PUBLIC LAW 101-239—DEC. 19, 1989 103 STAT. 2175 appropriate update (or updates) in the conversion factor (or factors) for all physicians' services in the following year. The Secretary may recommend a uniform update or dif- ferent updates for different categories or groups of services. In making the recommendation, the Secretary shall con- sider— "(i) the percentage change in the medicare economic index (described in the fourth sentence of section 1842(b)(3)) for that year; "(ii) the percentage by which actual expenditures for all physicians' services (as defined in subsection (f)(5)(A)) under this part for the fiscal year ending in the year preceding the year in which such rec- ommendation is made were greater or less than actual , expenditures for all such physicians' services in the fiscal year ending in the second preceding year; "(iii) the relationship between the percentage deter- mined under clause (ii) for a fiscal year and the performance standard rate of increase (established under subsection (fK2)) for that fiscal year; "(iv) changes in volume or intensity of services; "(v) access to services; and "(vi) other factors that may contribute to changes in volume or intensity of services or access to services. For purposes of making the comparison under clause (iii), the Secretary shall adjust the performance standard rate of increase for a fiscal year to refiect changes in the actual proportion of HMO enrollees (as defined in subsection (f)(5)(B)) in that fiscal year compared with such proportion for the previous fiscal year. "(B) ADDITIONAL CONSIDERATIONS.— In making rec- ommendations under subparagraph (A), the Secretary may also consider— "(i) unexpected changes by physicians in response to the implementation of the fee schedule; "(ii) unexpected changes in outlay projections; "(iii) changes in the quality or appropriateness of care; and "(iv) any other relevant factors not measured in the resource-based payment methodology. "(C) SPECIAL RULE FOR 1992 UPDATE.— In considering the update for 1992, the Secretary shall make a separate deter- mination of the percentage and relationship described in clauses (ii) and (iii) of subparagraph (A) with respect to the category of surgical services (as defined by the Secretary pursuant to subsection (j)(D). "(D) EXPLANATION OP UPDATE. — The Secretary shall in- clude in each report under subparagraph (A)^ "(i) the update recommended for each category of physicians' services (established by the Secretary under subsection (j)(D) and for each of the following groups of physicians' services: nonsurgical services, visits, con- sultations, and emergency room services; "(ii) the rationale for the recommended update (or updates) for each category and group of services de- scribed in clause (i); and
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