Voglio sapere a riguardo di…

42618

Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations
lotter on DSK11XQN23PROD with RULES5

of rural facilities was 17 percent higher than that of urban facilities after accounting for the influence of the other variables included in the regression.
This 17 percent adjustment has been part of the IPF PPS each year since the inception of the IPF PPS. For FY 2022, we proposed to continue to apply a 17
percent payment adjustment for IPFs located in a rural area as defined at 412.64b1iiC see 69 FR 66954 for a complete discussion of the adjustment for rural locations.
Comment: We received one comment in favor of the proposed extension of the 17 percent payment adjustment for rural IPFs. The commenter acknowledged CMS efforts to avoid disparities in payments to facilities in rural and underserved communities.
Response: We appreciate this comment of support. Since the inception of the IPF PPS, we have applied a 17 percent adjustment for IPFs located in rural areas. As stated in the previous paragraph, this adjustment was derived from the results of our regression analysis and was incorporated into the payment system in order to ensure the accuracy of payments to rural IPFs. CMS continues to look for ways to ensure accuracy of payments to rural IPFs.
Final Decision: For FY 2022, we are finalizing our proposal to continue to apply a 17 percent payment adjustment for IPFs located in a rural area as defined at 412.64b1iiC.
d. Final Budget Neutrality Adjustment Changes to the wage index are made in a budget-neutral manner so that updates do not increase expenditures.
Therefore, for FY 2022, we are finalizing our proposal to continue to apply a budget-neutrality adjustment in accordance with our existing budgetneutrality policy. This policy requires us to update the wage index in such a way that total estimated payments to IPFs for FY 2022 are the same with or without the changes that is, in a budget-neutral manner by applying a budget neutrality factor to the IPF PPS
rates. We use the following steps to ensure that the rates reflect the FY 2022
update to the wage indexes based on the FY 2018 hospital cost report data and the labor-related share in a budgetneutral manner:
Step 1: Simulate estimated IPF PPS
payments, using the FY 2021 IPF wage index values available on the CMS
website and labor-related share as published in the FY 2021 IPF PPS final rule 85 FR 47043.
Step 2: Simulate estimated IPF PPS
payments using the final FY 2022 IPF
wage index values available on the
VerDate Sep<11>2014

21:11 Aug 03, 2021

Jkt 253001

CMS website and final FY 2022 laborrelated share based on the latest available data as discussed previously.
Step 3: Divide the amount calculated in step 1 by the amount calculated in step 2. The resulting quotient is the FY
2022 budget-neutral wage adjustment factor of 1.0017.
Step 4: Apply the FY 2022 budgetneutral wage adjustment factor from step 3 to the FY 2021 IPF PPS Federal per diem base rate after the application of the market basket update described in section III.A of this rule, to determine the FY 2022 IPF PPS Federal per diem base rate.
2. Final Teaching Adjustment a. Background In the November 2004 IPF PPS final rule, we implemented regulations at sect; 412.424d1iii to establish a facility-level adjustment for IPFs that are, or are part of, teaching hospitals.
The teaching adjustment accounts for the higher indirect operating costs experienced by hospitals that participate in graduate medical education GME programs. The payment adjustments are made based on the ratio of the number of full-time equivalent FTE interns and residents training in the IPF and the IPFs average daily census ADC.
Medicare makes direct GME payments for direct costs such as resident and teaching physician salaries, and other direct teaching costs to all teaching hospitals including those paid under a PPS, and those paid under the TEFRA
rate-of-increase limits. These direct GME payments are made separately from payments for hospital operating costs and are not part of the IPF PPS.
The direct GME payments do not address the estimated higher indirect operating costs teaching hospitals may face.
The results of the regression analysis of FY 2002 IPF data established the basis for the payment adjustments included in the November 2004 IPF PPS
final rule. The results showed that the indirect teaching cost variable is significant in explaining the higher costs of IPFs that have teaching programs. We calculated the teaching adjustment based on the IPFs teaching variable, which is 1 + the number of FTE residents training in the IPF/the IPFs ADC. The teaching variable is then raised to the 0.5150 power to result in the teaching adjustment. This formula is subject to the limitations on the number of FTE residents, which are described in this section of this rule.
We established the teaching adjustment in a manner that limited the
PO 00000

Frm 00012

Fmt 4701

Sfmt 4700

incentives for IPFs to add FTE residents for the purpose of increasing their teaching adjustment. We imposed a cap on the number of FTE residents that may be counted for purposes of calculating the teaching adjustment. The cap limits the number of FTE residents that teaching IPFs may count for the purpose of calculating the IPF PPS
teaching adjustment, not the number of residents teaching institutions can hire or train. We calculated the number of FTE residents that trained in the IPF
during a base year and used that FTE
resident number as the cap. An IPFs FTE resident cap is ultimately determined based on the final settlement of the IPFs most recent cost report filed before November 15, 2004
publication date of the IPF PPS final rule. A complete discussion of the temporary adjustment to the FTE cap to reflect residents due to hospital closure or residency program closure appears in the RY 2012 IPF PPS proposed rule 76
FR 5018 through 5020 and the RY 2012
IPF PPS final rule 76 FR 26453 through 26456. In section III.D.2.b of this final rule, we discuss finalized updates to the IPF policy on temporary adjustment to the FTE cap.
In the regression analysis, the logarithm of the teaching variable had a coefficient value of 0.5150. We converted this cost effect to a teaching payment adjustment by treating the regression coefficient as an exponent and raising the teaching variable to a power equal to the coefficient value. We note that the coefficient value of 0.5150
was based on the regression analysis holding all other components of the payment system constant. A complete discussion of how the teaching adjustment was calculated appears in the November 2004 IPF PPS final rule 69 FR 66954 through 66957 and the RY 2009 IPF PPS notice 73 FR 25721.
As with other adjustment factors derived through the regression analysis, we do not plan to rerun the teaching adjustment factors in the regression analysis until we more fully analyze IPF
PPS data. Therefore, in this FY 2022
final rule, we are finalizing our proposal to continue to retain the coefficient value of 0.5150 for the teaching adjustment to the Federal per diem base rate.
b. Final Update to IPF Teaching Policy on IPF Program Closures and Displaced Residents For FY 2022, we proposed to change the IPF policy regarding displaced residents from IPF closures and closures of IPF teaching programs. Specifically, we proposed to adopt conforming changes to the IPF PPS teaching policy
E:FRFM04AUR5.SGM

04AUR5