农村“大苹果”：一家医院如何确定整个州的医疗保险急性设施工资指数

The rural “Big Apple”:How a single hospitalcan determine the Medicare acute facilitywage index for an entire state Brian ReganDrew OsborneMaria BeckerTaylor Call Medicare fee-for-service (FFS) payments vary by geographic area.For inpatient and outpatient facility reimbursement, this isaccomplished through the wage index. In the 2024 Final Rule,1theCenters for Medicare and Medicaid Services (CMS) changed its wageindex calculation in response to numerous lawsuits. A consequenceof the new calculation is that a single hospital can substantiallyinfluence, or even solely determine, an entire state’s wage index.Changes in the wage indexes from one year to the next are budget-neutral at the national level. Because the wage index adjustment isbudget-neutral, when one hospital’s wage index (and thereforereimbursement) increases, there is an offsetting decrease to all otherhospitals’ payments. AT A GLANCE 1.The wage index is the primaryway that Medicare’s inpatientand outpatient payments arearea-adjusted. 2.In 2024, in reaction to numerouslawsuits, CMS changed thewage index calculation.3.As a result of the changes,California, Florida, New York,and other states have seen largeincreasesaffecting significantparts of the state. Facilityreimbursement trends haveexceeded 10% in the mosthighlyimpacted areas.4.The wage index is budget-neutral, so when one area’swage index increases, paymentsin other areas decrease. Totaldollars redistributed as a result ofthe wage index changes are inthe billions of dollars.5.This paper discusses how thewage index calculation worksand provides a case study of thelarge changes in New York This paper discusses how wage indexes have changed in the lastseveral years, how the new calculation works,and how hospitals located in New York City were able to increase thewage indexes for most of the state by more than 10 percentagepoints through reclassification as rural hospitals. What is Medicare’s HospitalWage Index? Medicare FFS hospital payments are required by statute to beadjusted “for area differences in hospital wage levels by a factor(established by the Secretary) reflecting the relative hospital wagelevel in the geographic area of the hospital compared to the nationalaverage hospital wage level.”2The wage index represents thisadjustment, reflecting variation in average hourly hospital wages forlabor market areas as defined by core-based statistical areas(CBSAs). The wage index also reflects geographic reclassifications ofhospitals to other labor market areas, state-level minimums (the “ruralfloor”), and other rules. Recent wage index changes The table in Figure 1 shows theInpatient Prospective Payment System (IPPS)3rural wage index for the top five mostpopulous states, as well as the wage index for three cities in California. Key features are highlighted. In each state, awage index is calculated for each urban area as well as a single rural wage index for the state. The rural wage indexis shown because a key driver of recent changes to all wage indexes is the “rural floor,” which currently requires thateach urban area in a state must have a wage index at least as high as the rural wage index of that state. Combinedwith the 2024 changes to the rural wage index calculation, the rural floor can determine the wage index for asignificant proportion of the state, and in some cases the entire state. Of note in Figure 1: The rural wage index was relatively stable between 2022 and 2023 for these states, with the exception of Texas. 1.2.Starting in 2024, and continuing in 2025, the rural floor increased significantly in all of the states shownexcept Texas.3.The California rural wage index increased from 1.2534 in 2023 to 1.5189 in 2024. In 2023, Los Angeles and SanDiego were both slightly above the rural wage index. In 2024, because of the rural floor, the wage index for bothareas increased over 15%.5San Francisco, with much higher wages than southern California, was unaffected bythe rural floor.4.In 2024 and 2025, there were large increases in the rural wage index between the Proposed and Final Rule. Thisis in large part because hospitals do not need to make final decisions about which area to reclassify into untilafter the release of the Proposed Rule (reclassifications are discussed in more detail later in this paper). Most components of the wage index calculation, including both the impact of the rural floor and hospitalreclassifications,are budget neutral. CMS applies budget-neutrality factors to offset the increases allowed by thesepolicies and these factors can illustrate the magnitude of the 2024 calculation changes. The table in Figure 2 showsthe two budget-neutrality factors most impacted by the recent changes, with key features highlighted. The Reclassification Budget Neutrality Factor (left) affects the IPPS base rate (CMS’s Table 1, released with the FinalRule) and therefore has a larger impact on rates. The Rural Floor Budget Neutrality Factor (right) is applied to wageindex