Medicare Program; Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates: Final Fiscal Year 2009 Wage Indices and Payment Rates Including Implementation of Section 124 of the Medicare Improvement for Patients and Providers Act of 2008, 57888-58017 [E8-23083]
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Federal Register / Vol. 73, No. 193 / Friday, October 3, 2008 / Notices
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[CMS–1390–N]
RIN 0938–AP15
Medicare Program; Hospital Inpatient
Prospective Payment Systems and
Fiscal Year 2009 Rates: Final Fiscal
Year 2009 Wage Indices and Payment
Rates Including Implementation of
Section 124 of the Medicare
Improvement for Patients and
Providers Act of 2008
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Notice.
AGENCY:
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SUMMARY: This notice contains tables
listing the final wage indices, hospital
reclassifications, payment rates,
impacts, and other related tables
effective for fiscal year (FY) 2009. The
tables and impacts included in this
notice reflect the extension of the
expiration date for certain geographic
reclassifications and special exception
wage indices as required by section 124
of the Medicare Improvement for
Patients and Providers Act of 2008
(MIPPA), Public Law 110–275. These
geographic reclassifications and special
exception wage indices were previously
set to expire on September 30, 2008 and
are now extended through September
30, 2009. (Additionally, the final rates,
wage indices, budget neutrality factors
and tables included in this notice also
reflect a correction made to the wage
data for one hospital, as discussed in the
correction notice for the FY 2009 IPPS
final rule published elsewhere within
this Federal Register.)
DATES: Effective Date: This notice is
effective on October 1, 2008.
FOR FURTHER INFORMATION CONTACT: Tzvi
Hefter, (410) 786–4487.
SUPPLEMENTARY INFORMATION:
I. Background
In the August 19, 2008 Federal
Register (73 FR 48434) (hereinafter
referred to as the FY 2009 IPPS final
rule), we set forth our final rule for the
Medicare inpatient prospective payment
system (IPPS). Due to the July 15, 2008
enactment of the Medicare Improvement
for Patients and Providers Act of 2008
(MIPPA) (Pub. L. 110–275), we stated in
the final rule that we would publish the
FY 2009 wage index tables, rates, and
impacts reflecting the implementation
of this legislation in a Federal Register
document subsequent to the FY 2009
IPPS final rule. (See the FY 2009 IPPS
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final rule, 73 FR 48588 and 48589, for
a full explanation of the reasons for
such subsequent publication.) This
notice includes such wage index tables,
rates, and impacts. (Additionally, the
final rates, wage indices, budget
neutrality factors and tables included in
this notice also reflect a correction made
to the wage data for one hospital, as
discussed in the correction notice for
the FY 2009 IPPS final rule published
elsewhere within this Federal Register.)
II. Final FY 2009 Wage Indices and
Rates
A. Final FY 2009 Wage Indices
The final wage index values for FY
2009 (except those for hospitals
receiving wage index adjustments under
section 505 of Pub. L. 108–173) are
included in Tables 4A, 4B, 4C, and 4F
of the Addendum to this notice and are
posted on our Web site at https://www.
cms.hhs.gov/AcuteInpatientPPS/. For
hospitals that are receiving a wage index
adjustment under section 505 of Pub. L.
108–173, the hospital’s final wage index
will reflect the adjustment shown in
Table 4J of the Addendum to this notice.
In addition, Table 2 of the Addendum
to this notice includes the final wage
index value and occupational mix
adjusted average hourly wage (from the
FYs 2003, 2004, and 2005 cost reporting
periods) for each hospital. Table 4D–1 of
the Addendum of this notice lists the
State rural floor budget neutrality
factors for FY 2009.
B. Final FY 2009 Hospital Wage Index
Reclassifications/Redesignations
1. Section 508 Extension
On July 15, 2008, the Medicare
Improvements for Patients and
Providers Act of 2008, Pub. L. 110–275
was enacted. Section 124 of Pub. L.
110–275 extends through FY 2009 wage
index reclassifications under section
508 of the Medicare Prescription Drug
Improvement and Modernization Act of
2003 (MMA) (Pub. L. 108–173) and
certain special exceptions (for example,
those special exceptions contained in
the final rule promulgated in the
Federal Register on August 11, 2004 (69
FR 49105 and 49107) and extended
under section 117 of the Medicare,
Medicaid, and SCHIP Extension Act of
2007 (MMSEA) (Pub. L. 110–173)).
Under section 508 of Pub. L. 108–173,
a qualifying hospital could appeal the
wage index classification otherwise
applicable to the hospital and apply for
reclassification to another area of the
State in which the hospital is located
(or, at the discretion of the Secretary), to
an area within a contiguous State. We
implemented this process through
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notices published in the Federal
Register on January 6, 2004 (69 FR 661),
and February 13, 2004 (69 FR 7340).
Such reclassifications were applicable
to discharges occurring during the 3year period beginning April 1, 2004, and
ending March 31, 2007. Section 106(a)
of the Medicare Improvements and
Extension Act, Division B of the Tax
Relief and Health Care Act of 2006
(MIEA–TRHCA) extended any
geographic reclassifications of hospitals
that were made under section 508 and
that would expire on March 31, 2007.
On March 23, 2007, we published a
notice in the Federal Register (72 FR
13799) that indicated how we were
implementing section 106(a) of the
MIEA–TRHCA through September 30,
2007. Section 117 of the MMSEA further
extended section 508 reclassifications
and certain special exceptions through
September 30, 2008. On February 22,
2008, we published a notice in the
Federal Register (73 FR 9807) regarding
our implementation of section 117 of
the MMSEA.
Section 124 of Pub. L. 110–275 has
now extended the hospital
reclassification provisions of section
508 and certain special exceptions
through September 30, 2009 (FY 2009).
Because of the timing of the enactment
of Pub. L. 110–275, we were not able to
recompute the FY 2009 wage index
values for any hospital reclassified
under section 508 and special exception
hospitals in time for inclusion in the FY
2009 IPPS final rule. Instead, we stated
that we would issue the final FY 2009
wage index values and other related
tables, as specified in the Addendum to
the FY 2009 IPPS final rule, in a
separate Federal Register notice
published subsequent to the final rule.
We stated that we would analyze the
data of hospitals in labor market areas
affected by the MIPPA extension,
including hospitals with Lugar
redesignations, and make best efforts to
give those hospitals a wage index value
that we believe results in the highest FY
2009 wage index for which they are
eligible.
This final notice reflects the
reclassification withdrawal and
termination decisions we have made on
behalf of certain hospitals based on
what we perceive would be most
advantageous to the hospital and would
give the hospital the highest wage index
among its available options. (We note
one exception where a hospital notified
us prior to the publication of this notice
to request that we maintain its rural
reclassification, although the hospital’s
section 508 reclassification would have
resulted in a higher wage index.) Please
note that in some cases we may have
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terminated a hospital’s Lugar
reclassification under section
1886(d)(8)(B) of the Act in order to
receive the out-migration adjustment.
As explained in the FY 2009 final IPPS
rule, the intervening MIPAA legislation
affects only those areas including
hospitals whose reclassifications/special
exceptions are extended, or areas to
which such hospitals were reclassified
for FY 2009. Therefore, we are not
choosing wage index values for
hospitals reclassified to or located in
areas containing no hospitals whose
reclassifications or special exceptions
were extended by section 124 of Pub. L.
110–275.
We have also created special
procedural rules, effective August 19,
2008 the date of publication of the FY
2009 IPPS final rule, allowing hospitals
15 days from the Federal Register date
of publication of this separate notice to
notify us if they wish to revise the
decision that CMS makes on their
behalf. Members of a group
reclassification must ensure that all
members of the group (except hospitals
whose reclassifications or special
exceptions were extended by section
124 of Pub. L. 110–275) have signed the
revision request. Written requests to
revise CMS’s wage index decision (as
reflected in this notice) must be
received at the following address by no
later than 5 p.m., eastern daylight time
(e.d.t.) October 20, 2008: Division of
Acute Care, Mailstop C4–08–06, 7500
Security Boulevard, Baltimore, MD
21244, Attn: Brian Slater.
If we do not receive notice from the
hospital within such 15-day timeframe,
the determination we have made on
behalf of the hospital in this separate
notice is deemed final for FY 2009, and
it is as if the hospital made the
determination itself, on its own behalf.
(Note: In the case of the hospital
mentioned above that made the
determination itself to maintain its rural
reclassification rather than to receive
the higher section 508 reclassification
for which it was eligible, the hospital’s
rural reclassification is deemed final for
FY 2009. The hospital is ineligible to
now request a reversal of the decision
that it made on its own behalf.)
Hospitals that seek to revise the CMS
decision made on their behalf in this
notice may revert back only to the wage
index originally accepted for FY 2009
(using the ordinary 45-day process after
publication of the proposed rule). In
cases where CMS has terminated or
withdrawn a reclassification on a
hospital’s behalf in order to award the
hospital the wage index associated with
a section 508 reclassification, a special
exception, or the hospital’s home area
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for FY 2009, and the hospital does not
reverse or modify CMS’s decision
within the 15-day timeframe, we will
deem the hospital’s reclassification is
withdrawn or terminated for FY 2009
only, as section 508 reclassifications
and special exceptions are only
extended through FY 2009. Such
hospitals, if there is at least one
remaining year in their 3-year
reclassification, will automatically have
the Medicare Geographic Classification
Review Board (MGCRB) reclassification
they originally accepted for FY 2009
(within the ordinary 45-day time frame)
reinstated for FY 2010. To restate,
automatic reinstatement will occur only
in the following situation: (1) A hospital
accepted a particular reclassification for
FY 2009 following the ordinary process
(that is, the 45-day rule); and (2) CMS
withdraws or terminates such
reclassification in order for the hospital
to receive a 508 wage index, a special
exception wage index, or the wage
index of the hospital’s home area. The
hospital will be reinstated for the
remaining years of only the
reclassification originally accepted.
For example, if, in this notice, we
assign a hospital a section 508
reclassification wage index for FY 2009
and the hospital has accepted an
MGCRB reclassification for FY 2008
through 2010, the hospital’s previous,
FY 2008 through 2010 reclassification
will be automatically reinstated for the
remaining year, FY 2010. By the same
token, if the omission of a section 508
or special exception hospital from the
calculation of the reclassification wage
index in Table 4C results in the
reclassification wage index decreasing
to the point that a hospital should have
terminated the FY 2008 through 2010
MGCRB reclassification it accepted for
FY 2009 , we may terminate the
reclassification on the hospital’s behalf
in order to receive the home wage
index; however, such reclassification
will then be automatically reinstated for
FY 2010.
As stated in the FY 2009 IPPS final
rule, in the case of overlapping
reclassifications, these special
procedural rules will not change our
policy that hospitals are not permitted
to hold one MGCRB reclassification in
reserve while another is in effect. Thus,
in the case of a hospital with a choice
of two possible MGCRB 3-year
reclassifications for FY 2009, if CMS
chooses one reclassification on the
hospital’s behalf (and this decision is
not reversed within the 15-day
timeframe), then any other
reclassifications are permanently
terminated. Because CMS is acting on
behalf of the hospital, it is as if the
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hospital made the decision to accept the
reclassification listed in this notice, and
the hospital is then prohibited under 42
CFR 412.273(b)(2)(ii) from reinstating
any previous reclassifications. Likewise,
if a hospital had a choice of two
possible reclassifications, and we assign
the hospital a 508 or special exception
wage index in this notice (and the
decision is not reversed within the 15day timeframe), then only the
reclassification previously accepted by
the hospital (using the ordinary 45-day
rule) is reinstated—any other
reclassification is permanently
terminated.
As stated in the FY 2009 IPPS final
rule, we will not further recalculate the
wage indices, budget neutrality factors,
or standardized amounts now that CMS
has made decisions regarding what is
most advantageous to each hospital.
That is, we will not further recalculate
the wage indices (including any rural
floors or imputed rural floors) or
standardized amounts based on hospital
decisions that further revise decisions
made by CMS on the hospitals’ behalf.
When applying section 508, we
required each hospital to submit a
request in writing by February 15, 2004,
to the Medicare Geographic
Classification Review Board (MGCRB),
with a copy to CMS. We will neither
require nor accept written requests for
the extension required by MIPPA, since
that legislation simply provides a 1 year
continuation for any section 508
reclassifications and special exceptions
wage index set to expire September 30,
2008.
2. Special Considerations for Special
Exception Wage Indexes
As stated earlier, section 124(b) of
MIPPA extended certain special
exceptions through the end of FY 2009.
MIPPA achieved these extensions
through an amendment to the MMSEA.
As amended, section 117(a)(2) of the
MMSEA now reads as follows:
SPECIAL EXCEPTION
RECLASSIFICATIONS.—The Secretary of
Health and Human Services shall extend for
discharges occurring through the last date of
the extension of reclassifications under
section 106(a) of the Medicare Improvement
and Extension Act of 2006 (division B of
Public Law 109–432), the special exception
reclassifications made under the authority of
section 1886(d)(5)(I)(i) of the Social Security
Act (42 U.S.C. 1395ww(d)(5)(I)(i)) and
contained in the final rule promulgated by
the Secretary in the Federal Register on
August 11, 2004 (69 Fed. Reg. 49105, 49107).
Although MIPPA amended section
117(a)(2) of the MMSEA to extend the
specific special exceptions referenced
above, MIPPA failed to amend section
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117(a)(3) of the MMSEA. That provision
states: ‘‘For purposes of implementation
of this subsection, the Secretary shall
use the hospital wage index that was
promulgated by the Secretary in the
Federal Register on October 10, 2007
(72 FR 57634), and any subsequent
corrections.’’ We believe that the only
possible interpretation of this provision
is that hospitals whose special
exceptions are extended under MIPPA
section 124(b) are to receive the special
exception wage index assigned to them
for FY 2008; not a wage index based
upon FY 2009 data. The MMSEA
mandates that the wage index for a
hospital receiving a special exception
must be the wage index promulgated in
the October 10, 2007 Federal Register
and any subsequent corrections thereto.
The FY 2009 wage indices cannot be
viewed as corrections to the FY 2008
data, as these FY 2009 indices represent
a new fiscal year cycle of ratesetting—
and are not corrections of FY 2008 rates.
For these reasons, if a hospital is
assigned a special exception wage index
in this notice under section 117(a)(2) of
the MMSEA (as amended by Pub. L.
110–275), its wage index will reflect FY
2008 wage index data. (We note that
these special considerations do not
affect the rule discussed above allowing
a hospital to retain its reclassification or
home wage index if such wage index
exceeds the special exception wage
index, it is only in cases where a
hospital receives its special exception
wage index under section 117(a)(2) of
the MMSEA that such wage index will
be based upon FY 2008 data.)
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C. Final FY 2009 Prospective Payment
Systems Payment Rates for Hospital
Operating and Capital Related Costs
As discussed in the FY 2009 IPPS
final rule (73 FR 48759), wage data
affect the calculation of the outlier
threshold as well as the outlier offset
and budget neutrality factors that are
applied to the standardized amounts.
Thus, because we were not able to
calculate final wage rates as a result of
the intervening legislation contained in
section 124 of Pub. L. 110–275, we were
only able to provide tentative figures in
the FY 2009 IPPS final rule. We stated
that such tentative amounts would be
revised once we finalized wage index
figures as a result of implementing
section 124 of Pub. L. 110–275, and that
a subsequent Federal Register
document would list the final
standardized amounts, outlier offsets,
and budget neutrality factors effective
October 1, 2008, for FY 2009.
Additionally, the final rates, wage
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indices, budget neutrality factors and
tables also reflect a correction made to
the wage data for one New Hampshire
hospital as discussed in the correction
notice for the FY 2009 IPPS final rule
published elsewhere within this Federal
Register. This notice announces the
final FY 2009 prospective payment rates
for Medicare hospital inpatient
operating costs and Medicare hospital
inpatient capital-related costs. We
calculated these final rates using the
methodology adopted in the FY 2009
IPPS final rule.
We note that, because hospitals
excluded from the IPPS are paid on a
cost basis (and not under the IPPS),
these hospitals were not affected by the
tentative figures for standardized
amounts, offsets, and budget neutrality
factors. Therefore, the rate-of-increase
percentages for updating the target
amounts for hospitals excluded from the
IPPS that are effective October 1, 2008
were finalized in the FY 2009 IPPS final
rule (73 FR 48776) and are not included
in this notice.
1. Final FY 2009 Prospective Payment
Rates for Hospital Inpatient Operating
Costs
a. Final Budget Neutrality Adjustments
Factors for Recalibration of DRG
Weights and Updated Wage Index,
Reclassified Hospitals and Rural
Community Hospital Demonstration
Program Adjustment
Using the methodology adopted in the
FY 2009 IPPS final rule, for FY 2009 we
are establishing the following final
budget neutrality factors (which are
applied to the standardized amounts): a
final FY 2009 DRG recalibration and
wage index budget neutrality factor of
0.999553 ( we note that the DRG
recalibration and wage index budget
neutrality factor changed from the final
rule to this notice as a result of the
change in the wage data to one New
Hampshire hospital as discussed in the
correction notice for the FY 2009 IPPS
final rule published elsewhere within
this Federal Register); a final
reclassified hospital budget neutrality
factor of 0.992088 and a final rural
community hospital demonstration
program adjustment factor of 0.999764.
b. Rural and Imputed Floor Budget
Neutrality
As explained and finalized in the
final rule, for FY 2009, hospitals will
receive a blended wage index that is
comprised of 20 percent of the wage
index adjusted by applying the State
level rural and imputed floor budget
neutrality adjustment and 80 percent of
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the wage index adjusted by applying the
national rural and imputed floor budget
neutrality adjustment. This adjustment
is applied to the wage index and not to
the standardized amount.
Using the methodology established in
the FY 2009 IPPS final rule (73 FR
48762), we are establishing the
following final rural and imputed floor
budget neutrality factors: a national
rural and imputed floor budget
neutrality adjustment factor of 0.996272;
an additional adjustment factor of
0.999785 to ensure that the blended
wage indices remain budget neutral (as
explained in the FY 2009 IPPS final rule
(73 FR 48762)). The final State-level
rural and imputed floor budget
neutrality adjustment factors are in table
4D–1 of this notice.
c. Final FY 2009 Standardized Amount
We calculated the final FY 2009
standardized amounts using the
methodology we adopted in the FY 2009
IPPS final rule. For a complete
description of this methodology, please
see the FY 2009 IPPS final rule (73 FR
48759 through 48768). Tables 1A and
1B in the Addendum to this notice
contain the final national standardized
amount that we are applying to all
hospitals, except hospitals in Puerto
Rico. The final Puerto Rico-specific
amounts are shown in Table 1C. The
final amounts shown in Tables 1A and
1B differ only in that the labor-related
share applied to the final standardized
amounts in Table 1A is 69.7 percent,
and the labor-related share applied to
the final standardized amounts in Table
1B is 62 percent. (The labor-related
share is 62 percent for all hospitals
(other than those in Puerto Rico) whose
wage indices are less than or equal to
1.0000.)
In addition, Tables 1A and 1B include
final standardized amounts reflecting
the full 3.6 percent update for FY 2009,
and final standardized amounts
reflecting the 2.0 percentage point
reduction to the update (a 1.6 percent
update) applicable for hospitals that fail
to submit quality data consistent with
section 1886(b)(3)(B)(viii) of the Act.
In the FY 2009 IPPS final rule, we did
not supply a table that illustrated the
changes from the FY 2008 national
average standardized amount because at
that time we were only setting the
standardized amounts tentatively, but
we stated that we would provide the
table in the subsequent Federal Register
notice. Therefore, in this notice, we
include below a table that details the
calculation of the final FY 2009
standardized amounts.
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d. Final Adjustments for Area Wage
Levels
The final occupational mix adjusted
wage indices by geographic area are
listed in Tables 4A, 4B, 4C, and 4F in
the Addendum to this notice. (These
tables are also available on the CMS
Web site.)
e. FY 2009 Final Outlier Adjustment
Factors and Fixed-loss Cost Threshold
Using the methodology we adopted in
the FY 2009 IPPS final rule, we are
establishing a final outlier fixed-loss
cost threshold for FY 2009 equal to the
prospective payment rate for the DRG,
plus any IME and DSH payments, and
any add-on payments for new
technology, plus $20,045.
The final outlier adjustment factors
that are applied to the standardized
amount for the FY 2009 outlier
threshold are as follows:
Operating
standardized
amounts
National ....................................................................................................................................................................
Puerto Rico ..............................................................................................................................................................
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2. Final FY 2009 Prospective Payment
Rates for Acute Care Hospital Inpatient
Capital-Related Costs
We have calculated the final FY 2009
capital Federal rates, offsets, and budget
neutrality factors using the same
methodology we adopted in the FY 2009
IPPS final rule (CMS–1390–F) that was
used to calculate the tentative rates
included in that rule. (We note that for
the remainder of the section we will use
the term ‘‘FY 2009 IPPS final rule’’
when referring to CMS–1390–F, which
was published in the Federal Register
on August 19, 2008.) For a complete
description of this methodology, please
see the FY 2009 IPPS final rule (73 FR
48769 through 48773).
a. Inpatient Hospital Capital-Related
Prospective Payment Rate Update
The factors used in the update
framework are not affected by the
extension of the expiration date for
certain geographic reclassifications and
special exception wage indices as
required by section 124 of the MIPPA,
Pub. L. 110–275. Therefore, the update
factor for FY 2009 was not revised from
the capital IPPS standard Federal rate
update factor discussed in section
III.A.1. of the FY 2009 IPPS final rule
and remains at 0.9 percent for FY 2009.
A full discussion of the update
framework is provided in that final rule
(73 FR 48769 through 48711).
b. Outlier Payment Adjustment Factor
Based on the final thresholds as set
forth in section IIC.1.e. of this notice, we
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0.948996
0.954304
Capital federal
rate
0.946458
0.931050
estimate that outlier payments for
capital-related costs will equal 5.35
percent for inpatient capital-related
payments based on the final Federal rate
in FY 2009. Our estimate of outlier
payments for capital-related for FY 2009
remains unchanged from our estimate
discussed in section III.A.2. of the FY
2009 IPPS final rule (73 FR 48771).
Therefore, in determining the final FY
2009 capital Federal rate in this notice,
we will apply a final outlier adjustment
factor of 0.9465 for FY 2009.
As discussed in the FY 2009 IPPS
final rule, we estimate that the
percentage of capital outlier payments
to total capital standard payments for
FY 2009 will be higher than the
percentages for FY 2008. The final
outlier thresholds for FY 2009 are in
section IIC.1.e. of this notice. For FY
2009, a case qualifies as a cost outlier if
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The final labor-related and nonlaborrelated portions of the national average
standardized amounts for Puerto Rico
hospitals for FY 2009 are set forth in
Table 1C in the Addendum to this
notice. (The labor-related share applied
to the Puerto Rico-specific standardized
amount is either 58.7 percent or 62
percent, depending on which is more
advantageous to the hospital.)
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the cost for the case plus the IME and
DSH payments are greater than the
prospective payment rate for the MS–
DRG plus $20,045.
c. Budget Neutrality Adjustment Factor
for Changes in MS–DRG Classifications
and Weights and the GAFs
Using the methodology discussed in
section III.A.3. of the FY 2009 IPPS final
rule (73 FR 48771 through 48773), for
FY 2009, we are establishing a final
GAF/DRG budget neutrality factor of
1.0015, which is the product of the
incremental GAF budget neutrality
factor of 1.0021 and the DRG budget
neutrality of 0.9995 (calculations were
done with unrounded numbers). The
GAF/DRG budget neutrality factors are
built permanently into the capital rates;
that is, they are applied cumulatively in
determining the capital Federal rate.
This follows from the requirement that
estimated aggregate payments each year
be no more or less than they would have
been in the absence of the annual DRG
reclassification and recalibration and
changes in the GAFs. The final
cumulative change in the capital
Federal rate due to this adjustment is
0.9917 (the product of the incremental
factors for FYs 1993 though 2008 and
the final incremental factor of 1.0015 for
FY 2009). (We note that averages of the
incremental factors that were in effect
during FYs 2005 and 2006, respectively,
were used in the calculation of the final
cumulative adjustment for FY 2009.)
This factor accounts for MS–DRG
reclassifications and recalibration and
for changes in the GAFs, which include
the revisions to wage index that result
from the extension of the expiration
date for certain geographic
reclassifications and special exception
wage indices as required by section 124
of the MIPPA, Pub. L. 110–275
(discussed in section II.B. of this notice).
It also incorporates the effects on the
final GAFs of FY 2009 geographic
reclassification decisions made by the
MGCRB compared to FY 2008 decisions.
However, it does not account for
changes in payments due to changes in
the DSH and IME adjustment factors.
d. Exceptions Payment Adjustment
Factor
The adjustments made to the wage
index as a result of the extension of the
expiration date for certain geographic
reclassifications and special exception
wage indices as required by section 124
of the MIPPA, Pub. L. 110–275 had no
effect on capital exceptions payments.
Therefore, the special exceptions
adjustment factor remains at 0.9999 as
discussed in section III.A.4. of FY 2009
IPPS final rule (73 FR 48773).
e. Capital Standard Federal Rate for FY
2009
We are providing a chart that shows
how each of the factors and adjustments
for FY 2009 affect the computation of
the final FY 2009 capital Federal rate in
comparison to the FY 2008 capital
Federal rate. The FY 2009 update factor
has the effect of increasing the final
capital Federal rate by 0.9 percent
compared to the FY 2008 capital Federal
rate. The final GAF/DRG budget
neutrality factor has the effect of
increasing the final capital Federal rate
by 0.15 percent. The final FY 2009
outlier adjustment factor has the effect
of decreasing the final capital Federal
rate by 0.61 percent compared to the FY
2008 outlier adjustment factor. The FY
2009 exceptions payment adjustment
factor has the effect of increasing the
final capital Federal rate by 0.02 percent
compared to the FY 2008 exceptions
payment adjustment factor. As
discussed in the FY 2009 IPPS final rule
(73 FR 48773 through 48774), the
adjustment for improvements in
documentation and coding under the
MS–DRGs, which was unaffected by the
extension of the expiration date for
certain geographic reclassifications and
special exception wage indices as
required by section 124 of the MIPPA,
Pub. L. 110–275, has the effect of
decreasing the FY 2009 capital Federal
rate by 0.9 percent as compared to the
FY 2008 capital Federal rate. The
combined effect of all the changes is to
decrease the capital Federal rate by 0.46
percent compared to the average FY
2008 capital Federal rate.
COMPARISON OF FACTORS AND ADJUSTMENTS—FY 2008 CAPITAL FEDERAL RATE AND FY 2009 CAPITAL FEDERAL RATE
FY 2008
Update Factor 1 ................................................................................................................
GAF/DRG Adjustment Factor 1 ........................................................................................
Outlier Adjustment Factor 2 ..............................................................................................
Exceptions Adjustment Factor 2 .......................................................................................
MS–DRG Coding and Documentation Improvements Adjustment Factor 3 ....................
Capital Federal Rate ........................................................................................................
1.0090
0.9996
0.9523
0.9997
0.9940
$426.14
FY 2009
1.0090
1.0015
0.9465
0.9999
0.9910
$424.17
Change
1.0090
1.0015
0.9939
1.0002
0.9910
0.9954
Percent
change 4
0.90
0.15
¥0.61
0.02
¥0.90
¥0.46
1 The update factor and the GAF/DRG budget neutrality factors are built permanently into the capital rates. Thus, for example, the incremental
change from FY 2008 to FY 2009 resulting from the application of the 1.0015 GAF/DRG budget neutrality factor for FY 2009 is 1.0015.
2 The outlier reduction factor and the exceptions adjustment factor are not built permanently into the capital rates; that is, these factors are not
applied cumulatively in determining the capital rates. Thus, for example, the net change resulting from the application of the FY 2009 outlier adjustment factor is 0.9465/0.9523, or 0.9939.
3 Adjustment to FY 2009 IPPS rates to account for documentation and coding improvements expected to result from the adoption of the MS–
DRGs, as discussed above in section III.D. of the Addendum to the FY 2009 IPPS final rule.
4 Percent change of individual factors may not sum due to rounding.
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We provided a chart in the FY 2009
IPPS final rule that compared the
tentative FY 2009 capital Federal rate to
the proposed FY 2009 capital Federal
rate (see 73 FR 48775). We are now
providing a chart that shows how the
final FY 2009 capital Federal rate differs
from the proposed FY 2009 capital
Federal rate presented in the FY 2009
IPPS proposed rule (73 FR 23721).
COMPARISON OF FACTORS AND ADJUSTMENTS—PROPOSED FY 2009 CAPITAL FEDERAL RATE AND FINAL FY 2009
CAPITAL FEDERAL RATE
Proposed
FY 2008
Update Factor ..................................................................................................................
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Final FY
2009
1.0090
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1.0020
Percent
change
0.20
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COMPARISON OF FACTORS AND ADJUSTMENTS—PROPOSED FY 2009 CAPITAL FEDERAL RATE AND FINAL FY 2009
CAPITAL FEDERAL RATE—Continued
Proposed
FY 2008
GAF/DRG Adjustment Factor ..........................................................................................
Outlier Adjustment Factor ................................................................................................
Exceptions Adjustment Factor .........................................................................................
MS–DRG Coding and Documentation Improvements Adjustment Factor ......................
Capital Federal Rate ........................................................................................................
1.0007
0.9427
0.9998
0.9910
$421.29
Final FY
2009
* 1.0015
0.9465
0.9999
0.9910
* $424.17
Change
Percent
change
1.0008
1.0040
1.0001
0.0000
1.0068
0.08
0.40
0.01
0.00
0.68
* Final factor/rate for FY 2009, as discussed in section IIC.2. of this notice, which were revised from the tentative factors published in the FY
2009 IPPS final rule.
As a final comparison, we are
providing a chart that shows how the
final FY 2009 capital Federal rate differs
from the tentative FY 2009 capital
Federal rate as presented in the FY 2009
IPPS final rule.
COMPARISON OF FACTORS AND ADJUSTMENTS—TENTATIVE FY 2009 CAPITAL FEDERAL RATE AND FINAL FY 2009
CAPITAL FEDERAL RATE
FY 2009 1
Update Factor ..................................................................................................................
GAF/DRG Adjustment Factor ..........................................................................................
Outlier Adjustment Factor ................................................................................................
Exceptions Adjustment Factor .........................................................................................
MS–DRG Coding and Documentation Improvements Adjustment Factor ......................
Capital Federal Rate ........................................................................................................
1.0090
1.0010
0.9465
0.9999
0.9910
$423.96
FY 2009 2
1.0090
1.0015
0.9465
0.9999
0.9910
$424.17
Change
0.0000
1.0005
0.0000
0.0000
0.0000
1.0005
Percent
change
0.00
0.05
0.00
0.00
0.00
0.05
1 As published in the FY 2009 IPPS final rule without the implementation of the extension of the expiration date for certain geographic reclassifications and special exception wage indices as required by section 124 of the MIPPA, Pub. L. 110–275.
2 Final capital factors and rates after implementation of the extension of the expiration date for certain geographic reclassifications and special
exception wage indices as required by section 124 of the MIPPA, Pub. L. 110–275.
f. Special Capital Rate for Puerto Rico
Hospitals
Using the methodology discussed in
the FY 2009 IPPS final rule (73 FR
48775), the final FY 2009 special capital
rate for Puerto Rico is $198.77. (See the
FY 2009 IPPS final rule (73 FR 48775)
for additional information on the
calculation of FY 2009 capital PPS
payments.)
III. Collection of Information
Requirements
This document does not impose
information collection and
recordkeeping requirements.
Consequently, it need not be reviewed
by the Office of Management and
Budget under the authority of the
Paperwork Reduction Act of 1995 (44
U.S.C. Chapter 35).
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IV. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this
notice as required by Executive Order
12866 on Regulatory Planning and
Review (September 30, 1993, as further
amended), the Regulatory Flexibility
Act (RFA) (September 19, 1980, Pub. L.
96–354), section 1102(b) of the Social
Security Act, section 202 of the
Unfunded Mandates Reform Act of 1995
(Pub. L. 104–4), Executive Order 13132
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on Federalism (August 4, 1999), and the
Congressional Review Act (5 U.S.C.
804(2)).
Executive Order 12866 (as amended
by Executive Order 13258) directs
agencies to assess all costs and benefits
of available regulatory alternatives and,
if regulation is necessary, to select
regulatory approaches that maximize
net benefits (including potential
economic, environmental, public health
and safety effects, distributive impacts,
and equity). A regulatory impact
analysis (RIA) must be prepared for
major rules with economically
significant effects ($100 million or more
in any 1 year). We have determined that
this rulemaking is ‘‘economically
significant’’ as measured by the $100
million threshold, and hence also a
major rule under the Congressional
Review Act. Accordingly, we have
prepared a Regulatory Impact Analysis,
that to the best of our ability, presents
the costs and benefits of the rulemaking.
The RFA requires agencies to analyze
options for regulatory relief of small
businesses, if a rule has a significant
impact on a substantial number of small
entities. For purposes of the RFA, small
entities include small businesses,
nonprofit organizations, and small
government jurisdictions. We estimate
that most hospitals and most other
providers and suppliers are small
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entities as that term is used in the RFA.
The great majority of hospitals and most
other health care providers and
suppliers are small entities, either by
being nonprofit organizations or by
meeting the SBA definition of a small
business (having revenues of less than
$31.5 million in any 1 year). (For details
on the latest standard for health care
providers, we refer readers to page 33 of
the Table of Small Business Size
Standards at the Small Business
Administration’s Web site at https://
www.sba.gov/services/
contractingopportunities/
sizestandardstopics/tableofsize/
index.html. For purposes of the RFA, all
hospitals and other providers and
suppliers are considered to be small
entities. Individuals and States are not
included in the definition of a small
entity. We believe that this notice will
have a significant impact on small
entities. Because we acknowledge that
many of the affected entities are small
entities, the analysis discussed in this
section constitutes our final regulatory
flexibility analysis.
In addition, section 1102(b) of the Act
requires us to prepare a regulatory
impact analysis if a rule may have a
significant impact on the operations of
a substantial number of small rural
hospitals. This analysis must conform to
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the provisions of section 604 of the
RFA. With the exception of hospitals
located in certain New England
counties, for purposes of section 1102(b)
of the Act, we now define a small rural
hospital as a hospital that is located
outside of an urban area and has fewer
than 100 beds. Section 601(g) of the
Social Security Amendments of 1983
(Pub. L. 98–21) designated hospitals in
certain New England counties as
belonging to the adjacent urban area.
Thus, for purposes of the IPPS, we
continue to classify these hospitals as
urban hospitals.
Section 202 of the Unfunded
Mandates Reform Act of 1995 (Pub. L.
104–4) also requires that agencies assess
anticipated costs and benefits before
issuing any rule whose mandates
require spending in any 1 year of $100
million in 1995 dollars, updated
annually for inflation. That threshold
level is currently approximately $130
million. This notice will not mandate
any requirements for State, local, or
tribal governments, nor will it affect
private sector costs.
Executive Order 13132 establishes
certain requirements that an agency
must meet when it promulgates a
proposed rule (and subsequent final
rule) that imposes substantial direct
requirement costs on State and local
governments, preempts State law, or
otherwise has Federalism implications.
This notice will not have a substantial
effect on State and local governments.
The following analysis, in
conjunction with the remainder of this
document, demonstrates that this notice
is consistent with the regulatory
philosophy and principles identified in
Executive Order 12866, the RFA, and
section 1102(b) of the Act. The notice
will affect payments to a substantial
number of small rural hospitals, as well
as other classes of hospitals, and the
effects on some hospitals may be
significant.
The impact analysis for the policy
changes under the IPPS for operating
costs was included in the FY 2009 IPPS
final rule. As stated in the impact
analysis of the FY 2009 IPPS final rule
(73 FR 49064), we were unable to
provide final wage indices because we
were unable to account for the recently
enacted legislation (that is, section 124
of Pub. L. 110–275), that extended
certain special exceptions and
reinstated the provisions of section 508
of Public Law 108–173 relating to the
wage index reclassifications of hospitals
for an additional year, through FY 2009.
Therefore, at the time of the FY 2009
IPPS final rule, we were also unable to
finalize budget neutrality calculations,
the outlier threshold and outlier offsets
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to the standardized amounts because
these figures were all dependent on the
final wage indices. However, we
indicated that we would recalculate the
impacts and provide in a subsequent
Federal Register notice prior to October
1, 2008. Now that we have recalculated
the new wage indices to reflect the
extension for reclassification for section
508 of MMA and special exception
providers, we are providing final
impacts for FY 2009. Because the
extension of section 508 is a nonbudget
neutral provision, overall estimates for
hospitals have changed from our
estimate that was published in the FY
2009 IPPS final rule (73 FR 49064). We
estimate that the changes in the FY 2009
IPPS final rule, in conjunction with the
final IPPS rates and wage index
included in this notice, will result in an
approximate $5.0 billion increase in
operating payments.
B. Final FY 2009 Impacts on IPPS
Operating Costs
1. Analysis of Table I
Table I displays the results of our
analysis of the payment changes for FY
2009 after implementing section 124 of
Public Law 110–275, which extended
section 508 of MMA and special
exception reclassifications through FY
2009. These impacts update the
tentative ones that were published in
the FY 2009 IPPS final rule. As
explained in the FY 2009 final rule and
in this notice, we were unable to
implement the section 124 of Public
Law 110–275 that extended
reclassifications for section 508 of MMA
and special exception providers, so we
were unable to finalize the wage index,
standardized amounts, outlier threshold
and budget neutrality factors. In this
notice, we can now finalize the wage
index, standardized amounts, outlier
thresholds and budget neutrality factors,
and we are only displaying the impact
columns that were affected by the
Section 508 and special exception
reclassifications. Therefore, we are not
reprinting the impacts of the DRG
relative weights, the wage data, the DRG
and wage index changes that were
published in the FY 2009 IPPS final rule
because those columns are based on prereclassification wage data that is not
affected by the Section 508 and special
exception reclassifications. (See the FY
2009 IPPS final rule (73 FR 49065
through 49072) for a full discussion of
the FY 2009 regulatory impact analysis.)
In addition, we are adding a column to
display the impact of the
implementation of section 508 of MMA
and special exceptions.
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Table I displays the results of our
analysis of the changes for FY 2009. The
table categorizes hospitals by various
geographic and special payment
consideration groups to illustrate the
varying impacts on different types of
hospitals. The top row of the table
shows the overall impact on the 3,538
hospitals included in the analysis.
The next four rows of Table I contain
hospitals categorized according to their
geographic location: All urban, which is
further divided into large urban and
other urban; and rural. There are 2,553
hospitals located in urban areas
included in our analysis. Among these,
there are 1,408 hospitals located in large
urban areas (populations over 1
million), and 1,145 hospitals in other
urban areas (populations of 1 million or
fewer). In addition, there are 985
hospitals in rural areas. The next two
groupings are by bed-size categories,
shown separately for urban and rural
hospitals. The final groupings by
geographic location are by census
divisions, also shown separately for
urban and rural hospitals.
The second part of Table I shows
hospital groups based on hospitals’ FY
2009 payment classifications, including
any reclassifications under section
1886(d)(10) of the Act. For example, the
rows labeled urban, large urban, other
urban, and rural show that the numbers
of hospitals paid based on these
categorizations after consideration of
geographic reclassifications (including
reclassifications under section
1886(d)(8)(B) and section 1886(d)(8)(E)
of the Act that have implications for
capital payments) are 2,594, 1,430,
1,164 and 944, respectively.
The next three groupings examine the
impacts of the changes on hospitals
grouped by whether or not they have
GME residency programs (teaching
hospitals that receive an IME
adjustment) or receive DSH payments,
or some combination of these two
adjustments. There are 2,495
nonteaching hospitals in our analysis,
808 teaching hospitals with fewer than
100 residents, and 235 teaching
hospitals with 100 or more residents.
In the DSH categories, hospitals are
grouped according to their DSH
payment status, and whether they are
considered urban or rural for DSH
purposes. The next category groups
together hospitals considered urban
after geographic reclassification, in
terms of whether they receive the IME
adjustment, the DSH adjustment, both,
or neither.
The next five rows examine the
impacts of the changes on rural
hospitals by special payment groups
(SCHs, RRCs, and MDHs). There were
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days. These data were taken from the FY
2005 Medicare cost reports.
The next two groupings concern the
geographic reclassification status of
hospitals. The first grouping displays all
urban hospitals that were reclassified by
the MGCRB for FY 2009. The second
grouping shows the MGCRB rural
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reclassifications. In addition, the last
grouping reflects the 114 hospitals
currently reclassified as Section 508 and
special exception hospitals.
The final category shows the impact
of the policy changes on the 20 cardiac
specialty hospitals in our analysis.
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196 RRCs, 356 SCHs, 157 MDHs, 104
hospitals that are both SCHs and RRCs,
and 12 hospitals that are both an MDH
and an RRC.
The next series of groupings are based
on the type of ownership and the
hospital’s Medicare utilization
expressed as a percent of total patient
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a. Effects of MGCRB Reclassifications
(Column 1)
The changes in Column 1 reflect the
per case payment impact of moving
from this baseline to a simulation
incorporating the MGCRB decisions for
FY 2009 which affect hospitals’ wage
index area assignments. For information
on the payment impacts prior to
geographic reclassification, please see
the FY 2009 IPPS Final Rule (73 FR
49069 through 49070).
By Spring of each year, the MGCRB
makes reclassification determinations
that will be effective for the next fiscal
year, which begins on October 1. The
MGCRB may approve a hospital’s
reclassification request for the purpose
of using another area’s wage index
value. Hospitals may appeal denials of
MGCRB decisions to the CMS
Administrator. Further, hospitals have
45 days from publication of the IPPS
rule in the Federal Register to decide
whether to withdraw or terminate an
approved geographic reclassification for
the following year. This column reflects
all MGCRB decisions, Administrator
appeals and decisions of hospitals for
FY 2009 geographic reclassifications.
Because section 124 of Pub. L. 110–
275 extended certain special exceptions
and section 508 reclassifications
through FY 2009, we analyzed the data
of hospitals in labor market areas
affected by legislation, including
hospitals with Lugar redesignations, and
make best efforts to give those hospitals
a wage index value that we believe
results in the highest FY 2009 wage
index for which they are eligible.
Hospitals will have 15 days from the
date of Federal Register publication of
this separate notice to notify us if they
wish to revise the decision that we
made on their behalf.
The impacts shown in Column 1 of
Table 1 reflect our reclassification
decisions on behalf of hospitals, which
reflect the area that would give the
hospital the highest wage index. The
overall effect of geographic
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reclassification is required by section
1886(d)(8)(D) of the Act to be budget
neutral. The geographic budget
neutrality factor reflects the effect of the
geographic reclassifications based on
our reclassification decisions. Therefore,
for the purposes of this impact analysis,
we are applying an adjustment of
0.992088 to ensure that the effects of the
section 1886(d)(10) reclassifications are
budget neutral. Geographic
reclassification generally benefits
hospitals in rural areas. We estimate
that geographic reclassification will
increase payments to rural hospitals by
an average of 2.2 percent.
b. Effects of the Rural Floor and
Imputed Floor, Including the Transition
To Apply Budget Neutrality at the State
Level (Column 2)
As discussed in the FY 2009 IPPS
final rule (73 FR 49070), we are
applying the rural floor and imputed
floor budget neutrality at the State level
through a 3-year transition. In FY 2009,
hospitals will receive a blended wage
index that is 20 percent of a wage index
with the State level rural and imputed
floor budget neutrality adjustment and
80 percent of a wage index with the
national budget neutrality adjustment.
At the time of publication of the FY
2009 IPPS final rule, we could only
apply tentative rural floor budget
neutrality factors because we were
unable to finalize the wage index to
account for the section 124 of Pub. L.
110–275 that extended that the
reclassification for section 508 and
special exception hospitals. The
finalized national rural floor budget
neutrality applied to the wage index is
0.996272. The within-State rural floor
budget neutrality factors applied to the
wage index is available in Table 4D of
the Addendum to this notice. After the
wage index is blended, an additional
adjustment of 0.999785 is applied to the
wage index to ensure that payments
before the application of the rural floor
are equivalent to the payments under
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the blended budget neutral rural floor
wage index.
The column compares the postreclassification FY 2009 wage index of
providers before the rural floor
adjustment and the post-reclassification
FY 2009 wage index of providers with
the rural floor and imputed floor
adjustment with the transitional rural
floor budget neutrality factor applied.
We project that, in aggregate, rural
hospitals will experience a 0.2 percent
decrease in payments as a result of the
application of the rural floor including
the transition to within-State rural floor
budget neutrality. We project hospitals
located in other urban areas
(populations of 1 million or fewer) will
experience a 0.1 percent increase in
payments because only providers can
benefit from the rural floor. Rural New
England hospitals can expect the
greatest decrease in payment, 0.3
percent, because under the blended
rural floor budget neutrality adjustment,
hospitals in New Hampshire will
receive a rural floor budget neutrality
adjustment of 0.99236 or a reduction of
0.8 percent, and hospitals in
Connecticut will receive a rural floor
budget neutrality adjustment of 0.99000
or a reduction of 1 percent. New Jersey,
which is the only State that benefits
from the imputed floor, is expected to
receive a rural floor budget neutrality
adjustment of 0.99455, or a reduction of
less than 1 percent.
c. Effects of the Application of Section
508 Reclassification (Column 3)
This column displays the impact of
extending the reclassification for
Section 508 and special exception
providers through FY 2009. Because this
provision is not budget neutral,
hospitals, overall, will experience a 0.2
percent increase in payments. All the
hospital categories, depending on
whether Section 508 and special
exception providers are represented in
those categories, will either experience
an increase or no change in payments.
Providers in urban New England and
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East North Central can expect increases
in payments by 0.5 percent because
those regions have Section 508 and
special exception providers. Providers
in the urban Middle Atlantic region will
experience a 0.7 percent increase in
estimated payments because there are
several section 508 and special
exception providers located in New
Jersey.
d. Effects of the Wage Index Adjustment
for Out-Migration (Column 4)
Section 1886(d)(13) of the Act, as
added by section 505 of Pub. L. 108–
173, provides for an increase in the
wage index for hospitals located in
certain counties that have a relatively
high percentage of hospital employees
who reside in the county, but work in
a different area with a higher wage
index. Hospitals located in counties that
qualify for the payment adjustment are
to receive an increase in the wage index
that is equal to a weighted average of the
difference between the wage index of
the resident county, post-reclassification
and the higher wage index work area(s),
weighted by the overall percentage of
workers who are employed in an area
with a higher wage index. Section 508
providers and special exception
providers that may have qualified for
the out-migration adjustment in the FY
2009 IPPS final rule will now receive
their section 508 or special exception
reclassification wage index. With the
out-migration adjustment, rural
providers will experience a 0.1 percent
increase in payments in FY 2009
relative to no adjustment at all. We
included these additional payments to
providers in the impact table shown
above, and we estimate the impact of
these providers receiving the outmigration increase to be approximately
$31 million.
e. Effects of All Changes With CMI
Adjustment and Estimated Growth
(Column 5)
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Column 5 compares our estimate of
payments per case between FY 2008 and
FY 2009, incorporating all changes
reflected in this notice for FY 2009
(including statutory changes). This
column includes the FY 2009
documentation and coding adjustment
of ¥0.9 percent and the projected 1.8
percent increase in case-mix from
improved documentation and coding
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(with the 1.8 percent case-mix increase
assumed to occur equally across all
hospitals).
Column 5 reflects the impact of all FY
2009 changes relative to FY 2008. The
average increase for all hospitals is
approximately 5.0 percent. This
increase includes the effects of the 3.6
percent market basket update. It also
reflects the 0.4 percentage point
difference between the projected outlier
payments in FY 2008 (5.1 percent of
total DRG payments) and the current
estimate of the percentage of actual
outlier payments in FY 2008 (4.7
percent), as described in the FY 2009
IPPS final rule (73 FR 48766). As a
result, payments are projected to be 0.4
percentage points lower in FY 2008 than
originally estimated, resulting in a 0.4
percentage point greater increase for FY
2009 than would otherwise occur. This
analysis accounts for the impact of
section 124 of Pub. L. 110–275, which
extended certain special exceptions and
section 508 reclassifications for FY
2009. This nonbudget neutral provision,
that increases the wage index for 114
providers, results in an estimated
increase in payments by 0.2 percent.
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 5 may not equal the product
of the percentage changes described
above.
The overall change in payments per
case for hospitals in FY 2009 is
estimated to increase by 5.0 percent.
Hospitals in urban areas will experience
an estimated 5.1 percent increase in
payments per case compared to FY
2008. Hospitals in large urban areas will
experience an estimated 5.2 percent
increase and hospitals in other urban
areas will experience an estimated 4.9
percent increase in payments per case in
FY 2008. Hospital payments per case in
rural areas are estimated to increase 4.1
percent. The increases that are larger
than the national average for larger
urban areas and smaller than the
national average for other urban and
rural areas are largely attributed to the
differential impact of adopting MS–
DRGs.
Among urban census divisions, the
largest estimated payment increases will
be 6.5 percent in the Pacific region
(generally attributed to MS–DRGs, wage
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data and section 508 and special
exception reclassifications) and 5.5
percent in the Mountain region (mostly
due to MS–DRGs). The smallest urban
increase is estimated at 3.9 percent in
the Puerto Rico region.
Among the rural regions in Column 5,
the providers in the New England region
experience the smallest increase in
payments (3.5 percent) primarily due to
the transition to the within-State rural
floor budget neutrality adjustment. The
Pacific and South Atlantic regions will
have the highest increases among rural
regions, with 5.6 percent and 4.4
percent estimated increases,
respectively. Again, increases in rural
areas are generally less than the national
average due to the adoption of MS–
DRGs.
Among special categories of rural
hospitals in Column 9, the MDHs and
the RRCs will receive an estimated
increase in payments of 4.8 percent, and
the SCHs will experience an estimated
increase in payments by 3.7 percent.
Urban hospitals reclassified for FY
2009 are anticipated to receive an
increase of 5.2 percent, while urban
hospitals that are not reclassified for FY
2009 are expected to receive an increase
of 5.1 percent. Rural hospitals
reclassifying for FY 2009 are anticipated
to receive a 4.3 percent payment
increase and rural hospitals that are not
reclassifying are estimated to receive a
payment increase of 3.8 percent. Section
508 and special exception providers are
estimated to receive a payment increase
of 5.8 percent relative to last year.
2. Analysis of Table II
Table II presents the projected impact
of the changes for FY 2009 for urban
and rural hospitals and for the different
categories shown in Table I. It compares
the estimated payments per case for FY
2008 with the average estimated
payments per case for FY 2009, as
calculated under our models. Thus, the
table presents, in terms of 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 5 of
Table I.
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C. Final FY 2009 Capital-Related
Impacts (Including the Quantitative
Effects of the Extension of the
Expiration Date for Certain Geographic
Reclassifications and Special Exception
Wage Indices as Required by Section
124 of the MIPPA, Pub. L. 110–275)
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1. General Considerations
In accordance with § 412.312, the
basic methodology for determining
capital IPPS payments in FY 2009 is as
follows: (Standard Federal Rate) x (DRG
weight) x (GAF) x (COLA for hospitals
located in Alaska and Hawaii) x (1 +
DSH Adjustment Factor + IME
Adjustment Factor, if applicable). In
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addition, hospitals may also receive
outlier payments for those cases that
qualify under the threshold established
for each fiscal year.
The data used in developing the
impact analysis presented below are
taken from the March 2008 update of
the FY 2007 MedPAR file and the March
2008 update of the Provider-Specific
File that is used for payment purposes.
Although the analyses of the changes to
the capital prospective payment system
do not incorporate cost data, we used
the March 2008 update of the most
recently available hospital cost report
data (FYs 2005 and 2006) to categorize
hospitals. Our analysis has several
qualifications. We use the best data
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available and make assumptions about
case-mix and beneficiary enrollment as
described below. In addition, as
discussed in section III.A.5. of the
Addendum to the FY 2009 IPPS final
rule (73 FR 48773 through 48774), we
adjusted the national capital rate to
account for improvements in
documentation and coding under the
MS–DRGs in FY 2009. (As discussed in
section III.A.6. of the Addendum to that
same final rule, we did not adjust the
Puerto Rico specific capital rate to
account for improvements in
documentation and coding under the
MS–DRGs in FY 2009.) Furthermore,
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due to the interdependent nature of the
IPPS, it is very difficult to precisely
quantify the impact associated with
each change. In addition, we draw upon
various sources for the data used to
categorize hospitals in the tables. In
some cases (for instance, the number of
beds), there is a fair degree of variation
in the data from different sources. We
have attempted to construct these
variables with the best available sources
overall. However, for individual
hospitals, some miscategorizations are
possible.
Using cases from the March 2008
update of the FY 2007 MedPAR file, we
simulated payments under the capital
PPS for FY 2008 and FY 2009 for a
comparison of total payments per case.
Any short-term, acute care hospitals not
paid under the general IPPS (Indian
Health Service hospitals and hospitals
in Maryland) are excluded from the
simulations.
We modeled payments for each
hospital by multiplying the capital
Federal rate by the GAF and the
hospital’s case-mix. We then added
estimated payments for indirect medical
education (which are reduced by 50
percent in FY 2009 in accordance with
§ 412.322(c)), disproportionate share,
and outliers, if applicable. For purposes
of this impact analysis, the model
included the same assumptions as the
capital IPPS impact analysis presented
in the FY 2009 IPPS final rule (73 FR
49079). The model included the
following assumptions:
• We estimate that the Medicare casemix index will increase by 1.0 percent
in both FYs 2008 and 2009. (We note
that this does not reflect the expected
growth in case-mix due to improvement
in documentation and coding under the
MS–DRGs, as discussed below.)
• We estimate that the Medicare
discharges will be approximately 13
million in both FY 2008 and FY 2009.
• The capital Federal rate was
updated beginning in FY 1996 by an
analytical framework that considers
changes in the prices associated with
capital-related costs and adjustments to
account for forecast error, changes in the
case-mix index, allowable changes in
intensity, and other factors. The FY
2009 update is 0.9 percent (see section
II.C.2.e of this notice).
• In addition to the FY 2009 update
factor, the FY 2009 capital Federal rate
was calculated based on a GAF/DRG
budget neutrality factor of 1.0015, an
outlier adjustment factor of 0.9465, and
an exceptions adjustment factor of
0.9999.
• The FY 2009 national capital rate
was further adjusted by a factor to
account for anticipated improvements
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in documentation and coding that are
expected to increase case-mix under the
MS–DRGs. In the FY 2008 IPPS final
rule with comment period (72 FR
47186), we established adjustments to
the IPPS rates based on the Office of the
Actuary projected case-mix growth
resulting from improved documentation
and coding of 1.2 percent for FY 2008,
1.8 percent for FY 2009, and 1.8 percent
for FY 2010. However, we reduced the
documentation and coding adjustment
to ¥0.6 percent for FY 2008, and for FY
2009, we are applying an adjustment of
negative 0.9 percent, consistent with
section 7 of Public Law 110–90. (As
noted above, we are not adjusting the
Puerto Rico-specific capital rate to
account for improvements in
documentation and coding under the
MS–DRGs in FY 2009.)
2. Results
We used the actuarial model
described above to estimate the
potential impact of our changes for FY
2009 on total capital payments per case,
using a universe of 3,538 hospitals. As
described above, the individual hospital
payment parameters are taken from the
best available data, including the March
2008 update of the FY 2007 MedPAR
file, the March 2008 update to the PSF,
and the most recent cost report data
from the March 2008 update of HCRIS.
In Table III, we present a comparison of
estimated total payments per case for FY
2008 compared to FY 2009 based on the
FY 2009 payment policies. Column 2
shows estimates of payments per case
under our model for FY 2008. Column
3 shows estimates of payments per case
under our model for FY 2009. Column
4 shows the total percentage change in
payments from FY 2008 to FY 2009. The
change represented in Column 4
includes the 0.9 percent update to the
capital Federal rate, other changes in the
adjustments to the capital Federal rate
(for example, the 50 percent reduction
to the teaching adjustment for FY 2009),
and the additional 0.9 percent reduction
to the national capital rate to account for
improvements in documentation and
coding (or other changes in coding that
do not reflect real changes in case-mix)
for implementation of the MS–DRGs).
Consistent with the impact analysis for
the policy changes under the IPPS for
operating costs in section IV.B. of this
notice, for purposes of this impact
analysis, we also assume a 1.8 percent
increase in case-mix growth for FY
2009, as determined by the Office of the
Actuary, because we believe the
adoption of the MS–DRGs will result in
case-mix growth due to documentation
and coding changes that do not reflect
real changes in patient severity of
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illness. The comparisons are provided
by: (1) Geographic location; (2) region;
and (3) payment classification.
The simulation results show that, on
average, capital payments per case in FY
2009 are expected to increase as
compared to capital payments per case
in FY 2008. The capital rate for FY 2009
will decrease 0.46 percent as compared
to the FY 2008 capital rate, and the
changes to the GAFs are expected to
result in a slight decrease (0.1 percent)
in capital payments. In addition, the 50
percent reduction to the teaching
adjustment in FY 2009 will also result
in a decrease in capital payments from
FY 2008 as compared to FY 2009.
Countering these factors is the projected
case-mix growth as a result of improved
documentation and coding (discussed
above) as well as an estimated increase
in outlier payments in FY 2008 as
compared to FY 2009. The net result of
these changes is an estimated 0.7
percent change in capital payments per
discharge from FY 2008 to FY 2009 for
all hospitals (as shown below in Table
III).
The results of our comparisons by
geographic location and by region are
consistent with the results we expected
with the decrease to the teaching
adjustment in FY 2009 (§ 412.522(c)).
The geographic comparison shows that,
on average, all urban hospitals are
expected to experience a 0.6 percent
increase in capital IPPS payments per
case in FY 2009 as compared to FY
2008, while hospitals in large urban
areas are expected to experience a 0.3
percent increase in capital IPPS
payments per case in FY 2009 as
compared to FY 2008. Capital IPPS
payments per case for rural hospitals are
expected to increase 1.4 percent. These
differences in payments per case by
geographic location are mostly due to
the decrease in the teaching adjustment
as discussed in the FY 2009 IPPS final
rule (73 FR 49079). The capital impact
is largely consistent with the impacts in
the FY 2009 IPPS final rule (73 FR
49080 through 49081). However the
capital GAF is somewhat affected by the
wage index changes resulting from the
extension of the expiration date for
certain geographic reclassifications and
special exception wage indices as
required by section 124 of the MIPPA,
Pub. L. 110–275. Any changes from the
impact presented in the FY 2009 IPPS
final rule are mostly due to the revised
GAFs, which are based on the revised
wage indices.
Most regions are estimated to
experience an increase in total capital
payments per case from FY 2008 to FY
2009. These increases vary by region
and range from a 3.5 percent increase in
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the Pacific urban region to a 0.6 percent
increase in the West North Central
urban region. Two urban regions are
projected to experience a relatively
larger decrease in capital payments,
with the difference mostly due to
changes in the GAFs and the 50 percent
reduction in the teaching adjustment for
FY 2009: ¥1.8 percent in the Middle
Atlantic urban region and ¥2.2 percent
in the New England urban region. The
East North Central urban region is also
expected to experience a decrease of 0.2
percent in capital payments in FY 2009
as compared to FY 2008, mostly due to
changes in the GAFs. There are also two
rural regions that are also expected to
experience a decrease in total capital
payments per case: A 2.8 percent
decrease in the New England rural
region and a 0.4 percent decrease in the
Middle Atlantic rural region. Again, for
these two rural regions, the projected
decrease in capital payments is mostly
due to changes in the GAF, as well as
a smaller than average expected increase
in payments due to the adoption of the
MS–DRGs.
By type of ownership, voluntary and
proprietary hospitals are estimated to
experience an increase of 0.5 percent
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and 2.2 percent, respectively. The
projected increase in capital payments
per case for proprietary hospitals is
mostly because these hospitals are
expected to experience a smaller than
average decrease in their payments due
to the 50 percent teaching adjustment
reduction for FY 2009. Government
hospitals are estimated to experience a
decrease in capital payments per case of
0.2 percent. This estimated decrease in
capital payments is mostly due to a
larger than average decrease in
payments resulting from the 50 percent
teaching adjustment reduction for FY
2009.
Section 1886(d)(10) of the Act
established the MGCRB. Before FY
2005, hospitals could apply to the
MGCRB for reclassification for purposes
of the standardized amount, wage index,
or both. Section 401(c) of Public Law
108–173 equalized the standardized
amounts under the operating IPPS.
Therefore, beginning in FY 2005, there
is no longer reclassification for the
purposes of the standardized amounts;
however, hospitals still may apply for
reclassification for purposes of the wage
index for FY 2009. Reclassification for
wage index purposes also affects the
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GAFs because that factor is constructed
from the hospital wage index.
To present the effects of the hospitals
being reclassified for FY 2009, we show
the average capital payments per case
for reclassified hospitals for FY 2008.
All classifications of reclassified
hospitals are expected to experience an
increase in payments in FY 2009 as
compared to FY 2008. Urban
nonreclassified hospitals are expected to
have the smallest increase in capital
payments of 0.5 percent, while rural
reclassified hospitals are expected to
have the largest increase in capital
payments of 1.7 percent. Other
reclassified hospitals (that is, hospitals
reclassified under section 1886(d)(8)(B)
of the Act) are expected to experience a
1.4 percent increase in capital payment
from FY 2008 to FY 2009. The large
than average increase in projected
changes in capital payments for rural
reclassified and other reclassified
hospitals is mainly due to a smaller than
average change in payments from FY
2009 as compared to FY 2008 resulting
from the 50 percent reduction in the
teaching adjustment in FY 2009.
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D. Overall Conclusion
The changes we are making in this
notice will affect all classes of hospitals.
Some hospitals are expected to
experience significant gains and others
less significant gains, but overall
hospitals are projected to experience
positive updates in IPPS payments in
FY 2009. Table I of this section
demonstrates the statutorily mandated
extension of reclassification to section
508 and special exception providers
through FY 2009, and all other policies
reflected in the FY 2009 IPPS final rule.
Table I also shows an overall increase of
5.0 percent in operating payments or an
estimated increase of $4.97 billion. This
estimate includes the projected savings
associated with the hospital acquired
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conditions (HACs) policy ($21 million),
the hospital reporting of quality data
program costs ($2.39 million), the
estimated new technology payments
($9.54 million), and all operating
payment policies as described in section
II of this notice. Capital payments are
estimated to increase by 0.7 percent per
case, as shown in Table III of this notice.
Therefore, we project that the increase
in capital payments in FY 2009
compared to FY 2008 will be
approximately $60 million. The
operating and capital payments should
result in a net increase of $5.03 billion
to IPPS providers. The discussions
presented in the previous pages, in
combination with the rest of this notice,
constitute a regulatory impact analysis.
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E. Accounting Statement
As required by OMB Circular A–4
(available at https://
www.whitehouse.gov/omb/circulars/
a004/a-4.pdf), in Table IV below, we
have prepared an accounting statement
showing the classification of the
expenditures associated with the
provisions of this notice. This table
provides our best estimate of the
increase in Medicare payments to
providers as a result of the changes to
the IPPS presented in this notice. All
expenditures are classified as transfers
to Medicare providers.
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TABLE IV—ACCOUNTING STATEMENT:
CLASSIFICATION OF ESTIMATED EXPENDITURES FROM FY 2008 TO FY
2009
Category
Transfers
Annualized
Monetized
Transfers.
From Whom to
Whom.
$5.030 Billion.
Total ........
$5.030 Billion.
Federal Government to IPPS
Medicare Providers.
F. Executive Order 12866
In accordance with the provisions of
Executive Order 12866, the Office of
Management and Budget reviewed this
notice.
Authority: (Catalog of Federal Domestic
Assistance Program No. 93.773, Medicare—
Hospital Insurance; and Program No. 93.774,
Medicare—Supplementary Medical
Insurance Program).
Dated: September 11, 2008.
Kerry Weems,
Acting Administrator, Centers for Medicare
& Medicaid Services.
Approved: September 19, 2008.
Michael O. Leavitt,
Secretary.
Addendum
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This addendum includes tables
referred to throughout the notice which
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contain data relating to the final FY
2009 wage indices and the hospital
reclassifications and payment amounts
for operating and capital-related costs
discussed in section II. of this notice.
Table 1A—National Adjusted
Operating Standardized Amounts,
Labor/Nonlabor (69.7 Percent Labor
Share/30.3 Percent Nonlabor Share If
Wage Index Is Greater Than 1).
Table 1B—National Adjusted
Operating Standardized Amounts,
Labor/Nonlabor (62 Percent Labor
Share/38 Percent Nonlabor Share If
Wage Index Is Less Than or Equal To 1).
Table 1C—Adjusted Operating
Standardized Amounts for Puerto Rico,
Labor/Nonlabor.
Table 1D—Capital Standard Federal
Payment Rate.
Table 2—Hospital Case-Mix Indexes
for Discharges Occurring in Federal
Fiscal Year 2007; Hospital Wage Indexes
for Federal Fiscal Year 2009; Hospital
Average Hourly Wage for Federal Fiscal
Years 2007 (2003 Wage Data), 2008
(2004 Wage Data), and 2009 (2005 Wage
Data); Wage Indexes and 3-Year Average
of Hospital Average Hourly Wages.
Table 4A—Wage Index and Capital
Geographic Adjustment Factor (GAF) for
Urban Areas by CBSA—FY 2009.
Table 4B—Wage Index and Capital
Geographic Adjustment Factor (GAF) for
Rural Areas by CBSA—FY 2009.
Table 4C—Wage Index and Capital
Geographic Adjustment Factor (GAF) for
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Hospitals That Are Reclassified by
CBSA—FY 2009.
Table 4D–1—State Specific Rural
Floor Budget Neutrality Factors—FY
2009.
Table 4D–2—Urban Areas with
Hospitals Receiving the Statewide Rural
Floor or Imputed Wage Index—FY 2009.
Table 4E—Urban CBSAs and
Constituent Counties—FY 2009.
Table 4F—Puerto Rico Wage Index
and Capital Geographic Adjustment
Factor (GAF) by CBSA—FY 2009.
Table 4J—Out-Migration
Adjustment—FY 2009.
Table 9A—Hospital Reclassifications
and Redesignations by Individual
Hospitals and CBSA for FY 2009.
Table 9B—Hospital Reclassifications
and Redesignations by Individual
Hospital Under Section 508 of Pub. L.
108–173 for FY 2009.
Table 9C—Hospitals Redesignated as
Rural under Section 1886(d)(8)(E) of the
Act for FY 2009.
Table 10—Geometric Mean Plus the
Lesser of 0.75 of the National Adjusted
Operating Standardized Payment
Amount (Increased to Reflect the
Difference Between Costs and Charges)
or 0.75 of One Standard Deviation of
Mean Charges by Diagnosis-Related
Group (DRG)—September 2008.
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[FR Doc. E8–23083 Filed 9–29–08; 11:15 am]
BILLING CODE 4120–01–C
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]]>Agencies
[Federal Register Volume 73, Number 193 (Friday, October 3, 2008)]
[Notices]
[Pages 57888-58017]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E8-23083]
[[Page 57887]]
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Part V
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
Medicare Program; Hospital Inpatient Prospective Payment Systems and
Fiscal Year 2009 Rates: Final Fiscal Year 2009 Wage Indices and Payment
Rates Including Implementation of Section 124 of the Medicare
Improvement for Patients and Providers Act of 2008; Notice
Federal Register / Vol. 73, No. 193 / Friday, October 3, 2008 /
Notices
[[Page 57888]]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-1390-N]
RIN 0938-AP15
Medicare Program; Hospital Inpatient Prospective Payment Systems
and Fiscal Year 2009 Rates: Final Fiscal Year 2009 Wage Indices and
Payment Rates Including Implementation of Section 124 of the Medicare
Improvement for Patients and Providers Act of 2008
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: This notice contains tables listing the final wage indices,
hospital reclassifications, payment rates, impacts, and other related
tables effective for fiscal year (FY) 2009. The tables and impacts
included in this notice reflect the extension of the expiration date
for certain geographic reclassifications and special exception wage
indices as required by section 124 of the Medicare Improvement for
Patients and Providers Act of 2008 (MIPPA), Public Law 110-275. These
geographic reclassifications and special exception wage indices were
previously set to expire on September 30, 2008 and are now extended
through September 30, 2009. (Additionally, the final rates, wage
indices, budget neutrality factors and tables included in this notice
also reflect a correction made to the wage data for one hospital, as
discussed in the correction notice for the FY 2009 IPPS final rule
published elsewhere within this Federal Register.)
DATES: Effective Date: This notice is effective on October 1, 2008.
FOR FURTHER INFORMATION CONTACT: Tzvi Hefter, (410) 786-4487.
SUPPLEMENTARY INFORMATION:
I. Background
In the August 19, 2008 Federal Register (73 FR 48434) (hereinafter
referred to as the FY 2009 IPPS final rule), we set forth our final
rule for the Medicare inpatient prospective payment system (IPPS). Due
to the July 15, 2008 enactment of the Medicare Improvement for Patients
and Providers Act of 2008 (MIPPA) (Pub. L. 110-275), we stated in the
final rule that we would publish the FY 2009 wage index tables, rates,
and impacts reflecting the implementation of this legislation in a
Federal Register document subsequent to the FY 2009 IPPS final rule.
(See the FY 2009 IPPS final rule, 73 FR 48588 and 48589, for a full
explanation of the reasons for such subsequent publication.) This
notice includes such wage index tables, rates, and impacts.
(Additionally, the final rates, wage indices, budget neutrality factors
and tables included in this notice also reflect a correction made to
the wage data for one hospital, as discussed in the correction notice
for the FY 2009 IPPS final rule published elsewhere within this Federal
Register.)
II. Final FY 2009 Wage Indices and Rates
A. Final FY 2009 Wage Indices
The final wage index values for FY 2009 (except those for hospitals
receiving wage index adjustments under section 505 of Pub. L. 108-173)
are included in Tables 4A, 4B, 4C, and 4F of the Addendum to this
notice and are posted on our Web site at https://www.cms.hhs.gov/
AcuteInpatientPPS/. For hospitals that are receiving a wage index
adjustment under section 505 of Pub. L. 108-173, the hospital's final
wage index will reflect the adjustment shown in Table 4J of the
Addendum to this notice. In addition, Table 2 of the Addendum to this
notice includes the final wage index value and occupational mix
adjusted average hourly wage (from the FYs 2003, 2004, and 2005 cost
reporting periods) for each hospital. Table 4D-1 of the Addendum of
this notice lists the State rural floor budget neutrality factors for
FY 2009.
B. Final FY 2009 Hospital Wage Index Reclassifications/Redesignations
1. Section 508 Extension
On July 15, 2008, the Medicare Improvements for Patients and
Providers Act of 2008, Pub. L. 110-275 was enacted. Section 124 of Pub.
L. 110-275 extends through FY 2009 wage index reclassifications under
section 508 of the Medicare Prescription Drug Improvement and
Modernization Act of 2003 (MMA) (Pub. L. 108-173) and certain special
exceptions (for example, those special exceptions contained in the
final rule promulgated in the Federal Register on August 11, 2004 (69
FR 49105 and 49107) and extended under section 117 of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (MMSEA) (Pub. L. 110-173)).
Under section 508 of Pub. L. 108-173, a qualifying hospital could
appeal the wage index classification otherwise applicable to the
hospital and apply for reclassification to another area of the State in
which the hospital is located (or, at the discretion of the Secretary),
to an area within a contiguous State. We implemented this process
through notices published in the Federal Register on January 6, 2004
(69 FR 661), and February 13, 2004 (69 FR 7340). Such reclassifications
were applicable to discharges occurring during the 3-year period
beginning April 1, 2004, and ending March 31, 2007. Section 106(a) of
the Medicare Improvements and Extension Act, Division B of the Tax
Relief and Health Care Act of 2006 (MIEA-TRHCA) extended any geographic
reclassifications of hospitals that were made under section 508 and
that would expire on March 31, 2007. On March 23, 2007, we published a
notice in the Federal Register (72 FR 13799) that indicated how we were
implementing section 106(a) of the MIEA-TRHCA through September 30,
2007. Section 117 of the MMSEA further extended section 508
reclassifications and certain special exceptions through September 30,
2008. On February 22, 2008, we published a notice in the Federal
Register (73 FR 9807) regarding our implementation of section 117 of
the MMSEA.
Section 124 of Pub. L. 110-275 has now extended the hospital
reclassification provisions of section 508 and certain special
exceptions through September 30, 2009 (FY 2009). Because of the timing
of the enactment of Pub. L. 110-275, we were not able to recompute the
FY 2009 wage index values for any hospital reclassified under section
508 and special exception hospitals in time for inclusion in the FY
2009 IPPS final rule. Instead, we stated that we would issue the final
FY 2009 wage index values and other related tables, as specified in the
Addendum to the FY 2009 IPPS final rule, in a separate Federal Register
notice published subsequent to the final rule. We stated that we would
analyze the data of hospitals in labor market areas affected by the
MIPPA extension, including hospitals with Lugar redesignations, and
make best efforts to give those hospitals a wage index value that we
believe results in the highest FY 2009 wage index for which they are
eligible.
This final notice reflects the reclassification withdrawal and
termination decisions we have made on behalf of certain hospitals based
on what we perceive would be most advantageous to the hospital and
would give the hospital the highest wage index among its available
options. (We note one exception where a hospital notified us prior to
the publication of this notice to request that we maintain its rural
reclassification, although the hospital's section 508 reclassification
would have resulted in a higher wage index.) Please note that in some
cases we may have
[[Page 57889]]
terminated a hospital's Lugar reclassification under section
1886(d)(8)(B) of the Act in order to receive the out-migration
adjustment. As explained in the FY 2009 final IPPS rule, the
intervening MIPAA legislation affects only those areas including
hospitals whose reclassifications/special exceptions are extended, or
areas to which such hospitals were reclassified for FY 2009. Therefore,
we are not choosing wage index values for hospitals reclassified to or
located in areas containing no hospitals whose reclassifications or
special exceptions were extended by section 124 of Pub. L. 110-275.
We have also created special procedural rules, effective August 19,
2008 the date of publication of the FY 2009 IPPS final rule, allowing
hospitals 15 days from the Federal Register date of publication of this
separate notice to notify us if they wish to revise the decision that
CMS makes on their behalf. Members of a group reclassification must
ensure that all members of the group (except hospitals whose
reclassifications or special exceptions were extended by section 124 of
Pub. L. 110-275) have signed the revision request. Written requests to
revise CMS's wage index decision (as reflected in this notice) must be
received at the following address by no later than 5 p.m., eastern
daylight time (e.d.t.) October 20, 2008: Division of Acute Care,
Mailstop C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244, Attn:
Brian Slater.
If we do not receive notice from the hospital within such 15-day
timeframe, the determination we have made on behalf of the hospital in
this separate notice is deemed final for FY 2009, and it is as if the
hospital made the determination itself, on its own behalf. (Note: In
the case of the hospital mentioned above that made the determination
itself to maintain its rural reclassification rather than to receive
the higher section 508 reclassification for which it was eligible, the
hospital's rural reclassification is deemed final for FY 2009. The
hospital is ineligible to now request a reversal of the decision that
it made on its own behalf.)
Hospitals that seek to revise the CMS decision made on their behalf
in this notice may revert back only to the wage index originally
accepted for FY 2009 (using the ordinary 45-day process after
publication of the proposed rule). In cases where CMS has terminated or
withdrawn a reclassification on a hospital's behalf in order to award
the hospital the wage index associated with a section 508
reclassification, a special exception, or the hospital's home area for
FY 2009, and the hospital does not reverse or modify CMS's decision
within the 15-day timeframe, we will deem the hospital's
reclassification is withdrawn or terminated for FY 2009 only, as
section 508 reclassifications and special exceptions are only extended
through FY 2009. Such hospitals, if there is at least one remaining
year in their 3-year reclassification, will automatically have the
Medicare Geographic Classification Review Board (MGCRB)
reclassification they originally accepted for FY 2009 (within the
ordinary 45-day time frame) reinstated for FY 2010. To restate,
automatic reinstatement will occur only in the following situation: (1)
A hospital accepted a particular reclassification for FY 2009 following
the ordinary process (that is, the 45-day rule); and (2) CMS withdraws
or terminates such reclassification in order for the hospital to
receive a 508 wage index, a special exception wage index, or the wage
index of the hospital's home area. The hospital will be reinstated for
the remaining years of only the reclassification originally accepted.
For example, if, in this notice, we assign a hospital a section 508
reclassification wage index for FY 2009 and the hospital has accepted
an MGCRB reclassification for FY 2008 through 2010, the hospital's
previous, FY 2008 through 2010 reclassification will be automatically
reinstated for the remaining year, FY 2010. By the same token, if the
omission of a section 508 or special exception hospital from the
calculation of the reclassification wage index in Table 4C results in
the reclassification wage index decreasing to the point that a hospital
should have terminated the FY 2008 through 2010 MGCRB reclassification
it accepted for FY 2009 , we may terminate the reclassification on the
hospital's behalf in order to receive the home wage index; however,
such reclassification will then be automatically reinstated for FY
2010.
As stated in the FY 2009 IPPS final rule, in the case of
overlapping reclassifications, these special procedural rules will not
change our policy that hospitals are not permitted to hold one MGCRB
reclassification in reserve while another is in effect. Thus, in the
case of a hospital with a choice of two possible MGCRB 3-year
reclassifications for FY 2009, if CMS chooses one reclassification on
the hospital's behalf (and this decision is not reversed within the 15-
day timeframe), then any other reclassifications are permanently
terminated. Because CMS is acting on behalf of the hospital, it is as
if the hospital made the decision to accept the reclassification listed
in this notice, and the hospital is then prohibited under 42 CFR
412.273(b)(2)(ii) from reinstating any previous reclassifications.
Likewise, if a hospital had a choice of two possible reclassifications,
and we assign the hospital a 508 or special exception wage index in
this notice (and the decision is not reversed within the 15-day
timeframe), then only the reclassification previously accepted by the
hospital (using the ordinary 45-day rule) is reinstated--any other
reclassification is permanently terminated.
As stated in the FY 2009 IPPS final rule, we will not further
recalculate the wage indices, budget neutrality factors, or
standardized amounts now that CMS has made decisions regarding what is
most advantageous to each hospital. That is, we will not further
recalculate the wage indices (including any rural floors or imputed
rural floors) or standardized amounts based on hospital decisions that
further revise decisions made by CMS on the hospitals' behalf.
When applying section 508, we required each hospital to submit a
request in writing by February 15, 2004, to the Medicare Geographic
Classification Review Board (MGCRB), with a copy to CMS. We will
neither require nor accept written requests for the extension required
by MIPPA, since that legislation simply provides a 1 year continuation
for any section 508 reclassifications and special exceptions wage index
set to expire September 30, 2008.
2. Special Considerations for Special Exception Wage Indexes
As stated earlier, section 124(b) of MIPPA extended certain special
exceptions through the end of FY 2009. MIPPA achieved these extensions
through an amendment to the MMSEA. As amended, section 117(a)(2) of the
MMSEA now reads as follows:
SPECIAL EXCEPTION RECLASSIFICATIONS.--The Secretary of Health
and Human Services shall extend for discharges occurring through the
last date of the extension of reclassifications under section 106(a)
of the Medicare Improvement and Extension Act of 2006 (division B of
Public Law 109-432), the special exception reclassifications made
under the authority of section 1886(d)(5)(I)(i) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(I)(i)) and contained in the
final rule promulgated by the Secretary in the Federal Register on
August 11, 2004 (69 Fed. Reg. 49105, 49107).
Although MIPPA amended section 117(a)(2) of the MMSEA to extend the
specific special exceptions referenced above, MIPPA failed to amend
section
[[Page 57890]]
117(a)(3) of the MMSEA. That provision states: ``For purposes of
implementation of this subsection, the Secretary shall use the hospital
wage index that was promulgated by the Secretary in the Federal
Register on October 10, 2007 (72 FR 57634), and any subsequent
corrections.'' We believe that the only possible interpretation of this
provision is that hospitals whose special exceptions are extended under
MIPPA section 124(b) are to receive the special exception wage index
assigned to them for FY 2008; not a wage index based upon FY 2009 data.
The MMSEA mandates that the wage index for a hospital receiving a
special exception must be the wage index promulgated in the October 10,
2007 Federal Register and any subsequent corrections thereto. The FY
2009 wage indices cannot be viewed as corrections to the FY 2008 data,
as these FY 2009 indices represent a new fiscal year cycle of
ratesetting--and are not corrections of FY 2008 rates. For these
reasons, if a hospital is assigned a special exception wage index in
this notice under section 117(a)(2) of the MMSEA (as amended by Pub. L.
110-275), its wage index will reflect FY 2008 wage index data. (We note
that these special considerations do not affect the rule discussed
above allowing a hospital to retain its reclassification or home wage
index if such wage index exceeds the special exception wage index, it
is only in cases where a hospital receives its special exception wage
index under section 117(a)(2) of the MMSEA that such wage index will be
based upon FY 2008 data.)
C. Final FY 2009 Prospective Payment Systems Payment Rates for Hospital
Operating and Capital Related Costs
As discussed in the FY 2009 IPPS final rule (73 FR 48759), wage
data affect the calculation of the outlier threshold as well as the
outlier offset and budget neutrality factors that are applied to the
standardized amounts. Thus, because we were not able to calculate final
wage rates as a result of the intervening legislation contained in
section 124 of Pub. L. 110-275, we were only able to provide tentative
figures in the FY 2009 IPPS final rule. We stated that such tentative
amounts would be revised once we finalized wage index figures as a
result of implementing section 124 of Pub. L. 110-275, and that a
subsequent Federal Register document would list the final standardized
amounts, outlier offsets, and budget neutrality factors effective
October 1, 2008, for FY 2009. Additionally, the final rates, wage
indices, budget neutrality factors and tables also reflect a correction
made to the wage data for one New Hampshire hospital as discussed in
the correction notice for the FY 2009 IPPS final rule published
elsewhere within this Federal Register. This notice announces the final
FY 2009 prospective payment rates for Medicare hospital inpatient
operating costs and Medicare hospital inpatient capital-related costs.
We calculated these final rates using the methodology adopted in the FY
2009 IPPS final rule.
We note that, because hospitals excluded from the IPPS are paid on
a cost basis (and not under the IPPS), these hospitals were not
affected by the tentative figures for standardized amounts, offsets,
and budget neutrality factors. Therefore, the rate-of-increase
percentages for updating the target amounts for hospitals excluded from
the IPPS that are effective October 1, 2008 were finalized in the FY
2009 IPPS final rule (73 FR 48776) and are not included in this notice.
1. Final FY 2009 Prospective Payment Rates for Hospital Inpatient
Operating Costs
a. Final Budget Neutrality Adjustments Factors for Recalibration of DRG
Weights and Updated Wage Index, Reclassified Hospitals and Rural
Community Hospital Demonstration Program Adjustment
Using the methodology adopted in the FY 2009 IPPS final rule, for
FY 2009 we are establishing the following final budget neutrality
factors (which are applied to the standardized amounts): a final FY
2009 DRG recalibration and wage index budget neutrality factor of
0.999553 ( we note that the DRG recalibration and wage index budget
neutrality factor changed from the final rule to this notice as a
result of the change in the wage data to one New Hampshire hospital as
discussed in the correction notice for the FY 2009 IPPS final rule
published elsewhere within this Federal Register); a final reclassified
hospital budget neutrality factor of 0.992088 and a final rural
community hospital demonstration program adjustment factor of 0.999764.
b. Rural and Imputed Floor Budget Neutrality
As explained and finalized in the final rule, for FY 2009,
hospitals will receive a blended wage index that is comprised of 20
percent of the wage index adjusted by applying the State level rural
and imputed floor budget neutrality adjustment and 80 percent of the
wage index adjusted by applying the national rural and imputed floor
budget neutrality adjustment. This adjustment is applied to the wage
index and not to the standardized amount.
Using the methodology established in the FY 2009 IPPS final rule
(73 FR 48762), we are establishing the following final rural and
imputed floor budget neutrality factors: a national rural and imputed
floor budget neutrality adjustment factor of 0.996272; an additional
adjustment factor of 0.999785 to ensure that the blended wage indices
remain budget neutral (as explained in the FY 2009 IPPS final rule (73
FR 48762)). The final State-level rural and imputed floor budget
neutrality adjustment factors are in table 4D-1 of this notice.
c. Final FY 2009 Standardized Amount
We calculated the final FY 2009 standardized amounts using the
methodology we adopted in the FY 2009 IPPS final rule. For a complete
description of this methodology, please see the FY 2009 IPPS final rule
(73 FR 48759 through 48768). Tables 1A and 1B in the Addendum to this
notice contain the final national standardized amount that we are
applying to all hospitals, except hospitals in Puerto Rico. The final
Puerto Rico-specific amounts are shown in Table 1C. The final amounts
shown in Tables 1A and 1B differ only in that the labor-related share
applied to the final standardized amounts in Table 1A is 69.7 percent,
and the labor-related share applied to the final standardized amounts
in Table 1B is 62 percent. (The labor-related share is 62 percent for
all hospitals (other than those in Puerto Rico) whose wage indices are
less than or equal to 1.0000.)
In addition, Tables 1A and 1B include final standardized amounts
reflecting the full 3.6 percent update for FY 2009, and final
standardized amounts reflecting the 2.0 percentage point reduction to
the update (a 1.6 percent update) applicable for hospitals that fail to
submit quality data consistent with section 1886(b)(3)(B)(viii) of the
Act.
In the FY 2009 IPPS final rule, we did not supply a table that
illustrated the changes from the FY 2008 national average standardized
amount because at that time we were only setting the standardized
amounts tentatively, but we stated that we would provide the table in
the subsequent Federal Register notice. Therefore, in this notice, we
include below a table that details the calculation of the final FY 2009
standardized amounts.
[[Page 57891]]
[GRAPHIC] [TIFF OMITTED] TN03OC08.000
The final labor-related and nonlabor-related portions of the
national average standardized amounts for Puerto Rico hospitals for FY
2009 are set forth in Table 1C in the Addendum to this notice. (The
labor-related share applied to the Puerto Rico-specific standardized
amount is either 58.7 percent or 62 percent, depending on which is more
advantageous to the hospital.)
d. Final Adjustments for Area Wage Levels
The final occupational mix adjusted wage indices by geographic area
are listed in Tables 4A, 4B, 4C, and 4F in the Addendum to this notice.
(These tables are also available on the CMS Web site.)
e. FY 2009 Final Outlier Adjustment Factors and Fixed-loss Cost
Threshold
Using the methodology we adopted in the FY 2009 IPPS final rule, we
are establishing a final outlier fixed-loss cost threshold for FY 2009
equal to the prospective payment rate for the DRG, plus any IME and DSH
payments, and any add-on payments for new technology, plus $20,045.
The final outlier adjustment factors that are applied to the
standardized amount for the FY 2009 outlier threshold are as follows:
------------------------------------------------------------------------
Operating
standardized Capital
amounts federal rate
------------------------------------------------------------------------
National................................ 0.948996 0.946458
Puerto Rico............................. 0.954304 0.931050
------------------------------------------------------------------------
2. Final FY 2009 Prospective Payment Rates for Acute Care Hospital
Inpatient Capital-Related Costs
We have calculated the final FY 2009 capital Federal rates,
offsets, and budget neutrality factors using the same methodology we
adopted in the FY 2009 IPPS final rule (CMS-1390-F) that was used to
calculate the tentative rates included in that rule. (We note that for
the remainder of the section we will use the term ``FY 2009 IPPS final
rule'' when referring to CMS-1390-F, which was published in the Federal
Register on August 19, 2008.) For a complete description of this
methodology, please see the FY 2009 IPPS final rule (73 FR 48769
through 48773).
a. Inpatient Hospital Capital-Related Prospective Payment Rate Update
The factors used in the update framework are not affected by the
extension of the expiration date for certain geographic
reclassifications and special exception wage indices as required by
section 124 of the MIPPA, Pub. L. 110-275. Therefore, the update factor
for FY 2009 was not revised from the capital IPPS standard Federal rate
update factor discussed in section III.A.1. of the FY 2009 IPPS final
rule and remains at 0.9 percent for FY 2009. A full discussion of the
update framework is provided in that final rule (73 FR 48769 through
48711).
b. Outlier Payment Adjustment Factor
Based on the final thresholds as set forth in section IIC.1.e. of
this notice, we estimate that outlier payments for capital-related
costs will equal 5.35 percent for inpatient capital-related payments
based on the final Federal rate in FY 2009. Our estimate of outlier
payments for capital-related for FY 2009 remains unchanged from our
estimate discussed in section III.A.2. of the FY 2009 IPPS final rule
(73 FR 48771). Therefore, in determining the final FY 2009 capital
Federal rate in this notice, we will apply a final outlier adjustment
factor of 0.9465 for FY 2009.
As discussed in the FY 2009 IPPS final rule, we estimate that the
percentage of capital outlier payments to total capital standard
payments for FY 2009 will be higher than the percentages for FY 2008.
The final outlier thresholds for FY 2009 are in section IIC.1.e. of
this notice. For FY 2009, a case qualifies as a cost outlier if
[[Page 57892]]
the cost for the case plus the IME and DSH payments are greater than
the prospective payment rate for the MS-DRG plus $20,045.
c. Budget Neutrality Adjustment Factor for Changes in MS-DRG
Classifications and Weights and the GAFs
Using the methodology discussed in section III.A.3. of the FY 2009
IPPS final rule (73 FR 48771 through 48773), for FY 2009, we are
establishing a final GAF/DRG budget neutrality factor of 1.0015, which
is the product of the incremental GAF budget neutrality factor of
1.0021 and the DRG budget neutrality of 0.9995 (calculations were done
with unrounded numbers). The GAF/DRG budget neutrality factors are
built permanently into the capital rates; that is, they are applied
cumulatively in determining the capital Federal rate. This follows from
the requirement that estimated aggregate payments each year be no more
or less than they would have been in the absence of the annual DRG
reclassification and recalibration and changes in the GAFs. The final
cumulative change in the capital Federal rate due to this adjustment is
0.9917 (the product of the incremental factors for FYs 1993 though 2008
and the final incremental factor of 1.0015 for FY 2009). (We note that
averages of the incremental factors that were in effect during FYs 2005
and 2006, respectively, were used in the calculation of the final
cumulative adjustment for FY 2009.)
This factor accounts for MS-DRG reclassifications and recalibration
and for changes in the GAFs, which include the revisions to wage index
that result from the extension of the expiration date for certain
geographic reclassifications and special exception wage indices as
required by section 124 of the MIPPA, Pub. L. 110-275 (discussed in
section II.B. of this notice). It also incorporates the effects on the
final GAFs of FY 2009 geographic reclassification decisions made by the
MGCRB compared to FY 2008 decisions. However, it does not account for
changes in payments due to changes in the DSH and IME adjustment
factors.
d. Exceptions Payment Adjustment Factor
The adjustments made to the wage index as a result of the extension
of the expiration date for certain geographic reclassifications and
special exception wage indices as required by section 124 of the MIPPA,
Pub. L. 110-275 had no effect on capital exceptions payments.
Therefore, the special exceptions adjustment factor remains at 0.9999
as discussed in section III.A.4. of FY 2009 IPPS final rule (73 FR
48773).
e. Capital Standard Federal Rate for FY 2009
We are providing a chart that shows how each of the factors and
adjustments for FY 2009 affect the computation of the final FY 2009
capital Federal rate in comparison to the FY 2008 capital Federal rate.
The FY 2009 update factor has the effect of increasing the final
capital Federal rate by 0.9 percent compared to the FY 2008 capital
Federal rate. The final GAF/DRG budget neutrality factor has the effect
of increasing the final capital Federal rate by 0.15 percent. The final
FY 2009 outlier adjustment factor has the effect of decreasing the
final capital Federal rate by 0.61 percent compared to the FY 2008
outlier adjustment factor. The FY 2009 exceptions payment adjustment
factor has the effect of increasing the final capital Federal rate by
0.02 percent compared to the FY 2008 exceptions payment adjustment
factor. As discussed in the FY 2009 IPPS final rule (73 FR 48773
through 48774), the adjustment for improvements in documentation and
coding under the MS-DRGs, which was unaffected by the extension of the
expiration date for certain geographic reclassifications and special
exception wage indices as required by section 124 of the MIPPA, Pub. L.
110-275, has the effect of decreasing the FY 2009 capital Federal rate
by 0.9 percent as compared to the FY 2008 capital Federal rate. The
combined effect of all the changes is to decrease the capital Federal
rate by 0.46 percent compared to the average FY 2008 capital Federal
rate.
Comparison of Factors and Adjustments--FY 2008 Capital Federal Rate and FY 2009 Capital Federal Rate
----------------------------------------------------------------------------------------------------------------
Percent
FY 2008 FY 2009 Change change \4\
----------------------------------------------------------------------------------------------------------------
Update Factor \1\........................................... 1.0090 1.0090 1.0090 0.90
GAF/DRG Adjustment Factor \1\............................... 0.9996 1.0015 1.0015 0.15
Outlier Adjustment Factor \2\............................... 0.9523 0.9465 0.9939 -0.61
Exceptions Adjustment Factor \2\............................ 0.9997 0.9999 1.0002 0.02
MS-DRG Coding and Documentation Improvements Adjustment 0.9940 0.9910 0.9910 -0.90
Factor \3\.................................................
Capital Federal Rate........................................ $426.14 $424.17 0.9954 -0.46
----------------------------------------------------------------------------------------------------------------
\1\ The update factor and the GAF/DRG budget neutrality factors are built permanently into the capital rates.
Thus, for example, the incremental change from FY 2008 to FY 2009 resulting from the application of the 1.0015
GAF/DRG budget neutrality factor for FY 2009 is 1.0015.
\2\ The outlier reduction factor and the exceptions adjustment factor are not built permanently into the capital
rates; that is, these factors are not applied cumulatively in determining the capital rates. Thus, for
example, the net change resulting from the application of the FY 2009 outlier adjustment factor is 0.9465/
0.9523, or 0.9939.
\3\ Adjustment to FY 2009 IPPS rates to account for documentation and coding improvements expected to result
from the adoption of the MS-DRGs, as discussed above in section III.D. of the Addendum to the FY 2009 IPPS
final rule.
\4\ Percent change of individual factors may not sum due to rounding.
We provided a chart in the FY 2009 IPPS final rule that compared
the tentative FY 2009 capital Federal rate to the proposed FY 2009
capital Federal rate (see 73 FR 48775). We are now providing a chart
that shows how the final FY 2009 capital Federal rate differs from the
proposed FY 2009 capital Federal rate presented in the FY 2009 IPPS
proposed rule (73 FR 23721).
Comparison of Factors and Adjustments--Proposed FY 2009 Capital Federal Rate and Final FY 2009 Capital Federal
Rate
----------------------------------------------------------------------------------------------------------------
Proposed FY Final FY Percent
2008 2009 Change change
----------------------------------------------------------------------------------------------------------------
Update Factor............................................... 1.0070 1.0090 1.0020 0.20
[[Page 57893]]
GAF/DRG Adjustment Factor................................... 1.0007 * 1.0015 1.0008 0.08
Outlier Adjustment Factor................................... 0.9427 0.9465 1.0040 0.40
Exceptions Adjustment Factor................................ 0.9998 0.9999 1.0001 0.01
MS-DRG Coding and Documentation Improvements Adjustment 0.9910 0.9910 0.0000 0.00
Factor.....................................................
Capital Federal Rate........................................ $421.29 * $424.17 1.0068 0.68
----------------------------------------------------------------------------------------------------------------
* Final factor/rate for FY 2009, as discussed in section IIC.2. of this notice, which were revised from the
tentative factors published in the FY 2009 IPPS final rule.
As a final comparison, we are providing a chart that shows how the
final FY 2009 capital Federal rate differs from the tentative FY 2009
capital Federal rate as presented in the FY 2009 IPPS final rule.
Comparison of Factors and Adjustments--Tentative FY 2009 Capital Federal Rate and Final FY 2009 Capital Federal
Rate
----------------------------------------------------------------------------------------------------------------
Percent
FY 2009 \1\ FY 2009 \2\ Change change
----------------------------------------------------------------------------------------------------------------
Update Factor............................................... 1.0090 1.0090 0.0000 0.00
GAF/DRG Adjustment Factor................................... 1.0010 1.0015 1.0005 0.05
Outlier Adjustment Factor................................... 0.9465 0.9465 0.0000 0.00
Exceptions Adjustment Factor................................ 0.9999 0.9999 0.0000 0.00
MS-DRG Coding and Documentation Improvements Adjustment 0.9910 0.9910 0.0000 0.00
Factor.....................................................
Capital Federal Rate........................................ $423.96 $424.17 1.0005 0.05
----------------------------------------------------------------------------------------------------------------
\1\ As published in the FY 2009 IPPS final rule without the implementation of the extension of the expiration
date for certain geographic reclassifications and special exception wage indices as required by section 124 of
the MIPPA, Pub. L. 110-275.
\2\ Final capital factors and rates after implementation of the extension of the expiration date for certain
geographic reclassifications and special exception wage indices as required by section 124 of the MIPPA, Pub.
L. 110-275.
f. Special Capital Rate for Puerto Rico Hospitals
Using the methodology discussed in the FY 2009 IPPS final rule (73
FR 48775), the final FY 2009 special capital rate for Puerto Rico is
$198.77. (See the FY 2009 IPPS final rule (73 FR 48775) for additional
information on the calculation of FY 2009 capital PPS payments.)
III. Collection of Information Requirements
This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35).
IV. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this notice as required by
Executive Order 12866 on Regulatory Planning and Review (September 30,
1993, as further amended), the Regulatory Flexibility Act (RFA)
(September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social
Security Act, section 202 of the Unfunded Mandates Reform Act of 1995
(Pub. L. 104-4), Executive Order 13132 on Federalism (August 4, 1999),
and the Congressional Review Act (5 U.S.C. 804(2)).
Executive Order 12866 (as amended by Executive Order 13258) directs
agencies to assess all costs and benefits of available regulatory
alternatives and, if regulation is necessary, to select regulatory
approaches that maximize net benefits (including potential economic,
environmental, public health and safety effects, distributive impacts,
and equity). A regulatory impact analysis (RIA) must be prepared for
major rules with economically significant effects ($100 million or more
in any 1 year). We have determined that this rulemaking is
``economically significant'' as measured by the $100 million threshold,
and hence also a major rule under the Congressional Review Act.
Accordingly, we have prepared a Regulatory Impact Analysis, that to the
best of our ability, presents the costs and benefits of the rulemaking.
The RFA requires agencies to analyze options for regulatory relief
of small businesses, if a rule has a significant impact on a
substantial number of small entities. For purposes of the RFA, small
entities include small businesses, nonprofit organizations, and small
government jurisdictions. We estimate that most hospitals and most
other providers and suppliers are small entities as that term is used
in the RFA. The great majority of hospitals and most other health care
providers and suppliers are small entities, either by being nonprofit
organizations or by meeting the SBA definition of a small business
(having revenues of less than $31.5 million in any 1 year). (For
details on the latest standard for health care providers, we refer
readers to page 33 of the Table of Small Business Size Standards at the
Small Business Administration's Web site at https://www.sba.gov/
services/contractingopportunities/sizestandardstopics/tableofsize/
index.html. For purposes of the RFA, all hospitals and other providers
and suppliers are considered to be small entities. Individuals and
States are not included in the definition of a small entity. We believe
that this notice will have a significant impact on small entities.
Because we acknowledge that many of the affected entities are small
entities, the analysis discussed in this section constitutes our final
regulatory flexibility analysis.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to
[[Page 57894]]
the provisions of section 604 of the RFA. With the exception of
hospitals located in certain New England counties, for purposes of
section 1102(b) of the Act, we now define a small rural hospital as a
hospital that is located outside of an urban area and has fewer than
100 beds. Section 601(g) of the Social Security Amendments of 1983
(Pub. L. 98-21) designated hospitals in certain New England counties as
belonging to the adjacent urban area. Thus, for purposes of the IPPS,
we continue to classify these hospitals as urban hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L.
104-4) also requires that agencies assess anticipated costs and
benefits before issuing any rule whose mandates require spending in any
1 year of $100 million in 1995 dollars, updated annually for inflation.
That threshold level is currently approximately $130 million. This
notice will not mandate any requirements for State, local, or tribal
governments, nor will it affect private sector costs.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. This notice will not have a substantial effect on State
and local governments.
The following analysis, in conjunction with the remainder of this
document, demonstrates that this notice is consistent with the
regulatory philosophy and principles identified in Executive Order
12866, the RFA, and section 1102(b) of the Act. The notice will affect
payments to a substantial number of small rural hospitals, as well as
other classes of hospitals, and the effects on some hospitals may be
significant.
The impact analysis for the policy changes under the IPPS for
operating costs was included in the FY 2009 IPPS final rule. As stated
in the impact analysis of the FY 2009 IPPS final rule (73 FR 49064), we
were unable to provide final wage indices because we were unable to
account for the recently enacted legislation (that is, section 124 of
Pub. L. 110-275), that extended certain special exceptions and
reinstated the provisions of section 508 of Public Law 108-173 relating
to the wage index reclassifications of hospitals for an additional
year, through FY 2009. Therefore, at the time of the FY 2009 IPPS final
rule, we were also unable to finalize budget neutrality calculations,
the outlier threshold and outlier offsets to the standardized amounts
because these figures were all dependent on the final wage indices.
However, we indicated that we would recalculate the impacts and provide
in a subsequent Federal Register notice prior to October 1, 2008. Now
that we have recalculated the new wage indices to reflect the extension
for reclassification for section 508 of MMA and special exception
providers, we are providing final impacts for FY 2009. Because the
extension of section 508 is a nonbudget neutral provision, overall
estimates for hospitals have changed from our estimate that was
published in the FY 2009 IPPS final rule (73 FR 49064). We estimate
that the changes in the FY 2009 IPPS final rule, in conjunction with
the final IPPS rates and wage index included in this notice, will
result in an approximate $5.0 billion increase in operating payments.
B. Final FY 2009 Impacts on IPPS Operating Costs
1. Analysis of Table I
Table I displays the results of our analysis of the payment changes
for FY 2009 after implementing section 124 of Public Law 110-275, which
extended section 508 of MMA and special exception reclassifications
through FY 2009. These impacts update the tentative ones that were
published in the FY 2009 IPPS final rule. As explained in the FY 2009
final rule and in this notice, we were unable to implement the section
124 of Public Law 110-275 that extended reclassifications for section
508 of MMA and special exception providers, so we were unable to
finalize the wage index, standardized amounts, outlier threshold and
budget neutrality factors. In this notice, we can now finalize the wage
index, standardized amounts, outlier thresholds and budget neutrality
factors, and we are only displaying the impact columns that were
affected by the Section 508 and special exception reclassifications.
Therefore, we are not reprinting the impacts of the DRG relative
weights, the wage data, the DRG and wage index changes that were
published in the FY 2009 IPPS final rule because those columns are
based on pre-reclassification wage data that is not affected by the
Section 508 and special exception reclassifications. (See the FY 2009
IPPS final rule (73 FR 49065 through 49072) for a full discussion of
the FY 2009 regulatory impact analysis.) In addition, we are adding a
column to display the impact of the implementation of section 508 of
MMA and special exceptions.
Table I displays the results of our analysis of the changes for FY
2009. The table categorizes hospitals by various geographic and special
payment consideration groups to illustrate the varying impacts on
different types of hospitals. The top row of the table shows the
overall impact on the 3,538 hospitals included in the analysis.
The next four rows of Table I contain hospitals categorized
according to their geographic location: All urban, which is further
divided into large urban and other urban; and rural. There are 2,553
hospitals located in urban areas included in our analysis. Among these,
there are 1,408 hospitals located in large urban areas (populations
over 1 million), and 1,145 hospitals in other urban areas (populations
of 1 million or fewer). In addition, there are 985 hospitals in rural
areas. The next two groupings are by bed-size categories, shown
separately for urban and rural hospitals. The final groupings by
geographic location are by census divisions, also shown separately for
urban and rural hospitals.
The second part of Table I shows hospital groups based on
hospitals' FY 2009 payment classifications, including any
reclassifications under section 1886(d)(10) of the Act. For example,
the rows labeled urban, large urban, other urban, and rural show that
the numbers of hospitals paid based on these categorizations after
consideration of geographic reclassifications (including
reclassifications under section 1886(d)(8)(B) and section 1886(d)(8)(E)
of the Act that have implications for capital payments) are 2,594,
1,430, 1,164 and 944, respectively.
The next three groupings examine the impacts of the changes on
hospitals grouped by whether or not they have GME residency programs
(teaching hospitals that receive an IME adjustment) or receive DSH
payments, or some combination of these two adjustments. There are 2,495
nonteaching hospitals in our analysis, 808 teaching hospitals with
fewer than 100 residents, and 235 teaching hospitals with 100 or more
residents.
In the DSH categories, hospitals are grouped according to their DSH
payment status, and whether they are considered urban or rural for DSH
purposes. The next category groups together hospitals considered urban
after geographic reclassification, in terms of whether they receive the
IME adjustment, the DSH adjustment, both, or neither.
The next five rows examine the impacts of the changes on rural
hospitals by special payment groups (SCHs, RRCs, and MDHs). There were
[[Page 57895]]
196 RRCs, 356 SCHs, 157 MDHs, 104 hospitals that are both SCHs and
RRCs, and 12 hospitals that are both an MDH and an RRC.
The next series of groupings are based on the type of ownership and
the hospital's Medicare utilization expressed as a percent of total
patient days. These data were taken from the FY 2005 Medicare cost
reports.
The next two groupings concern the geographic reclassification
status of hospitals. The first grouping displays all urban hospitals
that were reclassified by the MGCRB for FY 2009. The second grouping
shows the MGCRB rural reclassifications. In addition, the last grouping
reflects the 114 hospitals currently reclassified as Section 508 and
special exception hospitals.
The final category shows the impact of the policy changes on the 20
cardiac specialty hospitals in our analysis.
BILLING CODE 4120-01-P
[GRAPHIC] [TIFF OMITTED] TN03OC08.001
[[Page 57896]]
[GRAPHIC] [TIFF OMITTED] TN03OC08.002
[[Page 57897]]
[GRAPHIC] [TIFF OMITTED] TN03OC08.003
BILLING CODE 4120-01-C
a. Effects of MGCRB Reclassifications (Column 1)
The changes in Column 1 reflect the per case payment impact of
moving from this baseline to a simulation incorporating the MGCRB
decisions for FY 2009 which affect hospitals' wage index area
assignments. For information on the payment impacts prior to geographic
reclassification, please see the FY 2009 IPPS Final Rule (73 FR 49069
through 49070).
By Spring of each year, the MGCRB makes reclassification
determinations that will be effective for the next fiscal year, which
begins on October 1. The MGCRB may approve a hospital's
reclassification request for the purpose of using another area's wage
index value. Hospitals may appeal denials of MGCRB decisions to the CMS
Administrator. Further, hospitals have 45 days from publication of the
IPPS rule in the Federal Register to decide whether to withdraw or
terminate an approved geographic reclassification for the following
year. This column reflects all MGCRB decisions, Administrator appeals
and decisions of hospitals for FY 2009 geographic reclassifications.
Because section 124 of Pub. L. 110-275 extended certain special
exceptions and section 508 reclassifications through FY 2009, we
analyzed the data of hospitals in labor market areas affected by
legislation, including hospitals with Lugar redesignations, and make
best efforts to give those hospitals a wage index value that we believe
results in the highest FY 2009 wage index for which they are eligible.
Hospitals will have 15 days from the date of Federal Register
publication of this separate notice to notify us if they wish to revise
the decision that we made on their behalf.
The impacts shown in Column 1 of Table 1 reflect our
reclassification decisions on behalf of hospitals, which reflect the
area that would give the hospital the highest wage index. The overall
effect of geographic reclassification is required by section
1886(d)(8)(D) of the Act to be budget neutral. The geographic budget
neutrality factor reflects the effect of the geographic
reclassifications based on our reclassification decisions. Therefore,
for the purposes of this impact analysis, we are applying an adjustment
of 0.992088 to ensure that the effects of the section 1886(d)(10)
reclassifications are budget neutral. Geographic reclassification
generally benefits hospitals in rural areas. We estimate that
geographic reclassification will increase payments to rural hospitals
by an average of 2.2 percent.
b. Effects of the Rural Floor and Imputed Floor, Including the
Transition To Apply Budget Neutrality at the State Level (Column 2)
As discussed in the FY 2009 IPPS final rule (73 FR 49070), we are
applying the rural floor and imputed floor budget neutrality at the
State level through a 3-year transition. In FY 2009, hospitals will
receive a blended wage index that is 20 percent of a wage index with
the State level rural and imputed floor budget neutrality adjustment
and 80 percent of a wage index with the national budget neutrality
adjustment. At the time of publication of the FY 2009 IPPS final rule,
we could only apply tentative rural floor budget neutrality factors
because we were unable to finalize the wage index to account for the
section 124 of Pub. L. 110-275 that extended that the reclassification
for section 508 and special exception hospitals. The finalized national
rural floor budget neutrality applied to the wage index is 0.996272.
The within-State rural floor budget neutrality factors applied to the
wage index is available in Table 4D of the Addendum to this notice.
After the wage index is blended, an additional adjustment of 0.999785
is applied to the wage index to ensure that payments before the
application of the rural floor are equivalent to the payments under the
blended budget neutral rural floor wage index.
The column compares the post-reclassification FY 2009 wage index of
providers before the rural floor adjustment and the post-
reclassification FY 2009 wage index of providers with the rural floor
and imputed floor adjustment with the transitional rural floor budget
neutrality factor applied. We project that, in aggregate, rural
hospitals will experience a 0.2 percent decrease in payments as a
result of the application of the rural floor including the transition
to within-State rural floor budget neutrality. We project hospitals
located in other urban areas (populations of 1 million or fewer) will
experience a 0.1 percent increase in payments because only providers
can benefit from the rural floor. Rural New England hospitals can
expect the greatest decrease in payment, 0.3 percent, because under the
blended rural floor budget neutrality adjustment, hospitals in New
Hampshire will receive a rural floor budget neutrality adjustment of
0.99236 or a reduction of 0.8 percent, and hospitals in Connecticut
will receive a rural floor budget neutrality adjustment of 0.99000 or a
reduction of 1 percent. New Jersey, which is the only State that
benefits from the imputed floor, is expected to receive a rural floor
budget neutrality adjustment of 0.99455, or a reduction of less than 1
percent.
c. Effects of the Application of Section 508 Reclassification (Column
3)
This column displays the impact of extending the reclassification
for Section 508 and special exception providers through FY 2009.
Because this provision is not budget neutral, hospitals, overall, will
experience a 0.2 percent increase in payments. All the hospital
categories, depending on whether Section 508 and special exception
providers are represented in those categories, will either experience
an increase or no change in payments. Providers in urban New England
and
[[Page 57898]]
East North Central can expect increases in payments by 0.5 percent
because those regions have Section 508 and special exception providers.
Providers in the urban Middle Atlantic region will experience a 0.7
percent increase in estimated payments because there are several
section 508 and special exception providers located in New Jersey.
d. Effects of the Wage Index Adjustment for Out-Migration (Column 4)
Section 1886(d)(13) of the Act, as added by section 505 of Pub. L.
108-173, provides for an increase in the wage index for hospitals
located in certain counties that have a relatively high percentage of
hospital employees who reside in the county, but work in a different
area with a higher wage index. Hospitals located in counties that
qualify for the payment adjustment are to receive an increase in the
wage index that is equal to a weighted average of the difference
between the wage index of the resident county, post-reclassification
and the higher wage index work area(s), weighted by the overall
percentage of workers who are employed in an area with a higher wage
index. Section 508 providers and special exception providers that may
have qualified for the out-migration adjustment in the FY 2009 IPPS
final rule will now receive their section 508 or special exception
reclassification wage index. With the out-migration adjustment, rural
providers will experience a 0.1 percent increase in payments in FY 2009
relative to no adjustment at all. We included these additional payments
to providers in the impact table shown above, and we estimate the
impact of these providers receiving the out-migration increase to be
approximately $31 million.
e. Effects of All Changes With CMI Adjustment and Estimated Growth
(Column 5)
Column 5 compares our estimate of payments per case between FY 2008
and FY 2009, incorporating all changes reflected in this notice for FY
2009 (including statutory changes). This column includes the FY 2009
documentation and coding adjustment of -0.9 percent and the projected
1.8 percent increase in case-mix from improved documentation and coding
(with the 1.8 percent case-mix increase assumed to occur equally across
all hospitals).
Column 5 reflects the impact of all FY 2009 changes relative to FY
2008. The average increase for all hospitals is approximately 5.0
percent. This increase includes the effects of the 3.6 percent market
basket update. It also reflects the 0.4 percentage point difference
between the projected outlier payments in FY 2008 (5.1 percent of total
DRG payments) and the current estimate of the percentage of actual
outlier payments in FY 2008 (4.7 percent), as described in the FY 2009
IPPS final rule (73 FR 48766). As a result, payments are projected to
be 0.4 percentage points lower in FY 2008 than originally estimated,
resulting in a 0.4 percentage point greater increase for FY 2009 than
would otherwise occur. This analysis accounts for the impact of section
124 of Pub. L. 110-275, which extended certain special exceptions and
section 508 reclassifications for FY 2009. This nonbudget neutral
provision, that increases the wage index for 114 providers, results in
an estimated increase in payments by 0.2 percent. 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 5 may not equal the product of the percentage changes
described above.
The overall change in payments per case for hospitals in FY 2009 is
estimated to increase by 5.0 percent. Hospitals in urban areas will
experience an estimated 5.1 percent increase in payments per case
compared to FY 2008. Hospitals in large urban areas will experience an
estimated 5.2 percent increase and hospitals in other urban areas will
experience an estimated 4.9 percent increase in payments per case in FY
2008. Hospital payments per case in rural areas are estimated to
increase 4.1 percent. The increases that are larger than the national
average for larger urban areas and smaller than the national average
for other urban and rural areas are largely attributed to the
differential impact of adopting MS-DRGs.
Among urban census divisions, the largest estimated payment
increases will be 6.5 percent in the Pacific region (generally
attributed to MS-DRGs, wage data and section 508 and special exception
reclassifications) and 5.5 percent in the Mountain region (mostly due
to MS-DRGs). The smallest urban increase is estimated at 3.9 percent in
the Puerto Rico region.
Among the rural regions in Column 5, the providers in the New
England region experience the smallest increase in payments (3.5
percent) primarily due to the transition to the within-State rural
floor budget neutrality adjustment. The Pacific and South Atlantic
regions will have the highest increases among rural regions, with 5.6
percent and 4.4 percent estimated increases, respectively. Again,
increases in rural areas are generally less than the national average
due to the adoption of MS-DRGs.
Among special categories of rural hospitals in Column 9, the MDHs
and the RRCs will receive an estimated increase in payments of 4.8
percent, and the SCHs will experience an estimated increase in payments
by 3.7 percent.
Urban hospitals reclassified for FY 2009 are anticipated to receive
an increase of 5.2 percent, while urban hospitals that are not
reclassified for FY 2009 are expected to receive an increase of 5.1
percent. Rural hospitals reclassifying for FY 2009 are anticipated to
receive a 4.3 percent payment increase and rural hospitals that are not
reclassifying are estimated to receive a payment increase of 3.8
percent. Section 508 and special exception providers are estimated to
receive a payment increase of 5.8 percent relative to last year.
2. Analysis of Table II
Table II presents the projected impact of the changes for FY 2009
for urban and rural hospitals and for the different categories shown in
Table I. It compares the estimated payments per case for FY 2008 with
the average estimated payments per case for FY 2009, as calculated
under our models. Thus, the table presents, in terms of 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 5 of Table I.
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C. Final FY 2009 Capital-Related Impacts (Including the Quantitative
Effects of the Extension of the Expiration Date for Certain Geographic
Reclassifications and Special Exception Wage Indices as Required by
Section 124 of the MIPPA, Pub. L. 110-275)
1. General Considerations
In accordance with Sec. 412.312, the basic methodology for
determining capital IPPS payments in FY 2009 is as follows: (Standard
Federal Rate) x (DRG weight) x (GAF) x (COLA for hospitals located in
Alaska and Hawaii) x (1 + DSH Adjustment Factor + IME Adjustment
Factor, if applicable). In addition, hospitals may also receive outlier
payments for those cases that qualify under the threshold established
for each fiscal year.
The data used in developing the impact analysis presented below are
taken from the March 2008 update of the FY 2007 MedPAR file and the
March 2008 update of the Provider-Specific File that is used for
payment purposes. Although the analyses of the changes to the capital
prospective payment system do not incorporate cost data, we used the
March 2008 update of the most recently available hospital cost report
data (FYs 2005 and 2006) to categorize hospitals. Our analysis has
several qualifications. We use the best data available and make
assumptions about case-mix and beneficiary enrollment as described
below. In addition, as discussed in section III.A.5. of the Addendum to
the FY 2009 IPPS final rule (73 FR 48773 through 48774), we adjusted
the national capital rate to account for improvements in documentation
and coding under the MS-DRGs in FY 2009. (As discussed in section
III.A.6. of the Addendum to that same final rule, we did not adjust the
Puerto Rico specific capital rate to account for improvements in
documentation and coding under the MS-DRGs in FY 2009.) Furthermore,
[[Page 57901]]
due to the interdependent nature of the IPPS, it is very difficult to
precisely quantify the impact associated with each change. In addition,
we draw upon various sources for the data used to categorize hospitals
in the tables. In some cases (for instance, the number of beds), there
is a fair degree of variation in the data from different sources. We
have attempted to construct these variables with the best available
sources overall. However, for individual hospitals, some
miscategorizations are possible.
Using cases from the March 2008 update of the FY 2007 MedPAR file,
we simulated payments under the capital PPS for FY 2008 and FY 2009 for
a comparison of total payments per case. Any short-term, acute care
hospitals not paid under the general IPPS (Indian Health Service
hospitals and hospitals in Maryland) are excluded f
