Engaging Self-Insured Employers in Multi-Payer Reform: Lessons from Arkansas and Walmart

Self-insured employer participation in multi-payer payment reform is critical for providers to receive consistent messages across payers—an important step toward fostering widespread improvement. A recent study echoes the experience of many state-led multi-payer initiatives experiencing difficulty in engaging self-insured employers. This study looked at reforms in four states: Arkansas, Oregon, Minnesota, Vermont. Only two, Arkansas and Vermont, had any private, self-insured employer participation.

States have long recognized the need to include both private and public self-insured employers in early planning of delivery and payment reforms, but have had limited success engaging the private, self-insured employers. Arkansas has successfully engaged Walmart, a large, private self-insured employer, into their Arkansas Health Care Payment Improvement Initiative (AHCPII). The AHCPII was initiated by Medicaid with early collaboration and planning by two other payers—Blue Cross Blue Shield of Arkansas (BCBS) and Qualchoice. This initiative implements two complementary strategies statewide: (1) episode-based payment; and (2) population-based advanced primary care via patient-centered medical homes (PCMHs). Walmart also later joined the state and federal led Comprehensive Primary Care Initiative,(CPCi”), a CMS funded four-year multi-payer CPC initiatives designed to strengthen primary care in seven U.S .regions). Walmart’s participation in these initiatives brought about 25,000 covered lives into the state’s health reform efforts.

We spoke with Michael Motley, Assistant Policy Director, Arkansas Center for Health Improvement (ACHI) and Lisa Woods, Senior Director Health Care Benefits, Walmart US to find out more of what they are doing and why Walmart chose to participate. Some themes emerged from this conversation that might help other multi-payer efforts engage self-insured employers.

Begin by engaging large, self-insured employers who are interested in innovations.

Arkansas began by reaching out to the largest self-insured employers in the state—these organizations have the most to gain from success and their participation could set a powerful example. ACHI used the state’s Economic Development Commission ranking of state employers by number of employees to identify the largest private employers in the state. Walmart was top of the list. In previous conversations with the ACHI and through the state’s Employer Advisory Committee, Walmart had expressed their commitment to payment reform to help shape and change the healthcare landscape. Lisa Woods reports, “We want to positively influence change through innovation, and we are not going to know if we don’t try.” The company’s leadership had also identified several areas where they believed improvements in the delivery of primary care would benefit its employees, such as appropriate use of antibiotics. These conditions set the stage for Walmart’s participation in the multi-payer reform and ACHI invited the employer to help design the AHCPII. The AHCPII was launched in 2012 and Walmart soon joined in both the PCMH and episode-based components of this initiative.

Engaging self-insured employers is a “retail business”.

ACHI and Walmart met frequently throughout the design and implementation of Arkansas’ AHCPII initiative. During this time, they developed a solid working relationship in which both were able to speak frankly about their questions and concerns. This strong relationship contributed to Walmart’s participation in the state’s next reforms, in particular the CPCi.

Walmart, as an early adopter has helped ACHI reach out to other large self-insured employers. Woods noted, “If its peer to peer or employer to employer, I think they [employers] will have a tendency to listen more.” Through both group and individual discussion, Walmart helped their peers understand the basics of the reforms (i.e., how does it work, how was it developed) and the benefits to participation.

In their planning, multi-payer initiatives also need to recognize that not all self-insured employers can be enticed by the opportunity to innovate, and that some employers simply will not make investments in payment reform until they see proven results (and some might not even then).
Carriers and self-insured employers are an important partnership.

Carriers can make it easier for employers to participate in payment reform. In Arkansas, Walmart’s main Third Party Administrator, BCBS, had already committed to participating in the state’s PCMH initiatives for its fully-insured population. Michael Motley explained that, “They [BCBS] can really explain and reinforce PCMH and episode of care concepts to their self- insured clients.” Before Walmart agreed to participate in AHCPII, BCBS had already set up the structures needed to add per member per month practice support payments to attributed PCMH practices. BCBS was then able to offer Walmart a turn-key package for implementing the payment model, which made it easy for Walmart to ‘say yes.’


The partnership between Arkansas and Walmart increased the reach of payment reform in Arkansas and other states.

In 2012, Walmart’s participation in Arkansas brought about 25,000 covered lives into the State’s initial payment reform efforts. Now, according to ACHI’s recently released 2nd Annual State Tracking Report, payers participating in either the CPC initiative or the Arkansas PCMH program also include Medicaid, BCBS, QualChoice, United Healthcare, Centene/Ambetter, Humana, Mercy Accountable Care Organization, and the State and Public School Employee benefits program,. (Note: In 2015 Arkansas implemented legislation requiring all Qualified Health Plans offered in the Health Insurance Marketplace to participate in PCMH—and several are looking to expand this participation to their fully-insured, non-exchange products.)

Early results detailed in the tracking report indicate that the partners are achieving their objectives. Participating payers have seen, among other outcomes, an increase in Hemoglobin A1c screenings for diabetics and a reduction in use of unnecessary antibiotics. BCBS found that congestive heart failure costs declined by 10.3 percent from 2013 to 2014. ACHI also reports that the PCMH component of the reforms reduced costs by about $34 million—about $5.3 million of which has been shared with participating providers who met quality and financial targets.

The effect of the partnership has not been limited to Arkansas. As a result of their participation in Arkansas’s initiative, Walmart became interested in joining multi-payer efforts in other states—and in January 2015, Walmart joined Colorado’s CPC initiative.


This blog is supported by the Kaiser Permanente. Thanks to Michael Motley, Assistant Policy Director, Arkansas Center for Health Improvement and Lisa Woods, Senior Director Health Care Benefits, Walmart US, for their interviews and review.