Purpose
The workgroup was created to explore:
The value and process of developing a business case to payers demonstrating the value of upstream programs;
Strategies for negotiating capitated rates with Medicaid and commercial payers that include payment for upstream prevention efforts; and
Identifying the most viable strategies for supporting integrated health models and the essential role that community health workers play in them.

Workgroup Members
Members of the MHCU Financial Sustainability Workgroup were:

Boston Children’s Hospital (Boston, MA)
Children’s Hospital of Wisconsin (Milwaukee, WI)
Cincinnati Children’s Hospital (Cincinnati, OH)
Health Resources in Action (Boston, MA)
Michigan Public Health Institute (Okemos, MI)
Nationwide Children’s Hospital (Columbus, OH)
Nemours Children’s Health System (Wilmington, DE)
New York-Presbyterian Hospital (New York, NY)
Seattle Children’s Hospital (Seattle, WA)
University of Chicago (Chicago, IL)
Emerging Lessons
Creating aligned incentives is critical but not sufficient in terms of health systems going upstream, leadership is a necessity at multiple levels, especially to enable sustainability infrastructure and capacity.
Financial sustainability is still the Holy Grail; Few, if any, health systems can claim to have “figured it out”.
Integration of population health and clinical care requires active physician engagement in an active, rather than passive, way.
Multiple integrators, at health system level and community levels, are helpful.
Integrators are not being fully supported, meaning their work is being valued on its own rather than existing as an added function to an already 100% job position.
Medicaid paying for prevention is an outlier; Payment structures (from Medicaid and other payers) that include prevention must be the norm. Building the case for prevention is critical.
Though there is a necessity for having a business case for prevention, the development and implementation of the business case together with the integration into ongoing efforts is very difficult.
Those entities that are most successful have initiatives that align with the needs of the vulnerable populations that they serve and the strategy of the health system/provider. Successful organizations also have visionary/champion in a position of influence that pushed these initiatives.
The use of the community health needs assessment as a strategic planning tool is not effectively leveraged by all organizations and, as such, strategic decisions around financing are not being made.
Additional Resources
Making an Effective Business Case
Core components of business planning, case studies, and resources- presented by Avivar Capital

Business Planning Guide
Overview of the 10 steps needed to create a compelling business case for upstream work

Engaging the “Right” Stakeholders in Upstream Prevention
From ReThink Health, considerations for engaging stakeholders in upstream work

Fact Sheet: CDC’s 6-18 Initiative
Summary of a CDC initiative aimed at accelerating the adoption of evidence-based prevention