Michael Dowling Has a Thing or Two to Say About the State of the HSE

Sunday Business Post
July 24, 2016

CV: Michael Dowling
Role: chief executive of US healthcare operation Northwell Health
Age: 66
Lives: Northport, New York
Family: married to Kathy with two grown-up children, Brian and Elizabeth
Favourite film: Analyse This
Favourite book: The Immortal Irishman: The Irish Revolutionary Who Became An American Hero, by Timothy Egan
You may not have heard of Michael Dowling, but he is a big deal in healthcare. He has Enda Kenny’s ear, advising the government on the future of the HSE, particularly the hospital system. And in the US, the Limerick man is a really huge deal.
Dowling, who runs a giant healthcare company called Northwell Health, has advised two US presidential administrations. Barack Obama and Bill Clinton both attempted to headhunt him to be part of their White House teams.
Presidential hopeful Hillary Clinton has made overtures to him for the Secretary of Health role in her administration if she succeeds, though he has said he is not interested.
He has too much that he still wants to do in his own business, he says.
Northwell Health is a $9.5 billion not-for-profit operation that is expanding fast towards becoming a $15 billion-plus group. That’s close to the operating budget the HSE also runs on.
Northwell has a network of 21 hospitals, hundreds of clinics, care homes and other health facilities, and employs 61,000 people. It is the largest employer in the state of New York and the biggest provider of healthcare in that 20 million population catchment.
Dowling is well remunerated. His salary is in the region of $1.4 million, with a performance-driven bonus of more than that amount. He travels back and forth to Ireland regularly and has hard-hitting views on how the Irish health service should be run.
We meet at his Manhattan office in a high-rise off Park Avenue, with incredible skyline views.
It’s a long way from Knockaderry, west Limerick, which he left well over 30 years ago. Apart from the occasional New York turn of phrase, he still speaks with such a beautifully rich Limerick accent he could have stepped off the plane yesterday.
Dowling is almost a cliche of the Irish emigrant self-made success story. He grew up in what sounds like fairly horrific poverty in the 1950s, in a thatched house with mud floors and just three rooms for the family of seven. There was neither electricity nor running water.
From 15, he was contributing to the family income, travelling to England during school holidays to work in a steel mill in Crawley.
Though she had little opportunity for formal education herself, his mother was passionately interested in it and there were always books at home, if not much else. Dowling remembers reading Shakespeare by candlelight as a child.
He did well in school and got into University College Cork. To earn his tuition, he would travel to New York each summer to work on the docks and at any other jobs he could get, making his fees and sending money home. After UCC, he went back to New York and enrolled part-time in Fordham University for an MA in social policy.
He joined Fordham’s faculty, but when Mario Cuomo became mayor of New York in 1983, he asked Dowling to join his team. Dowling became his deputy secretary and director of health, education and human services.
In the 1990s, he took up the job of running hospital services at North Shore, a predecessor of the business he now leads, then just a small group of Long Island hospitals.
He became chief executive in 2002 and, under his leadership, that operation has grown exponentially into a profitable business and the 14th largest healthcare system in the US.
So what changes does he recommend for the Irish healthcare system? Keeping people out of hospital whenever possible, for one thing, he says.
“The hospitals of the future will be for intensive care patients. Up to 40 per cent of people in a hospital should never be there at all. You’ve got to build the outside infrastructure. So I would start with the creation of a real substantive network of ambulatory care services. And stop being hospital-centric.”
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There has been talk in Ireland for years about the kind of integrated structure of primary care and other off-hospital facilities that Dowling refers to, to stop the pile-up of people in emergency departments or on waiting lists.
“I have said over and over again that, in the Irish system, they cannot fix the hospital side of the business without building a major outpatient network of services.”
In his operation, there are more than 500 locations outside the hospital network. “Some of these are very, very large, some of them are bigger than the hospitals. Primary care, imaging services, surgery – shoulder surgery, knee surgery – if you needed surgery, you wouldn’t [necessarily]go to a hospital at all in our system. They take you in in the morning, you’d be home by the afternoon. In and out.”
His is a highly competitive environment, and he thinks the public health system in Ireland suffers without competitive rigour.
“If a hospital or a facility doesn’t do well, there’s really not much you can do, there are no penalties. Here, if I don’t do well, the competition eats my lunch. So it changes the way you think,” he says.
“You’ve got to have a network of hospitals that work together as one integrated organisation, so that there’s movement of people and patients and information back and forth between them. I’ve been like a broken record on this, but it’s hard to get people to understand.”
Though Dowling knows that changing the HSE is a tall order, he says there needs to be management responsibility and quality targets that have to be met.
But what do you do about a cadre of managers who have been around for decades, who have survived many reworkings and restructures, and who may not be fit for purpose?
“You have to make changes,” he says. “You can’t say, ‘I’m here, and nobody can get rid of me’ – that’s an awful situation for everybody. Over there, it’s harder to do that, but you have to. Here, I’ve been in meetings where someone says: ‘Well, that person doesn’t agree’.Well then, let him go. Fire him.
“It’s hard. Everybody is scared. But you’ve a lot of people out there who want to be innovative, who will jump at the opportunity if they’re allowed.”
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Dowling has seen how the Irish health service functions close at hand. He has brought relatives out to the US for treatment to escape long waits for relatively routine surgeries or examinations, and he relates the detail behind one such case, getting animated and a little annoyed, and suddenly sounding very ‘New York’.
“I said, ‘Are you goddamn kidding me?’ It makes me so mad that people tolerate that. I mean, god, over here, you’d get fired on the spot for that kind of crap.”
His organisation is a massive machine. It gets over 600,000 job applications a year and hires 200 people a week, all of whom Dowling says he makes a point of meeting personally when they start work.
Northwell has its own nursing school, a medical school, even an insurance company. It has around 120 joint ventures with other companies.
Dowling has just set up a pharma venture arm to liaise with companies like biotech giants on teaming up on joint projects. It has its own central purchasing organisation, a $4 billion business that buys not only for Northwell but also sources stents, gloves, prosthetics etc for other healthcare firms.
It has about 140 ambulances and its own helicopter service. “We get crowded in our A&Es, but if I get crowded in one hospital, I can move patients to another hospital.”
Dowling has just signed a deal with a big health network in Australia, and Northwell is about to take over another facility in Brooklyn with a budget of about $1 billion. “We will be a $15 to $20 billion organisation in the next five years or so,” he says.
Would he ever, or has he been asked to, get involved in the Irish health system in a more hands-on way?
“You mean, running things over there?” he says. “I’ve been asked about some facilities and they’ve talked to me and I’m over there quite often, so I do get involved, and I’ve talked to Enda Kenny quite often. He’s been here, he spent half a day with me here and I took him to some of our locations.”
“It would be very hard for me to work in that culture, because I can’t be constrained by rules that don’t make a lot of sense. I would shoot myself within a week. It would be very hard for me to be told ‘There is a document of 500 pages you have to follow’.”
He has also had to tackle and rebuild broken operations.
“Most of the hospitals we took over were in terrible condition and losing money,” he recalls. “We’ve fixed them all. But it took time, sometimes years. You can’t do it quickly.
“In Ireland’s situation, and I’ve been telling everybody this, if you want to change the health system to be better than it is today, you’ve got to commit for ten years. It takes a long time.”
When asked who might replace Barack Obama in November, Dowling thinks Hillary Clinton will make it. He doesn’t have much time for Donald Trump.
“Politics is a funny business because things can change very fast, but I think Hillary will end up winning at the end of the day. I know her pretty well.”
Among the glaring faults of the US system, one which ‘Obamacare’ attempted to address, is the terrifying limbo that exists for people who don’t have a job or can’t afford health insurance.
“Everybody can get care,” Dowling insists. “We’ll never turn anyone away and we’ll eat the loss. That’s what most of the companies do here. And you won’t wait either.”
I say to him that this is not the outside view of US healthcare.
“Obviously, with individual private physicians, most won’t take you. But organisations like us, we take you. We have to, by law. That’s why we’re not-for-profit and have a tax exemption.”
Dowling has been married for years to Kathy, whose family is of Irish emigrant extraction, and they are about to spend a weekend together in Manhattan, a rare mini-holiday for him. But this business is his other love affair.
“To me it’s exciting, I get up every morning and cannot wait to get to work. I get up around 4.30am, I’m out of the house at 5.15am, I’ve meetings at 6 or 6.30, I just get a high from the ability to do things differently and disrupt and change. We struggle with ourselves on how we can do something differently and better.”
And there is a hell of a lot he wants to get done. “We’re going to get a lot bigger, we’re expanding all the time,” he says.

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