# Employer Health Coalitions and Smarter Purchasing. With Karen van Caulil. Source: https://ethosbenefits.com/podcast/employer-health-coalitions-karen-van-caulil Type: Podcast episode Series: The Business of Benefits, Episode 86 Published: 2026-09-10 Duration: PT41M57S Hosts: Chelsea Ryckis, Founder and President, Ethos Benefits Guests: Karen van Caulil, President and CEO, Florida Alliance for Healthcare Value Video: https://www.youtube.com/watch?v=D6ksGeUHp2o Publisher: Ethos Benefits Cite as: "Employer Health Coalitions and Smarter Purchasing. With Karen van Caulil.," The Business of Benefits, Episode 86, Ethos Benefits, https://ethosbenefits.com/podcast/employer-health-coalitions-karen-van-caulil, 2026-09-10. **Summary:** Employers that join an employer-led health coalition can move from paying for health care to purchasing it. Karen van Caulil of the Florida Alliance for Healthcare Value tells Chelsea Ryckis how coalitions build collective buying power, why claims data access comes first, how to use upcoming PBM rules now and how to judge the vendors you already buy. ## Key takeaways - Employers that ask health plans for the same change at the same time get further than a single employer, which Karen van Caulil says is often told a plan will not do a one-off. - Asking a vendor a compliance question is only half the job, because Karen van Caulil says plan sponsors also need to know what a good answer looks like. - Health care is local, so direct contracting, reference-based pricing and hospital price challenges work well in some regions and stall in others. - Karen van Caulil says employers are realizing that price, not only utilization, drives health plan cost. - Employers do not have to wait for federal PBM rules to take effect before asking for full rebate pass-through, claims-level data and audit rights. - Before adding another vendor, employers should check whether the programs they already buy are used, coordinated and free of auto-renewals that arrive before utilization data. ## Chapters - 00:00 Why employers still cannot see their own claims data (https://www.youtube.com/watch?v=D6ksGeUHp2o) - 03:04 What an employer health care purchaser coalition does (https://www.youtube.com/watch?v=D6ksGeUHp2o&t=184s) - 09:02 How employers acting together change health plan behavior (https://www.youtube.com/watch?v=D6ksGeUHp2o&t=542s) - 10:51 Contract language and what a good compliance answer looks like (https://www.youtube.com/watch?v=D6ksGeUHp2o&t=651s) - 12:57 Is there an employer health coalition in my state (https://www.youtube.com/watch?v=D6ksGeUHp2o&t=777s) - 16:37 Regional differences in hospital pricing and advanced primary care (https://www.youtube.com/watch?v=D6ksGeUHp2o&t=997s) - 21:25 How employers negotiate with hospital systems (https://www.youtube.com/watch?v=D6ksGeUHp2o&t=1285s) - 24:43 Employer health care cost trends for 2027 (https://www.youtube.com/watch?v=D6ksGeUHp2o&t=1483s) - 29:32 Hospital prices as a percent of Medicare and claims data access (https://www.youtube.com/watch?v=D6ksGeUHp2o&t=1772s) - 32:49 Using benefits compliance in PBM negotiations (https://www.youtube.com/watch?v=D6ksGeUHp2o&t=1969s) - 34:57 How to measure point solution utilization (https://www.youtube.com/watch?v=D6ksGeUHp2o&t=2097s) - 37:46 Why join an employer health coalition (https://www.youtube.com/watch?v=D6ksGeUHp2o&t=2266s) ## Quotes > It's difficult to be a sophisticated purchaser of something you can't see. Karen van Caulil, Florida Alliance for Healthcare Value > So sometimes innovation is not a new solution, right? It's demanding a better arrangement than you've currently got, that you're already buying. Karen van Caulil, Florida Alliance for Healthcare Value > And one of the things we say all the time is there is no good price for bad care. Karen van Caulil, Florida Alliance for Healthcare Value ## In this episode. Employers in a health care cost crisis have more bargaining power than they think when they buy together. Chelsea Ryckis of Ethos Benefits talks with Karen van Caulil, Ph.D., who leads the Florida Alliance for Healthcare Value, Florida's employer-led business coalition on health. Ethos Benefits is an affiliate member of the Florida Alliance. They cover how an [employer healthcare coalition](https://ethosbenefits.com/insights/employer-healthcare-coalition) helps plan sponsors move from passive payers to active purchasers, why hospital prices and data access sit at the center of the cost problem, and how employers can use federal rules as bargaining power before they take effect. - **Collective impact.** Health plans that refuse a one-off change for a single employer respond differently when many of their clients ask for the same thing. - **Know what a good answer looks like.** After the Consolidated Appropriations Act of 2021, Karen van Caulil saw vendors reply that a plan was "fine" on [mental health parity](https://ethosbenefits.com/benefits-101/mental-health-parity-nqtl) and [gag clauses](https://ethosbenefits.com/benefits-101/gag-clause-attestation). Fiduciary duty means checking the analysis, not accepting the reply. - **Regional differences.** Some markets challenge hospital pricing or invest in advanced primary care, and Chelsea Ryckis notes that [reference-based pricing](https://ethosbenefits.com/benefits-101/reference-based-pricing) works well in some states and meets resistance in others. - **Price, not only utilization.** Karen van Caulil walks through what employers named as their top cost concerns heading into 2027: hospital prices, high-cost claims and drug prices. - **Data first.** Employers cannot buy well what they cannot see, which is why [claims data access](https://ethosbenefits.com/insights/health-plan-claims-data-access) comes before most other strategies. - **Ask now.** With [PBM reform](https://ethosbenefits.com/insights/pbm-reform) on the way, employers can request rebate pass-through, claims-level data and audit rights at their next renewal or RFP. - **Review what you already buy.** Many add-on programs are underused, and auto-renewals can lock in another year before utilization data arrives. ## About the guest. Karen van Caulil, Ph.D., is President and CEO of the Florida Alliance for Healthcare Value, an independent coalition of public and private employers with lives in Florida. Her background is in health policy, and under her leadership the coalition has added health policy work to its education and research for employers. ## Guests - **Karen van Caulil**, President and CEO, Florida Alliance for Healthcare Value. Karen van Caulil, Ph.D., leads the Florida Alliance for Healthcare Value, Florida's employer-led business coalition on health, a role she has held for more than 15 years. She holds a master's degree in health policy and a doctorate in public affairs, and her work spans employer education, research, data analysis and health policy. ## Related guides - [The employer healthcare coalition](https://ethosbenefits.com/insights/employer-healthcare-coalition) - [Health plan claims data access](https://ethosbenefits.com/insights/health-plan-claims-data-access) - [PBM reform is now law](https://ethosbenefits.com/insights/pbm-reform) - [What is reference-based pricing?](https://ethosbenefits.com/benefits-101/reference-based-pricing) - [NQTLs and mental health parity](https://ethosbenefits.com/benefits-101/mental-health-parity-nqtl) - [The gag clause attestation](https://ethosbenefits.com/benefits-101/gag-clause-attestation) ## Frequently asked questions ### What is an employer health care purchaser coalition? An employer health care purchaser coalition is an independent, employer-led group that helps plan sponsors buy health care more deliberately. Karen van Caulil describes the Florida Alliance for Healthcare Value as both a learning community, where employers learn from each other, and a source of collective impact, where many employers asking for the same change at once makes it harder for a health plan to say no. ### Is there an employer health coalition in my state? Not every state has one, and some states have several. Karen van Caulil explains that many regional coalitions are members of the National Alliance of Healthcare Purchaser Coalitions, and its website lists those members. Coalitions vary in structure, from statewide groups to metropolitan and multi-state ones. ### How can employers negotiate with hospital systems? Employers negotiate better when they compare what they pay each hospital against quality data. Karen van Caulil describes coalition members in Central Florida pooling that information to challenge a health system that proposed a double-digit increase, which ended up spread over several years at a much lower rate. ### Why does claims data access matter for health plan cost control? Without claims data, an employer cannot measure what is working or explain a change to leadership and employees. Karen van Caulil says data is a strategic asset, and she cites the National Alliance's Pulse of the Purchaser survey as finding that employers with complete claims access put more cost strategies in place than those without it. ### Should employers wait for federal PBM rules to take effect before negotiating? No. Karen van Caulil says a statutory effective date does not stop an employer from negotiating toward those standards today, through a contract renewal or an RFP. Chelsea Ryckis adds that benefits compliance gives employers bargaining power, so they can ask now for rebate pass-through, claims-level data and audit rights. ### How do employers know which point-solution vendors are working? Employers should ask what is working before asking what to add. Karen van Caulil sees many programs that are underused or not connected to the rest of the plan, and Chelsea Ryckis warns about multi-year terms and auto-renewals that trigger before utilization data or renewal pricing arrives. ## Full transcript [00:00] Karen van Caulil: I'm hoping that same old, same old is a thing of the past, because they're saying, why can't I see my own claims data? I was in a meeting the other day and someone said, am I paying more because I'm getting better care? There is no association between cost and quality. And one of the things we say all the time is there is no good price for bad care. The employers aren't always at the table. My counterpart in Michigan came and spoke at one of our conferences a few years back, and he said, you're not at the table, but you're definitely on the menu. It's really difficult to be a sophisticated purchaser of something you can't see. [00:47] Chelsea Ryckis: Welcome to The Business of Benefits. The Business of Benefits is your no BS, no sales guide to real solutions. No gimmicks, just the truth about how to take control, transform your benefits, and care for your most valuable asset, your people. If you're tired of the same old sales pitch and you're ready to rethink your benefits, this podcast is for you. The truth is out there. Are you ready to hear it? [01:10] Chelsea Ryckis: Today we have the Florida Alliance for Healthcare Value on the Business of Benefits podcast. This is Karen van Caulil. She, as you will see shortly, is an incredible wealth of knowledge. She is somebody that, as you'll see in the episode as well, I admire and I respect. I think the work that she's doing for employers in Florida and on a national basis is absolutely incredible. She is very special, and you will learn a lot from her today. I highly encourage you, if you are a plan sponsor and you are not a part of some type of purchasing organization, a coalition, an association, some type of entity that is trying to push healthcare forward in a non-status quo type of way, because obviously we know what we're doing isn't working, right? Being a part of an organization that is actually trying to affect change, and doing it on the plan sponsor side, I could not recommend that more. I have learned from this organization. My clients have learned from this organization. She's going to go through some trends that she's been seeing. She's going to talk through a recent survey at the national level and what that showed as the primary concerns for plan sponsors nationwide. We talk about some regional differences. No surprise here, Florida's a hot mess, right? We know that with a lot of things. And then we talk about what this concept looks like on the national level of bringing plan sponsors together to affect change. So without further ado, let's get into this week's episode. [02:36] Chelsea Ryckis: Hi everybody, welcome to this week's episode of the Business of Benefits podcast. I'm your host, Chelsea Ryckis, and today I am with Karen van Caulil of the... let me get this one right. Even though I'm a member, I should know this. It's the Florida Alliance for Healthcare Value. I always call it Florida Alliance for short, but Florida Alliance for Healthcare Value. Karen, how are you? [02:57] Karen van Caulil: I'm good. And we all call it the Florida Alliance for short. So anyway, thanks for having me. [03:04] Chelsea Ryckis: Yeah, thanks for being here. I would love it if you could tell our plan sponsors listening what the Florida Alliance is and the mission. [03:13] Karen van Caulil: Sure. The Florida Alliance is a 501(c)(3) research and education organization. We are Florida's business coalition on health, and it's a membership organization. We're obviously so happy that Ethos is an affiliate member, but we are employer-led. We have employer members. We've got about 80 public and private sector employers, and they have to have lives in Florida to be a member. But most of our members have lives in other states, and some have them globally. So it's kind of an interesting mix, all different sizes, some big jumbos and then smaller size employers who purchase together. What we do as an independent employer-led coalition is really focus on improving the value of the healthcare for the employers and their employees and families. My way of describing it has evolved over time. Most of them are self-funded, and they still think, we're payers, we're payers. I said, ah, that sounds so passive. We're helping them move from paying to being sophisticated, proactive purchasers. So we help them understand where their healthcare dollars are going, to be able to get access to better information, ask better questions of your benefits consultants, your brokers, your health plans, PBMs, any of your vendors, and ultimately then become more effective purchasers. We do that through a lot of educational activities, whether those are in-person events or webinars or workshops and such. We develop tools, toolkits, and checklists. But I see it on a continuum of education leading to awareness, and then getting them to intent. And then that's where a lot of people get stuck: get them to action so we have some outcomes. And so, as I said, research and education, a lot of data analysis. Sometimes we're doing research projects to test a benefit design strategy or how to better engage plan members. We have moved into policy. When I interviewed for this job, which is 15-plus years ago, the search committee said, oh, you will not work in policy, not at all. And I thought that was kind of strange, because I have a master's in health policy. I have a doctorate in public affairs. And I was like, hmm, you sure you wanted to interview me for this job? [05:58] Chelsea Ryckis: I like it. [06:00] Karen van Caulil: Because I don't think your constituents, I don't think employers are being heard in Tallahassee, and they're not being heard in DC. So fortunately, we have been able to get more active in that space. I think the concern initially was, we don't want you to jeopardize our core business by pushing a healthcare policy. And it really, to me, didn't feel like a legitimate concern. Market-based solutions and policy change really go hand in hand. So it's kind of long, but... [06:37] Chelsea Ryckis: That's perfect. Well, and that actually speaks to my next point, which is you do a lot. And you do more than what you just said. So the Alliance itself, it's so interesting. I remember it being brought to us and somebody saying, hey, this might be an interesting organization for Ethos and your clients to be a part of. And transparently, I remember looking. We've been approached by a lot of group purchasing organizations, whether they're educational or they're actually doing a lot of the stuff that you're doing. And multiple times it's been, hey, you can join and you can sit on a committee, but it's $180,000. And you'd sit on the committee with [company removed] and [company removed]. Everything was misaligned. Oh, you could speak to the employers in the group if you pay half a million dollars to sit, again, with a bunch of misaligned vendors. And it's been so interesting to me to see how you run your organization. You do it with so much integrity. You balance. There's a lot to balance on your side, because you understand the status quo. You understand there's a better way to do it. You understand not everybody's ready for it. And you understand that all the players have value at one point or another in the lifecycle of an employee, or of purchasing healthcare, and you just balance it so amazingly well. I have to give you that compliment. [08:06] Karen van Caulil: Thank you. [08:08] Chelsea Ryckis: You tell the truth and you tell it respectfully. And yeah, it's been such an honor, truly, to learn from you, to be a part of your organization, and to work with the employers that you serve. Because again, on the national level, I don't know a lot of other purchasing groups that do it with the expertise that you have and the integrity. So just huge kudos to you. And for Florida employers listening, if you are not a part of this organization, seriously have a conversation with Karen, because even our clients that have joined, they're learning stuff all the time. I'm learning stuff all the time. I think one of the most impressive things I saw you put out was your mental health parity toolkit. It's not just, here's a webinar, here's a bulletin on compliance. It's actual things that, if plan sponsors use them, it's real leverage. So anyways, I just can't say enough good things about you. [09:02] Karen van Caulil: I really appreciate that. On any given day, I'm a mile wide and an inch deep, and so is my small team. So I appreciate that understanding and acknowledgement that it's hard. It's hard work to stay on top of things. But I guess also to go back to, what do we do? I try to describe it in a couple of buckets too. It's definitely a learning community. We're out there trying to get ahead of things, what's going on in policy or medical trends or whatever's happening, so that we can get that information to the employers. But we also learn from them. And we also learn from our affiliate members like Ethos, and that helps us to do a better job. But also in that learning community, the employers learn from each other. So it's really turned out to be all kinds of directions, right, to be able to help each other and to elevate what we're all trying to do. The other bucket, if you will, is collective impact. We're a coalition. And I can't tell you how many meetings I've been to, and even if it's an employer who's got 30,000 lives, you'll have a health plan say, oh, that change you want, we're not going to do a one-off for you. Well, how many employers, how many lives do you need in order to make this very important change that we've studied and all agreed would be the right way to go? And of course, there's no specific answer. But what we try to do is create a movement. So if a whole bunch of their clients are all asking for the same thing at the same time, it makes it a lot harder. [10:51] Chelsea Ryckis: And to your point, I think that's one of the really nice things that I'm seeing about publicly available documents. So like Nautilus, I'm sure you've seen that, a lot of the information that you're putting out, there's starting to be this fiduciary standard in terms of documentation, in terms of contracting, and what we're asking for across the board. And I think that's exactly how change happens. It's one employer at a time being exposed to organizations like yours, consultants like us that are willing to push back, willing to ask the harder questions, and then also give them the resources that they need. I spoke to a prospect yesterday that's going through their renewal right now. They're not able to make any changes this year. They're going to stay fully insured with the carrier that they're with, with the broker they're with. But nonetheless, I provided them with a document of contract language that they should request in their fully insured contract, that they can then use, hopefully, for next year to gain more leverage. And they were like, well, do we need to pay you for that? And I was like, just go make it better. [11:53] Karen van Caulil: Well, we do a lot of things like that too, right? Whether that's questions to ask or contract language or RFP language. What we've found out we need to do, and you maybe saw this in the Mental Health Parity Compliance Toolkit, is: what should the answer look like? [12:10] Chelsea Ryckis: I love that. [12:10] Karen van Caulil: Because that's kind of the next level. It's like, all right, I asked and they said, oh, we're fine. Hang on. [12:16] Chelsea Ryckis: Very good point. [12:17] Karen van Caulil: Trust them, but you've got to verify. And this is what you should be seeing in there, especially when we had the Consolidated Appropriations Act of 2021 come out. You had all of this, and I was like, yay, now finally they're going to get their data. All those gag clauses are going to go away, all of that. And then it was like, hey, they just said we're fine. I was like, yeah, your fiduciary duty, though, is to go past the easy button and at least be able to make a determination as to whether the analysis was appropriate. So we've had to get in that space too. And it was the learn-by-do method, for sure. [12:57] Chelsea Ryckis: So tell me, does each state have a coalition just like yours? Are you part of a larger entity? I know that it's probably a complicated answer, but for a plan sponsor that's thinking, well, our headquarters is in Texas, or Washington, or whatever, how does it all work? How can they be a part of that? [13:17] Karen van Caulil: There are a lot of independent employer healthcare purchaser coalitions operating in markets across the country. Some are statewide like ours, but we started in Central Florida 42 years ago and then became statewide. Some of them are metropolitan areas, and I'm like, wow, how nice would that be? But then there are some others who are multi-state, and I'm like, okay, Florida's big enough, thank you very much. They are not all the same in terms of structure. Some are purchasing coalitions, some are associations, some are like we are, a 501(c)(3). So they vary in their structure. A lot of these independent coalitions are members of the National Alliance of Healthcare Purchaser Coalitions. Talk about another long name. National Alliance for short. We're a member, a founding member in fact, and certainly actively involved. And so we can learn and collaborate nationally through the National Alliance while acting locally. I mean, you wish you had a dollar for every time you heard healthcare is local, but it is. So we all have to be able to look at the nuance in our respective regions and also within our membership. We're not a chapter of the National Alliance. We are a member. There's other membership organizations as well. But I have to say, that's where I learn. I learn from, just like I said, that learning community and that collective action. That applies to the National Alliance as well. The National Alliance is keeping an eye on things and they educate us. We educate them on what we're hearing and seeing. The regional coalitions teach each other, and it really is a very similar model. But that's, for me, one of the go-to groups. So I don't think that every state has a coalition. Some of the lower population [states], in comparison to Florida, do not. Some of them have multiple in a state. But if they go on the National Alliance website, there's a tab that has members. You can click on that, and reach out to me at any time, for sure. And because, as I said earlier, we have members who have lives in other states, if there's something going on... I met with a prospective member earlier this week. Most of their lives are in Florida. Second is in Mississippi. So she was asking me about how to connect with them, and what do they do, and how similar. So it's, as you said, kind of a long answer, but the membership of the National Alliance really gives us the opportunity to learn from each other, share our research and strategies, and then amplify that purchaser voice on issues that extend beyond any one market. [16:37] Chelsea Ryckis: In your conversations with other markets, I'm sure, just like we see when we have clients all over the nation, different regions have very different approaches to what they will accept or not accept. On the innovation scale, some could say maybe more progressive or less progressive. If you were to look at the country as a whole, what are you seeing in different regions? [17:04] Karen van Caulil: Yeah, some markets have been collectively challenging hospital pricing for years. [17:10] Chelsea Ryckis: Yes. [17:11] Karen van Caulil: And so you can kind of see what they've... well, there's politics involved if there's health policy changes that need to happen at a state level. That's certainly been an area where there are coalitions and states that have really been able to get some legislation in place that bolsters transparency and accountability. So you can definitely see that in some markets. Some are further along in direct contracting. And I think it depends on how competitive it is. In a lot of the places in Florida, we've only got two systems, and so there's some challenges there. Others have done really interesting work around advanced primary care, and that's an area that we've really been focusing on. It's not the go and have your annual visit for five to seven minutes with the provider with one foot out the door the whole time. It's really an opportunity to have a relationship, to be able to get at the real issues that that patient has, and hopefully prevention and early identification. So some have been able to work very heavily in getting the amount paid for primary care up. Because if you're expecting that first visit to be 75 minutes and the other model is 40 patients a day, you're not going to be paying the same. So I would say there are definitely areas where the employers remain more comfortable with that traditional model: hire a health plan, hire a PBM, hire a consultant, and largely delegate management of healthcare to them. But what I think is probably more important, what's changing across the markets that I'm seeing, is that employers are finally asking really harder questions of that traditional model. So I'm hoping that same old, same old is a thing of the past, because they're saying, why can't I see my own claims data? [19:25] Chelsea Ryckis: Yeah. Why can't I carve out the PBM? [19:29] Karen van Caulil: What is my PBM actually earning? Why does the cost of X service, why is it so dramatically different depending on where the employee is receiving that care? And we see that big time in Florida. The variation is tremendous. I was in a meeting the other day and someone said, am I paying more because I'm getting better care, or because a particular health system has greater market leverage? And I know you've addressed this on your podcasts, to say there is no association between cost and quality. And one of the things we say all the time is there is no good price for bad care. So finally, I think, at least the employers who are in my orbit through other coalitions and my own are really trying to... they have to be more progressive. They have fiduciary duty. We've got expected double-digit increases even when they're doing everything that they can. [20:37] Chelsea Ryckis: Right, exactly. [20:40] Patrick Williams: Hi, I'm Patrick Williams, co-founder of Fiduciary in a Box. Employers today need more than just renewal strategies. They need a smarter approach to benefits. And that's why I recommend the Business of Benefits podcast. It's packed with actionable ideas, thoughtful discussions, and insights from some of the top experts in the industry. For the past three years, Fiduciary in a Box has supported Ethos Benefits by delivering the fiduciary operating system that empowers employers to organize, document, and manage their fiduciary responsibilities with clarity and confidence. If you're looking to build a better health plan, not just maintain one, start tuning in to the Business of Benefits podcast. [21:25] Chelsea Ryckis: What I've seen is that there are certain states, like Texas, for example, where direct contracting is huge. I think it's really taking off there. Reference-based pricing is actually working really well there, which is really cool. But Michigan or Pennsylvania, for example, not so friendly on some of these more innovative strategies. And so it's really cool to come back to the idea that healthcare is so local and it is so regional, what will be accepted or not accepted in your particular regions. And I think that just adds value to organizations like yours that understand so deeply that local region, that employers can glean a lot of insights from you. And it sounds like you have gone to the negotiation table on behalf of some of your plan sponsors. It sounds like a lot of the times you're in almost a... and I'm sure you wouldn't say this yourself, but you're in a little bit of a consulting position, where you're really adding value to them beyond just, hey, it's a membership group, right? [22:33] Karen van Caulil: Yeah. I mean, I don't have a benefits consulting background. My background is health policy. [22:40] Chelsea Ryckis: Which is an advantage. [22:42] Karen van Caulil: Right. [22:42] Chelsea Ryckis: Well, maybe. [22:43] Karen van Caulil: And ask some questions, right. We had a situation a number of years ago, actually here in Central Florida, and we were able to work with a bunch of our members to look at what they were paying with the different hospitals and healthcare systems. And one of the healthcare systems said, we're going to do a double-digit increase for next year, because you're paying the other healthcare system that amount and you're happily doing that year after year. And we have higher quality, and why shouldn't we? So that was, we have transparency and, whoops, that wasn't what we wanted. That wasn't going to work out. And so we were working with their benefits consultants as well, and the employers, in these meetings to say, not everything you just said is true. You're charging this much more for imaging. Your quality isn't as high on this. So that broad statement isn't necessarily true. And what came out of that, and that was a pretty big win for us, because it was a significant increase that was being thrown out there that the benefits consultant and the health plans were not helping the employers with, in my personal opinion. They wound up stretching that increase over a much lower percent, like 3% or whatever it was, for the different line items, over quite a few years. And some things they didn't increase at all, because they said, oh, okay. So that's a really kind of extreme example of helping. But the employers aren't always at the table. My counterpart in Michigan came and spoke at one of our conferences a few years back, and he said, you're not at the table, but you're definitely on the menu. [24:43] Chelsea Ryckis: That is really interesting from a trend perspective, because I know you put out surveys. I've seen them. They're really, really interesting to go through, those results of your surveys, and read that. But what are you seeing as things that employers have grasped onto either this year, or what you anticipate for 2027? [25:06] Karen van Caulil: Your timing is really quite good, because I think yesterday the National Alliance released what's called the Pulse of the Purchaser survey. And we had enough of our employer members respond that we're getting the Florida-specific data. So I was going through that last night. We do a lot of benchmarking as well, but this really allows us to look at what's going on across the country and be able to compare Florida to other states. Certainly, affordability has reached another level. About 40 percent of our folks said they expect... So we had some saying they're expecting 11%, 12%, 13% if they don't make any plan changes. This is what we're expecting. So definitely you can see in the results they're saying, we're going to have to address the underlying cost. We can't cost shift and continue to do that. So they're really grappling with how do we address the underlying cost, the affordability piece. I think the hospital economics are becoming impossible to ignore, especially for us. We've got folks saying, I think the average is like 38% of their healthcare spend is hospital, and nationally it's like 30%. And I'm not surprised by that. And Chelsea, I'm sure you've heard me say this, and if there's folks listening in who have heard me say this, I apologize, but Florida is the number one most expensive state for employers purchasing hospital services. We are tied for that dubious honor with the state of Georgia. And that's data from the RAND Hospital Price Transparency Study. Now, that data is a couple of years old, and they are out recruiting now for the sixth round of that. And I don't see any indication that Florida's going to jump off of that number one spot. Employers are also identifying high-cost claims as continuing to be a big area of concern, with oncology as a big driver. But those conversations have been interesting too, in those surveys and discussions, because they say, all right, in this plan year it hit this. But start looking at these folks who have chronic situations year after year after year. I would argue they're a high-cost claimant as well. So lots of discussions about how can we mitigate. Certainly there's a lot of different types of patients in there, but as I said, a lot of them are cancer patients. What can we do to do better on screening and prevention and early identification, but also navigation and site of care? There's a lot of things that can be done. It's kind of an aside, but one of the things that we saw in the data was that a lot of the cancer patients were ending up in the ICU with vaccine-preventable viruses: pneumonia, flu, RSV. And so we're trying to think about, in this current climate of a lot of misinformation, couple that with the fact that once somebody's got a cancer diagnosis, I'm not really sure they're going to worry very much about whether they're up to date on their vaccines. But we're trying to get at what are some things that we can do to improve that. Drug prices, obviously. The GLP-1 situation has taken off, right? [29:01] Chelsea Ryckis: I knew that was going to come up. [29:04] Karen van Caulil: So I think the top significant affordability threats are the hospital price, high-cost claims, and drug prices. The employers are beginning to realize also that utilization is not the entire cost problem. It's price too. Because you can have meetings with the hospitals and they say, oh, it's total cost of care, oh, the utilization is up, but... [29:28] Chelsea Ryckis: No, it's mostly price, from what we're seeing. [29:31] Karen van Caulil: It's the cost. [29:32] Chelsea Ryckis: A lot of it, at least on the drug side. Absolutely. So for Florida employers listening, this is very specific advice for you. You mentioned, and what was it? You didn't say the actual percentage, but aren't we in Florida like 346%? [29:48] Karen van Caulil: Yeah, that's from 2020 to 2022 data. So 345%, yeah, of Medicare. And we're seeing way more than that with some of our... everybody thinks, oh, it's Miami and it's Orlando. [30:01] Chelsea Ryckis: It's 100% Orlando. [30:03] Karen van Caulil: Yeah, yeah. And some 500%, 600%. So it's really, really crazy. I know I was speaking specifically to Florida, but this is national. These are all issues that are occurring. But also, from a survey standpoint, getting that realization that data is a strategic asset. And that's what's handcuffing a lot of the employers to get, as I said, from intent to action. It's really difficult. It's difficult to be a sophisticated purchaser of something you can't see. And how do you measure? And in that survey that just went out this week from the National Alliance, the Pulse of the Purchaser, it was interesting. They did a new question, and they were able to see that employers who have complete claims access were able to implement at least four more strategies on average than those who didn't. Yet the two groups were considering roughly the same number of additional strategies. So they couldn't move forward if they didn't have visibility into their data. [31:17] Chelsea Ryckis: So that is... [31:18] Karen van Caulil: I'm still kind of teasing that out. But it makes sense, right? [31:23] Chelsea Ryckis: One is an educated, informed, data-driven decision. And one is throwing something at the wall to see what sticks. [31:29] Karen van Caulil: Right, the gut feeling, right? But it's hard to convince leadership. It's hard to communicate a change. Everybody's worried about disruption, and to be able to explain to plan members the method to the madness, right? We are doing this so that we're driving you to high-value care. And you need data to be able to do that. A lot of other areas, pharmacy, as we talked about. But we've got federal policy really reinforcing the direction that fiduciaries have a stronger right to information, raising that transparency standard. So I think the year ahead is: don't wait for 2029, for when the law is fully in place. You already know what those components are. Start acting now. Go ahead and say, look, you're going to have to do this in a year or so. Maybe it's a contract renewal. Maybe it's an RFP. Get that data. Get that information. Get that transparency. So yeah, I think that's a big area, for sure. [32:49] Chelsea Ryckis: I could not agree more. The legislation that is helping employers, especially on the PBM side right now, is such a tool. And I think you and I have talked about this a lot offline too, that compliance, benefits compliance, is actually leverage. But most plan sponsors see it as another, ugh, a thing I have to do, check the box, right? [33:13] Karen van Caulil: Yeah. Yeah. [33:14] Chelsea Ryckis: So especially CAA '21 and '26, for sure. And I love the advice of, we know that these big changes are coming around, specifically prescription reporting, rebates, fees, all of that. Why not ask your consultant, ask your PBM now, hey, are you familiar with all these changes that are going to be implemented after 8/1/2028? Can we design our plan accordingly now so we don't have to make big changes next year? And can we get our contracts in the right spot now, if we have to do it anyway? I completely think that the answers are yes, yes, and yes to this, right? [33:52] Karen van Caulil: Exactly right. Just because, I guess the term is statutory, whatever date, I'm drawing a blank on it. But for when it becomes mandatory, it doesn't prevent the employer from negotiating toward those standards now, to your point. So if you're going to market today, you can already ask for that. Ask for that 100% rebate pass-through, and that complete claims-level data, and those full audit rights, all those things that are in there. Why wouldn't you? [34:27] Chelsea Ryckis: Right. What would you say if you had to give plan sponsors listening... so I have to recap. I've heard you say a couple of things. You need your data, right? You need your data. And then number two would be, ask better questions. And you kind of just listed off a few of them, about auditing rights, prescription-level data, to-the-penny accounting, claims data. What other questions would you recommend plan sponsors start to ask of those that are advising them? [34:57] Karen van Caulil: I think the other thing that they need to do is... some of our employer members have so many point solutions. So many. And I think they really have got to start asking, not, what else can we add, but, what's actually working? [35:15] Chelsea Ryckis: Yes. [35:15] Karen van Caulil: How do we know? Something that I see over and over again is you go through this whole process and you tack on this point solution, and it's very underutilized. Or it's not connected to everything else. So I think, in addition to all that's going on in that PBM space, really look at what else you're offering. It could be some great stuff. It's just not utilized or coordinated. So sometimes innovation is not a new solution, right? It's demanding a better arrangement than you've currently got, that you're already buying. To me, I just see a lot of that. I mean, we've got one member who's got like 14 point solutions. And I was talking to them about the utilization, and you can't have tens of thousands of lives and seven people accessing a navigation program. I am being a little bit extreme, but I think there's a lot of good stuff out there. I will say there's a lot of great navigation and disease management and auditing and all of those. But really, really take a look at them and see what's working for you. [36:35] Chelsea Ryckis: Prioritize according to the data would be number one. And then number two would be, when you're looking at these point solutions, it's not just, is this something our employees are going to like, and what's the cost? A lot of the times what I continue to see is, in those contracts, there's three-year, five-year arrangements. There's auto-renewals. And auto-renewals are happening before any utilization data is being provided, before SLA-type agreements or SLA-type reporting is being provided, before renewals are being provided. There's auto-renewals happening. So the auto-renewal is 90 days, but they don't actually get the renewal pricing for 60. There's so many little things that just trip you up, and it causes plan sponsors to be like, okay, I guess we'll just do it for another year. And they get backed into that corner. So yeah, it's a super complex environment out there, which I think is why the alliance, the Florida Alliance or the National Alliance, any alliance really that is doing it through the lens of transparency and fiduciary duty, I think would be an amazing place for a plan sponsor to go and continue to learn. [37:46] Karen van Caulil: Yeah, there's just so much these folks have to stay on top of. I really feel for them. I know I have a lot to do in a day, and I know you have a lot to do in a day. But for them to be able to stay on top of what's going on, find those little parts of contracts that are buried, and they're typically not attorneys, it does help to be able to have peers to bounce ideas off. And back to that, healthcare is local. Even though a lot of these plans that they're with are national, there's nuances at the state or regional level. And they really do learn from each other. And as I said, that really helps us to be able to look at our education and our projects and our policy work. So I agree. I do think that the employers who are part of a movement, which is what this needs to be, a movement to greater value, a policy movement to be heard, to be able to represent, is really an important investment of their very limited time. I get that a lot. It's like, I don't have time for this. I was like, I understand. They're like, oh, you have so many things going on. I can't do them all. Well, you can't. You can't. You have to prioritize. And the data is the key right now. But if things continue the way they are, I don't know what's going to happen, especially in the public sector. Where are they going to get the money to cover these shortfalls? And it takes away from teachers and firefighters and police. And then even the private companies, how much more are you going to have to raise the price of what you're offering? How much can consumers bear? So it's a tough time. People keep asking me, when am I going to retire? I was a Girl Scout, and you have to leave things better than when you found them, right? I think I've done that, but not quite all the way. [40:05] Chelsea Ryckis: [I want] to end today's show by just saying kind of the way I started it, which is there is no better leader for the Florida Alliance, for this healthcare movement. [You] do a lot of very challenging things with such grace and professionalism, but also this humanity. I'm just endlessly impressed by you, and honored to be in your orbit and to be doing this fight with you. So just thank you for the hard work that you do. Don't ever retire. Thank you. And you're not allowed to. Where can our listeners find you and engage with you easiest? [40:43] Karen van Caulil: If you type in Florida Alliance for Healthcare Value, that'll get you to our website, but it's actually flhealthvalue.org. I'm on LinkedIn. I'm trying to do better in social media, kicking and screaming all the way. No, it's not that bad. But certainly, Chelsea, I'm sure if they reach out to you and they can't find me with our unique names, you should be able to. You'll connect me, and I'm happy to connect folks to my colleagues, my counterparts. And thank you again for all the kind words. Every day is challenging, and working with folks like you really makes it enjoyable, even on any given day, right? [41:32] Chelsea Ryckis: Absolutely. [41:34] Karen van Caulil: These are great people that we work with across the board. A lot of people say, oh, don't you get frustrated when things aren't moving along the way you'd like to? And it's like, yes, but everybody's really, really trying. So we've got to support each other. [41:52] Chelsea Ryckis: Exactly. Well, thank you for being here today. We'll see you soon. [41:56] Karen van Caulil: Okay. [41:56] Chelsea Ryckis: Take care. [41:57] Karen van Caulil: Bye-bye.