Chapter 6. Funding and Sustainability

Securing funding is a key component of maintaining a vital regional coalition. In the beginning stages of a new coalition, the focus often is on identifying initial funding rather than long-term sustainability. Many funding sources are available, both private and public, that can help coalitions obtain the financial resources necessary to initiate a first project.

To build and sustain momentum, it is important to consider targeting private grant opportunities rather than State-funded resources, which can be more time consuming.

General traits that funders look for in grant applications include how well the project aligns with the request for proposal or the overall focus of funding, the applicant's capacity to accomplish goals (for example, staff size and structure), and a realistic budget closely related to the scope of the project.

Grant funding, in particular, is not seen as a reliable means of long-term development. Most of the six Better Quality Information sites rely on a combination of membership fees and grant funding to sustain the coalition. Additionally, the sites have arranged funding opportunities unique to their circumstances:

• The Center for Health Information and Research is supported by a mix of research contracts and grants for specific projects, funding from Arizona State University's Office of the Vice President of Research and Economic Affairs, and foundation grants.
• The California Cooperative Healthcare Reporting Initiative receives much of its funding for specific programs from fees paid by participating health plans and physician groups. Grants and funding from the Pacific Business Group on Health provide additional resources.
• For the first 3 years of the Minnesota Community Measurement coalition, health plans and the Minnesota Medical Association sponsored the bulk of the costs. In 2007, the coalition's funding included a mix of sponsor funding from the founding organizations, private grants, fee-for-service contracts, and federal contracts. The Minnesota Community Measurement board is developing a new long-term financing strategy.
• The Wisconsin Collaborative for Healthcare Quality is structured as a membership organization, and member dues are a primary source of funding to support the organization. The dues cover a significant percentage of the collaborative's core operating budget, with the balance supported by an unrestricted grant from a local foundation. In exchange for the dues, members receive access to coalition tools and measurement specifications, have their data reported through the Wisconsin Collaborative for Healthcare Quality Web site, and are eligible to serve on the board.

One of the challenges the Wisconsin collaborative currently faces is health care consolidation, which decreases the number of its members. For example, the collaborative recently lost four members to consolidation, reducing the base of its membership and revenue. Consequently, it will be evaluating options for restructuring its dues to include a model that tiers payments based on organizational size. This likely would have the added advantage of making membership in the Wisconsin collaborative more accessible to smaller physician office practices.

Although the short-term focus is important, a new coalition also can begin developing a sustainable business case that defines its enduring value to the community beyond individual projects. The Better Quality Information sites identified the following tips for developing a sustainable case:

• Assess your market and community. Make sure that you have a market for your services and that your services do not overlap with other community efforts. (Go to "Assess Your Regional Environment" in Chapter 3.)
• Identify your customers. Who will benefit from your services? What contribution can they make to the coalition? Be sure to involve in your process those customers who can make changes in the early development.
• Develop flexible services of unique value that will grow to fit your customers' special long-term needs, such as the Indiana Health Information Exchange's DOCS4DOCS® service (discussed below).

Special Services

Some sites have created special services that generate revenue to sustain coalition activities. Special services provide easy access to data in formats that make stakeholders more effective and efficient.

The Center for Health Information and Research, Massachusetts Health Quality Partners, and Indiana Health Information Exchange developed unique services for stakeholders in return for sharing data. For example, a unique service the Center for Health Information and Research provides stakeholders is the fulfillment of ad hoc requests. Data partners often have questions about their own data or the prevalence of a particular condition for patients in their system versus the community. The center is able to quickly respond to these types of questions and does so pro bono as a benefit of being an Arizona HealthQuery data partner.

Massachusetts Health Quality Partners offers to oversample for granular data that physician groups may want in addition to the standard data the coalition reports. This optional service may create additional value for stakeholders.

The Indiana Health Information Exchange started as a way to create value and marketable services for stakeholders, in contrast to the other Better Quality Information sites, which focused primarily on developing quality improvement support and public reporting and are just now moving toward developing value-added services for participants. The exchange's DOCS4DOCS® service is an independent, community-based clinical messaging service that electronically delivers test results and other clinical information securely and effectively to physicians. The Quality Health First^SM program is a clinical quality program for health and chronic disease management that provides physicians and health insurers with standardized quality measures. The program provides payers with physician scores to support a pay-for-performance incentive program as well as detailed measurement information for the payer's enrollees.

The business model for Quality Health First^SM is that payers pay a per-member, per-month fee to the Indiana Health Information Exchange to administer the program and agree to provide physicians an incentive based on participation and overall health improvement of their patient population. The most beneficial aspect of the exchange's clinical messaging service is it engages providers by providing a valuable service and establishes shared goals in a nonthreatening way. Additionally, as DOCS4DOCS® has brought in more revenue, the Indiana Health Information Exchange's leadership has been able to increase its staff and branch out across the State.

The Indiana Health Information Exchange has successfully worked with other groups in the country in replicating Indiana's health information services. In Tennessee, for example, the Indianapolis Network for Patient Care model helped an informal group of stakeholders to grow into a fully running coalition within 3 years.

As the Indiana Health Information Exchange has pointed out, one potential drawback to this approach is that it does not build the same cohesion among stakeholders that other Better Quality Information sites have cultivated during the startup phase. The exchange primarily has concentrated on developing services in the Indianapolis area and, as it begins expanding across the State, may encounter challenges in getting buy-in for public reporting from statewide associations.

Tips for adapting the Indiana Health Information Exchange's data service model include:

• Develop data services in "baby steps" and make sure that they are adaptable to local communities and are self-sustaining (for example, clinical messaging).
• Focus services on regional needs, as different regions within a State can have very different needs and stakeholders.

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