Background

Improving the quality and value of health care is at the heart of Aligning Forces for Quality (AF4Q), and employers are a key stakeholder group, with both the incentive and market leverage to drive changes in how care is delivered and paid for and in how employees access care. Employers can serve as a communication vehicle to provide employees information to help them make better decisions and to better manage their health conditions. As purchasers, employers can also engage in value-based purchasing, negotiating with health plans and health systems to pay for value instead of volume, and providing employees with incentives to choose high-quality, low-cost care. However, while Aligning Forces Alliances have had some successes, most have been challenged in their efforts to engage employers as change agents, especially when it comes to more complex supply-side strategies like new care delivery models and experimenting with innovative payment models. 

Employer reluctance to engage in health system transformation is understandable; for the most part, employers and purchasers are not in the health care or health insurance business, nor do they want to be. Many employers find health care to be complex and unfamiliar, and as a result have been hesitant to assert their role in the health care marketplace. Too often, employers defer to the expertise of health plans on the other side of the negotiating table.[1] Uncertainty about health reform and how it may impact profit margins is further exacerbating employer reluctance. Even among employers with an interest in value based purchasing, engaging the right person with sufficient decision-making authority can be difficult, especially in the absence of a clearly articulated business case.

Most Alliances have been able to use employers as a vehicle to reach employees and build awareness of the need for local comparative quality information, and to make that information available at key decision points (e.g., open enrollment). Only a handful of Alliances, however, have been able to move their employer engagement strategies beyond information dissemination to active purchasing. Though progress has been slow and inconsistent, these Alliances’ collective experience provides insight into the factors that contribute to employers’ involvement in value-based purchasing.