[Page numbers followed by b, f, n, or t, refer to boxed text, figures, footnotes, or tables, respectively.]
A
Access to care
adjustments to address provider shortages, 29, 56–57, 117, 147
hospital wage index policy adjustment add-ons to improve, 62
Phase 2 study goals, 147
research needs, 113–114
Accountability
of data providers, 4
integration of care and, 58
Accountable Care Act, 58
Accuracy of data
for creation of payment areas, 45–46
current system, 4, 31, 70–72
definition, 4, 16n, 31
for hospital wage index calculation, 70
Occupational Employment Statistics, 74–77
proxy data for physician income, 117, 124–125
relative value units, 118
strategies for improving, 4
study goals, 2, 16–17, 18b, 29, 146
Accuracy of payments to facilities, 2, 15–16
Administrative burden of geographic adjustment
current hospital cost reporting and review, 73
labor market segmentation and, 55–56, 58
use of Bureau of Labor Statistics data and, 77, 82
Administrative staff of physician practice, 130
Advanced practice nurses, 148
Affordable Health Care for America Act, 17, 29, 30
Agency for Healthcare Research and Quality, 21
Ambulatory surgical centers, 9, 79–81, 83
American Community Survey
access to data, 128
commuting data, 94
employee compensation data, 132
for GPCI calculation, 125, 126–127t, 128–129
limitations, 128–129
physician work adjustment data, 11–12
scope of, 128
American Housing Survey, 13
American Medical Association, 23, 118
Average hourly wage
accuracy, 72, 81
health care practitioners, 54–55, 54t
health care sectors, 54–55, 54t
hospital wage index computations, 62–65, 81
inputs and weighting, 73, 78–79
Occupational Employment Statistics for calculation of, 74, 81
B
Balanced Budget Act, 22, 87
Basic Allowance for Housing, 13
Beneficiaries of Medicare
age distribution, 17
current coverage, 1, 17
economic status, 17
geographic distribution, 17
health status, 17
impact of geographic adjustment determinations, 2
nonelderly, 1, 17
Benefits valuation
in Bureau of Labor Statistics data, 75, 82
in hospital wage index, 71–72, 75, 82
Blum, Jonathan, 19b
Braley, Bruce, 28b
Budget neutrality adjustments, 29, 89, 90b
GPCI, 115–117
Bureau of Labor Statistics, 12
health care sector data, recommendations for use of, 8, 12, 58–59, 81–82, 141
labor market smoothing with data from, 89
See also Occupational Employment Statistics
C
Capital as factor of production in health care system, 37–38, 81
Care transitions, 58
Center for Studying Health System Change, 122
Centers for Medicare and Medicaid Services
administrative costs, 55–56, 58, 73, 77, 82
perception of geographic adjustment policy recommendations and implementation, 19b
recommendations for, 8, 9, 10, 12, 13, 82, 83, 139–140, 141
use of statistical areas, 43–45, 44b
See also Medicare
Combined statistical areas, 44b
Commuting, 7
consideration of, in current adjustment and classification system, 93–94
data sources, 94
hospital wage index adjustments, 22, 86–87
labor market smoothing based on, 88, 93–102, 107–109
modeling techniques, 9
patterns, 95, 96t
recommendations for smoothing labor market borders and payment areas, 9–10, 109–110
Section 505 adjustment for, 87
significance of, in setting labor market boundaries, 42
wage index smoothing, 53
Congress, U.S., 2, 16, 29–30
recommendations for, 8, 81–82
Contiguous-county smoothing
implementation, 91b
results of simulations, 91–93, 92t, 93t
shortcomings, 109
technical development, 89
Contract wages
in hospital wage index, 72, 75–76
as percent of hospital personnel expenses, 75–76
Conversion factor, 115
Core-based statistical areas, 44b, 85, 93–94
Cost-share weights, 10, 25, 118–119, 139
Cost Survey for Single Specialty Practices, 135
Critical access hospitals, 62
Current Procedural Terminology, 23, 25, 114
Customary, prevailing, and reasonable, 118
D
Dartmouth Atlas Project, 30, 52
Data sources
access to, 12, 117, 128
commuting patterns, 94
current concerns and criticisms, 4, 16, 31
for geographic variation in physician income, 121–122
for GPCI cost-share weights, 119
for input price determinations, 2, 4
on labor market conditions, 4–5, 32
for labor market smoothing, 89
physician office rent, 13, 132–135, 136t, 141–142
physician salary, 11–12
for physician work adjustment, 4, 124–129
for practice expenses GPCI adjustments, 130, 132
professional liability insurance premiums, 137–138
proxies for physician income calculation, 10–11
quality of current hospital wage index data, 70–74
recommendations for CMS access to BLS data, 12, 141
recommendations for GPCI construction, 8, 12–13, 58–59, 141–142
recommendations for hospital wage index construction, 8, 58–59, 81–82
research framework, 2–3, 33–34
strategies for improving hospital data, 73–74
study goals, 2, 4, 16–17, 18b, 31, 147
See also Accuracy of data
Department of Defense, 13
Department of Health and Human Services, 2, 8, 13, 16
E
Employee compensation
data sources, 130, 132
geographic adjustment rationale, 1–2
health sector-level wages, 130
occupational mix, 130
End-stage renal disease, 1, 17
Energy costs, 81
Equity issues, 17
F
Factors of production
definition, 37
scope of, in health care system, 37–38
scope of geographic variation in costs, 38
See also Input prices, health care
Frontier states, 22, 22n, 24f, 50b, 88, 92, 110, 115
G
General Services Administration, 13, 132, 142
Geographic adjustment, generally
budget neutrality in, 29, 89, 90b, 115, 117
consistent criteria for, 5, 32
current concerns and criticisms, 2, 15–16
definitional issues, 2, 48
policy adjustment and, 6, 10, 33
price and cost distinctions in methodology for, 19–21, 38–39, 59
rationale, 1, 15, 17–18, 31, 37, 113
study goals, 2, 16–17, 18b, 29–30, 146
See also Geographic adjustment factors; Geographic practice cost indexes (GPCIs); Hospital wage index; Research on geographic adjustment
Geographic adjustment factors
component adjusters, 25, 113, 118
county-level versus payment area, 51, 55
criticisms of, 29
effects of, in health care system, 3b, 17
for hospitals, 39b
for practitioners, 39b, 43–45
purpose and application, 1–2, 15, 17–18, 39b, 45–46
study goals, 3b, 18b
variation within payment areas, 51
See also Geographic practice cost indexes (GPCIs); Hospital wage index
Geographical information systems, 105
Geographic practice cost indexes (GPCIs)
budget neutrality, 115–117
components, 7, 25, 39b, 113, 114, 118. See also specific components
cost share weight calculations, 118–119, 119t
current concerns and criticisms, 2, 51, 115–117, 124–125
current structure and operations, 1, 15, 25, 114–117
future of exceptions, 110
historical evolution, 116b
hospital wage index and, 5–6, 32–33
implementation of recommendations for, 13–14
nonclinical labor-related expenses, 13, 25
office rent component, 13
one-quarter adjustments, 11, 140
payment areas, 117–118
price and cost distinctions, 85, 115
quality of current data sources, 4, 5, 31, 32, 117, 138–139
recommendations for cost-share-weight calculations, 10, 139
recommendations for data sources for construction of, 8, 12, 58–59, 141–142
recommendations for labor market and payment area definition, 7–8, 57–58, 118
recommendations for occupational inputs, 12, 141–142
recommendations for setting percentage of work adjustment, 11–12, 140
recommendations for smoothing labor market borders and payment areas, 9, 109–110
recommendations for use of physician income proxies, 10–11, 139–140
relative value units, 25–26
strategies for improving geographic adjustment system, 5–6, 32–33
study goals, 2, 3b, 18b, 138–139
update schedule, 115, 132
See also Physician payment areas; Physician work adjustment
Geospatial smoothing, 88
with inverse distance weighting, 105–107
nearest neighbor model, 102–105
Grassley, Charles, 28b
H
Health Care and Education Reconciliation Act, 29
Health care practitioners
average wages, 54–55, 54t
consideration of all economic sectors in labor market definition, 4–5, 32, 39, 42, 48–50, 59
definition of, 1n, 15n, 113n
distribution, Medicare payment system and, 2, 3b, 147
distribution of employment shares by region and statistical areas, 79t
employee compensation in physician practices, 130, 132
Phase 2 study goals, 2, 147
quality of cost data, 4, 31
study goals, 2, 3b, 17, 18b
trends, 148
See also Geographic practice cost indexes (GPCIs)
Health information technology, 148
Health technicians, 130
Healthcare Common Procedure Coding System, 23, 114
Home health agencies
hospital wage index calculations, 9, 79–81, 83
study goals, 2, 18b
Hospice facilities, 79–81
Hospital cost survey data, 7, 8
Hospital Outpatient Departments, 79–81
Hospital payment areas
alternative approaches to defining, 52–53
current structure, 42–43
metropolitan statistical areas and, 46–48
physician payment areas and, 7–8, 53–55, 57–58
reclassification appeals, 48
Hospital referral regions, 52
Hospital service areas, 52
Hospital wage index
administrative burden of reporting and review, 73, 77
alternative approaches to defining labor markets for, 52–53
benefits valuation in, 71–72, 75, 82
calculation from Occupational Employment Statistics, 74–79
case mix adjustment, 62
circularity problem in data, 50–51, 71
comparative effects of adjustments in different geographic areas, 62, 63t
contract wages in, 72, 75–76
current data sources and calculation methodology, 1, 2, 4, 5, 7, 8, 18–21, 31, 32, 39b, 42–43, 61–67, 81
current geographic distribution, 22, 23f
data needs for calculating, 70
exceptions and reclassifications, 22, 86–88, 109, 110
for facilities other than acute care hospitals, 9, 79–81, 83
future of exceptions, 110
GPCI and, 5–6, 32–33
historical evolution, 68–69b
hospital-specific, 52–53
implementation of recommendations for, 13–14
inputs and weighting, 9, 73, 78–79, 82–83
objectives for smoothing labor market borders, 88–89
occupational mix in calculation of, 9, 21, 39–40, 78–79
origins, 61
policy adjustment add-ons, 62
pre-classified, pre-floor, 79, 80n, 86
price and cost distinctions, 19–21, 61, 85
purpose, 15, 38, 61
quality of current data sources, 4, 5, 31, 32, 70–74, 81
recommendations for data sources for construction of, 7, 8–9, 58–59, 81–82, 83
recommendations for labor market and payment area definition, 7–8, 57–58, 118
recommendations for occupational inputs, 9, 82
recommendations for revision of controlling statute, 8, 81–82
recommendations for smoothing labor market borders and payment areas, 9–10, 109–110
rural floors, 87–88
strategies for improving data for, 73–74
strategies for improving geographic adjustment system, 5–6, 32–33
study goals, 2, 3b, 18b
transparency of cost report data, 72
types of labor market adjustments and exceptions, 86, 87t
use of all-industry or health sector data in calculation of, 4–5, 32, 39, 42, 48–50, 59, 70–71, 74–75, 75t, 76
volatility, 50, 76
wage data for defining, 48–51
See also Hospital payment areas
Housing costs, 41
I
Index floors, 10
Indexes, defined, 1n, 15, 16b
Inflation, 118–119
Inpatient Prospective Payment System (IPPS)
current methodology, 18–19
current reclassifications and exceptions, 24f
geographic adjustment in, 1–2, 15, 38–39
hospital wage index calculation, 61–62, 86
number of hospitals by labor market, 71t
Inpatient psychiatric facilities, 79–81
Inpatient rehabilitation facilities, 79–81
Input prices, health care
concerns about current geographic adjustment system determinations, 2
geographic adjustment rationale, 1, 37
for GPCI calculations, 10
GPCI cost-share weights, 118–119
inflationary changes over time, 118–119
major factors of production, 37–38
price and cost distinctions in methodology for geographic adjustment, 19–21, 38–39, 51, 59
quality of data, 4, 31
recommendations for GPCI calculation, 12, 13, 141–142
recommendations for hospital wage index calculation, 9, 82–83
source data for determination of, 2, 117
study goals, 2, 17, 18b
variation within payment areas, 117–118
Inverse distance weighting function, 105–107
IPPS. See Inpatient Prospective Payment System
L
Labor market areas, 53
Labor markets
alternative approaches to defining, 52–57
average wages, 54–55, 54t
as basis for geographic adjustment, 37, 40
boundary setting, 41–42, 85
conceptual framework, 6, 33
consideration of all economic sectors in definition of, 4–5, 32, 39, 42, 48–50, 59
defined by geopolitical units, 52–53
definition of, in geographic adjustment methodology, 2, 21, 38, 85
determinants of wage differentials, 40–41
as factor of production in health care system, 37–38
geographic variation in costs, 38, 40–41
hospital wage index exceptions and reclassifications, 22, 23f
number of, 5, 32
occupational mix in, 9, 12, 21, 27–28, 39–40
quality of data, 4–5, 32
recommendations for defining, 7–8, 57–58, 85, 118
recommendations for smoothing borders of payment areas and, 109–110
types of adjustments and exceptions, 86, 87t
updates, 58
wage data for defining, 48–51
See also Hospital payment areas; Payment areas; Physician payment areas; Smoothing labor market borders and payment areas
Land
as factor of production in health care system, 37–38
See also Rent
Licensed practical nurses, 39–40, 130
Long-term care hospitals, 79–81
Low-income communities
cost of providing health care services in, 121
hospital wage index adjustments, 62
Lugar County reclassifications, 24f, 50b, 86, 94
M
Malpractice. See Professional liability insurance
Medicaid and Medicare Extension Act, 123
Medical equipment, 38
Medical Group Management Association, 11–12, 13, 120, 125, 129, 135, 140, 142, 148
Medicare
coverage, 1, 17
current payment system, 18–28, 20f, 26f, 114–118
policy adjustments, 6
scope of geographic adjustment in, 1–2, 15
spending, 1, 17
See also Beneficiaries of Medicare; Geographic adjustment, generally
Medicare dependent hospitals, 23f
Medicare Economic Index, 10, 118–119, 129
Medicare Geographic Classification Review Board, 22n, 24f, 48, 50b, 86–87
Medicare Modernization Act, 22, 50b, 87, 123
Medicare Part B, 2, 12, 26f, 30, 115n, 141, 147
Medicare Payment Advisory Commission, 78, 80f, 89
Medicare Severity-Diagnosis Related Group, 19, 62, 67
Metropolitan statistical areas (MSAs)
in construction of hospital payment areas, 42
geographic distribution, 43f
number of, 5, 7, 21, 32, 42–43, 43n, 46, 55, 56
wage variation within, 53, 55
See also MSA/statewide non-MSA system
Micropolitan statistical areas, 42
definition and characteristics, 44b
geographic distribution, 43f
MSAs. See Metropolitan statistical areas
MSA/statewide non-MSA system
advantages, 58
commuting behavior considerations in, 93
distribution of employment shares by health care occupation, 79t
hospital payment areas, 42, 46–49, 53
hospital wage index reclassifications, 86–87
to influence provider distribution, 29, 56–57, 117
iterated approach, 56–57
as labor market proxy, 46, 53, 85
origins of, 44b
physician income variation within, 121–122
physician payment areas, 55–56
recommendations for labor market definition based on, 7–8, 57–58, 118
rural floor adjustments, 87–88
separation of high-cost MSAs, 56
See also Metropolitan statistical areas (MSAs); Micropolitan statistical areas; Statewide non-MSA statistical areas
N
National Compensation Survey, 75, 82
O
Occupational Employment Statistics
access to data, 77, 82
accuracy, 74–77
administrative burden of using, 77
employee compensation data, 130
for GPCI calculation, 124–125, 126–127t, 128
inputs and weighting, 78–79
labor market smoothing with data from, 89
limitations, 128
purpose, 74
recommendations for use of, 8, 10, 82
scope of survey, 74, 128
timeliness of data, 77
Occupational mix
in Bureau of Labor Statistics data, 78–79
in calculation of occupational mix adjustment, 65–67
in employee compensation data sources, 130
employment shares by geographic region and statistical areas, 79t
in hospitals, 21, 39–40
physician payment area variations, 27–28, 39
in physician practice, 131t
recommendations for calculation of hospital wage index, 9, 82–83
recommendations for GPCI calculation, 12, 141–142
required staffing levels, 78
similarities between needs of physician offices and hospitals, 53–54, 54t
Occupational mix adjustment
average hourly wage computations, 73
hospital wage index calculations, 64–67, 81
Occupational mix survey, 67, 70
Office of Management and Budget, 42
Office visits, 118
Omnibus Budget Reconciliation Act, 23, 115, 137
Omnibus Reconciliation Act, 86
Outmigration adjustment
commuting pattern-based smoothing, 93–102
purpose, 22, 87
recommendations for smoothing, 9, 110
See also Commuting; Section 505 reclassifications
P
Patient Protection and Affordable Care Act, 19b, 22, 88, 115
Payment areas
conceptual framework, 6, 33, 38
creation of new, 45–46
current concerns and criticisms, 2, 16
in current geographic adjustment system, 2, 7, 38
GPCI, 117–118
hospital wage index exceptions and reclassifications, 22
for hospitals, construction of, 42–43
need for consistent criteria in geographic adjustment, 5, 32
practice cost variation within, 27, 51, 117–118
recommendations for definition of, 7–8, 57–58, 118
recommendations for smoothing borders of labor markets and, 109–110
statewide consolidation, 45
study goals, 2, 18b
wage data for defining, 48–51
See also Hospital payment areas; Physician payment areas; Smoothing labor market borders and payment areas
Physician Assistants, 148
Physician Compensation and Production Survey, 125, 126–127t, 129
Physician Cost Survey, 13
Physician Fee Schedules, 23–25
basis for, 114
components, 113
in geographic adjustment system, 1–2, 15, 23–25
recommendations for future update methodology, 10, 139
Physician payment areas
administrative costs to Centers for Medicare and Medicaid Services, 55–56, 58
alternative strategies for defining, 53–57
construction of, 43–45
current concerns and criticisms, 27–28, 51, 57–58
current structure, 27, 27f, 43–45
in GPCI, 39b
hospital payment areas and, 7–8, 53–55, 57–58
metropolitan statistical areas and, 55, 56–57, 56t
number of, 55–56, 56t, 118
recommendations for, 7–8, 57–58
role in distribution of providers, 56–57
Physician Practice Information Survey, 119, 125, 126–127t, 129
Physician work adjustment, 39b
choices in level and scope of, 120–124
cost-share weight calculations, 118–119, 119t
current concerns and criticisms, 28
data sources for, 124–129, 140
definition, 25, 114
non-geographic factors, 11
office rent component, 13, 132–135, 136t, 141–142
proxy professions, 10–11, 123–125, 139–140
purpose, 120
recommendations for, 10–12, 139–140
statistical modeling, 11–12, 140
unique challenges in calculation of, 120
See also Geographic practice cost indexes (GPCIs)
Policy adjustments
geographic adjustments to address provider shortages, 29, 56–57, 117, 147
hospital wage index adjustments, 62, 86
Phase 2 study goals, 10, 17, 18, 33, 110, 147
purpose, 6, 18, 110
study goals and, 113–114
Population health, 2, 3b, 17
Poverty among Medicare beneficiaries, 17
Practice expenses
adjustment goals, 129
cost-share weight calculations, 10, 118–119, 119t, 139
data sources, 4, 16, 31
definition, 25, 114
employee compensation component, 13, 130–132, 142
occupational mix, 2, 12, 130, 132, 141
office rent component, 13, 132–135, 142
recommendations for GPCI calculations, 10, 12, 13, 139, 141, 142
as share of GPCI, 129
variation within payment areas, 27, 51
See also Physician work adjustment; Professional liability insurance
Primary Care Service Area, 52
Professional liability insurance, 7, 39b
as component of Physician Fee Schedule, 113, 114
cost-share weight calculations, 10, 118–119, 119t, 139
coverage, 137
definition, 25
GPCI data collection and calculation, 137–138
perceived need, 137
premiums, 137
source of geographic variation, 137
Prospective payment systems
geographic adjustment in, 1–2, 15
Medicare evolution, 38, 39
recommendations for hospital wage index calculation, 9, 83
Provider shortages, 29, 56–57, 117, 147
Proxy data, 4, 31, 141
MSA as labor market proxy, 46
for practice inputs, 117, 122, 123–124, 125
recommendations for, 10–11, 12, 139–140
in smoothing, 92, 107
Q
Quality of care
future research, 2, 17
study goals, 2, 3b, 18b
R
Reclassification
current IPPS hospitals, 24f
hospital labor market adjustments, 48, 86–87
smoothing of labor market borders and payment areas to replace, 7, 10, 22, 110
strategies to minimize wage cliffs, 50b
Recommendations
for Centers for Medicare and Medicaid Services, 8, 9, 10, 82, 83, 139–140, 141
for Congress, 8, 81–82
for determining nonclinical labor-related expenses, 13, 142
for determining office rent costs, 13, 141–142
for geographic practice index calculation, 7–8, 12, 57–59, 141
for hospital wage index calculation, 7–9, 57–59, 81–83
implementation, 13–14, 19b, 145, 147–148
for labor market definition, 7–8, 57–58
research framework for, 2–3, 33–34
for smoothing labor market borders and payment areas, 9–10, 109–110
for use of proxies for physician income calculations, 10–11, 139–140
Registered nurses
average wages, 54, 54t
geographic variation in pay, 38
occupational mix calculation, 39–40, 130
required staffing levels, 78
REIS, Inc., 13
Relative value units, 11
accuracy, 118
definition and function, 114–115
in GPCI calculations, 23, 25, 118
importance of, in current payment system, 118
types of, 114
Rent
data sources, 132–135, 136t
as factor of production in health care system, 37–38
geographic variation in costs, 38
recommendations for determining prices, 13, 141–142
Research on geographic adjustment
challenges, 146–147
data needs on physician compensation, 122
data sources, 2, 4, 31
Phase 2 report, 2, 114, 118, 139, 145, 146, 147
scope of study, 2, 146
study framework, 2–3, 33–34
study goals, 2, 3b, 18b, 29–30, 113–114
underlying principles and assumptions for, 4–6, 31–33
Resource-Based Relative Value Set, 115, 118
Retrospective cost reimbursement, 38
Rural areas, 110
cost of providing health care services in, 121
occupational mix, 76
physician earnings in, 122–123
Rural floor adjustments, 23f, 50b, 87–88, 92
Rural referral center hospitals, 23f, 62, 110
S
Schwartz, Allyson, 30b
Section 401 reclassifications, 24f
Section 505 reclassifications, 19, 50b, 87, 94. See also Outmigration adjustment
Section 508 reclassifications, 50b
Self-employed physicians, 120
Services sector, 13, 81
Short-term and acute care hospitals, 2, 18b
Skilled nursing facilities
hospital wage index calculations, 9, 79–81, 83
study goals, 2, 18b
Smoothing labor market borders and payment areas, 7
budget neutrality adjustments in, 89, 90b
commuting pattern-based, 88, 93–102, 107–109
comparison of current and alternative approaches to, 107–109, 108t
contiguous-county approach, 88, 89–93
design objectives, 88–89
geospatial methods, 88, 102–109
implementation, 9
need for, 85
outmigration adjustment for, 9, 22
policy adjustments and, 110
positive and negative adjustments, 89, 91b, 97–99, 110
purpose, 9, 10, 22, 53, 85, 88
recommendations for, 9–10, 109–110
to replace system of exceptions and reclassifications, 7, 10, 22, 109, 110
techniques, 9, 88
thresholds for county eligibility, 109–110
use of Bureau of Labor Statistics data for, 89
Smoothing of wage index values, 53
Social Security Act, 23, 115
recommendations for revision of hospital wage index provisions, 8, 81–82
Sole community hospital, 23f, 62
Statewide non-MSA statistical areas
consolidation within, 45
definition, 44b
distribution, 43f
hospital payment areas and, 42
input price variation within, 47–48, 117–118
number of, 5, 7, 21, 27, 32, 42–43, 45
See also MSA/statewide non-MSA system
T
Tax Relief and Healthcare Act, 67
Teaching hospitals, 62
Timeliness of hospital cost report data, 72, 73–74, 77
Transitions, care. See Care transitions
Transparency
Bureau of Labor Statistics data, 77
concerns about current geographic adjustment system, 2, 16
of hospital cost report data, 72, 77, 82
to improve data quality, 4, 31
of process for reviewing geographic adjustment system, 6, 33
study goals, 2, 18b
use of confidential data sources, 12, 82
U
U.S. Postal Service, 13
V
Value of care
future research, 2, 17, 148
study goals, 2, 3b, 18b
W
Wage cliffs
commuting pattern-based smoothing adjustments, 97
definition, 42
extent of problem, 47–48
hospital wage index adjustments to reduce, 86, 88
inverse distance weighting to smooth, 106, 106t
strategies for reducing, 50b
Wage comparability criteria, 86–87
Worksheet S-3, 62, 72, 73, 77, 82, 89