Discussion with Mr. Aron Boros, Commissioner of the Massachusetts Division of Health Care Finance & Policy

By Phillip Rakhunov

Introduction

 

On August 22, 2011, the Patrick-Murray Administration announced the appointment of Áron Boros as Commissioner of the Division of Health Care Finance and Policy.  Since 2008, Mr. Boros has served as Director of Federal Finance for state’s Office of Medicaid.

In his capacity as Director of Federal Finance at MassHealth, Mr. Boros has been engaged in key initiatives, including MassHealth and federal expenditures.  Over the last several years, he has been deeply involved in a variety of health care payment initiatives, including the MassHealth Section 1115 Medicaid waiver and and Health Safety Net programs.

Mr. Boros is also an attorney and received his J.D. and Masters in Public Policy from the University of Michigan. Prior to joining the Office of Medicaid, Mr. Boros worked as an Associate in Foley Hoag’s Boston Office, where he researched and implemented strategic initiatives for health care industry clients. His work included initiatives related to chronic disease management, health information technology, and evidence-based medicine. In this role, Boros became an expert on Medicaid and Medicare regulatory issues, including national coverage decisions, coding and payment concerns. Mr. Boros also has experience in a hospital setting, having served as a Law Clerk at Trinity Health’s Saint Joseph Mercy Hospital in Michigan.

Interview

Mr. Boros, please tell me about how you became interested in public health?

My dad is a doctor.  He is an oncologist, and oncology plays a particularly important role in our society.  It’s exciting medicine, it’s challenging medicine, and for many reasons: not just the science of it, but also the human aspect of it.  I always knew, however, that I did not want to spend fifteen years in [medical] school after high school, so ultimately I did not think that medicine was the direction I wanted to go in.

What really inspired me to go back to graduate school was– and this will date me a little bit – it was the Supreme Court election case of Bush v. Gore.  Yes, Bush v. Gore drove me to law school.  Even then, I knew I didn’t really want to be a lawyer in the long term, but I also knew I wanted more tools than a policy degree would give.  So, I went to the University of Michigan for a joint program in Law and Public Policy, hoping to develop a career in healthcare policy and policy making.  So fast forward, and this is a dream job for me.  The Division of Health Care Finance & Policy really straddles both those worlds.  It’s deep in the weeds on data analysis, data collection, and ultimately in really drawing a story out of the data at the lowest level.  At the same time we are involved in helping shape Massachusetts state policy and the interactions between federal and state policy at the systematic level.

I want to ask you a few questions about your background, going back to your years at Amherst College.  During your time at Amherst, were you already considering going into public service?

I was.  I always knew that there was an underlying social mission for me that was going to be more than, for example, investment banking.  But, back then, I certainly didn’t know what that was going to be.  My first job out of college was at a graphic design firm, but I always had that sense that giving back is important.  I’ve been given a lot of opportunities and I’ve been blessed with certain advantages in life, and I felt that there was a responsibility that came along with that.  I can’t say that I knew, when I was graduating from Amherst, exactly how that would play out – but it’s no surprise to me that I ended up in this kind of role.

Tell me how your legal education at the University of Michigan impacted your career.

While I was in law school, I did two really meaningful things that influenced my career path.  First, I worked for the General Counsel’s office at the Trinity Health’s Saint Joseph Mercy Hospital in Michigan.  It was a really interesting look into what healthcare law really is.  I think that a lot of law students don’t understand how much of healthcare law is transactional, as opposed to things like end of life decisions, or policy about minimum credible coverage. When you look at what hospitals are actually doing day-to-day and what they need legal advice about, you realize that most health law is transactional.

Take a big, integrated health care system: hospitals, physician groups, and other sites of care like community health centers . Because they are big employer, they have a lot of labor and employment issues. They are land-owners, so they have real estate and capital assets issues. Of course mergers and acquisitions and contracting have unique health law concerns, such as compliance with self-referral and antitrust laws.  Contracting also involves increasingly complicated relationships between hospitals, physician groups, and other kinds of ambulatory care providers and long term care providers, not to mention health plans.  Other industries aren’t regulated to the same extent as health care. Here we have special rules surrounding health care arrangements because of Medicare and Medicaid, for example.  So, every merger, every contract, has another layer of complexity.  The legal clerkship that I did at the Mercy Hospital was first time I heard about Stark laws; first time I heard about anti-kickback laws.

The other really important thing that I did when I was in law school is that I worked for the graduate employees union.  I was on the bargaining team that represented graduate employees in a couple different roles.  And that was also a really an important part of my career development.

After law school, you spent some time in the private sector at the law firm of Foley Hoag?

Yes. For several years after law school I worked at Foley Hoag LLP, in their government strategies group.  There, I got my education from Nick Littlefield and his team about how the world really works with respect to policy making and the way things get done in Washington.  I also did a lot of pricing work, working with payers.  For example, some of our clients had medical products of one kind or another, and we worked with Medicare and Medicaid about how those products would get paid for.  After Foley, I left to go work for the Patrick Administration in the Medicaid office.

Tell me about your work with the Medicaid Office. 

At the Medicaid Office, I worked on the financial aspects of the federal/state relationship.

And, is that the program known as the MassHealth?

So, you can decide how much you want to get into the weeds on this, but it’s probably good for people to understand that MassHealth is a specific state program that provides health care services.  Medicaid is the state-federal partnership that overlaps most, but not all of what MassHealth does. For example, Commonwealth Care is also part of the Medicaid Office.  So is the Health Safety Net that we run here at the Division of Health Care Finance & Policy and the Medical Security Program run by Division of Unemployment Assistance.  The Office of Medicaid is bigger than just MassHealth.

It is clear that you have had quite a diverse education and professional experiences; please tell me how these experiences have come together for you?

It all comes together as kind of building blocks:  in law school, I learned textbook law; in policy school, I learned textbook economics and statistics; at the Hospital, I learned what health law really was; and with the union, I started my education in politics and learned about power of negotiation and bargaining; then, I went to work for Nick [Littlefield at Foley] and learned how policy making and politics happen in the real world at the State and Federal level; and then went to work for the State and really got to understand how the sausage gets made.

What led you to begin your public service with the State Medicaid Office?

Primarily, it was that Massachusetts continues to be a leader in taking a hard look at the health care system and making it better.  Governor Patrick is upholding a long tradition of leadership on health care issues that stretches back for at least 20 years. Lots of people deserve credit for laying the foundation that the Governor is building on, including Governor Dukakis, Senator Kennedy, and Mitt Romney (whether he acknowledges it or not).

I want to ask you about a couple of the initiatives that I understand you worked on while you were at the Medicaid Office and which I believe are now a part of your areas of responsibility.  One that you mentioned earlier is the Health Safety Net and another that I wanted to ask about is the Essential Community Provider Trust Fund.

The Health Safety Net is a program run by my office that pays hospitals and community health centers for care that otherwise would be uncompensated.  This covers people who either are uninsured or under-insured for the services provided by the hospital.

Federal Health Reform (the Affordable Care Act) will have a significant impact on the Health Safety Net because of the way it changes the coverage market.  Over the next couple of years, until those federal rules come into effect, we will be taking a hard look at how the Safety Net fits into everything else that is going on with the implementation of the ACA in Massachusetts.

Is the Safety Net program unique to Massachusetts?

Yes.    It’s a claims-based system for paying for uncompensated care, which I believe is unique among states.

What is your take on the recent conversations about cost containment and payment reform?

The Patrick administration, from the Governor and the Secretary [of Health and Human Services], down to agencies like ours, has proposed an approach that achieves cost containment by promoting  integration of the delivery system and improvement of the experience of care and the delivery of care.  Instead of a hospital and a physician never speaking to each other and having their own isolated connections to the patient, we want to build those connections. That way, the physician knows when a patient goes to the hospital and manages some of their care in the hospital; for its part, the hospital communicates about discharge back to the physician and helps coordinate follow-up care to ensure the patient doesn’t end up back in the hospital.

The goal is to use the transformation of the delivery system to drive higher-value care –  better quality, and lower cost – by taking advantage of the improvements that you can get by breaking down some of these walls.  The idea is appealing, and it’s easy to string together some sentences about it – but it’s hard to do in practice.

If you know nothing else about the big picture of health care policy, take this: the [Centers for Medicare & Medicaid Services] just released data showing that in Massachusetts, per capita healthcare expenditures for every man, women and child are $9,278 per year.  That means that, on average, my family of three is paying almost $30,000 a year for health care expenditures.

This figure includes Medicare, Medicaid, out of pocket, and insured costs that either you or your employer are paying in premiums, distributed among the population.  This is the highest per capita cost of all of the states, in the highest per capita cost country in the world.  We can reduce those costs.  It will be hard, it will really take change to accomplish this, but it is possible and there is no reason for us to be the most expensive health care system in the world.

You’ve been in this job now for six months or so.  What has surprised you the most coming into this particular position of the Commonwealth?

There are a lot of hard choices to be made about lowering costs and improving quality, and there are lots of complex interactions between various stakeholders inside and outside of government.  What has surprised me the most is the high level of collegiality in the face of those hard choices and difficult tradeoffs. I expected there to be more contentiousness between the parties.  When push comes to shove with the cost containment legislation, that may change.  But I have been really impressed by the level of discourse inside and outside the Statehouse, and how everybody really is taking this problem seriously.

That said, the choices and challenges will only get harder and I encourage people who are thinking about this to continue to be bold while maintaining civil discourse, in order to push the envelope of what we can accomplish.

As you know, we are coming into what is anticipated to be a very heated election year, and I’m wondering whether the political climate impairs your ability to do your job of analyzing the data and trying to make decisions based on the numbers and economics, as opposed to politics.

The Division has, and deserves, a strong reputation for providing objective analysis.  I don’t see that changing.  We can’t control what different people try do with our analysis, but our reputation speaks for itself: we stick to our best understanding of what the data tells us.

Is there one issue that you would like to bring to the forefront of the readers’ minds?

No matter what happens, there is going to be a lot of change in the health care system in the next few years.  Your clients are going to need to invest in understanding value.  What I mean by that is that they are going to be asked more and more to prove that their piece of the heath system provides high-quality care that actually makes people healthier and happier at a reasonable price.    Attorneys who understand that communicating about value is going to drive a successful business model will be positioned to best support their health care clients.  To be a little bit more concrete, right now we are talking about cost and payment systems, integrated care.  The conversation of tomorrow will be quality measurement, outcome measurement, and really proving that the money spent is delivering results. I anticipate that attorneys who understand that dynamic are going to be in great demand.

Conducted on February 29, 2012

An experienced business litigator, Phillip Rakhunov represents financial institutions, health care organizations, investment professionals, fiduciaries and various other business entities in a broad array of business disputes, including securities fraud litigation, enforcement of restrictive covenants, and high stakes contract litigation. Mr. Rakhunov regularly appears in state and federal courts, as well as before arbitration and mediation tribunals. Fluent in Russian, Mr. Rakhunov also represents Russian-speaking clients and other clients in need of his unique background and language.

Mr. Rakhunov dedicates a considerable portion of his time to a wide array of pro bono work, including representing parents in international child abduction matters, representing victims of domestic violence in obtaining 209A restraining orders, and representing non-profit organizations in contract disputes, among others.

While attending law school, Mr. Rakhunov served as a judicial intern to The Honorable Patti B. Saris of the United States District Court for the District of Massachusetts.

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