Publication
Article
The American Journal of Managed Care
Managed Care Reflections: A Q&A With Dora Hughes, MD, MPH
Author(s):
To mark the 30th anniversary of The American Journal of Managed Care, each issue in 2025 includes a special feature: reflections from a thought leader on what has changed—and what has not—over the past 3 decades and what’s next for managed care. The September issue features a conversation with Dora Hughes, MD, MPH, chief medical officer and director of the Center for Clinical Standards and Quality at CMS.
Am J Manag Care. 2025;31(9):In Press
AJMC: How have the concept of managed care and the conversations around it changed over the past 30 years?
HUGHES: Over the past 30 years, managed care has undergone a fundamental transformation, from volume-based reimbursement to value-based care models that emphasize quality, safety, and patient experience alongside cost containment. What began primarily as a cost-control strategy has matured into a more holistic approach that supports better outcomes for patients and greater accountability for health systems.
This evolution has been propelled by key policy shifts, including establishment of accountable care organizations, the growth of Medicaid managed care, and [CMS] Innovation Center models that test new payment and delivery reforms. Medicare Advantage, now covering more than half of all Medicare beneficiaries, has further solidified managed care as a major lever for driving value across the system. As expectations for quality and transparency continue to grow, managed care has become an essential vehicle for delivering on those priorities.
AJMC: What changes do you see taking place in managed care over the coming years?
HUGHES: In the years ahead, I expect managed care will continue to evolve toward a more outcomes-focused, technology-enabled, and patient-centered model. Performance will be assessed not just at the individual clinical level, but across entire delivery systems—with greater emphasis on clinical outcomes, metrics, care experience, and cost-effectiveness.
Technology will play a central role in this transformation. Advances in analytics, artificial intelligence, and digital tools will enable more proactive care and better-informed clinical decision-making. Enhanced data interoperability and digital quality measures will support more timely insights and promote shared accountability. As these capabilities scale, managed care organizations will be better positioned to deliver whole-person care that meets patients where they are.
AJMC: In your role as chief medical officer and director of the CCSQ at CMS, how do you think about clinical standards as raising the bar for quality care by health care facilities and providers?
HUGHES: At CMS, we view clinical standards, specifically the Conditions of Participation,1 as foundational safeguards that ensure all patients receive care that is safe, effective, and grounded in evidence. These national health and safety standards apply to more than 20 types of health care providers and represent the baseline protections that every patient deserves.
I see CMS’ role as both protector and catalyst. These standards not only help prevent adverse events and promote safety, but they also foster a culture of continuous improvement. They are designed to be broadly applicable across settings, including rural and underserved communities, while allowing flexibility to support innovation in care delivery.
Beyond compliance, we support providers in improving the quality of their care through our quality reporting and value-based programs and the work of our Quality Improvement Organizations. These efforts help raise the bar by incentivizing providers to improve performance and share best practices. Ultimately, our goal is to ensure all patients benefit from a consistent floor of protections and a system that rewards excellence in health care delivery.
AJMC: How does CCSQ’s work align with the CMS Innovation Center’s goals2 of promoting preventive care and empowering people to live their healthiest lives as part of testing innovative payment and care delivery models to improve quality while reducing program costs?
HUGHES: CCSQ and the CMS Innovation Center are closely aligned in advancing a health system that prioritizes prevention and chronic disease management. Together, we are working to shift care upstream so patients stay healthier, longer.
Within CCSQ, we are reviewing our quality measures to identify opportunities to elevate prevention and wellness across our programs. We are also examining how to make the Medicare Annual Wellness Visit more impactful, such as exploring the use of asynchronous components or digital tools to enhance beneficiary engagement. Meanwhile, our Quality Improvement Organizations, in their newly launched 13th Scope of Work,3 are driving improvement in areas including behavioral health integration, chronic disease management, and patient safety.
Across all these efforts, our commitment is clear: [We want] to empower providers and patients alike in achieving better outcomes through earlier interventions, personalized care, and a renewed focus on whole-person health.
AJMC: You and colleagues recently wrote about the importance of quality measurement in clinical specialties, including oncology.4 How is CMS taking the next steps to enable quality measurement and reporting in oncology and beyond?
HUGHES: Oncology presents a uniquely complex landscape, and CMS is committed to ensuring our quality programs reflect the nuances of cancer care while supporting better outcomes for patients.5
Historically, oncology-specific data collection has been limited to the 11 Medicare Prospective Payment System–exempt cancer hospitals. We are now expanding this approach to include oncology patients across all hospitals, enabling a more comprehensive understanding of cancer care delivery nationwide. In addition, we are developing a Merit-based Incentive Payment System value pathway specifically for oncologists. This pathway will align performance measures with clinical practice and ensure data collection is both meaningful and actionable.
More broadly, we are focused on making quality measurements more relevant, more patient-centered, and more useful in improving care. That includes developing specialty-specific measures, integrated patient-reported outcomes, and leveraging digital tools to support real-time feedback. Whether in oncology or other high-stakes specialties, our goal is to ensure measurement drives the kind of care transformation that patients, caregivers, and clinicians want to see. n
REFERENCES
1. Conditions for Coverage (CfCs) & Conditions of Participation (CoPs). CMS. Updated September 10, 2024. Accessed August 20, 2025. https://www.cms.gov/medicare/health-safety-standards/conditions-coverage-participation
2. Strategic direction. CMS. Updated May 14, 2025. Accessed August 20, 2025. https://www.cms.gov/priorities/innovation/about/strategic-direction
3. QIO program 13th SoW. CMS. Updated June 5, 2025. Accessed August 20, 2025. https://www.cms.gov/medicare/quality/quality-improvement-organizations/current-work
4. Kline RM, Hughes DL, Schreiber M. Quality measurement in oncology: time to take the next step! JCO Oncol Pract. 2024;20(12):1563-1570. doi:10.1200/OP.24.00348
5. CMS quality reporting and value-based programs & initiatives. CMS. Updated July 2025. Accessed August 20, 2025. https://mmshub.cms.gov/about-quality/quality-at-CMS/quality/programs
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