i won't get cancer, have a heart attack, develop diabetes or suffer depression and need what's referred to as tertiary care. which augments and sustains those specialized services that va does well. within the va system veterans access those services oncology, surgery, neurology and are still closely followed by a specialized care team because of the interdisciplinary framework that's unique to va. that's why you cannot separate them. specialized services should demand tertiary services be driven completely to the private sector. so with this busy slide in front of you, we'll turn to the discussion on the attributes that make va health care unique based on my 14-year experience as a user of their health care, that's my focus here today. the slide lays out the characteristics of tertiary and

specialized care that most who opine on the topic likely do not know. here's a bit of education, i'd like to draw your attention to a few, starting with the ones in the red boxes. did you know. veterans who seek emergency medical care in the private sether do not have to pay the expenses for them provided a request to cover unauthorized medical expenses is timely provided. it's not so in the private sector. eligible veterans who have medical appointments are reimbursed for their mileage and travel provided -- unless provided by va or a contractor. that's not so in the private sector. enrolled veterans can receive access to prosthetics pharmacy service, va benefits assistance, and peer support during appointments, making it a more veteran-centric experience than they've receive anywhere else. that's not so in the private sector. eligible veterans do have a choice. through the choice act.

that's a good thing. because they can seek care from an alternate provider if timely va care is not available which is great as a component of va healthcare but not as a replacement. finally i'd like to close with comments on the most overlooked aspect of collaboration between va and the private sector. when discussing healthcare for veterans. title 38 of the united states code, the authority that governs the delivery of va benefits, including healthcare, protects veterans through due process provisions medical malpractice, congressional oversight and acrypted representation at no cost. but what many do not know is that title 38 protection do not follow the veteran who opts for care under the choice act. congress will not have the jurisdiction to compel testimony

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

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

it's a system that includes va healthcare providers and clinics as well as expertise from the private sector. unlike many other healthcare entities in the united states that are limited by their geographic markets. if you're starting a clinic, it's -- you actually do is patients come to you. va is completely opposite. we go to where the patients are. where the veterans live. our veterans live in every corner in the united states. some highly rural places, some highly urban places but they span the entire geography of america. and in those circumstances, we cannot have a brick and mortar facility in every one of those individual locations. and so we have to leverage community partnerships and they are really about partnerships, not just the purchase of care. partnerships that allow us to provide healthcare to veterans in those areas.

at the end of the day what we want to do is build an integrated healthcare network. i know the alliance puts on these programs and they focus on medicare. a medicare corollary would be an accountable medical organization. it's highly coordinated integrated and includes va and community providers. really, we need both aspects to meet the full spectrum of needs for our veteran population. so how do we get there? we really start with the veteran in the middle, and so va and va community care has been ongoing transformation really since the choice act came about. about a year ago we presented a plan to congress called our plan to consolidate care. we have multiple ways of purchasing care in the community. it's important to note that va

has been partnering with community providers for decades upon decades. the choice act might have put a little bit of a spotlight on our ability to purchase care, we purchase way more care outside of the choice act than within the choice act. we've been doing that for years and years and years. a perfect example is our great partnerships that we have with academic medical centers which started 70 years ago. we are able to not only share clinical knowledge, but also research and training expertise. so this is not new to va. this ability to partner with different providers across the country. and like i said, they span the spectrum from academic, community providers, federal institutions like d.o.d. and indian health service to your regular mom and pop shops across the country. so how do we get to this integrated healthcare network? we need to focus on the veteran and what we did is we actually talk to veterans, visits the different facilities and community providers and we mapped the veteran's journey

through community care. it starts with eligibility. we need to have a very clear set of eligibility criteria that makes it easy to understand that what veterans and community providers and our va staff to administer. because of the various programs, it creates confusion. the benefit that veterans and earned and deserve is not clear in the community. we have to be very specific about who is eligible and who is not and hopefully make it fair and equitable system and communicate that. that also translates to our community providers. because of all the various programs that exist which have different eligibility criteria, our community partners don't know if they're seeing a veteran 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 care of. second is a referral and authorization process, which is how do we make sure we get our veterans that are accessing community care timely access to that.

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

between the community and our healthcare system. we're hoping to leverage more electronic health information exchanges. the next one is the community care network, which is who is the network of providers we work with. this really does get to the idea of informed choice. right now, we have a broad network of providers, more than 350,000 partners we work with in va to deliver healthcare in the community of veterans. we want to make sure that the veteran is empowered to make informed decisions about the providers they want to see. and this is the same movement all of american medicine is getting to which is how do we get our community network to be able to report on quality, satisfaction, value so that veterans are able to choose a provider that makes sense for them. this is a healthcare is a very personal matter.

how do you choose a provider that actually meets their needs? part of this is also identifying what we call in va is our preferred providers. we know that our providers in the va by interacting with veterans really understand military cultural competency and some of the very unique circumstances and conditions that our veteran population has. and when i was practicing in the private sector, there just really isn't enough volume or touch points you have with veterans to really understand all the different nuances. so we want our preferred providers to not only be delivering excellent quality high levels of satisfaction and good value, but also have expertise in military cultural competency and be aware of veteran issues. i think that way we can start to help our veteran population really understand and choose a provider that meets their needs. next is provider payments this is critically important, we view our providers as partners. in order to be good partners to our providers we have to pay timely and accurately.

and this is something that va continues to work on because of the multiple ways we have of buying care today, it creates a lot of confusion. i'll give you one example. when the choice act was passed va by law was required to send out nine million cards to individuals. these cards looked like health insurance cards. and we've encountered many veterans that have taken that card to a community provider, the provider worked on the assumption was eligible and delivered care. but on the back end we were not able to pay the clinicians because they did not meet those criteria. we have to have very clear eligibility criteria that's simple. no red tape. make it very easy for folks to understand. so that the community and the veteran know exactly what is eligible and what isn't. and then also the va can do our

part to make sure we pay timely and accurately. then wrapped throughout all that is a focus on customer and customer service and our veterans. that makes sure we're able to get information to them in a quick and timely manner. that's really our journey at va right now on how we're tackling to improve community care. focus on the veteran, the touch points that are important to them. and then spooling up projects to be able to move the needle in each of those areas. for almost every one of those areas we need to partner with congress to make sure that we make the system less complicated than what it is. when you're trying to run a program and keeping the veteran in the middle, it makes it hard when actually there is not one program, there's seven or eight programs. we have to get to that one program that makes sense for our key population. i wanted to mention a little bit about how we can move towards a high performing network. this is a concept of this network i just described of internal va and external va partners. this graphic depicts that a little bit.

you can see veterans moving around from one location to another and including the va and our various community partners. we want to skate where the puck is. where is 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 so a value-based reimbursement model with preferred providers. with cms's investment in the cmmi and all the various demonstration projects, they're testing out various models that make sense from a value-based perspective. we want to participate in those as well. we want to make sure that we are not -- our community providers are not driven by volume but more towards value. we need legislative help in order to be able to do that. we also want to leverage better monitoring of quality utilization patient satisfaction and value. we want to be transparent about care we're delivering not only

in va but the community. right now va reports publicly a lot of various markers relate today access as well as quality and satisfaction. we want to get that same level from our cmunity providers our veterans are participating in. third, we want to transform to a care model that's more personalized. inside va we have teams that take care of veterans. we need to be able to leverage the same sort of personalized care as veterans go in and out of the va. that will be a unique challenge for us that, as i said, also is faced by many healthcare institutions across the country. being able to match a veteran with the right level of need. some veterans may need a navigator to let them know where to go, where to show up, what to bring. others may need a case manager to make sure they have

transportation for multiple appointments, so how do we really get to the needs of the patient and match them up with the right resources and have them follow through their trajectory as they go in and out of the va. lastly, we need to leverage better exchange of information. right now in american medicine, there are a number of different healthcare providers that all use different electronic health records. va has been in the business of ehrs for decades. and we need to figure out how we can communicate between those different entities. we have innovative ways of doing that by leveraging some of the community health exchanges that are in existence today and moving more towards portals that share information. so that's just a little bit about maybe the future of va and where we hope to get to, and some of the challenges we face from a legislative standpoint. then also i think opportunities for us to be able to lead the way in some ways for areas of american medicine. thank you. >> thank you. [ applause ] now we will move to david mcintyre of triwest.

>> marilyn, thank you, and good afternoon, everybody. thanks for being here. and those of you that represent members of congress, it's a privilege to serve your constituents. because every one of your bosses has veterans as constituents, so that's obviously part of why you're 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, and dr. yahia, who did a great job laying out where the system is today and where it needs to be going, going forward. the ask for me was to lay out how do we get to where we are from a choice perspective, what did that look like and what does the system currently do from a private sector perspective. i'm going to spend a little bit of time talking about the scaling that was involved to make this happen and where we sit when we look through my end of this lens. and that is, responsible for one

half of the country to build the integrated delivery system downtown that meets up next to the va delivery system. obviously, as sherman represents, we have the privilege of serving the best of the best in this country. they're the people who served this country. the choice act was born out of a crisis. i live in phoenix, arizona. in april of 2014 we all know what was disclosed in phoenix. very quickly congress passed legislation and funded at the same time to give va money to be able to scale internally but also to be able to buy more care downtown. they gave the private sector and va 90 days to stand this up. by the time the rules were actually figured out for what was going to be done, we had 33 days to go from a blank sheet of paper to full start-up. that's a very, very short period of time. but when we started, there were though four hour waits on the

phone. we were on our way headed down the track of what needed to be done and we spent a lot of time together trying to figure out where the gaps are between congress, the va and the private sector and how do we close those things. many adjustments had to be made both policy and operationally. and we probably gone about 75% down the track of closing those gaps. but there's a lot of refinement that's still remains to be done as one would expect. massive scale had to be built. and placement was key. but you had the greatest challenge was to get people to understand what was actually enacted by congress. both within the va, within congress itself and among the beneficiary population. as well as by the health care 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. over 5 million appointments have

occurred through the program. our company and the network we built has been responsible for 3.2 million of those. so how do you go about building out network? you've got to understand the demand curve. we spent a lot of time working with the individual of va medical centers understanding what demand looked like. if you had never fully delivered on demand you didn't really understand it. and so we tried to work that and map that. and if you look at 2014, this was the network, the blue areas are our area of responsibility. because we really didn't have a good sight line as to what the demand picture looked like for what needed to be purchased in the community and matched up next to va to give it the elasticity it needed. this is what it looks like now. so if you go backwards, that's what it was in 2014 of january, and this is what it is now. tailored to demand. the bottom line of it is, very few cases are returned to va in our area of responsibility

because there is 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 lifepoint for also being part of that network. and the 185,000 to 190,000 providers spread across 28 states that are delivering care today at the site of va to give them the elasticity that they need. in the first month we served 2,000 people. and you can see what the demand curve has looked like. as dr. yahia said, the va has been buying care in the private sector for a very long time. we're owned by two university systems, which gives us a lens into the delivery system. and we're owned by a bunch of non-profit blues plans. they buy care. they integrate care. that's the core of what they do. and so you look at this demand curve, we're not at the top of it yet. and yet, about 6,000 units of

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

dr. yahia 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 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 focussed in this space and we're making a lot more progress than we made 20 years ago with dod and if you request to a place lake rye yo grande in texas we just finished a triage lated

project together to bring the va together with the hospitals in the community together with our company to look at how do we get kramz right between all three of us and we changed the aperture dramatically in as short as five weeks so we planned to do that successively across the country. the third thing i would say we have a very inhumane conversation. this is not about privatizing the va. that is not a good idea. we as citizens have invested in the architecture and structure of a great system. at the end of the day, this is about resetting a system that's going to take ten 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 downpayment 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're in a place like sherman is, you may need to go to a place that's right next to a va medical center. the bottom line is the system is not really set for that so this is part of a resetting exercise and as bali said making sure eligibility works for streamlined. the last thing i say to those of you who are staffers here and i was a staffer a long time ago, back about 20 years ago is when i left capitol hill. in the '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. it is is time to step back and figure whether va should be the primary payer and whether we out to think about as a country the notion those that served our country the way veterans did had the right, first right to an entitlement. because a lot of things would end up in a very different place were that the case. and most of their care is financed by the federal government. so that will be a challenge of former colleagues and those who followed me as a staffer. lastly i would say this is about teamwork. again, i come from the city of phoenix. that's where the inferno started. on monday, this billboard was put up in phoenix. it replaced a billboard that was right outside the va that said the va is lying. for nine months, the staff that were driving the work saw that every day they went in. there are people that are dishonest that happen to be in the private sector. they're also in the public

sector. but not everybody is dishonest. the fact of the matter is it was demoralizing. what this billboard shows that now replaces that one as of monday is 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 8,800 providers in maricopa county of every specialty, giving them the elasticity they need to be able to deliver on care. thank you very much. [ applause ] >> thank you, david. now to kerry farmer of the rand corporation. >> thanks. that was great. so i'm going to give a little bit of a different perspective from the research side. so as something else that happened as part of the choice act was a requirement of an independent assessment of the

veterans health care. 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 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 the va regular reports many quality measures, as does the private sector. when we compared the performance by private is sector, i mean medicare, commercial hmos we compared a number of different ways. that the va performs as well or better than the private sector on these quality measures. turning to the timeliness of care we also examine 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

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 most veterans receive care within two weeks of their preferred date for care. of course there's 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 is much shorter. and on average, the wait time for a primary care appointment is six days. another aspect of the access issue is where do veterans live relative to where their health care is. looking at where veterans live relative to va facilities the vast majority live within 40 miles of some va facility. this can include a va hospital or outpatient clinic. when you start to look at more specialized needs for care, a

smaller pro% of the veteran population lives within 40 miles of a provider that can provide that kind of care. 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 health care in the u.s.? overall, we know the u.s. has a ways to go in improving quality of of care. this study was from 2003, it was one of the landmark studies looking at the quality of care across the united states, and in this case patients received 50% of all recommended care. the study examined care for chronic conditions and 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 health care conditions. dr. yehia also mentioned military cultural competence. providers in the community who are serving veterans need to understand the particular needs of those veterans, what their experience in serving the military are. in the study we conducted in 2014 we did a survey of behavioral health providers across the united states and found less than half regularly asked their patients whether they were veterans or have had ever served in the military. even fewer reported even knowing anything about military culture. and what do we know about the timeliness of care in the private sector? we actually know very little. it's difficult to compare the timeliness of va care to the timeliness of care in the private sector in part because everybody measures timeliness of care different. there's not one standard in how you measure this. in a couple of studies we were

able to find in the private sector this measured the time between when the patient called for an appointment and when the appointment occurred and we found that in these studies, the wait times are much longer. so 19 days for a primary care appointment in one study and 39 days in another study, and again, these studies also had a range. so when you compare that against six days on average in va, it does suggest the timeliness may not be solved by the private sector. finally, when we think about where veterans live relative to va on the slide i showed earlier, what about where veterans live relative to other providers in their community. this slide shows veterans who live 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 just

mental health care, less than half, this is 49%, live within 40 miles of a private sector mental health provider. and even fewer live within 40 miles of a private sector neurologist or endocrinologist. this means this is a challenge for rural health care overall. this is not particular to va. 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 is also important since we know very little about the quality of care for veterans that's provided in the community and the timeliness of care for

veterans provided in the community to really develop a mechanism for monitoring that care to ensure both the va and the care in the community that va is paying for is high quality and timely for veterans. i'll stop there. >> thank you, kerry. [ applause ] before we turn to our final speaker john kerndahl of lifepoint health, i would like to invite everybody both in the room and watching on c-span that you can participate in the twitter conversation #veteranshealth. also, after john speaks, we will open up to your questions. again, there are three ways in which you can ask questions. you can submit your questions on twitter using #vet rapshealth. 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'll hear from john, and you can be getting your questions ready in the meantime.

john? >> thank you, marilyn. thank you all for being here today. before i get started i would like to recognize david kritchlow who is our vice president of government reelss 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 lifepoint and who we are. it will frame any comments we that i make from a small non-urban sole community provider perspective. we'll walk through some of the volume indicators of the veterans we are seeing within lifepoint and talk a little bit about what we see as opportunities to expand the provider base within this program. so a little bit about lifepoint health, 72 hospital campuses in 22 states. as i mentioned, we are a non-urban, sole community provider.

there's a bull point that says leading health care provider in our communities. we are typically the sole health care provider, or at least acute care provider, within our communities. we operate in areas that the closest acute care facility is over 100 miles away. so i found it interesting in particular to kerry's comments about some of the availability to some of these higher-end services, these are typically the markets 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's not another acute care provider near us. so our ability to serve these vas and, 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 and our facilities are veterans themselves. they're in small communities. they know the veterans that live there. so this has been very important for them, very emotional for them.

and they have embraced this entirely. it was interesting, we were very proud of some of the work that 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 have embraced it significantly. so just some volume statistics of the care we had provided in 2015. we have provided care for over 15,000 veterans throughout lifepoint facilities. of those 15,000, 1,200 for inpatient admissions, 4,600 through our emergency rooms, 1,600 outpatient surgeries were performed and more than 7,100 outpatient proeurs 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'll talk a little bit, kind of comparing it back to lifepoint. all of our payers, when we look at days to pay, when do we get paid for services compared to when we discharge a patient, for all payers within lifepoint, including self-pay patients, that's 54 days and we are typically paid. within our group, and it says veterans choice, but it's the pc3 program in veterans choice. it typically takes 113 days on average in our 22 states to get paid. so here's why that is so important. for lifepoint we have a very strong balance sheet. we have the resources to basically finance this care. you know, our costs, we're paid at medicare rates which are almost by defacto costs. we have the ability to bridge that gap between paying for the cost of care we provided and then being paid 113 days later.

if you look at the stats for the critical access hospital, their days cash on hand is 69 days. i, or for the 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're waiting to get paid at cost where you then become almost the financing arm for these patients. so i think by reducing that, a lot of our sister independent rural hospitals don't participate just because of the cost issue. and so that's an area that we have looked at a lot within 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 those days from 113 down to maybe something closer to medicare because we believe in the hospitals we work with that would be attractive to them to get into these programs in these small communities. a lot of them simply can't afford to do that ch. so i -- last slide, going forward, again, strengthening guidelines, it does involve other providers side. and that we can improve on but i think coming together and figuring out a way to get through the pay issues we deal with we believe would bring small providers into this network and this important

program. [ applause ] okay, thank you. so it's -- we've now turned -- we're now going to turn the q&a portion of our program and i'd like to throw out the first question. we've talked about care within the v.a. 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. who is eligible for this program, how are they using it and to what extent? do we have just about everybody using it? what kinds of services are they getting? what is the experience like so far? >> 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. i think this is very important

because it is set to expire august 7 of next year so we're less than 12 months before this program expires. this is a huge issue because we see the train is coming and we've served more than a million veterans in this program. a million veterans have touched the community through this. this is one of the things v.a. is concerned about because they are a lot of folks that are receiving care through the program and kind of what happens next. we have seven or differeeight w purchasing care, this is one of them. they can fall into three types of buckets. one is distance. so it's 40 miles right now from a primary care provider. so if you live more than 40 miles from a primary care

physician in the v.a. you're eligible for the choice program. second is if you cannot get care within the wait time goals of the department. and third is -- they're called unusual and excessive so if there's a mountain range or a lake or a stream or severe weather we're 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 with a stable type of population. the wait time criteria alters. so an individual may be receiving care in the v.a. for one condition that maybe we can't provide as timely so they would go out on an open society of care in the community. but they'll get the rest of their care there. so that requires a lot of care coordination, so those are the tee types of career too ya. when we talk about the type of services that we're purchasing

in the community, they're common. probably when i think of the top five and top 10 we send out a lot of optometry so folks getting eye glasses. we do send out some orthopedic surgery. we set out a ton of laboratory testing so maybe someone is getting an mri, they'll get an mri closer to home than the v.a. and laboratory tests. so it seems to be local specialties but now as dave was mentioning we need to get a robust network where we can refer the most complicated procedures, cd sewerageries or neurosurgeries so that's a bit of the mix. >> so what you're seeing on the experienced side on our send that about 15% of the population is 40 miles in terms of who's utilizing this. about 50% are those near a v.a.

medical center and the v.a. 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 7. but at the same time, without action a whole program goes away. and that's what polly 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 the audience now. we have a we could if you could please identify yourself. >> hi, my name is regina leonard, a doctoral student from george mason in health policy and nursing administration. and i have a question -- well, a comment and a question. with veterans needing more access to care it would seem plausible the v.a. hospital would allowed a vanced practiced register nurse, also known as nps and clinical specialists to have full practice authority. hr-1247, the veterans access to quality care bill would allow this and help the v.a. hospital accomplish this goal. how do you foresee utilizing nps in the future? >> so that's a great question and also a very controversial question as you can imagine as v.a. is working on its nursing

handbook. we leverage a lot of nurse practitioners, physician assista assistants, provider extenders so i'm not exactly the right person to be able to address this specifically but what i will say in general is we do have veterans that live in every corner, as i mentioned, of the united states and as we were -- as a rand colleague was demonstrating, in some areas there are not physicians or there's a dearth of those providers so we might need to leverage more of our nurse practitioner colleagues and other providers to make sure we take care of veterans. >> can i make a comment to your question as well? . outside of any care that we provide for veterans, for us this is the small communities we ear in, nurse practitioners and physician assistants, a very important part of that provider network in some small communities so we use them very effectively. they provide great care in the 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 shows there's not a difference in the quality of care between those providers. [ applause ] [ laughter ] >> okay, question. >> i'm dr. caroline poplin, i'm a primary care physician. i have a question for the doctor, a very quick question for john. the question, i worked for the active duty military for 12 years, seven years at fort belvoir, five years at what was then bethesda naval hospital. the military all that time were working to make their electronic medical record into operable with the v.a. they spent millions 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 try 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 what you're -- the point that you're describing is an american medicine issue which is there's health care systems across the country, there's a market for electronic health records, it's competitive, everyone has different records so we have to think of it differently than what we've done before. we're doing a couple things at v.a. that are -- show a lot of promise. number one is leveraging community health exchanges. we are part of about 08 health

exchanges across the country, a lot are individual communities that get together, the hospital systems in that area saying we're going to share information, there's a standard template of what data they get so we share records with -- we have veterans that of more than half a million participating in these different exchanges. number two, knowing that not everyone is going to 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, d.o.d. 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 health care system and so with d.o.d. we have something called the joint legacy viewer where we're able to have a read-only view of the d.o.d. record. it is integrated. so it's not like we look at the d.o.d. record here, we look at

the v.a. record. when we look at the community viewer it's an integrated record and we have these all over the country and we're taking that knowledge and doing that and testing it out in a couple locations with community providers. we're 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 v.a. record and that way they can -- you know, as a practicing doctor if i wanted to look at the mri or the ekg i can look at it through this west-based portal so i'm envisioning more of those sort of cools, 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. >> and 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 v.a. is using telemedicine or other tools like home and community-based services to provide access to care for rural vets and those with mobility issues and how can congress help to encourage this? >> why don't i start? i would love for dave to also comment. v.a. is 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 ma we want to make sure we can provide access and reach in certain areas we may not be able to have a brick and mortar 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 maigt care, dermatologist, so we're kind of also looking at what other fields that

traditionally haven't even been done through a telt health venue can we do. so we're doing that, there are a couple things that could really help v.a. with being able to share information, especially with community providers, whether they're doing telehealth or not. and there's a couple statutes that prevent v.a. from sharing medical records. and these were developed decades ago and they're above and beyond the hipaa requirements, but v.a. is not allowed to share records if someone identifies as having hiv, sickle cell or mental health or substance abuse conditions. so you're taking a big chunk of our patient population that may have one of those conditions and in my mind 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 send it over to their doctor an the community. that has really limited our

ability to coordinate care, whether it's 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 provide higher quality care that's coordinated and it's outlined in our plan to consolidate care. so that's one thing 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 d.o.d. in colorado at the height of the wars, we actually placed in facilities in colorado springs nypd patients for mental health because the military hospital there did not have an inpatient unit and we forced rounds that were joint so we required sharing and sharing is important to make sure that the patient counter 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 exand from there that will put us behind the tip of the spear which is the v.a. but we will actual lly do telemental health. it will start with in the a particular market to help give them more supply, and 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 v.a. and i would 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 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 v.a. and death to have specialized in and make that available from a distance perspective with a coaching apparatus on the back end, that we designed in concert with v.a. and d.o.d. >> i agree with molly and dave that telemedicine and home-based health care is great force multiplier particularly in the area of mental health. i've seen many veterans who benefit from it and i know there were licensing issues that had to be worked out. somebody from san diego may want their same provider and may not mesh well with somebody in another area. i want to caution it's not a

panacea. the optimal form of health care is person to person in some instances. i'm always hearing from nurses who talk about an 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 you see in the person and i'm always happy to see my doctor once a year when i do my annual exams in person so there's 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 who need services. >> we have a question at the mike. >> hi. thank you for being here today. dr. taylor winkleman, senator m markey's office. it would seem to me that as scary as the 2017 deadline -- august 7 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 the challenges that we face. mr. gillums, i suspect you would recommend something to extend title 38 protection, but what would your asks be for improving this assuming that we could get a better more cohesive vision put together. >> one big area -- i should say a gap in the choice act -- and i think it was mentioned here, for those of us in specialized services it does no good to be 40 miles from a cboc, community-based outpatient clinic. but if you truly intend to open access to all veterans, that has to be looked at. so if i live two hours from a spine cord injury center and i can't get an appointment timely,

maybe there's a final cord injury expert in the private sector that can do a test or run tests that i need or take care of an acute issue and i'll 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 dcve or that would be one area where i would hope if we go down this road again someone takes a look at that. >> i really appreciate that question because we actually late 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 web site. 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'll just list a couple.

number one is the primary payer issue. in some circumstances our non-service connected veterans have to rely on their other health insurance. that means they have to pay co-pays to other health insurance, deductibles, premiums and no other program in v.a. works that way 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 they had to pay those specific portions. two, we need to be able to really work better with community partners, especially in rural areas, right now the choice law limits v.a. at medicare and so while medicare rates, the payment rate makes sense in some locales, it doesn't in others so we need to have some flexibility to partner with providers and pay them a higher rate because a lot of times we definitely do have issues in the payment area

sometimes it's not the slow, it's too low and so we have to get to flexibility and payments and move towards those value-based payments and i mentioned a couple of the 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 infrastructure, we've learned a lot, it these evolve, i don't think it should be scrapped and start from now because we'll go through the same exact growing pains we did two years ago. so it's how do we continue to take what's there and turn it into a program that makes sense for our veterans, for our community partners and for the v.a. >> i imagine some of our other panelists have ideas about what needs to happen with this program. >> i want to repeat what mr. gillum said. the issue around the 40 miles and the primary care facility as

an example is an issue we deal with all the time. a veteran will not qualify under the choice award because there may be a v.a. center within 40 miles but the v.a. center will not have a surgical suite, they may not have high-end diagnostic work so we will have a veteran three miles away from one of our facilities where we'll have an mri or 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 keep that veteran close to home. so that's an issue and there's very close too facilities to these veterans that meet the care of need that they have but they're not able to utilize it because of the 40-mile rule and all that's applied. >> just to comment on that piece because this is one of the things we have to be aware of what it could mean 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 v.a. have done those modelings. it would have a very large financial impact. apart from that, though, to sherman's point earlier, we have to be careful about referral patterns and in order to provide 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 bombs hard to actually gain competency and recruit doctors in those areas so i think it's definitely worthwhile looking at and figuring out how we can get flexibility for certain veterans that need to be seen because in some circumstances one mile is too far twoor day's wait is too long so we need some flexibility built into the system. but i do raise some concerns about completely being able to

open it up because what will that will do is defact the folks who are using it and want to use it because you may not be able to build out wrap around services if you don't have the specific volume or expertise to do that. >> so i would conquer with the notion that thinking about open -- completely open access is probably not the right place to end up. because we've invested in a lot of infrastructure and making that structure stronger and making sure that it's got sufficient supply to meet the need is going to be important. but for the last 15 years, we've deployed people from every zip code in this country and the mix of use of the garden reserve has been very different than at any other conflict we've ever been involved in and many of them want to go back home and they don't want to have to displace

where they are and they may want to take a year or two off and they have a right to do that and they have a benefit that they've earned so making sure they have access to care in a reasonable distance, i think we would all up here agree makes sense but it's thinking about how do we draw the parameters right and from a spend perspective, congress needs to decide how does it want to deal with the response that comes with the tail of conflict and there's a lot of money paid in travel and a lot of money that ends up being paid when someone doesn't get what they need on a tamely basis because when they're really sick it's more expensive so i would say for certain types of things you absolutely want to be in a v.a. facility. you absolutely want to be in a top-notch academic facility regardless of where you live in a state. then there's other things where you really could get the

orthopedic service across the state from where a v.a. facility is and i think you all will sort through those things and we look forward on our end doing whatever needs to be done to make sure we flex properly to make that work. >> let's pick up on what dave just said that, you know, in some ways there needs to be a bigger conversation about what is the obligation to veterans and if the decision is that we continue as it is and the v.a. has an annual budget that's submitted two years in advance every time there's an increase in demand beyond what was expected or projected, there are going to be access problems and they're going to have to be decisions to stay within those budgets so -- and this is going to be true for community care as well because the ability to constrain those costs, particularly if you increase eligibility, is going to be difficult so really thinking in the big picture of what is our responsibility to veterans? what is our commitment and how

are we going to pay for that? >> okay, we've had several questioners want to know how to make the -- how to get claims paid faster. what is the answer? [ laughter ] just a softball question. [ laughter ] >> i'll start and would love for others to comment. this is probably one of the things that i spend a big chunk of my day on, especially as a doctor, when one of our partners deliver care, they deserve to be paid on time and accurately. what we are realizing as we do more of these deep dives is there is a number of kind of root cause issues here that have to be addressed to make sure we're able to timely pay our providers. one gets back to the eligibility piece which is when we have six, seven, eight different programs all with different eligibility

criteria, if you don't match them up exactly right and you're providing care for a non-service connected condition in this case or a veteran that lives 38 miles not 40 miles then we don't have the authority as the department to cover the bill and that's really unfortunate because the criteria are so -- there's so many of them and they vary that many times a veteran receives care that is an authorizer that we don't have the ability to pay so that's one thing is how do we get to a simple set of eligibility criteria yah that's very clear to our patients and to our providers that there isn't any am bayh youty. in medicare it's simple -- you turn a certain sage, you have a card, you're good to go. or if you have a private health insurance plan they know what benefits are available. we need to get to that level of clarity and if we're going to continue of the seven, eight different programs operating

differently it will be hard for our patients and providers to know that. number two, we have to make some adjustments to the laws. many times today probably the biggest area where i get complaints about provider payments relates to e.r. care and e.r. care -- and we proposed a fix to this in our plan to consolidate care -- is very fragmented. in some circumstances v.a. is the primary payer, which is for service-connected patients, for service-connected condition. in other circumstances we're the payer of last resort for non-service connected care. and also by law and statute we pay 70% of the medicare rate. well, when we talk too old a lot of doctors and sit down with them and we're examining ars, we did pay -- and it's considered payment in full -- but they still carry a chunk of that on their accounts receivable and that's something we would not be able to pay until we get laws

changed and so that's where i see a lot of consternation around this unauthorized care where we have to figure out if they're service-connected or not and we are not allowed to pay the full medicare price by statute and so we propose a fix to this of making v.a. the primary pay sore we're table to pay the bill and really getting us more towards in line with what the rest of industry does. it does require some legal changes and some investment and some funds to do that. and thirdly if we're able to then get to good criteria, iron out some of the kinks in the e.r. system. that will then allow us to start to automate more and more and more and leverage community partners. it 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 e.r. care, to 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 a veteran have a -- was he seen for a knee injury and is that knee injury service connected? way too complicated, i don't want our team to continue doing that all the time. it takes a long time -- a time drag. we want to get to a system -- a set system where if a veteran goes into the community, the doctors there and the hospital systems know exactly what is offered and what they're able to deliver. the veteran knows if they have any obligations and we on the back end can automate it and pay it so this is a great opportunity for us for progress, however we need help, we cannot -- at v.a. we cannot meet the standard that we want to meet if we are just doing it by ourselves. we need some help from our legal and congressional colleagues. >> so as an entity that's now responsible for paying for 3.2 million appointments, i will tell you, we don't collectively

have this right yet. and if you go back to the start of tricare 20 years ago with the d.o.d., about three months in it became obvious that the d.o.d. had never paid its claims properly. and dr. yehia walked into a scenario, he didn't create it. and some of the history in this space that dates back a long time is that the v.a. was paying its claims market by market by market by market by market. that's not a very effective way to do it. it's hard to get to core competency. at the end of the day what they've done in choice is to consolidate what that looks like. that was a very needed change. so what they did is they took claims and aimed them in one direction on the government side. the second thing is when you're an institution, you have to file properly. when you're a provider you have to file properly. no one wants knob s to be in a

where claims get denied or are slow because at the end of the day we have to find another provider to send the next veteran. that's not in anybody's interest anywhere. so paying timely and accurately is in everyone's interest. but from a provider perspective, having done a lot of the work 20 years ago at the start of tricare to help 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 also have to 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 a different lane so now imagine being the billing office trying to figure out well, 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 and his team, myself, members of congress from that area and the hospitals in that area. it's an area where a lot of care moves downtown of all types because they have a community-based outpatient clinic and the rest of the work is done downtown. it's been that way for a long time. some of the hospitals of those four had a 50% denial rate on those claims. they did not know how to file accurately. within five weeks together we dropped it to 10%. that takes their historical pattern of payment and changes it dramatically. and so we all own a part of this responsibility. it starts with the provider filing accurately. then it goes to us making sure we have processes that work and that it's streamlined and consistent so you do it one way

and it's making sure it cycles back. from my perspective as an actor that spent time in the dote space back 20 years ago, the same issues existed then and they got fixed. and to those that are in the provider community that are leaning forward, thanks for doing that and thanks for hanging in there. i what i'm going to tell you from my perspective, what i've seen with my sleeves rolled is up that the v.a. team is right at my side and there's no separation with what we're trying to accomplish and the way this works is we pay the bill and then the v.a. pays us. so we all want it to work, right? and together i think we will be able to figure out what those pieces are, as dr. yehia said that needs to be changed but there's other pragmatic components that need to be changed as well in order to make this work right at the end of the day and we're picking a couple markets to test those together and we'll take what we learn out of those and apply

them to the rest of the enterprise. >> i would just expand on some of david's comments. i agree completely with the one pipeline. as a provider, we're used to dealing with very intricate payer rules, every payer is different, medicare is a great example. it's very tight around certain treatments that you provide a medicare recipient as to what the diagnosis has to be to get those paid but as providers, we know what those rules are, are there systems we can incorporate into our admitting processes? so we know when a medicare recipient comes in for a certain test exactly what that diagnosis has to be and can deal with it realtime. as you can imagine, the private payers have their own rules but they are consistent rules of that payer and we can develop systems and processes to deal with them so i think to the extee extent that's there's one pipeline, one set of rules,

areas the providers can develop their processes and systems around would be very beneficial. >> folks, we have time for one or two more questions as we are winding down. i would love to ask you to please fill out the blue evaluation form in your folders before you leaf us today. let's turn to now to a question at the mike. >> hello, i'm shannon firth. i wanted to ask you about the commission on care report that was put out a few months ago, i wanted to get your response to two of those recommendations, one was for an independent advisory board and one was to eliminate the time and distance requirements for the choice program. the first idea is obviously pretty controversial and possibly unconstitutional but i still wanted to see hypothetically what would be the impact of either of those two changes. dr. yehia and anyone else who

wants to comment. >> sure, i'll comment more on the latter. so the secretary and president kind of put out our response to the commission and in the president's response to the commission, they call out our plan to consolidate care as kind of an alternative approach to some of the recommendations in the commission. most of those recommendations were a little bit of mom and apple pie like we want to do those and you point out the ones that are most controversial. but we believe our plan that lays out getting all these different programs into one, coming up with an eligibility criteria that makes sense but also allows some flexibility so that when myself as a doctor, i'm seeing a patient in front of me, can make a decision about you would be better served at this institution, is important. getting to that single way of being able to do referrals, building that high network we're able to create partnerships that

makes sense for them and getting to timely payments wrapped around customer service. so all of that is laid out if our consolidation plan which is what the department and the administration is putting forward as an alternative to some of those specific recommendations. and in there it also lays out what we need to do that. what are the specific legislative changes that are required and what's the budget that's required to do that. and that's a good starting point of where we hope to get to. >> can i comment on the second recommendation? eliminating the time and distance requirements effectively opens up purchase care to all veterans enrolled in v.a. so looking at the numbers, there's 21 million veterans in the united states, nine million are enrolled in v.a., six million use v.a. health care in a given year. most veterans enrolled in v.a. health care have some other choice of health insurance, so i

have that medicare, private insurance through their employer or try care, other sources of health insurance and they choose whether to use v.a. health care or other insurance based on a number of factors, one of which is cost and access, things like that, so if you open up purchase care to the whole veteran population, what you're going to see is a giant increase in demand so some of those three million veterans enrolled in v.a. care and aren't using v.a. health care are going to start using v.a. health care because now they can go to their local doctor and v.a. will pay for it and they're probably not going to face a co-pay because it's through their v.a. benefit and they're not facing a co-pay. so the choice of seeing your same doctor, v.a. will pay for it, no co-pay, you go through your private insurance vladimir putin a co-pay and deductible is a no brainer and the number of people using v.a. health care will increase so that's one

thing to consider and the costs will be quite significant. the other thing to consider -- and this is the big-picture question of thinking about do we maintain our v.a. health care system as it is? do we transition to more of a private-sector model, is you can't have both with full open access to either. and the reason far is as you move -- as people choose to use private-sector v.a. care, fewer people will be using v.a. health care facilities and a lot of you are working on health care and you fully understand as volume decreases the quality of care decreases and there is a certain tipping point at which it is not sensible or reasonable to maintain those facilities and as v.a. facilities close, it furthers the move into the private sector and that decision from my perspective needs to be a thought out decision. it needs to be decided and not just something that happens as a death spiral of v.a. facilities

closing because of movement into the private sector. >> if i can follow up on what carrie is saying because you said that so eloquently. when folks sometimes think about, you know, quote/unquote privatizing the v.a. and giving everyone a card, as a clinician again what's missing there is care coordination and so when you think about medicare and the way that that program works, it for the most part is like a reimbursement system, you go out, you see -- you handle your own care and the government pays the bill. but what's missing from a clinical perspective, from a relationship perspective is how do you help folks navigate an american health care system and making sure their needs are met. i think the greater extent that there's just people doing it all on their own where it may work for a small segment of the population, for many folks it doesn't work.

so it's important to think about it from a clinical perspective which is from a veterancentric patient care approach do we want to have a coordinated system or do we want everyone to do it by themselves. >> okay, thank you. do you have a question? go ahead. we'll let you have the last question. >> okay, thank you. my question is about what's going on in technology space as far as companies like apple and other app development companies that are giving patients the opportunity top in control of their own medical data. so what i would like that know is is has the v.a. considered partnering with apple or other innovative technology companies in silicon valley that will allow veterans to have their own medical data with them so that when they go to visit providers they can have a dialogue based on the information they have. >> yes. in fact, we've been doing that for a while. who's heard of blue button?

blue button is exactly that. it's a very easy way to download an electronic version of your entire health record. the veteran can take it, do whatever they want with it, share it with their community providers if they choose and so we have an entire digital services team at v.a. that leverages folks from such as silicon valley that are thinking of creative ways we can partner and continue to exchange information so exactlily. >> and you said blue button? >> blue button. >> b-u-t-t-o-n? >> yes. >> and there's another service where you can get your medical records, talk to a doctor and get your medical records in pdf format and military records. so if you have to file a claim or advise somebody -- we have to advise somebody to file a claim for certain benefits, first thing we do is get them to sign

up for blue button so it works wonderfully. >> thanks. >> we have reached the end of our time so a few thank yous and a last plea to fill out your blue evaluation form, first i would like to thank the supporter for today's briefing, ascension health, and i would like to thank our panelists for an informed conversation and also thank you to all of you for being here today. thank you. [ applause ] >> and marilyn, thank you. >> thank you as well, marilyn. [ indistinct audio ] >> a look at the u.s. cap twrol

t -- capitol. among today's bills is one dealing with the export of commercial airplanes to iran. some news from the house where earlier today nancy pelosi announced her intention to seek another term as democratic leader. the california representative claims to have the sborlt of over two-thirds of her caucus. those elections will take place later this month. watch the house live on c-span. . in the senate, lawmakers are electing their party leadership for 115th congress. mitch mcconnell has been reelected majority leader and chuck schumer will take over for retiring harry reid to lead democrats. later the senate will work on a bill establishing revenue sharing for states involved in energy production. watch the senate live on c-span 2. and join us later today when john deutsche, the chairman of the secretary of energies advisory board and other nuclear physicists will testify on the future of nuclear power in the u.s. live coverage of that starts at

2:30 p.m. eastern here on c-span 3. this afternoon, cory booker will be interviewed by wade henderson, president and ceo on civil an human rights. you can see that live on 6 p.m. eastern here on c-span 3. tonight, hillary clinton in her first public appearance since losing last week's presidential election. she's being honored by the children's defense fund and that gets under way live at 8:00 eastern on our companion network, c-span 2. finally tonight, the national book awards are taking place in new york city hosted by comedian larry wilmore. our cameras are there. we'll show you the event sunday at 10:00 p.m. eastern on c-span 2's book tv. this weekend on american history tv on c-span 3, saturday night at 8:00 eastern on lectures in history. >> the only essential difference between a nazi mob hunting down

jews in central europe and an american mob burning black men at the stake in multiple sclerosis smst that one is encouraged by its national government and one is just tolerated by its national government. >> reporter: gettysburg college professor jill ogline titus on world war ii and its impact on civil rights. then at 10:00 on reel america, a 1968 film on the black panthers founded 58 years ago by huey newton and bobby seal. >> it's very apparent that the police are acting not for our security but for the security of the business owners in the community and also to see that the status quo is kept intact. >> sunday afternoon at 4:30 eastern, archaeologist dean snow on his findings while excavating the revolutionary war battlefield saratoga in new york and its spinspiration to his bo "1777, tipping point at saratoga." >> what was a little old lady doing throughout? she was at the time she died about five feet tall, at least 60 years old and she was a

battle casualty at saratoga. what is going on here? at 6:00 eastern on american artifacts -- >> the french method was they put you with the wings cut down. your second training flight, they give you more wing and a little bigger engine on the thing and you would hop up and down the field. when you were ready for the big day, you talk to your instructor who had been talking to you on the ground all the time, he'd pat you on the shoulder and go bon chance and you'd get in an airplane and make your first solo flight. >> pilot robert "boom" powell takes us on a tour of the military aviation museum in virginia, home to one of the largest collections of world war i and world war ii aircraft to learn about advances in aviation technology during those wars. for coour complete american history tv schedule, go to cspan.org. the nations historically black colleges and universities held their national conversation in arlington, virginia,

recently. this next panel discussion focuses on gun violence, campus safety and improving relations between law enforcement and students. you'll hear from officials from the fbi, the education department office of civil rights, the national institute of justice and the hbcu law enforcement executives association. this is just shy of an hour. pl. please welcome our panelists, calvin hognet, special advisor for campus public safety, department of justice on detail to the fbi. [ applause ] please welcome dr. nancy rodriguez, director of the

national institute of justice [ applause ] please welcome curtis johnson, president of the hbcu law enforcement executives and administrators. [ applause ] please welcome kat rip catherin, assistant secretary of civil rights u.s. department of education. [ applause ] and please welcome our facilitator, dr. michael sorrel, president of paul quinn college. [ cheers and applause ] >> i think our panelists can have a seat. i was tempted to have them do this whole thing standing up but that seems a little harsh. so we have a tradition at paul

quinn college where i greet everyone by saying good morning quinnites. so we'll adopt -- i realize not all of you are quinnites, but we are one big happy family this morning so we're just going to adopt it. how about this? good morning, family? >> all right! >> good morning. >> let's do it better because i didn't hear the people in the back. good morning family. >> good morning. >> was the attorney general amazing? >>. [ cheers and applause ] i hadn't had the privilege of listening to her in person before. i knew she was a sister of incredible abilities but as she sat and went through her remarks, i realized that she took every single point that i wanted to make -- [ laughter ] -- and said it ten times better than i could have said it. so i'm just going to tip my hat

and just be amazed at her eloquence and her passion because i think that's what we need in difficult times like these. so i am particularly proud to be here this morning because i am part of a group of hbcu presidents that are working on the issue of gun violence in our communities. rewrote a l we wrote a letter to america on our views of what was going on and about addressing the pain our students felt because the reality of it is the folks that are being traumatized, they're our students. and if they're not our students, our students know these men and women and if our students don't know these men and women some of them, they come from the same communities. they have parents, they have brothers and sisters and uncles and cousins who have been

imprisoned. we live with the reality of the prison system in our schools everyday. and to ignore that that is the case would just be unrealistic so we are thrilled to have this discussion because this is a timely discussion. as the attorney general said, this is the issue of our day and i am proud of our students. in fact, are the hbcu all-stars here or are they still at the white house? they're on their way? well, please listen, when they get here, my hbcu all-stars, destiny modesty, please make sure you let her know that we tried to recognize them because i don't want them protesting me. is [ laughter ] now, i'm going to stop our chitchat and get won the business of this morning. our first speaker is catherine lehman and i'm going to allow

each of the speakers to introduce themselves and so if you would do so, please just when you get done just pass the mike along or activate the mike along and we will start with ms. lehman. >> great, thank you so much. it's such a pleasure for me -- can you hear me mow? it's such a pleasure for me to get to be with all of you and with my friends and colleagues on this panel. i am catherine lehman, i'm assistant secretary for civil rights at the department of education which means that i enforce federal civil rights laws in schools both in institutions of higher education and in our p-12 system. our three major areas we focus on are race, sex and disability and we are actively engaged in the work of making sure all of our students live the promise that the attorney general talked about, experience in school, respect for their person,

opportunity to learn and the ability and the platform to realize their dreams. so it is such a pleasure to be with all of you who are doing that work everyday who are in partnership with us to make sure our students have that opportunity and i'm looking forward to this conversation. >> thank you. curtis? >> and good morning everybody. curtis johnson, current president for hbcu leea and i represent all of the chiefs and security directors of all of our institutions nationwide. it is a great honor and a privilege for me to sit before this body as we've done some good work over the last couple of years. i'm thrilled with my colleagues that i harass on a regular basis on behalf of our students to have this discussion. i think we've kind of started off the ball rolling a bit in a couple areas that the attorney general kind of talked about briefly. we brought students and chiefs to howard university, 20 chiefs

and 20 students to howard university in august to have a conversation about bridging the gap between law enforcement and campus communities. it was a very spirited conversation but we wanted to make sure it was an honest conversation so we started the day before with a team-building process to allow everyone to speak freely. we chose specifically not to include the press just to make sure folks can talk from the heart because we wanted to get to the root cause of issues at hand. that white paper was completed and released yesterday and i forwarded it to the chiefs first for them to have an opportunity to take a look at it and also to the students so they would also have an opportunity to look at it. it's available now as we speak on the national centers for campus public safety web site so that everyone in the nation can have an opportunity to see it. now, what where do we go from doing that piece of it? we're pushing that agenda forward to the nation because we

want it to be that organization that only to have a conversation but basically lead the nation in prying to put that out as far as direction to heal our communities throughout the country. so we're taking a few steps to try to get us on the right path but i wanted the hbcu family community to be that catalyst to get that started. so i'm happy to be here to have this conversation today and i'll pass it to miss nancy. >> good morning, everyone. i'm nancy rod guess,riguez. it's so wonderful to get a chance to hear my boss, the attorney general of the united states. as director of the science agency we are responsible for supporting and investing in high quality rigorous and research that really is geared to prevent crime and really advance our criminal justice system so we support area for an array of important issues all the way from violence prevention, school

safety, human trafficking, radicalization to violent extremism, forensic science, drugs and crime, gun violence, and every violence and every component within the criminal justice system, including, of course, policing. we are certainly very committed to broadening the reach of science. since my arrival at nij, we created different mechanisms to support young scholars, to support early career investigators as well as graduate students who i have to say, are, i think, more motivated, more skilled than ever before. i think getting them exposed to the important work that we, as scientists, can do to advance our criminal justice system is so important. we support scholars in an array of disciplines from biology,

chemistry, engineering, sociology, psychology and i hope that our discussion is one that not only exposes you to the various opportunities for faculty and students, but also one that has me walking away with how to strengthen, really, our relationship with another minority serving institution because i see you as partners in this effort. i can certainly and hope to be able to talk to you about what we are doing to support research in the area of policing to strengthen the relationship with communities and also what we are doing around school safety. we have been very fortunate that congress has authorized us significant amount of resources to invest in school violence and school safety. thank you. >> good morning. again, my name is calvin. i'm the fbi special adviser for

campus public safety. it's a great day. i'm glad everyone was able to make it here today. let me say this one point. i have been at the department of justice for 18 years. this morning, the attorney general of the united states said my name for the first time in 18 years. [ applause ] i immediately texted my wife. as the special adviser for campus public safety, my main job on a regular basis, a daily basis, not just for hcbu but all campuses throughout the country is to level the playing field. the playing field on hbos, not hbos, hbcus exist on a lot of levels on campus public safety. most of your campuses have sworn personnel, nonsworn personnel, contract personnel and also seek help from municipal agencies that surround you. what really happens most of the time, though, is a lot of

information is lacking in a lot of partnerships are not present. what i do on a regular basis is promote partnerships between campuses and local law enforcement and throughout campus law enforcement throughout the country and get them to work with 56 field offices around the country. on two different things, mainly. we tried our best to get them to work on building partnerships, take advantage of the fbi's reactive resources. 56 field offices, thousands of agents, we have a lot of resources to come to a campus when an issue or challenge happens there, whether it's a chemical spill or active shooter situation. the other part that we have is what i call proactive resources, which is we have training that we come to your campus and talk to your campus personnel about things such as not only active shooter training, but cyber threats, chemicals on campuses and things like that. i'm open to talking about all those different things as we go throughout this conversation here.

i would be behooved if i didn't say what i thought were the biggest threats on our campuses. most of your campuses are really blessed to be in the communities that you are in, as the attorney general talks about hbcus and communities, you know your university, most likely, was built out of the community that is around it. because of that, you exist in that community and you have a lot of violence and other things that is exist outside your walls. they may not fall into your definitions, but exist as students become victims of that. we work on behalf of students to get that kind of information out to you. our biggest -- your biggest threat on the campus these days are the threat of violence extremism. the people in this world and this land that want to take advantage of the attitude and tone going on in this country now, and our students caught up in the black lives matter and

other issues going on. but also leaves their mind open and susceptible to people who come in and just bring up other things to them that they may not be conducive to a learning environment. the other thing is cyber threats is the next biggest thing that is most campuses are victims of. those at private universities and state universities, those who see the open environment as a way to move into larger computer systems through your system, if you don't have an active firewall and those sort of things. they are using those systems to enter into state systems and federal systems. we are open to talking about those things, too. we have resources in our field offices that work through all those things. thank you. >> all right. well, we are now going to turn to our first question and kathryn, it's for you. we know that students, regardless of their race, their

origin, color, gender, all deserve a safe environment for their education. maybe if you can talk a little about the work you are doing around campus climate and how that factors into what we are seeing at hbcu. >> great, i would like to talk about stories in each major area. i will spend the most time on sexual violence because that's been a topic that is very much in the news, and i think it's very important for us to make sure we are actually living our civil rights promise in campuses on that topic. i do want to touch on race discrimination and disability discrimination because those issues are less in the news and very present still for students in school. i'll start with a story outside the hcbu context. resolution agreement with an alabama college that we entered into two years ago. i say that to emphasize how recent the harm to the student is.

a black student, who is an athlete happened to be sitting at the back of the bus and they were planning to go to an event that had been canceled. she asked her coach what they would do next. the coach told her to keep her black rear end, that was not his word, but that's what i will use here, her black rear end on the back of the bus rosa parks. and that's not all that she experienced at her school. she had her peers say to her that she shouldn't drive at night because she couldn't be seen, ask her to smile so she could be seen, call her a black girl, over and over and over. a hostile environment that her leaders on her campus perpetuated, her peers inflicted on her and her campus didn't take steps to address for her. they now have, happily. they have paid for counseling for her. they are subject to ongoing federal oversight. they have changed their practices. this is a young woman who made it to college. this is a young woman who is doing the things we tell our

kids they need to do. and then when she got there, she was made to feel unwelcome, made to feel like she can't succeed. that's unacceptable in our society, period. another story, from an hbcu, sorry to say. a young man with cerebral palsy who applied to college and was accepted. he came a few days before college with his social workers to say what he would need. the school saw he had cerebral palsy and revoked his admission. thank you for your shock. and revoked his admission. they revoked his admission. they reported to us. we thought you must be mistaken. when we called the college, they doubled dead and said we usually take a look at the individualized education plan they have in high school. if we think we can't support the student, we don't admit the student. wow! thank you. so unlawful. so that young man has been admitted to the college, he's doing fine, he's thriving. they have agreed to submit to my

office for three years every student they reject so we can evaluate whether they should have been rejected or should be admitted to the school. they have dramatically changed their practice. this is a place that should be welcoming for all students whoever there are and prepared to nurture and support them and profoundly missed our civil rights protections for students. then i want to turn to sexual violence. that has been, as i mentioned, in the news a lot. i need you to know that the facts that we see in our investigations are truly appalling. and they -- they range from a whole variety of the kinds of ways sexual violence can touch our young people's lives. because we are talking here about the relationship to law enforcement, i want to tell you one particular very recent resolution agreement with a campus in the university of maryland system from this summer in which a young woman reported she had been raped by a campus security officer in a

campus security vehicle. the school didn't investigate. they sent the issue to the criminal justice system, which is appropriate. that officer entered a plea agreement that required that officer to no longer be a campus security officer, which is good news. there was sufficient evidence his behavior was not an outlier. his plea agreement also required him to report on other incidents from other officers at that campus. the title ix coordinator did not investigate at that school. she didn't think there was evidence any other student was unsafe. she received the report from the county police investigating another officer. she never opened that report. she did not look at it. that tells you that we need to change our practices. i am very grateful the criminal justice system operated as it should have for the officer. i am deeply distressed the students at that school didn't receive the support they needed

from their school to make sure they would be safe and that no other student would suffer what the young woman who reported had suffered at the school. i say that to you to say, please, make sure you operate a campus that communicates to your student that every student is valued. you expect every student you admit to succeed and that you will be there to make sure all your students can enjoy the educational opportunity that our nation's laws promise to them. i'll stop there. [ applause ] >> catherine, i just want to follow up on something you said. one of the things that we experience is our students come to us the products of dysfunctional environments. one of the things we discovered on our campus was a tremendous amount of undiagnosed mental illness. right now, don't act like we don't all have undiagnosed

mental illness on our campus. the reality is, we don't talk about it. it's the dirty little secret in the back room. uncle so and so is just a little off. he's not off. right? there are issues there. how would you recommend that the institutions begin to address that the students are coming to them, the products of dysfunctional behavior that is a social but was normalized in their living context. you literally have to teach them a new way of operating. are there any resources that the department offers or any suggestions that you might have? because i have spoken to enough of my colleagues to know this isn't just an isolated incident. >> yeah, i think there are a couple levels to that question. how do we serve the student himself or herself who has the

undiagnosed mental illness and who needs to be supported. there our legal requirements are, if you have reason to know that a student needs accommodation on your campus, you need to evaluate and provide it. so where there is a student who seems a little off or who is indicating a need for help, you need to be sure that that student has access to information about how to ask for it, who to go to to seek the help and where your administrators and faculty have reason to know that they are able to reach out and offer resources to that student as well. so there is the how do we serve the student who is effectively asking for help. then there is what do we do on campuses and assimilate the students who come to us from their home lives, from their k-12 experiences that well precede their time on campus.

the reality is that racially hostile environments don't begin at 18. sexually violent environments don't begin at 18. these are kinds of experiences that students live before coming and sometimes experience once they get there. we need to make sure that we are communicating to our students at day one, before they come and every day when they are at school the environment we want them to thrive in at the school. so we encourage a statement of values. we encourage active communication about who you are and what's acceptable on your campuses and active encouragement of sharing thriving differences of viewpoints so people can express their ideas, share thoughts and learn in the campus about how to interact with others in a respectful way, in a way that is appropriate on that campus. we in the department of education recently released a set of tool kit and a set of guidance for k-12 schools about

sexual violence and about ways to ensure our students are learning before they get to college, appropriate ways to interact with each other and appropriate ways to be a good bystander and stand up for students who need it and ways for schools to focus on trauma informed learning to respond to the whole person who recollects students are as they get there. we are trying to address the issue before your students come to you and we also strongly encourage you to recognize you will have an influx of new students every year. you will have a changed campus climate every year. you need to be, every year, throughout the year, responsive to who you have on your campuses and how to make sure those students can succeed. >> thank you. i would like to add that it would be helpful from the department's perspective if there were some resources that could help the institutions engage in more preventive measures or in-depth opportunities for training for the students on the way in that would allow us to be more successful. we appreciate all the support

you guys give in that area. all right. we'll let you off the hot seat now. curtis? >> yes, sir. >> you are the president, as you stated, of hbculea. you have a tough job, a very, very tough job. i know that you are working across the institutions to do this, but maybe you can share with us some of the trends that you are seeing in terms of community policing externally and community policing internally that really help to alleviate some of the issues that we have seen outside of our campuses. >> fair question. so over the last couple years, i'll start with externally first. >> thank you. >> community relations is a huge deal for us at this particular juncture. if we started a few years back, i would say that community

issues was not at the forefront. the conversations we would have, marijuana was. as the laws across the country changed where you have states where students come to campuses from states that were -- where it was legal, they find themselves in a trick bag for the most part. they are thinking what i did at home, i can do here. subsequently, that involves them being charged with misdemeanor charges. if i have a student spending $160,000 a year or for a four-year degree and goes to get a job, they can't because they have a misdemeanor marijuana charge on their record. a lot of chiefs around the country where i work, arkansas baptist college, have a program in place where i work with the city and local judges and district judges to seal in clear records once students have, one, paid their debt to society. then, two, we need the folks to work and be able to be employable to get jobs.

that's part of an initiative from a community standpoint as far as outreach. the thing you are seeing before we started the talk about relationships in communities, with these guns on campus and gun violence on campus, i get a call every time we have an incident, thank you very much for the phone calls. curtis, what happened on this particular campus? i can tell you at a time over the last five years or so where you would see incidents where students would have bb guns on campus, or something of that nature. over the last five years i can tell you now where we may have found one real gun, i will find ten guns a year. i'm not only seeing guns, i'm seeing sawed-off shotguns, ak-47s. some campuses where we have campus safety personnel, you have unarmed

security officer on the campus where i have ak-47s being used. they are an extreme disadvantage it causes a problem for them and the community. the risk factor goes up. so the deal now is, how do we mitigate those issues not only from an internal perspective, but external perspective. we have taken a forward approach, if you will, approximately two years ago. i started to reach out to christiatharine and her team. i ask her as it relates to issues pertaining to sexual assault. it's a mixed bag when we look at a student who may have been accused of sexual assault. one, they are going to be adjudicated through student affairs on your campus. they are going to go through a law enforcement process as well. then you have a title ix investigation that is going to occur. the thing that is on the backside of it from a point of perspective is all three of those investigations can be discoverable and brought to trial to use against a

perpetrator or alleged perpetrator. now, how does due process work into that process, especially if it's a case that's unfounded. now you have a slanderous opportunity for somebody that may not have done it. we have those cases and god forbid, very sensitive to the issues where we have a sexual assault and we have to move forward. what happens when a victim who was not sexual assault screams rape? how does that affect a student in his career as he or she moves forward? we have it with different genders. we have to be cautious with that. we're moving forward with those issues. two years ago, we started with a focus group discussion in atlanta with the national center for campus public safety that centered around bringing campus safety chiefs to the table to start having these conversations. from that particular movement, along with some of the other things from community policing standpoint, we moved into vermont area, i want to say,

doing a legal issues conference, 2015, with national centers to discuss this issue we're dealing with with national policing. those are some of the things we have to get better at dealing with. the campuses have to get better from the perspective of what do we need to ensure our campuses are safe? now, let's be real here. we are a call center for most campuses when you talk about police departments and security departments. we are not a profit generating area. i can guarantee you the first time you have a shooting on your campus and your enrollment dips 200 students within the first 48 hours, you understand we need to invest in our campus safety process. when you have to field those phone calls from parents and i can tell you, september 27, 2012, when i lost someone to 2012, when i lost someone to