Rule2023-24709
VA Pilot Program on Graduate Medical Education and Residency
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
November 13, 2023
Effective
December 13, 2023
Issuing agencies
Veterans Affairs Department
Abstract
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.
Full Text
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<title>Federal Register, Volume 88 Issue 217 (Monday, November 13, 2023)</title>
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[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 [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-24709]
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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.
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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 <a href="/cdn-cgi/l/email-protection#acfaede1c5dfdfc5c3c2989c9fe4c9c0dcecdacd82cbc3da"><span class="__cf_email__" data-cfemail="9ccaddd1f5efeff5f3f2a8acafd4f9f0ecdceafdb2fbf3ea">[email protected]</span></a>.
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 <a href="http://www.regulations.gov">www.regulations.gov</a>.
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,''
<a href="http://www.merriam-webster.com">www.merriam-webster.com</a>. 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 <a href="http://www.regulations.gov">www.regulations.gov</a>.
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
<a href="http://www.peprec.research.va.gov">www.peprec.research.va.gov</a> 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
(<a href="http://www.va.gov/oaa">www.va.gov/oaa</a>).
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 <a href="http://www.regulations.gov">www.regulations.gov</a>.
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.
<bullet> 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.
<bullet> 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.
<bullet> Description of likely respondents: Participating
residents.
<bullet> Estimated number of respondents per year: 100.
<bullet> Estimated frequency of responses per year: 1 time per
year.
<bullet> Estimated average burden per response: 6 hours.
<bullet> Estimated total annual reporting and recordkeeping burden:
600 hours.
<bullet> 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.
<bullet> 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.
<bullet> Description of the need for information and proposed use
of information: This information is needed to provide data for the
annual report to Congress.
<bullet> Description of likely respondents: GME sponsoring
institutions.
<bullet> Estimated number of respondents per year: 10.
<bullet> Estimated frequency of responses per year: 1 time per
year.
<bullet> Estimated average burden per response: 120 hours.
<bullet> Estimated total annual reporting and recordkeeping burden:
1,200 hours.
<bullet> 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: <a href="https://www.bls.gov/oes/current/oes_nat.htm">https://www.bls.gov/oes/current/oes_nat.htm</a>.
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
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This is legal information, not legal advice. Laws vary by jurisdiction and change frequently. Always verify current law with official sources and consult a licensed attorney in your jurisdiction for advice on your specific situation.