engagement with -- wrong word. our interactions with russia almost starts with syria. i mean, we have a lot of issues we're dealing with on the european front. i get to those, but i mean, this is where they are really stepping way outside. we allowed a vacuum to be created in my mind. they stepped in. i think we need to figure out our syria policy, i agree with you on that. i think we need to figure out, first of all, stop the discussions in geneva because it just makes us look weak. figure out what it is we want. do we get back to assad must go? you know, obviously, there is a humanitarian crisis we have to deal with. we probably need to take steps to change the dynamic on the batt battlefield. we need to figure those things out. i think that some of the moves we should be taking, some of them you have heard discussed, safe havens, humanitarian

quarters, i think a new administration should come in and figure out, is there more th that we should do militarily, either u.s. militarily, allies, working with allies. i think we need to figure out where we're going on syria. i keep hearing the administration say there's no military solution in syria. well, putin clearly doesn't agree with that. we're the only ones saying that. i think we really need to get that right. so that would be the first 100 days, i think focus on syria and what needs to happen in syria is one thing because we're letting the russians set the agenda there and it's too important to let them set the agenda. on ukraine, i think ukraine, georgia, moldova all in the same, but on ukraine specifically, if the russians and the separatists do not implement minsk, we should not only increase sanctions. we should be providing arms to the ukrainian government. and you asked a question, what

about congress? congress is way ahead of the administration on this. i mean, from the beginning of the conflict, there has been legislation on the books authorizing lethal military assistance to the ukrainians. so congress, i don't think, is going to be a problem on that. on syria, i think we have to see. but i would like -- sanctions, yeah. i think we have to take a step back, though, too. david mentioned something in an earlier panel that i thought was actually correct. the president has to take leadership. has to own these policies. in order to bring along our international partners, bring along the american people. i mean, you might not have agreed with president bush on his europe policy about, you know, freedom agenda, europe, but when we went to bucharest summit, there was not a doubt in any leader's mind that map for

georgia and ukraine was a presidential priority. which is really the only reason that we got the language that we got in that communique that they would be a nation some time. the president has to own these issues in order to bring others along. so those are just -- >> now we have a conflict between john having the last word and also being the one that laid down the groundwork of needing 30 minutes. do you have comments before we open to questions? your decision. you're the host. >> okay. i'll speak. first 100 days, one, the president has to state publicly our interests in the global order, in the trans-atlantic relationship and strengthening nato and the eu. two, he or she should reendorse the warsaw summit decision on increasing our military capabilities in the baltic states, romania and poland, and perhaps increasing them. three, make clear that the war in eastern ukraine, not a civil war, and the united states is going to support ukraine in all

ways possible. we will announce our introduction of new sanctions and our intention to work with the europeans on new sanctions. we will provide defensive military lethal weapons but we will not announce it. let the russians discover it on the battlefields. we begin -- oh, syria. syria is a place where i may not agree with judy because i don't think you have options in syria that are acceptable. the opposition people we support cannot win. but we're enabling putin to look good in syria for two reasons. one is what everyone talks about. we let him act and we don't act. what i would do if i was president of the united states is every time he hits our guys, we hit assad's guys. we can do that with stand off missiles so there's no danger of a u.s./russian conflict. but we have been very effective going after isis. and effectiveness going after

isis has enabled assad with russian support to make gains on the road to aleppo. so there's kind of an interesting paradox here. if you want to know more about that, i did a piece on that on monday. take a look. finally, i agree we should also engage a dialogue with russia on strategic weapons and also very, very important, deconfliction of encounters of our war planes and ships and planes that could lead to death and then a real confrontation. >> thank you. i'm going to vary the rules slightly because i want the panel, from any panelist this morning starting with general breedlove and our keynote speaker, if you have a one-minute comment, please raise your hand and i'll recognize you. microphones? general breedlove here, up front. >> so just to the last remark, i mean, we have a good plan that works in the u.s./russia

relationship. >> it stands for at sea, we turned it to sea, land, air. we do all of them. what would be good if we could denote the same paradigm with nato and russia. there had been pushback from russia for a while. they were unwilling to reach a deal with the u.s. i think now they're more open to maybe doing this with nato. that would be a good step. and will, i may have misheard you. if i heard you correctly, or misheard, forgive me. i'm not a fan of we're america. we don't have to sort of, you know, get excited. i think that our inaction in a couple places, especially as it relates to crimea has bought us some problems. i think that the people of donetsk might have a different opinion of how things went with them. >> i'm sure that those people

have opinions about whether the united states should have done more for them. i get it. i -- if i were them, i would want it, too. in fact, you know, in all history, someone would love to, you know, have someone else come ride to their rescue. the question for me is, is do i want to potentially increase conflict between the united states and the soviet union for something that is peripheral to u.s. interests -- sorry, russia. all this talk about -- all this cold war mentality to my right has got me -- but i want to avoid going there. so what i say is, like, do we want to have conflict between, you know, the united states and russia that leads to problems that potentially will drag us into it? if i'm from des moines or from

houston, if i'm from new orleans, if i'm from seattle, i don't see how any of these places being in, under, over the russians makes them any safer. we have to draw lines in the world because we can't police everything and provide results everywhere. that doesn't mean we can't be a leader in the world, but i think we have to draw lines between vital and peripheral interests. >> quick response? >> he's got it. he made my response right at the end. i don't think we're in disagreement. we have to be a part of leading. and when we don't be a part of leading, we get a lot of chaos. >> okay. any other panelists? no. mitchell? in the middle aisle there. >> so excuse me if i'm slightly confused, but it sounds like a lot of this advice is advice to hillary clinton and not advice to donald trump who has announced he wishes to have a summit meeting with putin to

arrange a better agreement, you know, kind of on cooperation, et cetera. am i hearing this wrong? is this more advice to hillary clinton? or is this also -- are you saying this is the same advice you would give also to donald trump? i mean, i would have thought when we're there in moscow, you know, sort of palling around in this meeting he's planning to have, is this the kind of stuff that's realistically going to be listened to? >> would it be different whoever is president? you might have to couch it differently to persuade one candidate versus the other, but i thought that was what we were talking about. what should the next president, whoever he or she is, what should it be? what's in our long-term strategic national interest. that's my view. any of the panelists -- >> with president trump, i was picturing trump tower in st.

petersburg. >> general breedlove is somebody who goes and meets with both sides of the aisle. i don't think he changes what he says. >> i think the message needs to be delivered to both of them. >> okay. other questions? yes. up here, up front. and others raise your hand so we'll know. one, two. okay. we'll take two more and then get another round. >> i want to thank the panel for taking the 12-hour discussion and compressing it so admirably. but i got really bad news for you. the first 100 days, the president is going to form an administration. is going to be more concerned with economic policies, probably appointing a supreme court judge, involving a new director of the fbi, and could be dealing with all sorts of legal issues. the likelihood is they will form a study group that will take

months to come out about russia. >> they should listen to us. >> i understand. my question is this, however. donald trump has demeaned nato, saying it's obsolete and saying they're now just freeloaders, and hillary clinton was the author of the strategic pivot to asia. what insentives do you think or disincentives can we provide to mr. putin to change his general breedlove says, his behavior? i have heard a lot about ideas, but nothing about what actions and incentives can we have to change or at least get russia to do things that we would like them to do and stop doing things that we don't? >> thank you. we'll collect three questions. please, stand up and identify yourself. >> my question is, we know that russia is trying to build a russian world. trying to co-opt the russian

compatriots abroad. it's also very difficult to engage with the russian government. what new ideas would the united states have to engage in the russian world themselves, to engage russia and russian speakers both inside and outside of russia who have more liberal values, who value democracy and so on? >> and the third question, back on the aisle. then we'll have the next round. back on the side there. >> hi, my name is dumitre. thank you for an interesting and informative discussion. my question kind of piggybacks off the last question. this morning, i had an interesting conversation with a girl from moscow visited. i asked what was going on in moscow, and she said nothing good. then her next line was vladimir putin is the greatest president russia can have bought he's keeping russia from being put on its knees from the united states

of america. it's having a huge crisis on people domestically and economically. she felt that the united states is not only against putin but was also against russia, and against all russians. so my question was, what if the next president in the first 100 days, if you gathered 20 successful entrepreneurs and asked them to go to moscow and help with business development. would you approve of that, or just to show the russian people we're with them, and speaking of the post-1945 order, what could be done to strengthen the united nations and international law? thank you. >> want to take a stab at each of the questions? >> could i ask a clarifying question? did you say incentives to russia or incentives to trump to change? >> insentive centives to putin.

>> incentives to putin, democracy, and then specific ideas to change the balance with moscow. >> i think the incentives to putin are negative incentives. i think there are costs. if you go with any type of incentive, and i can't even think what it might be. i don't know, maybe one of the fellow panelists can come up with it, but i think it will be seen as weakness. there's no change of behavior, as general breedlove says, it starts with behavior. if there's no change in behavior and you're giving them an incentive, i'm not sure if the dynamic works with somebody like putin. i think a negative, you know, like sanctions, give arms to the ukrainians. do whatever in syria, whether it's safe havens, no-fly zones, whatever it might be, those are incentives in a way, but different incentives.

>> using pressure. >> to do it. in that sense, you know, i would take it that way. >> evelyn. >> i would agree with judy that the incentives are we will relax sanctions. we will eliminate sanctions if you do x, y, or z. putin has a nice conditionality for coming back into the nuclear disposition agreement with us so we can take the same approach. if you, you know, come back into that agreement, for example, we will do these things. we won't do the things he has on his list, though. because they run up against our values. i think on the issue of engaging the russian people, that is a real predicament because the propaganda machine in russia is so strong that the message that that woman gave is pretty much what the government wants her to take away, that it's a mess in russia. i guess, economically. because of the west, which is not actually the case. the sanctions that we developed when i was in the government were targeted.

targeted at putin cronies, quote/unquote. and they were not targeted at the russian people. but the problem or the good fortune was that they coincided with the fall in oil prices. so it looked like the sanctions affected the russian people. the other problem, though, and this is a big problem, why this delegation wouldn't work, besides business delegation idea wouldn't work, is that the biggest problem that russia has is the structure of their economy, which isn't going to change because that is what insures that putin and his cronies stay in power. until you can change and make it a truly normal noncorrupt economy, i don't know how we can get business people to go there and do serious business, aside from the ones that are already working there in industries and other industries like that where the russian state will guarantee more or less but not always their investment. so the lack of rule of law, the lack of protection for international business in russia is the biggest problem with your

proposal. i do, however, think that dangling those ideas out in front of the russians while we're taking the harder actions is not a bad idea because at some point, some russian leader in the kremlin is going to have to turn around and cooperate with us and europe, because the reality is that the future for russia lies in europe, and that the pivot to asia is real except that what was left out is that we pivot with our friends and partners economically and politically, not militarily, necessarily, because hopefully we can avoid that. towardsit isasia. there's a lot of lack of information, but -- i have spoken enough. >> do any of you -- >> i have one thing to add. he brought up the u.n. i don't think we have talked enough about our european allies to help handle russia. i think the united states has to find ways to incentivize either

carrot or stick our european allies to step up to their responsibilities. they're not meeting their responsibilities as part of this alliance, we need greater burden sharing. if russia is the threat that people are talking ut, we need to expect those folks to step up. leadership would be to press them more than we have been. >> and if i could elaborate, the question about the diaspora, because i know the baltic states are now doing more than they have before, with regards to the ethnic russian and russian-speaking minorities, but that's the kind of thing we can do and persuade them to do more to address the real grievances that russian speakers and ethnic russians have. >> in this round of questions, anything to add? >> i would say on the russian world piece, we're doing a little bit, we could do more in terms of digging up information programming, television and radio, in russian language, which would attract them to our

side of the information source. >> propaganda war is completely lopsided now. okay, so first question here. the second question there. is there a third? okay. so one, two, three, and then we'll go another round. >> my name is jack. i'm unaffiliated. my question is, can the members of the panel offer some positive suggestions to the next administration for how to deconflict our legitimate democracy promotion initiatives, with what russia perceives as its, quote, legitimate security interests, or is that even possible and we should just acknowledge that it's going to be conflict and the only question is how will the conflict unfold? >> second question is on the aisle, middle aisle. >> david colten, actually piggybacking on that comment. henny kissinger once remarked

that national power is means times will. and american will, it seems, is fractured because of what we have seen today on the panel, which is that we still are caught in relitigating 2002, 2003, with the professional wrestling notion that it's realism versus the neocons of 2002. i would like to ask my question based on what ambassador herbst and evelyn had mentioned which, isn't the larger macro question we're facing now an international challenge to liberal democracy and an anti-liberal democratic authoritarian push that we see in france with le pen, that we see in hungary, that we see in uk with the brexit vote, that we see here in the united states and elsewhere. for the first 100 days of a president, how can we articulate, how can a president articulate that support for liberal international democracy

is not 2002, is not 2003, not to will's concerns of overextension in that kind of emotional things, but what bob osgood said who was a founder member at johns hopkins where he said in 1954, that america must recognize and reconcile national interests with idealism. that is national power. that is means times will. and i'm interested in what the ambassador and others on the panel have to say. >> the third question? back there on the left. >> thank you. dominic. >> identify yourself louder. >> dominic from the foundation. i have a quick question on arming ukraine and the implications for the trans-atlantic relations. i mean, i'm in ukraine in an official way or unofficial way, but what do you think that will

do to trans-atlantic relations? we know that the europeans are not really completely united on that question. how to deal with that. but right now, there's more or less we don't want to cut off arm ukraine. you said also trans-atlantic relations are a priority. how do you bring those together if they're not a contradiction? >> i promised anya a word for all her work. >> elena. i'm sorry. >> yes. not all foreign people are named anna. thank you for the discussion. to be a bit of, i guess, a contrarian here, and to go back to the sanctions question, this is something all of you have discussed as a policy tool. we talked about it in the

previous panel. the one argument is our sanctions policy has had the unintended consequence of pushing russia further towards china. russia has also gone through a self-identified pivot east, right? that pivot has not been that successful because chinese bank s, they don't bank roll goldman sachs so they haven't received the credit they were looking for in lack of access to western loans. my question to you, what are the unintended consequences of increasing the ratcheting up of sanctions? are we going to see more of this ally nls of russia and china. as a consequence of that, how will it affect our policies and our national interests? and my last question, which actually is from the man to my left, is realistically, what kind of deal can you actually get with russia given all the tools we have talked about, sanctions, strengthening the eastern frank of nato, all of these things, what kind of deal

would you all want to see? >> okay, who wants to speak first? >> i have to take off because i have a train to make, but those are exactly the kind of questions i think we need to ask because if you just say, hey, we need to arm the ukrainians. we need to push the russians in syria, and exert leadership in all these other places and expand nato and really stick it to them, doesn't that provoke the kind of balancing behavior we have expected in world history? and with that, i will say good-bye. >> thank you very much. thank you to the koch institute's support of the conference. let's go in direct order. >> okay, i think on the question about democracy and the kissinger quote, as you would imagine, i agree. i don't really feel the need to elaborate too much on that. i believe that the next president should speak clearly and that will get us pretty far towards the will. and that actually leads me to answer the second question about

arming ukraine because i believe that in europe, there is, as you said, no consensus, but if anything, kind of a going along with the current status quo situation with regards to support of ukraine. if a new american president came in and articulated a new more robust policy of support for ukraine and not just ukraine but the other countries you mentioned before, that our allies in europe would follow suit and come along with us. and frankly speaking, some of the europeans are more ahead obviously, the ones in nato who are front line states, are more possibly more ahead than we are. so i think on the sanctions, i agree that that is a danger, and the in realistic view. i think we're going to see kind of a standstill, but we have to be strong so russia doesn't take more territory, take more

liberties, and feel embold eene to try to prevail over its neighbors and in the international arena. i don't know whether with this current regime in the kremlin we can change their minds. but the best we can do is try. this is why i think things like the iran deal, the agreed framework with north korea are good because they buy you time. whatever we can do to buy time until there's some other change is at least -- the least we can do. >> well, i could comment just a little bit on the ukrainian thing. really, i agree with evelyn on this. yes, there's a split in europe about arming the ukrainians. but i think i go back to the leadership issue. i think the u.s. really hasn't articulated our policy very well to the extent we have, there's clearly ambivalence or opposition on the part of the

administration to providing weapons to ukraine. and that's the situation i don't see the europeans stepping forward and doing it. i think if we were to do it, if a new president came in and it is now the policy of the united states to arm ukraine, obviously, it wouldn't be done without consultation with the allies, but i think it might be more of a willingness, even if it's not at 28, but maybe more of a willingness with some who are willing. they might be more willing to do that. and i don't think that's in conflict with the emphasis on good trans-atlantic relations. in some ways, it supports it because anything we can do to get more peace on the border, obviously, in those areas would improve trans-atlantic relations. new president, new policies. i think a lot of things might be possible in europe. but it will take presidential engagement to get some of this done. >> john? >> in support of the ladies

relating to arming ukraine, the pattern of the past 60 years has been the taking of strong military measures in europe in support of western security has required american leadership in the face of yoeuropean oppositi. anyone familiar with the deployment of the nuclear weapons in the '80s knows this exactly, and it came out fine. we deployed the missiles despite hundreds of thousands in the streets in britain, germany, italy. they accepted it afterwards, and then we had a deal with the russi russians. on the question of how the country would deal with putin. i don't know if we will. we may not. the point is he's pursuing aggressive policies that challenge our interests. and the various measures we talked about, sanctions, arms for ukraine, weaken him. if they don't weaken him, we

increase the costs of his activities which would make him less likely to intervene elsewhere, and if he chooses to, he will be weaker. finally, the point about an international challenge to delivering order. whether it's button put pitutin erdogan, it's true this is happening. i'm not saying we even put trump in that category, but we can argue about the details. turning back to our conversation, the challenge is putin. we defeat him, we get him a blow, that knocks the wind out of this movement dploebally. one more reason for us to do the smart thing, which is very much in our interest, and i think they will recognize this is a case where our ideals and interests are more or less in sync. >> before we all thank the panel, somebody who has worked on these, all thought about them and written about these, the questions of democracy and is is

compatible. could putin ever be persuaded, the answer is no to me. it's clear his vision and his system, his regime, depends on the nonspread of the kind of liberal ideals that bob talked about and others have mentioned. it cannot be done. that doesn't mean we can't act in a way that is nonthreatening, if we draw some borders beyond which we will not -- i think we have to pull back on how much democracy promotion we do right inside russia. but the idea that we could ever persuade him that it's compatible i think is not real. i would like to start by thanking, before i thank the panel, all of the wonderful staff of the atlantic council, and my deputy will stand up for a second. they worked every bit as hard today and maybe others in the organization.

and to our outstanding panel, our outstandingly a lly articul panel, we guot a very good not only review of the issues but deepening of the issues. i hope you will all work on deepening the understanding of the american public and the next administration. this conference, we will produce a conference report or a summary that will be sent around, hopefully, sent around to all of you. this is to be continued, and we thank you all for your extraordinarily active engagement and endurance. thank you very much. and thank you to the panel.

still to come this afternoon, a look at foreign influence on u.s. corporations. speakers include the assistance u.s. attorney general for the criminal division, watch that live at 3:00 p.m. eastern on c-span2. later, a discussion on access to the u.s. court system and an individual's right to sue. it's live from georgetown university law school at 5:30 eastern, also on c-span2. and our road to the white house coverage continues in the last days of the campaign. later today, hillary clinton stumps in the battleground state of north carolina. we're live from raleigh at 7:45

eastern, and that's on c-span. and more state race debates this evening, a debate between the candidates to represent new york's 22nd district in the u.s. house, republican claudia tenney, up against democrat kim myers. that's live at 8:00 p.m. eastern on c-span2. >> i think most of us when we think of winston churchill, we think the older man sending young men into war. but no one knew better, and few knew as well the realities of war, the terror and the devastation, and he said to his mother after his second war, you know, the raw comes through. you can't guild it. he absolutely knew the disaster that war was. >> sunday night, on "q&a," historian candice millard talked about the early military career of winston churchill in her book "hero of the empire." a daring escape and the making

of winston churchill. >> he says, give me a regiment, i want to go and i want to fight. so he ends up going with a regiment to pretoria on the day that it fell to the british. and he takes over the prison and he frees the men who have been his fellow prisoners. he puts into prison his former jailers and he watches as the flag is torn down and the union jack is hoisted in its place. >> sunday night at 8:00 eastern on c-span's "q&a." next, health care providers and government officials call for renewed recommendations into the quality and timeliness of health care services provided to veterans through the v.a. system. the alliance for health reform hosted this hour and 35 minute briefing in washington. >> hello, everyone. we're going to go ahead and get started.

on behalf of our honorary co-chairman senators blount and cardin, i would like to welcome you to today's briefing on veterans' health care. 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 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 a sponsor of this briefing because the care for our nation's veterans is so important. it's the issue that combines both veterans issues and healthcare issues so it's a great issue for different offices to meet each other that we don't always interact. it's a 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. and we participate in the veter veterans' choice program because we see caring for our nation's veterans, those who have served alongside the v.a., 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 c-span, you are welcome also to follow, and of course, those here in the room, you're welcome to follow and participate in the twitter conversation. the hashtag is #veteranshealth. 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. first, we have sherman gillm jr., executive director of the paralyzed veterans of america. he served our country in the marines for over a decade. after 9/11, as he was preparing to deploy for afghanistan, sherman sustained a cervical spine injury that ended his military career. since then, he served his fellow veterans through his work at the paralyzed veterans of america, so thank you, sherman, for your service to our country. next, we have dr. baligh yehia,

the deputy undersecretary for health, for community care at the veterans health care administration. before joining the v.a., the doctor 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. carrie farmer is a senior policy researcher and association director for the behavioral and policy 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 kerndl, senior environment and operations chief financial officer for lifepoint health. he overseas operation support and planning departments that provide direct assistance to

lifepoint's hospitals and providers. we're going to start off with sherman gillums. 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 what being a veteran meant, nor did i really care. i never set foot in a v.a. medical center, much less received care from a v.a. provider. any opinion i had of the v.a. health care system would have been based on second-hand 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 while i was unconscious, 11 more days of intensive care until i stabilized and my very first contact with the v.a. 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 v.a. 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 v.a. hospitals and spoken with numerous veterans to inform their thinking? so this is me now. a byproduct of v.a. health care. 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 system of health care that cannot be easily replicated

in the private sectors as they're currently structured. the version of me has used tricare and urgent care centers when a v.a. wasn't readily available. and on balance, the providers were all competent, 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 in line behind a cast of characters from all parts of society 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 nearest drugstore hoping they carried my prescription. more than one incident i had to bounce around for several drugstores or wait for the medication because it was out of stock. this is what non-veteran centric

fragmented health care looks like when taken out of the abstruct for the veterans who will be impacted. let's take a look who will be impacted today and in the future. as v.a. health care evolves. for most, getting dental care eyeglasses, hearing aids, x-rays, 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 v.a. should retain the function of providing specialized services. i keep hearing them say, well, v.a. can just do what it does best and privatize the rest. that will not work. here's why. 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 v.a. does well. within the v.a. system, veterans access those other services such as oncology, surgery, urology, neurology, and are still closely followed by a specialized care team because of the interdisciplinary framework that is unique to v.a. 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 the attributes that make v.a. care unique based on my 14 years of experience as a user of that care that's our focus today. the slide lays out all 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, enrolled veterans who sake emergency medical care in the private sector 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 v.a. or a contractor. that's not so in the private sector. enrolled veterans can receive seamless access to prosthetics, pharmacy services, v.a. benefits assistance and peer support during appointments making it a more veteran centric experience than they would 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 v.a. care is not available, which is great as a component of v.a. health care, but not as a replacement. finally i'd like to close with comments on the most overlooked aspect of collaboration between v.a. and the private sector. when discussing health care for veterans. title 38 of the united states code, the authority that governs the delivery of v.a. benefits, including health care, protects veterans through due process provisions, medical malpractice rights, congressional oversight, and accredit representation at no cost. but what many do not know is that title 38 protection do not follow the veterans who opt for care under the choice act. congress will not have the jurisdiction to compel testimony

from private sector ceos whose health care systems are found in the numbers or have hidden wait lists. maybe we're wrongly assuming it never happened. veterans will have to rely on the courts for re-dress if the health care goes awry, if they can afford it. this absolutely 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 v.a. for their health care, it needs to be a viable choice. thank you. [ applause ] >> thank you, sherman. now we'll turn to dr. yehia. >> thank you very much. there was just an amazing first-hand experience of some of

the care that's provided in v.a. just a little bit about myself. i'm a practicing physician within the v.a. when i'm not seeing patients, as often as i would like these day would like these days i'm in d.c. leading the va's office of community care. one of the other really key pieces about kind of my journey with va is i trained in v. a, i was a medical student down in gainesville, florida and a fellow at the university of pennsylvania at the philadelphia va, as many of you may know 70% of all of america's doctors at some point interact with the va and that's another really 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 of americans. to sherman's point, at the end of the day what we want to see as a vision for 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 leverages, expertise from the private sector. unlike many other healthcare entities in the united states that are limited by their geographic markets, so if you are starting a clinic it's -- what you actually do is patients come to you. va is completely opposite. we go to where the patients are, where the veterans live, and our veterans live in every corner of the united states, some highly rural and some -- some highly rural places, some highly urban places but they span the entire geography of america. in those circumstances we cannot have a brick and mortar facility in every one of those individual locations and so we have to leverage community partnerships and they really are about partnerships not just the purchase of care, partnerships that allow us to provide healthcare to veterans in those

areas. so at the end of the day what we want to do is build an integrated healthcare network and i know that the alliance puts on a lot of these various programs and they focus on if he had -- medicare so a medicare corollary would be an accountable care organization. this is what we're looking to build which is a network that is highly coordinated, integrated and includes both va and community providers because 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 a transformation really since the choice act came about and about a year ago we presented a plan to congress called our plan to consolidate care. right now we have multiple ways of purchasing care in the community and it's important to note that va has really been partnering with community

providers for decades upon decades. while 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 and 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 about 70 years ago. we were 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 dod or indian health service to fqhc's to your regular mom and pop shops across the country. so how do we get to this integrated healthcare network? we really need to focus on the veteran and what we did is we actually talked to veterans, visited the different facilities and community providers and we

mapped the veterans' journey through community care and it starts with eligibility. we need to have a clear set of eligibility criteria that makes it easy to understand that what veterans and community providers and our va staff to administer. right now bus of these various programs it creates confusion. the benefit that veterans have earned and deserve is not clear in the community to we have to be very specific about who is eligible and who is not and hopefully make it fair and he equitable system and communicate that. that also translates to our community providers. because of all the various rogs that exist which have different eligibility criteria our community partners sometimes don't know if they are seeing a veteran that will be covered by va or not and that creates problems with payments if they take care of an individual that we are not by law able to take care of. second is a referral and authorization process which is how do we make sure that we get our veterans that are accessing

community care timely access to that. and this really has to do with making sure that we are able to leverage electronic exchanges of information so that the doctor knows clearly what veteran they are seeing and the reason for that and the veteran also knows why they're seeing that doctor and when they're supposed to see them. now, care coordination i always kind of state is really why the magic happens here, this is the golden nugget that if we're able to get this right will serve a model not only for our healthcare system but all of american medicine. american medicine as we're moving in the era of value-based payments into more integrated networks this is the thing that still folks are trying to figure out because you cannot live in your own institutions anymore, you have to work with other community partners, whether they are 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 within our own healthcare system and we are hoping to leverage more electronic health information exchanges, portals to share medical records more seamlessly between the va and the community. the next one is the community care network which is who is this network of providers that we work with, and this really does get to the idea of informed choice. right now we have a broad network of providers more than 350,000 partners we work with in va to deliver healthcare in the community to veterans. with he 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 that 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 certainly 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 inter acting with veterans really understand military cultural competency and some of the very unique circumstances and conditions that our veteran population has. when i was practicing in the private sector there just really isn't enough volume or touch points that you have with veterans to really understand all the different nuances. so we want our preferred providers to 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 and 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 payment and this is critically important, especially being a practicing physician is we view our providers as partners and in

order to be good partners to our providers we have to pay timely and accurately and this is something that va continues to work on because of the multiple ways that we have of buying care today it creates a lot of confusion and i will just give you one example. when the choice act was passed va by law was required to send out about 9 million cards to individuals, these cards look like health insurance cards and we've encountered many veterans that have taken that card to a community provider, the provider worked on the assumption that this veteran was eligible and delivered care but then on the back end when we got claims we were not able to pay those clinicians because they were not -- they did not meet those criteria. so 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 us at the va can do our part to make sure that we pay

timely and accurately. and then wrapped throughout all of that is a focus on the customer and customer service on our veterans and that makes sure that we are able to get information to them in a quick and timely manner. so that's really our journey at va right now and how we're tackling to improve community care is 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 also 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 is seven or eight programs. so 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 and this is a concept of this network that i just described of internal va and external va

partners and you can -- 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. and we want to -- we want to skate where the puck is, which 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 fee for 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 are 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 just volume but more towards value. we do need some 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 the care that we're delivering not only in va but in the community. right now va reports public clee on a lot of various markers related to access as well as quality and satisfaction. we want to be able to get that same level from our community providers that are veterans -- our veterans are participating in. >> third, we want to transfer from a care model to a care model more personalized. we leverage the patient leverage home model where we have teams that take care of veterans. we need to be able to leverage that 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 health care institutions across the country. being able to match a veteran with the right level of need, so some veterans may just need a navigating to let them know where to go, who to show up what, to bring, others may need a case manager to help them work

all their multiple appointments, make sure they have transportation. how do we get to the needs of our patients 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 carolina providers that all use different electronic health records. va has been in the business of ehr's for decades and we need to figure out how we can communicate between those different -- different entities and i think we have some innovative ways of doing that by leveraging some of the community health exchanges that are in existence today and really moving more towards portals that share information. that's just a little bit about maybe the future of va and where we hope to get to and some of the challenges that we face from a legislative standpoint but then also i think opportunities for us to be able to really lead the way in some ways for areas of american medicine. thank you. >> thank you, dr. yehia.

now we will move to david mcintyre of tri-west. >> thank you and good afternoon, everybody, thanks for being here. those of you that represent members of congress it's a privilege to serve your constituents because every one of your bosses has veterans as constituents so that's obviously part of your' here. it's a privilege to follow sherman who did a great job of laying out the population that is the entity -- the individual that's responsible for being served by the system. dr. yehia who did a great job laying out where the system is today and where it needs to be going going forward. my -- the ask for me was to lay out how do we get to where we are from a choice perspective, what did that look like and what does the system currently do from a private sector perspective. so i'm going to spend a little 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 are the people who served this country. so the choice act was born out of a crisis. i live in phoenix, arizona. in april of 2014 we all know what was disclosed in phoenix. and very quickly congress passed legislation and actually funded it 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 va90 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 party to full startup. that's a very, very short period of time.

but when we started there were no four-hour waits on the phone and we were on our way headed down the track of what needed to be done and we spent a lot of time together trying to figure out where the gaps are between congress, the va and the private sector and how do we close those things. many adjustments had to be made, both policy and operationally and we probably have gone about 75% down the track of closing those gaps but there is a lot of refinement that still remains to be done as one would expect. massive scale had to be built and placement was key. but you had the greatest challenge was to get people to understand what was actually enacted by congress. both within the va -- within congress itself and among the beneficiary population, as well as by the healthcare provider community. because this was launched very, very quickly. but we sit here today a little bit past november 5th of 2014, when this needed to start and

over 5 million appointments have now occurred through this program. our company and the network that we built has been responsible for 3.2 million of those. so how do you go about building out network? you have to understand the demand curve and so 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 area is our area of responsibility because we really didn't have a good site 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 go i have it the elasticity that it needed. this is what it looks like now. if you go backwards, that's what it was in 2014 in january and this is what it is now. tailored to demand. the bottom line is very few cases are now returned to va in

our area of responsibility because they are not a provider available to see that person when the va itself is unable to deliver that care directly. i'd like to thank ascension for being part of that network and i'd like to thank life point for also being part of that network and the 185,000 to 195,000 providers spread across 28 states that are delivering care today at this side of va to give them the elasticity that they need. so in the first month we served 2,000 people and you can see what the demand curve has looked like. as dr. yehia said, the private -- 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 are owned by a bunch of nonprofit blues plans, they buy care, integrate care, that's the core of what they do and so you look at this demand curve, we are not at the top of it yet and yet about 6,000 units of care

are being placed a day now from 2,000 a month that was done previously. this is what's happened on the spin side. so at the beginning of choice as you start slowly into something like this it's chiropractic care, podiatry, the lower costello acute things, now it's brain, heart, digestive systems, brain injury, cancers, those things are getting placed in the community in support of va. so what are the challenges that remain? when i look at this i still believe we haven't entirely solved the access a equation, the issue at the end of the day is to make sure that we properly map the demand curve. as dr. yehia said, make sure we've got the right providers in the network and we are operating in an integrated way or virtually integrated way to make sure people have confidence that the providers and the community are the right ones to place the care with. the second one is continued

refinement and dr. yehia 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 tri-care when the dod stood up tri-care almost 20 years ago. i was in the same role then. it took three and a half years for the dod to engineer claims to get it right. what i'm going to tell you is the people in va are incredibly focused in this space and we're making a lot more progress than we made 20 years ago with dod. and in fact, if you go to a place like rio grande in texas, we just finished a die angulated

project there to bring the va together with the hospitals and the community, together with our company to be able to look at how do we get claims right between all three of us. and we changed the anner tour dramatically in as short as five weeks and we plan to do that successfully across the country. the third thing i would say is we have a very inhumane dialogue going on in this country 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 system. at the end of the day this is about resetting a system. that's going to take 10 to 15 years to its end point. 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 ten years that came from every zip code in this country have the ability to go back to where they came from and live there and receive care. and if you are in a place like sherman is, you may need to go to a place that's right next to a va medical center, but the bottom line is the system is not really set for that, so this is partly a resetting exercise. and then as -- and i was a staffer back about 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 not an entitlement.

the choice act makes it a virtual entitlement. that's a good thing, but it's time to step back and figure out whether va should be the primary pair and whether we ought to think about as a motion that loads who served our country the way veterans did have the right, first right, to an entitlement because a lot of things would end up in a very different place were that the case and most of their care is actually financed by the federal government so that would be a challenge to some former colleagues and those that followed me as a staffer. lastly i would say this is about teamwork. so again i come to 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 to work saw that every day they went in. there are people that are

dishonest, they happen to be in the private sector, they are also in the public sector, but not everybody is dishonest and the fact of the matter it was demoralizing. what this billboard shows that now replaces that one as of monday is that it takes a team to deliver for those that serve this country. not to replace va, but to give it the elasticity that it needs. 400 providers in the va hospital in phoenix surrounded by 8800 providers in maricopa county of every specialty giving them the elasticity that they need to be able to deliver on care. thank you very much. [ applause ] >> thank you, david and now to carrie farmer of the rand corporation. >> thanks, i 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 veterans healthcare and rand participated in an independent assessment, i'm going to share some of our findings about the quality of va care, access to care and then also talk about what we know about quality of care and access to care in the private sector. so starting with quality of care, in our assessment we looked at dr. yehia mentioned that va regularly reports many quality measures as does the private sector. when we compared va's performance on those quality measures compared to the private sector and by private sector in this case i mean medicare, commercial hmos, we compared it a number of different ways the va performed as well and in many cases better than the private sector on these quality measures. turning to the timeliness of care, we also examined va's wait time data. so when we think about timeliness of care we think about how long does it take to get an appointment. in this case va measures wait

times by how long is it between the preferred date of care? so that's the date that the veteran or their provider would like the appointment to occur and then the date when the appointment actually occurs. so in our analysis of this data we found that most veterans receive care within two weeks of their preferred date for care. of course, there is a lot of variabilities in these numbers. in phoenix it was not two weeks for an appointment, but in other parts of the country the wait time area is much shorter and on average the wait time for a primary care appointment was six days. another aspect of the access issue is where do veterans live relative to where their healthcare is. so looking at where veterans live relative to va facilities, the vast majority live within 40 miles of some kind of va facility, so this can include a va hospital or outpatient clinic. when you start to look at more

specialized needs for care a smaller proportion of the veteran population lives been 40 miles of a va facility that can provide that kind of care. so 26% of veterans 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 healthcare in the u.s.? overall we know that the u.s. has a ways to go in improving the quality of care. this study was from 2003, one of the landmark studies looking at the quality of cara cross the united states and in this case patients received 50% of all recommended care, this study examined both chronic care for chronic conditions and for acute conditions. since that time there has been a lot of work understanding the quality of care, the institute of medicine has had a number of studies examining the quality of

care in the united states and what we know about overall is that the quality of care in the united states is variable and there is room for improvement across all healthcare conditions. dr. yehia also mentioned military multiral competence. providers in the community serving veterans need to understand the particular needs of those veterans, what their experiences serving the military are. in a study we conducted in 2014 we did a survey of behavioral health providers across the united states and found that less than half regularly asked their patients whether they were veterans or had ever served in the military and even fewer reported knowing anything about military culture. and then what do we know about the timeliness of care in the private sector? it's difficult to compare the timeliness of va care to the timeliness of care in the private sector because everybody measures timeliness of care different and there is not one

standard in how you pressure this. in the couple of studies we were able to kind in the private sector this measured the time between when a patient called for an appointment and when the appointment occurred. in these studies these wait times are much longer, 19 days for a primary care appointment in one study and 39 days in another study and these studies also had a range. when you compare that against six days on average in va, it does suggest that the timeliness may not be solved by the private sector. finally when we think about where veterans live relative to the va on the slide i showed earlier how about where veterans live relative to other providers in their community. this slide shows vet rants who live far from a va, so live more than 40 miles from a 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 looking at mental health care less than half, 49%, live within 40 miles of a private sector mental health provider and even fewer live within 40 miles of a private sector neurologist or endocrinologist. what this means is that this is a challenge for rural healthcare overall. this is not particular to va and for veterans who live far from a va facility opening up the opportunity to seek care in the community isn't necessarily going to solve this problem because those providers may not exist in their communities, either. so looking at this overall it really does suggest that private sector care should complement va care, that va provides care in most cases with high quality in a timely manner and that the private sector should come in and complement not substitute for that care. it's also important since there's we know very little about the quality of care for

veterans that's provided in the community and the timeliness of care for veterans that's provided in the community to really develop a mechanism for monitoring that care to ensure that both in the va and the care in the community that va is paying for is high quality and timely for veterans. i will stop there. >> thank you, carrie. [ applause ] >> before we turn to our final speaker john kerndl i'd like to invite everybody in the room and watching on c-span that you can participate in the twitter conversation #veteranshealth. also after john speaks we will open it up to your questions. again, there are three ways in which you can ask questions, you can submit your questions on twitter using the hashtag #veteranshealth, you can 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. so we will hear from john and

you can be getting your questions ready in the meantime. john. >> thank you, marilyn and thank you all for being here today. before i get started i would like to recognize david children low who is our vice president of government relations who is here with me today and also available to answer any questions. i'm going to go through a few slides start just by identifying life point and who we are. it will frame any comments that i make from a small nonurban sole community provider perspective, i'm going to walk through some of the volume indicators of the veterans we are seeing within life point and then talk a little bit about what we see as opportunities to expand the provider base within this -- within this program. so i a little bit about life point health, 72 hospital campuses in 22 states. as i mentioned, we are a

non-urban sole community provider. there is a ballpoint that says leading healthcare provider in our communities. we are typically the sole carolina 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. so i found interesting in particular with carrie's comments about some of the availability to some of these higher end services, these are typically the markets that we serve. we are non-urban, there is not a va hospital near us, in a lot of our markets, most of our markets there is not another acute care provider near us. so our ability to serve these vas -- these veterans in our community is very important to us. avid supporter of veterans access choice and accountability act. this has been a very emotional issue for our leadership teams, a lot of our leadership in our facilities are veterans themselves, they are in small communities, this he know the veterans that live there and so

this has been very important for them, very emotional for them and they have embraced this entirely. it was interesting we were very proud of some of the work they had done in particular with veterans choice to reach out to their communities and to a certain extent became a resource for veterans to use to identify whether or not they were eligible for it, but we have embraced it significantly. so just some volume statistics of the care that we have provided in 2015. we have provided care for over 15,000 veterans throughout life point facilities. of those 15,000, 1,200 were inpatient admissions, 4, 600 through our emergency rooms, 1600 outpatient surgeries were performed and more than 7,100 outpatient procedures and tests in 2015, that's up from '14 and continues to grow, which we're very proud of.

so where can we improve? some stats here and i will talk a little bit kind of comparing it back to life point. all of our pairs when we look at days to pay, which is when do we get paid for services compared to when we discharge a patient for all payers within life point that's 54 days and we are typically paid. within our group and it says veterans choice but it's the p c3 program and veterans choice, it typically takes 113 days on average in our 22 states to get paid. so here is why that's so important for life point we have a very strong balance sheet, we have the resources to basically finance this care. you know, our costs that we are paid at medicare rates which are almost by de facto cost, we have the act to bridge that gap between paying for the cost of

care when we provide it and being paid 113 days later. if you look at the stats for a critical access hospital, their days cash on hand are 69 face. typical hospitals if you put them all together it's over 200, for these small community independent hospitals, in particular the rural hospitals, that are fairly fragile financially they only have 69 days on hand. so it's difficult for them when you provide care and you are 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 life point. what we have seen some of it is provider self-inflicted, but i think there are some ways to

maybe mirror medicare, our medicare days to pay are less than 21 days. and so what we would welcome in this is the opportunity to work collaboratively and see how we can get those days from 113 down to maybe something closer to medicare because we believe in the hospitals that we work with that would be very attractive to them to get into some of these programs in these small communities, a lot of them simply can't afford to do that. so last slide, going forward, again, strengthening some guidelines around prompt pay, 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 prompt pay issues that we deal with we believe would bring especially some small providers into this network and this important

program. [ applause ] >> okay. thank you. so we've now -- we are now going to turn to the q & a portion of our program and i'd like to throw out the first question. we've talked a lot about care within the va system and also in the private sector. i would love for one or more of our panelists to take us back to square one for a moment and talk about the choice program that was -- that came about in 2014 and help us to understand who is eligible for this program, how are veterans using it and to what extent are they using 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 actually see kind of the train is coming and we've served more than a million veterans in this program. so a million veterans have touched the community through this and so this is one of the things that va is very concerned about because there are a lot of folks that are receiving care through the program and kind of what happens next. so that's one important point. the second is this program serves a very specific -- has a very specific set of eligibility criteria and as i was mentioning before we have seven or eight different ways of purchasing care, this is one of them and their criteria are very targeted, they really can fall into three types of buckets, one is distance and so it's 40 miles right now from a primary care provider and so if you live more

than 40 miles from a primary care physician in the va you are eligible for the choice program. second is if you cannot get care within the wait time goals of the department. and then third is they are auld 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. so those are the three types of veterans that are eligible. 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 and so an individual may be receiving care in the va for one condition that maybe we can't provide as timely so they would go out on an episode of care in the community, but they will get the rest of their care there. so that requires a lot of care coordination. those are really the three types of criteria. now, when we talk about the type

of services that we're purchasing in the community, they're pretty common. probably when i think of the top five and top ten we send out a lot of optometry, so folks getting eyeglasses, we do send out some orthopedic surgery, we send out a ton of laboratory testing so maybe someone is getting an mri, they will get an mri closer to home than coming to the va and laboratory tests. so it tends to be a little bit of the more locally available specialties, although now as dave was mentioning we are able to get a robust -- a more robust network where we can actually refer some of the more complicated procedures, whether they are, you know, ct surgeries or neuro surgeries, so that's a little bit of the mix. >> so what you're seeing on the experience side on our end is that about 15% of the population is 40 milers in terms of who is utilizing this, about 50% are

those that are near a va medical center and the va medical center or community based outpatient clinic does not have the particular service that's needed and the 35%, the remaining 35%, is those that couldn't be seen within 30 days and choose to access their rights. if i could just for those that are staff members, the expiring in august of the program, it's very unusual for congress to authorize and appropriate at the same time, in fact, it usually doesn't happen outside of black box issues or other types of very rare occurrences. the federal budget rules had to be suspended, the congressional budget rules in order to get this through and that's what set the trigger for august 7th. but at the same time without action a whole program goes away and that's what baligh is talking about and the notion

that it needs to transfer to something else or in its current form it needs to be reauthorized from a budgetary perspective and an authorization perspective. >> okay. thank you. so let's turn to the audience now. we have a question, if you could please identify yourself. >> my name is regina leonard i'm from george mason in health policy and nursing administration. i have a question -- well, basically a comment and a question. with veterans needing more access to care it would seem plausible that the va hospital would allow advanced practice nurses also known adds mps and clinical specialists to have full practice authority. hr1247 the veterans access to quality care bill would allow this and help the va hospital accomplish this goal. how do you foresee utilizing mps in the future? >> so that's a great question and also a very controversial question as you can imagine as

va is working on its nursing handbook. we leverage a lot of nurse practitioners, physician assistants, provider extenders and so i'm not exactly the right person to be able to address this specifically, but what i will say in general is we do have veterans that live in every corner as i mentioned of the united states and as we were -- as our rand colleague was demonstrating in some areas they are not physicians or there is a dearth of those providers. so we might need to leverage more of our nursing -- nurse practitioners colleagues and other providers to make sure that we take of veterans. >> can i just make a comment to your question as well? outside of any care that we provide for veterans for us being in the small communities that we are in nurse practitioners and physician assistants very important part of that provider network in some of these small communities. so we use them very effectively, this he provide great care in these small communities and it's

a very important part of that provider network in a lot of these communities. >> i also want to jump in to say that one of our recommendations in the independent assessment was indeed that nurses -- advanced practice nurses should practice to the full scope of their license and that the evidence -- the research really shows that there is not a difference in the quality of care between those providers. >> thank you. >> okay. question here. >> i'm dr. caroline pop listen, i am a primary care physician. i'm a question for dr. yehia and a very quick question for john. the question for dr. yehia, i worked for the active duty military for 12 years, seven years at ft. bell voir, five years at what was then bethesda naval hospital. the military all that time were working to make their electronic medical record inter operable with the va.

they spent billions of dollars and 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 ehrs? obviously it can't be the way that we tried to integrate because that just didn't work. >> thank you. that's an excellent question. i don't think they've given up quite yet, but the point that you're describing is really an american medicine issue which is there is healthcare systems across the country, there is a market out there for electronic health records, it's competitive, everyone has different records. and so we have to think of it differently than what we've done before. we're doing a couple things at va that are -- show a lot of promise. number one is really leveraging community health exchanges. we are now part of about 80

health exchanges across the country. a lot of these are individual communities that get together, the hospital systems in that area say we're going to share information, there is a standard template of what data they get and so we share records with -- we have veterans that have coded more than half a million that are participating in these different exchanges. number two, knowing that not everyone is going to always have the same record the question is how can you share information between the records and what we've been able to do with our military treatment facilities, dod partners and now transferring that knowledge to the community is having something that's a viewer of the record so you can actually get a view only read of the record and not able to kind of alter it because that belongs in your healthcare system and so with dod we have something called the joint legacy viewer where we are able to actually have a read only view of the dod record, it actually is integrated so it's not like we look at the dod

record here, we look at the va record. when we look at the community viewer it's an integrated record. and we now have these all over the country and we are 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 and that way they can as a practicing doctor if i wanted to look at the mri or ekg i can look at it through this web-based portal. i'm envisioning more of those sort of tools, portals that connect systems rather than trying to get everyone on 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. >> okay. thank you. we have several questions about

the use of other tools such as telemedicine and how the va is using telemedicine or other tools like home and community-based services to provide access to care for rural vets and those are mobility issues. and how can congress help to encourage this? >> why don't i start and i'd love dave to also comment. va is actually really at the tip of the spear when it comes to telehealth. we have a number of telehealth hubs and have been doing various versions of telehealth for a long time and it's exactly for that, marilyn, which is we want to make sure that we can provide access and reach in certain areas that we may not be able to actually have a brick and mortal building. so we're leveraging more and more telehealth to be able to -- in all kinds of specialties, by the way, not only in primary care but mental health care, terminology, so we are kind of

also looking at what other fields that traditionally have not even been done through a telehealth venue can we do. we're 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 and that -- there is a couple statutes that prevent va from sharing medical records and these were developed decades ago and they are above and beyond the hipaa requirements, but va is not allowed to share records if someone identifies as having hiv, sickle cell or mental health or substance abuse conditions. so you are making a big chunk of our patient population that may have one of those conditions and in my mind, you know, it's almost as a stigmatization that we have to get them to sign a separate form above and beyond the normal hipaa compliance to be able to send it over to their doctor in the community.

that has really limited our ability to coordinate care, whether it through the telehealth venue or in-person venue. so that's one thing that i think doesn't necessarily cost any money, it's removing a barrier, it helps to provide higher quality care that's coordinated and it's outlined in our plan to consolidate care. that's one thing that i think they can do. >> i would completely concur with what dr. yehia said in terms of taking down those barriers. when we were doing work at the site of the dod in colorado at the heighth of the wars we actually placed in facilities in colorado springs inpatient -- inpatient patients for mental health because the military hospital there did not have an inpatient unit. and we actually forced grand rounds that were joint and so we required the sharing, and the sharing of that information is really, really important to making sure that the patient encounter is proper and that you

plug the gaps that might otherwise exist. starting next week we will be standing up a series of pilots that will roll out in two markets and then expand from there that will put us behind the tip of the spear which is the va, but we will actually do telemental health, it will start with medication management in a particular market to help give them more supply and then it will also do psychotherapy on that same backbone that will allow us to test out in both urban and rural areas how we jointly want to make sure that people are taken care of and leverage supply in the private sector when it's not available in the va. and i would just say that making sure that providers are understanding of who a veteran is and then we select carefully who we place people with is really, really important. and so we've put a million dollars into a nonprofit that's actually constructing the

teaching information that will be made available to providers all over this country as it relates to understanding a veteran, but then also the evidence-based therapy training that va and dod have specialized in and actually make that available from a distance perspective with a coaching apparatus on the back end that we designed in concert with va and dod. and that information will be available free of charge to providers all over this country that want to step forward and be helpful. >> i agree with baligh and dave that telemedicine and home based healthcare is a great force multiplier, particularly in the area of mental health. i have seen many veterans who had trouble access benefit from it, i know there were licensing issues that had to be worked out, somebody from san diego might want their same provider and might not mesh well with

somebody in another area. i do want to caution it's not a panacea, i think the optimal form of healthcare is person to person in some instances. i'm always hearing from nurses to talk about, for example, the decubitus ulcer, you can see it on the screen but it's not the same as appreciating how bad it is when you're there and see it in person. i'm always happy to see my doctor once a year when i do my channel a.m.s in person. there is something that doesn't necessarily get lost but we don't want to see it as the end-all be all for all types of care but it's a great force multiplier for opening care for veterans who need services. >> okay. great. we have a question at the mic. >> hi. thank you all for being here today. dr. taylor winkel man senator murphy's office. it would seem to me as scary as the 2017 deadline, august 7th deadline, is it also provides us with an opportunity to introduce

changes to the program and as a veteran who remembers what it was like living 98 miles away from a facility before veterans choice came in i certainly can relate to the benefits and challenges that we face. mr. gillums i would assume you would recommend something to extend title 8 protection but what would your asks be for improving this assuming we could get a better, more cohesive vision put together? >> one big area or i should say a gap in the choice act and i think it was mentioned here for those of you in these specialized services it does not good to be 40 miles from a cboc community based outpatient clinic for ft. bell voir if they can't provide a service. it will cost money but if you truly intend to open access to all veterans that has to be looked at. if i live two hours from a spinal cord injury center and i can't get there timely or can't get an appointment timely maybe

there is a spinal cord injury expert in the private sector that can do a test or run someest its that i need or take care of an acute issue and then i will follow up. but that was a gaping hole. i would never be eligible because the care that i would need wouldn't be at the d.c. va or wouldn't be at the ft. bell voir cbop. that would be one area i would hope if we go down this road again someone would take a look at that. >> i really appreciate that question because we actually laid out our vision of where we want choice to evolve and that's in our plan to consolidate care that should be available to all on the website. we have to actually not just extend it past this date, there has to be changes. this program as dave was describing came very rapidly, was implemented rapidly, in partnership with congress we were able to change the law four times already, which is great, but we have a number of other asks to make the program work better for veterans and i will

just list a couple. number one is this primary payer issue, in some circumstances our non-service connected veterans they have to rely on their other health insurance. so what does that mean? it means they have to pay their copays to the other health insurance, deductibles, premiums and no other program in va works that way. and so it's exposing them to some financial costs that they never had before and a lot of them were very upset about that. not knowing that they had to pay those specific portions. two, we need to be able to -- we need to be able to really work better with community partners, especially in rural areas. right now the choice law limits va at medicare and so while medicare rates, the payment rate, makes sense in some locales, it doesn't in other. and so we need to be able to have some flexibility to be able to partner with providers and pay them a higher rate because a lot of times we definitely do have some issues in the payment

area. it's -- sometimes it's not the slow it's too low. so we have to be able to get to flexibility in payments and move towards value-based payments. then i mentioned a couple of other things of being able to coordinate care better by allowing us to share information and really the penultimate thing is we have to evolve this program. we've invested a lot of infrastructure, our partners have invested a lot of truer, we have learned a lot. it has to evolve. i don't think it should be completely scrapped and start from new because we will go through the same exact growing pains that we did two years ago and so it's how do we continue to take what's there and turn it into a program that really makes sense for our veterans, for our community partners and for the va. >> i imagine some of our other panelists have ideas about what needs to happen with this program. >> you know, i would repeat what mr. gillums said. the issue around the 40 miles

and the primary care facility as an example really is 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, but the va center will not have a surgical suite, they may not have high end diagnostic work. so we will have a veteran that is three miles away from one of our facilities where we will have an mri or have a surgical suite if they need a surgery and we've been able to work through those issues, but it's always one off negotiations with the veterans administration to try to keep that veteran close to home and provide that care. so that has been an issue and i think absolutely there is very close facilities to a lot of these veterans that meet the care of need that they have but they are not able to utilize it because of the 40-mile rule and though that's applied. >> just to comment on that piece because this is one of those things that we have to be aware of what it could mean and so sometimes we talk about 40 miles from a primary care doctor

versus 40 miles from where you can get the service and a lot of folks outside of the va have also done some mod lgs. it definitely would have a very large financial impact. apart from that, though, to sherman's point earlier, we have to be careful about kind of referral patterns and in order to provide really high quality care, for example, for our service connected veterans or tbi patients if we cannot provide wrap-around services because a lot of those are being delivered somewhere else in the system outside the system then it becomes hard to actually gain competency and recruit doctors in those areas. so i think it is definitely worthwhile looking at and figuring out how we can get flexibility for sort of veterans that need to be seen because in some circumstances one mile is too far or two days' wait is too long. so we definitely need some flexibility built into the system, but i do -- i do raise

some concerns about completely being able to open it up because what that will actually do is detract from the folks that actually are using it and want to use it because you might not be able to build out those wrap-around services if you don't want to use it. if you don't have the specific volume or expertise to be able to do that. >> so i would concur with the notion 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 has 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. and the mix of use in the guard and reserve has been very 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 the displace where they are. and they may want to take a year or two off. they have a benefit they have earned. so to have reasonable care in reasonable distance we all agree. but how do we draw the parameters right? i think congress 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 and a lot of money that is paid when someone doesn't get what they need on a timely basis. because when they're really sick, it's more expensive. for certain types, you absolutely want to be in a v.a. facility you want to be in a top-notch academic facility

regardless of where you live in the state. but there are other things where you could get the orthopedic service across the state from where a v.a. facility is. we look forward on our end doing whatever needs to be done to make sure we flex properly to make that work. >> in some ways there knees to be a conversation about what is the obligation to veterans. and if the decision is we continue as it is and v.a. has an annual budget submitted two years in advance, every time beyond what was expected or projected, there will be access problems and decisions to stay within the budgets. and if you increase the eligibility, it is going to be difficult. so thinking in the big picture

of what is your responsibility to veterans, what is our commitment and how are we going to pay for that. >> okay. we have had several questioners want to know how to make the -- how to get claims paid faster? just a softball question. >> 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 are realizing is there is a number of of root cause issues here that have to be addressed to make sure we're able to timely pay our providers. one is the eligibility piece. when we have six, seven, eight

different programs all with different criteria, if you tonight match them up exactly right and you're providing care for a nonservice connected condition in this case or a veteran that lives 38 miles, not 40 miles, we don't have the authority as a department to cover the bill. and that's really unfortunate because the criteria -- the there's so many of them. and they vary. many times a veteran receives care that isn't authorized or we don't have the ability to pay. that's one thing. how do we get to a simple set of eligibility criteria that is clear to our patients and our providers that there isn't any ambiguity. you turn a certain age, you have a card and you're good to go. we need to be able to get to that level of clarity. if we're going to continue to

have seven or eight different programs all operating differently, it's going to be hard for our patients and for our providers to know that. number two, we have to make adjustments to the laws. many times today, probably the biggest area where i get complaints about provider payments really relates to e.r. care. it is very fragmented. in some cases v.a. is the primary payer. in other circumstances we are payer of last resort. also by law and statute we pay 70% of the medicare rate. well, when we talk to the a lot of doctors and sit down with them and examining ars we actually did pay, it and is considered payment in full, but they still carry a chunk of that on their accounts receivable.

that's something we would not be able to pay until we get some of the laws changed. that is where i see a lot of consternation is around unauthorized care where we have to figure out if they're service connected or not. we are not allowed to pay the full price by statute. thirdly, if we're able to get the good criteria, iron out some of the kinks er system, that will allow us to automate more and more and more. it is is very hard to automate like medicare does when you actually have to go to the medical record, which is what we have to do in er care to the determine if that specific service that was provided in the

emergency room was for a service connected condition. you can't really do that by computer. you actually have to see did the veteran -- was he seen for a knee injury and is that knee injury service connected. way too complicated. i don't want to do that all the time. it takes 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 and the hospital systems know exactly what is offered and what they are able to deliver. so i think this is a great opportunity for us for progress, however we need help. we need help from our legal and congressional colleagues.

>> if you go back to the start of try care 20 years ago with the d.o.d. the three months in it came player d.o.d. the never paid properly. and some of the history in this space that dates back a long time is the v.a. was paying its claims market by market by market by market. that's not a very effective way to do it. it is hard to get to core competency. what we have done in choice now is to the consolidate what that looks like. that was a very needed change. what they did is took all claims and aimed them on one side. the second thing is when you're an institution you have to file properly. when you're a provider you have to file properly. no one wants to be in a place

where claims get denied where they're slow. because at the end of the day we have to go find another provider in order to send the next veteran. that's not in anybody's and anywhere. so paying timely, paying accurately is everyone's interest in this process. but what i will tell you is from a provider perspective, having done a lot of work at the start of try care at the health the d.o.d. get this right and then get it right across the system to make it the fastest and most accurate payer of those types of programs, you have to also pay one way. and right now if the care moves directly from the v.a. to the community they pay one way. they file one way. if it moves through choice, it goes down differently. so now imagine being the billing office trying to figure out which place do i send this, how does this work rather than it

goes through one consolidated pipe. so that's something that needs to get fixed. we did a project in texas, dr. yehia, myself, members of congress from that area and the hospitals in that area. it is an area where a lot of care moves downtown in all types because they have a community-based outpatient clinic. it has been that way for a long time. some of the hospital offices of four had a 50% denial. they did not know how to file accurately. we took it down to 10%. we all own a part of this responsibility. it starts with the provider filing accurate. then it goes to us making sure we have processes that