technology is, how good your defensive team is or how great your network is, without motivated men and women, you don't have the edge you need. that is what gives you the difference. that's why i think so many of you being here today is very important to the future. we have to roller sleeves up as a nation, we have to realize this is not a short-term phenomenon. this is long-term, hard work, for all of us. we are going to step back and ask ourselves what we need to do to change the current dynamic. as i said earlier i don't think any of us would argue that we are where we want to be right now in terms of cyber security. with that, let's open it up for questions. >> good morning. my name is david and on the the host and producer of cyber wire podcast. we have questions that were sent in to the conference app through social media.

and that's from some of our local media outlets. we will take some questions from the audience as well. we'll start off with this one. is our ability to defend cyberspace better today than it was five years ago? are we improving or deteriorating, and how and what needs to happen? >> if you read the news it's easy to step back and tell yourself it's just getting worse and worse, what i tried to tell our team is let's step back for a moment. let's think about where we have come in the last five years. the first thing i remind people is that we are way past debating whether this is something that merits attention. five years ago i was spending a lot of time in discussions with leaders about is this something i should really care about. why should i put time, people, resources on this. we don't have those discussions anymore. the number one positive for me

is that we have widespread recognition that we have challenges that are going to take focus, effort, and investment to deal with we have created, again on the government side partner with the private sector we have created well-defined lanes in the road in terms of who does what and the federal government. we have articulated how we will provide support in partnership with the private sector and we have created the mechanisms to do that. those are the things that are strong positives. on the other hand, i remind myself and we have to acknowledge that we are not where we want to be. i'm just not interested in said in back and patting ourselves on the back and say look how much better things are now than they were. that's interesting but not particularly applicable or the primary focus, it's about what we need to do to move forward. when i think about what we need to do to forward i'm struck by

other government side that we have a transition point coming up in january, that's a great opportunity for us to step back into internal assessment, where are we, are we happy with the structures we have created, are the assumptions we made proving out to be actually factual. we need to step back and reassess, how do we get a broader set of partnership and team work. don't forget the international dynamic. cyber doesn't recognize geographic boundaries. it is challenging to come up with solutions that will only work for one particular country. we have to acknowledge we will need need to do something broader and global. >> one of your predecessors, general hayden was quoted as describing russian hacking of the dnc as a legitimate intelligence operation. obviously it legitimate are not welcome once in the call for a response. you have have reactions to his characterization. >> is always fun when they say hey so-and-so said acts.

so we have acknowledge that the russians were behind the penetration, the hackers if you will behind those penetrations of the democratic national committee and several other targets clearly designed to generate insights with respect to political activity. we need to step back as a nation and think about so what are the implications of that. is that something were comfortable with. some ways i would argue this is a pattern of behavior in terms of the use of information, the attempt to persuade, and many played others. there's been a fairly consistent pattern for the russians over time. cyber as another dimension to this. now enables individuals, enables individuals, actors, groups, nationstates, groups, nationstates to acquire data at massive scale.

amendable to that and make that data publicly available. there is a lot of things we have to think through with respect to that. fundamentally as a nation it's important to us that we all believe and trust that the mechanisms of governance are going to generate outcomes we can all believe inches that is foundational. as. as we work our way through this particular issue that is always at the forefront of our mind. how do do we help engender trust and confidence in our citizens and how do we send strong messages to others in the world outlining what is acceptable and what is not acceptable. >> one of the biggest challenges facing the split between the nsa and cyber command outside the previous comments on finding the right time a process for split. >> so i have talked publicly about a matter that is under review by the president, he is the chief executive, he will make the ultimate decision. i will not get into specifics, good back, how would we assist and see and then as a good subordinate my job is to make it work with the best my ability

and that's what we will do. >> the technology evolution is currently outpacing the training and education, and build out of the workforce, what is nsa in u.s. cyber command doing to address maintaining a workforce that understands the technical evolution specifically from the acquisition perspective. >> on the acquisition side for nsi is an intelligence organization, the thing that i find very gratifying as an intel organization we have flexibility and capabilities that make us fast and agile when it comes to generating capability. in terms of what we can do internally. cyber command to the challenges are different. it's a traditional department of defense operational command not in acquisition information it doesn't design and generate. get our experience with six years as an organization is that

we need to step back and ask ourselves, does that make sense and is that the novel of the future. there's a test within the defense language from last year's defense authorization act which grants u.s. cyber command on a test basis for the first time both acquisition authority and a very small amount of money. we are working our way through with the department of defense was the frame work we will put in place to grant those authorities to cyber command and how will we execute those. we will see that rollout in the current fiscal year. then we have to report back to congress on our -- >> mobility is a mess within the federal government and dod. certifications get completed after devices have been mothballed. not allowing mobile devices inside the agency is creating hiring issues for younger employers.

the threat for these products grows. how do you see mobility today and in the future and housing agency trying trying to improve the certification process? >> mobility is critical, i bet less than 10% of you do not have a portable digital device on you right now. that's the nature of the world were in. i don't see that changing. it's grim because great benefit. i'm the first to acknowledge, soon as i leave here and get in a vehicle the first thing i will do is pull out my device and getting connected with the world again. is foundational for the future. at the same time, we have to acknowledge it is a bit of a double edge sword. it represents both connectivity and opportunity but it also represents vulnerability. each organization has to make an assessment of risk and given that full mobility what is the level of risk you're comfortable with given your mission and the kind of information you have and

what might be acceptable for one organization, say company that is -- because of the leader of an intelligence organization maybe that level of goods is not so acceptable to us. this is not going to be a one-sided fits all. you also have to educate our young workforce. i have 22 young millennial sons in their 20s. one of whom is a naval officer. they both believe the constitution forgot the part where they should've talked about, and the ability to access state in the format of your choice at the time and place in the device of your choice. so the life they have lived is all they ever know. dad, i can get whatever data i want and whatever format i want on anyone of multiple devices. what's the matter with you that you don't get it. well, i'm here to be your fossil son.

it's funny, had this conversation with both of them. the older one was a naval officer i say, i got it, i need to step back for a minute and look at it from the perspective where were a little concerned about operational security and the ability of others to use that device to gain insight as to where you are, what you're doing, are doing, and who you are communicating with. trust me, there are nationstates, actors, groups out there who are doing that every day. they have interest in individuals and will use that connectivity is a vehicle to generate insights as to where they are and what they're doing. by the same same token, i also acknowledge it offers great benefit, sought i always remind them for example for the older one i'll say what works for your brother to work in the private sector is not necessarily going to work for you. it is not a one-size-fits-all. one-size-fits-all. i think it's a great challenge for leaders to find that

balance. for us were trying to do it and take nsa and cyber command as an example. the compromise we are working on is let us provide you that unclassified connectivity in a format by means that we have high confidence that we minimize the risk. rather each one of you bringing in your own device, let us generate the means for you to access that information while you are at work and to do that in multiple formats and multiple mediums. that's what we'll sign up. we think there's value here and we we want you to do it because we understand it that for many of our workforce want to have access to this anytime, anyplace. when i cannot bring my device and i don't like it. i find it i find it unsettling. it's something i'm not comfortable with. it's not a sacrifice that i'm prepared to make. the people we are competing for have a lot of options out there.

for example of that portable device in the connectivity that it it implies is important, they very male jeff blashill ago where i can do that. we are trying to anticipate and deal with this. it is not unique to us. >> will open up to the audience for questions. if you have a question i believe i believe we have some runners with microphones. in the meantime i'll ask another question, what you see is a significant open source intelligence will play in national security as technology continues to be compromised at an alarming rate? >> i would argue that open sources and that's a phrase we use in the intelligence community to describe information which is unclassified and readily available to all. unclassified is readily available to all. >> experiences telling us that

open-source represents another primary means of acquiring information and insight. just a single intelligence and focus on the two missions that open-source offers an attractive set of insights that we may not have had access to. as an intelligence professor i remind people that every source of intelligence and insight has inherent limitations. not one of them, i don't care what it is, it thought a medical that whatever you see or hear if you can believe. an open source is no different. we need to keep that in mind. so open-source, all of us in the intelligence community are trying to work on how can we bring that is another tool to complement the work we are doing. >> again -- it is not going to

go away. it represents an amazing potential source of insight. and i want to take advantage of the. >> to have questions ready in the audience? >> heavily met before? >> i believe we have, sir. >> i'm doing well. thank you. >> sir, you spoke towards our struggle as a nation trying to come as workforce to catch up to the incoming cyber threat. a good example been trying to reinforce our electrical grid against potential cyber attacks. with the ever accelerating rate that cyber is growing in the change of the approaching internet of things, it seems this idea of mobility and our only threat to our own personal information being leaked our cell phones, is changing to all of the objects in our homes and

the objects around us. with his interconnected network that is growing within our nation not only the private sector but the military as well, how are are we preparing to address such drastic change with objects that were never designed to be cyber safes such as -- >> my first comment would become i think we have to be honest with ourselves and say as a society we may not truly and understand all of the implications of the broader connectivity, the internet of things been the most visible largest phenomenon. we are increasingly -- everyday devices that we take for granted. we think it's not thomas object. no. it's not a thomas anymore. it is now connected to a broader set of capabilities. those connections offer both potential opportunity.

today you will see this with all this is the automobile. when i got my license the automobile wasn't autonomous, mechanical device no software systems, no decision-making capability. it only ability to receive information was largely an issue was in the form of the radio and it's only ability to communicate to the outside world was either through a horn or visually through lights and signals. that was a car. that is not the automobile of the 21st century. the automobile of of today that most of us as we are looking at getting transportation. the automobile of today is a series of integrated and a thomas software set of

capabilities in which a plethora all of conductivity to the outside world is occurring at a level we don't understand. it is just built into the car in a way that none of us know and understand. so think through the implications of that. to put another way, not just the internet of things, that goes to the first part of your question. i have this discussion with my family at times or i will will tell them, so tell me what you think autonomy and privacy mean for the digital world. and how do we, as individuals achieve the degree of autonomy and privacy that we're comfortable with. realizing that the footprints that we are all leaving are growing in the number of footprints and in the duration.

we have really got to step back and ask ourselves what does that mean. for me, it's things like talking in the workforce about you need to think about the social media profile that you are creating. you need to think about the information you are comfortable sharing with others. in a world were living in and as we have seen of the last several months, the idea that many of the things we're doing on her networks and digital world increase probability that these will become more readily acceptable is a sad consequence in some ways in the world that we find yourselves inches i don't see that changing in the immediate near term. we have to ask ourselves what does that mean for us. both as the leader of an organization i think about what it means for the two organizations that i leave the national security agency. i think about that as a father, husband, with the family what

does that mean. and for myself. i think we need to step back and think about what does that mean as a nation. i think another challenge we have to acknowledge is that we find ourselves in the world right now where technology has outpaced the legal and policy frameworks we have in place. not trying to argue that's good or bad, and tried to say look, we have to acknowledge it is. so we have to ask ourselves, number one are we comfortable with that. number comfortable with that. number two i would argue that question is what is the right level not only are we comfortable with this, what is it mean. what are the changes we need to make given this incredible rate of technological change. in some ways if you take the emotion out of it that is really

at the heart of the encryption discussion right now. where technology and the legal and policy frameworks we have had in place are mismatched. we need to step back and ask ourselves if we are comfortable with that and what are the implications. thank you very much. >> thank you, sir. >> we have time for a few more questions. >> good morning, sir. you mentioned the di use and silicon valley in boston, how does the robust innovation community here in maryland, northern virginia plug-in to the department of defense that we are also helping to inform decisions about innovation and opportunity? >> di ux we often highlight is the most visible manifestation of a broader set of initiatives that were trying to execute. i don't want you to think that is the only way were trying to

address the challenge of innovation and how we interface with the private sector and to do it in a broader way. my memories rate, i apologize i have not done it in a few weeks so i may be may be wrong. if you go to the dod website on the unclassified side. my memories that you will see there is a pulldown that talks about the private sector, how you connect with dod and what particular area you might be interested in connecting with. having said that i think we are all within the government trying to come to grips with the phenomenon of how do we create the mechanisms that go from talking about this to doing something. i'll i'll be the first to admit that don't ever forget, it's about outcomes. we have to get the outcomes. whatever were doing has to be focused on driving us to generating outcomes. i'm not interested in talking about things for the sake of talking about them, just as i'm not interested in developing

technology for the sake of technology. i lead to technologically focus organizations with incredibly motivated workforces. many whom love technology for the sake of technology. i will listen now's a very interesting and i'm grateful but tell me how that ties to a mission outcome. in the in the end don't forget that's why we're created and the nation invested in us and what we have to be held accountable for. so i would suggest that would be a good starting plan. i think you and others for your willingness to do that with the dod. we are the first to acknowledge that we can be a cumbersome, a cumbersome, unwieldy, and bureaucratic organization. acknowledge that. what can we do working together. >> we have time for one more question. in the front.

>> nonoaud. [inaudible] [inaudible] >> to increase standards of education with the various countries and nato. >> nato has adopted a policy in which they say cyber is an operational. as a member of the alliance united states is one of the 20 nations that are members of the alliance and supportive of that idea. we have been working with their nato teammates to say here has been our experience. we think they is great applicability to the alliance and we suggest the alliance considers cyber is an operational domain. and they came together and announce that at the warsaw

summit earlier this year. now, again as a member of the alliance we have to work our way through so that you have recognized it what's its implications and how do you create a workforce in an operational structure. how do you prioritize and define risk. the alliance is working through that and were part of those discussions. it's not easy to bring 28 nations to consensus. i'm grateful that were part of an alliance willing to have those discussions. with that i want to say thank you very much. again remember what cyber maryland is all about. an ecosystem we have here in the state which we are proud to be a part of at both the united states command and the agency. how can we work together to maximize outcomes for all of us? and it's hard, we see that in

the reserve effort here in the state, you see that in the academic arena, the college as well as high school. you see that the state and employers, us, many others i others i tried to do out there. this is an amazing placement comes to cyber. there's a lot of great capability a great people. there is a sense of look this is an important trust is a region and we can do good things here. thank you for your willingness to be a part of that. thank you for your willingness to roll up with sleeves. as a nation, as a state, a state, as an area we have a lot of hard work. it's amazing what you can do with motivated men and women. thank you very much. climax. >> thank you admiral rogerson thank you for the work you do for the nsa and for cyber

command. can i have another round of applause? [applause] also has like to think day from the cyber wife, thank you for hosting a moderating that session. thank you. [applause] also, one more recognition for steve and andrew from viola lakefield high school. [applause] we are off to a great couple of days here i want to make sure everyone is aware that we have a conference app and everybody can download it to your smart phone. there are instructions on a poster outside or in the program.

if you have questions see the event staff. is a great way to network. we will communicate any changes to the event in real time through the app. makes you download it. you download it. it's a great networking tool. we've had a great couple of days. thank you for being here and this will conclude the session. thank you again. [applause] >> when you grow up in an environment like i did unit need a lot of people to play a hot heroic role in your life to have a chance. luckily i had that. i have my grandpas, my brother and sister. this is the story of how they impacted my life in positive ways. >> send in at a q&a, author jd vance talks about growing up in a poor, white family. in his memoir. >> there wasn't a clear connection that exist in my mind between education and opportunity. even the people who did well at school didn't necessarily make a lot out of themselves. you saw people not making or

having good opportunities. it was hard to believe school mattered. >> sunday. >> sunday night at 8:00 p.m. eastern on c-span's q&a. >> next, look at the availability of veterans healthcare services. then a discussion on the refugee crisis. then the director of national intelligence talks about election security and russian hacking. >> now a briefing of veterans access to be a old healthcare facilities and suggested changes to the veterans choice act which is going to expire in august of 2017. this is this is over an hour and a half. >> hello everyone. we will get started. my name is marilyn, i'm with the alliance for health reform and on behalf of our honorary cochairman, senators i would

like to welcome you to today's briefing on veterans health care. veterans choice act became law in 2014, creating a pathway for some veterans to receive some of their healthcare through the private sector. there's been a debate about how best to deliver health care to veterans for quite some time. in the last two years have provided some experience to consider as policymakers in washington decide how to proceed going forward. today, our speakers are going to help us systemsnd the complex through which veterans receive care and how that is changing given unique needs of veterans. i like to think our sponsor, a sentient health. over going to turn over the mike for a few minutes to mark hayes for a few words. >> . . much for coming to this important briefing on a very important issue. ascension is very pleased to be

a sponsor of this briefing because the care for our nation's veterans is so important and it's the issue that combines both veterans issues and health care issues and so it's a great issue for the l.a. and different offices to meet each other that we don't always interact, but it's a great opportunity. we have a great panel this morning, ascension is the largest nonprofit health system in the united states and the largest catholic system in the world and we participate in the veterans choice program because we see caring for our nation's veterans, those who have served alongside the va, as something that is very central to our mission. and so, we are very pleased to participate in the program and are looking forward to what we will learn this morning. thank you all for being here.

>> thank you, mark. so if you are following at home on c-span, you are welcome also to follow and those in the room are welcome to follow and participate in the twitter conversation, the #veteranshealth. you can also use twitter to post questions to the panelists after each speaks and after we go through the line, we'll turn to your questions and you can ask several different ways, pose your question via twitter #veteranshealth. we have two microphones in the room and also in your pacts, you have a green card and you're welcome to write your questions on the green card and our staff will pick them up and i will present those questions to the panelists.

also, if you are not with us here in the room today, you can find the speakers presentations and also other resources at our website, allhealth.org. so, now i'm going to introduce our panelists today. first, we have sherman gillum, jr., the director of paralyzed veterans of america and served our country in the marine for over a decade. after 9/11 as he was preparing to deploy for afghanistan, sherman sustained a cervical spine injury that ended his military career. since then he's served his fellow veterans with work at the paralyzed veterans of america. thank you, sherman for your service to our country. and next we have the deputy undersecretary for health for community care at the veterans health administration. before joining the va he was a

leader in hiv medicine in pennsylvania. and from tri-west, and carry farmer for the behavioral and policy, social science-- excuse me sciences for the rand corporation and access to and quality of behavioral health care for military service members and veterans, as well as treatment and recovery from traumatic brain injuries. and finally, we have john kerndell. senior vice-president for lifepoint health and oversees operation support and planning departments that provide direct assistance to life points hospitals and providers. so, we're to start off first with sherman. so, i turn it over to you. >> thank you, marilyn.

good afternoon, everyone. these pictures show me the book ends of my military career, 17-year-old private first class that became the 29-year-old commission officer that you see on the slide. and at that time, i didn't know much about what being a veteran meant, nor did i really care. i never set foot in a va medical center much must less receive care from the va system. anything i had would have been secondhand knowledge at best and ignorance at worse and we have too many in media and government that share the same lack of ip sight and since they know what's best for veterans. and hopefully we can change that in this forum today.

and here is why. because this happens. car accidents, mishaps, illnesses, and inflictions inherit to the hazard of military service. this was my car after i was extricated. following spine surgery and intubation while i was unconscious, 11 days of intensive care until i stabilized and my very first contact with the va medical center, where i'd start my rehabilitation journey. there was virtually no decision that was my own. my life was literally in the hands of others. the same with service member who suffer the fate in the future and those veterans who had seen war and profound mental and physical hardship. so here are the questions, what will the va of the future look like for them? what will change?

will it be better or worse? more importantly, who will decide? will that decision only be on public outrage for isolated incidents? or will decision makers at least have set foot in several va hospitals and spoken with numerous veterans to inform their thinking? so this is me now. byproduct of va health care. one of many who have filtered through the system, seen firsthand what needs to improve and there are things that need to improve. and no experience that makes it unique. a veterans system of health care that cannot easily be replicated as they're currently constructed. there's more work to do. this version of me has coverage through tri care and i've

accessed emergency rooms when the va wasn't readily available. >>nect that wa >> we need medical care while still dealing driving myself to the nearest drugstore in more than one instance of have to bounce around because the medication was out of stock. fot this is what bond and veteran center clicks likend when taken on the of the abstract.ed today and

in the future as health care evolves for most getting dental care x-rays or hearing aids or even urgency care in a timely manner is a good thing but what about the men and women better in my circumstances they're not just to teesix veterans quality of life is a matter of life and death for the rest of their life here in is a problem of the privatization to retain a function of specialized services i keep hearing them say it does what it does best to privatize the rest but that will not work. having a spinal cord injury does not mean what it cancer. develop diabetes or suffer't aspression.

and those are accessed such as oncology with the specialized care team with that framework that is unique so the demand for tertiary services. in the private sector.ely so with this slide in front of you with those attributes with those 14 years of experience it leaves of all of the characteristics of the specialized care so here it is a bit of the education

starting with the ones in the red boxes. did you know, what those that seek emergency medical care to not have to pay the expenses and provided a request to cover unauthorized expenses is timely provided but not in. the private sector. medical implements are reimbursed for mileage and travel unless it is provided by the contract but not so in the private sector. veterans can receive seamless prosthetics and here support during appointments making morea veteran centric experience than they can receive anywhere else but not so in the private sector. se and now eligible veterans to have a choice with the choice act and that is a good thing because it is an

alternate providers now available which is great as a component but not as a replacement with the most overlooked aspect when discussing health care forat veterans with the united states code the authority that governs pretax veteranscarc with medical malpractice rates with the accredited representation at no cost. but do not follow the veteran under the choice act. congress doesn't have the jurisdiction of the private sector ceos saw maybe wrongly assuming it never

happens. allowing the courts to redress if they can affordth it. if collaboration would have been and must be addressed. as long as the veterans know that they have a man given just a choice but beyond simply hoping for the best choosing v.a. for health care must be viable. [applause] >> now be will turn to the doctor. >> that was an amazingma firsthand experience of the care that is provided through v.a.. i am a practicing physician

within the v.a. when not seeing patients as often as i would bike i am in the liaison office but none of the other pieces with my journey through v.a. is titrate with v.a. but was a medical student and a fellow at the university of pennsylvania philadelphia v.a. 70% of all american doctors at some point are interactive with the v.a. and not only to take care of our veterans but to trade the next-generation of nurses and other health care professionals. to the point at the end of the day to see a vision is i to be called the integrated health care system to i include the health care providers and clinics as

well as expertise from the private sector. i'd like many other health care entities that are limited by the geographic markets, if you start a clinic, patients come to you v.a. is completely opposite we go to where the patients are edward davis. they live in every corner ofve the united states but they span the entire word jap -- geography. we cannot have brick and mortar facility in every one of those individual locations. we have to leverage community partnerships and they really are. to allow us to provide health care for veterans in those areas. so we want to build the integrated health care network the alliance does put on various programs and

they focus on medicare so that corollary is really where we look to build the network that is highly coordinated in a degraded with the needs of the veteran population. how do you get there restart with the inveterate and so the community care is ongoing transformation and about when your ago we presented a plan to consolidate care. right now we have a way to purchase care in the community it is important to note did is partnering with community partners while the choice act may have put a spotlight on the ability to purchase care we have

weighed more outside and within the choice act is been going on for years or years. the great partnership that would start 70 years ago to not holy share the knowledge by research and training expertise. so it's different providersid across the country to stand commspectrum from academic federal institutions to the regular mom-and-pop shop across the country. how do we get to the integrated health care network? focusing on the veteran we talked to veterans and visited the facilities and mapped the journey through community care and starts with eligibility we need tota have a very clear set of criteria that makes it easy

to understand that what veterans think community providers candid minister. right now because of the various programs it createst crs confusion. the benefits is not clear in the community so we need to be very specific and hopefully make it fair and equitable system to communicate that but it also translates to community providers because of the different eligibility criteria they don't know if they see a veteran that will be covered by v.a. or not that creates problems toen take care of an individualhat wn that we by law cannot take care of. also the authorization process also those that absent to have timely access and this is to make sure we can leverage and electronic

exchange of information so they clearly know what veteran they are seeing in the reason for that and why they see the doctor and when. really where the magic happens is the golden nugget to survey model model before the health care systems but all-american madison now as they moved into integrated networks this is what they dryexx to figure out you cannot live in your constitution you have to work with community partners to deliver health care or community resources to take care of patients. we are uniquely positioned because of our ability to enter great care with the ony health care system and

hoping to leverage more exchange portals to share of medical records more t seamlessly. the best one is the community care network who is a network of providers that we work with? this really does get to the adl of informed choice we have a broad network 350,000 partners to deliver health care to veterans but we want to make scheerer that is the power to make informed decisions apply this is the same movement all-american medicine is getting out in a report quality satisfactionep value so veterans can choose a provider that health care is a personal matter how do you choose a provider that meets their needs? this is the preferred providers we know that our

providers by interacting with veterans with theet unique circumstances that population has and there really isn't enough volume or touch points to understand the new ones is not only to deliver an excellent quality, have expertise in military cultural competence to be aware of veteran issues to choose a provider that meetsed their needs.ly and this is criticallyim important and in order to be good partners accurately.cause because of the multiple ways

that we have care today when the choice act was passed it was required to send outindivid. cards to individuals of look like health-insurance cardsity d because the provider worked under the assumption to deliver care but then on the back they could not pay the conditions because they did not meet the criteria. we need to have clear eligibility that is simple simple, no red tape so the committee and the veteran know what is eligible and what isn't and then to do our part to pay timely and accurately. then focus on customer service to make sure they can get the information in a

so thaand timely manner. at is our journey how we improve community care with the touch points that our important to them and then move the needle. so most everyone of those areas many to partner to make sure we make the system less complicated than what it is. when you try to run a program keeping the veteran in the middle there are seven or eight but we have to get to the one that makes sense for the key population . i do want to mention how weou can move toward a highgh performing network it is known is internal and extra all partners and that depicts that a little bit. you can see them moving around from one location to another.

and where is health care going in the future to position us we are meeting the needs of tomorrow. a evolving from the fee-for-service are valued reimbursement based model with the investment of the demonstration projects to test out the model we want to participate to make sure that our community providersnot are not driven by volume but value.va legislative health to do that but we also want to leverage better monitoring of patient satisfaction and be transparency about the care we are delivering. right now it reports on

various markers as well as quality and satisfaction.o get >> guest: to get that from l those of our veterans and are participating. third, go from a care model that is more personalized and coordinated.inside va we we have teams that take care of veterans to leverage that same sort of personalized care proposal that is a unique challenge for us that is faced by many health care institutions so with the right level of need to let them know what to bring others may need a case manager to make sure they have transportation's though how do we get to the needs of our patients? have now fallen through theec trajectory as they go in and

out. leslie to have better change information right now there is a number of different health care providers of all use different electronic use di records. v.a. is bad and the business for decades many to figure out to communicate through those entities and reduce costs of innovative ways toin leverage the community health exchanges to move toward information. that is a little bit of a future where we hope to get with the challenges that we face but the opportunities for us to lead the way for areas. thank you. [applause]e of >> good afternoon. thanks for being here and

those that represent members of congress it is my pleasure to serve your constituents because all of your bosses has a constituent. it is a privilege to follow sherman who pointed out but the end of the individual that is responsible for being served by the system of wearing it is today and where it is going forward? how do we get to where we are? and what does the system currently do crack some point to spend a lot better time of where we set to when you look through this lens

and that makes up next to the v.a. delivery system. re we have the privilege to serve the best of the best in this country so the choice act was born i live in phoenix, arizonaas dis april 2014 when it wasph disclosed very quickly congress passed education -- legislation to give them money so they gave the v.a. 90 days by the time of the rules were figured out we had 33 days to go for the public should of paper to a false start up but there were no for an hour waits on the phone and headed down the track of what needed to be done and spent time

together to figure out the gaps between congress and the private sector and how do we close those? many adjustments had to be vague policy and operational we probably went 75 percent down the track to close the gaps and. but a lot needs to be done. but the greatest challengegr was to get people to understand what was enacted by congress. and within congress and the beneficiaries as well as the health care providers because it was launched very quickly. q as we sit here today and now 5 million opponents and to be responsible 3.2 million

revs how do buildup of aor network? t >> peace plan to align the time to understand what demand looks like. if you never fully demanded did not understand. this is the blue area ofar responsibility because we did not have a good sightline as to what the picture did to look like to be matched up with the elasticity that it needed. this is what it looks like now.now, tailore >> the bottom line is their fear cases because the reason to provider available if they can deliver the care

exactly and thanks to be for a part of that. the 185,000 providers and their delivery at the site in elasticity that they need the first month we served 2,000 people you can see the demand curve the va has been brave plan negative buying private for a long time this give us an into the delivery system.system and b but they buy care na integrates and so if you look at the demand curve but then about 6,000 and from the 2000 amount that was done previously.

the beginning of hiking give you care practic it clear -- but it is heart and digestive systems and his infant and to stimulate the community is supportive v.a.. are the lisa hasidim smiled - - have access equation to make sure we demanded the right provider's seven never set reintegrated in a virtually integrated way that they have confidence safe the day will place the care if. the other is continued refinement through those various acts month negative aspects with the biggest issue at the moment is to

make sure that providers understand what it takes to file a claim hasn't been as they reimburse us.st we still have work you have work landed to human. >> it to three years engineer. but i will tell you. >> the people are incredibly focused in remaking more progress than 20 years ago with the dot if you go towards the reopened but to be with our company to figure out how we can do

that between now three of us? we changed the aperture dramatically we plan to do that successfully across the country. third, we have the very inhumane dialogue:on. >> we have invested a lot of money of infrastructure of a great system. at the end of the day this is about resetting pests dead -- 10 or 15 years and when you pass the bill and some of us remember with will from read. that tech eight years pet

they came from every city code in its pitch. >> if you are in a place like seven but it is right next door alleviate medical centers of this but then to make sure ronan but those that are staffers here and i a was of back by 20 years agoen when i left capitol hill. in the '60s passing medicare/medicaid we created tenements v.a. is not an entitlement. the choice act may each - - makes it virtual but it is time to step back to figure

out if v.a. should be the primary payer or think about the notion those that serve have a first-rate because the lot of things would end up in a very different place without the case and most of their care is financed by the federal government so i sa progress of former colleague has said tyco from the city of phoenix. on monday but for thosehe staff that we were driving. there are people there also in the public sector.e fact of h

but it was demoralizing. but this billboard shows it replaces that as of monday and it takes 17 to deliver for those who serve this country. to give it the elasticity. 400 providers in phoenix. >> thank you very much. [applause] u very much. [applause] >> thank you, david, now to carrie farmer of the rand corporation. >> thanks, that was great. so i'm going to give a little bit of a different perspective from the research side. so, as something else that happened as part of the choice act was a requirement of an independent assessment of a veterans health care and rand participated in the independent assessment. i'm going to share some findings about the quality of va care, access to care and

then also talk about what we know about quality of care and access to care in the private sector. so starting with quality of care, in our assessment, we looked at dr. yehia that va regularly reports many quality measures as does the private sector. when we compared va's performance on those quality measures compared to the private sector, in in case i mean medicare, commercial hmo's and we compared in many ways. that va performed better than them on the-- >> and the wait time data when we think about timeliness of care. how long does it take to get an appointment. in this case va measured wait times, how long is it between the preferred date of care. >> that's the date that the veteran or provider would like

the appointment to occur and the date when the appointment actually occurs. >> in our analysis, most veterans received care within two weeks of their preferred dates for care. of course, there's a lot of varabilities in these numbers. in phoenix it was not two weeks for an appointment, but in other parts of the country, the wait time nearly is much shorter. on average the wait time for a primary care appointment was six days. another aspect of the access issue, where do veterans live. looking where they live relative to the va facilities, the vast majority live within 40 miles of some kind of va facility so this could include a va hospital or an outpatient clinic. when you start to look at more specialized needs for care a smaller proportion of the veterans population, live within miles of the facility that can give that care.

and 46% of veterans live within 40 miles of a va hospital that provide the full spectrum of veterans care. >> so what does this mean about va turning to the community to help fill some of those gaps? what do we know about care in the community? >> what do we know about health care in the u.s.? overall, we know that the u.s. has a ways to go in improving the quality of care. this study way from 2003, one of the landmark studies looking at quality of care across the united states. in this case, patients received 50% of all recommended care. the study examined chronic-- care for chronic conditions and for acute conditions. and since that time, there's been a lot of work understanding the quality of care, the institute of medicine had a number of studies, and examining the quality of care in the united states, and what we know about overall, is that the quality of care in the united states is variable. and there is room for improvement across all health care conditions. >> dr. yehia also mentioned

military cultural competence. providers in the community serving veterans need to understand the particular needs of those veterans, with their experiences in the military are. in 2014 we did a survey of behavioral health providers in the united states, less than half regularly ask their patients whether they were veterans or served in the military and even fewer reported knowing anything about military culture. >> and then what do we know about the timeliness of care in the private sector? >> we actually know little. it's difficult to prepare the timeliness of va care to timeliness of care in the private sector. everybody measures time limits of care different and there's not one standard how you measure this. in a couple of studies that we were able to find in the private sector, this measures the time between when the patient calls for an appointment and when the appointment occurred and we

found that in these studies, that the times we-- the wait times were much longer. so 19 days for an appointment in one study and 39 in another study and these studies had a range. so when you compare that against six days on average in va, it does suggest that the timeliness might not be solved by the private sector. >> and finally, when we think about where veterans live relative to va on the slide i showed earlier, what about where veterans live relative to other providers in our community. this slide shows veterans who live far from the va. more than 40 miles from the va. among those who live far from the va facility. 80% live within 40 meals of a primary care provider in the community. when we look at specialized needs and mental health care, less than half, this is 49%, lived within 40 miles of a private sector mental health provider.

and even fewer lived within 40 miles of a private sector neurologist or endocrinologist. this is for health care overall and not particular to the va. for veterans who live far from the veterans facility, in the community cares, those providers may not exist in their communities either. so looking at this overall, it really does suggest that private sector care should complement va care, that va provides care in most cases with high quality in a timely manner and the private sector should come in and complement not substitute for care. it's important since we know very little about the quality of care for veterans that's provided in the community and timeliness of care for veterans that's provided in the community, to really develop a mechanism for monitoring that care to ensure that both in the

va and care in the community that va is paying for is high quality and timely for veterans. >> thank you, carrie. music v. [applause] >> before we turn to our final speaker from lifepoint health. i'd like everybody in the room and in c-span, you can participate in the conversation, there are three ways, submit on twitter #rheter veteranshealth care, and you have a green card, you can ask your questions there. john? >> thank you, marilyn and thank you for being here today. before i get started i would

like to recognize david krichlow our vice-president of government relations here with me today and available to answer any questions. i'm going to go through a few slides, start just by identifying lifepoint and who we are. it will frame any comments that i make from a small, nonurban sole community provider perspective, walk through some of the volume indicators of the veterans that we're seeing in lifepoint and then talk a little about what we see as opportunities to expand the provider base within this program. >> so a little about lifepoint health. 72 hospital campuses in 22 states. as i mentioned, we are a nonurban, so community provider. there's a bullet point that says leading health care provider in our communities. we're typically the sole health care provider or at least acute

care provider within our communities. we operate in areas that the closest acute care facility is over 100 miles away. i found interesting with carrie's comments with availab availability. these are the markets that we see. we're not urban, there is not a va hospital and there's not acute care near us. our ability to serve these veterans in our community is very important to us. avid supporter of the accountability act. this has been a very emotional issue for our leadership team. our leadership and our facilities are veterans themselves. they know the communities and they live there. this has been very important for them and emotional for them and they have embraced this entirely. and we were proud with some of the work they had done, in

particular with veterans choice. to reach out to the community and to a certain extent be a resource for veterans to identify whether or not they were eligible for it, but i've embraced it significantly. >> so just some volume statistics of the care that we have provided in 2015. we have provided care for over 15,000 veterans throughout lifepoint facilities. of those 15,000, 1200 for inpatient admissions and 4600 through our emergency rooms, 1600 outpatient services were performed and more than 7100 outpatient procedures and test ins 2015 it's up from 14 and continues to grow which we're very proud of. >> so where can we improve? some staff is here and i'll talk a little and comparing it back to the lifepoint.

all of our payers when we look at days to pay. when do we get paid for services compared to when we discharge a patient. for all payers on lifepoint. that's 54 days and we are typically paid, within our group and it says veterans choice, but it's the program at veterans choice. it typically takes 113 days on average in our 22 states to get paid. so, here is why that's so important. for lifepoint, we have very strong balance sheet. we have the resources to basically finance this care. you know, our costs that we're paid at medicare rates almost by defacto costs, we have the ability to bridge that gap between paying for the cost of care we provided and then being paid 113 days later. if you look at the staff for a critical access hospital, their

days cash on hand are 69 days, but typical hospitals if you put them altogether, it's over 200, but for the small community, independent hospitals, in particular the rural hospitals, they're fairly fragile financially and we only have 69 days on hand so it's difficult for them when you provide care and you're waiting to get paid at cost, where you then become almost the financing arm for these patients. so, i think by reducing that, a lot of our sister, independent rural hospitals don't participate just because of the cost issue. and so, that's an area that we have looked at. a lot within lifepoint. what we've seen, some of it is provider self-inflicted, but i think there are some ways to maybe mirror medicare, our medicare to pay less than 21 days. so what we would welcome in

this is the opportunity to work collaboratively and get those days from 113 down to maybe something closer to medicare because we believe in the hospitals that we work with. that would be very attractive to them to get into some of the programs in these small communities. a lot of these simply can't afford to do that. so i-- last slide going forward again, strengthening guidelines. it does provide on the provider side. there are things that we do wrong and that we can improve on, but i think coming together and figuring out a way to get through some of the prompt pay issues that we deal with, we believe, would bring especially some small providers into this network in this important program. program. [applause] >> okay. thank you. so we've now turned--

we're going to turn to the q & a portion of our program and i'd like to throw out the first question. we've talked a lot about care within the va system and the private sector. i would love for one or more of our panelists to take us back to square one for a moment and talk about the choice program that was-- that came about in 2014 and help us to understand. who is eligible for this program? how are veterans using it? and to what extent are they use it go? do we have just about everybody using it and what kinds of services are they getting? what is the experience like so far? >> sure, why don't i take that one? so the choice program came about approximately two years ago or so. and it's a temporary program so i think this is very important because it actually is set to expire august 7th of next year. so we're less than 12 months before this program expires.

this is a huge issue because we actually see kind of the train is coming and we have served more than a million veterans in this program. so a million veterans have touched the community through this. so this is one of the things that va is very concerned about, because there are a lot of folks that are receiving care through the program and kind of what happens next. so, that's one important point. the second is, this program serves a very specific-- has a very specific set of eligibility criteria and as i was mentioning before, we have seven or eight different ways of purchasing care, this is one of them, and their criteria are very targeted. they really can fall into three types of buckets, one is distance, and so it's 40 miles right now from a primary care provider and so if you live more than 40 miles from a primary care position in the va you're eligible for a choice program. if you cannot get care within

the wait time goals of the department and third is, they're called unusual and accepted. if there's a mountain range or a lake or stream or severe weather, there's exception. those are the three types that are eligible. as you can imagine, the geographic criteria for the most part are the stable type of population. and so, an individual may be taking-- may be receiving care in the va for one condition that may be we can't provide timely so they would go out on an episode of care in the community and they would still get the rest of the care there. so, that requires a lot of care coordination, so those are really the three types of criteria. now, when we talk about the type of services that we're purchasing in the community, they're pretty common, one of the-- probably when i think of the top five and top ten, we send out a lot of folks getting

eyeglasses and we do send out some orthopedic surgery, we send out a ton of laboratory testing and maybe someone is getting an mri, closer to home than coming to the va and lab tests, laboratory tests so it tends to be a little bit of the-- more locally available specialties, although now, as dave was mentioning, we are able to get a more robust network where we can refer to some of the complicated procedures, whether they're ct surgeries or neurosurgery and that's a little bit of the neck. >> what you're seeing on the experienced side on our end is then about 15% of the population is 40 miles in terms of who is utilizing this, about 50% are those that are near a va medical center and the va medical center or community to base outpatient clinic doesn't

have the service needed and 35%. the remaining 35% is those that couldn't be scene within 30 days and choose to access their rights. if i could just, for those that are staff members, the expiring in august of the program, it's very unusual for congress to authorize and appropriate at the same time. in fact, it usually doesn't happen outside of black box issues or other types of very rare occurrences. the federal budget rules had to be suspended, in order to get this through and that's what set the trigger for august 7th, but at the same time without action, a whole program goes away. and that's what he's talking about and the notion that it needs to transfer to something else or in its current form it needs to be reauthorized from a bugetary perspective and an authorization perspective.

>> okay. thank you. so let's turn to the audience now, we have a question. if you could please identify yourself. >> my name is regina leonard, i am a doctoral opportunity in health policy and nurse administration. i have a question, with veterans needing more access to care, it would seem possible that the va hospital would allow advanced practice for nurses, m p's and clinical specialists and have full practice authority. hr-1247, the veterans access to quality care bill would help the va hospital accomplish its goals. how do you see utilizing m p's in the future? >> that's a very great question and also controversial as va is working on the nursing handbook. we leverage a lot of nurse practitioners and physician assistant provider extenders so

i'm not exactly the right person to be able to address this specifically, but what i will say in general is we do have veterans that live in every corner, as i mentioned, in the united states and as we were-- as a colleague was demonstrating. in some areas they are not physicians or there's a derth of those providers so we might need to leverage more of our nursing-- nurse practitioners colleagues and providers and make sure that we take care of veterans. >> i had a ' like to comment to your question as well. aside from care to veterans, the small communities we're in, physician assistants and nurse practitioners are very important in these communities. we use them effectively and they provide great care in the small communities and it's an important part of the network in these communities. >> and i want to jump in, one of the recommendations in the independent assessment is

indeed that nurses, nurses practice to the full scope of their license and that the evidence, the research really shows that there's not a difference in quality of care between nurse providers. >> okay. question here. >> i'm dr. carolyn poplin, a primary care physician. i have a question for dr. yehia. a quick question for john. the question for the doctor, i worked for the active duty military for 12 years, seven yea years, and five years at what was then bethesda naval hospital. the military all of that time were working to make their electronic medical record interoperable with the va, they spend millions of dollars and my understanding is they've given up. they couldn't make it happen.

how are you planning to make these interoperable-- obviously can't be the way that we tried integrate because that didn't work. >> thank you, an excellent question. i don't think they've given up quite yet, but the point that you're describing is american medicine issue which is there are health systems across the country and market out there for electronic health records, everyone has different records so we have to think of it differently than before. we're doing a couple of things to show promise. community health exchanges we are 80 across the country and a lot of these are individual communities that get together, the hospital systems in that area say we're going to share information.

there's a standard template of what data they get, so we share records, we have veterans that quoted more than half a million participating in different exchanges. number two, knowing that not everyone is going to have the same record, how can you share information between the records and what we've been able to do with our military treatment facility, dod partners and now transferring that knowledge to the community is having something that is a viewer of the records. we can actually get a view only read of the record and not able to kind of alter it 'cause that belongs in your health care system so we have something called the joint legacy viewer. and we have a read only view. it's not like we look at the dod record and when we look at community viewer it's integrated record and we are-- we now have these all over the country and taking that

knowledge, and doing that and testing it out in a couple locations with community providers and we're now testing in the state of new york, new york and washington working with specific community partners and give access to read-only view of the va record, that way they can as a practicing doctor if i want today look at the mri and ekg i can look at it through the web-base portal. i'm viewing those, rather than trying to get everyone on the same system, i don't ng it practical in the short-term. >> my question for john-- several questions about the use of other tools such as telemedicine and how the va is using telemedicine or other

tools like home and community-based services to provide access to care and how can congress help to encourage this. >> why don't i start and comment. va is really at the tip of the spear when it comes to telehealth. we have a number of telehealth clubs that have been doing, various versions for a long time, and it's exactly for that, marilyn, we want to make sure that we can provide access and reach certain areas that we may not be able to have a brick and mortar building, so we're leverages more and more telehealth in all kind of specialties by the way not only in primary care, but mental health care and looking at other fields that traditionally have not been done through telehealth that we can do so we're doing that, there are a

couple of things that could really help va with being able to share information and especially with community providers, whether they're doing telehealth or not. and that there's a couple of statutes that prevent va from sharing medical records. and these were developed decades ago and above and beyond the hipaa requirements. the va is not allowed to share records with someone identified as having hiv, sickle cell or a mental health or substance abuse condition so you're taking a big chunk of our patient population and have one of those conditions and in my mind, almost as a st stigmatizization that we have to have them sign more than the hipaa and send it to the doctor in their community. that's an ability to coordinate care whether it's there the

telehealth venue or in person venue. that's one thing not providing-- it's outlined in our plan to consolidate care. one thing i think they can do. >> i would completely concur with what dr. yehia said in terms of taking down the barriers. when we were doing dod at the height of the wars, we actually placed in facilities in colorado springs, inpatient of-- inpatient patients for mental health because the military hospital there did not have an inpatient unit and we actually forced grand rounds that were joint. so we required the sharing and the sharing of that information is really, really important to making sure that the patient encounter is proper and that you plug the gaps that might exist. starting next week we will be standing up a series of pilots that will roll out in two markets and expand from there.

that will put us behind the tip of the spear, which is the va, but we will do telemental health and start with medication management in a particular market to help give them more supply and then it will also do psychotherapy on that same backbone that will allow us to test out in both urban and rural areas how we jointly want to make sure that people are taken care of and leveraged supply in the private sector when it's not available in the va. and i would just say that making sure that providers are understanding of who a veteran is. and then we select carefully who we place people with is really, really important. and so we've put a million dollars into a nonprofit that's actually constructing the teaching information that will be made available to providers all over this country as it

relates to understanding a veteran and evidence training that va and dod have specialized in, and actually make that available from a distance perspective with a coaching apparatus on the back end that we designed in concert with va and dod and that information will be available free of charge to providers all over this country that want to step forward and be helpful. >> i agree that telemedicine and home-based health care is great for small supplier, it i cannily the area of mental health. i've seen many veterans who have troubles who benefit from it, and there are issues that have ton worked out and somebody from san diego might want their same provider and not mesh well in another area. i want to caution, it's not a panacea. i think the optimum health care is person to person. in so many instances, hearing

nurses talk about, for example, decubitus ulcer. you can see it on the screen, but it's not the same as appreciating how bad it is when you're there and seeing it in person and happy to see my doctor once a year when i do my annual exams in person. there's something that doesn't want to loose, but don't want to see it as end all-be all care, but for opening care to veterans who need, you know, services. >> great, we have a question at the mic? >> hi, thank you all for being here today, dr. taylor winkleman. it would seem as scary as the 2017 deadline, august 7th deadline is, it provides us with an opportunity to introduce changes to the program and as a veteran who remembers what it was like living 98 miles away from a facility before veterans choice came in, i can certainly

related to the benefits and challenges that we face. and mr. gillums i recommend you would extend something to extend title 38. but what would your ask be for improving this ap better more cohesive vision put together.

>> but. >> we have to actually have to have changes. this program as was describing came very rapidly and was in it implemented rapidly with congress could change the law for times already which is great and we have other ideas to let the programs work better bed number one is primary-care issue and in some circumstances we have to rely on other health insurance so what does that

mean? were have to pay the coach pay and deductibles and premiums and no other program works that way. so it is exposing them to some financial conflict they never had before and a lot of them more upset about that not knowing they have to pay the specific portion. number two we need to be able to work better with community partners especially in the rural areas. right now the choice law limits the v.a. that medicare so now that makes sense to some locales but not others so we have to pass that flexibility to partner with providers at a higher rate because a lot of times but definitely have issues sometimes it isn't that is the flow but it is too low without flexibility of pavement and then i

mention the other things to coordinate care better to share information that we have to leave of the program we have invested a lot of infrastructure and we have learned lot. behalf to revolve it should not be completely scrapped as it will go through the same growing pains of a few years ago. but it is how we continue to take what is there for what makes sense for our veterans and community partners. >> i imagine some other panelist imagine what needs to happen with the program put. >> the issue of the primary-care facility that they will not qualify if

there was not to the v.a. center within 40 miles. with a veteran that is 3 miles away from the facilities to work through those issues it is those negotiations with the veterans of ministrations but that has been issued and that there is close facilities with that care of need but they cannot utilize >> just to comment on that piece, it is one of the things we have to be aware of. talk about 40 miles from the primary-care doctor or 40 miles from others and a lot of people look at that model definitely would have

a very large financial impact. apart from that and with that referral patterns with the service connected to veterans if we cannot provide wraparound services because a lot of those are deferred samara else outside the system then becomes hard to gain competency to recruit doctors in the area. so figuring out flexibility for those veterans that need to be seen. sometimes it is too long but i do raise some concerns about completely because what that will do is contract for those that want to use it because you must

not be able to build up the wraparound service if you don't have that volume more expertise to do that. >> i concur so open access is not the right place to open up investing a lot of infrastructure and to make that stronger to make sure it has sufficient supply is important but for the last 15 years we employ people from every set coded this country and has spent very different from many of their conflict. and they don't have to displace where they are they may take a year or two off the have a right to do that with the benefit they have

earned. and we all agree that it makes sense but how do we draw the parameters? said from that perspective congress needs to decide how does it want to deal with the responsibility and there is a lot of money that is paid in travel and the lot of money paid when someone doesn't get what they need of a timely basis. because when they are really sick is more expensive. for those things you want to be and the v-8 facility absolutely a top-notch academic is a witty could regard this of where you live in the state that they're great could get the orthopedic service across the state and i think you will sort through those.

and when reflects properly to make that work. >> and some ways there is the bigger conversation about what is the obligation and if the decision is and has an annual budget every time there is an increase of demand beyond what was expected rejected there will be access problems and this will be true for community care as well. particularly if you increase the eligibility. so in the bigger picture what is our responsibility to veterans or our commitment and how to be paid for that? >> we have had several

questioners want to know how to get claims paid faster? what is the answer? >> this is one of the things that i spend a big chunk of my day on one of the partners delivers care and what we are realizing there is the number of the root cause issues to major to pay providers. one gives back to the eligibility peace six source seven or eight different programs with criteria that if you don't match the but exactly right and you are providing care for a veteran

that lurk ... 40 miles then we don't have the authority and that is unfortunate because uh criteria is so many of them that a veteran receives care that we don't have the ability. so how do we get to that eligibility criteria that is clear for the patients and providers that there isn't any ambiguity? medicare is pretty simple. u-turn a certain age you have a card and you are good to go. and to get to that love all of clarity it will be hard for providers to know that.

to make adjustments to the allies the biggest area right get complaints about provider payments relates to the emergency room care. er care is a plan to consolidate is very fragmented. in some circumstances it is the primary pair of those conditions and in other circumstances it is hell last resort. by a lot and statute we pay 70 percent of the medicare rate fell with doctors with the er it is considered payment in full but they have to carry a chunk of that of their accounts receivable and then they cannot pay us until we get the law changed. that is around the unauthorized care we have to figure out that the services

connected or not. so we could pay the bill to get this more in line with a progressive industry does. does require some investment and if we can get the good criteria in the king said of the system and then we can leverage the community partners. when you actually go to the medical records and then the emergency room you cannot do that by the computer.

and with that knee injury service. way to complicated it takes a long time. to get to a system where to the kennedy adopters to know what they are able to deliver. end however we need help in we cannot meet the standard that we want to meet from the legal and congressional colleagues. >> now responsible for paying 322 million appointments i will tell you what we don't collect. if you go back to their try care 20 years ago about

three months in it was obvious it never paid claims properly. now walking into a scenario he did not create. of that dates back the long time that the v.a. was paying claims by market by market by market. that is not a very effective way to do with. it is hard to get to core competency. and now to consolidate what that looks like was a very needed change. en to have that one direction on the government side. in the institution and to file properly. did to be in a place where the claims are denied. and then to send the next

that is not in anybody's interest anywhere. and with a provider perspective at us start and then get a ride across the system to make it the fastest in the most accurate from those types of programs , you also have to pay one way. right now those from the community they pay one way and file one way if it is through choice it goes down the different ways so of mansion trying to figure out how does this work as a consolidated pipe. we had a project in arlington and texas the

members of congress from the area because to have a community-based outpatient clinic. the son of the hospitals have a 50% denial rate. they did not know how to file accurately. within five weeks together we drop dead at 10%. that makes their historical pattern of pavement changes dramatically. it is part of the responsibility starting with the provider fighting accurately than it does to us to make sure reprocesses the work and then to do inconsistently and that it cycle's back. as an actor that's spent

time 20 years ago and those in the provider community so from my perspective and then they are riding my side and there is no separation was what they try to accomplish. and then the va pays as. and then to figure out what those pieces are that needs to be changed but there is another pragmatic component to get this work right at the end of the day. we will test that then take what we learned to apply to the rest of the enterprise. >> i would expand on the

comments as a provider leered used with the intricate rules medicare is the great example very tight around the medicare recipients but as providers we know what those rules are to incorporate into those processes we know what a medicare recipient comes in for a test what the diagnosis has to be if you can imagine the fear of had their own rules we could develop the systems and process. one pipeline nor one set of rules. and that is very beneficial.

>> one or two more questions. please fill up the blue evaluation for before you leave us today. >> the commission on care reports. with the advisory board and one is to eliminate the requirements that are possibly in constitutional but hypothetically what would bidi impact of either of those changes. >> double comment on the of latter.

and with the response and to those recommendations. just like mom and apple pie those that our most controversial. that people leave and then to, but that eligibility criteria when myself as a doctor but getting to that same goal way to do referrals with the hide networks to create a partnership of that utilization and an that wrapped around customer

service says it was laid out in the consolidation plan and also the way we need to do that. the specific legislative changes and also the budget. and that is a point we hope to get to. >> to all those veterans looking at the numbers 9 million are enrolled in a v.a. 6 million use v.a. health care. most have other waitresses medicare or private insurance through blair and they choose whether to use

v.a. or other sources based on a number of factors that is cause and access. if you opened up what you will see is a gigantic increase the demand. and then the va will pay for it and because the v.a. benefits don't have the co-pay. and go through your private insurance or deductibles and and just uh number that is one thing to consider. the other thing to consider

is do we maintain uh va health care system are transition to a private sector model? you cannot have both with open access. the reason is that people choose to use private sector v.a. care. and you felicia understand the quality of care decreases there is the tipping point and is not reasonable and as they close and from my perspective needs to be thought out it isn't just uh death spiral. is moving into the private sector.