001 update of the cost reports for PPS-IX (cost reporting periods beginning in FY 1992), PPS-X (cost reporting periods beginning in FY 1993), PPS-XI (cost reporting periods beginning in FY 1994), PPS-XII (cost reporting periods beginning in FY 1995), PPS-XIII (cost reporting periods beginning in FY 1996), PPS-XIV (cost reporting periods beginning in FY 1997), PPS-XV (cost reporting periods beginning in FY 1998), and PPS-XVI (cost reporting periods beginning in FY 1999). In addition, to model payments, we use the April 1, 2001 update of the provider-specific file, and the March 1995 update of the intermediary audit file.
Since hospitals under alternative payment system waivers (that is, hospitals in Maryland) are currently excluded from the capital prospective payment system, we excluded these hospitals from our model.
We developed FY 1992 through FY 2001 hospital-specific rates using the provider-specific file and the intermediary audit file. (We used the cumulative provider-specific file, which includes all updates to each hospital's records, and chose the latest record for each fiscal year.) We checked the consistency between the provider-specific file and the intermediary audit file. We ensured that increases in the hospital-specific rates were at least as large as the published updates (increases) for the hospital-specific rates each year. We were able to match hospitals to the files as shown in the following table:
| Source | Number of hospitals |
|---|---|
| No Match | 1 |
| Provider-Specific File Only | 188 |
| Provider-Specific and Audit File | 4,606 |
| Total | 4,795 |
One hundred sixteen of the 4,795 hospitals had unusable or missing data, or had no cost reports available. For 50 of the 116 hospitals, we were unable to determine a hospital-specific rate from the available cost reports. However, there was adequate cost information to determine that these hospitals were paid under the hold-harmless methodology. Since the hospital-specific rate is not used to determine payments for hospitals paid under the hold-harmless methodology, there was sufficient cost report information available to include these 50 hospitals in the analysis. We were able to estimate hospital-specific amounts from the cost reports as shown in the following table.
| Cost report | Number of hospitals |
|---|---|
| PPS-9 | 1 |
| PPS-12 | 1 |
| PPS-13 | 1 |
| PPS-14 | 1 |
| PPS-15 | 2 |
| PPS-16 | 13 |
| Total | 19 |
Hence, we were able to use 69 (50 plus 19) of the 116 hospitals. The remaining 47 of the 116 hospitals could not be used in the analysis because we were not able to estimate their hospital-specific amount. An additional 41 hospitals could not be used in the analysis because we could not determine their capital costs, either because we had no cost reports for them or because there was insufficient cost report data. Accordingly, we used 4,707 hospitals for the analysis. Eighty-eight (47 plus 41) hospitals could not be used in the analysis because of insufficient (missing or unusable) information. These hospitals account for about 0.3 percent of admissions. Therefore, any effects from the elimination of their cost report data should be minimal.
We analyzed changes in capital-related costs (depreciation, interest, rent, leases, insurance, and taxes) reported in the cost reports. We found a wide variance among hospitals in the growth of these costs. For hospitals with more than 100 beds, the distribution and mean of these cost increases were different for large changes in bed-size (greater than ±20 percent). We also analyzed changes in the growth in old capital and new capital for cost reports that provided this information. For old capital, we limited the analysis to decreases in old capital. We did this since the opportunity for most hospitals to treat "obligated" capital put into service as old capital has expired. Old capital costs should decrease as assets become fully depreciated and as interest costs decrease as the loan is amortized.
The new capital cost model separates the hospitals into three mutually exclusive groups. Hold-harmless hospitals with data on old capital were placed in the first group. Of the remaining hospitals, those hospitals with fewer than 100 beds comprise the second group. The third group consists of all hospitals that did not fit into either of the first two groups. Each of these groups displayed unique patterns of growth in capital costs. We found that the gamma distribution is useful in explaining and describing the patterns of increase in capital costs. A gamma distribution is a statistical distribution that can be used to describe patterns of growth rates, with the greatest proportion of rates being at the low end. We use the gamma distribution to estimate individual hospital rates of increase as follows:
(1) For hold-harmless hospitals, old capital cost changes were fitted to a truncated gamma distribution, that is, a gamma distribution covering only the distribution of cost decreases. New capital costs changes were fitted to the entire gamma distribution, allowing for both decreases and increases.
(2) For hospitals with fewer than 100 beds (small), total capital cost changes were fitted to the gamma distribution, allowing for both decreases and increases.
(3) Other (large) hospitals were further separated into three groups:
• Bed-size decreases over 20 percent (decrease).
• Bed-size increases over 20 percent (increase).
• Other (no change).
Capital cost changes for large hospitals were fitted to gamma distributions for each bed-size change group, allowing for both decreases and increases in capital costs. We analyzed the probability distribution of increases and decreases in bed size for large hospitals. We found the probability somewhat dependent on the prior year change in bed size and factored this dependence into the analysis. Probabilities of bed-size change were determined. Separate sets of probability factors were calculated to reflect the dependence on prior year change in bed size (increase, decrease, and no change).
The gamma distributions were fitted to changes in aggregate capital costs for the entire hospital. We checked the relationship between aggregate costs and Medicare per discharge costs. For large hospitals, there was a small variance, but the variance was larger for small hospitals. Since costs are used only for the hold-harmless methodology and to determine exceptions, we decided to use the gamma distributions fitted to aggregate cost increases for estimating distributions of cost per discharge increases.
Capital costs per discharge calculated from the cost reports were increased by random numbers drawn from the gamma distribution to project costs in future years. Old and new capital were projected separately for hold-harmless hospitals. Aggregate capital per discharge costs were projected for all other hospitals. Because the distribution of increases in capital costs varies with changes in bed size for large hospitals, we first projected changes in bed size for large hospitals before drawing random numbers from the gamma distribution. Bed-size changes were drawn from the uniform distribution with the probabilities dependent on the previous year bed-size change. The gamma distribution has a shape parameter and a scaling parameter. (We used different parameters for each hospital group, and for old and new capital.)
We used discharge counts from the cost reports to calculate capital cost per discharge. To estimate total capital costs for FY 2000 (the MedPAR data year) and later, we use the number of discharges from the MedPAR data. Some hospitals had considerably more discharges in FY 2000 than in the years for which we calculated cost per discharge from the cost report data. Consequently, a hospital with few cost report discharges would have a high capital cost per discharge, since fixed costs would be allocated over only a few discharges. If discharges increase substantially, the cost per discharge would decrease because fixed costs would be allocated over more discharges. If the projection of capital cost per discharge is not adjusted for increases in discharges, the projection of exceptions would be overstated. We address this situation by recalculating the cost per discharge with the MedPAR discharges if the MedPAR discharges exceed the cost report discharges by more than 20 percent. We do not adjust for increases of less than 20 percent because we have not received all of the FY 2000 discharges, and we have removed some discharges from the analysis because they are statistical outliers. This adjustment reduces our estimate of exceptions payments, and consequently, the reduction to the Federal rate for exceptions is smaller. We will continue to monitor our modeling of exceptions payments and make adjustments as needed.
The average national capital cost per discharge generated by this model is the combined average of many randomly generated increases. This average must equal the projected average national capital cost per discharge, which we projected separately (outside this model). We adjusted the shape parameter of the gamma distributions so that the modeled average capital cost per discharge matches our projected capital cost per discharge. The shape parameter for old capital was not adjusted since we are modeling the aging of "existing" assets. This model provides a distribution of capital costs among hospitals that is consistent with our aggregate capital projections.
Once each hospital's capital-related costs are generated, the model projects capital payments. We use the actual payment parameters (for example, the case-mix index and the geographic adjustment factor) that are applicable to the specific hospital.
To project capital payments, the model first assigns the applicable payment methodology (fully prospective or hold-harmless) to the hospital as determined from the provider-specific file and the cost reports. The model simulates Federal rate payments using the assigned payment parameters and hospital-specific estimated outlier payments. The case-mix index for a hospital is derived from the FY 2000 MedPAR file using the FY 2002 DRG relative weights included in section VI. of the Addendum to this final rule. The case-mix index is increased each year after FY 2000 based on analysis of past experiences in case-mix increases. Based on analysis of recent case-mix increases, we estimate that case-mix will decrease 0.9 percent in FY 2001. We project that case-mix will increase 1.0 percent in FY 2002. (Since we are using FY 2000 cases for our analysis, the FY 2000 increase in case-mix has no effect on projected capital payments.)
Changes in geographic classification and revisions to the hospital wage data used to establish the hospital wage index affect the geographic adjustment factor. Changes in the DRG classification system and the relative weights affect the case-mix index.
Section 412.308(c)(4)(ii) requires that the estimated aggregate payments for the fiscal year, based on the Federal rate after any changes resulting from DRG reclassifications and recalibration and the geographic adjustment factor, equal the estimated aggregate payments based on the Federal rate that would have been made without such changes. For FY 2001, the budget neutrality adjustment factors were 0.99933 for the national rate and 1.00508 for the Puerto Rico rate. In determining these factors, we used the factors from the first half of FY 2001 (October 2000 through March 2001) published in the August 1, 2000 final rule since section 547 of Public Law 106-554 specifies that the special increases and adjustments in effect between April and October 2001 do not apply for discharges occurring after FY 2001 and should not be included in determining the payment rates in subsequent years.
Since we implemented a separate geographic adjustment factor for Puerto Rico, we applied separate budget neutrality adjustments for the national geographic adjustment factor and the Puerto Rico geographic adjustment factor. We applied the same budget neutrality factor for DRG reclassifications and recalibration nationally and for Puerto Rico. Separate adjustments were unnecessary for FY 1998 and earlier since the geographic adjustment factor for Puerto Rico was implemented in FY 1998.
To determine the factors for FY 2002, we first determined the portions of the Federal national and Puerto Rico rates that would be paid for each hospital in FY 2002 based on its applicable payment methodology. Using our model, we then compared, separately for the national rate and the Puerto Rico rate, estimated aggregate Federal rate payments based on the FY 2001 DRG relative weights and the FY 2001 geographic adjustment factor to estimated aggregate Federal rate payments based on the FY 2001 relative weights and the FY 2002 geographic adjustment factor. In making the comparison, we held the FY 2002 Federal rate portion constant and set the other budget neutrality adjustment factor and the regular and special exceptions reduction factors to 1.00. To achieve budget neutrality for the changes in the national geographic adjustment factor, we applied an incremental budget neutrality adjustment of 0.99666 for FY 2002 to the previous cumulative FY 2001 adjustment of 0.99933, yielding a cumulative adjustment of 0.99599 through FY 2002. For the Puerto Rico geographic adjustment factor, we applied an incremental budget neutrality adjustment of 0.98991 for FY 2002 to the previous cumulative FY 2001 adjustment of 1.00508, yielding a cumulative adjustment of 0.99494 through FY 2002. We then compared estimated aggregate Federal rate payments based on the FY 2001 DRG relative weights and the FY 2002 geographic adjustment factors to estimated aggregate Federal rate payments based on the FY 2002 DRG relative weights and the FY 2002 geographic adjustment factors. The incremental adjustment for DRG classifications and changes in relative weights is 0.99668 nationally and for Puerto Rico. The cumulative adjustments for DRG classifications and changes in relative weights and for changes in the geographic adjustment factors through FY 2002 are 0.99268 nationally and 0.99164 for Puerto Rico. The following table summarizes the adjustment factors for each fiscal year:
| Fiscal year | National | Incremental adjustment | Geographic adjustment factor | DRG reclassifications and recalibration | Combined | Cumulative | Puerto Rico | Incremental adjustment | Geographic adjustment factor | DRG reclassifications and recalibration | Combined | Cumulative |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1992 | 1.00000 | |||||||||||
| 1993 | 0.99800 | 0.99800 | ||||||||||
| 1994 | 1.00531 | 1.00330 | ||||||||||
| 1995 | 0.99980 | 1.00310 | ||||||||||
| 1996 | 0.99940 | 1.00250 | ||||||||||
| 1997 | 0.99873 | 1.00123 | ||||||||||
| 1998 | 0.99892 | 1.00015 | 1.00000 | |||||||||
| 1999 | 0.99944 | 1.00335 | 1.00279 | 1.00294 | 0.99898 | 1.00335 | 1.00233 | 1.00233 | ||||
| 2000 | 0.99857 | 0.99991 | 0.99848 | 1.00142 | 0.99910 | 0.99991 | 0.99901 | 1.00134 | ||||
| 20011 | 0.99846 | 1.00019 | 0.99865 | 0.99933 | 1.00365 | 1.00009 | 1.00374 | 1.00508 | ||||
| 20012 | 3 0.99771 | 3 1.00009 | 3 0.99780 | 0.99922 | 3 1.00365 | 3 1.00009 | 3 1.00374 | 1.00508 | ||||
| 2002 | 4 0.99666 | 4 0.99668 | 4 0.99335 | 0.99268 | 4 0.98991 | 4 0.99668 | 4 0.99662 | 0.99164 | ||||
| 1 Factors effective for the first half of FY 2001 (October 2000 through March 2001). | ||||||||||||
| 2 Factors effective for the second half of FY 2001 (April 2001 through September 2001). | ||||||||||||
| 3 Incremental factors are applied to FY 2000 cumulative factors. | ||||||||||||
| 4 Incremental factors are applied to the cumulative factors for the first half of FY 2001. | ||||||||||||
The methodology used to determine the recalibration and geographic (DRG/GAF) budget neutrality adjustment factor is similar to that used in establishing budget neutrality adjustments under the prospective payment system for operating costs. One difference is that, under the operating prospective payment system, the budget neutrality adjustments for the effect of geographic reclassifications are determined separately from the effects of other changes in the hospital wage index and the DRG relative weights. Under the capital prospective payment system, there is a single DRG/GAF budget neutrality adjustment factor (the national rate and the Puerto Rico rate are determined separately) for changes in the geographic adjustment factor (including geographic reclassification) and the DRG relative weights. In addition, there is no adjustment for the effects that geographic reclassification has on the other payment parameters, such as the payments for serving low-income patients or the large urban add-on payments.
In addition to computing the DRG/GAF budget neutrality adjustment factor, we used the model to simulate total payments under the prospective payment system.
Additional payments under the exceptions process are accounted for through a reduction in the Federal and hospital-specific rates. For FY 2002 additional payments for the "regular" exceptions are made only for cost reporting periods that begin before October 1, 2001. The adjustment for "special" exceptions payments (see § 412.348(g)) is described in section V.D. of the preamble of this final rule. Therefore, we used the model to calculate the exceptions reduction factor. This exceptions reduction factor ensures that aggregate payments under the capital prospective payment system, including exceptions payments, are projected to equal the aggregate payments that would have been made under the capital prospective payment system without an exceptions process. In modeling exceptions for FY 2002, we calculated exceptions only for qualifying cost reporting periods. Since changes in the level of the payment rates change the level of payments under the exceptions process, the exceptions reduction factor must be determined through iteration.
In the August 30, 1991 final rule (56 FR 43517), we indicated that we would publish each year the estimated payment factors generated by the model to determine payments for the next 5 years. Since we will no longer use the model after this final rule for the FY 2002 rates, we will discontinue publishing this table after this final rule for the FY 2002 rates. The table below provides the actual factors for FYs 1992 through 2002, and the estimated factors that would be applicable through FY 2006. We caution that these are estimates for FYs 2003 and later, and are subject to revisions resulting from continued methodological refinements, receipt of additional data, and changes in payment policy. We note that in making these projections, we have assumed that the cumulative national DRG/GAF budget neutrality adjustment factor will remain at 0.99268 (0.99164 for Puerto Rico) for FY 2002 and later because we do not have sufficient information to estimate the change that will occur in the factor for years after FY 2002.
The projections are as follows:
| Fiscal year | Update factor | Exceptions reduction factor | Budget neutrality factor | DRG/GAF adjustment factor1 | Outlier adjustment factor | Federal rate adjustment | Federal rate (after outlier) reduction |
|---|---|---|---|---|---|---|---|
| 1992 | N/A | 0.9813 | 0.9602 | .9497 | 415.59 | ||
| 1993 | 6.07 | .9756 | .9162 | .9980 | .9496 | 417.29 | |
| 1994 | 3.04 | .9485 | .8947 | 1.0053 | .9454 | 2 .9260 | 378.34 |
| 1995 | 3.44 | .9734 | .8432 | .9998 | .9414 | 376.83 | |
| 1996 | 1.20 | .9849 | N/A | .9994 | .9536 | 3 .9972 | 461.96 |
| 1997 | 0.70 | .9358 | N/A | .9987 | .9481 | 438.92 | |
| 1998 | 0.90 | 9659 | N/A | .9989 | .9382 | 4 .8222 | 371.51 |
| 1999 | 0.10 | .9783 | N/A | 1.0028 | .9392 | 378.10 | |
| 2000 | 0.30 | .9730 | N/A | .9985 | .9402 | 377.03 | |
| 20015 | 0.90 | .9785 | N/A | .9979 | .9409 | 382.03 | |
| 2002 | 1.30 | 6 .9929 | N/A | 0.9933 | .9424 | 390.74 | |
| 2003 | 0.70 | .9975 | N/A | 7 1.0000 | 7 .9424 | 4 1.0255 | 405.39 |
| 2004 | 0.70 | .9975 | N/A | 1.0000 | .9424 | 408.23 | |
| 2005 | 0.90 | .9975 | N/A | 1.0000 | .9424 | 411.90 | |
| 2006 | 0.90 | .9975 | N/A | 1.0000 | .9424 | 415.61 | |
| 1 The incremental change over the previous year. | |||||||
| 2 OBRA 1993 adjustment. | |||||||
| 3 Adjustment for change in the transfer policy. | |||||||
| 4 Balanced Budget Act of 1997 adjustment. | |||||||
| 5 Rates are for the first half of FY 2001 (October 1, 2000 through March 31, 2001). | |||||||
| 6 Product of general exceptions factor (0.9941) and special exceptions factor (0.9988) | |||||||
| 7 Future adjustments are, for purposes of this projection, assumed to remain at the same level. | |||||||
Appendix C: Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services
I. Background
Several provisions of the Act address the setting of update factors for inpatient services furnished in FY 2002 by hospitals subject to the prospective payment system and by hospitals or units excluded from the prospective payment system. Section 1886(b)(3)(B)(i)(XVII) of the Act, as amended by section 301 of Public Law 106-554, sets the FY 2002 percentage increase in the operating cost standardized amounts equal to the rate of increase in the hospital market basket minus 0.55 percentage points for prospective payment hospitals in all areas. Section 1886(b)(3)(B)(iv) of the Act sets the FY 2002 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 all other hospitals subject to the prospective payment system, or the rate of increase in the market basket minus 0.55 percentage points. Under section 1886(b)(3)(B)(ii) of the Act, the FY 2002 percentage increase in the rate-of-increase limits for hospitals and units excluded from the prospective payment system ranges from the percentage increase in the excluded hospital market basket less a percentage between 0 and 2.5 percentage points, depending on the hospital's or unit's costs in relation to its limit for the most recent cost reporting period for which information is available, or 0 percentage point if costs do not exceed two-thirds of the limit.
In accordance with section 1886(d)(3)(A) of the Act, we are updating the standardized amounts, the hospital-specific rates, and the rate-of-increase limits for hospitals and units excluded from the prospective payment system as provided in section 1886(b)(3)(B) of the Act. Based on the second quarter 2001 forecast of the FY 2002 market basket increase of 3.3 percent for hospitals subject to the prospective payment system, the update to the standardized amounts is 2.75 percent (that is, the market basket rate of increase minus 0.55 percentage points) for hospitals in both large urban and other areas. The update to the hospital-specific rate applicable to SCHs and MDHs is also 2.75 percent. The update for hospitals and units excluded from the prospective payment system can range from the percentage increase in the excluded hospital market basket (currently estimated at 3.3 percent) minus a percentage between 0 and 2.5 percentage points, or 0 percentage point, resulting in an increase in the rate-of-increase limit between 0.8 and 3.3 percent, or 0 percent.
Section 1886(e)(4) of the Act requires that the Secretary, taking into consideration the recommendations of the Medicare Payment Advisory Commission (MedPAC), recommend update factors for each fiscal year that take into account the amounts necessary for the efficient and effective delivery of medically appropriate and necessary care of high quality. In its March 1, 2001 report, MedPAC stated that the legislated update of market basket minus 0.55 percentage points would provide a reasonable level of payments to hospitals. MedPAC did not make a separate recommendation for the hospital-specific rate applicable to SCHs and MDHs.
Under section 1886(e)(5) of the Act, we are required to publish the update factors recommended under section 1886(e)(4) of the Act. Accordingly, we published the FY 2002 update factors recommended by the Secretary as Appendix D of the May 4, 2001 proposed rule (66 FR 22888). In that appendix, we discussed the recommendations of appropriate update factors, the analysis underlying our recommendations, and our response to MedPAC's recommendations concerning the update factors.
I. Secretary's Final Recommendations for Updating the Prospective Payment System Standardized Amounts
In recommending an update, the Secretary takes into account the factors in the update framework, as well as the recommendations of MedPAC, the long-term solvency of the Medicare Trust Funds, and the capacity of the hospital industry to continually provide access to high quality care to Medicare beneficiaries through adequate reimbursement to health care providers.
We received several comments concerning our proposed recommendation.
Comment: One commenter questioned the reason for the difference between the 3.05 percent update to the standardized amounts recommended by the Secretary to the Congress as printed in the May 4, 2001 proposed rule (65 FR 22885) and the 2.55 percent proposed update used to establish the rates printed in the May 4, 2001 proposed rule (65 FR 22738).
Response: The President's FY 2002 budget estimated that the market basket for FY 2002 would be 3.6 percent. This estimate is prepared by the Office of Management and Budget (OMB) by applying future assumptions of economy-wide wage and consumer price index growth to the historical relationship between these factors and the market basket.
The market basket we have historically used to actually update the standardized amounts is estimated by our Office of the Actuary, in conjunction with Global Insights, Inc., DRI-WEFA. Although this estimate is generally very close to the OMB estimate, there are often some discrepancies due to the timing of the estimate and the differing future assumptions of the input factors.
Our final recommendation of the market basket percentage increase minus 0.55 percentage points for the update for hospitals subject to the prospective payment system, which is consistent with current law, did not differ from the proposed. However, the second quarter forecast of the market basket percentage increase is 3.3 for prospective payment hospitals (up from 3.1 estimated in the proposed rule). Thus, the Secretary's final recommendation is that the update to the prospective payment system standardized amounts for both large urban and other urban areas is 2.75 percent (or consistent with current law, market basket percentage increase minus 0.55 percent). The update to the hospital-specific rate applicable to SCHs and MDHs is also 2.75 percent (or consistent with current law, market basket percentage increase minus 0.55 percentage points).
Comment: Several commenters addressed the recent increases in the price of blood products. One commenter stated the increases represent up to one percent of annual DRG payments for hospitals that perform a significant number of surgeries. The commenters urged us to ensure that the DRG payments reflect price increases associated with rising blood prices.
Response: Section 301(c) of Public Law 106-554 requires the Secretary to consider the price of blood and blood products in the market basket index when the market basket is next rebased and revised and to determine whether those prices are adequately reflected.
III. Secretary's Final Recommendation for Updating the Rate-of-Increase Limits for Excluded Hospitals and Units
We received no comments concerning our proposed recommendation. Our final recommendation for excluded hospitals and units did not differ from the proposed. However, the second quarter forecast of the market basket percentage increase is 3.3 for excluded hospitals and units (up from 3.0 estimated in the proposed rule). Thus, the Secretary's final recommendation is that the update for hospitals and units excluded from the prospective payment system can range from market basket increase of 3.3 percent minus a percentage between 0 and 2.5 percent, or 0 percent depending on the relationship between the hospital's or unit's costs and its rate-of-increase limit, which results in an increase in the rate-of-increase limit between 0.8 and 3.3 percent, or 0 percent for FY 2002.
[FR Doc. 01-18868 Filed 7-31-01; 8:45 am]
BILLING CODE 4120-01-P