turn out. but there will be a lot of people who will be sitting back rather than actively involved. and the one thing that hasn't been mentioned here tonight, is when this election is over, the chapter that is going to be written is michelle obama and barack obama. >> oh, yeah. >> those are the two people who drove this election as much as anything in terms of moral terms and in terms of being able to stimulate the groups that hillary clinton needed to have. >> unfortunately we have time for only one more question. >> thank you, good to see you. >> thank you. as far as i'm aware neither your normal boss nor his father have been willing to endorse the republican candidate. if we assume the polls today are correct and that the republicans are going to take a thumping two weeks from tomorrow. tell me from a gop strategy perspective what goes on inside the heads of the leaders of the

party on the morning of november 9th? >> i think they'll be celebrating. >> no, actually assuming that the polls are correct. >> well, no, i can't do that. i'm not going to assume the polls correct because i don't assume the polls are correct. i think they're incorrect. you have to remember this is not somehow some unprecedented time of history when political division has gone on with the republican party. if you recall, back in the democratic midterm election how the democrats ran away from president obama in terms of the midtermz a midterms and they lost. when senator mccain was running for president, when he did not invite president bush to speak at the convention and didn't campaign together. it's not uncommon for past republicans to not attend or speak at the convention. for the life of me i can't understand why the democrats don't invite jimmy carter to speak at their conventions. the narrative that somehow republican presidents not endorsing or being on the

campaign trail for the incoming nominee is not true. and i think what it boils down to is what you have to do politically. and so that's why mr. trump has said in private, do what you have to do. at the end of the day speaker ryan knows that in order to advance the opportunity agenda, that he wants to do for every american including minorities and children, including those in d.c., he's going to have to do that with a president donald j. trump and he cannot enact any of that with hillary clinton there. that's why he's going to support donald trump. that's why he has supported donald trump. and that's why the republican leadership is staying behind donald trump. they know that the alternative is so much more dire for the american people and for the legislative agenda of the republicans. that's why the majority of republicans are going to stick with mr. trump, especially the establishment. they can do what they have to do politically because they have to answer to their base or donors or lobbyists or whom ever. when they go in the ballot box they're going to vote, i promise you for donald trump.

>> well -- [ inaudible question ] >> i think that it's going to depend if donald trump loses, it's going to depend in large part on the size of the defeat. and i think if it is a close election, the most interesting purely political story of the next year or so is going to be the recriminations of the republican party between the people who blame the part of the party to make sure who couldn't get elected and the other side who blames the people who wouldn't get behind. i think that the party is going to have to work through the recriminations before they can get to the point of figuring out their path forward. >> we could do this all night. you've gotten a taste of why this is such a remarkable election. it's really one of the most fascinating elections. this was a fascinatesing conversation, thank you, it's been a terrific conversation,

thank you very much. [ applause ] >> who wins and how many lectoral votes do they get? >> donald trump, 270. >> clinton 347. >> clinton. over 325. >> general. >> 269, 269. >> that's the best predictor of the day. >> glutton for punishment. >> clinton, 371. >> wow. >> i can't go there, because i'm still like, trying to figure out how jeb bush didn't get the nomination. >> low energy. [ applause ]

james comey tells congress the agency is investigating whether new e-mails that have emerges in its probe of hillary clinton's private server may contain classified information. director comey said in july the investigation was finished. the disclosure raises the possibility of the fbi reopening the criminal investigation involving mrs. clinton just days before the election. although it is not clear, if that will happen. on election day, november 8th the nation decides our next president and which party controls the house and senate. stay with cspan for coverage of the presidential race, including campaign stops with hillary clinton, donald trump and their surrogates. and follow key house and senate races with our coverage of their candidate debates and speeches. cspan, where history unfolds daily.

a new poll in two battle ground states, nevada and new hampshire put together by nbc news and joining us is the director, thank you very much for being with us. >> my pleasure. >> let's talk about new hampshire, the presidential race, where is hillary clinton, where is donald trump. this is a key state for both candidates. >> yes, yes, although it only has four lectoral votes, bottom lines if this is close this may end up counting. what we see in our latest poll is that it was pretty much a toss up, clinton had a two point edge in our previous poll. right now, she's got a nine point lead and there's several factors contributing to that, not the least of which is a 33 point gender gap. she's carrying women by 25. he's carrying men by eight. so there's this huge, very wide gender gap and she's also

getting more republicans than he's getting democrats. so the republican party is less unified in new hampshire around trump than we're seeing in other states where he does better. so right now, it's working clinton's way in the granite state. >> new hampshire, was key to donald trump winning the republican primary earlier this year. are the problems he's facing nationally a microcosm of what's happening in new hampshire, his inability to expand his base? >> i think that's part of it. new hampshire of course has as you know, a very independent strain to it in terms of the voters. and right now, hillary clinton is not only getting more democrats than he's getting republicans, so she's got a seven point advantage among unaffiliated independent voters. and so the lead she has right now of seven points is a good lead for her. there's a lot of national polls, some are better than that, some are worse than thatment you

know, when push comes to shove we're talking electoral votes. if she can have these four, that's one of the states that she needs to put together to insure that he does not get to 270. she may get it without new hampshire. but it serves as a blocking against trump if he does carry. i might say, there's a major difference also in terms of their favorability ratings. we hear that both clinton and trump are unpopular. when you look at the new hampshire numbers, clinton has a 44% favorability and only a 45% negative. so she's pretty even. donald trump has only 29% people likely voters say that they view him positively. 68% view him negatively. this is rough terrain for donald trump right now. >> new hampshire is also home to one of the most closely watched senate races, the democrat

candidate challenging senator kelly ayotte. >> it's been getting a lot of attention and will continue until election day. it's a one point difference. it makes it a toss up. what's interesting about this is kelly ayotte is running 12 points ahead of what donald trump is getting in this state. so she's been able to separate from the trump numbers to what she needs. as a result, she's competitive, obviously, 48 for her is much better than the 36 he's getting. and so it's very close race. this is, you know, clearly the control of the u.s. senate may go through new hampshire. and if it does, how this race ends up will be absolutely critical. >> another battle ground state that you've been polling in nevada and your poll indicates it's tied up. >> this is a fascinating one. 43%, 43%. our previous poll had it at a

one point difference. it's almost some of the things we're saying about new hampshire just the opposite in nevada. here the independents instead of clinton having a seven point lead as she does in new hampshire, here trump has a six point lead among independents. and trump is getting more democrats than she's getting republicans. so it's just the opposite, although the gender gap at 26 points is still very, very wide. so this is a state that's got a lot of things going on in it in terms of demographic changes, in terms of, you know, voters. you know, trump does better in states that have more non-college white voters. and not to get too demographic and start carving people up into little categories, this is a state where many of the white voters are not college educated and therefore, it's a group that he is running up a lead of 19 points above.

so that's very strong for him. and it offsets what she's doing right now among latino voters. >> gary johnson, the libertarian party nominee, a western governor from new mexico. how is he resonating in nevada? >> he's right now getting 10%. and so he becomes factor in all this. i must say about the so-called minor party candidates, you know, pollsters do it two ways and sometimes they offer the names and sometimes they don't. and if you offer the names as we did in that particular case, the candidates tend to get more than they will when you just don't and somebody has to volunteer the choice. so ten may be his ceiling. but in the race that's 43%, 43%. anything he's getting should that go to one of the other candidates could tip the vote that way. >> finally, nevada and open seat with the retirement of the senate democratic leader harry

reid. both parties eyeing nevada to pick up the seat for the republicans and keep it for the democrats. >> right now, the congressman heck is up seven points. as we were talking about in new hampshire, he's running ahead of donald trump. he's running six points ahead of donald trump. and seven points ahead of his opponent. it's interesting, clark county is where a lot of the votes in nevada come from. and that's a very democratic area typically. and when we watch election night, if this is a close state for president as it is right now, they're going to be looking at the vote from clark county. his congressional seat is in clark county. as a republican, he's really in an area where he is siphoning off potential votes that might have gone to the democrats. this is a very interesting dynamic. it's still close enough it could go either way. but the advantage right now is that senator reid's seat may end up going to a republican. and wouldn't that be ironic if that ended up being the deciding

seat. >> the director of the institute for public opinion out with the latest poll along with nbc news and the wall street journal. thank you for your time. >> my pleasure. they're looking to see what kind of leaders we choose. who will entrust our country and their future to. will it be the one respected around the world? or the one who frightens our allies and emboldens our enemies. the one with the deep understanding of the challenges we face? or the one who is unprepared for them? a steady hand, or a loose cannon. commonsense and unity, or drama and division. the woman who spent her life helping children and families, or a man who spent his life helping himself. our children are looking to us.

what example will we set? what kind of country will we be? hillary clinton. because we're stronger together. >> i'm hillary clinton, and i approve this message. far too many families today don't earn what they need and don't have the opportunities they deserve. i believe families deserve quality education for their kids, childcare they can trust and afford. equal pay for women, and jobs they can really live on. people ask me, what will be different if i'm president. well, kids and families have been the passion of my life and they will be the heart of my presidency. i'm hillary clinton and i approve this message. what's at stake in this election? it's not just who goes here. it's who rules here. the supreme court. the justice who guaranteed your right to own a gun is gone. now, the next president's choice breaks the tie. four supreme court justices

supports your right to own a gun for self-defense. four justices would take away your right. >> the second amendment is out dated. >> the right to possess a gun is clearly not a fundamental right. >> what does the second amendment mean to you? >> not the right of an individual to keep a gun next to his bed. >> and hillary says. >> when it comes to guns, we have just too many guns. the supreme court is wrong on the second amendment. >> hillary's made her choice, now you get to make yours. defend freedom. defeat hillary. the nra institute for legislative action is responsible for the content of this advertising. healthcare providers and some government officials are calling for renewed recommendations into services provided to veterans through the va system. the alliance for health reform hosted this breathing in washington. the access to mental health

services for veterans and recommended changes to the veteran's choice act which is set to expire next august. this about 90 minutes. hello, everyone we're going to go ahead and get started. i'm with the alliance for health reform. on behalf of our honorary co-chairman senators blount and carden i'd like to welcome you to today's briefing on veteran's healthcare. the veteran's 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 healthcare to

veterans for quite some time. and the last two years have provided some experience to consider as policymakers here in washington decide how to proceed going forward. today our speakers are going to help us to understand the complex system through which veterans receive their care, and how that it is 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 mike now for a few minutes to mark hayes for a few words. >> well, welcome. i'm going to be very brief. i want to thank you all so much for coming to this important briefing on a very important issue. ascension is very pleased to be sponsor of this briefing. because the care for our nation's vaerneterans is so important. it's the issue that combines

veterans and healthcare issues so it's a great issue for different offices to meet each other. we don't always interact. it's great opportunity. we have a great panel this morning. ascension is the largest non-profit health system in the united states and the largest catholic system in the world we participate in the veteran's 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. we are very pleased to participate in the program and are looking forward to what we'll learn this morning. thank you all for being here. >> thank you, mark. so if you are following at home on cspan, you are welcome also to follow and of course those here in the room, you're welcome

to follow and participate in a twitter conversation. the hashtag is veterans health. you can also use twitter to post questions to the panelists after each of them speaks. after we go through the line of all of them speaking, we will turn to your questions. and you'll be able to ask questions in several different ways. you can pose your questions via twitter. again, hashtag veteran's health. we have two microphones in the room. and you also in your packets have a green card and you are welcome to write your questions on the green card. and our staff will be around to pick those up and they'll bring them here to me and i'll present those questions to the panelists. also, if you are not with us here in the room today, you can find the speaker's presentations and also other resources at our website, allhealth.org.

i'm going to introduce our panelists today. we have sherman gil gillam jr. 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 served his fellow veterans. thank you sherman for your service to our country. next we have dr. yahia, the deputy undersecretary for health for community care at the veterans health administration. before joining the va, he was a leading expert in hiv medicine at the university of pennsylvania. david mcintyre jr. is president and ceo of triwest healthcare alliance which he founded in

1996. carry farmer is an associate director for the behavioral and policy social -- sciences department at the rand corporation. her areas of research include access to and quality of behavioral healthcare for military service members and veterans. as well as treatment and recovery from traumatic brain injuries. and finally, we have john kerndal the senior vice president and operations chief financial officer for lifepoint health. he overseas operation support and planning departments that provide direct assistance to providers. we're going to start off with sherman gillams. i turn it over to you. >> thank you, marilyn. i'm playing with the clicker here. good afternoon, everyone.

these pictures show me at the book ends of my military career. 17-year-old private first class that became the 29-year-old commission officer you see on the slide. at that time i didn't know much about being a veteran meant, nor did i really care. i never set foot in a va medical center or received care from a va provider. any opinion i'd had of the va healthcare system would have been based on secondhand knowledge at best. our problem today is we have too many in government who share the same lack of informed insight. yet insist they know what's best for veterans in terms of delivering healthcare. hopefully we'll change that in this forum today. and here's why. because this happens. car accidents. training mishaps, combat injuries, illnesses and other afflictions inherent to the hazards of military service.

this was my car after i was extricated from the vehicle 14 years ago. follow up was an emergency spine surgery, three days of intubation, 11 more daze of intensive care until i stabilized and my very first contact with the va medical center. where i started my rehabilitation journey. there was virtually no decision that was my own. my life was in the hands and judgment of others. the same is true of those service members who will suffer similar fates in the future as well as veterans today who have 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 be wholly based on public outrage and reaction to isolated incidents? will political pundits and

decision makers look beyond statistic and headlines and at least have set foot in several va hospitals and spoken with numerous veterans to inform their thinking? so this is me now. a by product of va healthcare. one of many who have filtered through the system, seen first-hand what needs to improve. there are things that need to improve. and know by experience what makes it unique, a veteran centric healthcare that cannot easily be replicated in the private sectors. the version of me has used tricare and urgent care centers when a va wasn't readily available. the providers were competent and compassionate and responsive to my needs. but there was a disconnect that was stark. for example, have to recall as

much of my relevant medical history as i could while fighting a debilitating fever due to an infection because my records weren't available. i'd be left sitting in a waiting room as just another guy in a wheelchair who needed medical care. after the episode of care while still dealing with what ailed me i'd have to drive myself to the near rs it drugstore hoping it carries my prescription. more than one incident i had to wait for the medication because it was out of stock. this is what non-veteran centric fragmented healthcare looks like when taken out of the abstract for the veterans who will be impacted. let's take a look who will be impacted today and in the future. for most, getting dental care eye glasses, x-raies, urgent and

emergency care in a more timely manner is a good thing. 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's a problem for those who advocate for complete privatization, yet agree that va should retain the function of providing specialized services. i keep hearing thim sem say tha can do what it does best and privatize the best. that will not work. having a spinal cord injury doesn't mean i won't get cancer. have a heart attack. develop diabetes or suffer depression and need tertiary care. which augments and sustained those specialized services that va does well. within the system veterans access those services and are

still closely followed by a specialized care team because of the interdisciplinary framework that's unique to va. that's why you cannot separate them. specialized services should demand tertiary services be driven completely to the private sector. so with this busy slide in front of you we'll turn to the discussion of my experience. the slide lays out the characteristics of tertiary and specialized care that most who opine on the topic likely do not know. here's a bit of education, i'd like to draw your attention to a few starting with the ones in the red boxes. did you know. a road veterans who speak emergency medical care in the private sether do not have to pay the expenses for them provided a request to cover

unauthorized medical expenses is timely provided. it's not so in the private sector. eligible veterans who have medical appointments are reimbursed for their mileage and travel provided -- unless provided by va or a contractor. that's not so in the private sector. enroll veterans can receive access to prosthetics pharmacy service va benefits assistance and peer support during appointments. making it a more veteran centric experience than they've receive anywhere else. that's not so in the private sector. eligible veterans do have a choice. through the choice act. that's a good thing. because they can seek care from an alternate provider if timely va care is not available which is great as a component of va healthcare but not as a replacement. finally i'd like to close with comments on the most overlooked aspect of collaboration between

va and the private sector. when discussing healthcare for veterans. title 38 of the united states code, the authority that governs the delivery of va benefits, including healthcare, protects veterans through due process provisions medical malpractice, congressional oversight and no cost. but what many do not know is that title 38 protection do not follow the veteran who ops for care under the choice act. congress will not have the jurisdiction to compel testimony from private sector ceo's who healthcare systems are found to have gained the numbers or have hidden weight lists. maybe we're wrongly assuming it never happened. veterans will have to rely on the courts for dress if healthcare goes awry. this must be addressed.

as long as the veterans know that's the reality, we've given them not just a choice but an informed choice beyond simply hoping for the best. if they chose va for their healthcare it needs to be a viable choice. thank you. [ applause ] >> thank you, sherman. now we'll turn to dr. yahia. >> thank you very much. there was just an amazing first-hand experience of some of the care that's provided in va. just a little bit 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's office of community care. one of the key pieces about my journey with va, is that i

trained in va. i was a medical student in gainesville, florida, and then a fellow at the university of pennsylvania at the philadelphia va. and as many of you may know, 70% of all 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 healthcare 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 a va and va healthcare, is what we call an integrated healthcare system. it's a system that includes va healthcare providers and clinics as well as expertise from the private sector. unlike many other healthcare entities in the united states that are limited by their geographic markets. if you're starting a clinic, it's -- you actually do is patients come to you.

va is completely opposite. we go to where the patients are. where the veterans live. our veterans live in every co corner in the united states. some highly rural places, some highly urban places but 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 are really about partnerships, not just the purchase of care. pr partnerships that allow us to provide healthcare to veterans in those areas. at the end of the day what we want to do is build an integrated healthcare network. i know the alliance puts on these programs and they focus on medicare. a medicare corollary would be an accountable medical organization. it's highly coordinated

integrated and includes va and community providers. really, we need both aspects to meet the full spectrum of needs for our veteran population. so how do we get there? we really start with the veteran in the middle, and so va and va community care has been ongoing transformation really since the choice act came about. about a year ago we presented a plan to congress called our plan to consolidate care. we have multiple ways of purchasing care in the community. it's important to note that va has been partnering with community providers for decades upon decades. the choice act might have put a little bit of a spotlight on our ability to purchase care, we purchase way more care outside of the choice act than within the choice act. we've been doing that for years and years and years. a perfect example is our great partnerships that we have with academic medical centers which started 70 years ago. we are able to not only share clinical knowledge, but also

research and training expertise. so this is not new to va. this ability to partner with different providers across the country. and like i said, they span the spectrum from academic, community providers, federal institutions like d.o.d. and indian health service to your regular mom and pop shops across the country. so how do we get to this integrated healthcare network? we need to focus on the veteran and what we did is we actually talk to veterans, visits the different facilities and community providers and we mapped the veteran's journey through community care. it starts with eligibility. we need to have a very clear set of eligibility criteria that makes it easy to understand that what veterans and community providers and our va staff to administer. because of the various programs, it creates confusion. the benefit that veterans and

earned and deserve is not clear in the community. we have to be very specific about who is eligible and who is not and hopefully make it fair and equitable system and communicate that. that also translates to our community providers. because of all the various programs that exist which have different eligibility criteria, our community partners don't know if they're seeing a individual that is covered by va or not. second is a referral and authorization process, which is how do we make sure we get our veterans that are accessing community care timely access to that. and this really has to do with making sure that we're able to leverage electronic exchanges of information so the doctor knows clearly what veteran they're seeing and the reason for that and the veteran knows why they're seeing the doctor and when they're supposed to see them. care coordination is the golden

nugget that if we're able to get this right we'll serve a model not only for our healthcare system but for all of american medicine. american medicine now as we're moving in the era of value based payments and to more integrated networks, this is a thing that folks are still trying to figure out. you cannot live in your own institutions anymore. you have to work with other community partners whether they're for delivering healthcare or delivering community resources like housing or transportation in order to actually take care of patients. and so at va i think we're uniquely positioned to start to address this because of our ability of integrating care between the community and our healthcare system. we're hoping to leverage more electronic health information exchanges. the next one is the community care network, which is who is the network of providers we work

with. this really does get to the idea of informed choice. right now, we have a broad network of providers, more than 350,000 partners we work with in va to deliver healthcare in the community of veterans. we want to make sure that the veteran is empowered to make informed decisions about the providers they want to see. and this is the same movement all of american medicine is getting to which is how do we get our community network to be able to report on quality, satisfaction, value so that veterans are able to choose a provider that makes sense for them. this is a healthcare 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 in va is our preferred providers. we know that our providers in the va by interacting with veterans really understand military cultural competency and some of the very unique circumstances and conditions that our veteran population has. and when i was practicing in the private sector, there just really isn't enough volume or

touch points you have with veterans to really understand all the different nuances. so we want our preferred providers to not only be delivering excellent quality high levels of satisfaction and good value, but also have expertise in military cultural competency and be aware of veteran issues. i think that way we can start to help our veteran population really understand and choose a provider that meets their needs. next is provider payments this is critically important, we view our providers as partners. in order to be good partners to our providers we have to pay timely and accurately. and this is something that va continues to work on because of the multiple ways we have of buying care today, it creates a lot of confusion. i'll give you one example. when the choice act was passed va by law was required to send out nine million cards to individuals. these cards looked like health

insurance cards. and we've encountered many veterans that have taken that card to a community provider, the provider worked on the assumption was eligible and delivered care. but on the back end we were not able to pay the clinicians because they did not meet those criteria. we have to have very clear eligibility criteria that's simple. no red tape. make it very easy for folks to understand. so that the community and the veteran know exactly what is eligible and what isn't. and then also the va can do our part to make sure we pay timely and accurately. then wrapped throughout all that is a focus on customer and customer service and our veterans. that makes sure we're able to get information to them in a quick and timely manner. that's really our journey at va right now on how we're tackling to improve community care. focus on the veteran, the touch points that are important to them. and then spooling up projects to

be able to move the needle in each of those 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 what it is. when you're trying to run a program and keeping the veteran in the middle, it makes it hard when actually there is not one program, there's seven or eight programs. we have to get to that one program that makes sense for our key population. i wanted to mention a little bit about how we can move towards a high performing network. this is a concept of this network i just described of internal va and external va partners. this graphic depicts that a little bit. you can see veterans moving around from one location to another and including the va and our various community partners. we want to skate where the puck is. where is healthcare going in the future and what can we do at va to position us to make sure that we are meeting the needs of veterans not only today but also

tomorrow. and that means evolving from a service model to a value based reimbursement model with preferred providers. with cms's investment in the cmmi and all the various demonstration projects, they're testing out various models that make 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 need legislative help in order to be able to do that. we also want to leverage better monitoring of quality utilization patient satisfaction and value. we want to be transparent about care we're delivering not only in va but the community. right now va reports publicly a lot of various markers relate today access as well as quality and satisfaction. we want to get that same level from our community providers our veterans are participating in. we want to transform to a care

model that's more personalized. inside va we have teams that take care of veterans. we need to be able to leverage the same sort of personalized care as veterans go in and out of the va. that will be a unique challenge for us that as i said, also is faced by many healthcare institutions across the country. being able to match a veterans with a light level of need. some veterans may need a navigator to let them know where to go, what to bring. others may need a case manager to make sure they have transportation, so how do we really get to the needs of the patient and match them up with the right resources and have them follow through their 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 healthcare providers that all use different electronic health records. va has been in the business of ehr's for decades.

and we need to nothifigure out e can communicate between those different entities. we have innovative ways of doing that by leveraging some of the community health exchanges that are in existence and moving more towards portals that share information. so that's just a little bit about maybe the future of va and where we hope to get to and some of the challenges we face from a legislative standpoint. then also i think opportunities for us to be able to lead the way in some ways for areas of american medicine. thank you. >> thank you. now we will move to david mcintyre of triwest. >> thank you. and good afternoon, everybody. thanks for being here. and those of you that represent members of congress, it's a privilege to serve your constituents. every one of your bosses has veterans as constituents. that's part of why you're here. it's a privilege to follow shurm

who -- sherman who did a great job of laying out the person who is responsible for being served by the system. and the doctor did a great job laying out where the system is today and where it needs to be going going forward. the ask for me was to lay out how do we get to where we are from a choice system. i'm going to spend a little bit of 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 that is, responsible for one half of the country to build the integrated delivery system downtown that meets 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 served this country. 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. very quickly congress passed legislation and funded at the same time to give va money to be able to scale internally but also to be able 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 though four hour waits on the phone. 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 both policy and operationally. and we probably gone about 75% down the track of closing those

gaps. but there's a lot of refinement that's 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. this was launched very, very quickly. but we sit here today, a little bit past november 5th of 2014 when this need today start. over 5 million appointments have occurred through the program. our company and the network we built has been responsible for 3.2 million of those. so how do you go about building out network? you've got to understand the demand curve. we spent a lot of time working with the individual of va medical centers understanding what demand looked like. if you had never fully delivered on demand you didn't really understand it. and so we tried to work that and

map that. and if you look at 2014, this was the network, the blue areas are our area of responsibility. because we really didn't have a good sight line as to what the demand picture looked like for what needed to be purchased in the community and matched up next to va to give it the elasticity it needed. this is what it looks like now. so if you go backwards, that's what it was in 2014 of january, and this is what it is now. tailored to demand. very few cases are returned to va because there is not available to see that person when the va itself is unable to deliver that care directly. i'd like to thank ascension for being part of the network and i'd like to thank lifepoint for also being part of that network. and the 185 to 190,000 providers spread across 28 states that are delivering care today to give va

the elasticity they need. in the first month we served 2000 people. and you can see what the demand curve has looked like. as the doctor said, the va has 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 we're owned by a bunch of non-profit blues plans. they buy care. they integrate care. that's the core of what they do. and so you look at this demand curve, we're not at the top of it yet. and yet, about 6,000 units of care are being placed day now from 2000 a month that was done previously. this is what's happened on the spend side. at the beginning of choice, as you start slowly into something like this, it's chiropractic care, podiatry. now it's brain, it's heart, it's digesive systems. it's brain injury, cancers.

those things are getting placed in the community and support of va. so what are the challenges that remain? when i look adtht this i believe still haven't entirely solved the equation. the issue at the end of the day is to make sure we properly map the demand curve, as the doctor said make sure that we've got the right providers in the networks and we're operating in a integrated way to make sure that people have confidence that the providers in the community are the right ones to place the care with. the second one is continued refinement. and the doctor went through the various aspects of what's being 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 work to do. i was here at the start of tricare when the d.o.d. stood up tricare almost 20 years stood up try care i was in the same role then. it took three and a half years for the dod to engineer claims to get it rightment what i'm going to tell you is the people in va are incredibly focused in this space. we're making a lot more problems that we made 20 years ago with dod. if you go to rio grand in texas, we just finished a try an lated project there to bring the a together with the hospitals and the community, together with your company, to be able to look at how do we get claims right between all three of us. and we changed the apperature in as little as five weeks. so we plan to do that

successively. the third is we have a humane dialogue going on around this issue. this isn't about privatizing the va. that is not a good idea. we as citizens have invested a lot of money in the architecture and infrastructure of a great tomorrow. 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. and 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 10 years that came from every zip code in this country had 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 is right next to a va medical center. but the bottom line is the system is not really set for that. this is partly a resetting exercise. as bali said, making sure no eligibility works more streamlined. the last thing i would say to those of you who are staffers here, and i was a staffer a long time ago, back 20 years ago is when i left capitol hill. in the 60s when we passed medicare and medicaid, we created them as entitlements. the va is is not an entitlement. the choice act makes virtual entitlement. it is is time to step back and figure whether va should be the primary payer and whether we ought to think about the notion those that served our country the way veterans did had the right, first right to an entitlement. because a lot of things would

end up in a very different place if that were the case. and most of their care is financed by the federal government. so that will be a challenge of former colleagues and those who followed me as a staffer. lastly i would say this is about teamwork. again, i come from the city of phoenix. that's 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 the work saw that every day they went in. there are people that are dishonest that happen to be in the private sector. they're also in the public sector. but not everybody is dishonest. the fact of the matter is it was demoralizing. what this billboard shows is it now replaces that one as of monday is it takes a team to deliver for those that serve this country. not to replace a, but to give it

the elasticity that it need. 400 providers in the va hospital in phoenix surrounded by 8,800 providers in maricopa county of every specialty, giving them the elasticity they need to be able to deliver on care. thank you very much. [ applause ]. >> thank you, david. now kerry 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 the veterans health care. i'm going to share some of our findings about the quality of va care, access to care and talk about quality of care and access to care in the private sector. so starting with quality of care. in our assessment we looked at the doctor who mentioned that

the v is a regularly reports many quality measures, as does the private sector. when we compared the performance by private is sector, i mean medicare, commercial hmos, we compared a number of different ways. that the va performs as well or better on these quality measures. turning to the timeliness of care, we also examine the wait time data. we how long does it take to get an appointment. va measures wait times by how long is it between preferred date of care. that's when the provider would like the appointment to occur and the date when the appointment actually occurs. we found most veterans receive care two weeks.

of course there's a lot of variability. in phoenix it was not two weeks. but in other parts of the country, the wait time is much shorter. and on average, the wait time for a primary care appointment is six days. another aspect of the access issue is where do veterans live relative to where their health care is. looking where veterans live relative to va facilities the vast majority live within 40 miles of some va facility. when you start to look at more specialized needs of care, a smaller proportion lives within 40 miles of a provider that can provide that kind of care. 26% live within 40 miles of a va hospital that provides the full spectrum of specialty 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 the u.s. has a ways to go improving quality of of care. this study was from 2003, looking at the quality of care across the united states. in this case patients received 50% of all recommended care. the study examined both care for chronic conditions and acute conditions. since that time there has been a lot of work understanding the quality of care. we have had a lot of studies examining the quality of care in the united states. what we know over y'all is the quality of care in the united states is variable and there is room for improvement across all health care conditions. the doctor also mentioned military cultural competence. providers who are serving veterans need to understand the particular needs of those veterans, what their experiences

serving the military are. in the study we conducted in 2014 we did a survey of behavioral health providers and found less than half regularly asked their patients whether they were veterans or have had ever served in the military. even fewer reported even knowing about military culture. and what do we know about the timeliness of care in the private sector? we actually know very little. it's difficult to compare the timeliness of va care to the private sector in part because everybody measures timeliness of care different. there's no one standard in how you measure this. in a couple of studies we were able to find in the private sector, it measured the time between when the patient called for an appointment and when the point occurred. the wait times are much longer. so 19 days in one study. 39 days in another study. again, these studies also had a range.

so when you compare that against six days on average in va, it does suggest the timeliness may not be solved by the private sector. 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 their community. this slide shows veterans who live more than 40 miles from the va. among those veterans who live far from a va facility, 80% live within 40 miles of a primary care provider in their community. but when you look at more specialized needs and just mental health care, less than half, this is 49%, live within 40 miles of a private sector mental health provider. and even fewer live within 40 miles of a private sector neurologist oren dough chronologist. this means this is a challenge for rural health care overall.

this is not particular to va. for veterans who live far from the facility, it isn't necessarily going to solve the problems. so looking at this overall, it really does suggest that private sector care should complement va care. that va provide care in most cases with high quality, in a timely manner, and that the private sector should come in and complement, not substitute, for that care. it is also important since we know very little about the quality of care for veterans that's provided in the community and the timeliness of care for veterans provided in the community to really develop a mechanism for monitoring that care to ensure both the va and the community and the care va is paying for is timely and high quality for veterans. >> thank you, kerry. [ applause ]. before we turn to our final

speaker of lifepoint health, i would like to invite everybody both in the room and watching on c-span that you can participate in the twitter conversation #detective advancehealth. also, after john speaks, we will open up to your questions. there are three ways to ask questions. submit on twitter using the #veteranshealth, ask questions at the microphones here in the room. also in your packets you have a green card, and you can write your questions there. we'll hear from john is. and you'll be getting your questions in the meantime. >> thank you, marilyn. thank you all for being here today i would like to recognize david kritchlow. i would like to start by

identifying life point and who we are. it will frame any comments we make for a small nonurban sole provider perspective. we'll walk through some of the volume indicators of the veterans we are seeing within lifepoint and talk a little bit about what we see as opportunities to expand the provider base within this program. so a little bit about lifepoint health, 72 hospital campuses in 22 states. as i mentioned, we are a nonurban, sole community provider. leading health care provider in our communities. we are 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. in particular to kerry's comments about some of the availability to some of these

hiring services, these are typically the markets we serve. we are nonurban. there is not a va hospital near us in a lot of our markets. so our ability to serve these veterans and our community is very important to us. avid supporter of veterans access. this has been a very emotional issue for our leadership teams. a lot of our leadership and our facilities are veterans themselves. they're in small communities. they know the veterans that live there. so this has been very important for them, very emotional for them. and they have embraced this entirely. incident was interesting. we are very proud of some of the work they had done with veterans choice to reach out to their communities and to a certain extent became a resource for veterans to use to figure out whether they are eligible for it but embraced it significantly.

so just some volume statistics of the care we had provided in 2015. we have provided care for over 15,000 veterans throughout lifepoint facilities. of those 15,000, 1,200 for in-patient admissions, 4,# 00 through our emergency rooms, 1,600 outpatient surgeries were performed, and 7,100 tets. it continues to he grow, which we are very proud of. so where can we improve? some stats here, and i'll talk kind of comparing it back to lifepoint. all of our payers, when we look at days to pay, when do we get paid to services compared to when we discharge a patient, including self-pay patients,

that's 54 days and we are typically paid. within our group, and it says veterans choice. it is is pc3 program. it takes 113 days on average in our 22 states to get paid. so here's why that is so important. for lifepoint we have a very strong balance sheet. we have the resources to basically finance this care. you know, our costs, we're paid at medicare rates which are almost by defacto costs. we pay the cost of care, and be paid 113 days later. if you look at the stats for the critical access hospital, the days cash on hand is 69 days. typical hospitals be put altogether is over 200. for the small community, in hospitals, in particular the rural hospitals that are fairly

fragile, they only have 69 days on hand. so it is 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. we have seen provider, self inflicted. but i think there are some ways medicare, medicare days to pay are less than 21 days. they will work collaboratively to see how we can get from 113 down to something closer to medicare. that would be very attractive to

them in these small communities. a lot of them can't afford to do that. so last slide, it does involve 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 front pay issues we deal with we believe would bring, especially small providers into this network and this important program. [ applause ]. >> okay. thank you. so we are now going to turn to the q&a portion of our program i would like to throw out the first question. we talked a lot about the care within the va system and within the private sector.

i would love for or more of panelists to take us back to square one and talk about the choice program 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 losing it? 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 are less than 12 months before this program expires. this is a huge issue because we see the train is coming. we have served more than a million veterans in this program. a million veterans have touched the community. so this is one of the things the

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 serve has a set of eligibility criteria. as i was mentioned before, we have seven or eight ways of purchasing care. this is one of them. their criteria are targeted. they can really fall into three types of buckets. one is distance. and so it's 40 miles right now from a primary care provider. if you live more than 40 miles from a primary care physician in the va you are eligible for the choice program. second is if you cannot get care within the wait time follows of the department. and the third is they're called unusual and excessive. so if there's a mountain range or a lake or a stream or very severe weather, we are able to use those exceptions. those are the three types of

veterans that are eligible is. as you can imagine, the geographic criteria for the most part is pretty set. we have a stable type of population. the wait time criteria alter. so an individual may be taking -- may be receiving care in the va for one condition that may be we can't provide as timely. so they would go out on an episode of care. they will get the rest of the care there. those are the three types of criteria. when we talk about the type of services that were purchased in the community, they're pretty common. probably when i think of the top 5, top 10, we is send out a lot of optometry for folks getting eyeglasses. we send out orthopedic surgery. we send out a ton of laboratory testing. maybe someone is getting mri.

and laboratory tests. although now as dave was mentioning we are able to get a robust network for some of the procedures. so that's a little bit of the mix. >> about 15% of the population in terms of who is utilizing this. 50% are those near a va medical center. and the va medical center were community based outpatient clinic does not have the particular service that's needed. and the 35%, the remaining 35% are those that couldn't be seen 30 days who choose to access their rights. for those of our staff members,

the expiring in august of the program, it's very unusual for congress to authorize and appropriate at the same time. it usually doesn't happen outside on of black box issues or other types of very rare occurrences. the congressional budget rules had to be suspended in order to get this through. that's what set the trigger for august 7th. but at the same time without action a whole program goes away. and the notion that it needs to transfer to something else in its current form needs to be reauthorized from a budgetary perspective and an authorization perspective. >> so let's turn to the audience now. we have a question. if you could please identify yourself. >> i'm regina leonard from

george mason student i have a question. with veterans needing more access to care, it would seem plausible they would allow nps and clinical specialists to have full practice authority. hr 1247, the veterans access to quality care bill, would allow this and hope the va hospital accomplish this goal. how do you foresee using nps in the future? >> so that's a great question and very controversial question as you would imagine. as va is working on its nursing hand book. we leverage a lot of practitioners, provider extenders. so i'm not exactly the right person to be able to address this specifically. but what i will say in general we do have veterans that live in every corner of the united

stat states. as a rand colleague was demonstrating, they are not physicians or there is a ddirth of those providers. >> outside of any care for us being in the small communities we're in, physician assists, very important part of that network in the small communities. we use them very effectively. they provide great care in the small communities. it is an important port of the network in the small communities. >> one of the independent assessment is nurses should practice to the full scope of their license. and the evidence doctor the research shows there was not a difference in the quality of care in those providers.

>> i'm dr. caroline poplin, primary care physician. i have a question for the doctor and a quick question for john. the question for the doctor, i work for the active duty military for 12 years, seven years at fort beltor r and five years at the naval hospital. they were working to make their electronic medical record interoperable with the va. they spent billions of doctors. my understanding is they've given up. they couldn't make it happen. how are you planning to make things interoperable with all of these community providers who have all kinds of different

vhrs. obviously it can't be the way we tried to integrate because that just didn't work. >> thank you. that's an excellent question. i don't think they have given up quite yet. but the point that you're describing is really an american sin issue. there's health care systems across the country. there's a market for electronic health records. it's competitive. everyone has different records. so we have to think of it differently than what we've done before. we're doing a couple things at va that show a lot of process. one is leveraging community health exchanges. we are now part of about 80 across the country. a lot of these are individual communities that get-together, the hospital systems say we're going to share information. there's a standard template of what data they get. so we share records with -- we have veterans that have half a million that are participating in these different exchanges. number two, knowing not everyone

is going to have the same record. the question is, well, how can you share information between the records? and what we've been able to do with our military treatment facility is, do td partners and transferring that to the community is having a viewer of the record. so you can get a view-only read of the record and not able to kind of alter it because that belongs with your health care system. we have the joint legacy viewer where we are able to have a read-only view of the dod record. it actually is integrated. it is not like we look at the record here. when we look at the community viewer, it is an integrated record. we have these all over the country. we're taking that knowledge and doing that and testing it out in a couple locations with community providers. we are now testing in the state of new york, north carolina, and washington where we are working with specific community partners and giving them access to a

read-only view of the va record. that way as a practicing doctor if i wanted to look at the mri or ekg i can look at it through this web-based portal. so i am envisioned the portals that connect systems rather than get everyone in the same system. which i don't think is practical in the short-term. >> my question for john, is your system for profit or not for profit? >> we are for profit. >> thanks. we have several questions about the use of other tools such as telemedicine and how the va is using telemedicine or home and community-based services to provide access of care for rural vets and those with mobility issues and how can congress help to encourage this.

>> i will start and i would love dave to comment. we have a number of telehealth hubs and have been doing various version or for a long time. it is exactly for that, marilyn. we want to make sure we can provide access and reach certain areas we may not be able to have a brick and mortar building. not only in primary care, but determine tolling. we are looking at what other fields have been done through telehealth. so we are doing that. there are a couple things that could really help va with being able to share information, especially with community providers whether they are doing telehealth or not.

there are a couple stat sheets that prevent v from sharing records. you can't share records with hiv, sickle-cell or melling health or substance abuse. so you are taking a big chunk if they have one of those conditions. in my mind it is almost a stigmatization that we have to get them to sign a separate form above and beyond the normal hipaa to send it over to the doctor in the community. so that's one thing that i think doesn't necessarily cost any money. it is is hiring quality care. so that's one thing i think they can do. >> i would completely concur

with what the doctor has says said in terms of taking down those barriers. when we are doing work at the side of the dod in colorado at the height of the wars, we actually placed in facilities in colorado springs inpatient patients for mental health. the military hospital there did not have an inpatient unit. and we forced ground rounds. we required the sharing. it is really, really important to make sure that the encounter is proper and you plug the gaps that might otherwise exist. starting next week we will be standing a series of pilots that will roll out in two markets and expand from there that will put us behind the tip of the sphere from the va. it will start with medication management in a particular market to give them more supply.

and it will also do psychotherapy on that same backbone that will allow us to test out in rural and urban areas how we want to jointly make sure people are taken care of and leverage supply what is available in the va. and i would just say making sure they are understanding of who a veteran is and who we place them with is really, really important. so the nonprofit will be made available to providers all over this country as it relates to understanding a veteran. but then also the evidence based therapy training they 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. that information will be available free of charge to providers all over this country that want to step forward. >> i agree with bali and dave. home based health care is great force multiplier particularly in the area of melting health. i have seen many veterans who had trouble with access benefit from it. # i know there were licensing issues. you had somebody from san diego might want their same provider and not mesh well with somebody in another area. i do want to caution, though, it is is not a panacea. it is person-to-person in some areas. i hear from nurses talking about ulcer. you can see it on the screen but it is not the same as appreciating how bad it is when you are there and see it in person. i'm always happy to see my

doctor once a year when i do my annual exams. it doesn't necessarily get lost but we don't want it to see it be the be all end all. >> great. we have a question at the mike. >> hi. thank you all for being here today. dr. taylor wink el man. it would seem as scary as the 2017 deadline, august 7th deadline is it also provides us with an opportunity to introduce changes to the program. as a veteran who remembers what it was like living 98 miles away from a facility before veterans choice came in, i can certainly relate to the benefits and challenges we face. will you extend title 38 protection. but what will your asks be for

improving this assuming we can get a better, more cohesive vision put together? >> one big area, or a gap in the choice act. they can't provide a service. it's going to cost money. it will. but if you truly intend to open access to all veterans, and it has to be looked at. so if i live two hours away in a spinal injury center and i can't get an appointment timely, maybe there is a spinal injury expert that can do a test or run some tests on me or take care of an acute issue and i'll follow up. that was a gaping hole. i would never be be eligible because the care wouldn't be there. so that would be one area i

would hope if we go down this road again someone would take a look at. >> we actually laid out our vision where we want choice to evolve, and that's in our plan to consolidate care and that should be available to all on the web site. there has to be changes. this program, as dave was describing, came rapidly, implemented rapidly, in partnership with congress we were able to change the law four times already, which is great. we have a number of other asks to make the program work better for veterans. i'll just list a couple. number one is this primary payer issue. our nonservice connected veterans have to rely on other health insurance. what does that mean? they have to pay their co-pays, deductibles, premiums and no other program works that way. it is exposing them to other

costs they have never had before a lot of them were upis set. we need to work better with community partners especially in rural areas. the choice law limits va at medicare. so while medicare rates, the payment rates makes sense in some locales it doesn't in others. we need to partner and pay them a higher rate. a lot of times we definitely do have issues within the payment area. sometimes it's not the slowest. it's too low. and being able to coordinate care better by allowing us to share information. and the penultimate thing is we need to involve this program.

we have in vested a lot of infrastructure. we have learned a lot. we'll go through the same exact growing pains we did two years ago. we can take what's there and turn into a program that really makes sense for veterans, community partners, and the va. >> i imagine some of our other panelists have ideas about what need to happen with this program? >> i'm going to repeat what mr. gill am said. the issue on the 40 miles is really an issue we deal with all the time. so a veteran will not qualify under the choice award because there may be a va center within 40 miles. they may not have high end diagnostic work. so we'll have a veteran three miles away from our facility

where we will have a surgical suite if they need a surgery. we have been able to work through those issues, but it is always one off negotiations with the veterans association to keep the veteran close to home. it allows veterans to meet the care need that they have but they are not able to use it because of the 40 mile rule. >> just to comment on that piece. we have to be aware of what it could mean. so sometimes we talk about 40 miles from primary care doctor versus 40 miles from where you get the service. a lot of folks outside the va have done those modelings. it definitely would have a very large financial impact. apart from that, to sherman's point earlier, we have to be careful about referral patterns. in order to provide really high quality care, for example, for our service connected veterans

or tbi patients, if we cannot provide wraparound services because a lot are being delivered somewhere else in the system, outside the system, then it becomes hard to regain confidence. i think it is definitely worth looking at and figuring out how we can get them to be seen. one mile is too far. we need flexibility built into the system. but i do raise some concerns about completely being able to open it up. because what that will do is detract from the folks who are using it and want to use it because you might not be able to build out the wraparound services if you don't have the specific volume or expertise to be able to do that. >> so i would concur with the notion that that thinking about open -- completely open access

is probably not the right place to end up. because we've invested a lot of infrastructure. and making that infrastructure stronger and making sure that it's got sufficient supply to meet the need is going to be important. but for the last 15 years, we've deployed people from every zip code in this country. the mixed use of the guard and reserve has been different than any other conflict we've ever been involved in. and many of them want to go back home and they don't want to have to displace where they are. and they may want to take a year or two off. they have a right to do that. they have a benefit they've earned. so making sure they have access to care that's in a reasonable distance, i think we would all agree up here makes accepts. but thinking about how do we draw the parameters right. and i think congress just needs

to decide how does it want to deal with the responsibility that comes with the tale of conflict. there's a lot of money that's paid in travel. and then there's a lot of money that end up being paid when someone doesn't get what they need on a timely paves. because when they're really stick it's more expensive. so i would say for certain types of things you absolutely want to be in a va facility, you absolutely want to be in a top notch academic facility regardless of where you live in the state. but then there's other where you could get the orthopedic service across the state from where a va facility is. i think you will all sort through those things. we look forward on our end doing whatever needs to be done to make sure we flex properly to make that work. >> i want to pickup on what dave just said. in some ways there needs to be a

bigger conversation about what is the obligation to veterans. and if the decision is we continue as it is and va has an annual budget submitted two years in advance, every year there is an increase, there are going to be access problems. there are going to be decisions to stay within those budgets. and this is going to be true for community care as well. because the ability to constrain those costs, particularly if you increase eligibility is going to be difficult. so really thinking in the big picture of what do we -- what is your responsibility to veterans. what is your commitment. and how are we going to pay for that. >> okay. we've had several questioners want to know how to make the -- how to get claims paid faster. what is the answer? just a softball question.

>> i'll start. i'd love others to comment. this is probably one of the things that i spend a big chunk of my day on especially as a doctor. when one of our partners delivers care, they deserve to be paid on time and accurately. what we're realizing as we do more of these deep dives is there's number of root cause issues. one gets back to the eligibility piece, which is when we have six, seven, eight different programs all with different eligibility criteria, if you don't match them up exactly right and you're providing care for a nonservice connected condition in this case, and one lives 38 miles not 40 miles, we don't have the authority as a department to cover the bill. that's really unfortunate because the criteria, there's so many of them and they carry that

many times a veteran receives care that isn't authorized or we don't have the ability to pay. so that's one thing. how do we get to a simple set on of eligibility criteria that is very clear to our patients and our providers that there isn't any ambiguity. in medical care, you turn a certain age, you're good to go. or if you have private health insurance plan, they know what benefits are available is. we need to be able to get to that level of clarity. if we continue to have seven, eight different programs all operating differently it's going to be hard for our patients and our providers to know that. number two, we have to make some adjustments to the laws. many times today, probably the biggest area where i get complaints about provider payments really relates to er care. er care, we proposed a fix in

this to our plan to consolidate care. sit fragmented. sometimes it primary payer for service connected condition. in other i circumstances, we're the payer of last resort for nonservice connected care. and also by law and statute, we pay 70% of the medicare rate. when we talk to the doctors, we sit down with them and examining ars, we actually did pay and it is considered payment in full but they still carry a little bit of chunk of that on their accounts receivable. and that's something that we would not be able to pay until we actually get some of the laws changed. that's where i see a lot of consternation is around this unauthorized care where we have to figure out if they are service connected or not and we are not allowed to pay the full price by statute. we propose a fix to this by making va the primary payer so we are able to pay the bill and

getting us more in lines with what the rest of industry does. it requires some legal changes and investments to do that. thirdly, if we're able to then really get the good criteria, iron out some of the kinks in the er system. that will allow us to start to automate more and more. it is haar to automate like medicare does when you have to go to the medicare record, which is what we have to do, to determine if that specific is service was for a service connected condition. you can't do that by a computer. you have to say was he seen for a knee injury and is that service connected? way too complicated. i don't want to continue to do that all the time. it takes the a long time, a time drag. we want to be able to get to a set system where if a veteran

goes into the community, the doctors there and the hospital systems know exactly what is offered and what they're able to deliver. the veteran knows if they have any obligations and we on the back end can automate it and pay it. i think this is a great opportunity for us for progress. however, we need help. we cannot at the va, we cannot meet the standard that we want to meet if we are doing it by ourselves. we need help from legal and congressional colleagues. >> so as an entity now responsible for paying for 3.2 million appointments, i will tell you we don't collect. if you go back to the start of try care 20 years ago with the dod, three months in it became obvious the dod never claimed its properly. some of the history of this space that dates pack a long

time is the va was paying its claims market by market by market. that's not a very effective way to do it. it's hard to get to core competency. what they have done is to consolidate what that looks like. that is a very needed change. so they took all the claims and aimed them in one direction on the government side. the second thing is when you're an institution, you have to file properly. no one wants to be in a place where claims get denied or they're slowed. at the end of the day we have to go find another provider in order to accepted the next veteran. that is not in anybody's interest anywhere. so paying timely and accurately in everyone's interest in this process. what i will tell you is from a provider perspective, having done a lot of work at the start of try care to help the dod get

this right and then get it right across the system to make the fastest and most accurate payer of those types of programs, you also have to pay one way. right now if the care moves from the va to the community, they pay one way. they file one way. if it moves through choice, it goes down differently. now imagine being the billing office figuring out where do i send this? rather than one consolidated pipe. we did a project in texas. dr. yehia and myself, members of congress from that area, and the hospitals in that area. it is an area where a lot of care moves downtown of all

types. some of the hospitals of those four had a 50% denial rate on their claims. they did not know how to file accurately. within five weeks together we dropped it to 10%. that takes their historical pattern on of payment and changes it dramatically. and so we all own a part of this responsibility. it starts with the provider filing accurately. then it goes to us making sure we have processes that work and that it is streamlined and consistent. so you do it one way. as an actor that spent time in the dod space back 20 years ago, the same existed then and they got fixed. those are leaning forward, thanks for doing that. thanks for hanging in there.

what i will tell you from my perspective, what i have seen with my sleeves rolled up, is va team is right at my side. there is no separation with what we are trying to accomplish. we pay the bill. and then the va pays us. so we all want it to work, right? together we will figure out what the pieces are as dr. yehia saided that need to be changed. but there are other pragmatic components that need to be changed as well to make this work right at the end of the day. we're making a couple of markets to test those things together. we will take what we learn and apply them through the rest of the enterprise. >> i do agree completely with the one point line. as a provider, we have used to dealing with intricate rules. medicare is a great example. it is very tight around certain

treatments that you provide a medicare recipient. but as providers we know what the rules are, other systems we can incorporate into our knitting processes. so we know when they come in exactly what that diagnosis needs to be and how to deal with it real-time. they are consistent rules and we can develop systems and processes to deal with them. i think it would be very beneficial. >> folks, we have time for one or two more questions. please fill out the evaluation form in your folders before you leave us today. let's turn to a question at the mike. >> hello. i'm shannon firth with medicine

page. i want to ask about the commission on care report that was put out a few months ago. i wanted to get your response to two of those recommendations. one was for an independent advisory board, and one was to eliminate the time and distance requirements for the choice program. the first idea is pretty controversial and could be unconstitutional. i want to see hypothetically what would be the impact of either of those two changes. dr. yehia and anyone else who wants to comment. >> sure. i'm comment more on the latter. the be secretary and the president kind of put out our response to the commission. in the president's response in the commission on care they actually call out our plan to consolidate karas an alternative approach to some of the

recommendations in the commission. believe our plan that lays out getting all of these different programs into one, coming up with eligibility criteria that makes sense but also allows some flexibility so when myself as a doctor i am seeing a patient can make a decision about, oh, you would be better served at this institution in the community is important. getting to the single way of being able to do referrals, building a high network. we're able to create partnerships that make sense for them, monitoring quality utilization and getting to timely payments wrapped around customer service. all of that is laid out in our consolidation plan which is what the department is putting forward, an alternative to some of those specific recommendations. it lays out what we need to do

that. what are the specific legislative changes required and what is the budget required to do that. that's a really good starting point of where we need to get to. >> i'm going to comment on the second recommendation. eliminating the time and distance effectually opens up purchase care for all veterans enrolled in va. there's 21 million veterans in the united states, 9 million enrolled in va, 6 million use va health care in a given year. most veterans enrolled in va health care have another choice in health care. medicare, private insurance through their employer, or try care or other sources of health insurance and they choose whether to use va or their other source of insurance based on a number of factors. one is cost and access, things like that.

if you open purchase care to the whole population you will see a giant increase in command. some of the veterans enrolled in va health care will start using va health care. now they can go to their local doctor and va will pay for it. and they will probably not face a co-pay because it is is through their va benefit and they're not facing a co-pay. so the choice of seeing your same doctor, va will pay, no co-pay, it is kind of a no-brainer. and just the number of people using the health care will increase. that is one thing to consider. and the cost of that will be quite significant. the other thing to consider, and this is sort of the big picture question of do we maintain our va health care system as it is. do we transition more to a private sector model is you can't really have both with full open access to either. and the reason for that is as you move -- as people choose to

use private sector va care, viewer people will be using the health care facilities. so a lot of you are working on health care and you fully understand as volume decreases the quality of care decreases. there is a tipping point at in which it is is acceptsable or reasonable to maintain those facilities. as va facilities close, it furthers the move into the private sector. and that decision from my perspective really needs to be a thought out decision, not just something that happens as a death spiral because of movement into the private sector. >> and if i can follow up on what kerry is saying you had that so eloquently. instead of just giving everyone a card, what is missing is care coordination. when you think of medicare and

the way the program works, for the most part it is like a reimbursement system. you handle your own care and the government pays the bill. what's missing from a clinical perspective, from a relationship perspective is how you help folks navigate a very complicate american health care system and making sure their needs are met. i think the greater extent that people are just doing it all on their own, while it might work for a small segment of the population, for many folks it doesn't work. i think that is very important to think about it from the clinical perspective from a veteran senn particular patient care approach, do we want to have the coordinated system or do we want just everyone to kind of do it by themselves. >> thank you. >> okay. thank you. do you have a question? go ahead. we'll let you have the last question >> thank you.

my question is about what's going on in technology space as far as companies like apple and other app development companies that are giving patients the opportunity to be in medical data. and so what i would like to know is has the va considered partnering with apple or other innovative technology companies in silicon valley that will allow veterans to have their own medical data with them, so that when they go to visit providers, they can have a dialogue based on the information that they have? >> yes, and we've been doing that for a while. who has heard of blue button? so blue button is exactly that. it is a very easy way to be able to download an electronic version of your entire health record. the veteran can take it and do what they want with it. share it with their providers if they choose. we actually have an entire digital services team that leverages folks such as silicon valley that are really thinking

of creative ways that we can partner and continue to exchange information. absolutely. >> okay, you say blue button. >> blue button. >> b.u.t.t.o.n. >> and there is also myhealthyvet. you can talk to your doctor, prescription meds, get your medical records in pdf for matt and also military records, if you have to file a claim, we have to advise somebody to file a claim for certain benefits, first thing we do is get them to sign up for my healthevet and blue button. it works wonderfully. >> we have reached the end of our time. a few thank yous and i would like to thank the supporter for today's briefing, essential health and an informed

conversation, and also, thank you to all of you for being here today. thank you. [ applause ] >> marlylyn, thank you. fbi director james comey is investigating whether new e-mails that. [ inaudible ] reopening the criminal investigation involving mrs. clinton just days before the election. although it is not clear [ audio

not clear ]. until congress remembers after the elections, tonight, american artifacts, flight 93 national memorial center. and freedom of information act, and also visits to the battleship wisconsin, moses myer's house and the senate office building on capitol hill. american history tv primetime tonight, starting at 8:00 eastern. this weekend until c-span 3. >> the british empire and its commonwealth, men will still say, this was our finest hour.

>> live for the 33rd international churchill conference in washington, d.c., focusing on the prime minister's friends and includes andrew robert, author of "masters and commanders." how four titans won the war in the west. 1941-45. later on at 7:00, commissioner george p bush, jose menendez, and musician phil collins, talk about the alamo, at the treb butte. >> the memories of my impression at that time was that this group of people were going and they knew they were going to die but they went or they were there, you know, crockett went. but there was something very noble and very, you know, romantic. i love that it wasn't quite as black and white as -- and that's one of the things i think would be good in this day and age, you

know, that we put it into context. >> then sunday evening at 6:00, on "american artifacts." >> you notice he isn't wearing a weapon. you see he was only wearing the riding crop he was wearing on his left hand. if the colonel, and later the brigadi brigadier, i can take it too. >> we visit the mac arthur, allied fors in the pacific during world war ii and at 8:00. >> they serve as conscience as chief, with the highest level of integrity. with their moral compass locked on true north so that we can always count on them to do the right thing when times get tough, or when no one is looking. >> author talmage boston, providing examples of presidents

who excelled. for our complete american history tv schedule, go to c-span.org. nsa director and u.s. cyber commander, admiral michael rogers says the u.s. needs to recruit highly skills cyber security professionals. he spoke at the maryland conference in baltimore. he spoke and answered questions for about 45 minutes. hi, good morning, everyone. we're going to go ahead and get started in a minute, so if we can have you find your seats. good morning on behalf of the cyber maryland advisory board.

i would like to welcome you to the sixth annual cyber maryland sub summit. i'm david powell. joining me is rick garetz, cyber maryland advisory board, and it is migrate pleasure to welcome the speakers, exhibiters and sponsors, and also, the local, state policymakers and others in the audience. six years ago, cyber maryland started as an idea to build silicon valley for cyber security to unify the cyber maryland eco system around a common theme. to be the epicenter of cyber security, and six years later, looking around the room, i would say we've been successful. would you agree? [ applause ]

the question we always ask is what is next. it becomes the model for other state, and earlier today, we made an announcement about cyber usa, community of communities, and cyber states, which will be led by former under secretary for commerce, phil bond, and the first dhs secretary, tom ridge, former governor of pennsylvania. >> so we wanted to kick off the session today as everyone knows that cyber security is the new space race, right. 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. it doesn't represent 21212. colorado, california and so on, so the first move was to now bring all the states together in a collaborative effort with cyber usa.

and then what we wanted to do is one of the major parts of building a cyber eco system is building a generation, the next generation, which we call the cyber generation. so we thought it would be appropriate to have a student in high school that is teaching introduce our keynote speaker. i've had the pleasure of introducing emma rogers in varying different sessions and conferences, but what is unique about this is about a year ago, we stood on stage at this conference with rob joyce and cathy hudson and chris alexia, sna day of cyber. we just reached 5 million students that signed up to start to explore their future. and as our introduction to the keynote speaker happens, this all got started here because

three years ago, we were -- i was teaching high school at dunbar class on technology and i asked him a bunch of students what, do you want to be when you grow up. their answer was doctor, lawyer, ray lewis. now what we're hearing, as early as last month, in arkansas, maryland, virginia, everywhere, doctor, lawyer, forensic analyst, doctor, lawyer, reverse engineer. i think this 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. so it is my pleasure now to introduce a teacher of a local high school, steve moral, and one of the students to come up and introduce rogers, and steve, if you guys would make your way t