[Federal Register Volume 78, Number 72 (Monday, April 15, 2013)]
[Proposed Rules]
[Pages 22219-22221]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2013-08794]



38 CFR Part 17

RIN 2900-AO51

Removal of Penalty for Breaking Appointments

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.


SUMMARY: The Department of Veterans Affairs (VA) proposes to remove a 
regulation that states that a veteran who misses two medical 
appointments without providing 24 hours' notice and a reasonable excuse 
is deemed to have refused VA medical care. The current regulation 
states that no further treatment will be furnished to a veteran deemed 
to have refused care except in emergency situations, unless the veteran 
agrees to cooperate by keeping future appointments. VA believes that 
the current regulation is incompatible with regulatory changes 
implemented after the regulation was promulgated, is not in line with 
current practice, and is inconsistent with VA's patient-centered 
approach to medical care.

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DATES: Comments must be received by VA on or before June 14, 2013.

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-AO51--Removal of Penalty for Breaking Appointments.'' 
Copies of comments received will be available for public inspection in 
the Office of Regulation Policy and Management, Room 1068, between the 
hours of 8:00 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 

FOR FURTHER INFORMATION CONTACT: Ethan Kalett, Director, Office of 
Regulatory Affairs (10B4), Department of Veterans Affairs, 810 Vermont 
Ave. NW., Washington, DC 20420; (202) 461-5657. (This is not a toll-
free number).

SUPPLEMENTARY INFORMATION: Over the past two decades, there has been a 
dramatic shift in the United States toward providing patient-centered 
medical care. Under this approach, patients are equal partners in 
making treatment decisions, and health care providers deliver care in 
the least restrictive environment practicable. VA has adopted this 
approach and, whenever possible, eliminates both potential and proven 
barriers to care. This is especially important in cases where VA 
provides treatment to vulnerable veteran populations, veterans who rely 
on VA as their primary source of medical care, and those with service-
connected disabilities. This rulemaking will eliminate a potential 
barrier to care by removing 38 CFR 17.100.
    Under the current regulation, breaking two medical appointments 
without providing at least 24 hours' notice and a reasonable excuse is 
deemed a refusal to accept VA treatment. With the exception of 
emergency care, no further treatment is furnished until the veteran 
agrees to cooperate by keeping appointments.
    We propose to remove this regulation because denying follow up 
medical treatment for even a short period can interfere with continuity 
and coordination of care, and the punitive nature of the regulation 
could have a negative impact on the therapeutic relationship. In 
addition, VA has taken steps to encourage certain veterans to use our 
health services, including homeless veterans and other veterans who may 
not have readily available support such as reliable telephone access or 
dependable transportation to and from scheduled appointments. VA 
believes that refusing to provide further medical services to those 
patients because of broken appointments is counterproductive and may 
discourage them from attempting to access care in the future. Further, 
while the current regulation allows VA to provide treatment for an 
emergent condition, we do not believe this provides an adequate safety 
net for our patients, especially those with chronic or poorly 
controlled medical conditions.
    Finally, it is not the current practice of VA to deny care to an 
eligible enrolled veteran who breaks a scheduled appointment. VA's 
outpatient appointment scheduling processes and procedures do not 
include documenting the reason given for a missed appointment. Thus, 
the proposed change will bring regulations in line with current 
    In a note to 38 CFR 17.107 we state, ``Although VA may restrict the 
time, place, and/or manner of care under this section, VA will continue 
to offer the full range of needed medical care to which a patient is 
eligible under title 38 of the United States Code or Code of Federal 
Regulations. Patients have the right to accept or refuse treatments or 
procedures, and such refusal by a patient is not a basis for 
restricting the provision of care under this section.'' Section 17.107 
sets forth procedures for addressing disruptive behavior of patients by 
imposing reasonable restrictions on the care for which they are 
eligible. The regulation we intend to remove deems breaking an 
appointment without 24 hours' notice and a reasonable excuse to be a 
refusal to accept VA treatment, and denies access to further care based 
on that refusal. We believe this is contrary to VA's mission and core 
values, and to Sec.  17.107.

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 proposed rulemaking if 
possible or, if not possible, such guidance would be superseded by this 

Paperwork Reduction Act

    This proposed rule contains no provisions constituting a collection 
of information under the Paperwork Reduction Act of 1995 (44 U.S.C. 

Regulatory Flexibility Act

    The Secretary hereby certifies that this proposed rule 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 proposed rule would directly affect only 
individuals and would not directly affect small entities. Therefore, 
pursuant to 5 U.S.C. 605(b), this rulemaking is exempt from the initial 
and final regulatory flexibility analysis requirements of 5 U.S.C. 603 
and 604.

Executive Order 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,'' requiring 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

[[Page 22221]]

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 the expenditure by 
State, local, and tribal governments, in the aggregate, or by the 
private sector, of $100 million or more (adjusted annually for 
inflation) in any one year. This proposed rule would have no such 
effect on State, local, and tribal governments, or on the private 

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance numbers and titles for 
the programs affected by this document are 64.007, Blind Rehabilitation 
Centers; 64.008, Veterans Domiciliary Care; 64.009, Veterans Medical 
Care Benefits; 64.010, Veterans Nursing Home Care; 64.011, Veterans 
Dental Care; 64.012, Veterans Prescription Service; 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 March 25, 2013, for publication.

List of Subjects in 38 CFR Part 17

    Administrative practice and procedure, Alcohol abuse, Alcoholism, 
Claims, Day care, Dental health, Drug abuse, Foreign relations, 
Government contracts, Grant programs--health, Government programs--
veterans, Health care, Health facilities, Health professions, Health 
records, Homeless, Medical and dental schools, Medical devices, Medical 
research, Mental health programs, Nursing homes, Reporting and 
recordkeeping requirements, Scholarships and fellowships, Travel and 
transportation expenses, Veterans.

    Dated: April 10, 2013.
Robert C. McFetridge,
Director of Regulation Policy and Management, Office of General 
Counsel, Department of Veterans Affairs.

    For the reasons stated in the preamble, the Department of Veterans 
Affairs proposes to amend 38 CFR part 17 as follows:


1. The authority citation for part 17 continues to read as follows:

    Authority: 38 U.S.C. 501, and as noted in specific sections.

Sec.  17.100  [Removed]

2. Remove Sec.  17.100 and the undesignated center heading that 
precedes it.
[FR Doc. 2013-08794 Filed 4-12-13; 8:45 am]