An employer healthcare coalition runs on one simple asymmetry. A health plan will tell a single employer no. Telling forty of them no at the same time is much harder, and that difference is the most underused source of leverage available to a mid-market company right now.
On Episode 86 of The Business of Benefits, Chelsea Ryckis sat down with Karen van Caulil, Ph.D., President and CEO of the Florida Alliance for Healthcare Value, Florida’s business coalition on health. Karen has spent more than fifteen years helping employers move from writing checks to actually purchasing healthcare.
Here are the five plays from that conversation. You can run them whether or not you ever join an employer healthcare coalition.
What is in this article
- What an employer healthcare coalition actually is
- Why one employer, even a large one, still gets told no
- The five plays in the employer healthcare coalition playbook
- Where the leverage actually comes from
- What this means for a mid-market employer
- Data access is the difference between intent and action
- How to find or start an employer healthcare coalition in your market
- The fiduciary case for acting together
- Frequently asked questions
What an employer healthcare coalition actually is
An employer healthcare coalition is an independent, employer-led organization that helps companies buy healthcare more intelligently. Not a carrier. Not a broker. Not a vendor with something to sell you.
The Florida Alliance is a 501(c)(3) research and education organization with roughly 80 public and private sector employer members. It started in Central Florida forty-two years ago and grew statewide.
Karen describes the employer healthcare coalition model in two buckets. The first is a learning community, where employers learn from research, from policy tracking, and from each other. The second is collective impact, and that is the part most employers underestimate.
Dozens of these organizations operate across the country, some statewide, some in a single metro area. Many belong to the National Alliance of Healthcare Purchaser Coalitions, which connects them nationally while each works its own local market.
“Most of them are self-funded, and they still say, we’re payers, we’re payers. I said, that sounds so passive. We’re helping them move from paying to being sophisticated, proactive purchasers.”
Karen van Caulil, Ph.D., President and CEO, Florida Alliance for Healthcare Value
Why one employer, even a large one, still gets told no
Karen has sat in meetings where an employer with 30,000 covered lives asked a health plan for a change. A reasonable change, studied, agreed on by people who understand the plan. The answer: we are not going to do a one-off for you.
Thirty thousand lives. Still not enough.
There is no published number for what would be enough, because the number is not the point. A single client asking for something unusual is a support ticket. A dozen clients asking for the same thing in the same quarter is a market signal, and that is the mechanic Karen’s team works deliberately.
If you have ever left a renewal meeting feeling like the answer was decided before you arrived, this is why. You were negotiating alone against an organization that negotiates for a living. An employer healthcare coalition changes who is in the room with you.
The five plays in the employer healthcare coalition playbook
You do not need an employer healthcare coalition membership to run these. You do need to ask questions your vendors are not used to hearing.
Play 1: Pool the question, not just the purchasing
Most employers assume an employer healthcare coalition is a group purchasing arrangement where the value is a bulk discount. Sometimes it is. More often the real value is that everyone asks the same question at once.
When a health plan hears the same request from a dozen of its clients inside one renewal cycle, the calculation changes. Refusing one employer costs the plan nothing. Refusing twelve puts a book of business at risk.
That works at a small scale too. If you belong to an industry association, a chamber, or a peer CFO group, you already have the beginnings of a coalition. Compare notes on what you each asked for and what you each got told. That pattern is information you cannot buy.
Play 2: Put price data on the table before the negotiation starts
A Florida hospital system told a group of employers it was taking a double-digit increase for the coming year. The justification had two parts: our quality is higher, and you are already paying the competing system that much, year after year, without complaint.
The employers had the pricing and quality data, and went line by line. Imaging cost more at that system. Quality was not higher on several measures. The broad claim did not survive contact with the numbers.
The double-digit increase became something closer to 3% per line item, spread over several years. Some line items did not go up at all. That required no new legislation and no new vendor, only employers who could see what they were paying.
The national context makes the case sharper. RAND’s Hospital Price Transparency Study found private health plans paid hospitals 254% of what Medicare would have paid for the same services in 2022, and that most of the variation is explained by hospital market power rather than patient mix. Florida sits among the states above 300%. That study exists because self-insured employers and coalitions pooled their own claims data through the employer-led Employer Price Transparency Project.
Play 3: Know what a good answer looks like before you ask
Karen’s team builds compliance toolkits for members, and found that handing employers the right questions was only half the job. Employers would ask, the vendor would answer, and nobody could grade the answer. So the toolkits started covering a second question: what should the answer look like?
The Consolidated Appropriations Act gave plan sponsors a real right to their own information and knocked down the gag clauses that kept it locked away. Employers now file an annual Gag Clause Prohibition Compliance Attestation confirming their contracts contain no such language.
Karen’s reaction at the time was optimism. Employers were finally going to get their data. Then the answers came back in three words. We’re fine.
As she put it: “I asked, and they said, oh, we’re fine. Well, hang on. Trust them, but you gotta verify.”
Accept those three words and nothing changed for your plan. You still cannot see what your pharmacy vendor earns on your spend.
Going past it is specific work, not complicated work. Ask for the analysis itself rather than a summary. Ask who performed it and when. Ask to see the documentation. Then write that standard into the contract before your next renewal.
Play 4: Ask for tomorrow’s requirements today
Federal transparency and pharmacy rules are already law and phasing in on a schedule. Your vendors know what they will be required to hand over. Most employers do nothing with that until the deadline gets close, then renegotiate under time pressure and pay whatever urgency costs.
Karen’s advice runs the other way. You already know what those components are, so start acting now. Maybe it is a contract renewal, maybe an RFP. Either way, get the data, get the information, get the transparency.
Nothing stops you from negotiating toward those standards today. Ask for full rebate pass-through, complete claims-level data, and full audit rights. As Karen said, why wouldn’t you?
Play 5: Audit what you already bought
Employer healthcare coalition members have the same vendor sprawl as everyone else. The better question is not what else can we add, but what is actually working, and how do we know?
Karen described one member carrying about 14 point solutions. On a navigation program she found tens of thousands of covered lives and seven people using it. She calls that case a little bit extreme herself, so treat it as an illustration rather than a benchmark.
The products are often good. They are simply unused, unpromoted, or disconnected from everything else your employees touch. Which leads to the line worth taking into your next renewal: sometimes innovation is not a new solution, it is demanding a better arrangement on what you already buy.
Chelsea added the contracting trap. Point solution agreements routinely run three and five years with automatic renewals, and the notice deadline is often 90 days while the renewal pricing does not arrive until 60. You decide a month before you are allowed to know, so the plan sponsor signs for another year. Not because the program worked, but because the clock ran out.
Where the leverage actually comes from
Strip the model down and an employer healthcare coalition creates leverage in four ways.
Volume of voice. Pooled demand for the same change, arriving at the same time.
Comparable data. One employer’s claims are an anecdote. Forty employers’ claims are a market benchmark, which is how the RAND figures came to exist.
Shared cost of expertise. No mid-market company can staff a full-time health policy analyst. An employer healthcare coalition can, and every member gets the output.
Peer calibration. When a vendor says something is impossible, ask nine other employers whether they heard the same sentence. That costs nothing and it is available this week.
None of this replaces your consultant. An employer healthcare coalition does not negotiate your contracts or run your renewal for you. It supplies the benchmark and the peer context that make those conversations sharper, which is why an employer healthcare coalition and a good advisor work better together than either does alone.
What this means for a mid-market employer
If you cover a few hundred employees, it is tempting to read this as a story about jumbo employers. It is not. Cost pressure does not scale down.
KFF’s 2025 Employer Health Benefits Survey put the average annual premium for family coverage at nearly $27,000, up 6% in a single year, with workers contributing $6,850 out of their paychecks. Karen’s own members are forecasting increases of 9% or more, and some 11%, 12%, or 13% with no plan changes at all.
Hospital care runs about 38% of total healthcare spend for Florida Alliance employer members, compared with roughly 30% nationally. Your largest category is the one where price does the most damage, and the one most employers have never examined facility by facility.
Smaller employers do have one advantage. Decisions move faster. If you can see your data, you can act before your next renewal rather than the one after.
Data access is the difference between intent and action
The Pulse of the Purchaser survey, which drew 408 responses from employers and purchasers, added a new question this year. Employers with complete claims access implemented at least four more strategies on average than employers without it, while both groups were considering roughly the same number of additional strategies.
Same ambition, same list of ideas. One group could act, and the difference was whether they could see their own data.
Karen’s framing: data is a strategic asset, and the lack of it handcuffs employers between intent and action. It is really difficult to be a sophisticated purchaser of something you cannot see and measure.
How to find or start an employer healthcare coalition in your market
Not every state has an employer healthcare coalition. The National Alliance website lists member coalitions by state, which is the fastest way to see what exists near you. Three questions are worth asking before you join.
What is the structure? Some are purchasing groups, some are trade associations, and some are research and education nonprofits like the Florida Alliance. An employer healthcare coalition set up as a nonprofit tends to publish more of its work, which changes what membership gets you.
Who else is at the table? Karen’s organization is employer-led by design. Some group purchasing arrangements will take your fee and seat you on a committee alongside the very vendors whose economics you are trying to understand. That is not a coalition. That is a room where nothing gets said.
What is the output? Webinars are fine. Toolkits, model contract language, benchmark data, and answer keys change a renewal. If there is nothing in your market, start smaller. Three peer employers comparing renewal letters beats what you had last quarter.
The fiduciary case for acting together
If your plan is self-funded, it is your money and your plan, and you carry the fiduciary responsibility for it. Karen puts the standard bluntly: your fiduciary duty is to go past the easy button.
That is the honest reason an employer healthcare coalition matters. Not because collective action is nice, but because a fiduciary who cannot see their own claims data or benchmark their own hospital prices cannot defend a single line of the renewal they just approved.
Karen’s line about quality is the one to keep. There is no association between cost and quality, and as her coalition says all the time, there is no good price for bad care.
At Ethos, this is the conviction behind our Fiduciary Framework. Transparency is not a value statement on a wall. It is a set of contract terms, data rights, and audit provisions that either exist in your agreements or do not.
Ready to see your own numbers
Every play here starts with knowing what your plan actually pays. A Strategic Analysis puts your claims, hospital pricing, and vendor contracts in front of you, so you walk into your next renewal with data instead of hope.
Hear the full conversation in Episode 86 of The Business of Benefits with Karen van Caulil, Ph.D.
Frequently asked questions
What is an employer healthcare coalition?
An employer healthcare coalition is an independent, employer-led organization that helps companies purchase healthcare more effectively through shared research, benchmark data, education, and collective negotiating pressure. Its members are the employers themselves.
Do you have to be a large employer to join one?
No. Membership spans jumbo employers down to smaller companies that purchase together. The Florida Alliance has roughly 80 public and private sector employer members across a wide range of sizes.
How is an employer healthcare coalition different from a group purchasing organization?
A group purchasing organization is usually built around negotiated discounts. An employer healthcare coalition may do that, but its primary output is often research, benchmark data, model contract language, and coordinated pressure on shared issues.
What can an employer do this quarter without joining anything?
Three things. Find what multiple of Medicare your plan pays for hospital services. Ask vendors for the analysis behind their compliance answers, not the summary. And compare renewal letters with two or three peer employers.
Why does claims data access matter so much?
Because it decides how many of your other strategies ever happen. Employers with complete claims access implemented at least four more strategies on average than employers without it, even though both groups were considering about the same number of ideas.
What does it cost to join an employer healthcare coalition?
Fees vary by organization and are usually scaled to employer size, so ask directly rather than assuming. The more useful question is what you get back. An employer healthcare coalition that produces benchmark data, model contract language, and answer keys can pay for itself in a single renewal cycle. One that produces webinars alone will not.
Ethos Benefits is an affiliate member of the Florida Alliance for Healthcare Value. This article is general information, not legal or investment advice.
