Medicare Program; Physician Fee Schedule Conversion Factor for Calendar Year 1998 and Sustainable Growth Rate for Fiscal Year 1998

SUMMARY: This final notice announces the calendar year 1998 Medicare

physician fee schedule conversion factor and the fiscal year 1998

sustainable growth rate for expenditures for physicians' services under

the Medicare Supplementary Medical Insurance (Part B) program as

required by sections 1848(d) and (f), respectively, of the Social

Security Act. The 1998 Medicare physician fee schedule conversion

factor is $36.6873. The sustainable growth rate for fiscal year 1998 is

1.5 percent.

EFFECTIVE DATE: The provisions in this final notice pertaining to the

Medicare sustainable growth rate of increase are effective October 1,

1997, and the provisions pertaining to the Medicare physician fee

schedule conversion factor are effective January 1, 1998, as provided

by the Medicare statute.

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FOR FURTHER INFORMATION CONTACT: Ordering information: See ADDRESSES

section.

Content information: Don Thompson, (410) 786-4586.

SUPPLEMENTARY INFORMATION:

I. Background and Summary of Legislation

The following discussion contains references to the conversion

factor and relative value units as components of the Medicare physician

fee schedule. The 1998 physician fee schedule final rule, published

elsewhere in this Federal Register issue, explains how these factors

are used in determining payments under the fee schedule.

A. Calendar Year 1998 Physician Fee Schedule Conversion Factor

There are currently three conversion factors used in the physician

fee schedule: one for primary care services, one for surgical services,

and one for all other services. However, section 1848(d)(1)(C) of the

Social Security Act (the Act), as amended by section 4501 of the

Balanced Budget Act of 1997 (BBA 1997) (Pub. L. 105-33), enacted on

August 5, 1997, states that the 1998 physician fee schedule conversion

factor for all services ``shall be the conversion factor for primary

care services for 1997, increased by the Secretary's estimate of the

weighted average of the three separate updates that would otherwise

occur were it not for the enactment of . . . the Balanced Budget Act of

1997.''

The conversion factor is also affected by section

1848(c)(2)(B)(ii)(II) of the Act, which requires that any changes to

the relative value units of the Medicare physician fee schedule not

cause expenditures to increase or decrease by more than $20 million

from the amount of expenditures that would have been made if such

adjustments had not been made. We implement this requirement through a

uniform budget neutrality adjustment to the conversion factor.

B. Fiscal Year 1998 Medicare Sustainable Growth Rate

Section 1848(f) of the Act, as amended by section 4503 of the BBA

1997, replaces the volume performance standard with a sustainable

growth rate standard. It specifies the formula for establishing yearly

sustainable growth rate expenditure targets for physicians' services

under Medicare. The use of sustainable growth rate targets is intended

to control the actual growth in Medicare expenditures for physicians'

services.

The sustainable growth rate targets are not limits on expenditures.

Payments for services are not withheld if the sustainable growth rate

target is exceeded. Rather, the appropriate fee schedule update, as

specified in section 1848(d)(3)(A) of the Act, is adjusted to reflect

the success or failure in meeting the sustainable growth rate target.

The amended section 1848(f)(2) of the Act now states that ``the

sustainable growth rate for all physicians' services for a fiscal year

(beginning with fiscal year 1998) shall be equal to the product of--

(A) 1.0 plus the Secretary's estimate of the weighted-average

percentage increase (divided by 100) in the fees for all physicians'

services in the fiscal year involved,

(B) 1.0 plus the Secretary's estimate of the percentage change

(divided by 100) in the average number of individuals enrolled under

this part (other than Medicare+Choice plan enrollees) from the previous

fiscal year to the fiscal year involved,

(C) 1.0 plus the Secretary's estimate of the projected percentage

growth in real gross domestic product per capita (divided by 100) from

the previous fiscal year to the year involved, and

(D) 1.0 plus the Secretary's estimate of the percentage change

(divided by 100) in expenditures for all physicians' services in the

fiscal year (compared with the previous fiscal year) that will result

from changes in law or regulations determined without taking into

account estimated changes in

[[Page 59262]]

expenditures resulting from the update adjustment factor determined

under subsection (d)(3)(B), minus 1 and multiplied by 100.

C. Physicians' Services

Because the scope of physicians' services covered by the

sustainable growth rate is identical to the scope of services that was

covered by the Medicare volume performance standards, we are using the

same definition of physicians' services for the sustainable growth rate

as we did for the Medicare volume performance standard. The November

22, 1996 final notice (61 FR 59717) announcing the fiscal year 1997

volume performance standard rates of increase contains a detailed

description of this scope of services.

II. Provisions of This Final Notice

A. Calendar Year 1998 Physician Fee Schedule Conversion Factor

Under the requirements of the amended section 1848(d)(1)(C) of the

Act, the 1998 physician fee schedule conversion factor is $36.6873. We

determined this conversion factor as follows:

1997 Primary care conversion factor........................... 35.7671

Weighted average update if BBA 1997 not enacted............... 1.034

Budget neutrality adjustment*................................. 0.992

1998 Physician fee schedule conversion factor................. 36.6873

* This adjustment results from section 1848(c)(2)(B)(ii) of the Act and

is described in the 1998 physician fee schedule final rule, published

elsewhere in this Federal Register issue.

Under the requirements of section 1848(d)(1)(D) of the Act, as

amended by section 4504 of the BBA 1997, the 1998 anesthesia conversion

factor is equal to 46 percent of the 1998 physician fee schedule

conversion factor. This calculation yields a 1998 anesthesia conversion

factor of $16.8762.

The specific calculations to determine the conversion factor for

physicians' services for calendar year 1998 are explained in section

III. A. of this notice.

The following table shows the combined effect on calendar year 1998

payments (relative to calendar year 1997) of the move to a single

conversion factor and the changes to the 1998 Medicare physician fee

schedule relative value units (described in the 1998 physician fee

schedule final rule published elsewhere in this Federal Register

issue).

Table 1.--1998 Percent Change in Payments by Specialty*

------------------------------------------------------------------------

Change due

to single Change due Combined

Specialty conversion to relative change

factor value units

------------------------------------------------------------------------

M.D./D.O. Physicians:

Radiation Oncology............... 9.2 -0.7 8.4

Psychiatry................... 9.0 -0.7 8.2

Radiology.................... 9.0 -0.7 8.2

Pathology.................... 9.3 -1.1 8.1

Hematology/Oncology.......... 7.1 0.8 8.0

Neurology.................... 7.9 0.0 7.9

Pulmonary.................... 8.1 -0.4 7.7

Rheumatology................. 5.7 1.4 7.2

Gastroenterology............. 8.5 -1.3 7.1

Internal Medicine............ 6.4 0.6 7.0

Family Practice.............. 5.0 1.3 6.4

Cardiology................... 7.9 -1.4 6.4

Other Physician.............. 6.4 -0.2 6.2

General Practice............. 4.7 1.2 6.0

Nephrology................... 6.0 -1.2 4.7

Clinics...................... 4.5 -0.1 4.4

Emergency Medicine........... 3.8 -0.6 3.2

Anesthesiology............... 1.2 0.9 2.1

Obstetrics/Gynecology........ -2.3 3.0 0.6

Otolaryngology............... -0.1 0.6 0.5

General Surgery.............. -4.0 1.8 -2.3

Vascular Surgery............. -4.0 1.5 -2.6

Urology...................... -3.3 0.4 -2.9

Orthopedic Surgery........... -4.8 0.8 -4.0

Dermatology.................. -4.8 0.2 -4.6

Plastic Surgery.............. -6.9 1.7 -5.3

Ophthalmology................ -3.3 -2.6 -5.8

Neurosurgery................. -5.7 -0.2 -5.9

Thoracic Surgery............. -7.0 -0.2 -7.2

Cardiac Surgery.............. -8.1 -0.7 -8.8

Others:

Chiropractic................. 9.3 -0.8 8.4

Suppliers.................... 9.3 -1.0 8.2

Optometry.................... 5.7 0.1 5.8

Nonphysician practitioners... 5.1 -0.6 4.5

Podiatry..................... -5.2 0.8 -4.4

------------------------------------------------------------------------

* Table reflects changes from 1997 payments due to the relative value

units and single conversion factor, excluding the 0.3 percent volume

and intensity increase associated with the single conversion factor

and the 0.1 percent volume and intensity increase associated with the

relative value unit changes.

[[Page 59263]]

B. Physician Sustainable Growth Rate for Fiscal Year 1998

Under the requirements in sections 1848(f)(2)(A) and (B) of the

Act, as amended by section 4503 of the BBA 1997, we have determined

that the sustainable growth rate of increase for physicians' services

for fiscal year 1998 is 1.5 percent.

This determination is based on the following statutory factors:

------------------------------------------------------------------------

Percent

Statutory factors change

------------------------------------------------------------------------

Fees......................................................... 2.3

Enrollment................................................... -2.4

Increase in Gross Domestic Product........................... 1.1

Legislation.................................................. 0.6

----------

Total........................................................ 1.5

------------------------------------------------------------------------

The specific calculations to determine the sustainable growth rate

for physicians' services for fiscal year 1998 are explained in section

III. B. of this notice.

III. Detail on Calculation of the Calendar Year 1998 Physician Fee

Schedule Conversion Factor and the Fiscal Year 1998 Sustainable Growth

Rate

A. Physician Fee Schedule Conversion Factor

1. The Weighted Average Update

The weighted average update if the BBA 1997 had not been enacted is

3.4 percent. This was determined based on the Medicare Economic Index

(MEI) and the Medicare volume performance standard (MVPS) adjustments

as follows:

------------------------------------------------------------------------

Update

Service 1998 MEI MVPS (prior to

adjustment BBA 1997)

------------------------------------------------------------------------

(2)[In Percent]

--------------------------------------

Primary Care..................... 2.2 5.3 7.5

Surgical......................... 2.2 0.3 2.5

All other........................ 2.2 -0.3 1.9

Weighted average................. ........... ........... 3.4

------------------------------------------------------------------------

The MEI and the MVPS adjustments are described below.

2. The Percentage Change in the Medicare Economic Index

The MEI measures the weighted-average annual price change for

various inputs needed to produce physicians' services. The MEI is a

fixed-weight input price index, with an adjustment for the change in

economy-wide labor productivity. This index, which has 1989 base

weights, is comprised of two broad categories: (1) Physician's own

time, and (2) physician's practice expense.

The physician's own time component represents the net income

portion of business receipts and primarily reflects the input of the

physician's own time into the production of physicians' services in

physicians' offices. This category consists of two subcomponents: wages

and salaries, and fringe benefits. These components are adjusted by the

10-year moving average percent change in output per man-hour for the

nonfarm business sector to eliminate double counting for productivity

growth in physicians' offices and the general economy.

The physician's practice expense category represents the rate of

price growth in nonphysician inputs to the production of services in

physicians' offices. This category consists of wages and salaries and

fringe benefits for nonphysician staff and other nonlabor inputs. Like

physician's own time, the nonphysician staff categories are adjusted

for productivity using the 10-year moving average percent change in

output per man-hour for the nonfarm business sector. The physician's

practice expense component also includes the following categories of

nonlabor inputs: office expense, medical materials and supplies,

professional liability insurance, medical equipment, professional car,

and other expense. The table below presents a listing of the MEI cost

categories with associated weights and percent changes for price

proxies for the 1998 update. The calendar year 1998 MEI is 2.2 percent.

Increase in the Medicare Economic Index Update for Calendar Year 1998

\1\

------------------------------------------------------------------------

CY 1998

1989 percent

weights \2\ changes

------------------------------------------------------------------------

Medicare Economic Index Total................. 100.0 2.2

1. Physician's Own Time\3\ \4\............ 54.2 2.5

a. Wages and Salaries: Average hourly

earnings private nonfarm, net of

productivity......................... 45.3 2.8

b. Fringe Benefits: Employment Cost

Index, benefits, private nonfarm, net

of productivity...................... 8.8 1.2

2. Physician's Practice Expense \3\....... 45.8 1.9

a. Nonphysician Employee Compensation. 16.3 2.4

1. Wages and Salaries: Employment

Cost Index, wages and salaries,

weighted by occupation, net of

productivity..................... 13.8 2.6

2. Fringe Benefits: Employment

Cost Index, fringe benefits,

white collar, net of productivity 2.5 1.4

b. Office Expense: Consumer Price

Index for Urban Consumers (CPI-U),

housing.............................. 10.3 2.9

c. Medical Materials and Supplies:

Producer Price Index (PPI), ethical

drugs/PPI, surgical appliances and

supplies/CPI-U, medical equipment and

supplies (equally weighted).......... 5.2 1.6

d. Professional Liability Insurance:

HCFA professional liability insurance

survey\5\............................ 4.8 -1.8

e. Medical Equipment: PPI, medical

instruments and equipment............ 2.3 -0.4

f. Other Professional Expense......... 6.9 2.5

1. Professional Car: CPI-U,

private transportation........... 1.4 2.3

2. Other: CPI-U, all items less

food and energy.................. 5.5 2.6

[[Page 59264]]

Addendum:

Productivity: 10-year moving average of

output per man-hour, nonfarm business

sector................................... N/A 0.8

Physician's Own Time, not productivity

adjusted................................. 54.2 3.3

Wages and salaries, not productivity

adjusted............................. 45.3 3.6

Fringe benefits, not productivity

adjusted............................. 8.8 2.0

Nonphysician Employee Compensation, not

productivity adjusted.................... 16.3 3.2

Wages and salaries, not productivity

adjusted............................. 13.8 3.4

Fringe benefits, not productivity

adjusted............................. 2.5 2.2

------------------------------------------------------------------------

\1\ The rates of change are for the 12-month period ending June 30,

1997, which is the period used for computing the calendar year 1998

update. The price proxy values are based upon the latest available

Bureau of Labor Statistics data as of September 1997.

\2\ The weights shown for the MEI components are the 1989 base-year

weights, which may not sum to subtotals or totals because of rounding.

The MEI is a fixed-weight, Laspeyres-type input price index whose

category weights indicate the distribution of expenditures among the

inputs to physicians' services for calendar year 1989. To determine

the MEI level for a given year, the price proxy level for each

component is multiplied by its 1989 weight. The sum of these products

(weights multiplied by the price index levels) over all cost

categories yields the composite MEI level for a given year. The annual

percent change in the MEI levels is an estimate of price change over

time for a fixed market basket of inputs to physicians' services.

\3\ The Physician's Own Time and Nonphysician Employee Compensation

category price measures include an adjustment for productivity. The

price measure for each category is divided by the 10-year moving

average of output per man-hour in the nonfarm business sector. For

example, the wages and salaries component of Physician's Own Time is

calculated by dividing the rate of growth in average hourly earnings

by the 10-year moving average rate of growth of output per man-hour

for the nonfarm business sector. Dividing one plus the decimal form of

the percent change in the average hourly earnings (1+.036=1.036 by one

plus the decimal form of the percent change in the 10-year moving

average of labor productivity (1+.008=1.008) equals one plus the

change in average hourly earnings net of the change in output per

manhour (1.036/1.008=1.028). All Physician's Own Time and Nonphysician

Employee Compensation categories are adjusted in this way. Due to a

higher level of precision the computer calculated quotient may differ

from the quotient calculated from rounded individual percent changes.

\4\ The average hourly earnings proxy, the Employment Cost Index

proxies, as well as the CPI-U, housing and CPI-U, private

transportation are published in the Current Labor Statistics Section

of the Bureau of Labor Statistics' Monthly Labor Review. The remaining

CPIs and PPIs in the revised index can be obtained from the Bureau of

Labor Statistics' CPI Detailed Report or Producer Price Indexes.

\5\ Derived from a HCFA survey of several major insurers (the latest

available historical percent change data are for calendar year 1997).

This is consistent with prior computations of the professional

liability insurance component of the MEI.

n/a Productivity is factored into the MEI compensation categories as an

adjustment to the price variables; therefore, no explicit weight

exists for productivity in the MEI.

3. Medicare Volume Performance Standard Performance Adjustment

Prior to the enactment of the BBA 1997, the update methodology set

forth in section 1848(d)(3)(B)(i) of the Act would have increased the

primary care services update by 5.3 percentage points, increased the

surgical services update by 0.3 percentage points, and decreased the

update for all other services by 0.3 percentage points. These

adjustments reflect the percentage increase in expenditures between

fiscal year 1995 and fiscal year 1996 relative to the volume

performance standard rates of increase for fiscal year 1996. The volume

performance standard rates of increase were targets for the growth in

Medicare expenditures for physicians' services that have subsequently

been replaced by the sustainable growth rates. The success or failure

in meeting the volume performance standard targets was taken into

account in determining the Medicare physician fee schedule update. The

update methodology prior to the enactment of the BBA 1997 is described

in detail in the November 22, 1996 final notice announcing the

physician fee schedule update for 1997 (61 FR 59717).

The MVPS adjustments were derived as follows:

------------------------------------------------------------------------

FY 1996 FY 1996 MVPS

Service MVPS increase in adjustment

target expenditures difference)

------------------------------------------------------------------------

(2)[In Percent]

---------------------------------------

Primary Care.................... 9.3 4.0 5.3

Surgical........................ -0.5 -0.8 0.3

All other....................... 0.6 0.9 -0.3

------------------------------------------------------------------------

B. Fiscal Year 1998 Sustainable Growth Rate

Below we explain how we determined the increases for each of the

four factors used in determining the sustainable growth rate for fiscal

year 1998.

Factor 1--Percentage Increase in Fees for Physicians' Services (Before

Applying Legislative Adjustments) for Fiscal Year 1998

This factor was calculated as a weighted average of the calendar

year 1997 and 1998 fee increases that apply during fiscal year 1998.

Adjustments to the fee increases, such as the move to a single

conversion factor, are accounted for in Factor 4 (the increase in

expenditures resulting from changes in law or regulations).

Most of the fees for physicians' services (as defined in section I.

C. of this notice) are updated by the MEI. However, laboratory

services, which

[[Page 59265]]

represent about 13 percent of the Medicare allowed charges for

physicians' services, are updated by the Consumer Price Index for Urban

Consumers (CPI-U). The following table, therefore, shows both the MEI

and CPI-U updates that were used in determining the percentage increase

in physicians' fees for fiscal year 1998.

Medicare Economic Index and Consumer Price Index for Urban Consumers for

Calendar Years 1997 and 1998

------------------------------------------------------------------------

1997 1998

------------------------------------------------------------------------

MEI................................................... 2.0 2.2

CPI-U................................................. 2.7 3.0

------------------------------------------------------------------------

After taking into account all the elements described above, we

estimate that the weighted-average increase in fees for physicians'

services in fiscal year 1998 before applying any legislative

adjustments will be 2.3 percent for all physicians' services.

Factor 2--The Percentage Change in the Average Number of Part B

Enrollees from Fiscal Year 1997 to Fiscal Year 1998

Due to the rapid growth in Medicare+Choice plan enrollees (whose

Medicare-covered medical care is outside the scope of the sustainable

growth rate), we estimate that the average number of Medicare Part B

enrollees excluding those in Medicare+Choice plans will decline by 2.4

percent. This was derived as follows:

----------------------------------------------------------------------------------------------------------------

Average Medicare Part B enrollment (in

millions)

------------------------------------------

Overall

Overall Medicare excluding

+Choice* Medicare+Choice

----------------------------------------------------------------------------------------------------------------

FY 1997.............................................................. 36.384 4.461 31.923

FY 1998.............................................................. 36.775 5.627 31.148

Percent change................................................... ........... ........... -2.4%

----------------------------------------------------------------------------------------------------------------

* Because the Medicare+Choice program does not begin until 1998, the 1997 Medicare+Choice enrollment was proxied

by the risk health maintenance organization enrollment.

Differences between projected and actual enrollment will be

adjusted for in subsequent years.

Factor 3--Estimated Real Gross Domestic Product Per Capita Growth in

Fiscal Year 1998

In calculating the sustainable growth rate, section 1848(f)(2)(C)

of the Act, as amended by section 4503 of the BBA 1997, requires the

Secretary to project real gross domestic product per capita growth for

the coming fiscal year. We estimate that this growth will be 1.1

percent in fiscal year 1998.

Differences between projected and actual real gross domestic

product per capita growth will be adjusted for in subsequent years.

Factor 4--Percentage Increase in Expenditures for Physicians' Services

Resulting from Changes in Law or Regulations in Fiscal Year 1998

Compared with Fiscal Year 1997

Legislative changes contained in the BBA 1997 will impact

expenditures for physicians' services in fiscal year 1998. Although the

move to a single conversion factor for the Medicare physician fee

schedule will cause the payments for surgical services to decline, it

will increase the payments for nonsurgical services sufficiently to

cause an overall increase in expenditures for fiscal year 1998 relative

to fiscal year 1997. The Medicare coverage changes for screening

mammography, colorectal cancer screening, screening PAP smears, and

screening pelvic exams will cause increases in Medicare expenditures.

The changes in payments for nurse practitioners, clinical nurse

specialists, and physician assistants will also increase expenditures.

Medicare to be secondary payer and the provisions relating to payments

for laboratory services will cause reductions in Medicare expenditures.

In response to the fee changes associated with implementation of

the 1998 physician fee schedule, we anticipate that the volume and

intensity of physician services provided to Medicare beneficiaries will

increase by 0.1 percent. In order to prevent an increase in

expenditures as a result of this volume and intensity response, an

offsetting 0.1 percent reduction is made to the conversion factor.

Because we incorporate both the volume and intensity response and the

offsetting conversion factor reduction into the sustainable growth rate

target, if the volume and intensity response does not occur, the

sustainable growth rate system returns the offsetting reduction to the

conversion factor in form of higher future updates to the Medicare

physician fee schedule.

After taking into account all the BBA 1997 provisions, the increase

in expenditures for physician services due to changes in law or

regulations is estimated to be 0.6 percent.

IV. Inapplicability of a Notice and Comment Procedure and of a 30-Day

Delay in Effective Date

We find good cause to waive notice and comment procedure for this

final notice. It is an interpretive rule because section 1848 of the

Social Security Act, as amended by sections 4501 and 4503 of the BBA

1997, sets out in detail the factors and procedures necessary to

calculate the conversion factor for calendar year 1998 and the

sustainable growth rate of increase for fiscal year 1998. As required

by the statute, section I. A. of this notice discusses the replacement

of the three conversion factors that are currently used under the

physician fee schedule with a single conversion factor, and the method

used to determine the conversion factor for calendar year 1998. Section

I. B. of this notice discusses the replacement of the volume

performance standard with the sustainable growth rate of increase, and

the formula for establishing the fiscal year 1998 sustainable growth

rate target for physicians' services under Medicare. Therefore, it

would be impracticable and unnecessary to submit this notice to the

public for a notice and comment procedure.

We usually provide a delay of 30 days in the effective date for

final Federal Register documents. In this case, however, the

sustainable growth rates of increase are required by law to be

published by November 1, 1997 and are effective on October 1, 1997.

Thus, the

[[Page 59266]]

Congress has clearly indicated its intent that the rates of increase be

implemented without the usual 30-day delay in the effective date and

has foreclosed any discretion by us in this matter. Therefore, the

requirement for a 30-day delay in the effective date does not apply to

this notice. With regard to the physician fee schedule conversion

factor, the effective date will be January 1, 1998, which exceeds the

30-day requirement for the publication of this notice.

V. Regulatory Impact Statement

We generally prepare a regulatory flexibility analysis that is

consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601

through 612) unless the Secretary certifies that a notice will not have

a significant economic impact on a substantial number of small

entities. For purposes of the RFA, States and individuals are not

entities, but we consider all physicians to be small entities.

We are not preparing a regulatory flexibility analysis since we

have determined, and the Secretary certifies, that this notice will not

have a significant economic impact on a substantial number of small

entities.

Also, section 1102(b) of the Act requires the Secretary to prepare

a regulatory impact analysis if a notice may have a significant impact

on the operations of a substantial number of small rural hospitals.

This analysis must conform to the provisions of section 604 of the RFA.

For purposes of section 1102(b) of the Act, we define a small rural

hospital as a hospital that is located outside of a Metropolitan

Statistical Area and has fewer than 50 beds.

We are not preparing a rural impact analysis since we have

determined, and the Secretary certifies, that this notice will not have

a significant impact on the operations of a substantial number of small

rural hospitals.

In accordance with the provisions of Executive Order 12866, this

notice was reviewed by the Office of Management and Budget.

(Sections 1848(d) and (f) of the Social Security Act) (42 U.S.C.

1395w-4(d) and (f))

(Catalog of Federal Domestic Assistance Program No. 93.774,

Medicare--Supplementary Medical Insurance Program)

Dated: October 27, 1997.

Nancy-Ann Min DeParle,

Deputy Administrator, Health Care Financing Administration.

Dated: October 28, 1997.

Donna E. Shalala,

Secretary.

[FR Doc. 97-29028 Filed 10-30-97; 8:45 am]

BILLING CODE 4120-01-P