Talking health care reform with Anya Rader Wallack

As special assistant to the governor for health reform, Anya Rader Wallack, Ph.D., was a key figure in the development, debate and passage of H. 202, a bill that sets Vermonton a path toward a first-in-the-nation publicly financed health care system.
The Green Mountain Physician recently asked Dr. Wallack about the legislation, its future, and how it will impact physicians and the patients they care for.
Green Mountain Physician: Some people have argued that H.202, the new health care form legislation, goes too far, too fast, while others say it doesn’t go far enough, quickly enough. How did the administration come to the multi-step, multi-year process that we are now on track for and since this is going to be a multi-step process, how can physicians provide their input as the details of the new system are being worked out?
Anya Rader Wallack, Ph.D.: We have tried to lay out a clear vision for where we think Vermont should go to get the most out of its health care system, while providing a thoughtful process and timeline for how we get there. Governor Shumlin believes a single-payer system will be best for Vermont because it will cover everyone, de-link health insurance from employment, simplify the insurance system and reduce administrative waste. But we can’t get there overnight. It will take time to develop the infrastructure for a single payer, particularly a health care budgeting system that will assure we can reduce health care cost growth without compromising the quality of our system.
There will be lots of opportunity for input from Vermonters to the further development of the single payer plan, but input from physicians will be particularly critical. The foundation for making this plan work is a redesigned health care delivery system, and we simply can’t do that (or can’t do it well) without guidance from physicians about what works on the ground.
The most important venues for physician input will be the Green Mountain Care Board, which will be responsible for developing cost containment, overseeing payment reform and defining benefits for the single payer, among other things. And the legislature, which will vote on a more detailed single payer plan and other elements of reform over the next several years.
GMP: It seems that whenever the state is in fiscal stress, one of the first places it looks for savings is physician reimbursement for public insurance programs such as Medicaid. A real concern of the state’s physicians is that when all patients are enrolled in some form of government-controlled insurance, doctors will be even more susceptible to the yearly political winds. How can physicians trust the state as a business partner?
Dr. Wallack: This is a legitimate concern because under the current system, state budget-makers approach Medicaid cost control from the narrow perspective of Medicaid costs alone and they have crude tools for keeping costs down – cutting eligibility for coverage, cutting benefits, or cutting provider fees. As you know, provider fees are where we go, year after year, when the budget gets tight.
One of the central goals of the new health reform law is to get away from this narrow budgeting and look at the whole picture. The law requires that the Green Mountain Care Board approach budgeting on an all-payer basis, meaning cost-shifting from public payers to private payers needs to stop. This is a complex task, but the intent of the law is clear: overall budgeting, without cost-shifting, and fair pay for providers.
GMP: If you ask physicians about the biggest problems in medicine today, you’d hear from a lot of them that overbearing administrative burdens are really getting in the way of caring for patients. What effect, if any, will a publicly financed health care system have on the amount of time physicians must spend submitting and resubmitting insurance claims, justifying treatments to payers, complying with regulatory requirements, etc.?
Dr. Wallack: One of the main reasons the Governor supports a single payer is the potential for it to vastly simplify health care administration. Right now physicians and other providers are overburdened with paperwork and insurance companies are way too involved in clinical decision-making. We need to cut out this waste and put physicians back in the driver’s seat for health care.
GMP: One of the biggest arguments opponents of H.202 made was the fact that how this reform is going to be paid for has yet to be determined. How can we start planning a publicly financed health care system without first knowing the sources and size of revenue?
Dr. Wallack: Act 48 sets in motion a process to develop a single payer financing plan that will be presented to the legislature in 2013. Before the financing plan can be developed, the Green Mountain Care Board needs to be created, which by law won’t be until October 1st of this year.
The Board will develop the single payer benefits package. The Secretary of Administration’s office will then develop a financing plan based on the proposed benefits package. We think this is a responsible approach to developing the details of the financing plan in a timely manner and allowing appropriate input and legislative oversight before we ask to move ahead.
GMP: One of the issues H.202 is going to research is how a publicly financed health care system will effect physician recruitment and retention. Do you think the system will make it easier or harder to recruit physicians to the state? Why?
Dr. Wallack: As the Governor has said, if we do this right, Vermont will be the best place in the country to practice medicine. We’ll reduce the hassle factor and allow physicians to do what they were trained to do – help their patients stay healthy and treat their illnesses when they are not. The current system of health care financing is not working for Vermont’s physicians. We should be able to design one that works a whole lot better.
GMP: No other state has pushed health care reform as far as Vermont. What makes the state a good place to test this concept?
Dr. Wallack: Vermont’s health care system is relatively free from the type of entrepreneurial influences that make change difficult in other places. Physicians don’t come to Vermont to be the wealthiest they can be. Vermont has fairly distinct health care communities that allow us to think about caring for the state’s population in a different, more organized and effective way. And, we have a much simpler insurance market than many states, with just three health insurance carriers and only two in the small group market.

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