>> afterwards, sunday night at 9:00 p.m. eastern on book tv. go to book tv.org booktv.org for the complete we can schedule.

>> now, nsa director and u.s. cyber commander michael rogers on cyber security and the need to recruit, train, and retain highly skilled professionals. he spoke at the cyber maryland conference in both more. this is just over 45 minutes. >> good morning everyone. we will get started in just a minute so if we could have you find your seat. [inaudible] [inaudible] >> good morning. on behalf of cyber maryland advisory board i like to welcome you to the sixth annual cyber maryland summit. i am david, joining me is rick, where the cofounders, cultures of the cyber maryland advisory

board. it is my great pleasure to welcome the attendees, speakers, exhibitors, and sponsors to this event. also our locals, state, and federal policy makers and other dignitaries in the audience. six years ago cyber maryland started as an idea that built in silicon valley to unify the cyber maryland ecosystem around a common theme. to be the epicenter of cyber security. six years later, looking around the room i would say that we have been successful. would you agree? [applause] >> the question we always ask is what is next, cyber maryland has become a model for other states and earlier today we made an announcement about a program called cyber usa. a community of communities and

cyber states which will be led by the former under secretary of commerce, fill bond and the first dhs secretary, tom ridge, former governor of pennsylvania. >> we wanted to kick off at the session today as everyone knows that cyber security is the news space-age. what happened when the space race was going on, countries were trying to get to the moon. right now we have a situation where cyber security does not have a zip code, does not represent 2121 two. colorado, california, california, and so on so the first move was to numbering the states together in a collaborative effort was cyber usa. then we wanted to do one of the major parts of building this cyber ecosystem is building the next generation which we call the cyber generation. we thought it would be

appropriate to have a student, and high school that is teaching introduce our keynote speaker. i've had the pleasure of introducing, rogers in varying different sessions and conferences, but what is unique about this is that a year year ago we stood on stage at this conference with rob joyce and kathy hudson and nsa launched a program called the nsa day of cyber. yesterday we reached 5 million students that signed up to start to explore their future. as our introduction to the keynote speaker happens, this got started because three years ago is teaching a high school at dunbar, class on technology and i asked a bunch of students what you want to be when you grow up in their answer was, doctor boyer, ray lewis.

>> now we are hearing them as early as last month in arkansas, california, virginia, maryland, everywhere, is doctor lawyer, forensic analysts. doctor, lawyer, lawyer, forensic analysts. dr., lawyer, reverse engineer. i think the grassroots movement has created a movement that our neighboring states are now starting to work upon and collaborate upon so we can protect the nation and create the cyber generation. it is my pleasure now to introduce a teacher of a local high school, steve, and one of his students to come up and introduce emma rogers. steve, if you you can make your way to the stage i want to just make a comment about this teacher in general. this is the world's first cyber teacher who, at, at a high school level has now built a program in a high school where

the most popular sport on campus cyber. over 1106 middle school, and high school students come after school from 3227 under their own accord to learn, compete, and he has now built this into the cyber high school in the model. so now high high schools around the country and around the world are modeling this on how do you give students who have the capability to really demonstrate cyber skills to be able to continue and grow this model across the country. it is my pleasure to introduce steve from loyola high school. [applause] >> good morning. my name is steve, i'm director of technology in maryland. thank

you for for the opportunity to be here, the cyber maryland conferences near and dear to my heart. this really was the inspiration five years ago to start our program. it is nice to be in a room full of like-minded folks who have the same goal. that is educating the next cyber generation. over the past five years one of the goals and my goals to solve the talent pipeline problem from k-12 through higher ed and then through industry. we started as rick mentioned five years ago was six students. i thought, well that was a fun club for a year. and now we have 106, don't hang posters come i don't get on the morning announcement. it is been driven by student interest because students in the high school can do more. then what we may think this morning we're joined by several students, one in particular, here is junior -- andrew is in the second year with us.

this past summer is a sophomore, think back to my summary and high school, i think i was still mowing grass in my summer. he did a internship at the health systems in chattanooga, tennessee where he was a member of the network security team. he brought that information back to layla and is no teaching to our students in grades eight through 12, he is a junior. he is already looking forward to continuing his education in college when he graduates in 2018. he is carrying a full load of ap courses, please worsen the rugby, and works in our science program because he wants to, not not because he has too. so motivation is key. with that, i am pleased to introduce you to andrew,. [applause]

>> thank you. i would also like to thank you for inviting me to the cyber summit this morning. as a junior in high school, i completed an internship in chattanooga, tennessee and found great passion the field within two years. relates to everything we do every day and it excites me in the direction of which the field is headed. we are joined by a man whose whose position is the head of national security agency and central security service, to organizations that play a crucial role in today's world. more information about admiral rogers, can be found in the bio in your programs. as we are aware, cyber has become the next to me to defend and is the space race of my generation. with the growth of the field, unemployment is nonexistent. hundred admiral rogers, i'm

proud to say that that essay has welcome our interns my age than ever before. we are faced with real-world, challenging issues and i am willing and eager to fulfill those needs of this country. by accepting interns from high school and college, i appreciate that admiral rogers have recognized in a brace that young adults can do more than expected. it is with great pleasure that i welcome admiral rogers to the stage. [applause] >> is that an oppressive young man, or what. >> imagine, thank you very much

imagine if you were 16 or 17 years old and someone ask you to stand up in front of hundreds of people, cameras, introduce a man you never met and to do it in front of a lot of people. thank you very much i want to thank you all very much for taking time to support cyber maryland, i'm here because i'm part of the maryland cyber ecosystem both as commander of the cyber command and director of the national security agency. were proud to be part of this ecosystem. i'm here because i want to share a few thoughts and challenges on cyber security, also if there is a young man or woman in this audience who is interested in challenging work in the cyber field at nsa and cyber command we have great opportunities. i'm interested in getting every motivated and talented person to be apart and help build a future in defending structures, networks within the united states government and how we as nsa, part of a much bigger team can do our part to help defend our nation and help our friends and allies around the world. cyber is the ultimate team activity.

in the 35 years i've been an officer in the united states navy have never been part of a mission before in which your success and the ability to generate operational outcomes is so dependent on a broad variety of partners. that is both challenging but it also represents opportunity. you see that in this audience today, among you are high school students, college students, the naval academy, people involved in academics, people involved in industry. people industry. people involved in the government at the state and federal and local level. it is our ability to harness all of these capabilities that these groups represent and into an integrated team that is working on some tough problems i think we all have to acknowledge that we are not where we want to be where it comes to cyber security.

let's is reflected in the level of investment, as reflected in the increased level of activities that you read about in whatever your potential source of news is, whether print, online media, whatever, you cannot go literally hours without something popping about a major a major cyber challenge somewhere both here within the united states, but globally as well. this is not a phenomena that is restricted to a particular nation, particular area, or particular sector, or segment. there is literally activity of concern out there and every segment of our private sector, across the u.s. government, with our allies and friends around the world. i suspect that dynamic is not going to be changing in the immediate near term. collectively we need to step back and ask ourselves what we can do to work together to address the challenges associated with the cyber environment that we're dealing with today. that means information sharing is going to be critical. the government with legislation that has been passed in the last 18 months, we started initial

framework with how are going to do that. in the federal government we've taken time to outline the roles of the different parts of the federal government and how we're going to provide support both coordinating internally within the government and perhaps more importantly, how are we going to apply that capability more broadly across our nation. as a part of that team on the first to acknowledge that one of our objectives has to be how can we help simplify to our private sector friends how you interact with us. we have to make it easier for you. we have to align the insights that we generate to generate value for you so what is the information you need, how do you need it, and what format, what truly is the value to you. you don't want us deciding that. we need to partner with you and understand what it is you feel that you need. at the same time, we are are out

there competing for the same workforce. that challenge is not going away. if you look at the human capital piece of that challenge, i would argue that in some way that is the greatest challenge of all. that while the technology is incredibly important to our ability to meet the needs that are associated with the challenges of cyber and cyber security, perhaps the greatest challenge is not the technology but the human capital. how do you make user smarter? that they are making smart, intelligent, well-informed decisions, you can have the greatest defensive strategy in the world, but if your users are making choices that undermined that security, you have have made your job that much tougher. by the same token, you need need an incredibly motivated and focused workforce. you not only have to have a workforce in which segments of

various specialized training, but as i said, we have to raise the knowledge level of every single individual within our structures. so the human dimension and the ability to generate trained men and women with the right kind of background insight is a challenge that as a nation we are only beginning to come to work with. i don't think any of us in this audience would tell us that i have all the people i meet meet with all the right skills in all the right background. we clearly are not where we need to be. that is one of the reasons why i like to do things like cyber maryland. an essay and cyber command we want to be part of the solution. you heard in the introduction some of the things were doing in terms of outreach to the private sector in terms of the academic world, with students, one of the things andrew mentioned was her internship program. we have come to the conclusions that one of the greatest returns

of investment is getting young, motivated men and women familiar with us at nsa and cyber command earlier and earlier. we have an aggressive internship program at the high school, undergraduate, and the masters level for our organization. in fact i've been the director now at nsa for a little over two and a half years and i can remember the first week on the job. one of the things i like like to do is go down, walk around in a lunch in the cafeteria so i can talk to some of the workforce. the first week on the job i go downstairs for my office, go on the cafeteria and along the way stop and say hello to two young ladies. after lunch i go back to my office and i said to my team, i cannot believe how young we are hiring people. i just met two young ladies who i swear looks like there are 14 or 15 years old.

i got, will sir they were probably interns. and i said we have interns, the thought to me, again just starting the job was that you mean we are giving security clearances to 15 and 16 -year-olds. i was the first to admit i was struck by while this is a different world and were going to have to do things differently than we have historically done. but i would tell you the internship program has among the highest returns of things we do. something over 65% of the people who in turn with us and up working with us. once they complete their education. that is a great place for us to be. you see that investment not just in us. many organizations are doing it. as a naval officer i highlight the work that were doing at the naval academy. we are making cyber courses mandatory for the entire brigade

of the naval academy. we believe cyber is foundational for the future and everyone must have some baseline level of knowledge. we are past the time where it can be a don't need to worry about that, that's what my it guys do. as i said, given the challenges associated, that is not going to work. we have cyber major, we have broken the grounds or soon will come of this month we are breaking the ground on a new cyber center at the naval academy and we are now directly commissioning officers out of the naval academy within the cyber arena. something we had not done just until a couple of years ago. as a service we recognize that the world around us is changing and we realize we have to do things differently. you see that what the secretary is done in terms of our defense, innovation and experimentation. we acknowledge that as a department we have to go where the best technology and

innovation resides in much of that is outside the government and outside the department of defense. we have to be willing to go to the outside world and say what can we learn from you, how can we partner, what kind of capabilities and insights you have that would generate value from us and help us in our mission to help defend the nation as well as defend her key friends and allies. another thing that i am telling the workforce is that because of the defensive side is a core aspect of our job we must constantly drive for success but at the same time we must acknowledge despite her best interest there will be times that we will fail. we must be prepared to deal with failure. when i first started my personal time and cyber i remember thinking to myself, the entire focus was to keep the opponent out of your network. that still remains the primary driver, after 15 years doing this in the department i've come to the conclusion that you must not only spend time focused on

the but you must acknowledge that despite your best efforts you are likely to be penetrated. given that, that, what are you going to do. i will tell you as an individual who has had to deal with major penetration it is a very different thought process, different methodology and leadership style. what i'm dealing with problems in the investments were trying to make or stall as opposed our response. it is a great leadership challenge. it goes back to the human capital piece. as important as the technology is, don't ever forget about the importance of motivating men and women. without motivated men and women i don't care what your 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

half. >> hello, everyone, we're going to go ahead and get started. i'm marilyn serafini, and on behalf of blunt and carden, i'd

like to welcome you to the veterans briefing on health care. the veterans choice act became law in 2014 creating a pathway for some veterans to receive some of their health care through the private sec torre. there's been a debate how best to deliver health care to veterans for quite some time and the last two years have some experience to consider as policy makers here in washington decide how to proceed going forward. today our speakers are going to help us understand the complex system through which veterans receive their care and how it's changing given the unique needs of veterans. i'd like to thank our sponsor for today's event, ascension health, and i'm going to turn over the mic now to mark hayes for a few words. >> well, welcome. i'm going to be very brief. i just want to thank you all so 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. providers were competent and compassionate to my needs, but there was a disconnect that was stark. as i recall much of my relevant history while fighting a debilitating favor because my records weren't available. i'd be left sitting in a waiting room behind the line of cast of characters as just another guy in a wheelchair who needed medical care. after dealing with what ailed me, i'd have to drive myself to the nearest drug store hoping to carry my prescription. i'd have to bounce around to several drug stores or simply wait for medication because it was out of stock. >> and this is what fragmented health care looks like when taken out of the abstract for veterans who would be impacted.

let's take a look who will be impacted today and in the future as va health care evolves. for most, getting dental care, eyeglasses, hearing aids, x-rays, urgent and emergency care in a timely manner is a good thing. but let's not underestimate what that means for the men and women in my circumstances or worse. you see the numbers on the slide. to me, they're not just statistics. these are veterans whose quality of life is a matter of life and death in many cases for the rest of their lives. here is a problem for those who advocate for complete privatization, yet agree that va should provide the function for specialized services and i keep hearing, they can do what they can and privatize the rest. that doesn't work, having the spine doesn't mean i won't have

cancer, develop diabetes or need what is referred to as tertiary care. and the veterans access those other services such as oncology, surgery, cardiology, neurology and because of the interdisciplinary frame work unique to va. that's why you cannot separate them. in kt fa-- in fact, specialized services should demand that tertiary services be driven completely to the private center. so with this busy slide in front of you, we'll turn to the discussion of the attributes that make va unique during my 14 years of using that. and the tertiary and specialized care that most who opine on the topic likely do not know. here is a bit of education.

i'd like to draw your attention to a few starting with ones in the red boxes. did you know, a veteran seeking care in the private sector do not have to pay for the expenses for them providing a request to cover unauthorized medical expenses is timely provided. that's not so in the private sector. eligible veterans who have medical appointments are reimbursed for their mileage and travel provided-- unless provided by the va or contractor. that's not so in the private sector. a veterans receive access to prosthetics, va benefit assistance and peer support durling appointments, making it a more veteran centric experience than they'd receive anywhere else. that's not so in the private sector. now eligible veterans do have a choice, they have a choice and that's a good thing because they can seek care from alternate provider of timely va

care, is not available, which is great as a component of va health care, but not as a replacement. >> finally, i'd like to close with comments on the most overlooked aspect of collaboration between the va and the private sector when discussing health care for veterans. title 38 of the united states code, the authority that governs the delivery of health care, products veterans through due process provisions, medical, and title 38 afforded protection do not follow the veteran who opts for care under the choice act. congress will not have the jurisdiction to compel testimony from private sector ceo's whose health care systems, gained the numbers or have hidden -- maybe we're

wrongly assuming it never happened. moreover, veterans rely on the courts if health care goes awry if they can afford it. it's effective and sustainable collaboration is to happen this absolutely must be addressed. as long as these veterans know that, that's the reality, then we've given them not just a choice, but an informed choice. beyond simply hoping for the best. if they chose va for their health care, it needs to be a viable choice. thank you. >>. [applause] >> thank you, sherman. now we will turn to the doctor. >> thank you very much. that was just an amazing experience of some of the care that's provided in va. just a little about myself. i'm a practicing physician within the va.

when i'm not seeing patients, as often as i would like these days, i'm in d.c. leading the va office of community care. one of the other key pieces about kind of my journey with va is i trained in va. i was a medical student down in gainsville, florida and then a fellow at university of pennsylvania, the philadelphia va, as many of you may know, 70% of all of america's doctors at some point interact with the va. that's another key feature of the system not only taking care of our veterans, but also training the next generation of nurses, doctors, and other health care professionals that will take care of all americans. to sherman's point, at the end of the day, what we want to see as a vision for va, and va health care, is what we call an integrated health care system. it's a system that includes va health care providers and clinics, as well as leverages,

expertise from the private sector. unlike many other health care entities in the united states that are limited by their geographic markets, so if you're starting a clinic, it's-- what you actually do is patients come to you. va is completely opposite. we go to where the patients are. where the veterans live. and our veterans live in every corner of the united states. some highly rural and some highly rural places and urban places and they span the entire geography of america. and in those circumstances, we cannot have a brick and mortar facility in every one of those individual locations. and so, we have to leverage community partnerships and they really are about partnerships, not just the care. partnerships that allow us to provide health care to veterans in those areas. so at the end. day, what we want to do is build an integrated health care network and i know that the

alliance puts on a lot of these various programs and they focus on medicare, and so, medicare correlary would be an accountable care organization. this is really where we're looking to build, which is a network that is highly coordinated, integrated and includes va and community providers, really, we need both aspects to meet the full spectrum of needs for our veterans population. how do we get there? we start with the veteran in the middle. so va and va community care has been ongoing transformation since the care came out and a year ago we presented a plan to congress, called the plan to consolidate care and right now we have multiple ways of purchasing care in the community and it's important to note that va has been partnering with community providers for decades upon decades. >> the choice act might have been a spotlight on our ability to purchase care, we purchase

way more care outside of the choice act than within the choice act and we've been doing that for years and years and years. and a perfect example, the partnership we have with economic medical centers we started out 70 years ago. we're able not only to share clinical knowledge, but also research and training expertise. so, this is not new to va, this ability as a partner with different providers across the country. and like i said, they span the spectrum from academic, community providers and federal institutions like dod or in the health service to fqac's to regular mom and pop shops across the country. so, how do we get to this integrated healthcare? we look at the community providers and we map the veterans journey through community care. it starts well --

with eligibility. right now base of the various programs, it creates confusion. the benefits that veterans earned and deserve are not clear in the community. so we have to be very specific who is eligible and who is not and hopefully make it fair and he c he can he can quitable system. and hour community partners don't know if the veteran will be covered by va or not and that creates problems with payments. if they take care of an individual that we are not by law able to take care of. second is a referral and authoritization process. how do we make sure that we get our veterans care, timely access to that. this is making sure that we're

able to leverage electronics, exchanges of information so that the doctor knows clearly what veteran they're seeing and the reason for that and the veteran also knows why they're seeing that doctor and when they're supposed to see them. care coordination, i always kind of state is where the magic happens here, this is the golden nugget if we're able to get this right we'll serve a model not only for our health care system, but for all of american medicine. and it's in the era of value-based payments and integrated networks and this is the thing that folks are trying to figure out because you cannot live in your own institutions anymore, you have to work with other community partners, whether they're for delivering health care or community resources, housing and transportation in order to actually take care of patients. at va, we're uniquely positioned to start to address this because of our ability of integrating care between the community and within our own health care system and we're

hoping to leverage more electronic health information exchanges and portals to share medical records between va and the community. the next one is the community care network, which is who is this network of providers that we work with. and this really does get to the idea of informed choice. right now, we have a broad network of providers, more than 350,000 partners that we work with in va with the community of veterans. we want to make sure that the veteran is empowered to make informed decisions about the providers that they want to see and this is the same movement that all of american medicine is getting to. how do we get our community network to report on quality, satisfaction, value, so that veterans are able to choose a provider that makes sense for them, that this is a health care is a very personal matter, how do you choose a provider that actually meets their needs? part of this is also identifying what we call at va is our preferred providers.

we know our providers in the va by interacting with veterans understand military competency and unique circumstances and conditions that our veteran population has. when i was practicing in the private sector, there just really isn't enough volume or touch points that you have with veterans to really understand all the different nuances. so we want our preferred providers to know the only deliver excellent quality, high levels of value and expertise in military cultural competency and be aware of veterans issues and i think that way we can start to help our veteran population understand and choose a provider that meets their needs. next, is provider payment. and this is critically important, especially it being a practicing physician, as we view our providers as partners. and in order to be good partners to our providers, we have to pay timely and accurately. and this is something that the va continues to work on because of the multiple ways that we

have of buying care today, it creates a lot of confusion. and i'll give you one example. when the choice act was passed, va by law was required to send out about 9 million cards to individuals. these cards look like health insurance cards and we have encountered many veterans that have taken that card to a community provider. the provider worked on the assumption that this veteran was eligible and delivered care and on the back end, we got plans and not able to pay those clinicians because they did not meet those cry criteria. so we have to have eligible criteria that's simple, no red tape, make it easy for folks to understand so that the community and the veteran know exactly what is eligible and what isn't. and then us at the va can do our part that we pay timely and accurately and wrapped throughout all of that is a focus on the customer and customer service on our veterans and that makes sure they're able to get information

to them in a quick and timely manner. so that's really our journey at va right now, on how we're tackle to improve community care. it's focused on the veterans and the touch points important to them and then spooling up projects to be able to move the needle in each of the areas. for almost every one of those areas we need to partner with congress to make sure that we make the system less complicated than it is. when you're trying to run a program and keeping the veteran in the middle, it makes it hard when actually there's not one program, but seven or eight and we have to get to one program that makes sense for our population. >> i wanted to mention a little about how we can move towards a high performing network and this is a concept of this network that i described as internal va and external va partners and this graphic depicts that a little bit. you can see veterans moving from one location to another

and including the va and our various community partners. and we want to-- we want to state where the puck is, where is health care in the future and what can we do with va to make sure we're meeting the needs of veterans not only today, but also tomorrow. and that means evolving from the fee for service model to a value based reimbursement model with preferred providers. with cms's and all the various demonstration projects, they're testing out various model that makes sense from a value-based perspective. we want to participate in those as well. we want to make sure that we are not-- our community providers are not driven by volume, but more towards value. we do need some legislative help in order to do that. we also want to leverage better monitoring of quality of patient satisfaction and value. we want to be transparent about the care we're delivering in the va. the va reports publicly in a

lot of various markers related to access as well as quality and satisfaction. we want to be able to get that same level from our providers that are veterans and are participating in. >> third, we want to transform from a care model that-- to a care model that's personalized and coordinated. inside va we have a central medical model we have teams that take care of veterans and we need to leverage that personalized care as veterans that go in and out of the va. that's a unique challenge for us, that, as i said, also by many health care institutions across the country that being able to match a veteran with the right level of need and some veterans might just need a navigator to let them know where to go, what to bring and others need multiple point men and make sure they have transportation. how do we match them with the right resources and follow through the trajectory as they

go in and out of the va? lastly, we need to leverage better exchange of information. right now in american medicine, there are a number of different health care providers that all use different electronic health records. and va has been in the business for decades and we need to communicate between those different entities and he think we have some innovative ways of doing that by really leveraging some of the community health exchanges that are in existence today and moving more towards the portals of information. that's a little about the future of va and where we hope to get to and some of the challenges that we face from a legislative standpoint, but also, i think opportunities for us to be able to really lead the way in some ways for areas of american medicine. thank you. >> thank you, dr. yehia. [applause] >> now to david mcintyre of tri west. >> marilyn, thank you, and good afternoon, everybody.

thanks for being here and those of you that represent members of copingress, it's a privilege to serve your constituents, because every one of your bosses have constituents, and part of why you're here. it's great to follow sherman who did a great job of weighing out the population, the individual responsible for being served by the system. and dr. yehia who did a great job laying out where the system is today and where it needs to be going going forward. my-- they asked for me to layout how did we get to where we are from a choice perspective. what did that look like and what does the system currently do from a private sector perspective? so i'm going to spend a little time talking about the scaling that was involved to make this happen and where we sit when we look through my end of this lens. and this is responsible for one half of the country to build the integrated delivery system

that makes up next to the va delivery system. obviously, as sherman represents, we have the privilege of serving the best of the best in this country. they're the people who serve this country. so, the choice act was born out of a crisis. i live in phoenix, arizona. in april of 2014, we all know what was disclosed in phoenix and quickly congress passed legislation and actually funded it at the same time to give va money to be able to scale internally and also to buy more care downtown. they gave the private sector and va 90 days to stand this up. by the time the rules were actually figured out for what was going to be done, we had 33 days to go from a blank sheet of paper to full start-up. that's a very, very short period of time. but when we started, there were no four-hour waits on the phone and we were on our way headed down the track of what needed to be done and we spent a lot of time together trying to

figure out where the gaps are between congress, the va, and the private sector and how do we close those things. many adjustments had to be made, policy and operationally and we'd probably gone about 75% down the track of closing those gaps, but there's a lot of refinement that still remains to be done as one would expect. massive scale had to be built and placement was key, but you had the greatest challenge was to get people to understand what was actually enacted by congress. both within the va, within congress, itself and among the beneficiary population as well as by the health care provider community because this was launched very, very quickly. but we sit here today. a little past november 5th of 2014 when this needed to start and over five million appointments have now occurred through this program. our company and the network that we built is responsible

for 3.2 million of those. how do you go about building out network. you've got to understand the demand curve. so we spent time working with the individual va medical centers understanding what demand looked like. if you had never filled out demand, you didn't understand that. we tried to map that. when you look at 2014, the blue area is our area of responsibility because we really didn't have a good sight line as to what the demand picture look like for what needed to be purchased in the community and matched up next to va to give it the elasticity that it needed. this is what it looks like now. if you go backwards, that is what it would in 2014 of january, and this is what it is now, tailored to demand. and the bottom line of it is, very few cases are now returned to va in our area of responsibility because there's not a provider available to see that person, when the va itself is unable to deliver that care

directly. i'd like to thank ascension for being a part of that network and thank lifepoint for also being a part of that network and the 185 to 190,000 providers spread across 28 states, they're delivering care today at the site of va to give them the elasticity that they need. in the first month, we served 2000 people and you can see what the demand curve has looked like. as dr. yehia said, the va's been buying care in the private sector for a very long time. we're owned by two university systems which gives us a lens into the delivery system and by those that buy care and coordinate care and that's the core of what they do. you look at the demand curve and we're not at the top of it. yet, 6,000 units of care are placed from 2000 a month that was done previously. this is what's happened on the spend side.

so, at the beginning of choice, as you start slowly into something like this, it's chiropractic care, podiatry, the lower cost, low acuity things. now it's brain, it's heart, it's digestive systems, it's brain injury, it's cancers. those things are placed in the community as opposed to va. what are the challenges that remain? i don't believe that we've entirely solved the access equation. the issue at the end of the day is make sure we properly map the demand curve. make sure we're operating in an integrated way to make sure that people have the confidence that the provider in the community are the right ones to place care with. the second one is continued refinement and dr. yehia went through the various aspects of what's refined today. the biggest issue for us at the

moment on our side, is to make sure that providers understand what it takes to file a claim properly. and then the process works in a streamlined fashion on our side, and then as the va reimburses us for the payment that we make to providers, that that full stream works. we still have works. and the doj stood up, and i was in the same role then. it took three and a half years for the dod to engineer claims to get it right. what i'm going to tell you is the people in va are incredibly focused in the space and we're making a lot more progress than we made 20 years ago with dod. and in fact, if you go to a place like rio grande in texas, we just finished a triangulated project there to bring the va together with the hospitals in the community, together with our company to be able to look

at how do we get claims right between all three of us. and we change the apiture dramatically in as short as five weeks and we plan to do that across the country. the third thing i would say, we have a very inhumane dialog going on in this country around this issue. this isn't about privatizing the va. it's not a good idea. we, as citizens have invested a lot of money in the architecture and infrastructure of a great system. at the end of the day, this is about resetting a system. that's going to take 10 to 15 years to its end point. unfortunately, folks thought when you pass a bill, when you fund it, you're done. no, that was just the down payment on getting started. and some of us remember what happened with walter reed. it needed to be reset and reengineered. that took eight years. this is an entire system and

it's about making sure that the people who served in combat the last ten years, they came from every zip code in this country, have the ability to go back to where they came from and live there and receive care. and if you're in a place like sherman is, you may need to go to a place that's right next to a va medical center, but the bottom line is, the system's not really set for that so this is partly a resetting exercise. and then as they said, making sure eligibility works more streamline. the last thing i would say to those of you that are staffers here and i was a staffer a long time ago, back about 20 years ago, is when i left capitol hill, in the 60's when we passed medicare and medicaid, we created them as entitlements. >> the va is not an entitlement. the choice act makes it a virtual entitlement. that's a good thing. it's time to step back and

figure out whether va should be the primary pair and whether we ought to think about, the notion that those that served our country, the way that veterans did, had the right, the first right to entitlement. because a lot of things would end up in a very different place were that the case and most of their care is financed by the federal government. >> so i said, that would be a challenge for former colleagues and those that followed me as a staffer. lastly, i would say this is about teamwork. again, i come from the city of phoenix where the inferno started. on monday, this billboard was put up in phoenix. it replaced a billboard that was right outside the va that said the va is lying. for nine months, the staff that were driving to work saw that every day they went in. there are people that are dishonest. they happen to be in the private sector. they're also in the public sector, but not everybody's dishonest. and the fact of the matter, it

was demoralizing. what this billboard shows that now replaces that one, as of monday, is that it takes a team to deliver for those who served this country. not to replace va, but to give it the elasticity it needs. 400 providers at the hospital in phoenix, surrounded by 800 providers in maricopa county, of every specialty. to give them the elasticity to deliver our care. thank you 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