By George Capsis
I first heard the Limerick accent of Michael J. Dowling four years ago as he stood on the stage of P.S. 41 where my wife and I had sent our three kids, and where I had been the President of the PTA.
Dowling was trying to reassure a packed auditorium that the urgent care facility they planned to build in the Joseph Curran building would take care of 85% of all medical emergencies. I got up on the stage to say that I was not concerned with the 85% but the 15%. I pointed to him sitting in the front row and demanded that he open the closed St. Vincent’s Hospital. The chant was picked up by the audience—“Open it, open it.”
A few days ago, I heard that Limerick accent again: There was Dowling being interviewed on “The Long Island Business Report” and I began to hear a clear, frank summary of the hospital business today. It was a near-perfect summation and I wanted our readers to read it. So, I emailed Terry Lynam (yet another Irishman), Senior Vice President and Chief Public Relations Officer at Northwell, to request a transcription. He kiddingly replied, “It’s going to cost too much,” and sent me the video link. We did the transcription ourselves and I kiddingly sent it to him.
But before I start to quote Dowling, I want to go back to what I learned of his background. It is an unmatched story of dignified poverty elevated to a position of surprising power. But he is still the lad from Limerick without a shadow of pretension.
In an earlier television interview, Dowling talks about growing up in Limerick as the oldest of six. His father worked for the county as a road worker and had to walk or bicycle miles to get to work each morning. Dowling’s mother became totally deaf at age six after taking an improper dose of medicine. Later, his father became disabled with arthritis and could not work, leaving Michael the principal wage earner for the family.
The family lived in a three-room thatched home built in the 1850s with a dirt floor, a large middle room with a fireplace, and two small rooms. Dowling slept three in a bed. After heavy rains, the walls became so damp that if you brushed up against them you came away wet. There was no electricity, no hot water, and only outside toilets.
They lived in farm country but they had no farm, and from a very early age, Dowling worked as a farmhand milking cows and killing pigs which they salted and hung. One night, during a particularly heavy rain, the thatched roof collapsed. However, they rebuilt and Dowling smiles when he adds, “Now they build thatched huts like ours for the tourists.”
One day, a neighboring farmer who was sending his son to college looked at Dowling sadly and offered that, with his intelligence, it was too bad he would never to college. A steely resolve to do just that coalesced in young Dowling’s mind. To get into college, you had to achieve a high score in high school. When the envelope containing the results arrived, Dowling let it sit for hours before he teased open the flap in sheer terror that he had not made the score and would be a workman for life. He made it though and came to New York for his advanced degrees. Ultimately, Dowling received a call from Mario Cuomo for a job in Health and Human Services. He then moved on to the Long Island Jewish Hospital and up the ranks to President of Northwell.
Northwell is the largest health organization in New York State and the largest employer with over 60,000 employees; they hire 175 people per week. (Dowling gives a little speech of encouragement and challenge to the new batch of employees every Monday morning.)
Since first hearing that Limerick accent on the stage of P.S. 41, I have made the pages of WestView available to people like Dr. David Kaufman (who led the fight to save St. Vincent’s Hospital) to campaign for a new hospital to serve the West Village and indeed all of Lower Manhattan. (We only have the relatively small downtown hospital south of the Brooklyn Bridge, which on September the 11, 2001, treated 160 patients and admitted 40. It performed multiple surgeries with only one death. After that day, could anybody argue that we did not need St. Vincent’s and that we should sell it for condominiums?
Through the half-century my family lived on Charles Street, my wife and children’s medical emergencies were treated at St. Vincent’s so I was unable to accept that an “urgent care” center could replace a 161-year-old hospital—and I still am.
However, both the practice and business of medicine has changed. Forty years ago, while showing off, I lifted a heavy garden slate and felt my intestines pop through my flabby muscle wall. I found myself at Mount Sinai with two young surgeons vying to cut me open, push back my breakfast, and sew me up. I awoke in the hospital bed and left the next day.
About three years ago, I had another hernia for again trying to lift the same garden slate. That time, I was treated at Phillip’s Ambulatory Care Center in Union Square. The new “procedure” was performed with remote instrumentation in 20 minutes. I was then conducted to a chair to await full recovery and instructed to make room for the next patient in 30 minutes.
The ribbon-cutting ceremony at the Northwell Health Urgent Care Center took place on Wednesday, October 26th and celebrated a row of six new ambulatory surgery units. That is the operative word, ‘ambulatory.’
In the old days, management would boast about how many beds a hospital had. Now, it is their margin or profit, which brings us back to the words of Dowling’s interviewer who asked if hospital consolidation is a good thing.
In his interview, Dowling states, “Oh. I believe so.” He goes on to say that many of the small hospitals would be out of business now without consolidation. If you have a hospital in an area with lots of Medicaid and little commercial payment, that hospital is in trouble. Medicaid does not pay you enough to run the hospital. Dowling singles out Brooklyn hospitals, 80% of which are troubled. They are losing hundreds of millions of dollars and they will go under unless a financially stronger hospital acquires them.
However, Dowling cautions that acquiring distressed hospitals is dangerous and that Northwell is more and more getting out of the traditional hospital business. The biggest growth in the last decade is the expansion of ambulatory locations. “So while we have 21 hospitals today, [we] have almost 600 ambulatory locations.”
An ‘ambulatory’ location can be as big as a 50,000-square-foot cancer center or it can be a lobby suite of offices on 15th Street. That is where Alex Hellinger, the Executive Director of Northwell Health, sent me. There, I interacted with a lovely female doctor three months out of medical school who takes my vitals every month and offers, “You should exercise.”
Northwell now makes $11 billion per year with a profit of 1% to 1.5%. Other parts of the country show 5% or 6% profit margins with lower labor costs.
Dowling offers that they try to financially balance the kind of medical services they provide. “If I were to sit back and say I only want to do cardiac and I only want to do orthopedics and only want to do cancer. Oh I can make a margin of [5%, 6%, 7%]. But then I’m not treating the totality of the population. I’m avoiding the tough stuff.”
Many of the other hospitals that are compared to New York hospitals don’t have psychiatric facilities. You lose money on psychiatric hospitals because they mostly treat patients with Medicaid. (Northwell has a psychiatric hospital.)
To the interviewer’s question, “Will the cost of medicine come down?” Dowling offers a “No.” At best, we can slow the rate of the increase. Thanks to advances in medicine, people are living longer and it is the elderly that need medical treatment. Years ago, we could do little for a heart condition but now we can open the chest and insert a stent. (Dowling noted that he has one after a heart attack a few years ago.)
The television interview ending left me with raised eyebrows as Dowling offered that they had become venture capitalists and that they had 80 new ventures!
The shift to becoming a new business investor is dictated by the fact that, with a growing number of patients using Medicare and Medicaid, the government is your biggest payer and it keeps reducing the amount it pays you.
Therefore, you have to create ways of making money, so Northwell starts a lot of new businesses. But in the end, Dowling wants to be in the business of “We’re the best at keeping you well and the best at taking care of you when you are sick.”
As the ribbon cutting ceremony ended, I got up and revealed something that Dowling had just confided (they are looking at opening a catheterization lab to treat heart attacks—the one medical capability I have been demanding) “But you know, [it is] difficult to get permission [for cath labs],” stated Dowling, referring to the New York State Department of Health Commissioner. So now I will turn the WestView guns on Albany.
In Michael Dowling we have a sincere and supportive partner to bring back a good part of St. Vincent’s Hospital. I am glad we are now both on the same side.