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“The idea with WellGenie is, what if we can increase access and remove the cost burden? Then we give the opportunity for people to not delay care.” - Chris Mathew, WellGenie Many employees have insurance they can’t afford to use. Every prescription, virtual visit, and specialist appointment costs them money, so they put off care until small problems become expensive ones. Chris Mathew joined me this week to explain how WellGenie makes everyday care free for each employee and up to four family members: generic and brand medications, unlimited virtual and behavioral health care, same-day specialist access, and a personal health guide.  It runs alongside an employer’s existing carrier, TPA, and PBM, keeps those costs off the health plan, and refunds 40% of its fees if it doesn’t lower costs in the first year. Chris also shares why one state was told to walk away from $110 million in savings, and the thank-you bottle of wine he once sent a broker before learning how brokers get paid. If your employees are insured but avoiding care, this is the episode for you. 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: Free Care, Lower Costs (00:00:19) The State That Was Told to Stand Down (00:05:00) Broker vs. Consultant (00:07:10) The Thank-You Note to His Broker (00:15:30) Catching Up With Chris (00:20:53) Insured but Can’t Afford Care (00:28:13) $0 Generics and Cheaper Brand Drugs (00:33:38) Unlimited Virtual and Behavioral Care (00:44:08) Same-Day Specialist Access (00:46:42) The Personal Health Genie (00:57:03) The Money-Back Guarantee (01:11:59) Recap and Closing Thoughts Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

“Medical physicians are trained that [diabetes is] not reversible... Still to this day, I would say 95% of medical physicians do not know it’s reversible.” - Dr. Jeffrey Hockings, Diabetes Reversal Group Type 2 diabetes costs a self-funded employer about $15,000 a year per diabetic employee, and the standard of care is to manage it with medications for life. Dr. Jeffrey Hockings has spent almost 17 years showing it can be reversed instead. More than 10,000 people have reversed it on Diabetes Reversal Group’s patented program of food and supplements. Jeffrey explains how DRG works with each employee’s own doctor to wean them off medications, and how its money-back guarantee lets employers offer the program with no risk. He also covers why making the program free can backfire, why it cuts out dairy entirely, and his take on GLP-1s. If diabetes is one of the biggest line items in your plan, this is the episode for you. 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: Most Doctors Think It Can’t Be Reversed (00:02:37) Meet Dr. Jeffrey Hockings and DRG (00:06:29) Why Doctors Aren’t Taught Reversal (00:08:37) What Diabetes Costs an Employer (00:10:26) Fix Health, Not Just Healthcare (00:12:50) From Direct-to-Consumer to Employers (00:13:59) How the Money-Back Guarantee Works (00:16:32) Why DRG Skips CGMs (00:18:56) What Patients Eat (00:20:58) Why Dairy Is Off the Table (00:24:21) Treat Days After Reversal (00:28:14) Why Free Programs Fail (00:31:28) Getting Doctors to Take Patients Off Meds (00:38:00) GLP-1s and the Fen-Phen Comparison (00:41:46) What’s Next for DRG (00:47:42) The Role of Exercise (00:49:07) Closing Thoughts Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"He went from injury Friday night to in front of the correct surgeon on Monday afternoon." - Dr. Tom Weber, MD Ortho Most MSK spend goes to the wrong care: ER visits for back pain, $3,000 MRIs that could cost $450, weeks of waiting, and surgeries that never needed to happen. Dr. Tom Weber spent 24 years as an orthopedic and sports medicine physician before building MD Ortho to fix that. It gives every employee a physician-led team that steers them to the right care from the first call. Tom and Peter Krahn explain how MD Ortho covers both employee benefits and workers' comp, why their clients average 15 to 20% utilization, and how every client has seen at least a 2x return. They also share how a retiree avoided a $25,000 surgery and how a call about neck pain turned out to be a heart attack. If MSK claims are quietly draining your plan, this is the episode for you. 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: Injured Friday, Seeing a Surgeon by Monday (00:00:30) Meet Dr. Tom Weber, Peter Krahn, and MD Ortho (00:02:17) From Ancillary Sales to MSK (00:05:11) Why a Sports Medicine Doctor Built MD Ortho (00:08:11) Covering Workers' Comp and Employee Benefits (00:11:54) The Team Physician Model (00:13:44) The Most Common MSK Problems (00:15:22) Should Employers Waive Copays? (00:18:03) How MD Ortho Measures ROI (00:20:01) Driving 15 to 20% Utilization (00:24:56) Why Workers' Comp Is Different (00:28:35) Working With DPC and Onsite Clinics (00:30:56) The $25,000 Surgery That Didn't Happen (00:35:34) How to Add MD Ortho to Your Plan (00:42:29) Stop-Loss and a 0% Renewal (00:45:35) Catching a Heart Attack Over Video (00:49:02) What's Next for MD Ortho (00:51:09) Fully Insured Plans and Group Size (00:53:25) Where Healthcare Is Headed (00:59:41) Closing Thoughts Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"[AI] absolutely is an arms race, and this is what we're dealing with on a daily basis." - Stephen Carrabba, ClaimInformatics In this episode of Last Month in Healthcare, Producer Nathaniel and I sat down with Stephen Carrabba, president and co-founder of ClaimInformatics, to break down the biggest healthcare news stories of September 2026. We started with Blue Cross Blue Shield's claim that AI-powered medical coding tools added $942 million in costs over the past two years. One example: anemia diagnoses rose sharply at some hospitals with no matching rise in transfusions. The coding companies' response is that in a fee-for-service system, capturing a more complete picture of the visit means a bigger bill. Stephen deals with upcoding and unbundling every day. His take: if a service was rendered, it should be billed, but hospitals' AI and insurers' AI are now fighting each other, and the self-funded employer is the one paying for both. We also dug into ICHRA's federal rebrand as the "CHOICE arrangement," a survey showing 73% of small and mid-size employers are considering dropping group coverage for 2027, and Oscar Health's projection of 2.5 million ICHRA lives by 2029. I shared the story of an employer who moved to ICHRA for $400,000 in projected savings and wanted out within a month. Plus, more than half of hospitals still aren't fully complying with price transparency rules. Stephen explains why, for many health systems, paying the fine is cheaper than disclosing their prices. To cap it off, we built two health plans by coin toss, where Stephen made the case against bundled payments from a payment integrity perspective. I also answered a listener question about how much of a stop-loss increase is normal before you should shop it. Thank you to Walk-On Clinic for sponsoring this episode. Visit walkonclinic.com to learn more. Chapters: (00:00:00) Intro: Stephen Carrabba and Walk-On Clinic(00:01:48) AI Billing and the $942M Fight(00:04:51) ICHRA Becomes CHOICE(00:07:49) 73% of Small Employers Weigh Dropping Coverage(00:11:00) Oscar Predicts 2.5M ICHRA Lives by 2029(00:12:13) Hospitals Still Dodging Price Transparency(00:16:45) Game: Build a Health Plan by Coin Toss(00:37:27) Ask Spencer Anything: When to Shop Stop-Loss

"We pay them a $2,500 flat fee for the time that they spend with the patient and make that recommendation for no surgery. If you don't, then you've wasted their time." - Matt Eurey Most of healthcare is paid for volume, so employers end up paying for surgeries that never needed to happen. When RAND studied Carrum Health's data, about 30% of surgeries were avoided once the first step was checking whether the patient actually needed one. Matt Eurey ran benefits at Lowe's, which spent about a billion dollars a year on healthcare. He explains how Carrum pairs bundled prices with surgeon-held warranties and charges nothing per employee per month. He also covers why more than half of Carrum's new buyers last year made the program mandatory, and how the model extends to cancer and substance use disorder. If surgical and specialty claims are driving your trend, this is the episode for you. 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: Paying Surgeons Not to Operate (00:00:20) Meet Matt Eurey and Carrum Health (00:01:56) How Carrum Decides if Surgery Is Appropriate (00:05:34) Rooting Out Perverse Incentives (00:07:01) Running Benefits for 225,000 at Lowe's (00:13:26) The Early Days of Care Navigation (00:18:49) Why Matt Joined Carrum (00:20:50) What Value-Based Care Actually Means (00:26:33) Why Carrum Doesn't Use Benchmarks (00:28:44) Zero PEPM: How Carrum Gets Paid (00:30:28) Mandated vs. Voluntary Programs (00:37:01) Can This Become the Standard? (00:41:01) How Claims Flow Back to the TPA (00:43:17) The Member Experience, Start to Finish (00:49:03) Cancer and the Two-Year Warranty (00:51:45) Substance Use Disorder Care in Hours (00:56:14) Why Carrum Added Cancer and SUD (00:59:44) Why Wouldn't an Employer Do This? (01:01:33) What's Next for Carrum (01:03:10) What Happens If We Don't Fix Costs (01:05:08) Closing Thoughts Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"Over 90% of the time, there is some change recommended to the care path someone is on. Oftentimes we make two to four separate recommendations." - Peter Bridges, AccessHope Cancer is one of the largest cost drivers in any self-funded plan, and most of the strategies built to manage it focus on price. Peter Bridges argues the bigger lever is making sure the patient is on the right treatment in the first place. Only about 20% of cancer patients are treated at one of the country's 57 NCI-designated comprehensive cancer centers. The other 80% get care locally, from oncologists seeing a full schedule across multiple cancer types while the science moves faster than any one doctor can track. That gap shows up in outcomes, and it shows up in claims. AccessHope closes it by bringing subspecialists from centers like Dana-Farber, Johns Hopkins, and Fred Hutch directly to the local oncologist. The diagnosis is identified in claims data, the treating physician is contacted, and the patient never has to travel, switch doctors, or ask for help. We get into why lung cancer isn't a single diagnosis, why most local oncologists welcome an expert review rather than resist it, and why working-age adults now make up more than half of new cancer cases. Peter also explains why getting someone onto the right treatment early is the better financial decision for the plan, and what an employer actually has to do to put this in place. If cancer claims are a line item you worry about every renewal, this is the episode for you. 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: Bordering on Cruel (00:05:12) Meet Peter Bridges and AccessHope (00:11:40) The 80% Treated Outside Top Cancer Centers (00:17:25) Lung Cancer Isn't One Diagnosis (00:23:08) Finding Cancer Patients in Claims Data (00:28:44) Inside an Expert Review (00:34:30) Why 90% of Reviews Change the Care Path (00:40:02) Why Local Oncologists Say Yes (00:45:37) Cancer in Working-Age Adults (00:51:15) Why the Right Treatment Is the Cheaper Treatment (00:57:06) Putting It in Place as an Employer (01:03:22) Stories From the Field (01:08:40) Closing Thoughts Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

Monique Burke buys more stop-loss than almost anyone in this business, and the rate is the last thing she looks at. She built OneDigital's stop-loss center of excellence starting with a spreadsheet, an offshore data team, and one other person. It's doubled year over year since. Now it covers everything from marketing a case through claims reimbursement, plus TPA and captive selection, because every time they solved one problem another piece of the stack turned out to be broken. We get into what she checks first on every quote and why, the non-negotiables she won't place a policy without, and why a panel needs roughly ten carriers to function. Monique also explains why a carrier quoting 10% of what you send them is normal, what happens when an employer keeps a sick employee on the plan out of loyalty and finds out too late they weren't eligible, and what her underwriter and nurse are seeing right now in the claims data. If you've ever put a stop-loss spreadsheet in front of a client, this one will change how you read it. Tune in. “We look at what are the contingencies, what are the exclusions. Those are the two things I will always go to first, because that's going to make or break the policy or the decision. I don't care what your rate is." - Monique Burke, OneDigital 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: Building a Stop-Loss Center of Excellence (00:05:00) Why the TPA Choice Makes or Breaks the Plan (00:10:25) If You Want Change, You Have to Make Changes (00:16:00) Meet Monique Burke (00:20:00) Tell Me the Problem, Not the Solution (00:24:00) Building the Panel From Scratch (00:26:00) Why You Need Ten Carriers (00:28:00) They Quoted 48 Out of 412 (00:34:00) Pharmacy and the Claims Nobody Caught (00:38:30) What the Claims Data Looks Like Right Now (00:43:00) The Two Things She Checks First (00:46:30) The Non-Negotiables (00:48:30) The Eligibility Trap (00:55:00) Inside OneDigital (01:05:00) When a Captive Beats Going It Alone (01:13:00) Closing Thoughts Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

Two kids called Brett Morris to tell him he saved their father's life. The man had cancer and had decided not to fight it. He'd spent his working life saving for their education and he wasn't going to spend it on himself. Samaritan Fund covered his care, he changed his mind, and he beat it. That's the business. Brett finds people facing catastrophic medical costs, sources third-party funds to cover their premiums and out-of-pocket maximum, and the employer's plan gets relief as a byproduct. He started in 2021 doing 13 cases himself. He's now in 49 states and the Virgin Islands, working with over 2,000 employer groups, and just crossed a billion dollars in certified savings. We get into how the compliance actually works and why Nixon Peabody invited the Department of Labor into the room before Brett ever asked, why the employer is contractually barred from contacting the participant, and the 84% success rate that varies wildly by state depending on which hospitals accept individual coverage. Brett also explains why he won't take a case under $50,000, what happens when a plan doesn't renew, and why he thinks the industry's obsession with winning the case is backwards. If you have a laser or an exclusion on your plan right now, this is the episode. Tune in. "When people are faced with a difficult disease, their first concern is the cost of the care. And second is the actual disease." - Brett Morris, Samaritan Fund Program 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: "You Saved Our Father's Life"(00:03:21) From 13 Cases to 2,000 Employer Groups(00:09:49) Nixon Peabody and the Department of Labor(00:13:18) Why the Participant Comes First(00:15:43) What the Participant Experience Looks Like(00:20:35) Medical Debt and 41% of Americans(00:24:11) The Clinical Team and Forecasting a Prognosis(00:27:48) Not Breaking Up Someone's Transplant Team(00:30:05) How Nobody Gets Singled Out(00:33:05) What Consultants Should Do and When(00:37:17) What Happens in Year Two(00:39:56) The Foundation and What's Next(00:45:25) A Billion in Certified Savings(00:48:24) Lasers, Exclusions, and Hospitals That Won't Play(00:52:34) Closing Thoughts: Find the People Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"I look at it as an opportunity for everybody else. You're already seeing people on LinkedIn saying, I can't wait for the disruption." - Lamont Thurston, BeneRe In this episode of Last Month in Healthcare, Producer Nathaniel and I sat down with Lamont Thurston, founder and CEO of BeneRe, to break down the biggest healthcare news stories of August 2026. We started with Aon's $17 billion all-cash acquisition of USI, a deal that lit up LinkedIn for a week straight. KKR took USI private for $4.3 billion in 2014, so they're exiting at 3.4x, and Aon walks away with a serious middle-market position. Lamont's take on the antitrust question is worth hearing, and so is his argument that this creates more room for independents rather than less. We also dug into Aon's projection of a 9.5% healthcare cost increase for 2027, pushing average cost per employee past $19,000 and marking the fourth consecutive year of near-double-digit trend. Lamont's point: four years in a row isn't a spike, it's structural, and that number is now eating wage increases. Plus, employer use of the big three PBMs fell from 63.4% to 54.3% in a single year, driven mostly by employers under 1,000 lives, and the Fifth Circuit struck down the No Surprises benchmark over something called ghost rates. To cap it off, we played an over/under game on ten healthcare numbers heading into 2027, and I answered a listener question about what to do when your biggest client's HR contact retires and the new one wants to bid everything out. Thank you to Walk-On Clinic for sponsoring this episode. Visit walkonclinic.com to learn more. Chapters: (00:00:00) Intro: Lamont Thurston and Walk-On Clinic (00:01:32) Aon Acquires USI for $17 Billion (00:04:04) 9.5% Trend and the Fourth Straight Year (00:08:16) Employers Are Leaving the Big Three PBMs (00:10:47) Ghost Rates and the No Surprises Ruling (00:13:57) Game: Healthcare Over/Under for 2027 (00:25:12) Ask Spencer Anything: Your Client's HR Contact Just Retired

There are roughly 9,000 ambulatory surgery centers in the United States, and most of them aren't running at capacity. Ronen Elefant figured out that he didn't need to build another one; he just needed to reach the ones already sitting half empty. My guest this week is a trauma surgeon in Pennsylvania who has been flying his own plane to work for fourteen years. About a year ago he turned that into a business: rent time at an ASC, fly in, do the cases, fly home. One bundled price covering the facility, the anesthesiologist, and the surgeon. No insurance, no three separate bills arriving weeks apart. We get into how the economics work at three or four cases per trip, and why patients drive six hours from the Dakotas to get on a cash schedule. Ronen also explains what certificate of need laws actually protect, why he thinks insurance should only exist for catastrophic care, and how an employer could plug fly-in surgery into a self-funded plan without building anything. If you've been looking at surgical bundles and wondering how the supply side works, this is the episode. Tune in. "Burnout doesn't come from surgeons standing up all day. It comes from doing all this stuff on behalf of the insurance company." - Dr. Ronen Elefant, ACES 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 (00:02:19) Growing Up in the Family Practice (00:07:33) Why Surgery, and Why Trauma (00:13:04) Fourteen Years of Flying to Work (00:18:47) Healthcare Economics (00:24:37) The $2,500 Colonoscopy Across the Street (00:30:11) How ACES Was Born (00:35:56) Renting Time in Half-Empty Surgery Centers (00:41:38) How the Bundle Prices Work (00:47:20) Certificate of Need and Who It Protects (00:52:47) What Insurance Should Actually Be For (00:58:33) Ayn Rand, Rights, and the Role of Government (01:04:29) Plugging ACES Into a Self-Funded Plan (01:10:12) “Burnout Is Not From Standing All Day” (01:14:08) Closing Thoughts Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

This episode was recorded live on LinkedIn with Bill Dembereckyj, CFO of Imagine360, and it's a look at renewal season from the seat that ultimately signs off on it.  Bill walks through three real cases: a 250-life senior living facility staring at a 50% increase, an 85-life restaurant group facing a $450,000 jump, and a 140-life private school looking at 60%. We get into why CFOs are being brought in far too late, why Bill started his own plan renewal in Q1, and what happens when finance only gets handed the result and asked to bless it. Audience questions from the live cover captives with RBP, whether stripping the network hurts steerage, and what happens when a member needs care somewhere you're not contracted. If you want to be more useful to the CFO in the room this renewal season, this is the episode. Tune in. "You've taken away all my other strategic choices. Now the only lever I have left is how much employees pay versus how much the company pays." — Bill Dembereckyj, CPA 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: What Is Imagine360 and What Is RBP? (00:02:56) The CFO's Role in the Renewal (00:04:35) The Bias Toward Procrastination (00:08:13) Balancing HR, Finance, and the CEO (00:09:36) Audience Question: Captives, RBP, and Cash Pay (00:13:40) Case One: Senior Living, 250 Lives, 50% Renewal (00:18:30) Fixed Budgets and the Fear of Maximum Exposure (00:21:09) Case Two: Restaurant Group, 85 Lives, 60% Renewal (00:24:19) What Healthcare Inefficiency Does to Company Value (00:28:31) Don't Pull Every Lever at Once (00:29:50) Audience Question: Does RBP Hurt Steerage? (00:33:08) Pharmacy: The $400,000 Rebate Nobody Saw (00:38:13) Case Three: Private School, 140 Lives, 60% Renewal (00:43:24) What Bill Wants From Consultants (00:49:09) Give Your Broker Some Grace (00:52:16) Closing Thoughts Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

Whole genome sequencing costs about $1,000 today. Ten years ago it was fifteen. Clinical guidelines already say kids with epilepsy or developmental delay should be escalated to it, and more than half of them never are. My guest this week is Joshua Resnikoff, founder of Sunstone Health and a former bench scientist at Harvard.  He came to this the hard way. His middle son started spiking 105-degree fevers at 18 months old, and it took three years and several pediatricians to name the condition. When they finally did, the answer was that there's no treatment. Josh knew the tests existed. He just couldn't reach them. So he built a business that runs employer claims data, finds kids with a likely genetic basis for their disease, and gets them trio whole genome sequencing in twelve weeks instead of seven years. The part that matters for a plan sponsor: this runs as a voluntary benefit. No new plan language, no TPA codes, no prior auth, no insurance in the equation at all. Four documents and a claims feed. Josh takes the testing cost at risk, and getting a family to a diagnosis meaningfully cuts their utilization from there. We also cover why single-gene and exome testing miss 97% of the genome, what it costs, and why these families are already expensive whether you find them or not. If you're looking for cost containment that actually helps the member, this is the episode. Tune in. "We can help you deal with that before it ever actually becomes a claim." - Joshua Resnikoff, Sunstone Health 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 Black Box of Healthcare Pricing (00:04:24) 98.6 to 105 in the Time It Takes to Get Milk (00:11:01) Everything on the Shelf, Nothing Within Reach (00:16:40) One in Ten Americans (00:22:45) What Genetic Testing Actually Means (00:29:33) Who Pays, and Why the Families Already Know (00:34:56) The Case for Sequencing Everyone (00:40:00) The Guidelines Say Do It. Half Don't. (00:45:17) Direct Primary Care and the Voluntary Benefit Model (00:50:57) The Mechanics: Four Documents and a Claims Feed (00:55:40) Vendor Fragmentation and the Netflix Problem (01:00:48) The Moonshot and the $2 Trillion in Waste Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

Half of what this pharmacy compounds is GLP-1s. The other half is a category most benefits professionals have never had to think about, and probably will within a few years. I got a tour of Optimal Balance Pharmacy's facility and sat down with co-owner Rick Manuel to talk through what peptides actually are, how the FDA's category two list works, and what happens if those compounds move to category one. We get into why BPC-157 has a better safety profile than ibuprofen and the mechanism behind that, how lyophilization quietly strips 30 to 40% of protein concentration out of the product people buy online, and what to look for in a compounding pharmacy's sterility and endotoxin testing. Rick also explains why compounded GLP-1s can be dosed twice weekly instead of once, why physicians are having to self-educate on a category medical school never covered, and why he thinks insurance coverage for peptides is roughly a decade away. If you've been seeing this stuff on Instagram and wondering what's real, this is a look behind the curtain. Tune in. This episode is a discussion of an emerging category and is not medical advice. "It's not the drug that's making you lose muscle. It's the reduction of appetite." — Rick Manuel Chapters: (00:00:00) What Peptides Actually Are (00:00:46) The FDA Category Two List (00:01:44) Why BPC-157 Beats Ibuprofen (00:04:15) How Peptides Signal the Body (00:07:20) The Instagram Problem and Lyophilization (00:09:24) Inside Optimal Balance's Testing and Compliance (00:12:33) Educating Physicians on a New Category (00:14:27) Compounded vs. Brand GLP-1s (00:15:54) The Rules for Compounding Right Now (00:16:38) Why Twice a Week Beats Once (00:20:36) The Recovery Blend (00:24:23) Protein, Resistance Training, and Muscle Loss (00:26:50) Where This Goes Next (00:28:18) Why Peptides May Never Be FDA Approved Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

Everyone in this market is optimizing for the wrong thing. Consumers want the most weight loss for the cheapest price, and up to 40% of what they're losing is muscle. My guests this week are Nicholas Syhler, a former cardiologist who left his residency to work upstream of the heart attacks he was treating, and Paul Elsass, an exercise physiologist who spent years in startup land before landing on the one root cause nobody had solved.  Their company, Embla, runs a coach-first GLP-1 program out of Copenhagen with peer-reviewed data on almost 5,000 patients showing 55% less medication and the same weight loss outcomes seen in clinical trials. We get into why the drug was never designed to shut off hunger, why members can sit on a quarter milligram of semaglutide for months instead of escalating every 30 days, and the claims data suggesting aggressive dosing is quietly driving up MSK spend. We also cover why they built the model around self-funded employers rather than direct-to-consumer, what one bundled price under $500 a month actually includes, and their plan to move from weight loss into full cardiometabolic care with deprescribing as the goal. If you're evaluating a GLP-1 strategy for 2027, this one reframes the question. Tune in. "We were seeing four to six pounds per week. That's way too much. It should be one to two." — Nicholas Syhler 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: Meet Embla(00:01:30) From Cardiology Residency to Quitting Medicine(00:05:56) Reading the First Line on the Label(00:07:07) Losing Weight Too Fast: The Muscle Problem(00:08:34) Why "Eat Less, Move More" Fails(00:12:43) Coach First, Clinician Second(00:14:19) A Quarter Milligram for Four Months(00:16:52) Semaglutide vs. Tirzepatide(00:19:29) The MSK Claims Nobody Saw Coming(00:22:17) Why Self-Funded Employers, Not Consumers(00:25:09) Where the Name Embla Comes From(00:27:28) One Price, Everything Included(00:30:42) Learning About PBMs the Hard Way(00:34:43) Deprescribing and Cardiometabolic Care(00:42:30) Why America Makes This Harder(00:46:30) The Three Behavioral Levers(00:49:27) How the Program Actually Rolls Out(00:54:14) Diet, Fasting, and Food Quality(00:57:10) The Moonshot(01:00:59) Closing Thoughts Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

Katy Talento ran healthcare at the White House Domestic Policy Council and helped push through the price transparency executive order. Now she runs health plans for a living, including for the convent where she once lived as a nun. She spends this episode on why a post-network world keeps hitting the same wall: the three-way contracts between carrier, TPA, and provider that make the network Plan A by force. She explains why she thinks those provisions violate the Sherman Act, what DOJ has started doing about it, and why the workarounds employers use today amount to an underground railroad rather than a functioning market. We also cover the 2026 CAA and the DOL rule that together make PBMs fiduciaries and may do the same to TPAs, her four-part "school choice for healthcare" plan to scale cash pay nationally, and the AI upcoding wave she thinks is breaking stop-loss actuarial models right now. If you've ever wondered why the obvious fix isn't available to you, this is the episode. Tune in. "Nobody in the entire town understands employer-sponsored care. All the oxygen is on 20 million people on the ACA. But 180 million people over here, we're not doing any policy for." - Katy Talento 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(00:01:05) From Epidemiologist to Capitol Hill(00:05:37) The Nun Years and Her First Client(00:10:50) Inside the Price Transparency Executive Order(00:16:58) Why Washington Ignores 180 Million People(00:20:33) What Transparency Data Can Actually Do Now(00:25:55) The Plantation Contracts(00:29:01) DOJ, the Sherman Act, and Anti-Competitive Provisions(00:33:04) The CAA and the DOL Rule That Reset Fiduciary Duty(00:39:16) Why the Big Three PBM Model Is Now Illegal(00:46:53) RBP's Access Problem: The Nuns at NYU Langone(00:54:54) The Holy Grail: One Cash Price(00:57:46) School Choice for Healthcare(01:13:43) AI Upcoding and Why Stop-Loss Models Broke(01:21:15) Closing Thoughts: Tell Your Story Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/