Over its 23 year history, the Commonwealth Fund Fellowship, along with California Endowment Scholars program and Joseph Henry Oral Health Fellowship, has a proven track record of creating physician/other health professional leaders; the Alumni Spotlight interviews showcase the expertise and dedication to care for vulnerable populations as a testament of that success. Interviews have been edited for length and clarity.
Dora Hughes (CFF ’00)
Chief Medical Officer, Center for Medicare and Medicaid Innovation, Baltimore, MD
Q. Could you please describe your current role in your organization?
A. My current role is Chief Medical Officer at the CMS Innovation Center (CMMI). The Center was created by the Affordable Care Act to test models that would improve the quality of care, reduce the cost of care, or, ideally, both. Through the CMS Innovation Center, we have supported about 50 models since 2010, and we have about 28 models operating right now. The models span the gamut of health care interventions: Some are focused on particular provider types, such as primary care physicians. Some are focused on particular diseases, such as diabetes or cancer. We have models that focus on certain communities, such as rural communities. We are taking an expansive view of health system transformation and trying to take advantage of all potential levers to achieve such transformation.
I just hit the one-year mark, and I was asked to hit the ground running, to come in immediately and focus on health equity. Historically, the CMS Innovation Center has not focused on equity to the extent that it could have. Many of our models did not include a focus on underserved populations or safety-net providers. In our evaluations, we didn't assess the health equity impact of our models. We took a step back after the first 10 years, thinking about our next ten-year strategy, which coincided with the COVID-19 pandemic as well as a change in Administration. For a number of reasons, it made sense to ask: How can we better advance health equity? What are the tools and technologies? What are the opportunities that we have? So that's been the early part of my focus. I am the lead on health equity here at the CMS Innovation Center, which has provided a lot of opportunities to think about how can we better embed health equity in the work that we do every day.
Q. Tell us about your journey to this current role.
A. Immediately after residency, I participated in the fellowship. I was in the fourth class, and after I completed the fellowship year, I actually worked at the Commonwealth Fund for a little over two years as the Senior Program Officer for the Quality of Care for Underserved Populations program. From there, I went to the Senate. I was the Deputy Director for the Health, Education, Labor and Pensions (HELP) Committee under Senator Ted Kennedy. I focused on a number of different bills, including a minority health legislation bill, the Healthcare Equality and Accountability Act. From there, I served as health policy advisor to then-Senator Obama's office and joined the Obama Administration in the Department of Health and Human Services. Again, I was able to include a focus on equity in my work, both indirectly or directly. As examples, we developed a racial and ethnic disparities plan and I was able to co-lead a sickle cell disease initiative. In addition, we focused quite a bit on community-level interventions. It was the early days of thinking about how we can better integrate community and clinical interventions that can address the social determinants of health—which certainly disproportionally would benefit underserved populations.
From there, I consulted for five years, mostly for clients in the life-sciences industry. But I missed my own north star in terms of focusing on equity, on tackling racial, ethnic, and other health inequities. I had the opportunity to join the faculty at the GW School of Public Health with a secondary appointment in the School of Medicine. For nearly three years, I focused almost exclusively on health equity, including social determinants of health and opportunities to advance health equity through the state marketplaces.
It was a very productive three years, very much built on the foundation of the fellowship from way back when, and on the roles that followed. It was a very logical next step to take on this role at CMS, where they were specifically looking for someone who could hit the ground running on developing the health equity strategy undergirding our overall 2030 strategy. So that's what I do now, in addition to the more traditional Chief Medical Officer function.
Q. Could you describe your leadership style?
A. In terms of leadership style, it depends on the role. In some positions, when you are the decision maker, then you can have a more direct say. In other cases, you lead more by influence, coaching others and trying to support them to do their very best work. And in other instances, you can lead by using the bully pulpit.
Certainly, when I was in a senior role at the Commonwealth Fund, I was able to help determine who would receive grants. When I was a staffer on the HELP Committee while in Senator Obama's office, because he was such a junior Senator, he didn't have a power base within the Senate. However, he had an extraordinary presence and we were able to use the bully pulpit to share many of his ideas that helped influence action. When I was at HHS, I was in a more decision-making role, so my leadership style was more direct. However here at the CMS Innovation Center, I would say it's more about being able to influence the direction, trying to encourage others to put new ideas on the table, to galvanize interest and support. I am part of the approval process and the clearance process, but I don’t have the final say. And thankfully, there is a whole cadre of individuals at various stages of their career who are quite committed to promoting equity, and because of that, we've been able to really make good progress in advancing health equity.
Q. Can you tell us about your approach to making difficult decisions?
A. When I worked for Senator Kennedy, he was often known—for better or for worse, depending on whom you were talking to—as an incrementalist. He was willing to compromise to keep the ball moving forward. And over his forty-plus years in the Senate, he had an amazing track record in terms of major legislative accomplishments, but they were not always perfect. He never let the perfect be the enemy of the good. So, it was a major learning lesson for me to watch the art of compromise in negotiation while keeping an eye on the long-term prize. Having that experience while working on the Hill was very influential on my thinking.
But the challenge, then, is: what is the right compromise? When are you agreeing too early? Is this the most that can be achieved? Or just balancing the idealism—what you would like to get done—with the pragmatic considerations of every decision. What are the legal constraints, the budgetary constraints, the regulatory constraints? All of that must be considered while still making sure that you're moving the ball forward, even on some days where progress seems to be pretty minimal.
Q. What’s the best piece of leadership advice you’ve gotten?
Again, reflecting back to Senator Kennedy's style of leading and a number of my other bosses, is the importance of grounding your decisions in the evidence and in the facts, so that you're always a trustworthy source of information that people can really count on. That’s critically important. And another piece is surrounding yourself with a cadre of like-minded individuals—whether your friends, colleagues through the fellowship, which has always been very instrumental in that regard, colleagues at work, and so forth, both your informal, social network, as well as your formal network.
Q. Please tell us about your career goals, past and present.
A. During the fellowship, including the fellowship’s seminar series, my takeaway from the speakers that came to present to us was that each of them had their own unique pathway. It was a career track that they could never have predicted. In some cases, it made no sense. The speakers emphasized that we needed to learn to be comfortable with that level of uncertainty. So, for me (and I suspect this is true for many of the fellows), I never had a long-term or defined career plan. I don't see that as a negative. Because when you enter into health policy from a traditional provider background (physician, dentist, etc.), in many cases, you may not have any idea what the possibilities are. Being open to the possibilities—that has been one of my guiding principles. I could never have imagined some of the amazing opportunities that I’ve had. That has been a wonderful outlook that the fellowship helped foster.
Q. What key obstacles do you see for advancing health equity?
A. It was harder, prior to 2020, before the pandemic and the killings and the heightened focus on inequities. Health equity wasn't always a space supported by significant attention or resources or funding. Making progress could, in some cases, be a fairly Herculean task. And so, it's changed now in this current environment. But one of my concerns now is that some of that attention, some of the support and the excitement around the possibilities—I worry that could dissipate.
One of my colleagues here at CMS said, "For those of us who are committed to advancing health equity, this is our moment. But it's only a moment." Her point was that we really have to seize this moment and do as much as we can, because we're not guaranteed to keep having this same level of energy or support. And that I think motivates me—and I suspect quite a few of us—in the field of health equity.
Q. When you're in a situation where stakeholders do not share the same values regarding health equity or social justice, how have you been able to move the needle and seek the outcomes you're after?
A. Some of it is understanding that when you're working with individuals who don't share your values, you need to know what are their values? And where's the overlap? Working on the Hill, it was very helpful to understand that in some cases, some of the stakeholders, some of the Congressional members—they might not care about X, but they do care about Y. You could pair the two, or help explain how advancing health equity can advance their interest in whatever their issue is.
As an example, sometimes when we talk about racial and ethnic populations, it may not interest somebody, but if you start talking in terms of what health equity could mean for rural communities, or for disability justice, it’s a different story. I think about what are some of the ways to tackle an issue that would resonate with the broadest number of stakeholder groups? As a leader, you also have to be willing to keep pushing forward, even in the absence of support, just continue to march forward. Eventually, maybe your different stakeholders will fall in line or come around to your point of view. But first, think about how you can address others' interests. Trying to be really inclusive is always the very first step, although sometimes you just have to make the decision to keep pushing forward.
The other issue I find, is that sometimes people just frankly don't know what you mean by “health equity.” You need to be really clear and specific, very granular about what you're attempting to do, grounding that in why you want to do it, and linking that to the objectives or principles of whatever you're working on. And being very clear on how that advances the business interests or academic interests or whatever the priorities may be for the other party.
Q. What does your current work on health equity at the CMS Innovation Center look like?
A. At the CMS Innovation Center, we are asking how we can better embed equity in our new models. What financial considerations or payment policy could, for example, support safety net providers who are taking care of a disproportionate number of underserved populations? What's the benefit package? What care delivery interventions are needed? What types of proposals could help improve the care or reduce the cost of care for underserved populations, that is what we're thinking about.
We’re also asking how we can increase the number of beneficiaries from such populations that have access to our models. We have said very candidly that in many of our models, it's disproportionately white and higher-income beneficiaries. How do we increase the numbers of participants from historically underserved populations, including racial and ethnic groups, rural residents, people with disabilities, and other underserved populations? And key to that is increasing the number of safety net providers—again, because they care for a disproportionate number of underserved individuals. Safety net providers include federally qualified health centers, many rural health clinics, and providers that have large numbers of beneficiaries on Medicaid.
We’re also thinking about the evaluation design up front—asking the questions and collecting the data so that at the end of a five-year model period, we're able to assess the impact that our model has had on health equity. We’re working to strengthen sociodemographic data collection too, namely collecting more information on our beneficiaries’ racial and ethnic background, geography, sexual orientation, gender identity, and disability. The data continues to be a challenge. We'd love to have better information on beneficiaries defined by sexual orientation and gender identity. That's on the demographic side. And then on the social side, we’re thinking about how we can collect more information on social needs, specifically information on our beneficiaries who need assistance with housing, transportation, food, or utilities, or those who are experiencing intimate partner violence. These are non-clinical, non-demographic factors, but very important when you think about health and life expectancy.
I would have to say it's pretty exciting working here because we are also working with other centers at CMS, with our colleagues in the Center for Medicare, and the Center for Medicaid and CHIP Services, so that we can align our efforts. Our models last for five years, generally, but we want to make sure that whatever we achieve can be sustainable in the long-term, so it's important for us to work with our partners in Medicare and Medicaid. We’re able to partner with other agencies at HHS too. Behavioral health is an example where we're working very closely with our colleagues in the Health Resources and Services Administration and the Substance Abuse and Mental Health Services Administration. In other cases, we're working more closely with our colleagues in the Administration for Community Living. CMS is the nation's largest payer and the largest financial institution and we’re really trying to think about how we work with our partners in public health and the social service sector to leverage each other's knowledge, expertise, and resources for better outcomes for our beneficiaries.
Q. How has your personal narrative and past experience influenced your career?
A. As a child, my father was in the Army, so we moved around a lot. I was often the only person of color in elementary and middle school, and we lived in some pretty tough places. That definitely shaped some of my early thinking, with personal experiences with discrimination and segregation.
When I was in residency, I was diagnosed with multiple sclerosis. At different points in time, I've been quite sick. So, I had that early experience as a patient, and a patient who's female, who's Black, who sometimes needs certain supports. I saw how these factors intersect and compound the difficulties that so many of our patients have to deal with every day.
Also, when I first started in health policy, there weren’t too many of us doctors in certain settings, such as in the congress. I was often thrust into new situations where I didn’t fully understand all the dynamics, and found myself always having to be on my toes. That experience has been helpful in parts of my professional life.
In addition, I think there's just a perennial difficulty for many of us having to balance the personal and professional. I think you have to be comfortable with the tradeoffs that you make, and particularly if you have children of certain ages that may require a higher level of involvement. That has shaped what I have been able to do at certain points in time. I left after the first term in the Obama Administration because I had a toddler, and it was increasingly difficult to balance the personal and professional commitments. That said, I also think that times have changed for the better. Previously, there wasn’t always same level of flexibility or support for families that you see now. Increasingly, I hear mothers and fathers who say, "Well, I can't join a meeting before 8:30, I have school drop-off." Or, "I have to pick up my kid soon and so I have to leave." You know, that was unheard of twenty years ago. I think that people are just much more focused on what's meaningful to them, their families and personal commitments, and are more transparent and flexible in terms of achieving balance. So, I think it's a welcome shift.
Q. Is there anything you’d like to add?
A. I still maintain pretty close relationships with many of the fellows, both personal relationships and working relationships. The fellows have served as a major resource for me, helping me when I reach out to say, "I need help identifying an expert in this field," or "I need someone to help teach a class for me." Recently, I asked another fellow, "Can I shadow you in your clinic?" which was a lot of fun. It's just been a joy to witness all the different accomplishments of the fellows and also to know that you can rely on them, knowing that you'll always be supported and championed.
Interview date: August 2022
