[Federal Register Volume 79, Number 5 (Wednesday, January 8, 2014)]
[Rules and Regulations]
[Pages 1332-1333]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2014-00098]



38 CFR Part 17

RIN 2900-AO51

Removal of Penalty for Breaking Appointments

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.


SUMMARY: The Department of Veterans Affairs (VA) amends its regulations 
to remove an outdated regulation that stated that a veteran who misses 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. VA removes 
this penalty because we believe it 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.

DATES: Effective Date: This rule is effective February 7, 2014.

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: On April 15, 2013, VA published in the 
Federal Register (78 FR 22219) a proposed rule to amend VA regulations 
by removing Sec.  17.100. This regulation stated 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 and no 
further treatment will be provided to that veteran, except in emergency 
situations, unless the veteran agrees to cooperate by keeping future 
appointments. We stated that this penalty is inconsistent with VA's 
goal of providing patient-centered care, may interfere with continuity 
and coordination of care, and could have a negative impact on the 
therapeutic relationship. In addition, refusing to provide further 
medical services to certain veterans, including homeless veterans and 
other veterans who lack reliable telephone access or dependable 
transportation to and from scheduled appointments is counterproductive 
and may discourage them from attempting to access care in the future. 
Lastly, providing treatment only in emergent circumstances does not 
provide an adequate safety net for our patients, especially those with 
chronic or poorly controlled medical conditions.
    Interested persons were invited to submit comments to the proposed 
rule on or before June 14, 2013, and we received six comments. All of 
the comments were supportive of removing Sec.  17.100, and did not 
suggest changes to the proposed removal of the rule. However, two 
commenters raised issues that we believe should be addressed.
    One commenter expressed support for removing this regulation, but 
suggested a different approach to addressing the issue of broken 
appointments. The commenter suggested that, after two consecutive 
missed appointments, VA should follow a series of steps to contact the 
veteran and to place a limit (``moratorium'') on the care available to 
the veteran on the particular health issue.
    VA appreciates the commenter's input. However, VA has determined 
that the appropriate course of action is to remove the penalty for 
breaking appointments. In practice, the problem of missed appointments 
has been adequately addressed through internal VA processes, as well as 
by using non-punitive measures and maintaining an open channel of 
communication between VA clinical/administrative staff and veterans. 
The penalty contemplated by Sec.  17.100 is incompatible with 
regulatory changes implemented after that regulation was published, is 
not in line with current practice, and is inconsistent with VA's 
patient-centered approach to medical care. Even a short break in a 
course of treatment can interfere with continuity and coordination of 
care, and the punitive nature of the regulation could have a negative 
impact on the therapeutic relationship.
    Another commenter supported removing the penalty for breaking 
medical appointments, but stated that the regulation should be removed 
because it violates due process protections. VA disagrees. The 
regulation we remove by this final rule did not terminate a benefit; it 
merely attempted to facilitate efficient delivery of limited health 
care resources. The veteran remained enrolled to receive health care, 
and could receive treatment for any emergent condition that may arise. 
To schedule a non-emergency medical appointment, the veteran merely had 
to agree to attend the appointment. In any event, this issue is moot 
because we are removing the penalty.
    This commenter also suggested that VA should employ social workers 
to be responsible for tracking and contacting veterans who habitually 
miss medical appointments. VA does use various methods to follow up 
with those veterans in an effort to ensure they receive necessary 
medical care. Veterans are contacted via mail, phone, or electronic 
means after a missed appointment, and are encouraged to contact VA to 
    We do not make any changes based on these comments.
    Based on the rationale set forth in the proposed rule and in this 
final rule, VA is adopting the provisions of the

[[Page 1333]]

proposed rule as final, and removes Sec.  17.100.

Effect of Rulemaking

    Title 38 of the Code of Federal Regulations, as revised by this 
final rulemaking, represents VA's implementation of its legal authority 
on this subject. Other than future amendments to this regulation or 
governing statutes, no contrary guidance or procedures are authorized. 
All existing or subsequent VA guidance must be read to conform with 
this rulemaking if possible or, if not possible, such guidance is 
superseded by this rulemaking.

Paperwork Reduction Act

    This final rule contains no provisions constituting a collection of 
information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-

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-
612. This final rule will directly affect only individuals and will 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 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'' requiring review by the Office of 
Management and Budget (OMB), unless OMB waives such review, 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 final rule have been examined, and it has been 
determined not to be a significant regulatory action under Executive 
Order 12866. VA's impact analysis can be found as a supporting document 
at http://www.regulations.gov, usually within 48 hours after the 
rulemaking document is published. Additionally, a copy of the 
rulemaking and its impact analysis are available on VA's Web site at 
http://www1.va.gov/orpm/, by following the link for ``VA Regulations 

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 final rule will have no such effect on 
State, local, and tribal governments, or on the private sector.

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. Jose D. 
Riojas, Chief of Staff, Department of Veterans Affairs, approved this 
document on December 20, 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: January 3, 2014.
Robert C. McFetridge,
Director, Office of Regulation Policy and Management, Office of the 
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:


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. 2014-00098 Filed 1-7-14; 8:45 am]