Self-Funded

"If you're expecting to pay $50k, but it hits an outlier clause, you could be paying upwards of three, four, five, six hundred thousand dollars."What if the single biggest driver of your high-cost claims isn't your discount, your network, or your utilization, but a contract provision almost nobody in this industry has ever read?My guest this week is Ryan Bojrab, who leads new solution development at Aon and came into this business through a channel almost nobody uses: he started his career as a clinician with a doctorate in physical therapy, treating patients inside a federally qualified health center. When carriers started dictating how many visits he could give a patient, he began pulling the thread, and hasn't stopped since.Ryan and I spend this episode discussing the outlier clause: the provision buried in hospital-carrier contracts that flips your negotiated discount once billed charges cross a threshold. Expecting a 50% discount on an open heart surgery? Once the trigger hits, you may be paying 70% of billed charges on the entire episode of care, and watching a $50,000 claim become a $500,000 one. Ryan calls it the casino's high roller table, and it's where hospitals make their money. It also produces one of the most perverse incentives in American healthcare: the longer you're in the bed, the worse your discount gets.If you've ever put two networks side by side, seen a massive pricing delta, and couldn't explain why - tune in.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: The Best Kept Secret in Network Contracts(00:05:59) From Clinician to Consultant: On the Receiving End of Every Vendor Pitch(00:10:46) Why Indiana Became a Self-Funding Powerhouse(00:16:00) What Is an Outlier Clause? The Casino's High Roller Table(00:21:00) The Hospital's Defense and the Inverted Discount(00:27:43) What You Can Actually Do: RFP Language and Direct Contracting(00:35:12) Prompt Pay Providers and the Death of Spec Advance(00:41:17) A Quarter-Million-Dollar Claim With No Checks and Balances(00:47:39) Decoupling Primary Care From Insurance(00:53:36) The Four Buckets of Quality(00:58:53) Tiering and Steering at National Scale(01:05:36) Closing Thoughts: Contract Terms Are the Next FrontierKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"What used to be a once-a-year catastrophic claim is now happening every single week across the stop-loss market."We're back for the fourth year in a row with our annual whiteboard review of Tokio-Marine HCC’s Stop Loss Report. Drawing from a massive block of over $2 billion in force premium, this report gives us one of the clearest, most objective looks at what is actually happening under the hood of self-funded health plans across the country.In this episode, I break down the biggest trends shaping the 2026 stop-loss environment. We look at the tightening stop-loss market, why underwriter discipline is ramping up, and why we likely won't see market stabilization until at least 2027.If you are a consultant, TPA, or plan sponsor trying to navigate renewals and protect your plan over the next 3 to 5 years, this breakdown is packed with actionable data. Tune in!Chapters:(00:00:00) Intro: 2026 Tokio Marine HCC Stop Loss Report Breakdown(00:01:25) The $2M Claim Spike & Tightening Stop-Loss Market(00:04:23) Catastrophic Claim Trajectory: $500K vs. $2M Thresholds(00:06:05) Top Disease Categories: Cancer, Cardiovascular & Nervous System(00:09:12) Analyzing Severity: $85 Million Across 30 Claims(00:14:43) Underwriting Mechanics: How Lag & Claims Data Impact Renewals(00:17:35) Evolution of Specific Deduuctibles & Optimal Risk Corridors(00:24:05) Pediatric Risk & High-Cost Perinatal/Neonatal Claims(00:28:57) How "Leverage Trend" Silently Inflates Your Premium(00:30:10) Mental & Behavioral Health Cost Trends (+123% Increase)(00:31:35) Macro Takeaways: IDR Arbitration, Cost Shifting, and 2027 Outlook

"I relate it to one of the Wizard of Oz characters... I've seen behind the curtain. I know how it's all put together."What happens when a man who spent nearly five decades inside every corner of the self-funded industry decides his final act is to give the playbook away?My guest this week is Charlie Gragg, a true first-generation veteran of self-funding. Charlie started in the late 1970s underwriting stop-loss cases on napkins from payphone booths, went on to run his own TPA, and has now semi-retired into a role he believes the industry desperately needs: the fiduciary co-pilot.He won't take your broker of record letter; he doesn't want it. Instead, he partners with brokers, consultants, and C-suite executives to build health plans from scratch, the way an owner would.If you're a broker who knows you have a ceiling on your self-funding expertise, this episode is your permission slip to get help. Tune in.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: Behind the Curtain of Self-Funding(00:00:55) The Fiduciary Co-Pilot: Why Charlie Won't Take Your BOR(00:02:58) Charlie's Background: First-Generation TPA in the Late '70s(00:04:46) Napkin Underwriting and $2,000 Aggregate Stop-Loss(00:06:18) The Two Sales: Selling the Employer AND the Underwriter(00:07:20) Why the TPA Business Is So Hard to Do Right(00:11:27) The Fiduciary TPA: Accountant of the Health Plan(00:13:32) The 401(k) Parallel: Fiduciary Standards Are Coming for Brokers(00:14:43) Building Custom Plans vs. Buying the Box(00:16:25) Stop Haggling Over Stop-Loss — Solve the Claims Instead(00:18:46) Owning Your Stop-Loss Through a Group Captive(00:21:25) The 3-6 Month Setup: Finding Fiduciary Partners First(00:23:34) The One Question to Ask Every TPA(00:26:07) Why PBMs Need the Fiduciary Standard Too(00:28:01) Eating the Elephant: Meeting Employers Where They Are(00:30:56) Winning Over the C-Suite Before the HR Director(00:34:42) Claims Negotiators, Re-Pricers, and the Lost Art of the Phone Call(00:39:11) Do You Still Need a Carrier Network?(00:41:51) The Quality Anomaly: Why the Best Care Costs Less(00:43:34) DRG Bundles and the $20,000 Burn Unit That Never Was(00:46:52) Wellness, Behavioral Health, and the Loyalty Dividend(00:55:31) Building the Utopian Health Plan: The Blueprint(01:01:03) What's Missing? Belief.(01:04:18) The Future: Adoption in the Mid-Market(01:06:33) Closing Thoughts: The System Won't Fix ItselfKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"Employers have the right to expect much more from their benefit consultants than ever before. This isn't just about managing the fully insured renewal anymore."In this week’s special bonus episode, I’m joined by Dr. Dena Bravata, physician, healthcare entrepreneur, and Clinical Advisor for ParetoHealth, to break down the findings from Pareto’s inaugural 2026 State of Healthcare Spend Report.Based on responses from nearly 1,600 CEOs, finance, and HR leaders, Dena and I unpacked why employers have finally reached their "damn it" moment. We discussed the massive unpredictability of fully insured renewals, why 80% of employers are actively considering alternative funding mechanisms, and the real reason half of the market is ready to fire their current broker.We also dove into the clinical side of the data. We looked at top cost drivers like cancer, MSK, and GLP-1s, and explored why treating mental health and substance use as a core component of your medical plan is non-negotiable for cost containment.If you advise SMB employers or manage a health plan yourself, the era of the broker "apology tour" and basic renewal management is over. This episode is a reality check on exactly what clients are expecting right now. Tune in!Visit 2026 State of Healthcare Spencer Self Funding Podcast to review the report. Thank you to ParetoHealth for sponsoring this episode!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/events/ to learn more.Episode Chapters(00:00:00) Intro: Dr. Dena Bravata & The 2026 Healthcare Spend Report (00:01:05) Why Small & Midsize Employers Are Ignored in Healthcare Data (00:02:37) The "Damn It" Moment: Approaching $20,000 Per Employee (00:04:09) Survey Demographics: 1,600 Leaders Across 14 Industries (00:05:44) 80% of Employers Saw Double-Digit Healthcare Increases (00:07:28) Why Half of the Market is Ready to Fire Their Broker (00:10:59) Top Medical Cost Drivers: Cancer, MSK, and GLP-1s (00:15:01) The Amplifier Effect of Mental Health & Substance Use (00:18:38) Pharmacy Spend & Why Primary Care Can't Manage Obesity (00:21:14) Price Variance and the Need for Care Navigation (00:22:18) The Era of the "Apology Tour" and Renewal Management is Over (00:24:37) Closing Thoughts: Demand More From Your ConsultantKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"This is why insurance is such a beautiful problem... there is no solution. There are only psychological or philosophical answers to it."What if the rising cost of health insurance is a deeply ingrained philosophical problem?My guest this week is Tom Stein, CEO of American Trust Administrators (ATA). But this episode isn’t just a tactical breakdown of stop-loss and aggregate underwriting; it is a masterclass in the history, psychology, and economics of the U.S. healthcare system.Tom and I explore the deeply embedded Machiavellian forces that drive insurance carrier monopolies, and why small business owners often choose the "safe" option of a 97% fully-insured renewal simply out of a psychological fear of loss. We trace the origins of employer-sponsored care back to Henry Kaiser and WWII, discuss the ethics of "compulsion vs. choice" in taxation and single-payer models, and analyze whether the U.S. is currently in a "Fourth Turning" crisis phase of our healthcare delivery system.This is one of the most fascinating conversations you will hear all year. Tune in.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: The Philosophy of the Insurance Problem (00:01:35) The Illusion of Comfort: Why Employers Flee Responsibility (00:05:17) Breaking the System: When "Decent Men" Say Enough (00:08:05) The Psychology of Loss Aversion in Benefits Consulting (00:10:24) Are You a Serf or a Landlord? The Risk of Self-Funding (00:13:08) The "Marshmallow Test" and Delayed Gratification in Business (00:19:42) Tom's Background and the Origins of Level-Funding (00:23:39) Level-Funding a 5-Life Group: The Hard Way to Underwrite (00:30:56) The Fascinating History of U.S. Employer-Sponsored Healthcare (00:35:13) Machiavelli, Trust, and the "Brother Rule" of Business (00:41:09) Are We in the "Fourth Turning" of Healthcare? (00:45:54) How AI Will Bring Deeper Value to Client Relationships (00:49:40) Subsidizing Medicare: The Hidden Tax on Commercial Plans (00:53:35) Milton Friedman's Four Types of Money and the State (01:00:01) The Morality of Healthcare Bankruptcies (01:04:27) The Crisis of Meaning and "Earned Leisure" (01:08:23) Closing Thoughts: The Optimism of the Next GenerationKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"When you see $6.5 billion in healthcare fraud, we all end up absorbing that in the commercial market."In this episode of Last Month in Healthcare, Producer Nathaniel and I sat down with Sid Sinha, founder and CEO of Avant/Nara Health, to break down the biggest healthcare news stories of June 2026. We started by looking at the DOJ's massive $6.5 billion healthcare fraud crackdown and what 1,400 revoked provider privileges actually means for the commercial market.We also tackled the stark reality that only 49% of U.S. adults now feel "cost-secure" about their healthcare, debated the downstream effects of Medicare's temporary coverage for GLP-1s, and looked at a new House bill that might literally force hospitals to print their prices on clinic walls.To cap it off, we ran a World Cup bracket-style game to crown the ultimate cost-containment strategy for self-funded plans, and I answered a listener question on how to keep clients from bailing on self-funding as medical inflation continues to rise into 2027. Tune in for a great conversation!Chapters:(00:00:00) Intro: Sid Sinha and Walk-On Clinic(00:02:13) The DOJ’s $6.5 Billion Healthcare Fraud Crackdown(00:04:25) The Plunge in American Healthcare Affordability(00:07:55) Medicare’s Temporary $50 Copay for GLP-1 Drugs(00:10:33) Will Hospitals Be Forced to Put Prices on the Wall?(00:14:26) The 153% Increase in Digital Health Tool Usage(00:17:30) World Cup Bracket Game(00:28:03) Ask Spencer Anything: Beating 2027 Medical Inflation

"Fee-for-service has led to transactional primary care where providers have 10 or 15 minutes to code as much as they can just to keep the doors open. We’ve moved away from the idea of primary care as the quarterback of the entire health ecosystem."My guest this week is Matt Taylor, VP of Sales at Castlight. Having spent his career navigating the complex landscape of health plans, telehealth, and enterprise analytics, Matt has a unique vantage point on why our current approach to "sick care" is failing both employers and employees.We have spent decades trying to patch a system that treats health insurance and healthcare as the same thing. In reality, our current model is fundamentally incomplete - it's built to diagnose, treat, and triage symptoms, not to keep us well.In this episode, explore the shift back toward primary care as the foundation of the health plan. We discuss why point solution fatigue is killing engagement, how "benefits-aware" primary care can finally steer members toward high-quality, lower-cost providers, and how one app - acting as a centralized "front door" - can remove the administrative bloat that is currently crushing our physicians and confusing our members. We also dive into the future of healthcare navigation, moving beyond basic search tools and into personalized, next-best-action guidance that manages patient risk before it becomes a catastrophic claim.If you are an HR leader or consultant looking to move beyond the commodity trap of traditional benefit offerings and rebuild your health plan from the ground up, tune in.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: The "Nintendo Cartridge" Healthcare Reset (00:01:21) Meet Matt Taylor: From Optum to Telehealth IPOs (00:06:50) The Telehealth Boom and the "Ashes" of COVID (00:09:44) Why the Current Primary Care Model is Transactional (00:13:30) Specialization vs. The "Quarterback" Model of Care (00:17:05) Point Solution Fatigue: Why Engagement Strategies Are Failing (00:23:08) How to Create a Centralized "Front Door" for Benefits (00:29:44) The Value of Personalization and AI-Driven Navigation (00:36:20) Understanding Acuity and Frequency in Healthcare Choices (00:40:48) The Seismic Shift: Investing in Primary Care Foundations (00:44:34) Redefining the Employer's Role in Whole-Person Health (00:49:12) The Promise (and Limitations) of AI in Healthcare Administration(00:53:18) Aligning Incentives for Independent Physicians (00:56:26) Scaling On-Site Success to Mid-Market Employers (01:00:10) Future Predictions: Transparency and the End of the "Sick Care" EraKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/

"The most unused cash in the country right now is the money you're wasting on healthcare... If you save a million dollars a year, that's $20 million in market cap."Is your company treating its healthcare spend like a business strategy, or are you just writing a blank check to the major insurance carriers every year?In this episode, I was (finally) joined by Mark Cuban, Ann Lewandowski, and Matt Miron. After answering how he would approach healthcare for a hypothetical company on Shark Tank, Mark broke down his exact playbook for mid-market employers: why you should fire traditional networks, the massive ROI of hiring an internal "Healthcare CFO" to negotiate single-case agreements, and why "carve-out" is the most important phrase for your benefit strategy this year. Together, we also discussed the dark side of healthcare economics, including the exorbitant spread pricing of PBMs and distributors, how to use AI (like Claude or ChatGPT) to find the hidden "gotchas" in your ASO contracts, and the terrifying legal liabilities CEOs face when their carriers deny life-saving treatments.This one has been in the works for years, and I hope it doesn’t disappoint. Tune in!Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Introductions: Mark Cuban, Ann Lewandowski, and Matt Miron (00:01:08) Mark Cuban's Healthcare Playbook for Shark Tank Companies (00:05:54) Single Case Agreements and Hiring an Internal Healthcare CFO (00:10:08) Why the Keyword for 2026 is "Carve Out" (00:14:32) Fiduciary Duty and Waiving Employee Deductibles (00:20:52) Starting with Out-of-Network Negotiations (00:25:09) The No Surprises Act, IDR Arbitration, and Secret Payouts (00:29:12) Why Mark Started Cost Plus Drugs (and Cost Plus Wellness)(00:32:10) How Distributors and PBMs Inflate Drug Prices (00:36:49) Using AI (Claude/ChatGPT) to Audit Your Carrier Contracts (00:37:52) The 340B Scam and Fiduciary Lawsuits (00:44:27) Increasing Enterprise Value: Why Healthcare Savings = Market Cap (00:47:46) CEO Liability for Life-Threatening Claim Denials (00:50:37) The Perverse Economics of Prior Authorizations and Appeals (00:52:59) Final Takeaways: Watch Your Money and Carve OutKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"There's no reason why I should be able to do an infusion for 50% of the cost of what it's currently being allowed at. We've seen allowed amounts between $57,000 and $80,000 for Keytruda. I typically can have that in the home at $29,000."My guest this week is Jake Velie, CEO and co-founder of National Integrative Health (NIH). After spending the first half of his career in the clinical "meat grinder" of value-based care on the provider side, Jake realized the only way to truly fix the system was to control the dollars on the commercial plan side. Today, NIH acts as the ultimate watchdog and independent pharmacy solution for self-funded employers, actively managing J-codes, specialty drugs, and clinical coordination.In this episode, we unpack the exorbitant markups hospitals charge for infusions and how NIH has spent years building a 50-state network to redirect patients to safe, comfortable, and massively discounted at-home infusion care. Jake also breaks down the brutal reality of GLP-1 adherence, why his team refuses to fill 90-day prescriptions for weight-loss drugs, how they enforce formularies to switch patients from expensive biologics like Humira to low-cost biosimilars like Yusimry, and the absolute truth about the safety of international drug sourcing.If you want to know how to stop the bleeding on your pharmacy and medical claims while actually improving the white-glove customer service your employees receive, this is a masterclass in specialty cost containment.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: Moving Keytruda to the Home Setting (00:01:47) Defining True Value-Based Care (00:03:20) The Genesis of NIH and Leaving the Provider "Meat Grinder" (00:07:01) Building a 50-State Home Infusion Network (00:09:22) Why Specialty Meds Drive 90% of Pharmacy Spend (00:14:53) Demystifying J-Codes and Q-Codes (00:17:01) Exorbitant Hospital Markups and Hidden Fees (00:24:59) The Mechanics of Redirection: Mandatory vs. Voluntary (00:30:27) Coordinating Carve-Outs with Stop-Loss Carriers (00:34:08) Enforcing Formularies: Converting Humira to Yusimry (00:41:12) The Reality of International Sourcing and the FDA (00:47:35) Managing GLP-1s and the Danger of 90-Day Fills (00:51:48) The Ideal Employer Profile for NIH (00:58:04) Overcoming Healthcare's Terrible Customer Service (01:02:05) The Future: Oncology, Cell, and Gene TherapiesKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"We did this survey with a third-party consulting group who talked to 2,000 brokers. Their perception was that 25% of bills are going to be balance bills; it's actually 3%."Is Reference-Based Pricing (RBP) still something that just creates endless problems for HR?My guest this week is Jeff Bak, CEO of Imagine360. Jeff brings 30 years of healthcare and private equity experience to the table, and he's leading the charge to rebrand and evolve RBP from a defensive "pay and defend" model into a comprehensive, full-stack alternative health plan.In this episode, we tackle the persistent broker misconceptions surrounding RBP, dissecting exactly why the actual balance bill rate is closer to 3% while plan savings average over 20%. We also explore how Imagine360 blends RBP with strategic direct hospital contracts (like Baylor and Northwestern) to give employees a seamless "PPO-like" experience without the inflated PPO price tag. Jeff also breaks down the reality of the No Surprises Act (NSA) and Independent Dispute Resolution (IDR) process, and why hospitals are currently winning the majority of those arbitration cases.If you are a benefits consultant or an employer looking to truly break away from the traditional "BUCA" networks, while ensuring your employees aren't stranded with unmanageable balance bills, this conversation is the reality check you need.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: Dispelling Broker Myths Around RBP (00:03:52) Jeff's Background: From the NFL to Healthcare CEO (00:10:15) Defining Reference-Based Pricing (Cost-to-Charge vs. Medicare) (00:14:22) Why Traditional Plans are Like Buying a Ford F-150 Every Year (00:16:19) The Evolution from ELAP's "Pay and Defend" to Imagine360 (00:20:09) Blending RBP with Direct Hospital Contracts (00:26:01) Unpacking the Broker Survey: Perceived vs. Actual Balance Bill Rates (00:34:19) Building an Integrated, Full-Stack Health Plan (00:39:11) How to Transition a Workforce to RBP (Dual Option & Slice) (00:45:34) Managing Single Case Agreements & Redirection (00:50:16) Navigating the NSA and the IDR Arbitration Process (00:54:26) The Ideal Employer Profile for an Alternative Health Plan (00:59:37) The Future of RBP & Price Transparency (01:04:57) Closing Thoughts: The "Barbecue Sandwich" MarginKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"The average marketplace deductible grew by about $1,000 per person in 2026. Premium payments increased by an average of 58%... We might be seeing the death throes of the fully insured market."Welcome back to Last Month in Healthcare! This month, Spencer, Nathaniel, and special guest Jonathan Lopez break down the most impactful healthcare headlines and regulatory shifts from May 2026.The episode kicks off with a discussion on the sudden resignation of FDA Commissioner Dr. Marty Makary following reported clashes with the food, tobacco, and pharmaceutical industries. From there, the guys dive into the shocking 58% premium hikes and 37% deductible increases hitting the ACA marketplace as carriers like Cigna exit the space.Finally, Spencer and Jonathan play a World Cup-themed game guessing the cost of medical procedures across different North American cities and answer a listener question about Cost Plus Drugs and the rise of direct-to-consumer pharmacy models.If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Thank you to our sponsor, Walk On Clinic. This month, we shared a tragic reminder to our listeners on the critical importance of early cancer detection and proactive primary care. To hear Chris's brother-in-law's music, tune in here: https://open.spotify.com/artist/1SKw4DO9FNLjcZDb5Q81q4?si=Dwpuz2wOTRawhMDfR5NIsAEpisode Chapters:(00:00:00) Intro: The Importance of Early Detection & Walk-On Clinic(00:02:30) Dr. Marty Makary Resigns as FDA Commissioner(00:04:37) ACA Marketplace Premiums Skyrocket by 58%(00:07:51) HR 8163: Stopping the Squeeze on Physician Reimbursements(00:12:34) Harvard Study: AI Outperforms Doctors in ER Triage(00:14:53) The FDA's Push for Hospital-at-Home Devices(00:17:18) Game: Guess the Procedure Cost (World Cup Edition)(00:21:22) Ask Spencer Anything: Cost Plus Drugs & D2C Pharmacies

"Within five years of calling us charlatans, that hospital system was sued for multiple millions of dollars by their participants... You can go from charlatan to change agent fast."Is history about to repeat itself in the health benefits world?My guest this week is Jay Gepfert, Managing Partner of Culpepper RFP. Jay spent his corporate career on the retirement and 401(k) side of the industry, where he witnessed a massive fiduciary paradigm shift 15 years ago. Driven by regulatory changes and a wave of aggressive class-action lawsuits, traditional retirement "brokers" were forced to stop taking undisclosed kickbacks, disclose 100% of their compensation, and legally sign on as fiduciaries for their clients.Now, Jay warns that a “tsunami” is hitting the health insurance space. With major lawsuits filed at the end of 2025 targeting plan sponsors and major brokers over voluntary benefits and PBM conflicts, employers can no longer hide behind the "we've always done it this way" excuse.In this episode, we break down exactly what it means for a benefits consultant to legally act as a fiduciary, how hidden compensation and broker overrides create toxic conflicts of interest, and how Jay's firm helps employers run rigorous, process-driven RFPs to audit their vendors and protect themselves from massive legal liabilities.If you are a CFO, HR leader, or benefits consultant trying to navigate the new era of ERISA compliance and Consolidated Appropriations Act (CAA) enforcement, this episode is a stark wake-up call.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Episode Chapters(00:00:00) Intro(00:01:40) Meet Jay Gepfert and Culpepper RFP (00:03:30) Origin Story: Transitioning from 401(k)s to Health Benefits RFPs (00:06:54) The 401(k) Paradigm Shift: How Retirement Got Cleaned Up (00:08:50) The 2025 Wave of Health Benefits Fiduciary Litigation (00:13:49) Voluntary Benefits and the Commission Tsunami (00:17:19) What it Actually Means to be a Fiduciary for a Plan Sponsor (00:19:05) Mandating Your Broker Becomes a Fiduciary Consultant (00:21:05) Flat Fees, Eliminating Hidden Comp, and Disentangling Commissions (00:27:24) Exposing Toxic PBM Conflicts of Interest (00:30:19) The Customer Experience: Running a Modern Fiduciary RFP (00:35:08) Why Process and Documentation Matter More Than Perfection (00:38:13) The Consolidated Appropriations Act (CAA) & Gag Clauses (00:41:18) The Catalyst: When Will the Market Finally Shift? (00:44:14) The Multi-Million Dollar Lawsuit: From Charlatan to Change Agent (00:48:56) The 5 Questions That Eliminate Status Quo Brokers (00:56:18) The Ideal Plan Sponsor: Proactive vs. Reactive (00:58:54) Shifting the CFO Mindset & Unlocking the Bottom Line (01:04:01) Big Picture: The Breaking Point of Employer-Sponsored Care (01:06:40) Closing ThoughtsKey Links for Social:@SelfFunded on YouTube - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/

"Insurance is there for when you're sick or when something goes incredibly wrong. It's not there for prevention."The traditional healthcare system is designed to treat you when you are sick. You go to a doctor for 15 minutes, get a basic blood panel, and if you are within the "reference range," you are told you are fine. The goal of this system is to get you from -1 back to 0.My guest this week is Prabhat Dhar, the Head of Growth for Superpower, a new platform that wants to take you from 0 to 100. Rather than treating late-stage diagnoses, Superpower provides comprehensive biomarker testing, looking at advanced metrics like ApoB, Fasting Insulin, and HSCRP, to detect diseases like cardiovascular risk or metabolic dysfunction up to a decade before they materialize as claims.In this episode, we discuss how Superpower translates complex biological data into a highly personalized, AI-driven action plan for your health (and your lifestyle). We also dive into why employers must stop relying on health insurance carriers to manage wellness, the power of decoupling proactive screening from the traditional system, and how to start bending the cost curve by focusing on root-cause analysis instead of late-stage symptom management.If you want to know what the future of employee health benefits looks like when it's built on individual biology instead of group claims data, this episode is for you.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Episode Chapters(00:00:00) Intro: Getting from 0 to 100 (Not Just -1 to 0) (00:01:21) Why the Primary Care "Quarterback" System is Broken (00:04:47) Decoupling Proactive Health from Health Insurance(00:07:42) The Origin Story of Superpower & Treating Crohn's Disease (00:12:06) Democratizing "Concierge" Functional Medicine (00:15:22) Why Traditional Blood Tests Miss the Real Signals (00:19:06) Translating Biomarkers into Personalized Action Plans (00:23:44) Overcoming "Point Solution Fatigue" with Biological Data (00:27:55) The Superpower Member Experience: How It Works (00:31:41) Integrating an AI Doctor Chat and Clinical Teams (00:33:42) How Superpower Augments Direct Primary Care (DPC) (00:41:22) The 5 Biomarkers You Need to Be Testing For (00:49:36) Moonshot: The Future of the "Health Super App" (00:54:51) Closing Thoughts: Moving from Success to SignificanceKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"To quote my business partner, a broker makes you broker."To celebrate the 5-year and 250th-episode anniversary of the podcast, we recorded a special live panel in front of an audience featuring three of the most forward-thinking minds in the benefits space: Chris Hamilton (Hotchkiss Insurance), Taylor Rogers (CCIG), and Seth Denson (Acrisure).In this "State of the Union" episode, we tackle the existential crisis facing mid-market employers and the healthcare industry at large. The panel holds nothing back as we debate the illusion of PPO network discounts, the weaponization of AI in medical billing, and why staying fully-insured absolutely does not protect a CFO from fiduciary liability lawsuits. The guys also share their personal "Jerry Maguire" moments - the exact turning points in their careers when they decided to stop chasing commissions and start fighting for the patients and employers footing the bill.Following the main discussion, we hosted a Q&A featuring questions from the audience.If you are an employer looking to take control of your healthcare spend or an advisor wanting to stay relevant in a rapidly changing market, this live discussion is packed with actionable strategy.Thank you to all who have listened for helping us get to 5 years!Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Episode Chapters(00:00:00) Intro: Welcome to the 5-Year Anniversary Live Show (00:01:51) Meet the Panel: Chris Hamilton, Taylor Rogers, and Seth Denson (00:04:56) State of the Union: Is the Benefits Industry in a Crisis? (00:11:12) Broker vs. Consultant: Defining the Difference (00:17:26) Following the Money: Controlling Facility Costs & Member Experience (00:24:02) Are Traditional PPO Networks a Scam? (00:34:46) Building Tiered Benefit Structures and Narrow Networks (00:40:22) The AI Threat: Weaponized Billing and the Loss of the "Training Ground" (00:55:40) Fiduciary Responsibility and the Threat of Employer Lawsuits (01:05:03) The Next 5 Years: Breaking Up Insurance Monopolies (01:11:18) Audience Q&A: Preventing High-Cost Claimants with DPC (01:15:30) The Panel's "Jerry Maguire" Career Moments (01:20:46) The Reality of Price Transparency and Medical Shopping (01:26:03) Navigating the Wild West of the No Surprises Act (NSA) (01:29:45) Why Fully-Insured Plans Don't Protect CFOs from Fiduciary Liability (01:32:21) Closing Remarks and the 5-Year Whiskey GiveawayKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"If we can do it for Whole Foods, which is a very large organization, why can't we do this for other employers?"Is the era of relying on national, opaque "BUCA" networks finally coming to an end?My guests this week are Blake Allison, CEO of Employers Health Network (EHN), and Philip Eaves, from Ascension. Together, they break down the exact blueprint they used to build a direct-to-employer, high-performance network for Whole Foods - and how they are scaling that exact same model for self-funded employers across the country.In this episode, we explore the hospital system's perspective on direct contracting. Phil explains why massive health systems like Ascension are eager to bypass traditional carriers to work directly with employers, citing faster payments, zero collection risk, and the ability to proactively manage patient care. We also discuss how to successfully integrate Direct Primary Care (DPC) into a localized network, the lessons commercial plans must learn from Medicare Accountable Care Organizations (ACOs), and why the future of healthcare relies on "re-localizing" how we buy medical services.If you are an employer, benefits consultant, or healthcare provider who is fed up with the transactional, nickel-and-dime nature of traditional insurance carriers, this conversation proves that a better, more collaborative model already exists.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: Whole Foods and the Move Away from BUCAs  (00:07:29) The Whole Foods Case Study: Building a Direct Network (00:12:15) Why Health Systems Want Direct Employer Contracts (00:17:15) The Evolution from RBP to High-Performance Networks (00:19:21) Integrating Direct Primary Care and Care Management (00:23:41) The Challenges of Scaling Direct Contracts Nationally (00:28:15) Re-Localizing Healthcare: Buying Care in Your Community (00:33:36) Overcoming the Negative Stigma of "Networks" (00:36:55) Applying Medicare ACO Lessons to Commercial Populations (00:42:31) Defining True Value-Based Care and Downside Risk (00:45:51) The Ideal Employer Profile for Direct Contracting (00:50:52) Lowering Costs with Local, Community-Based Care (01:05:17) Future Predictions: Site Neutrality and Price Transparency (01:11:25) Closing Thoughts: Providers Are Open for BusinessKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"Employers are at a point where they want to help create that ideal healthcare system, not the one that they have been dictated to."Is your company's health plan actually keeping your employees healthy, or is it just waiting for them to get sick?My guest this week is Ben Miller, Chief Revenue Officer at Premise Health, the nation's largest direct healthcare provider operating over 850 onsite and near-site wellness centers. Ben joins the show to discuss why the traditional fee-for-service model is failing both employers and employees, and how Advanced Primary Care is stepping in to serve as the new "front door" to the healthcare system.In this episode, we break down what Advanced Primary Care actually entails, from integrated behavioral health and lifestyle medicine to onsite pharmacies offering 90-day prescriptions for $1. Ben shares the results of a massive Milliman study showing how this model reduces total claims costs by an astonishing 30%. We also cover how employers of various sizes can implement near-site clinics, address employee privacy concerns, and utilize Epic-integrated care navigation to guide patients to high-quality, cost-effective specialists.If you are an employer or benefits consultant looking for a proven strategy to bend the cost curve while delivering an incredible healthcare experience to employees, this episode is a must-listen.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: The Shift Towards Advanced Primary Care (00:00:33) Meet Ben Miller & Premise Health (00:02:17) Defining Advanced Primary Care, On-Site, and Near-Site Clinics (00:05:06) Ben's Journey from Kaiser Permanente to Premise Health (00:10:32) The Breaking Point: Why Employers are Flocking to APC (00:16:07) How to Build and Customize an On-Site Clinic (00:20:11) Creating the "Front Door" to Healthcare & Navigating GLP-1s (00:25:20) Integrating Behavioral Health & Lifestyle Medicine (00:28:29) The On-Site Pharmacy Experience ($1 Medications) (00:30:22) Overcoming the "Big Brother" Privacy Stigma (00:32:36) The Milliman Study: Proving a 30% Reduction in Claims Cost (00:36:12) Group Size Requirements & The Power of "Coopetition" (00:39:35) Managing Catastrophic Risk & Epic Care Navigation (00:43:43) Expanding the Clinic: PT, Dental, and Vision Services (00:49:54) How Claims & TPA Integration Actually Work (00:52:33) Closing Thoughts: The Future of Employer-Sponsored CareKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

Welcome back to Last Month in Healthcare! This month, Spencer and Nathaniel sit down without a guest to unpack the biggest healthcare headlines and regulatory shifts from April 2026.From state-level crackdowns on PBMs to a surprising loophole that allows urban hospitals to siphon rural hospital aid, the guys dissect the policy changes and market moves that are actively reshaping the industry. They also discuss the affordability crisis driving a 26% surge in ACA Bronze plan enrollment, Amazon's aggressive new play into the GLP-1 and primary care market, and why CMS is finally (and officially) killing the fax machine by 2028.Plus, Spencer plays a game of "Blind Ranking," attempting to properly order the top 10 best practices and features of a modern self-funded health plan (including pass-through PBMs, cash-pay surgery networks, and pharmacogenomics) without knowing what's coming next.Thank you to this year's sponsor, Walk On Clinic!If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Chapters: (00:00:00) Intro & Sponsor Shoutout: Walk On Clinic (00:01:42) Bipartisan State Healthcare Regulations & PBM Oversight (00:04:40) ACA Shifts: The Rise of Bronze Plans & HSA Eligibility (00:08:38) The FTC's Vague New Healthcare Task Force (00:10:10) The Rural Hospital Aid Loophole Exploited by Urban Hospitals (00:11:27) Amazon Launches a $149/mo GLP-1 & Primary Care Program (00:15:18) CMS is Finally Ending the Fax Machine (Saving $781M) (00:16:48) Game: Blind Ranking the Best Self-Funded Plan Features (00:24:45) PSA: Watch Out for These Hidden Carrier Contract Clauses

"I would rather take this risk because I will never give another dime to a fully-insured carrier as long as I live."In an era of double-digit medical trend and skyrocketing fully-insured renewals, is the traditional insurance broker obsolete?This week, my guest is John Kountz, a benefits consultant at Frost Insurance who believes that the days of the "renewal carousel" - shopping the big 4 carriers and accepting double-digit increases every year - are finally over. In this episode, John shares his journey from feeling completely helpless as a broker to discovering the power of true consulting.We discuss the critical differences between a "broker" and a "consultant," how he uncovered that an employer was secretly paying 45% of their entire $10 million pharmacy spend in rebates, and how taking a fully-insured client directly to Reference-Based Pricing (RBP) cut their $1,000/month employee-only premium completely in half. John also breaks down the emerging power of pharmacogenomics, why 2026 is poised to be an even more brutal renewal year, and why you must replace your traditional broker with a true consultant.If you are an employer tired of throwing away money on fully-insured premiums, or a broker wanting to make the jump to self-funding, this conversation is the push you need.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: Why the Benefits Consultant is Healthcare's Most Important Role (00:04:03) Staying Independent in an Era of Broker Consolidation (00:11:51) Getting Out of the "Renewal Carousel" (00:18:18) The Turning Point: Discovering 45% of Rx Spend Was Going to Rebates (00:20:41) Converting a Fully-Insured Group to Reference-Based Pricing (RBP) (00:30:11) The Real Definition of Self-Funding (The Chassis vs. The Car) (00:36:05) Finding the Root Cause: Diet, Inflammation & Autoimmune Disease (00:46:04) The Future of Prescribing: Pharmacogenomics (00:57:20) Why the 2026 Renewal Season Will Be a "Bloodbath" (01:02:00) Closing Thoughts: Stop Working With Traditional BrokersKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/