Anya Rader Wallack, PhD is the senior vice president for strategic communications for the University of Vermont Health Network (UVMHN), and the new board chair for OneCare Vermont. Prior to joining UVMHN, Wallack served in Rhode Island as the director of the state’s health insurance exchange, Medicaid Director and acting secretary of Health and Human Services. In Vermont, she served as the first chair of the Green Mountain Care Board, special assistant for health policy to Governor Shumlin, and deputy chief of staff and special assistant for health policy to Governor Dean. Immediately prior to joining the network, Wallack was a professor in Brown University’s School of Public Health.
We sat down with Wallack and asked her some questions to get to know her better and hear her perspective on what’s next for health care reform in Vermont.
Tell us your story—where it all began and how it all led to your involvement in health care reform in Vermont.
I was born and raised in Vermont and went to UVM to study political science. Right after I got out of college, I went to work in the Vermont legislature. A couple of years into that, Governor Snelling passed away, Howard Dean became governor overnight, and he asked me to work for him as one of his policy analysts. Quickly, health care policy became such an all-consuming issue for the Dean administration that I was focused solely on that and was elevated to the position of Special Assistant for Health Care Reform.
After a couple of years doing that, I left state government and eventually ended up running the Vermont Program for Quality in Health Care. I think it was at that point that I decided that I really like health policy and I settled into being an expert of sorts. Eventually I decided to go to grad school and get a PhD, thinking that I would like to do more academic and less political work. Somehow the academic part never really stuck, maybe because in my heart I am a pretty concrete, practical person.
Over my career, I’ve gone in and out of various roles, but I always come back to positions where my job is to craft health policy solutions, given the avenues that are available to us and, probably most important, to translate this complex stuff to key audiences. That has become my niche. I’ve done various jobs over the years—running state agencies in Rhode Island, coming back and working for Peter Shumlin, and so forth—but I’d say that’s the crux of it: tackling huge, intractable health policy problems and explaining those problems and their potential solutions to the public and other critical constituencies.
How would you describe the state of the American healthcare system? And where do you see the greatest opportunities to transform the system here in Vermont?
The state of American health care system is that it can provide amazing care and results, but it is horribly complex and expensive and can be very frustrating, both from the inside looking out and the outside looking in. I think you’d be hard pressed to find many constituencies who say, ‘yay, this is great!’ because even if you’re working in health care, you can see all sorts of opportunities for simplification and improvement. To outsiders, I think it remains opaque, expensive, and disorganized and most people don’t understand why.
The greatest opportunities in Vermont are the same as everywhere – better organize the “system” so that it actually is a system, and change the financial incentives so that everyone is rewarded for improving outcomes like patient experience and health. What is unique about Vermont is that we have health care providers who are deeply committed to improving the health care system, we have OneCare as an organizing force, we have state laws that say we must improve, we have a regulatory body (the Green Mountain Care Board) whose job it is to carry out those laws, and we have a one-of-a-kind arrangement with the federal government under the all-payer model that supports these efforts.
What did we learn from the attempt to establish a single-payer system in Vermont and how does the all-payer model and the work of the OneCare accountable care organization (ACO) relate to the goals of a single-payer system?
Ultimately, we learned that it is important to engage in payment reform to move away from the fee-for-service model, and that we need to better organize health care delivery, whether we’re under the current financing system or something very different. What’s heartening to me is that we’ve stuck with those important goals and gained some critical experience around value-based payment and population health management over the past ten years. And payers and regulators still see the value in this. That to me is really important, no matter how we finance the system.
What excites you about the work OneCare is doing to bring a more affordable, trusted, and equitable health care experience to Vermonters?
OneCare has done a really good job of creating a network of health care providers who didn’t previously have a relationship with each other to enter into value-based contracting and population health management—providers who probably didn’t have much capability to do that on their own. I’m excited to take this to the next level and assist health care providers in moving to the next plane, no matter where they’re at. I want OneCare to continue to be that forum where providers come together and advance this agenda. There’s a lot further we can go to improve health care in Vermont, banded together.
Nationally, ACOs are zeroing in on how fundamental health equity is to achieving quality in health care. What do you see as OneCare’s unique role in realizing health equity in Vermont?
Through OneCare’s work on population health management and data feedback to providers, we can be leaders in measuring health equity and disparities, packaging information for individual providers about how they’re doing on health equity measures—and provide expertise about how to improve relative to those measures. So I think just being that source of leadership and truth on the issue is the main contribution that OneCare can provide.
What do you think are the key changes needed in negotiations with the Centers for Medicare & Medicaid Services (CMS) to build on the accomplishments of the first all-payer model (APM) and accelerate success in the APM 2.0 agreement ?
My observation of what CMS has done with ACO models in general over the last 10 years is that a lot of them have been “underpowered.” They haven’t provided enough of a financial incentive for providers to change how they do business, and remember that the whole idea behind this is that financial incentives matter. You’re changing the payment methodology because if you do that, you provide more flexibility for providers to do the right thing and you reward them for doing the right thing. My hope would be that in this next round of the model, CMS recognizes that we’ve had some success and that to be more successful, they need to move more fully away from fee-for-service payment, take a little more risk themselves and really reward the right behavior in terms of high quality, low cost, population health improvement and health equity.
As the board chair of OneCare, what do you hope to accomplish under your leadership?
I’m excited to work with the whole array of people who are involved in the organization. It’s kind of a unique perspective that you get through OneCare on a whole bunch of different kinds of providers who are trying to move in the same direction, the right direction. You have everything from critical access hospitals to FQHCs, to an academic medical center, to PPS (Prospective Payment System) hospitals. I think it’s really exciting to get all the great minds who are involved in OneCare together to talk about how we can create a more robust and sustainable health care system for Vermont and provide better care to Vermonters.