Richard Torrenzano: As you look at hospitals and hospital systems, what are the two or three things, the two or three big challenges, facing them today?

Michael Dowling: There is a changing culture, a change in the understanding
that hospitals are not the center of the universe, the way hospitals were a decade or 15 years ago. You have to think of the delivery of healthcare very differently than thinking about it from a hospital perspective.

There is a practical/tactical aspect of how you address that, but just as important there is the cultural aspect, the thought processes. You get people who have been trained and worked in hospitals for the last decades, many people their entire careers, to think different about what healthcare really is, and not confine it to something that happens inside the four walls of a hospital.

RT: Let’s talk about this health care delivery change taking place: consolidation, dilution, delivery in non-traditional venues and others. What role will big central hospitals play in the next five to ten years ?

M. Dowling: Big systems, which include hospitals, will be a lot more than hospitals. I would not define them as hospital systems. I think in the next five years, you will see an increasing transition of care outside hospitals.

The big systems, over the next five years, will evolve into figuring out how to coordinate care better and how to deliver care using health care terminology, in the least restrictive settings.

They will figure out how to coordinate care among the various disciplines because what has happened over all of these decades, partly as a result of educational influences through traditional medical schools, we have created professional silos.

The customer is not carved up into silos. One of the biggest problems is to figure out how you have the seamless provision of care, not just by silo. That is a psychological issue and a cultural issue, as well as a practical issue. Traditional hospitals are all about silos. That will be changing, because it has to change.

RT: It is total focus on the customer.

MD: It is total focus on the customer, and it is not just about the provision of care once people are sick. It will be increasingly about the provision of care to try to keep them healthy, moving, as is often used as terminology, from a sickness care to healthcare. Quite frankly, if we are honest, we do not deliver healthcare. We are very good at delivering episodic medical care and there is a big difference between the two.

RT: Talk about what some of these entrepreneurial areas will be in the next couple of years, and how you approach them differently than other healthcare systems.

MD: We are very innovative in education and in research. On the educational front, we created an in-house university.

We use simulation more so than most…been doing it for ten years. Today, you will see many systems using simulation. We modeled this after the aviation industry.

We innovated in creating freestanding emergency rooms. We opened up the first one in New York, the first freestanding emergency room is a 24/7 and comprehensive, facility not simply an urgent care center. When we proposed it five years ago, everybody said, “This is crazy. This does not work. You cannot have an emergency room without beds.” We asked the question, “Why not?” We have done it. It is working.

Now, interestingly enough, all of the people that said to us, “You are crazy and this is nuts,” are now all proposing the same thing. I sit back and I say, “That is nice.” They are now following what we did, even though they criticized it at the beginning.

We also innovated in putting together one of the few really and truly integrated systems, where multiple hospitals and ambulatory facilities are all interconnected. We have similar standards of care across them. People will tell you that when you see one health system, you see one health system. You see very few purely clinically integrated health systems. But we are one of those. Innovation has to be a core part of your DNA. You have to be challenging the preceding all the time.

RT: One of the really important things for your future in areas of innovation has been CareConnect, your new insurance company. Tell us where it is today and where it is going over the next couple of years.

MD: CareConnect is our insurance company. We are the only one in this region, this part of the country, with an insurance company as part of a provider system. There are others across the United States, but in this area we are ahead.

You have to learn how to manage the continuum of care better. When you are an insurance company, it forces you to think that way. The other thing is that you want to get control of the full premium dollar.

If I get the full premium dollar as distinct from being able to negotiate with an insurance company and get 10% of the premium dollar, if I have the full premium dollar, now I can sit back and say, “How do I want to spend it? Where do I want to put my emphasis? How do I keep people healthy? How do I prevent people, potentially, from getting ill? How do I get people to take responsibility for their own actions, since the bulk of healthcare problems are the result, in part, of lifestyle, behavior and social circumstance.”

People do things to themselves, which causes an awful lot of problems. Now you can refocus the whole thing. It also focuses the whole organization thinking differently. Our insurance company has only been in business six or seven months. Right now, we have over 10,000 members.

We anticipate having almost 40,000 by the end of 2015. We have been growing it relatively slowly, because you want to make sure you make these transitions carefully. Great new ideas, if you move too fast sometimes, disrupt the core business too and can cause some severe problems. We have to avoid those.

RT: You talked a lot about how that is going to benefit the overall hospital. Now explain how it is going to benefit the individual member of that insurance company, the person who pays their monthly or annual premium.

MD: If you do it right, you are able to use the network of services of the health system. We have all of the various components of healthcare delivery. You are able to use all of those to work with the individual to provide the care in a much more coordinated way, focus on health and not just only illness, focus on health education and focus on getting the person to engage more in working on the improvement of their own health.

It changes the whole dynamic. Remember, we have always only gotten paid after somebody got sick. If somebody got sick, they showed up at a facility, we did something to them and we got paid.

There is no focus on the overall holistic nature of dealing with individuals.

RT: Clearly, there has been a lot of debate about the healthcare systems in England and Canada. Some people love it, others hate it. These are old systems. What’s good, what’s bad ?

MD: You have to put that question into context about people’s expectations, historic culture, the nature of those countries, the capitalism focus in the United States vis-à-vis the socialism focus in many of those other countries. It is very hard to look at these systems in total isolation from that context. You have to understand the context.

With that understanding, in those other systems which I am somewhat familiar with because as you can tell, I grew up in Ireland and we have a system like that over there, and I am involved in it today, in trying to figure out how to make some changes, they have universal coverage. Everybody has coverage. Everybody has insurance. Having insurance is not the same as having access. I will come back to that point. They are two completely different things.

Everybody says they want universal insurance coverage. That is fine. That does not mean anything if you do not have access to care when you need it.

They are very primary care focused. In general, because there are outliers here, they are more primary care focused. The problem with those systems is that, in many ways, they limit innovation and entrepreneurship because they are government micromanaged.

​Those systems are in a straightjacket with very little freedom for the practitioners of care and the people who administer the local care, to be able to be innovative and doing things differently, because they are going outside the rule book.

You need guidelines, but you do not need to be rule constrained.

I am afraid in the United States we are moving toward that kind of an orientation, which I do not think is the best thing for healthcare in the long run. I think in part, that is an outgrowth of recent legislation that was passed in the U.S., where everything is by the rules.

If you run a hospital these days, even here, you are inundated with new rules every day. Most of them do not make a heck of a lot of sense. Many are conflicting. In those other countries, if you talk to a local hospital administrator like I have spoken to many times, they have very little flexibility about who to hire.

They have very little flexibility about who to let go. In fact, they cannot let people go in general. They have very little flexibility about capital budgets.

I often wonder, when I talk to them, what they do. They cannot do too much. They are totally constrained. Government has a role in setting rules, which it should do on the roads. You can only drive on one side of the road, if you are going east, you can only drive on the other side coming west, you cannot let the people drive whatever the heck they want to drive.

But the government should not be driving the car. Set the rules, but do not drive the car.

RT: As all these changes happen, and because you are an entrepreneurial environment, there are going to be core areas of medicine where the emphasis will change over the next couple of years. What are one or two areas, core areas of medicine, that are going to be very important to Northshore LIJ over the next five to ten years? What areas may not be as important as they are today ?

MD: It depends on the particular areas you look at, because technological advancements and advances in medical science will increasingly dictate changes in how we do things.

For example, let’s take cardiac care. It was not that many years ago, and it is interesting to go back and look at a number of decades, if you suffered from severe heart disease 30 years ago or 40 years ago, there was not much we could do for you. Then new technologies came in and we could have a lot of interventions like stents and surgery.

Today, a lot of the change is where there is going to be less and less of that potentially, and there are more medical treatments and more lifestyle treatments. Those kinds of developments are going to be occurring more and more.

One of the biggest challenges will be the population aging issue, the aging or the greying problem.

I have made this point many times: while everybody focuses on the failure of healthcare, you cannot pick up a newspaper today without talking about how things do not go right, and how the cost of healthcare is too high, in many ways we are suffering from a crisis of success, not only from a crisis of failure.

If we had not been so successful in keeping people alive so long, we would not have the problem of figuring out how to take care of people and the expense of taking care of them, if we had not been so successful in extending the life cycle.

We have added 35 years to life in the last 100 years. You have this increasing and growing, aging population where comorbidities and chronic illness are going to be a huge challenge. It does not necessarily mean this care is always going to have to be delivered in a hospital. The role of home care will increase dramatically, as well as the role of ambulatory care.

The tradition has always been if an older person gets sick, put them in a hospital or put them in a nursing home. Now you can actually do an awful lot in the home.

Neurosurgery and neuroscience is going to become huge, just like cardiac was years ago. I think neuroscience is a growing area because of the advances in science. We know more about what we can do. We can do things today we could not even imagine doing years ago.

Behavioral health, mental health issues, which is an unbelievably large unmet need, and we are one of the largest providers of behavioral health in this region. This is going to be a major thing. There is a mental aspect to so many of the things we deal with, but we have not been very good at integrating them into the health part of the business, along with the medical. I do not think we have figured that one out yet.