Among organizations impacted by the first wave of Covid-19 in the spring, few stand out more than Northwell Health. Situated in the heart of the New York Metropolitan Area, Northwell was hit quickly and hit hard. Over the first three months of the outbreak, Northwell treated around 50,000 Covid-19 patients—15,000 of which were admitted to the hospital. Northwell's CEO, Michael Dowling, recently sat down (virtually!) with Aaron Mauck, a senior director at Advisory Board and Northwell’s Research Partner, to reflect on how Northwell responded to this extraordinary event, and to consider the lessons Covid-19 holds for the future of health care.
Question: Michael, thank you for taking the time to speak with me. I want to start by asking you a little about your experience as a system addressing the Covid-19 crisis. We know that achieving a more integrated approach to care was a priority for many systems before the Covid-19 crisis, and has only become more important in the midst of the pandemic. Did you find that operating as an integrated system put you at an advantage in confronting Covid-19?
Michael Dowling: Yes. Fundamentally, we saw the benefits of being a truly integrated health system rather than a series of individual facilities. For example, I'm the CEO of each hospital and facility. Our local operations differ from location to location, but we operate with a single clinical and administrative leadership. The crisis hit us with such severity that if we had been operating as if our hospitals were quasi-standalone facilities, these hospitals would have been dead in the water. The only way we were able to deal with the crisis was by having all the components of the health system—hospital, ambulatory, post-acute—all working together.
This allowed us to "load balance." We moved almost 1,000 patients from overrun hospitals in the epicenter of the pandemic (Queens and western Nassau County) to other hospitals that had more capacity. We were moving 60 to 70 patients a day. If you don't have systemwide integration, you can't make that happen. We also have our own transport system. So, when I needed to move patients from one hospital to another—and I'm talking about moving them 20, 30, 50 miles, or more—all it took was a phone call. It didn't take a debate, a discussion, an argument—it was a phone call. And it happened.
A lot of systems call themselves "integrated," which means that they look good on a map. But they're not functionally or clinically integrated. In my view, larger integrated systems have proved their worth during this pandemic, especially in New York where we saw such a large volume of cases. Because of our integration and preparedness, we managed it pretty well.
Question: At the same time, I think we all know there is still a great deal of running room when it comes to designing truly integrated care delivery. Have you found areas of opportunity in the midst of Covid-19?
Dowling: Yes, one area where there is clearly room to improve is in coordination among competing entities. One of the things we did in New York during the crisis was to get all the systems to work together. The five big systems got together every other day using virtual platforms to work out what we needed to get done collectively. We shared information, we shared policies, we talked about how to move patients back and forth, and we talked about clinical research and testing capabilities. We'll still compete, but there are areas where we can continue to work together after this crisis. One of the areas where I think we can coordinate moving forward is in helping communities that have been disproportionately impacted by Covid-19.
Question: The pandemic has certainly prompted greater discussion of the health disparities that prevail between different communities, both in New York and across the country. But this is one of those areas where we've seen a lot more discussion than action in the past. Do you think Covid-19 will prompt health systems to approach health disparities in a different way?
Dowling: In our case, the Covid-19 crisis made the problem of health disparities so visible that we absolutely had to respond. We've always worked with underserved communities to some extent, but it's clear we need to do significantly more in those communities to foster health by strengthening infrastructure and providing more effective preventative care. Over the past several months, we've worked with 64 faith-based organizations within underserved communities throughout the New York area, performing thousands of antibody and diagnostic tests for Covid, and we will continue to do this work going forward.
But it's an open question how we're going to sustain that momentum effectively. Often, when you go into underserved communities and expand your services there, you lose money. Now, people will ask, "Why don't you do capitation arrangements for those communities?" But that's difficult to do, since many people in these communities are uninsured or on Medicaid. There are pockets of private insurance, but most people don't have this resource.
We would need a new approach to get a capitation arrangement to work, and this is not something most commercial insurers have been interested in pursuing since they can't see the ROI. This would be a great area for partnerships between payers and providers, but I'm not so sure that the payers are interested in insuring people in these underserved communities. That being said, we have an obligation to figure out how to do it, and to do it in such a way that we're giving these communities what they really need. We can't go in and say, "We have a master plan for how you do it.' That's not going to work.
Question: You mentioned the potential for partnerships between payers and providers to resolve the complex payment puzzles that arise when you try to tackle challenges like health disparities. There is a lot of discussion about the potential benefits of such partnerships, but I'm curious what your experience has been working with payers throughout the pandemic?
Dowling: I've been one of the strongest advocates for increased partnerships between payers and providers. I've bent over backwards for the last five years—or more—to help build those relationships. Everybody says "yes." Everybody gives lip service. But when it comes to actually doing something, you find out that they're not really serious. During the crisis, we found the insurance companies were completely unhelpful. Despite all efforts we've put in place to get them to come to the table to be a partner, they decided they didn't want to do that.
I'm a fan of insurance companies, because I believe that without them the government will take a bigger role. And I still believe that if we don't come together to achieve something, the government is going to come in and fill the vacuum. The people that will be hurt the most by that will be the insurance companies themselves! We need to have better partnerships going forward, but I've got to tell you, the Covid-19 crisis soured me on the potential. This may not be a positive lesson, but it's a real one.
Question: Another area of considerable interest is how Covid-19 will impact care delivery. Systems have clearly seen an evolution in their strategy over the last eight months, but it seems to me some new priorities may be more permanent than others. What changes have you seen at Northwell, and how permanent do you think those changes will be?
Dowling: We're seeing a lot of changes in the organization of our services. For instance, changes in how people work. The number of people that will be working remotely on a part- or full-time basis is going to dramatically increase, so we will likely have real estate available to us now. Prior to Covid-19 we didn't have enough real estate for our employees. My guess is we will have 15,000 permanently working remotely part time or full time. During the crisis we had 30,000 people working from home.
Our approach to patient access will also continue to evolve. The ambulatory and post-acute side of the business is going to continue to grow, while our hospital footprint will not increase or will increase minimally. All our expansion in the past seven or eight years has been on the ambulatory or outpatient side. We have 800 locations now, and that will continue to expand. We often don't talk about post-acute care as much, but this is an area that is absolutely key, because you can't get people out of the hospital unless you have ambulatory and post-acute resources. So I think we're going to continue to grow in that direction. That doesn't mean neglecting inpatient services, of course. We also need to identify where we may need new inpatient capacity. In fact, during the Covid-19 crisis, we added 2,000 new beds in our health system over five weeks.
We have seen tremendous growth in the area of telehealth. We have been offering a range of telehealth services at Northwell for years, but until the pandemic, we had challenges with uptake. There was resistance to moving procedures to a virtual setting. A lot of physicians didn't want to use it, and commercial insurers and the federal government didn't want to reimburse for it. But telehealth has exploded since the Covid-19 crisis began in March. Previous opponents of telehealth became strong proponents. I believe the growth of telehealth will fundamentally change how we approach access and consumer relationships going forward. The Genie is out of the bottle now.
Question: In terms of your broader strategy, what additional lessons do you think your experience at Northwell holds for those working at other systems?
Dowling: One thing that has become clear is that you have to create a permanent culture and infrastructure around emergency preparedness. It can't be done in the midst of a crisis. It's a way of thinking, it's a cultural issue, and it's the way you approach things. Because, if you get hit as fast as we did with Covid-19, and you have to put something in place immediately, you're not going to be able to do it well. So it has to be a permanent part of your organization.
The emotional and physical health of your employees also has to become a central priority for every organization. We talk about this all the time, but Covid-19 has really elevated its importance. It's in the midst of a crisis that you realize how much you didn't do before, that you now must do throughout the crisis, and continue to do going forward.
We also need to think about how we can become much more consumer focused: Looking at things from a consumer point of view and how they define health, rather than how we define health. Virtual care and the use of technology in the delivery of care for all consumers will be part of this.
Finally, we need to think about how we can become leaders in our community outside of health care. We have influence that surpasses most other sectors of the economy, and the question is, how will we utilize that influence. Right now, the trust that the public has for health care providers and health care staff is extraordinary. The outpouring of gratitude by the public has been remarkable, and we now have that to build on. But leadership has to be visible to continue to elevate the stature of our industry. It can't be hiding. There's a responsibility for health care leaders to stand up and be counted.