Nassau University Medical Center and Stony Brook University Hospital expect to hear news within the next few months that could mean hundreds of millions of dollars for Long Island and fundamentally change how they and scores of other local health care organizations do business.
Both have been designated lead organizations on Long Island in the state's Delivery System Reform Incentive Payment, or DSRIP, program. Part of the state's attempt to overhaul the health care system to improve care for low-income patients, DSRIP will allocate $6.42 billion to safety net or public hospitals and their community collaborators statewide over the next five years.
The goal? To cut avoidable hospital use among Medicaid recipients by 25 percent by the end of 2019 or risk losing this federal funding.
"This is the biggest change since the formation of Medicaid and Medicare," said Dr. Victor Politi, chief executive of NuHealth, a public benefit corporation that includes NUMC. It "is going to change the face of health care."
The money comes from $8 billion the Centers for Medicare & Medicaid Services gave back to the state after New York's 2011 Medicaid Redesign Team reforms saved the federal government $17.1 billion.
But unlike some other programs, this money is tied directly to performance: Unless the hospitals and their collaborators meet specific goals each year, they don't get the bucks.
NUMC has already gotten $37.3 million and Stony Brook $8.5 million in interim DSRIP funds to bolster their finances as they develop their programs.
The other unusual requirement: The hospitals must collaborate with other hospitals and health care providers, many of whom typically see each other as business rivals.
"If it works, it's going to be great," said Kevin Dahill, chief executive of the Nassau-Suffolk Hospital Council. But that "if" is not a small one, he said: "How do you get all these disparate organizations to come together when very often they are in competition?"
But, he said, those involved in the state's Medicaid redesign process came to see that cooperation among all health care providers was the only way "to break down the walls that would make care more seamless and efficient."
If successful, Dahill said, it could affect not just the 749,000 Long Islanders on Medicaid or who are uninsured, but also how medicine in general is practiced. The approach is in line with goals of the federal Affordable Care Act that focus more on keeping people healthy and out of the hospital to reduce costs.
Politi acknowledged the challenge of getting everyone -- especially other hospitals -- paddling in the same direction.
"This is no small feat," he said. "This is kind of like getting five major countries to sit around a table and share information."
Politi is presiding over a collaboration of more than 6,500 partners, ranging from all the hospitals in Nassau County and eastern Queens and the Rockaways, to social services and housing agencies, community-based organizations, health plans, health homes, physicians, pharmacists, nursing homes, labs and dental groups, among others.
So far, he said, cooperation has been "forthright and forthcoming."
Similarly, Stony Brook is working with about 300 organizations, including all the hospitals in Suffolk County, the county health department, nine county health clinics, 46 nursing homes and certified home health and long-term care agencies, private physicians, dental practices, pharmacies and community-based organizations, among others.
Each of these partners stands to get a portion of the money from the state if they meet their goals.
"They are tying everybody together to build an integrated delivery system," said Gary Bie, Stony Brook's chief financial officer. That means, he said, they must forge "stronger primary care networks and migrate the inpatient [hospital] business to outpatient, appropriately."
Both Stony Brook and NUMC have been working for months to choose among a list of projects to tackle over the next five years to reach the state's goal of reducing avoidable hospital use.
'Holy Grail of health care'
Both have proposed 11 projects each, after conducting community assessments to figure out what their low-income residents need.
Many of the proposed projects focus on improving ways to manage care, especially for chronic diseases such as heart disease or diabetes, as well as mental health problems or substance abuse. That means following up with a patient who may have other social issues related to poverty and coordinating his or her care among the labyrinth of doctors, specialists, rehab centers, community groups or nursing homes he or she may see.
"This is the Holy Grail of health care," Bie said. "It's not easy stuff."
But the stakes -- and money -- are high, especially for the hospitals, which are being asked to cut their inpatient business and take responsibility for the whole spectrum of a patient's care.
"If you're not on board, you're not going to get the financial benefits, and hospitals have the most to lose overall," Bie said. " . . . We think it's the right thing to do. It's our turn to try to implement change."
DELIVERY SYSTEM REFORM INCENTIVE PAYMENT PROGRAM
The goal: Cut Medicaid recipients' avoidable hospital usage by 25 percent by 2019.
The plan: The system will allocate $6.42 billion to safety net hospitals and community collaborators statewide.
The catch: Unless the hospitals and their collaborators meet specific targets each year, they don't get the bucks.
So far: NUMC has received $37.3 million and Stony Brook $8.5 million to develop their programs.