Amendment of Section
Pub. L. 115–182, title I, § 101(a)(1), (b), June 6, 2018, 132 Stat. 1395, 1403; Pub. L. 115–251, title II, § 201, Sept. 29, 2018, 132 Stat. 3171, provided that, effective on the later of the date that is 30 days after the date on which the Secretary of Veterans Affairs submits the report required under section 101(q)(2) of Pub. L. 113–146 (38 U.S.C. 1701 note) or the date on which the Secretary promulgates regulations pursuant to section 101(c) of Pub. L. 115–182 (set out below), this section is amended to read as follows:
§ 1703. Veterans Community Care Program
(a) In General.—(1) There is established a program to furnish hospital care, medical services, and extended care services to covered veterans through health care providers specified in subsection (c).
(2) The Secretary shall coordinate the furnishing of hospital care, medical services, and extended care services under this section to covered veterans, including coordination of, at a minimum, the following:
(A) Ensuring the scheduling of medical appointments in a timely manner and the establishment of a mechanism to receive medical records from non-Department providers.
(B) Ensuring continuity of care and services.
(C) Ensuring coordination among regional networks if the covered veteran accesses care and services in a different network than the regional network in which the covered veteran resides.
(D) Ensuring that covered veterans do not experience a lapse in care resulting from errors or delays by the Department or its contractors or an unusual or excessive burden in accessing hospital care, medical services, or extended care services.
(3) A covered veteran may only receive care or services under this section upon the authorization of such care or services by the Secretary.
(b) Covered Veterans.—For purposes of this section, a covered veteran is any veteran who—
(1) is enrolled in the system of annual patient enrollment established and operated under section 1705 of this title; or
(2) is not enrolled in such system but is otherwise entitled to hospital care, medical services, or extended care services under subsection (c)(2) of such section.
(c) Health Care Providers Specified.—Health care providers specified in this subsection are the following:
(1) Any health care provider that is participating in the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), including any physician furnishing services under such a program.
(2) The Department of Defense.
(3) The Indian Health Service.
(4) Any Federally-qualified health center (as defined in section 1905(l)(2)(B) of the Social Security Act (42 U.S.C. 1396d(l)(2)(B))).
(5) Any health care provider not otherwise covered under any of paragraphs (1) through (4) that meets criteria established by the Secretary for purposes of this section.
(d) Conditions Under Which Care Is Required To Be Furnished Through Non-Department Providers.—(1) The Secretary shall, subject to the availability of appropriations, furnish hospital care, medical services, and extended care services to a covered veteran through health care providers specified in subsection (c) if—
(A) the Department does not offer the care or services the veteran requires;
(B) the Department does not operate a full-service medical facility in the State in which the covered veteran resides;
(C)(i) the covered veteran was an eligible veteran under section 101(b)(2)(B) of the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113–146; 38 U.S.C. 1701 note) as of the day before the date of the enactment of the Caring for Our Veterans Act of 2018;
(ii) continues to reside in a location that would qualify the veteran for eligibility under such section; and
(iii) either—
(I) resides in one of the five States with the lowest population density as determined by data from the 2010 decennial census; or
(II) resides in a State not described in subclause (I) and—
(aa) received care or services under this title in the year preceding the enactment of the Caring for Our Veterans Act of 2018; and
(bb) is seeking care or services within 2 years of the date of the enactment of the Caring for Our Veterans Act of 2018;
(D) the covered veteran has contacted the Department to request care or services and the Department is not able to furnish such care or services in a manner that complies with designated access standards developed by the Secretary under section 1703B of this title; or
(E) the covered veteran and the covered veteran’s referring clinician agree that furnishing care and services through a non-Department entity or provider would be in the best medical interest of the covered veteran based upon criteria developed by the Secretary.
(2) The Secretary shall ensure that the criteria developed under paragraph (1)(E) include consideration of the following:
(A) The distance between the covered veteran and the facility that provides the hospital care, medical services, or extended care services the veteran needs.
(B) The nature of the hospital care, medical services, or extended care services required.
(C) The frequency that the hospital care, medical services, or extended care services needs to be furnished.
(D) The timeliness of available appointments for the hospital care, medical services, or extended care services the veteran needs.
(E) Whether the covered veteran faces an unusual or excessive burden to access hospital care, medical services, or extended care services from the Department medical facility where a covered veteran seeks hospital care,medical services, or extended care services, which shall include consideration of the following:
(i) Whether the covered veteran faces an excessive driving distance, geographical challenge, or environmental factor that impedes the access of the covered veteran.
(ii) Whether the hospital care, medical services, or extended care services sought by the veteran is provided by a medical facility of the Department that is reasonably accessible to a covered veteran.
(iii) Whether a medical condition of the covered veteran affects the ability of the covered veteran to travel.
(iv) Whether there is compelling reason, as determined by the Secretary, that the veteran needs to receive hospital care, medical services, or extended care services from a medical facility other than a medical facility of the Department.
(v) Such other considerations as the Secretary considers appropriate.
(3) If the Secretary has determined that the Department does not offer the care or services the covered veteran requires under subparagraph (A) of paragraph (1), that the Department does not operate a full-service medical facility in the State in which the covered veteran resides under subparagraph (B) of such paragraph, that the covered veteran is described under subparagraph (C) of such paragraph, or that the Department is not able to furnish care or services in a manner that complies with designated access standards developed by the Secretary under section 1703B of this title under subparagraph (D) of such paragraph, the decision to receive hospital care, medical services, or extended care services under such subparagraphs from a health care provider specified in subsection (c) shall be at the election of the veteran.
(e) Conditions Under Which Care Is Authorized To Be Furnished Through Non-Department Providers.—(1)(A) The Secretary may furnish hospital care, medical services, or extended care services through a health care provider specified in subsection (c) to a covered veteran served by a medical service line of the Department that the Secretary has determined is not providing care that complies with the standards for quality the Secretary shall establish under section 1703C.
(B) In carrying out subparagraph (A), the Secretary shall—
(i) measure timeliness of the medical service line at a facility of the Department when compared with the same medical service line at different Department facilities; and
(ii) measure quality at a medical service line of a facility of the Department by comparing it with two or more distinct and appropriate quality measures at non-Department medical service lines.
(C)(i) The Secretary may not concurrently furnish hospital care, medical services, or extended care services under subparagraph (A) with respect to more than three medical service lines described in such subparagraph at any one health care facility of the Department.
(ii) The Secretary may not concurrently furnish hospital care, medical services, or extended care services under subparagraph (A) with respect to more than 36 medical service lines nationally described in such subparagraph.
(2) The Secretary may limit the types of hospital care, medical services, or extended care services covered veterans may receive under paragraph (1) in terms of the length of time such care and services will be available, the location at which such care and services will be available, and the clinical care and services that will be available.
(3)(A) Except as provided for in subparagraph (B), the hospital care, medical services, and extended care services authorized under paragraph (1) with respect to a medical service line shall cease when the remediation described in section 1706A with respect to such medical service line is complete.
(B) The Secretary shall ensure continuity and coordination of care for any veteran who elects to receive care or services under paragraph (1) from a health care provider specified in subsection (c) through the completion of an episode of care.
(4) The Secretary shall publish in the Federal Register, and shall take all reasonable steps to provide direct notice to covered veterans affected under this subsection, at least once each year stating the time period during which such care and services will be available, the location or locations where such care and services will be available, and the clinical services available at each location under this subsection in accordance with regulations the Secretary shall prescribe.
(5) When the Secretary exercises the authority under paragraph (1), the decision to receive care or services under such paragraph from a health care provider specified in subsection (c) shall be at the election of the covered veteran.
(f) Review of Decisions.—The review of any decision under subsection (d) or (e) shall be subject to the Department’s clinical appeals process, and such decisions may not be appealed to the Board of Veterans’ Appeals.
(g) Tiered Network.—(1) To promote the provision of high-quality and high-value hospital care, medical services, and extended care services under this section, the Secretary may develop a tiered provider network of eligible providers based on criteria established by the Secretary for purposes of this section.
(2) In developing a tiered provider network of eligible providers under paragraph (1), the Secretary shall not prioritize providers in a tier over providers in any other tier in a manner that limits the choice of a covered veteran in selecting a health care provider specified in subsection (c) for receipt of hospital care, medical services, or extended care services under this section.
(h) Contracts To Establish Networks of Health Care Providers.—(1)(A) The Secretary shall enter into consolidated, competitively bid contracts to establish networks of health care providers specified in paragraphs (1) and (5) of subsection (c) for purposes of providing sufficient access to hospital care, medical services, or extended care services under this section.
(B) For purposes of subparagraph (A), the requirement to enter into consolidated, competitively bid contracts shall not restrict the authority of the Secretary under other provisions of law when modifying such a contract after entering into the contract.
(2)(A) The Secretary shall, to the extent practicable, ensure that covered veterans are able to make their own appointments using advanced technology.
(B) To the extent practicable, the Secretary shall be responsible for the scheduling of appointments for hospital care, medical services, and extended care services under this section.
(3)(A) The Secretary may terminate a contract with an entity entered into under paragraph (1) at such time and upon such notice to the entity as the Secretary may specify for purposes of this section, if the Secretary notifies the appropriate committees of Congress that, at a minimum—
(i) the entity—
(I) failed to comply substantially with the provisions of the contract or with the provisions of this section and the regulations prescribed under this section;
(II) failed to comply with the access standards or the standards for quality established by the Secretary;
(III) is excluded from participation in a Federal health care program (as defined in section 1128B(f) of the Social Security Act (42 U.S.C. 1320a–7b(f))) under section 1128 or 1128A of the Social Security Act (42 U.S.C. 1320a–7 and 1320a–7a);
(IV) is identified as an excluded source on the list maintained in the System for Award Management, or any successor system; or
(V) has been convicted of a felony or other serious offense under Federal or State law and the continued participation of the entity would be detrimental to the best interests of veterans or the Department;
(ii) it is reasonable to terminate the contract based on the health care needs of veterans; or
(iii) it is reasonable to terminate the contract based on coverage provided by contracts or sharing agreements entered into under authorities other than this section.
(B) Nothing in subparagraph (A) may be construed to restrict the authority of the Secretary to terminate a contract entered into under paragraph (1) under any other provision of law.
(4) Whenever the Secretary provides notice to an entity that the entity is failing to meet contractual obligations entered into under paragraph (1), the Secretary shall submit to the Committee on Veterans’ Affairs of the Senate and the Committee on Veterans’ Affairs of the House of Representatives a report on such failure. Such report shall include the following:
(A) An explanation of the reasons for providing such notice.
(B) A description of the effect of such failure, including with respect to cost, schedule, and requirements.
(C) A description of the actions taken by the Secretary to mitigate such failure.
(D) A description of the actions taken by the contractor to address such failure.
(E) A description of any effect on the community provider market for veterans in the affected area.
(5)(A) The Secretary shall instruct each entity awarded a contract under paragraph (1) to recognize and accept, on an interim basis, the credentials and qualifications of health care providers who are authorized to furnish hospital care and medical services to veterans under a community care program of the Department in effect as of the day before the date of the enactment of the Caring for Our Veterans Act of 2018, including under the Patient-Centered Community Care Program and the Veterans Choice Program under section 101 of the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113–146; 38 U.S.C. 1701 note), as qualified providers under the program established under this section.
(B) The interim acceptance period under subparagraph (A) shall be determined by the Secretary based on the following criteria:
(i) With respect to a health care provider, when the current certification agreement for the health care provider expires.
(ii) Whether the Department has enacted certification and eligibility criteria and regulatory procedures by which non-Department providers will be authorized under this section.
(6) The Secretary shall establish a system or systems for monitoring the quality of care provided to covered veterans through a network under this subsection and for assessing the quality of hospital care, medical services, and extended care services furnished through such network before the renewal of the contract for such network.
(i) Payment Rates for Care and Services.—(1) Except as provided in paragraph (2), and to the extent practicable, the rate paid for hospital care, medical services, or extended care services under any provision in this title may not exceed the rate paid by the United States to a provider of services (as defined in section 1861(u) of the Social Security Act (42 U.S.C. 1395x(u))) or a supplier (as defined in section 1861(d) of such Act (42 U.S.C. 1395x(d))) under the Medicare program under title XI or title XVIII of the Social Security Act (42 U.S.C. 1301 et seq.), including section 1834 of such Act (42 U.S.C. 1395m), for the same care or services.
(2)(A) A higher rate than the rate paid by the United States as described in paragraph (1) may be negotiated with respect to the furnishing of care or services to a covered veteran who resides in a highly rural area.
(B) In this paragraph, the term “highly rural area” means an area located in a county that has fewer than seven individuals residing in that county per square mile.
(3) With respect to furnishing care or services under this section in Alaska, the Alaska Fee Schedule of the Department of Veterans Affairs shall be followed, except for when another payment agreement, including a contract or provider agreement, is in effect.
(4) With respect to furnishing hospital care, medical services, or extended care services under this section in a State with an All-Payer Model Agreement under section 1814(b)(3) of the Social Security Act (42 U.S.C. 1395f(b)(3)) that became effective on or after January 1, 2014, the Medicare payment rates under paragraph (2)(A) shall be calculated based on the payment rates under such agreement.
(5) Notwithstanding paragraph (1), the Secretary may incorporate, to the extent practicable, the use of value-based reimbursement models to promote the provision of high-quality care.
(6) With respect to hospital care, medical services, or extended care services for which there is not a rate paid under the Medicare program as described in paragraph (1), the rate paid for such care or services shall be determined by the Secretary.
(j) Treatment of Other Health Plan Contracts.—In any case in which a covered veteran is furnished hospital care, medical services, or extended care services under this section for a non-service-connected disability described in subsection (a)(2) of section 1729 of this title, the Secretary shall recover or collect reasonable charges for such care or services from a health plan contract described in section 1729 in accordance with such section.
(k) Payment by Veteran.—A covered veteran shall not pay a greater amount for receiving care or services under this section than the amount the veteran would pay for receiving the same or comparable care or services at a medical facility of the Department or from a health care provider of the Department.
(l) Transplant Authority for Improved Access.—(1) In the case of a covered veteran described in paragraph (2), the Secretary shall determine whether to authorize an organ or bone marrow transplant for that covered veteran at a non-Department facility.
(2) A covered veteran described in this paragraph—
(A) requires an organ or bone marrow transplant; and
(B) has, in the opinion of the primary care provider of the veteran, a medically compelling reason to travel outside the region of the Organ Procurement and Transplantation Network, established under section 372 of the National Organ Transplantation Act (Public Law 98–507; 42 U.S.C. 274), in which the veteran resides, to receive such transplant.
(m) Monitoring of Care Provided.—(1)(A) Not later than 540 days after the date of the enactment of the Caring for Our Veterans Act of 2018, and not less frequently than annually thereafter, the Secretary shall submit to appropriate committees of Congress a review of the types and frequency of care sought under subsection (d).
(B) The review submitted under subparagraph (A) shall include an assessment of the following:
(i) The top 25 percent of types of care and services most frequently provided under subsection (d) due to the Department not offering such care and services.
(ii) The frequency such care and services were sought by covered veterans under this section.
(iii) An analysis of the reasons the Department was unable to provide such care and services.
(iv) Any steps the Department took to provide such care and services at a medical facility of the Department.
(v) The cost of such care and services.
(2) In monitoring the hospital care, medical services, and extended care services furnished under this section, the Secretary shall do the following:
(A) With respect to hospital care, medical services, and extended care services furnished through provider networks established under subsection (i)—
(i) compile data on the types of hospital care, medical services, and extended care services furnished through such networks and how many patients used each type of care and service;
(ii) identify gaps in hospital care, medical services, or extended care services furnished through such networks;
(iii) identify how such gaps may be fixed through new contracts within such networks or changes in the manner in which hospital care, medical services, or extended care services are furnished through such networks;
(iv) assess the total amounts spent by the Department on hospital care, medical services, and extended care services furnished through such networks;
(v) assess the timeliness of the Department in referring hospital care, medical services, and extended care services to such networks; and
(vi) assess the timeliness of such networks in—
(I) accepting referrals; and
(II) scheduling and completing appointments.
(B) Report the number of medical service lines the Secretary has determined under subsection (e)(1) not to be providing hospital care, medical services, or extended care services that comply with the standards for quality established by the Secretary.
(C) Assess the use of academic affiliates and centers of excellence of the Department to furnish hospital care, medical services, and extended care services to covered veterans under this section.
(D) Assess the hospital care, medical services, and extended care services furnished to covered veterans under this section by medical facilities operated by Federal agencies other than the Department.
(3) Not later than 540 days after the date of the enactment of the Caring for Our Veterans Act of 2018 and not less frequently than once each year thereafter, the Secretary shall submit to the Committee on Veterans’ Affairs of the Senate and the Committee on Veterans’ Affairs of the House of Representatives a report on the information gathered under paragraph (2).
(n) Prohibition on Certain Limitations.—(1) The Secretary shall not limit the types of hospital care, medical services, or extended care services covered veterans may receive under this section if it is in the best medical interest of the veteran to receive such hospital care, medical services, or extended care services, as determined by the veteran and the veteran’s health care provider.
(2) No provision in this section may be construed to alter or modify any other provision of law establishing specific eligibility criteria for certain hospital care, medical services, or extended care services.
(o) Definitions.—In this section:
(1) The term “appropriate committees of Congress” means—
(A) the Committee on Veterans’ Affairs and the Committee on Appropriations of the Senate; and
(B) the Committee on Veterans’ Affairs and the Committee on Appropriations of the House of Representatives.
(2) The term “medical service line” means a clinic within a Department medical center.
See 2018 Amendment notes below.
Amendments
2018—Pub. L. 115–182 amended section generally. Prior to amendment, section related to contracts for hospital care and medical services in non-Department facilities.
Subsec. (h)(1). Pub. L. 115–251, § 201(a), designated existing provisions as subpar. (A) and added subpar. (B).
Subsec. (h)(5)(A). Pub. L. 115–251, § 202, substituted “the effective date specified in section 101(b)” for “the date of the enactment”.
2011—Subsec. (d)(4). Pub. L. 112–37 substituted “September 30, 2020” for “September 30, 2013”.
2008—Subsec. (d)(4). Pub. L. 110–387 substituted “September 30, 2013” for “September 30, 2008”.
2005—Subsec. (d)(2). Pub. L. 109–13 substituted “shall be available, without fiscal year limitation, for the purposes” for “shall be available for the purposes”.
2004—Subsec. (d). Pub. L. 108–422 added subsec. (d).
1996—Subsec. (a). Pub. L. 104–262, § 104(b)(1), struck out “or 1712” after “, as authorized in section 1710” in introductory provisions.
Subsec. (a)(2)(A). Pub. L. 104–262, § 104(b)(2)(A), substituted “1710(a)(1)(B)” for “1712(a)(1)(B)”.
Subsec. (a)(2)(B). Pub. L. 104–262, § 104(b)(2)(B), added subpar. (B) and struck out former subpar. (B) which read as follows: “a veteran described in paragraph (2), (3), or (4) of section 1712(a) of this title, for a purpose described in section 1712(a)(5)(B) of this title;”.
Subsec. (a)(2)(C). Pub. L. 104–262, § 104(b)(2)(C), substituted “section 1710(a)(2)(E) of this title, or a veteran who is in receipt of increased pension, or additional compensation or allowances based on the need of regular aid and attendance or by reason of being permanently housebound (or who, but for the receipt of retired pay, would be in receipt of such pension, compensation, or allowance),” for “section 1712(a)(3) (other than a veteran who is a former prisoner of war) of this title”.
Subsec. (a)(7). Pub. L. 104–262, § 104(b)(3), substituted “1712(a)(1)(F)” for “1712(b)(1)(F)”.
1992—Subsec. (a)(1)(C). Pub. L. 102–585 added subpar. (C).
1991—Pub. L. 102–83, § 5(a), renumbered section 603 of this title as this section.
Pub. L. 102–83, § 4(a)(5), substituted “non-Department” for “non-Veterans’ Administration” in section catchline.
Subsec. (a). Pub. L. 102–83, § 5(c)(1), substituted “1710 or 1712” for “610 or 612” in introductory provisions, “1712(a)(1)(B)” for “612(a)(1)(B)” in par. (2)(A), “1712(a)” for “612(a)” and “1712(a)(5)(B)” for “612(a)(5)(B)” in par. (2)(B), “1712(a)(3)” for “612(a)(3)” in par. (2)(C), “1720” for “620” in par. (3), and “1712(b)(1)(F)” for “612(b)(1)(F)” in par. (7).
Pub. L. 102–83, § 4(b)(1), (2)(E), substituted “Secretary” for “Administrator” in introductory provisions and in par. (2)(C).
Pub. L. 102–83, § 4(a)(5), substituted “non-Department” for “non-Veterans’ Administration” in introductory provisions and in pars. (3) and (5).
Pub. L. 102–83, § 4(a)(3), (4), substituted “Department” for “Veterans’ Administration” wherever appearing in introductory provisions and pars. (2), (3), (5), and (6).
Subsec. (a)(2)(B). Pub. L. 102–54, § 14(b)(9)(A), struck out “section” before “paragraph”.
Subsec. (a)(7). Pub. L. 102–54, § 14(b)(9)(B), substituted “section 612(b)(1)(F)” for “section 612(b)(1)(G)”.
Subsec. (a)(8). Pub. L. 102–83, § 4(a)(1), substituted “administered by the Secretary” for “administered by the Veterans’ Administration”.
Subsec. (b). Pub. L. 102–83, § 4(b)(1), (2)(E), substituted “Secretary” for “Administrator” in two places.
Pub. L. 102–83, § 4(a)(5), substituted “non-Department” for “non-Veterans’ Administration”.
Subsec. (c). Pub. L. 102–83, § 5(c)(1), substituted “1712A, 1720, 1720A, 1724, and 1732” for “612A, 620, 620A, 624, and 632”.
Pub. L. 102–83, § 4(b)(1), (2)(E), substituted “Secretary” for “Administrator” in two places.
Pub. L. 102–54, § 14(b)(9)(C), inserted before period at end “(Public Law 100–322; 102 Stat. 501)”.
1988—Subsec. (a). Pub. L. 100–322, § 104(b)(1), substituted “furnish any of the following:” for “furnish—”.
Subsec. (a)(1). Pub. L. 100–322, § 104(b)(2), (3), substituted “Hospital” for “hospital” and the period for semicolon at end.
Subsec. (a)(2). Pub. L. 100–322, § 104(b)(2), (3), substituted “Medical” for “medical” and the period for semicolon at end.
Subsec. (a)(2)(B). Pub. L. 100–687 substituted “paragraph (2), (3), or (4) of section 612(a)” for “612(a)(4)”, and “612(a)(5)(B)” for “612(a)(5)”.
Pub. L. 100–322, § 101(e)(3)(A), substituted “section 612(a)(4) of this title, for a purpose described in section 612(a)(5) of this title” for “section 612(f)(1)(A)(ii) of this title”.
Subsec. (a)(2)(C). Pub. L. 100–322, § 101(e)(3)(B), substituted “section 612(a)(3) (other than a veteran who is a former prisoner of war)” for “section 612(g)”.
Subsec. (a)(3). Pub. L. 100–322, § 104(a)(1), (b)(2), (3), substituted “Hospital” for “hospital”, inserted “or nursing home care under section 620 of this title”, and substituted the period for semicolon at end.
Subsec. (a)(4), (5). Pub. L. 100–322, § 104(b)(2), (3), substituted “Hospital” for “hospital” and the period for semicolon at end.
Subsec. (a)(6). Pub. L. 100–322, § 104(b)(2), (4), substituted “Diagnostic” for “diagnostic” and the period for “; or”.
Subsec. (a)(7). Pub. L. 100–322, § 104(b)(2), substituted “Outpatient” for “outpatient”.
Subsec. (a)(8). Pub. L. 100–322, § 104(a)(2), added par. (8).
Subsec. (c). Pub. L. 100–322, § 112(a), added subsec. (c).
1986—Subsec. (a)(5). Pub. L. 99–272, § 19012(c)(5)(A), made conforming amendment to Pub. L. 99–166, § 102(b)(1). See 1985 Amendment note below.
1985—Subsec. (a)(5). Pub. L. 99–166, § 102(b)(1), as amended by Pub. L. 99–272, § 19012(c)(5)(A), inserted “(other than the Commonwealth of Puerto Rico)” after “in a State” and substituted “contiguous States and the Commonwealth of Puerto Rico” for “contiguous States, but the authority of the Administrator under this paragraph with respect to the Commonwealth of Puerto Rico shall expire on September 30, 1988, and until such date the Administrator may, if necessary to prevent hardship, waive the applicability to the Commonwealth of Puerto Rico of the restrictions in this paragraph with respect to hospital patient loads and the incidence of the furnishing of medical services”.