[Federal Register Volume 88, Number 217 (Monday, November 13, 2023)]
[Rules and Regulations]
[Pages 77514-77522]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-24709]



[[Page 77514]]

=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AR01


VA Pilot Program on Graduate Medical Education and Residency

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

-----------------------------------------------------------------------

SUMMARY: The Department of Veterans Affairs (VA) adopts as final, with 
changes, a proposed rule amending its medical regulations to establish 
a new pilot program on graduate medical education and residency, as 
required by section 403 of the John S. McCain III, Daniel K. Akaka, and 
Samuel R. Johnson VA Maintaining Internal Systems and Strengthening 
Integrated Outside Network Act of 2018.

DATES: This rule is effective December 13, 2023.

FOR FURTHER INFORMATION CONTACT: Andrea Bennett, Office of Academic 
Affiliations, Veterans Health Administration, Department of Veterans 
Affairs, at (202) 368-0324 or [email protected].

SUPPLEMENTARY INFORMATION: On February 4, 2022, VA published a proposed 
rule in the Federal Register (87 FR 6456) to revise its medical 
regulations to establish the Pilot Program on Graduate Medical 
Education and Residency (PPGMER) in Sec. Sec.  17.243 through 17.248 of 
title 38, Code of Federal Regulations (CFR). The proposed rule provided 
a framework to establish additional medical residency positions at 
certain covered facilities, consistent with the John S. McCain III, 
Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems 
and Strengthening Integrated Outside Network Act of 2018 (the Act), 
Public Law (Pub. L.) 115-182. Section 403 of the Act, codified as a 
note to section 7302 of title 38 United States Code (U.S.C.), 
establishes parameters for VA to determine the covered facilities in 
which residents will be placed (including prioritization of certain 
covered facilities such as those operated by an Indian Tribe or tribal 
organization), and authorizes VA to pay resident stipends and benefits 
as well as certain startup costs of new residency programs when 
residents are placed in such programs. VA provided a 60-day comment 
period.
    On March 25, 2022, prior to the end of the 60-day comment period, 
VA published a second proposed rule (87 FR 17050) to extend the comment 
period by 90 days to end on July 5, 2022, to ensure tribal stakeholders 
were aware of the proposed rule and had sufficient time to provide 
meaningful input. On March 30, 2022, VA sent a letter to tribal leaders 
and tribal health program leadership to inform them of the rulemaking 
and to provide information for a virtual information session for tribal 
leaders on April 19, 2022, and a virtual tribal consultation on May 10, 
2022. The transcripts from those events are available as part of this 
rulemaking docket on www.regulations.gov.
    VA received 19 comments on the proposed rule from four large 
professional medical organizations, six tribes and tribal 
organizations, and numerous members of the public. All 19 comments were 
supportive of the rule, and we thank the commenters for their 
thoughtful and detailed feedback. We address the substantive 
recommendations and clarify certain aspects about the program below. We 
adopt the proposed rule as final with two substantive changes and one 
minor technical change as described in more detail below.

 Sec.  17.243--Purpose and Scope

    Section 17.243, as proposed, provided a broad overview of the 
authority for the PPGMER as well as general description of the function 
and scope of the PPGMER. One commenter recommended revising Sec.  
17.243 to include a description from the regulatory impact analysis 
that accompanied the proposed rule of the ``numerous benefits the 
program will offer to both veterans and non-veterans'' and the 
explanation of how the PPGMER will ``fulfill the VA's broader 
missions.'' The commenter stated that including this information in the 
purpose and scope at 38 CFR 17.243 would ``strengthen the VA's argument 
for both the compelling need and the statutory authority of this 
regulation.'' Because the purpose and scope section is a broad overview 
of the authority for the PPGMER, not a detailed explanation of the many 
benefits it may provide, we make no changes to the rule based on this 
comment.

Sec.  17.245--Covered Facilities

    Section 17.245, as proposed, listed the covered facilities in which 
residents may be placed under the PPGMER, consistent with section 
403(a)(2) of the Act. Multiple commenters recommended VA add additional 
facilities to the covered facilities explicitly listed in Sec.  17.245. 
In particular, they suggested the inclusion of Rural Health Clinics, 
rural training sites, ``non-VA facilities with ACGME-accredited GME 
programs in non-contiguous areas,'' Urban Indian Organization 
facilities, and consortia of Indian Health Service, Tribal, and Urban 
Indian Organization (``I/T/U'') facilities. The commenters stated that 
the inclusion of these additional covered facilities would improve 
access to health care for either underserved populations and/or 
individuals in rural locations.
    We make no changes to the rule based on these comments. As 
proposed, the language in Sec.  17.245(f) already allows VA to consider 
those types of facilities as covered facilities for the purposes of the 
PPGMER. The language proposed by VA to describe the six categories of 
covered facilities in Sec.  17.245(a) through (f) is almost identical 
to the language Congress used to describe the covered facilities in 
section 403(a)(2)(A) through (F) of the Act. The first five paragraphs 
of both the statute and the regulation enumerate five specific 
categories of health care facilities that are considered covered 
facilities for purposes of the PPGMER. Both authorities then provide a 
sixth and final category allowing VA to consider any other health care 
facilities deemed by VA to be appropriate for participation.
    As stated in the proposed rule, the language of 38 CFR 17.245(f) 
provides VA the ability to place residents in a variety of facilities 
without curtailing the discretion given to VA in section 403(a)(2)(F) 
of the Act. Explicitly listing the five facilities suggested by the 
commenters as additional covered facilities in 38 CFR 17.245 does not 
provide additional flexibility beyond what is provided in paragraph 
(f). VA intends to use the inclusive authority of paragraph (f) to the 
maximum extent possible, which will allow for potential resident 
placements at all facilities meeting the intent of the pilot program; 
we do not anticipate placing limitations on which facilities may be 
considered. Therefore, further specificity in the regulation does not 
substantively impact whether these five additional categories of 
facilities may be deemed appropriate covered facilities by VA.

Placement of Residents

    Prior to addressing certain comments on proposed Sec. Sec.  17.246 
through 17.248 that concern the placement of residents under the 
PPGMER, we first clarify VA's role in such placements under both its 
traditional graduate medical education (GME) programming and the new 
PPGMER. In administering traditional GME programming, VA forms 
relationships with non-VA institutions that sponsor GME programs (most 
often medical schools or teaching hospitals),

[[Page 77515]]

and it is those sponsoring institutions that provide the residents that 
would be available for placement in VA facilities. The same would be 
true for the PPGMER.
    VA, therefore, does not control the pool of participating 
educational programs or available residents, although VA does assess 
the requirements for traditional GME placements under 3 U.S.C. 7302(e) 
to determine the best placement locations for such residents in VA 
facilities, and VA will do similarly for the PPGMER in accordance with 
the provisions in 38 CFR 17.246 and 17.247. VA in effect then does not 
place residents but does provide for resident positions to be filled in 
VA facilities under its traditional GME programming and will similarly 
provide for resident positions to be filled in covered facilities as 
defined in Sec.  17.245 under the PPGMER.

Sec.  17.246(a)--Placement of Residents

    Section 17.246, as proposed, established factors that VA would 
consider when determining in which covered facilities residents would 
be placed under the pilot, consistent with section 403(a)(4) of the 
Act. We received multiple comments requesting modifications and 
additions to the consideration factors for placement of residents found 
in 38 CFR 17.246(a). Paragraphs (a)(1) through (6) of Sec.  17.246 
enumerate six specific factors VA will consider in determining the 
clinical need for health care providers before determining resident 
placements. These six factors use almost identical language to the 
language used in section 403(a)(4)(A) through (G) of the Act. 
Additionally, the final factor listed in 38 CFR 17.246(a)(7) gives VA 
the ability to consider any other criteria important in determining 
which covered facilities are not adequately serving area veterans, 
consistent with section 403(a)(4)(G) of the Act.
    We considered each comment related to 38 CFR 17.246(a) and address 
each individually below. However, we make no changes to 38 CFR 
17.246(a) due to the flexibility provided in paragraph (a)(7), which 
equips VA to consider all other important criteria not otherwise 
specifically listed in paragraphs (a)(1) through (a)(6) when 
determining resident placement (and further provides a non-exhaustive 
list of such other criteria as examples in (a)(7)(i) and (ii)). VA 
intends to use the broad consideration permitted by paragraph (a)(7), 
along with the six specific factors in paragraphs (a)(1) through (6), 
to ensure that every covered entity submitting a proposal for resident 
placement receives consideration to the maximum extent authorized by 
section 403(a)(4) of the Act.
    Sec.  17.246(a)(1). One commenter recommended that the term 
``general practitioners and specialists'' be changed to ``primary care 
physicians and other specialists.'' This commenter also requested that, 
when determining the ratio of veterans to VA providers under this 
paragraph, VA calculate separate ratios for internal medicine and for 
family medicine. The commenter stated that the term ``primary care 
physicians and specialists'' would be inclusive of family medicine 
practitioners who provide women's health care and young adult care and 
are well-positioned to serve the entire veteran population, while 
internal medicine focuses exclusively on adult medicine. We do not make 
changes based on this comment. We believe the term ``general 
practitioners'' captures the category of ``primary care physicians'' 
suggested by the commenter, and further, we would not want to unduly 
restrict consideration only to ``primary care physicians,'' which would 
be in conflict with the clear language of the statute as stated in 
section 403(a)(4)(A) of the Act. We also do not believe that further 
distinguishing the ratios of primary care providers between internal 
medicine and family medicine will have a significant impact on the 
success of the PPGMER, although any important criteria related to these 
distinctions may be considered under 38 CFR 17.246(a)(7).
    Sec.  17.246(a)(1)(i). Two commenters expressed concern with VA's 
decision to use ``county'' to define a ``standardized geographic area'' 
for the placement factors enumerated in Sec.  17.246(a)(1) and (2). One 
commenter believed that using ``county'' as the standard would not 
account for ``truly remote areas such as non-contiguous states.'' This 
commenter did not offer a recommendation for an alternate standard, but 
emphasized that Hawaii has unique healthcare challenges in a non-
contiguous area with a high population of Native Hawaiians and Pacific 
Islanders and would like VA to include them to the extent authorized by 
law. Another commenter asked VA to apply a standard similar to the one 
used to designate a health professional shortage area (HPSA) under 42 
U.S.C. 254e(a)(1), ``which need not conform to the geographic 
boundaries of a political subdivision and which is a rational area for 
the delivery of health services,'' as justification for removing the 
requirement to rely on geographic area based on county in this 
paragraph.
    VA believes that a ``county'' can both account for truly remote 
areas and serve as a ``rational area for the delivery of health 
services'' in line with the standard established in 42 U.S.C. 
254e(a)(1). Further, a ``county'' is a simple standard in the context 
of Sec.  17.246(a)(1) and (2) to provide clarity to covered facilities 
submitting proposals as well as to VA in evaluating proposals. As 
stated in the proposed rule, the factors in 38 CFR 17.246(a)(1) and (2) 
that use the ``county'' standard are only two of six enumerated factors 
VA will consider in determining the clinical need for health care 
providers in an area. VA may therefore consider all other important 
criteria using the authority in paragraph (a)(7) to ensure 
consideration of these commenters' concerns, to include being in a non-
contiguous State. We make no change to the rule based on these 
comments.
    Sec.  17.246(a)(3). One commenter requested that VA ``draw upon a 
combination of resources beyond the OIG [Office of Inspector General] 
report'' to assess whether the specialty of a provider is included in 
the most recent staffing shortage determination in 38 CFR 17.246(a)(3). 
We make no changes to the rule based on this comment. The language used 
in the regulation for this factor is almost identical to the language 
in section 403(a)(4)(C) of the Act. Additionally, the OIG report has 
consistently been the manner in which VA determines its yearly staffing 
shortages and we have no reason to believe this data will be 
insufficient. VA may further consider all other important criteria 
using the authority of 38 CFR 17.246(a)(7), including any relevant 
information derived from sources beyond the OIG report.
    Sec.  17.246(a)(5). One commenter stated that HPSA designations may 
not be an adequate measure of the clinical need for health care 
providers in a non-contiguous area. The commenter specifically 
requested that VA use its authority under section 403(a)(4)(G) of the 
Act to grant special allowance for non-contiguous areas to be 
considered as an important criterion for determining resident 
placement. We make no change to the rule based on this comment. The 
HPSA standard used in 38 CFR 17.246(a)(5) is directed by section 
403(a)(4)(E) of the Act. However, as mentioned previously, 38 CFR 
17.246(a)(7) provides VA the ability to consider the unique situation 
of all covered facilities submitting proposals, including the clinical 
need for health care providers in a non-contiguous area. The HPSA 
standard in Sec.  17.246(a)(7) will not limit VA's ability to consider

[[Page 77516]]

non-contiguous areas when determining resident placement.
    Additional Specific Criteria. Two commenters suggested VA add 
additional consideration factors when determining the placement of 
residents. One commenter recommended that VA explicitly include ``the 
accessibility of gender and sexual orientation services'' to the 
``other criteria'' in Sec.  17.246(a)(7). Another commenter recommended 
we add ``availability of culturally sensitive healthcare options'' and 
``ongoing healthcare shortages at a covered facility.'' Because these 
factors may be considered using the authority in 38 CFR 17.246(a)(7), 
we make no changes to the rule to explicitly include them.

Sec.  17.246(b)--Priority in Placements

    Consistent with section 403(a)(5) of the Act, Sec.  17.246(b), as 
proposed, established that there would be a prioritized placement of at 
least 100 residents under the PPGMER. In the proposed rule, we 
clarified that VA would interpret the term ``residents'' to refer to 
the unique, individual physicians participating in the PPGMER and would 
not interpret the term ``residents'' to refer to each individual 
residency position (or ``slot'') in which an individual physician 
participating in the PPGMER would be placed. We further explained that 
multiple PPGMER participants could occupy a single residency position 
while individually counting toward the priority placement mandate. 
Multiple commenters expressed disagreement with our proposed 
interpretation, stating VA should interpret ``residents'' to mean 
``residency positions'' and should aim to place more than 100 
individual physicians into these priority placements. The commenters 
expressed concern that VA's interpretation in the proposed rule was 
indicative of VA's intention only to place 100 individual physicians 
and no more.
    We make no changes to the rule based on these comments. The term 
``resident'' is commonly understood as a reference to a unique, 
individual person in the medical context, as Merriam-Webster defines 
``resident'' (in the medical context) to mean a physician serving a 
residency. See Merriam-Webster Dictionary Online, ``resident,'' 
www.merriam-webster.com. This definition aligns with VA's 
interpretation that in the medical context, ``resident'' refers to the 
individual physician participating in a residency program. As we noted 
in the proposed rule, interpreting ``residents'' to refer to the 
unique, individual physicians participating in the PPGMER, not the 
residency positions themselves, is also consistent with a plain reading 
of section 403(a)(5) of the Act. That plain reading, both on its own 
and when using the aforementioned medical definition of ``resident'', 
supports VA's decision to consider priority placement of ``no fewer 
than 100 residents,'' not 100 resident positions. Counting the unique, 
individual physicians who are placed in covered facilities given 
priority is the most logical way to ensure we meet Congressional 
intent.
    We emphasize that we do not interpret anything in section 403 of 
the Act nor this rulemaking to limit how many unique, individual 
physicians may serve in covered facilities given priority in 
placements. That is, VA may exceed the minimum requirement for priority 
in placements in the PPGMER.
    We received a related comment requesting that VA ``reserve'' a 
minimum of ten percent of resident positions created by the PPGMER for 
Indian Health Service and tribal health care facilities. We make no 
change to the rule based on this comment. As an initial matter, it is 
unclear from the comment whether the ten percent would be ten percent 
of the minimum 100 residents placed in prioritized facilities under 
section 403(a)(5) of the Act, or ten percent of the total resident 
positions created by the PPGMER. Regardless, we do not read any 
authority in section 403 of the Act allowing VA to reserve a percentage 
of residents for a particular covered facility. Subsection (a)(5) is 
the sole provision in section 403 of the Act related to prioritization 
of resident placement in particular covered facilities. While it does 
not expressly require VA to reserve any percentage of resident 
placement to Indian Health Service and tribal care facilities, we note 
that three of the four enumerated categories of covered facilities in 
which no fewer than 100 residents must be placed are those operated by 
the Indian Health Service, an Indian tribe, or a tribal organization.
    We further believe that regulating additional criteria in Sec.  
17.246(b) to place no fewer than 100 residents under section 403(a)(5) 
the Act would be arbitrary and unnecessarily restrictive because the 
need for residents among the four types of prioritized facilities could 
shift over the life of the PPGMER, and VA's selection of facilities for 
resident placement will be based on information VA receives pursuant to 
the request for proposal (where that information will vary each cycle 
that VA issues the request for proposal).

Sec.  17.246--Weighting of Factors

    Section 17.246, as proposed, did not specify any particular 
weighting of consideration factors for placement of residents under the 
PPGMER. We received multiple comments stating VA should specify the 
weighting to be given to each consideration factor for placement of 
residents. Some commenters believed that VA should be transparent about 
how it will weigh factors and another commenter stated that VA's 
decision directly contradicts Congressional intent to give priority to 
placements in covered facilities operated by the Indian Health Service, 
an Indian Tribe, a tribal organization, or located in communities 
designated as undeserved. We make no changes based on these comments. 
The consideration factors and priority in placements listed in Sec.  
17.246 are a restating of the factors listed in section 403(a)(4) and 
(5) of the Act, and section 403 of the Act does not otherwise establish 
any weighting of the factors. As stated in the proposed rule, weighting 
is not further included in the regulatory text itself so that VA 
maintains flexibility to adjust the relative importance of each 
consideration factor throughout the duration of the PPGMER. Consistent 
with 38 CFR 17.247(a)(1), each request for proposal will describe the 
specific consideration factors that will be used to evaluate responses, 
along with the relative importance of each factor.
    Because this is a pilot program, it is imperative that VA retain 
the ability to make crucial changes from year to year, addressing the 
outcome and lessons learned from prior resident placements and 
accounting for any changes in the medical and educational landscape. 
The decision not to include weighting in the regulation ensures VA can 
fully meet the intent of the PPGMER.

Sec.  17.247--Request for Proposal

    Section 17.247, as proposed, stated that a request for proposal 
(RFP) would be issued by VA Central Office to VA health care facilities 
announcing opportunities for residents to be placed in covered 
facilities and to have costs paid or reimbursed in accordance with 
Sec.  17.248. The proposed rule further stated that VA health care 
facilities, in collaboration with covered facilities, would submit 
responses to the RFP directly to VA Central Office. Multiple commenters 
stated that establishing a process where the RFP is issued directly to 
VA health care facilities, and subsequently entrusting those facilities 
to announce the RFP and collect responses from potential covered 
facilities, could prevent consideration of

[[Page 77517]]

facilities that do not currently have an affiliate relationship with 
VA. The commenters recommended that VA publicly announce the RFP and 
allow proposals to be submitted directly by covered facilities.
    We agree that the RFP process contemplated in the proposed rule 
could limit VA's ability to reach the facilities intended for 
participation the PPGMER. Therefore, we will change proposed Sec.  
17.247(a), which states that ``VA Central Office will issue a request 
for proposal (RFP) to VA health care facilities to announce 
opportunities for residents to be placed in covered facilities and to 
have costs paid or reimbursed under Sec.  17.248'' and remove the 
phrase ``to VA health care facilities,'' so the sentence states that 
``VA Central Office will issue a request for proposal (RFP) to announce 
opportunities for residents to be placed in covered facilities and to 
have costs paid or reimbursed under Sec.  17.248.'' This change will 
ensure there is no limitation on how VA Central Office may issue the 
RFP.
    We make two similar changes to clarify that covered facilities will 
submit responses to the RFP directly to VA Central Office. We will 
change proposed Sec.  17.247(b), which states that ``VA health care 
facilities, in collaboration with covered facilities, will submit 
responses to the RFP to VA Central Office'' and remove the phrase ``VA 
health care facilities, in collaboration with'' so the paragraph states 
that ``covered facilities will submit responses to the RFP to VA 
Central Office.'' We also change proposed paragraph (c), which states 
that ``consistent with paragraph (a) of this section, VA Central Office 
will evaluate responses to the RFP from VA health care facilities and 
will determine those covered facilities where residents may be placed 
and costs under Sec.  17.248 are paid or reimbursed'' and remove the 
phrase ``from VA health care facilities'' so it states, ``consistent 
with paragraph (a) of this section, VA Central Office will evaluate 
responses to the RFP and will determine those covered facilities where 
residents may be placed and costs under Sec.  17.248 are paid or 
reimbursed.''
    These changes to Sec.  17.247 ensure that all potential covered 
facilities may be considered for participation in the PPGMER and 
alleviate any burden on VA health care facilities to serve as an 
intermediary to announce, collect, and submit responses to the RFP to 
VA Central Office. VA believes these changes to the RFP process address 
the commenters' concerns, meet the intent of the PPGMER to reach 
underserved areas, and clarify that the PPGMER is not a public funding 
opportunity or grant program.

Sec.  17.248--Costs

    Section 403(a)(6) of the Act authorizes VA to pay the proportionate 
cost of stipends and benefits for residents participating in the 
PPGMER. In addition to stipends and benefits, if a covered facility 
establishes a new residency program and is selected for PPGMER 
participation, section 403(b) of the Act authorizes VA to reimburse 
certain initial costs associated with establishing that program. The 
statutory provisions related to these costs are codified and further 
clarified in 38 CFR 17.248.
    Multiple commenters requested that VA amend the regulation to allow 
covered facilities with established residency programs to be eligible 
for reimbursement of costs associated with program operation. 
Specifically, these commenters requested VA cover expenses such as 
incremental costs for additional residents or slots, costs associated 
with expanding an existing GME program, costs for a ``wide range of 
necessities'' in operating residency programs, and costs that support 
tribes in attracting high quality providers (and setting aside a tribal 
allocation for this purpose).
    We make no change to the rule based on these comments. The 
statutory authority is clear--unlike section 403(a)(2)(F) and 
(a)(4)(G), which provide VA the authority to consider ``such other'' 
covered facilities and consideration criteria when determining resident 
placements, the cost provisions in section 403(a)(6) and (b) of the Act 
are finite. Congress has not authorized VA to expand payment or 
reimbursement of costs beyond those expenses specifically enumerated in 
statute.
    Additionally, one commenter suggested that VA offer scholarships to 
residents participating in the PPGMER. We do not believe VA has 
authority under section 403 of the Act to offer any type of PPGMER-
specific scholarship to residents placed under the PPGMER. PPGMER costs 
related to support of residents (as opposed to support of new residency 
programs) are provided in section 403(a)(6) of the Act, which limits 
payments to only stipends and benefits for residents placed under the 
PPGMER program.
    Additionally, one commenter provided recommendations for how VA 
should execute funding principles during administration of the PPGMER. 
Although these suggestions are administrative in nature and do not 
directly impact the regulation, we address each to provide further 
information to stakeholders. The commenter suggested VA should fund 
actual costs, rather than a predetermined amount per resident; should 
make awards of no less than five years in duration; and should allow 
participation in any other Federal GME program if no costs were 
duplicated among the funding agencies. While not specifically stated, 
we believe these recommendations are related to the reimbursable 
expenses permitted for new residency programs in accordance with 
17.248(b)(1) (since the commenter stated these expenses are ``above and 
beyond'' the stipends and benefits permitted under 17.248(a)). First, 
section 403(b) of the Act provides specific and limited authority for 
the types of expenses that can be reimbursed under the PPGMER. VA will 
treat the PPGMER equitably with its existing GME programming and will 
not exceed VA's established maximum amounts for these types of payments 
under any existing GME agreements. Second, the authority for the PPGMER 
ends in 2031, which would provide a very limited window to make awards 
no less than five years in duration. Finally, participation in the 
PPGMER will not preclude participating in other Federal GME programs 
provided no costs are duplicated among the funding agencies. We make no 
changes based on these comments.

Reporting and Evaluation

    Multiple commenters provided input related to the reporting 
requirement contained in section 403(c) of the Act requiring VA to 
provide yearly reports to Congress on the implementation of the PPGMER. 
While these reports will be submitted by VA directly to Congress, the 
data used to compile these reports must be collected by the covered 
facilities and residents participating in the PPGMER.
    One commenter requested that VA ensure that reporting requirements 
are not burdensome and only include data required by section 403(c) of 
the Act. Two commenters requested that VA explicitly include any 
reporting requirements in regulation, and one of those commenters also 
requested that VA outline how it will store the collected data. One 
commenter further requested that VA include three questions for 
evaluation of the pilot program in the final regulation, specifically: 
(1) was the PPGMER successful in accomplishing a predetermined goal; 
(2) does the PPGMER provide increased access for veterans to 
comprehensive primary care

[[Page 77518]]

and needed specialty care; and (3) are the physicians trained under the 
PPGMER continuing to provide access to veterans after training, and in 
areas of greatest need? We thank these commenters for their feedback, 
but we make no changes to the rule based on these comments. VA intends 
to collect only the data explicitly required by section 403(c) of the 
Act and will provide those statutory requirements in the RFP, which is 
in line with the commenter's suggestion to only request data required 
by section 403(c) of the Act and would not be more burdensome than 
required. VA will not include additional questions evaluating the 
PPGMER in regulation, as it would be unnecessary. The aim of the 
Paperwork Reduction Act (PRA) is to reduce the total amount of 
paperwork burden the Federal government imposes on private businesses 
and citizens, and VA does not want to add any additional burden when we 
do not believe the commenter's suggested questions would provide 
additional value in evaluating the PPGMER. VA will use only the 
reporting requirements stated in the Act. Additionally, VA will not 
provide information on data storage in regulation because requirements 
for the handling of Federal records are contained in 36 CFR chapter 
XII, subchapter B, parts 1220 through 1234, and further detailed in VA 
Directive 6300, Records Information and Management (September 21, 
2018). Further information on data collection and the estimated 
paperwork burden for the PPGMER is outlined in the PRA section of this 
rulemaking.
    Additionally, one commenter pointed out that VA did not outline a 
plan for data collection in the proposed rulemaking. After publication 
of the proposed rule, VA published a Federal Register notice detailing 
the information collection related to this rulemaking. See 87 FR 65852 
(November 1, 2022). That Federal Register notice is available as part 
of this rulemaking docket on www.regulations.gov.

Impact Analysis

    One commenter provided extensive feedback on the regulatory impact 
analysis (RIA) associated with the rulemaking. Much of the commenter's 
input focused on the methodology and costing used to formulate the RIA, 
and did not relate to the regulatory framework proposed by VA. However, 
the commenter stated that the RIA provided information on the benefits 
of the PPGMER and how it will fulfill VA's broader mission, which 
should be included in the purpose and scope in 38 CFR 17.243. We thank 
the commenter for this feedback but make no changes to the rule. It 
would be unnecessary to describe the PPGMER's potential benefits in 
regulation, and VA will keep the purpose and scope focused on the 
framework of the rulemaking. Regarding the commenter's input on the RIA 
itself, the RIA details the anticipated need for rulemaking and sets 
out the assumptions and methodology used to determine the estimated 
financial impact of the PPGMER and the associated rulemaking. This 
estimate was created using regular VA business practices for its 
current GME programming.

Clarifications

    We received multiple comments that we believe warrant 
clarification. Most importantly, multiple comments urged VA to conduct 
a tribal consultation prior to publishing a final rule. As mentioned at 
the beginning of this rulemaking, VA extended the public comment period 
by 90 days in order to conduct both an information session with tribal 
leaders and a full tribal consultation as required by VA policy and 
Executive Order 13175. We received comments from six tribes and tribal 
organizations, and all of the input we received was carefully 
considered as part of this final rulemaking.
    Many commenters seemed to have a general misunderstanding that the 
PPGMER was focused on increasing access to medical care for veterans 
specifically. We reiterate that the focus of this program is on the 
placement of residents who will provide medical care, not on the 
specific demographics of the individuals who will receive medical care 
from such residents. Neither the regulation nor section 403 of the Act 
contain any criteria or curtailments regarding the individuals eligible 
to receive medical care from residents participating in the PPGMER.
    While 38 CFR 17.245(a) allows for resident placements at a VA 
health care facility consistent with section 403(a)(2)(A) of the Act, 
we do not anticipate using the PPGMER to supplement the resident 
positions permanently authorized under VA's existing GME authority. 
Instead, we intend to prioritize placements at non-VA facilities 
outlined in 38 CFR 17.245(b) through (f). While we believe it is 
possible that a veteran could end up receiving medical care from a 
resident participating in the PPGMER, we imagine this situation would 
occur at a non-VA facility and involve a veteran eligible for health 
care through another (non-VA) source.
    Additionally, some comments indicated a misunderstanding that VA is 
involved in the actual selection and placement process of individual 
residents for participation in the PPGMER. One commenter stated that VA 
should clarify how residents are selected for participation, one 
commenter requested VA fill positions with rural and American Indian/
Alaska Native residents, and one commenter provided recommendations for 
how to better incentivize participation in the program.
    As stated in the proposed rule, residents apply to and are hired 
directly by GME institutions, which are most often medical schools or 
teaching hospitals. VA forms relationships with non-VA institutions 
sponsoring GME programs, and it is those sponsoring institutions that 
will provide residents to participate in the PPGMER. VA does not select 
residents for its GME programming authorized under 38 U.S.C. 7302, and 
VA will not deviate from that process in the administration of the 
PPGMER. While VA maintains an affiliate relationship with certain GME 
institutions, placement of residents at VA and non-VA facilities lies 
solely within the discretion of the affiliate institution, not VA. Once 
VA has selected the covered entities where residents will be placed, 
those affiliate institutions will select individual residents to fill 
those PPGMER resident positions.
    One commenter provided multiple recommendations related to the 
actual substance of the training residents participating in the PPGMER 
will receive. Consistent with section 403 of the Act, the regulation 
mentions training only in reference to the standard medical educational 
process and in referencing certain reimbursable costs for new residency 
programs. Because the substantive training of residents is beyond the 
scope of this rulemaking, we do not specifically address these 
comments.
    One commenter asked for clarification as to what VA considers 
``medically underserved.'' VA must consider five or more factors under 
section 401 of the Act, one of which is ``whether the local community 
is medically underserved.'' Under 38 CFR 17.246(a)(4), VA will consider 
whether the local community of a covered entity is designated as 
``underserved,'' and both the statute and the regulation state that VA 
will make the ``underserved'' determination using criteria developed 
under section 401 of the Act. The determination of whether a VA 
facility is underserved is led by VA's Partnered Evidence-Based Policy 
Resource Center (PEPReC). Each year PEPReC, in coordination with VA's 
Office of Veterans Access to Care and

[[Page 77519]]

various program offices, uses intricate statistical modeling to 
generate a list of potentially underserved VA facilities to help local 
and national leaders provide better access to care for veterans. 
Further detailed information on the methodology and model variables 
used to make this determination is available on PEPReC's website at 
www.peprec.research.va.gov under ``Our Projects.''

Other Comments

    We received multiple comments requesting VA take certain actions in 
conjunction with the PPGMER. While these comments are not within the 
scope of the rulemaking itself, we want to acknowledge and briefly 
address the thoughtful input provided by the commenters. We note that 
while these comments are administrative in nature, they could be 
appropriate for inclusion in a covered facility's proposal.
    We received multiple comments urging VA to support residency 
programs at covered facilities already in existence, to include tribal-
affiliated residency programs. We make no changes based on these 
comments. While there is no preference for existing programs over new 
programs in the regulation or in section 403 of the Act, we believe 
existing residency programs at covered facilities will be strong 
candidates for PPGMER resident placements, and tribal-affiliated 
covered facilities will receive priority in placements under 38 CFR 
17.246(b).
    One commenter urged VA to consider how we can provide long-term 
support for small and new residency programs after completion of the 
pilot program. We make no changes based on this comment. Once the pilot 
concludes, VA may only rely on its existing GME authority to fund 
resident salary and benefits for residents placed in VA facilities. 
Certain additional costs, such as VA's share of accreditation fees, may 
be reimbursed using an Educational Cost Contract between VA and the 
sponsoring institution. However, the authority in section 403 of the 
Act is not intended to provide ``long-term support'' as suggested by 
the commenter.
    One commenter suggested VA collaborate with IHS and tribal health 
facilities directly to ``determine specialty specific needs for medical 
residents'' to better serve tribes, and another commenter suggested VA 
engage the VA Advisory Committee on Tribal and Indian Affairs to 
develop and implement the PPGMER, especially the reimbursement 
mechanism. We make no changes based on these comments. VA plans to work 
through its Office of Tribal and Government Relations (OTGR) and the VA 
Advisory Committee on Tribal and Indian Affairs to ensure widest 
dissemination of the RFP to tribal stakeholders, including IHS and 
tribal health facilities.
    One commenter urged VA to ``consider recent successes in residency 
programs at urban facilities as an indicator of the need and impact 
residency programs have in urban AI/AN [American Indian/Alaska Native] 
communities.'' Another commenter requested VA collaborate directly with 
and increase funding to GME programs with high rates of AI/AN 
graduates. We make no changes based on these comments. VA will use the 
statutory criteria to prioritize locations for resident placements 
under 38 CFR 17.246(b), which would include urban AI/AN facilities 
operated by IHS, an Indian tribe, or a tribal organization.
    One commenter wanted VA to provide specific guidance on how rural 
communities will be targeted, and another commenter similarly urged VA 
to expand the pilot in ways that will support the training of more 
physicians in rural communities. We make no changes based on these 
comments. VA will use the statutory criteria to prioritize locations 
for resident placements under 38 CFR 17.246(b), which would include 
facilities located in the same areas as VA facilities designated as 
underserved under 38 CFR 17.246(b).
    Finally, one commenter requested that VA provide a public report to 
inform future policymaking. The commenter suggested that the report 
contain information about the PPGMER such as the VA health care 
facilities that submitted proposals, the covered facilities chosen for 
resident placements, the participating GME affiliates, and the 
specialties of residents participating in the PPGMER. We make no 
changes based on this comment. VA intends to make certain PPGMER 
information available on the Office of Academic Affiliations website 
(www.va.gov/oaa).

Change Not Based on Comments

    VA makes one minor technical change to the definition of ``VA 
health care facility'' in 38 CFR 17.244 to remove the capitalization of 
``Veteran,'' changing the term to ``veteran.'' This change maintains 
consistency of the term's usage throughout these and other VA 
regulations.

Executive Orders 12866, 13563, and 14094

    Executive Order 12866 (Regulatory Planning and Review) directs 
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 14094 (Executive Order on 
Modernizing Regulatory Review) supplements and reaffirms the 
principles, structures, and definitions governing contemporary 
regulatory review established in Executive Order 12866 of September 30, 
1993 (Regulatory Planning and Review), and Executive Order 13563 of 
January 18, 2011 (Improving Regulation and Regulatory Review). The 
Office of Information and Regulatory Affairs has determined that this 
rulemaking is a significant regulatory action under Executive Order 
12866, as amended by Executive Order 14094. The Regulatory Impact 
Analysis associated with this rulemaking can be found as a supporting 
document at www.regulations.gov.

Regulatory Flexibility Act

    The Secretary hereby certifies that this final rule will 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 
through 612). The residents who will be placed in covered facilities 
and have certain stipends and benefits paid for by VA are individuals 
and not small entities. To the extent that any covered facilities are 
small entities, there is no significant economic impact because the 
rulemaking only permits VA's reimbursement of certain start-up costs 
associated with new residency programs. Additionally, there is no 
funding opportunity for which covered facilities may apply to be 
considered and otherwise no economic gain or loss for covered 
facilities associated with this rule. Therefore, pursuant to 5 U.S.C. 
605(b), the initial and final regulatory flexibility analysis 
requirements of 5 U.S.C. 603 and 604 do not apply.

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

[[Page 77520]]

(adjusted annually for inflation) in any one year. This final rule will 
have no such effect on State, local, and Tribal Governments, or on the 
private sector.

Paperwork Reduction Act

    The Paperwork Reduction Act of 1995 (44 U.S.C. 3507) requires that 
VA consider the impact of paperwork and other information collection 
burdens imposed on the public. According to the implementing 
regulations for the Paperwork Reduction Act (5 CFR 1320.8(b)(2)(vi)), 
an agency may not collect or sponsor the collection of information, nor 
may it impose an information collection requirement, unless it displays 
a currently valid Office of Management and Budget (OMB) control number.
    This rule includes provisions constituting collections of 
information under the Paperwork Reduction Act of 1995 that require 
approval by OMB. Accordingly, pursuant to 44 U.S.C. 3507(d), VA is 
submitting a copy of this rulemaking action to OMB for review. The 
proposed rule did not include a PRA notice, and the 60-day notice was 
published separately in the Federal Register on November 1, 2022 (Vol. 
87, No. 210, pages 65852-65853). VA did not receive any public comments 
on the proposed information collection in response to this notice. OMB 
assigns control numbers to collections of information it approves. VA 
may not conduct or sponsor, and a person is not required to respond to, 
a collection of information unless it displays a currently valid OMB 
control number. If OMB does not approve the collection of information 
as requested, VA will immediately remove the provisions containing a 
collection of information or take such other action as is directed by 
OMB.
    Participants in the PPGMER must collect and provide VA with certain 
programmatic data to enable VA to report to Congress on the pilot 
program, as required by statute, until the program terminates on August 
7, 2031. This information would be collected by the residents placed in 
covered facilities under the PPGMER and their GME sponsoring 
institutions. The sponsors themselves will determine the best method 
for collection of the necessary data depending on their own resources 
and staffing. The information to be collected will include required 
elements, such as number of patients seen per day by each resident 
placed in a covered facility under the PPGMER, for the annual report on 
the pilot program submitted to Congress by VA.
    Title: Physician Resident Data Collection.
     Summary of collection of information: This collection of 
information is used to determine the number of patients seen by 
physician residents each day/month under the PPGMER, pursuant to Sec.  
17.243. The information would be collected by residents placed in 
covered facilities under the PPGMER.
     Description of the need for information and proposed use 
of information: This information is needed to calculate the total 
number patients seen by residents placed in covered facilities under 
the PPGMER.
     Description of likely respondents: Participating 
residents.
     Estimated number of respondents per year: 100.
     Estimated frequency of responses per year: 1 time per 
year.
     Estimated average burden per response: 6 hours.
     Estimated total annual reporting and recordkeeping burden: 
600 hours.
     Total estimated cost to respondents per year: VA estimates 
the total annual cost to respondents will be $23,006. The mean hourly 
wage for a resident is $38.34 (for data collection). The estimated wage 
information was taken from VA's internal data systems, using average 
salary data for physician residents in post-graduate years 1 to 3.
    Title: GME Sponsor Annual Data Consolidation.
     Summary of collection of information: This collection of 
information is used to consolidate physician resident data and compile 
an annual report to Congress, pursuant to Sec.  17.243. The GME 
sponsoring institutions will collect the data and provide it to VA for 
inclusion in the report to Congress.
     Description of the need for information and proposed use 
of information: This information is needed to provide data for the 
annual report to Congress.
     Description of likely respondents: GME sponsoring 
institutions.
     Estimated number of respondents per year: 10.
     Estimated frequency of responses per year: 1 time per 
year.
     Estimated average burden per response: 120 hours.
     Estimated total annual reporting and recordkeeping burden: 
1,200 hours.
     Total estimated cost to respondents per year: VA estimates 
the total annual cost to respondents will be $30,708. The mean hourly 
wage for a health information technologist is $25.59 (for data 
consolidation and reporting). The estimated wage information was taken 
from the Bureau of Labor Statistics from the following website: https://www.bls.gov/oes/current/oes_nat.htm.

Congressional Review Act

    Pursuant to the Congressional Review Act (5 U.S.C. 801 et seq.), 
the Office of Information and Regulatory Affairs designated this rule 
as not a major rule, as defined by 5 U.S.C. 804(2).

List of Subjects in 38 CFR Part 17

    Administrative practice and procedure, Colleges and universities, 
Education, Government contracts, Health care, Health facilities, Health 
professions, Indians, Medical and dental schools, Reporting and 
recordkeeping requirements, Scholarships and fellowships, Schools, 
Veterans.

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, signed and approved 
this document on September 14, 2023, 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.

Luvenia Potts,
Regulation Development Coordinator, Office of Regulation Policy & 
Management, Office of General Counsel, Department of Veterans Affairs.

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

PART 17--MEDICAL

0
1. Amend the authority citation for part 17 by adding an entry for 
Sec. Sec.  17.243 through 17.248 in numerical order to read in part as 
follows:

    Authority:  38 U.S.C. 501, and as noted in specific sections.
* * * * *
    Sections 17.243 through 17.248 are also issued under 38 U.S.C. 
7302 note.
* * * * *

0
2. Add an undesignated center heading and Sec. Sec.  17.243 through 
17.248 to read as follows:

VA Pilot Program on Graduate Medical Education and Residency


Sec.  17.243  Purpose and scope.

    (a) Purpose. This section and Sec. Sec.  17.244 through 17.248 
implement the VA Pilot Program on Graduate Medical Education and 
Residency (PPGMER), which permits placement of residents in existing or 
new residency programs in covered facilities and permits VA to 
reimburse certain costs associated with establishing new residency 
programs in covered facilities, as authorized by section 403 of Public 
Law 115-182.
    (b) Scope. This section and Sec. Sec.  17.244 through 17.248 apply 
only to the

[[Page 77521]]

PPGMER as authorized under section 403 of Public Law 115-182, and not 
to VA's more general administration of graduate medical residency 
programs in VA facilities as authorized under 38 U.S.C. 7302(e).


Sec.  17.244  Definitions.

    For purposes of Sec. Sec.  17.243 through 17.248:
    Benefit means a benefit provided by VA to a resident that has 
monetary value in addition to a resident's stipend, which may include 
but not be limited to health insurance, life insurance, worker's 
compensation, disability insurance, Federal Insurance Contributions Act 
taxes, and retirement contributions.
    Covered facility means any facility identified in Sec.  17.245.
    Educational activities mean all activities in which residents 
participate to meet educational goals or curriculum requirements of a 
residency program, to include but not be limited to: clinical duties; 
research; attendance in didactic sessions; attendance at facility 
committee meetings; scholarly activities that are part of an accredited 
training program; and approved educational details.
    Resident means physician trainees engaged in post-graduate 
specialty or subspecialty training programs that are either accredited 
by the Accreditation Council for Graduate Medical Education or in the 
application process for such accreditation. A resident may include an 
individual in their first post-graduate year (PGY-1) of training (often 
referred to as an intern), and an individual who has completed training 
in their primary specialty and continues training in a subspecialty 
graduate medical education program (generally referred to a fellow).
    Stipend means the annual salary paid by VA for a resident.
    VA health care facility means any VA-owned or VA-operated location 
where VA physicians provide care to veterans, to include but not be 
limited to a VA medical center, independent outpatient clinic, 
domiciliary, nursing home (community living center), residential 
treatment program, and community-based clinic.


Sec.  17.245  Covered facilities.

    A covered facility is any of the following:
    (a) A VA health care facility;
    (b) A health care facility operated by an Indian tribe or tribal 
organization, as those terms are defined in 25 U.S.C. 5304 and at 25 
CFR 273.106;
    (c) A health care facility operated by the Indian Health Service;
    (d) A federally-qualified health center as defined in 42 U.S.C. 
1396d(l)(2)(B);
    (e) A health care facility operated by the Department of Defense; 
or
    (f) Other health care facilities deemed appropriate by VA.


Sec.  17.246  Consideration factors for placement of residents.

    (a) General. When determining in which covered facilities residents 
will be placed, VA shall consider the clinical need for health care 
providers in an area, as determined by VA's evaluation of the following 
factors:
    (1) The ratio of veterans to VA providers for a standardized 
geographic area surrounding a covered facility, including a separate 
ratio for general practitioners and specialists.
    (i) For purposes of paragraphs (a)(1) and (2) of this section, 
standardized geographic area means the county in which the covered 
facility is located.
    (ii) VA may consider either or both of the ratio(s) for general 
practitioners and specialists, where a higher ratio of veterans to VA 
providers indicates a higher need for health care providers in an area.
    (2) The range of clinical specialties of VA and non-VA providers 
for a standardized geographic area surrounding a covered facility, 
where the presence of fewer clinical specialties indicates a higher 
need for health care providers in an area.
    (3) Whether the specialty of a provider is included in the most 
recent staffing shortage determination by VA under 38 U.S.C. 7412.
    (4) Whether the covered facility is in the local community of a VA 
facility that has been designated by VA as an underserved facility 
pursuant to criteria developed under section 401 of Public Law 115-182.
    (5) Whether the covered facility is located in a community that is 
designated by the Secretary of Health and Human Services as a health 
professional shortage area under 42 U.S.C. 254e.
    (6) Whether the covered facility is in a rural or remote area, 
where:
    (i) A rural area means an area identified by the U.S. Census Bureau 
as rural; and
    (ii) A remote area means an area within a zip-code designated as a 
frontier and remote area (FAR) code by the Economic Research Service 
within the United States Department of Agriculture, based on the most 
recent decennial census and to include all identified FAR code levels.
    (7) Such other criteria as VA considers important in determining 
those covered facilities that are not adequately serving area veterans. 
These factors may include but are not limited to:
    (i) Proximity of a non-VA covered facility to a VA health care 
facility, such that residents placed in non-VA covered facilities may 
also receive training in VA health care facilities.
    (ii) Programmatic considerations related to establishing or 
maintaining a sustainable residency program, such as: whether the 
stated objectives of a residency program align with VA's workforce 
needs; the likely or known available educational infrastructure of a 
new residency program or existing residency program (including the 
ability to attract and retain qualified teaching faculty); and the 
ability of the residency program to remain financially sustainable 
after the cessation of funding that VA may furnish under Sec.  17.248.
    (b) Priority in placements. For the duration in which the PPGMER is 
administered, no fewer than 100 residents will be placed in covered 
facilities operated by either the Indian Health Service, an Indian 
tribe, a tribal organization, or covered facilities located in the same 
areas as VA facilities designated by VA as underserved pursuant to 
criteria developed under section 401 of Public Law 115-182.


Sec.  17.247  Determination process for placement of residents.

    Section 403 of Public Law 115-182 does not authorize a grant 
program or cooperative agreement program through which covered 
facilities or any other entity may apply for residents to be placed in 
covered facilities or to apply for VA to pay or reimburse costs under 
Sec.  17.248. VA therefore will not conduct a public solicitation to 
determine those covered facilities in which residents may be placed or 
to determine costs that may be paid or reimbursed under Sec.  17.248. 
VA will instead determine those covered facilities in which residents 
may be placed and determine any costs to be paid or reimbursed under 
Sec.  17.248 in accordance with the following parameters:
    (a) VA Central Office will issue a request for proposal (RFP) to 
announce opportunities for residents to be placed in covered facilities 
and to have costs paid or reimbursed under Sec.  17.248. This RFP will 
describe, at a minimum:
    (1) Consideration factors to include the criteria in Sec.  17.246, 
that will be used to evaluate any responses to the RFP, as well as the 
relative importance of such consideration factors;
    (2) Information required to be in any responses to the RFP; and

[[Page 77522]]

    (3) The process to submit a response to the RFP.
    (b) Covered facilities will submit responses to the RFP to VA 
Central Office.
    (c) Consistent with paragraph (a) of this section, VA Central 
Office will evaluate responses to the RFP and will determine those 
covered facilities where residents may be placed and costs under Sec.  
17.248 are paid or reimbursed.


Sec.  17.248  Costs of placing residents and new residency programs.

    Once VA determines in which covered facilities residents will be 
placed in accordance with Sec. Sec.  17.246 through 17.247, payment or 
reimbursement is authorized for the following costs:
    (a) Resident stipends and benefits. For residents placed in covered 
facilities, VA may pay only the proportionate cost of resident stipends 
and benefits that are associated with residents participating in 
educational activities directly related to the PPGMER, in accordance 
with any contract, agreement, or other arrangement VA has legal 
authority to form.
    (b) Costs associated with new residency programs. (1) If a covered 
facility establishes a new residency program in which a resident is 
placed, VA will reimburse the following costs in accordance with any 
contract, agreement, or other arrangement VA has legal authority to 
form.
    (i) Curriculum development costs, to include but not be limited to 
costs associated with needs analysis, didactic activities, materials, 
equipment, consultant fees, and instructional design.
    (ii) Recruitment and retention of faculty costs, to include but not 
be limited to costs associated with advertising available faculty 
positions, and monetary incentives to fill such positions such as 
relocation costs and educational loan repayment.
    (iii) Accreditation costs, to include but not be limited to the 
administrative fees incurred by a covered facility in association with 
applying for only initial accreditation of the program by the 
Accreditation Council for Graduate Medical Education (ACGME).
    (iv) Faculty salary costs, to include only the proportionate cost 
of faculty performing duties directly related to the PPGMER.
    (v) Resident education expense costs, to include but not be limited 
to costs associated with the required purchase of medical equipment and 
required training, national resident match program participation fees, 
and residency program management software fees.
    (2) VA considers new residency programs as only those residency 
programs that have initial ACGME accreditation or have continued ACGME 
accreditation without outcomes, and have not graduated an inaugural 
class, at the time VA has determined those covered facilities where 
residents will be placed under Sec.  17.247(c).

[FR Doc. 2023-24709 Filed 11-9-23; 8:45 am]
BILLING CODE 8320-01-P