[Federal Register Volume 77, Number 44 (Tuesday, March 6, 2012)]
[Proposed Rules]
[Pages 13236-13238]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2012-5355]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 17
RIN 2900-AO27
Exempting In-Home Video Telehealth From Copayments
AGENCY: Department of Veterans Affairs.
ACTION: Proposed rule.
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SUMMARY: The Department of Veterans Affairs (VA) is proposing to amend
its regulation that governs VA services that are not subject to
copayment requirements for inpatient hospital care or outpatient
medical care. Specifically, the regulation would be amended to exempt
in-home video telehealth care from having any required copayment. This
would remove a barrier that may have previously discouraged veterans
from choosing to use in-home video telehealth as a viable medical care
option. In turn, VA hopes to make the home a preferred place of care,
whenever medically appropriate and possible.
DATES: Written comments must be received on or before April 5, 2012.
ADDRESSES: Written comments may be submitted through
www.Regulations.gov; by mail or hand-delivery to the Director,
Regulations Management (02REG), Department of Veterans Affairs, 810
Vermont Ave. NW., Room 1068, Washington, DC 20420; or by fax to (202)
273-9026. Comments should indicate that they are submitted in response
to ``RIN 2900-AO27]-- Exempting In-home Video Telehealth from
Copayments.'' Copies of comments received will be available for public
inspection in the Office of Regulation Policy and Management, Room
1063B, between the hours of 8 a.m. and 4:30 p.m. Monday through Friday
(except holidays). Please call (202) 461-4902 for an appointment (this
is not a toll-free number). In addition, during the comment period,
comments may be viewed online through the Federal Docket Management
System (FDMS) at www.Regulations.gov.
FOR FURTHER INFORMATION CONTACT: Kristin J. Cunningham, Director
Business Policy, Chief Business Office, Department of Veterans Affairs,
810 Vermont Ave. NW., Washington, DC 20420; (202) 461-1599. (This is
not a toll-free number.)
SUPPLEMENTARY INFORMATION: Many of our nation's veterans must travel
great distances in order to obtain health care at a VA hospital or
medical center. To improve veterans' access to VA health care, VA
established community-based outpatient clinics (CBOCs) located in local
communities. VA has continued its efforts to improve veterans' access
to VA medical care by establishing ``telehealth'' services. Telehealth
allows VA to provide certain medical care without requiring the veteran
to be physically present with the examining or treating medical
professional. Telehealth helps ensure that veterans are able to get
their care in a timely and convenient manner, by reducing burdens on
the patient as well as appropriately reducing the utilization of VA
resources without sacrificing the quality of care provided. The
benefits of using this technology include increased access to
specialist consultations, improved access to primary and ambulatory
care, reduced waiting times, and decreased veteran travel.
VA provides various telehealth services, including clinical video
telehealth and in-home video telehealth care. Clinical video
telehealth, as the name implies, occurs between two clinical settings,
such as two VA Medical Centers (VAMCs), a VAMC and a CBOC, or two
CBOCs. Clinical video telehealth may also connect patient and provider
between VAMCs and VA Centers of Specialized Care, such as those
established for Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI)
and Multiple Sclerosis (MS). Clinical video telehealth uses real-time
interactive video conferencing, sometimes with supportive peripheral
devices, such as a camera to closely examine skin. This allows a
specialist located in another facility to assess and treat a veteran by
providing care remotely.
Like clinical video telehealth, in-home video telehealth care is
used to connect a veteran to a VA health care professional using real-
time videoconferencing, and other equipment as necessary, as a means to
replicate aspects of face-to-face assessment and care delivery that do
not require the health care professional to make an examination
requiring physical contact. However, in-home video telehealth care is
provided in a veteran's home, eliminating the need for the veteran to
travel to a clinical setting. Using telehealth capabilities, a VA
clinician can assess elements of a patient's care, such as wound
management, psychiatric or psychotherapeutic care, exercise plans, and
medication management. The clinician may also monitor patient self-care
by reviewing vital signs and evaluating the patient's appearance on
video.
Prior to this proposed rulemaking, veterans have been required to
pay a copayment for in-home video telehealth care. We believe that VA
has authority by statute to discontinue charging copayments for these
services.
Section 1710(g)(1) of 38 U.S.C. states:
The Secretary may not furnish medical services (except if such
care constitutes hospice care) under subsection (a) of this section
(including home health services under section 1717 of this title) to
a veteran who is eligible for hospital care under this chapter by
reason of subsection (a)(3) of this section unless the veteran
agrees to pay to the United States in the case of each outpatient
visit the applicable amount or amounts established by the Secretary
by regulation.
VA has interpreted section 1710(g)(1) to mean that VA has the
discretion to establish the applicable copayment amount in regulation,
even if such amount is zero. One such implementing regulation is 38 CFR
17.108.
Generally, VA calculates the amount of a copayment based on the
complexity of care provided and the resources needed to provide that
care. In addition, VA may exempt certain care from the copayment
requirement in an effort to make health care more accessible to
veterans, or to encourage veterans to become more actively involved in
their medical care, and thereby improve health care outcomes (which, in
turn, lowers overall health care costs). VA proposes to make in-home
video telehealth care exempt from copayments because it is not used to
provide complex care and its use significantly reduces impact on VA
resources compared to an in-person, outpatient visit. It also reduces
any potential negative impact on the veteran's health that might be
incurred if the veteran were required to travel to a VA hospital or
medical center to obtain the care that would be provided via in-home
video telehealth. VA also wants to encourage veterans to use the in-
home video telehealth care option when their provider finds it
appropriate because we believe that it would help ensure that veterans
comply with outpatient treatment plans by regularly following up with
physicians and medical professionals, taking medication in appropriate
doses on a regular basis, and generally being more engaged with their
VA health care providers.
[[Page 13237]]
As previously stated in this rulemaking, in-home video telehealth
allows a VA clinician to assess the elements of a veteran's care, while
the veteran remains at home. Conversely, clinical video telehealth
assess the veteran's medical condition in a clinical setting using
resources and technology that allows a medical specialist, who may be
hundreds of miles away, to interact with the veteran and provide the
level of care needed to treat the medical condition. VA would not
exempt clinical video telehealth services from the copayment
requirement because the type of care a veteran receives in clinical
video telehealth requires not just the use of CBOC's technological
resources, but also patient interaction between the attending physician
that may be hundreds of miles away, and the medical staff in the CBOC.
The attending medical staff in the CBOC follows the attending
physician's instructions in the placement of the adapted equipment that
is used in clinical video telehealth in order to assess the veteran's
medical condition, to include the set up of the conference, use of the
teleconference room, etc. All of these additional services provide a
veteran a higher level of care than the level of care that the veteran
receives through in-home video telehealth.
Paragraph (e) of Sec. 17.108 contains a list of services that are
not subject to copayment requirements for inpatient hospital care or
outpatient medical care.
Based on the rationale set forth in this preamble, VA proposes to
amend Sec. 17.108(e) by adding a new paragraph (e)(16) to include in-
home video telehealth care as exempt from copayment requirements.
Administrative Procedure Act
Concurrent with this proposed rule, we also are publishing a
separate, substantively identical direct final rule in the ``Rules and
Regulations'' section of this Federal Register. The simultaneous
publication of these documents will speed notice and comment rulemaking
under section 553 of the Administrative Procedure Act should we have to
withdraw the direct final rule due to receipt of significant adverse
comments.
For purposes of the direct final rulemaking, a significant adverse
comment is one that explains why the rule would be inappropriate,
including challenges to the rule's underlying premise or approach, or
why it would be ineffective or unacceptable without change. If
significant adverse comments are received, VA will publish a notice of
receipt of significant adverse comments in the Federal Register
withdrawing the direct final rule.
Under direct final rule procedures, unless significant adverse
comments are received within the comment period, the regulation will
become effective on the date specified above. After the close of the
comment period, VA will publish a document in the Federal Register
indicating that no adverse comments were received and confirming the
date on which the final rule will become effective. VA will also
publish a notice withdrawing this proposed rule.
In the event the direct final rule is withdrawn because of
significant adverse comments, VA can proceed with the rulemaking by
addressing the comments received and publishing a final rule. The
comment period for the proposed rule runs concurrently with that of the
direct final rule. Any comments received under the direct final rule
will be treated as comments regarding the proposed rule. VA will
consider such comments in developing a subsequent final rule. Likewise,
significant adverse comments submitted to the proposed rule will be
considered as comments regarding the direct final rule.
Effect of Rulemaking
The Code of Federal Regulations, as proposed to be revised by this
proposed rulemaking, would represent the exclusive legal authority on
this subject. No contrary rules or procedures would be authorized. All
VA guidance would be read to conform with this rulemaking if possible
or, if not possible, such guidance would be superseded by this
rulemaking.
Paperwork Reduction Act
This document contains no provisions constituting a collection of
information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-
3521).
Regulatory Flexibility Act
The Secretary hereby certifies that this proposed regulatory
amendment would not have a significant economic impact on a substantial
number of small entities as they are defined in the Regulatory
Flexibility Act, 5 U.S.C. 601-612. This rulemaking would not directly
affect any small entities. Only VA beneficiaries would be directly
affected. Therefore, pursuant to 5 U.S.C. 605(b), this amendment would
be exempt from the initial and final regulatory flexibility analysis
requirements of sections 603 and 604.
Executive Orders 12866 and 13563
Executive Orders 12866 and 13563 direct agencies to assess the
costs and benefits of available regulatory alternatives and, when
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, and other advantages; distributive impacts;
and equity). Executive Order 13563 (Improving Regulation and Regulatory
Review) emphasizes the importance of quantifying both costs and
benefits, reducing costs, harmonizing rules, and promoting flexibility.
Executive Order 12866 (Regulatory Planning and Review) defines a
``significant regulatory action,'' which requires review by the Office
of Management and Budget (OMB), as ``any regulatory action that is
likely to result in a rule that may: (1) Have an annual effect on the
economy of $100 million or more or adversely affect in a material way
the economy, a sector of the economy, productivity, competition, jobs,
the environment, public health or safety, or State, local, or tribal
governments or communities; (2) Create a serious inconsistency or
otherwise interfere with an action taken or planned by another agency;
(3) Materially alter the budgetary impact of entitlements, grants, user
fees, or loan programs or the rights and obligations of recipients
thereof; or (4) Raise novel legal or policy issues arising out of legal
mandates, the President's priorities, or the principles set forth in
this Executive Order.''
The economic, interagency, budgetary, legal, and policy
implications of this regulatory action have been examined and it has
been determined not to be a significant regulatory action under
Executive Order 12866.
Unfunded Mandates
The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C.
1532, that agencies prepare an assessment of anticipated costs and
benefits before issuing any rule that may result in expenditure by
State, local, or tribal governments, in the aggregate, or by the
private sector, of $100 million or more (adjusted annually for
inflation) in any given year. This proposed rule would have no such
effect on State, local, or tribal governments, or on the private
sector.
Catalog of Federal Domestic Assistance
The Catalog of Federal Domestic Assistance program number and title
for this proposed rule are as follows: 64.007 Blind Rehabilitation
Centers; 64.008, Veterans Domiciliary Care; 64.009, Veterans Medical
Care Benefits; 64.010, Veterans Nursing Home Care; 64.014,
[[Page 13238]]
Veterans State Domiciliary Care; 64.015, Veterans State Nursing Home
Care; 64.018, Sharing Specialized Medical Resources; 64.019, Veterans
Rehabilitation Alcohol and Drug Dependence; and 64.022, Veterans Home
Based Primary Care.
Signing Authority
The Secretary of Veterans Affairs, or designee, approved this
document and authorized the undersigned to sign and submit the document
to the Office of the Federal Register for publication electronically as
an official document of the Department of Veterans Affairs. John R.
Gingrich, Chief of Staff, Department of Veterans Affairs, approved this
document on February 28, 2012, for publication.
List of Subjects in 38 CFR Part 17
Administrative practice and procedure, Health care, Health
facilities, Mental health programs, Nursing homes, Veterans.
Dated: March 1, 2012.
Robert C. McFetridge,
Director, Office of Regulation Policy and Management, Office of the
General Counsel, Department of Veterans Affairs.
For the reasons set forth in the preamble, we propose to amend 38
CFR part 17 as follows:
PART 17--MEDICAL
1. The authority citation for part 17 continues to read as follows:
Authority: 38 U.S.C. 501, and as noted in specific sections.
2. Amend Sec. 17.108 by adding paragraph (e)(16) to read as
follows:
Sec. 17.108 Copayments for inpatient hospital care and outpatient
medical care.
* * * * *
(e) * * *
(16) In-home video telehealth care.
* * * * *
[FR Doc. 2012-5355 Filed 3-5-12; 8:45 am]
BILLING CODE 8320-01-P