Rebooting Health Care: An Optimistic Outlook

Interview · June 11, 2019

Michael Dowling Charles Kenney and Tom Lee head shots

Thomas H. Lee, MD, interviews Michael Dowling, MSW, Chief Executive Officer for Northwell Health, and Charles Kenney, Northwell’s Chief Journalist and a well-known author on health care quality.


Tom Lee: This is Tom Lee for NEJM Catalyst. We’re talking today with Michael Dowling, the CEO for Northwell Health, and Charles Kenney, [Chief Journalist] there. Charles is also a well-known author and thinker on health care quality. Northwell is New York’s largest health care provider, with 23 hospitals and more 665 outpatient locations. These two gentlemen live in the real world and they know its problems, but they’ve published a health care book that’s remarkably different from most recent health policy books that I’ve read. It’s actually optimistic. I’m holding in front of me now: Health Care Reboot: Megatrends Energizing American Medicine.

Michael and Charles, the conventional wisdom is that our system is broken, but your book Health Care Reboot suggests that we might be on our way to greatness. Is that really the way you feel? Mike, do you want to chime in first on that?

Michael Dowling:  Yes. That is the way I feel. I recognize our deficiencies and problems in health care as we know it today, but if you look at the history of health care over the last 4 or 5 decades, it’s a history of phenomenal success. We are much better off today than we were decades ago. And looking forward, based upon the history of the last number of decades and the trends that are going on today, we’re pretty optimistic about the future. We believe that optimism is important, and that there is a great basis for optimism about the possibilities that we can achieve over the next number of years.

Lee:  What’s impressive about the book — which I did enjoy a lot — it’s not a long book, but its sweep is impressive. You touch on many different types of issues, but you do it in an optimistic perspective. Like hepatitis C treatments are not viewed as a financial disaster; they’re viewed as a medical miracle. You’ve divided a whole range of topics into what you call “megatrends.” I was wondering if each of you might pick one or two of your favorites, say what you mean by that megatrend and why the developments make you feel optimistic. Charles, maybe you want to go first.

Charles Kenney:  When we were writing the book, we came to the conclusion that all of the trends that we wrote about, individually and collectively, have a certain power to them, and I feel a real sense of optimism around all of those things. But I suppose the one that, to me, is the most powerful is payment reform. If you can shift from fee-for-service to a value-based payment system and get closer to real value, and the type of value that you and Michael Porter have been writing about, then you make enormous strides. If you look at some of the Medicare Advantage plans right now that are taking full risk and getting up-front payments for taking care older people, who have many medical needs, multiple complex chronic conditions, you’re seeing from innovative startups — like Iora, Oak Street, CareMore, and others — some progress in terms of quality and affordability.

What you get with value-based payment is you give providers the freedom to practice the way they want to practice. The freedom that they get is enormously valuable, and it moves us to an important new place. The other thing that you get with value-based payments is you move more toward the [social determinants of health] that Michael has spoken often about in the past, both from his experience in government and in leading the health system. So with payment reform, you get a big bang for your buck.

Lee:  Clearly, the payment changes are huge and they’re intertwined with a lot of other topics, as you suggest. Michael, what megatrend would you highlight?

Dowling:  There are two of them that are obviously a bit connected. We should feel unbelievably optimistic and positive about the increasing recognition and the actions being taken by many health organizations across the country on the social determinants. The recognition that health is more than just the delivery of medical care and that if we don’t deal with the nonmedical — the lifestyle, the behavior, and the environmental issues — then we’re not going to affect health care quality and outcome over the long haul. And the recognition by almost everybody that I’m familiar with that this is an area that requires and is getting more and more attention is a wonderful thing, because it defines health in its broadest sense. I know that over the decades, this has been discussed, but I do think today there is much more action being taken by most health systems I am familiar with that are innovative and progressive in addressing that.

The second one that is equally as important, but interconnected, is the response to the increasing issue of consumerism. The recognition that what’s important is understanding that we have to deal with patients and consumers from their perspective. We have to listen to them, we have to make sure that it’s not just about what providers and others say is good for them that matters. It’s what’s good for the consumer that matters. The more consumer-centric and patient-centric we become, and seeing patients as consumers of health care — which means we have to enhance our service delivery, our service offerings, our responsiveness — this is something that will dramatically, over time, change health care in a very positive way. We see examples of that each day in our business and in our organization. The combination of consumerism with the growing emphasis on technology, enhances in consumer-based technology, is something that we should feel unbelievably optimistic about.

Kenney:  It’s interesting what Michael said because he touched on a series of things: consumerism, social determinants, technology. Adding that to the payment reform we talked about earlier, right there is a series of powerful things that are happening in health care today. But even an avid reader of many different journals isn’t going to find much in the way of positive coverage of those sorts of things, certainly not in the popular press. There was a [recent piece] in the New York Times where the headline talked about the “disaster” of the American health care system. What we tried to do here, as Michael outlined, is identify those specific things that are real, that are happening on the ground at the front lines and that are moving us in a positive direction.

Dowling:  Negativity gets quick attention. We do have an avalanche of negativity, especially from many of our public leaders and people on television, but when you’re on the ground like we are on a regular basis and have been for quite a while, we see the facts and understand that there are a lot more positive things going on. If you’re optimistic and you have an optimistic outlook, you see the potential. It’s also important for all the tens of hundreds of thousands of staff who work in health care to be recognized, that people understand the good things that they’re doing each and every day. Otherwise, it becomes demoralizing. It’s not true, all this negativity, and it misrepresents what’s good about health care in this country.

Lee:  It’s not often that I worry about being the least optimistic person in a room. Let me go a little deeper with social determinants. I’m a big believer in its importance. I think everyone understands that, how important they are now, but it’s been like the weather: everyone talks about it and no one does anything about it. In your book, you get to some examples that suggest that maybe we’re moving into a period where people are doing things about it, e.g., Northwell, Kaiser Permanente. Is there an example or two that you might put out there for the audience to suggest that, yes, something actually is happening?

Kenney:  There’s a lot happening at Northwell, and Michael can speak to that. Michael and I were recently talking to Patrick Conway, who, as you know, Tom, recently left his position leading the Center for Medicare and Medicaid Innovation. Patrick is now the CEO at Blue Cross Blue Shield of North Carolina. He announced an innovative program where he has gotten five of the largest provider organizations around North Carolina to buy into a value-based payment approach, where the core of the whole approach is focused on the social determinants of health. I don’t know exactly what their blueprint is, but there is a commitment there, and you’re talking about a person leading that who has many years of experience in the federal government, saw a lot of pilot projects around social determinants. And that’s the whole state of North Carolina — that’s a significant laboratory to test things out in. So that’s a very important and good piece of news.

Lee:  Going deeper in consumerism, a lot of your chapter there is about measures, measures that matter to patients, that “actually matter,” as you put in your subtitle. That suggests the measures we currently use, a lot of them may not matter so much to patients. Can you give our audience a feel for measures in both categories, ones that we’re currently using that don’t matter to patients and some that you think we should be emphasizing more because they really do to the new era of the patient consumer?

Dowling:  Let me answer this one briefly. Most of the measures that we use at the moment are measures that are primarily connected to what happens inside a hospital setting. But increasingly more and more care is being delivered on the ambulatory side, outside the hospitals. A lot of things that we currently measure inside, such as documentation, process measures — things that in my view don’t necessarily add to the outcomes of the quality of what happens to the patient or what’s good for the patient — would consume an awful lot of time for the providers and the nurses and the other staff, people who work with them. That area needs to be dramatically rethought.

The other thing we need to be focusing on is along the area of convenience and access, and asking the patient and the patient’s family what matters to them, taking a view from the outside in rather than taking a view from the inside out, which has been typical in health care over the decades. If we look at people as not only patients, but as consumers, like any industry that you deal with on a regular basis, when they want to find out how they respond, they look at what’s good for the customer and then they respond in kind. I do believe that there needs to be major refocus on minimizing the micro-regulations and the micro-measures that we spend an awful lot of time engaged in that I don’t think add much at all to a person’s health.

Kenney:  And I would add to that, Tom, that in terms of measures — and it hasn’t maybe taken hold in any way definitively, nationally or internationally — you and Michael Porter have written about outcomes achieved that matter to patients as sort of the holy grail in measurement, and the ICHOM standards that Michael Porter and his colleagues have put together are extremely interesting. Again, it’s not far down the road, but more and more people, certainly who I run into and talk to, are aware of it, understand it, and are willing to try to dig in more deeply into it and consider adopting that kind of thinking. Rome wasn’t built in a day. These sorts of things happen slowly in health care, but that’s a positive sign that more people are interested in that and talking about it.

Dowling:  Let me add onto the question you had earlier about social determinants. One of the things [we’re working on] is providing healthy food to patients who don’t have access to healthy food. Looking at food as medicine and basically figuring out how to educate people — which we’re doing — better on nutrition and nutrition intake, using nutrition cultures and nutritionists to help people cook, to buy food for them, help them in figuring how to buy healthy food. Those are the things that we need to be focusing on much, much more and also measuring, because food is medicine and we have to treat food as medicine. That’s why inside Northwell, we have recently hired a Michelin Star chef to head up our food services inside all our facilities rather than looking at only the provision of medical care.

Lee:  As we start to wrap up here, I know that there are these other chapters like on medical advances, technology, and behavioral health, and the advances within them are all thrilling. But collectively, I know that some policy experts and some clinicians would raise concerns they’re going to overwhelm us financially, and they’re going to overwhelm us in terms of what we have to do and cause more burnout and so on.

Clearly, you guys understand that there are some things we have to do if we’re going to accelerate the progress as possible as opposed to just creating tremendous disruption with the side effects and the turbulence that results. What two or three things can we focus on to help make your optimistic vision of the future move more quickly?

Dowling:  For me, it would be that anybody who is involved in health care needs to stand back and ask themselves the question, “What do you mean by health?” If you take a holistic view of health, we have to dramatically do things differently than we have been doing in the past and focus on those things that, overall, we believe improve health. Because maybe [80 to 90%] of it basically has to do with nonmedical.

I would say focus on the trends that we outlined in the book. I know it looks like a lot, but if we eliminate a lot of the unnecessary regulatory things that we currently have to comply with — there’s a plethora of them — reduce the unnecessary documentation that results in burnout increasingly, and focus on those things that we dramatically believe improve health in the long run, I think that you will provide a more optimistic view of what’s possible. If people know that they’re doing things that improve health long term, I believe that the employees who work in these organizations all over the country will be much more engaged to do that which will move the ball upfield rather than continuing to do things the way we’ve always done them.

Lee:  I think that your perspective is the right one, it’s the long view, and I do think that your book makes the argument that, to paraphrase Martin Luther King Jr., the arc of history is toward a better health care system. It is an arc because there’s a lot of stuff to surmount in order to get there, but your book is going to make everyone who works in health care feel better about what they’re doing, and I hope it will help us do what we do better as a result.

I thank you for your writing it, and I want to thank you for the work you guys do to turn it into reality. We will be checking in as the years go by to see how your perspective is evolving. Thanks again to both of you.

Kenney and Dowling:  Thank you, Tom.

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