Relates to understanding a veteran and evidence training that va and dod have specialized in, and actually make that available from a distance perspective with a coaching apparatus on the back end that we designed in concert with va and dod and that information will be available free of charge to providers all over this country that want to step forward and be helpful. I agree that telemedicine and homebased health care is great for small supplier, it i cannily the area of mental health. Ive seen many veterans who have troubles who benefit from it, and there are issues that have ton worked out and somebody from san diego might want their same provider and not mesh well in another area. I want to caution, its not a panacea. I think the optimum health care is person to person. In so many instances, hearing nurses talk about, for example, decubitus ulcer. You can see it on the screen, but its not the same as appreciating how bad it is when youre there and seeing it in person and happy to see my doctor once a year when i do my annual exams in person. Theres something that doesnt want to loose, but dont want to see it as end allbe all care, but for opening care to veterans who need, you know, services. Great, we have a question at the mic . Hi, thank you all for being here today, dr. Taylor winkleman. It would seem as scary as the 2017 deadline, august 7th deadline is, it provides us with an opportunity to introduce changes to the program and as a veteran who remembers what it was like living 98 miles away from a facility before veterans choice came in, i can certainly related to the benefits and challenges that we face. And mr. Gillums i recommend you would extend something to extend title 38. But what would your ask be for improving this ap better more cohesive vision put together. But. We have to actually have to have changes. This program as was describing came very rapidly and was in it implemented rapidly with congress could change the law for times already which is great and we have other ideas to let the programs work better bed number one is primarycare issue and in some circumstances we have to rely on other Health Insurance so what does that mean . Were have to pay the coach pay and deductibles and premiums and no other Program Works that way. So it is exposing them to some financial conflict they never had before and a lot of them more upset about that not knowing they have to pay the specific portion. Number two we need to be able to work better with Community Partners especially in the rural areas. Right now the choice law limits the v. A. That medicare so now that makes sense to some locales but not others so we have to pass that flexibility to partner with providers at a higher rate because a lot of times but definitely have issues sometimes it isnt that is the flow but it is too low without flexibility of pavement and then i mention the other things to coordinate care better to share information that we have to leave of the program we have invested a lot of infrastructure and we have learned lot. Behalf to revolve it should not be completely scrapped as it will go through the same growing pains of a few years ago. But it is how we continue to take what is there for what makes sense for our veterans and Community Partners. I imagine some other panelist imagine what needs to happen with the program put. The issue of the primarycare facility that they will not qualify if there was not to the v. A. Center within 40 miles. With a veteran that is 3 miles away from the facilities to work through those issues it is those negotiations with the veterans of ministrations but that has been issued and that there is close facilities with that care of need but they cannot utilize just to comment on that piece, it is one of the things we have to be aware of. Talk about 40 miles from the primarycare doctor or 40 miles from others and a lot of people look at that model definitely would have a very large financial impact. Apart from that and with that referral patterns with the Service Connected to veterans if we cannot provide Wraparound Services because a lot of those are deferred samara else outside the system then becomes hard to gain competency to recruit doctors in the area. So figuring out flexibility for those veterans that need to be seen. Sometimes it is too long but i do raise some concerns about completely because what that will do is contract for those that want to use it because you must not be able to build up the Wraparound Service if you dont have that volume more expertise to do that. I concur so open access is not the right place to open up investing a lot of infrastructure and to make that stronger to make sure it has sufficient supply is important but for the last 15 years we employ people from every set coded this country and has spent very different from many of their conflict. And they dont have to displace where they are they may take a year or two off the have a right to do that with the benefit they have earned. And we all agree that it makes sense but how do we draw the parameters . Said from that Perspective Congress needs to decide how does it want to deal with the responsibility and there is a lot of money that is paid in travel and the lot of money paid when someone doesnt get what they need of a timely basis. Because when they are really sick is more expensive. For those things you want to be and the v8 facility absolutely a topnotch academic is a witty could regard this of where you live in the state that theyre great could get the Orthopedic Service across the state and i think you will sort through those. And when reflects properly to make that work. And some ways there is the bigger conversation about what is the obligation and if the decision is and has an annual budget every time there is an increase of demand beyond what was expected rejected there will be access problems and this will be true for Community Care as well. Particularly if you increase the eligibility. So in the Bigger Picture what is our responsibility to veterans or our commitment and how to be paid for that . We have had several questioners want to know how to get claims paid faster . What is the answer . This is one of the things that i spend a big chunk of my day on one of the partners delivers care and what we are realizing there is the number of the root cause issues to major to pay providers. One gives back to the eligibility peace six source seven or eight different programs with criteria that if you dont match the but exactly right and you are providing care for a veteran that lurk. 40 miles then we dont have the authority and that is unfortunate because uh criteria is so many of them that a veteran receives care that we dont have the ability. So how do we get to that Eligibility Criteria that is clear for the patients and providers that there isnt any ambiguity . Medicare is pretty simple. Uturn a certain age you have a card and you are good to go. And to get to that love all of clarity it will be hard for providers to know that. To make adjustments to the allies the biggest area right get complaints about provider payments relates to the emergency room care. Er care is a plan to consolidate is very fragmented. In some circumstances it is the primary pair of those conditions and in other circumstances it is hell last resort. By a lot and statute we pay 70 percent of the medicare rate fell with doctors with the er it is considered payment in full but they have to carry a chunk of that of their accounts receivable and then they cannot pay us until we get the law changed. That is around the unauthorized care we have to figure out that the Services Connected or not. So we could pay the bill to get this more in line with a progressive industry does. Does require some investment and if we can get the good criteria in the king said of the system and then we can leverage the Community Partners. When you actually go to the medical records and then the emergency room you cannot do that by the computer. And with that knee injury service. Way to complicated it takes a long time. To get to a system where to the kennedy adopters to know what they are able to deliver. End however we need help in we cannot meet the standard that we want to meet from the legal and congressional colleagues. Now responsible for paying 322 million appointments i will tell you what we dont collect. If you go back to their try care 20 years ago about three months in it was obvious it never paid claims properly. Now walking into a scenario he did not create. Of that dates back the long time that the v. A. Was paying claims by market by market by market. That is not a very effective way to do with. It is hard to get to core competency. And now to consolidate what that looks like was a very needed change. En to have that one direction on the government side. In the institution and to file properly. Did to be in a place where the claims are denied. And then to send the next that is not in anybodys interest anywhere. And with a provider perspective at us start and then get a ride across the system to make it the fastest in the most accurate from those types of programs , you also have to pay one way. Right now those from the community they pay one way and file one way if it is through choice it goes down the different ways so of mansion trying to figure out how does this work as a consolidated pipe. We had a project in arlington and texas the members of congress from the area because to have a communitybased outpatient clinic. The son of the hospitals have a 50 denial rate. They did not know how to file accurately. Within five weeks together we drop dead at 10 . That makes their historical pattern of pavement changes dramatically. It is part of the responsibility starting with the provider fighting accurately than it does to us to make sure reprocesses the work and then to do inconsistently and that it cycles back. As an actor thats spent time 20 years ago and those in the Provider Community so from my perspective and then they are riding my side and there is no separation was what they try to accomplish. And then the va pays as. And then to figure out what those pieces are that needs to be changed but there is another pragmatic component to get this work right at the end of the day. We will test that then take what we learned to apply to the rest of the enterprise. I would expand on the comments as a provider leered used with the intricate rules medicare is the great example very tight around the medicare recipients but as providers we know what those rules are to incorporate into those processes we know what a medicare recipient comes in for a test what the diagnosis has to be if you can imagine the fear of had their own rules we could develop the systems and process. One pipeline nor one set of rules. And that is very beneficial. One or two more questions. Please fill up the blue evaluation for before you leave us today. The commission on care reports. With the Advisory Board and one is to eliminate the requirements that are possibly in constitutional but hypothetically what would bidi impact of either of those changes. Double comment on the of latter. And with the response and to those recommendations. Just like mom and apple pie those that our most controversial. That people leave and then to, but that Eligibility Criteria when myself as a doctor but getting to that same goal way to do referrals with the hide networks to create a partnership of that utilization and an that wrapped around Customer Service says it was laid out in the consolidation plan and also the way we need to do that. The specific legislative changes and also the budget. And that is a point we hope to get to. To all those veterans looking at the numbers 9 million are enrolled in a v. A. 6 million use v. A. Health care. Most have other waitresses medicare or private insurance through blair and they choose whether to use v. A. Or other sources based on a number of factors that is cause and access. If you opened up what you will see is a gigantic increase the demand. And then the va will pay for it and because the v. A. Benefits dont have the copay. And go through your private insurance or deductibles and and just uh number that is one thing to consider. The other thing to consider is do we maintain uh Va Health Care system are transition to a private sector model . You cannot have both with open access. The reason is that People Choose to use private sector v. A. Care. And you felicia understand the quality of care decreases there is the Tipping Point and is not reasonable and as they close and from my perspective needs to be thought out it isnt just uh death spiral. Is moving into the private sector. Said nikes said that so eloquently. But as a clinician what is missing is coordinations was the thinking about the way the Program Works it is the reimbursement system you handle your own care and the government pays the bill but what went missing from my relationship perspective is how do helpful the american Health Care System to make sure their needs are met . The greatest extent that people do it on their own while there is a small segment of the population for many it doesnt work. And if you look at the critical perspective, do we want to have a coordinated system floor by themselves . You can have the last question. My eighth question is what is going on in technology those seven giving patients the opportunity so has it considered partnering with apple or other Technology Companies to have their own medical data they can have a dialogue greg. We have spent doing that for a while. Is the very easy way to download the version of your Health Record to share with their Community Providers so we have an entire Digital Services team to leverage that are thinking of creative ways to exchange information. I was pleasantly surprised. And with your medical records so if you follow a claim for certain benefits benefits, it works wonderfully. We have reached a the end of our time. Please fill out your evaluation form. Thanks to our supporters and to our panelists for informed conversation and to all of you. [applause] [inaudible conversations] things welcome perfectly, but the outcome just to be clear, even though things woke zero well, your point is there is an no intentional effort to alter the outcome of the election. It is the inevitable results of america being america on election day. You have been watching elections for a while and you are one of the countrys experts picked is that surprise you that things go awry on election day, particularly president ial elections . It doesnt surprise me because and there are a variety of reasons why things go wrong, so on the president s we went around and held meetings and public groups to find out why lines form and we talked to Election Administrators at this date local level, Stakeholder Group and the voters themselves and one of the things we found was that every four years we pay a lot of attention to elections and its usually as mentioned earlier, in the month or so before the president ial election , maybe in the primaries if there interesting this years been a roller coaster, but in the off cycle years when they go to their legislatures trying to get legislation for reform for improvements, for resources, for funding they dont have the attention they should get and many of those reforms are known and tried and true around the country and they are in the president ial commission on Election Administration on the american voting experience, so there are set reforms we know can improve the voting xrays in the united states. Many states have picked up some of those reforms and recommendations and will be trying them out. This will be the first president ial election. Theyve implemented them in the last clear since the report and thats important to know that its not for lack of trying. In many cases and if you look at the National Conference of state legislators, they keep track of whats trending, of reforms and elections are being introduced and passed, so we have more states with online Voter Registration. We know it can improve the voter rolls and we have more and more states joining crosscheck programs and we know the efficiencies there could you stop there and back as. Not everyone has followed these reforms are at the commissions report. I think its well written and not can you just push a little bit . Certainly. We were passed by executive order to look at 10 different areas of Election Administration. Everything from Voter Registration, providing language assistance, military and overseas voters, voting technology, you name it. Its was a buffet of election issues, so we came up with a myriad of recommendations, bipartisan and unanimous by the commission and the commission cochaired by bob bauer whose president obamas former general counsel and then ginsburg who was governor of romneys attorney. So, it was unanimous and bipartisan and we came up with reforms like Bipartisan Legislation being something we should do to modernize our registration process, so if you want the foundation of your democracy to be accurate at the polls on election day, lets really look at how voters are registering, when they are registering, when they are keeping their information current because the majority of voters believe when they change their address with the department of Motor Vehicles it changes their registration. States have different interpretation of the National Voter registration act and whether or not thats an automatic often or opt out, but states are revisiting some of the ways theyre keeping their Voter Registration accurate.