This regulation, issued on November 24, 2010, outlines several changes to the Medicare program regarding the following: (1) the hospital outpatient prospective payment system, (2) the ambulatory surgical center payment system, (3) payments to hospitals for graduate medical education (GME) costs and indirect medical education (IME) costs, (4) rules governing physician self-referrals and related provider agreements in hospitals where physicians have investment interests or in hospitals owned by physicians, and (4) payments for certified registered nurse anesthetist services in rural and critical access areas. Changes to the hospital and ambulatory surgical centers payments systems will be to the amounts and factors used to determine payment rates. For both GME and IME hospital payments this regulation implements new provisions under the Patient Protection and Affordable Care Act. With respect to physician self-referrals, this regulation introduces new limitations. And as to anesthesia services there will be changes to the effective date of when hospitals can begin receiving reasonable cost payments for these services.