John Agwunobi, MD, MBA, MPH
Founding Employee of HSCSN, Former CMO at Hospital for Sick Children and Former CMO at HSCSN, Currently Semi-Retired
In commemoration of HSCSN’s 30th Anniversary, Deborah Wilson, Sr. Manager of Provider Relations at HSCSN, sat down with Dr John Agwunobi, former CMO at HSCSN, for a conversation about his experience and insight 30 years ago.
Deborah Wilson
Thank you, Dr. John, for joining me today to discuss Health Services for Children with Special Needs (HSCSN). As a former Chief Medical Officer and a founding employee from when HSCSN was established in 1994, how does that make you feel?
Dr. John Agwunobi
I'm incredibly proud of HSCSN and everything it has accomplished over the past 30 years. That longevity alone speaks volumes about the importance of its work and the need for it in our community.
When HSCSN was created, it was essentially an experiment—a way to test a new model for providing care. We weren’t sure if we’d be around from one year to the next, as it was never guaranteed beyond the duration of our contract. I’m proud that the team has remained cohesive and continues to serve the people of the district.
Many of us began our journey at the HSC Hospital for Sick Children and ended up at HSCSN. In the early days, because we were experimenting, we were constantly innovating. Everything we did was new to us.
Deborah Wilson
Yes, we are still innovating. What did you learn during your time at HSCSN?
Dr. John Agwunobi
Although my time there was relatively short, I dedicated myself as a pediatrician to children with special health care needs, including those who were ventilator-dependent, had developmental disabilities, heart disease, chronic illnesses, or HIV. One key lesson I learned at HSCSN was the importance of understanding the social context of a patient.
In a hospital setting, you primarily interact with the patient and provide information to their family. The family typically plays a supporting role in decision-making, but it’s a very controlled environment. It was only when I joined HSCSN that I truly grasped the significance of helping children in their community.
Our goal is to support them in living healthy lives, even with chronic diseases. Achieving this requires recognizing that it's not just about the individual patient; it’s about their living situation, their siblings, and other environmental factors. For instance, you can't place a noisy ventilator in a bedroom shared with other children—it disrupts everyone’s sleep.
We also need to consider logistics. How will a parent get from work to the hospital? When a child has a chronic illness, it’s essential to coordinate their doctor's appointments and school schedule effectively.
I learned that no person is an island; they exist within their community context. Understanding a family’s weekly routine—what they do on Sundays and Mondays, whether they are single-parent households, and how many siblings they have—becomes crucial. The social context can be even more significant than the illness itself and certainly more important than the providers involved.
While HSCSN is a managed care entity focused on organizing healthcare, the real impact on outcomes comes from the community aspects surrounding the child. This was a vital lesson I learned during my time at HSCSN.
Yes, the impact on the family is profound. Health insurance doesn’t cover the time, energy, and effort families invest, nor does it address the challenges that arise, such as a father needing to forgo a second job to be available for their child. Hospital care is often the straightforward part; the real challenge lies in community care.
Deborah Wilson
We're looking at innovative ways to support the enrollee and the family.
Dr. John, what was your greatest accomplishment and your greatest challenge while at HSCSN?
Dr. John Agwunobi
During my time at HSCSN, I simultaneously served as the Chief Medical Officer for both HSC, Hospital for Sick Children, and HSCSN, which created a unique set of challenges and opportunities. I often found myself navigating conflicting priorities—sometimes admitting a child to the hospital while, as CMO of HSCSN, I had to deny an extended hospital stay. This dual role highlighted the complexities of healthcare management and the need for thoughtful communication between providers and payers.
Wilson, Deborah
I can see how that could be a challenge.
Dr. John Agwunobi
There’s an opportunity to finding the right balance when you're sitting on one side or the other. When you're in both settings, it allows you to realize there's a place in the middle and that's the right place.
It requires you to negotiate between the provider and the payer to make sure that you're finding the right place and it's hard sometimes.
Deborah Wilson
Right.
Dr. John Agwunobi
You want to be around next year. You want to hit your targets so that you can grow the program. So there's good reasons for the decisions on both sides.
Deborah Wilson
Yes.
Dr. John Agwunobi
So that was both a challenge for me, but it was also an opportunity for me, too. It taught me, and those playing on both sides, just how complex this situation is and how important it is to have real in-depth, thoughtful communication and collaboration between payer and provider, and a lot of the lessons that I learned in that interaction, me as the CMO on the hospital side, simultaneously the CMO in the managed care company. I used that opportunity to help forge relationships with other payers, United and Cigna. Humana. I would insist upon having one on one direct relationship with decision makers of those payers as the CMO in the hospital, because I wanted them to better understand the context, not just the patient's medical record, and understanding everything about the patient will allow both to make better decisions.
Deborah Wilson
Yes. And I've worked on both sides and so most of my experience has been on the payer side, not on the provider side.
And so when I went to work for a hospital, I understood the patient and the focus is really on the patient's care, whereas on the payer side, it's more on how can we meet our targets, you know, and reduce costs. We still care about the patient; however, the focus is a little different. I got a chance to really see what it's like on the other side and it really caused me to be a little more compassionate because you're sort of driven on the health on the payer side to get things done and to get the providers to do what we want them to do you know meet these measures.
Dr. John Agwunobi
But the other thing that isn't often talked about, because I've been on both sides, there's also a lot of inefficiency in the provider space.
Why is the patient not discharged? Oh, the doctor was out on vacation yesterday.
Well, why should the system pay an extra hospital day stay because the doctor was on vacation playing golf? You know you left to itself. By the way, the doctor's entitled to be on vacation. The patient is safe in the hospital, but the system shouldn't be paying for that hospital day. With foresight, someone should have known when the doctor's going out. Tomorrow let's make all the discharge papers ready and effective for tomorrow. Let's prepare them for today or let's make sure that there's a covering doctor who's authorized to discharge the patient on that day.
So I do think that as much as compassion typically sits within the provider side, I also believe that the payer side has an important role it helps and by the way, hospitals aren't safe places there's, those are corneal infections, there's a bunch of things that can happen, and for a child there’s no better place than home typically, right?
So and every extra day, even though there's love and compassion in the hospital or in a healthcare setting, there's no better place for a child than home. So having said that, I'll guess what I'm saying is if you can build 2 organizations, a payer and a provider, both of which are focused on the compassion for the patient. They have different goals, different metrics, and both are negotiating with each other in good faith on behalf of the child or patient.
You can get to that happy place where everyone's fighting for the same thing, even though one is driving, and one is doing something else. You know, even though they have different roles I think that's what HSCSN mission was always about.
It was about saying someone must manage efficiency to make sure that we spread these resources properly to as many people as possible in the right way and by the way, there's more than just resource management. There's also quality assurance, making sure that the quality is at the right level, and I think it's helped both sides.
HSCSN back then, it helped both sides get better and that’s the relationship they had.
Deborah Wilson
I agree with you. We both must work together. We should be working together for the good of the patient and yes, we're doing that now. We have done it for 30 years and will continue to do it in partnership with DHCF. Speaking of DHCF, what was one significant change that you experienced with DHCF with the CASSIP contract?
Dr. John Agwunobi
I wasn't there that long, so I think I might have been there for one contract cycle, which kind of goes to one of the big challenges. One of the challenges that we had that, as I mentioned before was, we were experimental and when it first started, there was really no guarantee that we would be around beyond the length the of the contract, there was no guarantee of that at the time. We didn’t know that the innovation we were bringing to the market, to the healthcare space in DC, was going to be around in the future. It kind of limited our ability to think long term.
The problem was the program, when we first started, was on a year-to-year contract.
Deborah Wilson
Ok. The program is now a five-year contract.
Dr. John Agwunobi
Since it was experimental, it was kind of hard to think out five years.
So, my hope is one day we can say and that we can at least guarantee that HSCSN built something where these children will always have HSCSN. Once you're in, we will be your caregiver, your provider, your, your payer, and your Care coordinator until the day you age out because it will allow us to do things a lot differently.
My hope is that out in the future, people begin to realize this program isn't going away. It's doing too good a job. Here we are 30 years later, and we recognize that there's nothing better. This is a great program. It serves so many on Medicaid, let's establish this as a long-term program and every child who gets enrolled.
Deborah Wilson
Yes, I think it's an important program for the enrollees in the DC area. There's no one else doing it like we're doing it. 30 years later, we're still here.
So, we must be doing something right.
Thank you for that response.
How did your experience as a CMO at HSCSN propel your next professional career move? Where did you go when you left HSCSN?
Dr. John Agwunobi
It had a direct impact on the rest of my career. It was probably one of the most influential pieces of my life when I started out as a pediatrician and then went straight to HSC, Hospital for Sick Children. My role at first was just I was inpatient Pediatrics. My job was to be in house physician and relationship was with the 200 patients that were in the hospital. When I went to HSCSN, as I recall, we had 1000 or 2000 beneficiaries of the program and I suddenly realized as I mentioned before, that it's not just about medicine. The health of a child is not just about medicine, it's about their society, their community, their village and their family.
It is so much more it taught me that there are many other determinants that determine whether a person's going to be ill, or whether a person's going to get better over time. How a person's going to survive.
After I left, HSCSN, I went to the State of Florida and became the Deputy Secretary for Children's Medical Services in Florida. So essentially all the children in the State of Florida who are supported by the state.
So children in the child protection system at indigent children, children with a lack of resources throughout the state. It was my responsibility to make sure there were clinics in every county. Make sure there were providers in every city that would care for the state's wards. I went from having the two thousand people that were at HSCSN to now responsible for about 60,000 people in Florida. It drove me into public health and actually into a business degree. I was going to school at Georgetown as I was working at HSCSN trying to better understand the business of health care. It also started me looking for jobs where it was more about population health.
So, I've been an individual provider and it kind of steered me into population health first at the state level as Deputy Secretary and then the Secretary of Health in Florida and then at the federal government as the assistant Secretary for Health for Public Health within the Office of the Surgeon General, all of the public health agencies, reported to me and responsible for millions of people. I became a population health practitioner. My experience at HSCSN changed my life.
Wilson, Deborah
Is this what you envisioned your career to be?
John Agwunobi
To be honest, no, I thought I was going to be the best pediatrician in town. I thought I was going to do a specialization in the ICU or NICU. I spent a lot of time doing night shifts in NICU, even as a young pediatrician. I found myself in my career trying to prevent rather than treat and that was the journey I went on. Eventually I got a public health degree, a master’s degree in public health from Johns Hopkins and became a public health professional.
Deborah Wilson
What are you doing now?
Dr. John Agwunobi
I'm semi-retired. I serve on three paid Boards in managed care and one volunteer board, which means that I have meetings every couple of days with one board or the other.
Deborah Wilson
Well, you know things are changing in healthcare and over 30 years, there's been a lot of changes in medicine, innovations and healthcare delivery technology.
Are you involved in any technology, or do you have any desire?
John Agwunobi
No, not directly. I don't serve on any technology company Boards just yet. Although I'm considering one but, the one thing that is guaranteed in healthcare, I knew this when I worked at HSCSN, is there will always be dramatic change. There will always be changes. Hopefully, more positive than negative. There will be some negative as well. The system is constantly trying to figure out better ways to do things, and sometimes it makes mistakes.
Wilson, Deborah
Yes.
Dr. John Agwunobi
I'm glad that HSCSN was not a mistake. It's proven that it was not a mistake. It's shown that it makes a difference.
Debora Wilson
Yes. I feel the same way.
I guess the last question is what are you excited about today?
Dr. John Agwunobi
Yeah, I think in the same way that science excites me every time it comes up with something new, I'm also very excited about HSCSN. HSCSN is an example of policy innovation. I think if HSCSN has a risk, it's that it's when you're 30 years old. You have enough history that it becomes hard to learn new things. You know, old dogs don't learn tricks quite as easily as young dogs, but I am excited by the fact that the journey continues that, as you described, that HSCSN continues to innovate.
HSCSN is a healthcare system that continues its journey. It hasn't stopped trying to get better. There's this constant effort to try to make things better.
In terms of the next 100 years of healthcare in the United States in terms of children's care in DC, I am extraordinarily excited because it's a dynamic space.
It's moving. It's evolving and we're learning now. We're learning what works. We're learning what doesn't.
Ultimately, I think that's going to guarantee that HSCSN is beautiful today and in the future for our children and grandchildren.
Deborah Wilson
Absolutely. I agree with you.
I think that's the end of my questions. Is there anything that you want to share that we haven't discussed in the interview?
Dr. John Agwunobi
I encourage the HSCSN staff to take a moment to reflect on their accomplishments over the past 30 years. The impact they've had on countless lives is profound. Many of the children we supported are now adults with families of their own, illustrating the lasting legacy of HSCSN. I would urge the staff of HSCSN to stop one day and just celebrate.
Celebrate not what you did yesterday, but what you've done over the last three decades has been dramatic. The experiment that became an important pillar within the DC infrastructure, the DC village. Congratulations!
Deborah Wilson
Thank you so much for your time, Dr. John. I appreciate the interview.