Self-Funded

“You talk to the janitor or the field worker making hourly pay and looking at these figures, knowing we better stay healthy this year, because there’s no way we can afford this.” - Sebastian Sanchez, RHSB In this episode of Last Month in Healthcare, Producer Nathaniel and I sat down with Sebastian Sanchez, benefits consultant at RHSB in Dallas, to break down the biggest healthcare news stories of...

“Rebates, I’ll go out on a limb and say, they’re almost inherently evil... Your sickest employees are paying for that rebate.” - Steve Ditto PBM rebates are sold as savings. Steve Ditto argues they do the opposite. Manufacturers pay for rebates by raising list prices, and members’ copays and deductibles are based on those inflated prices. The employer cashes the rebate check while its sickest memb...

“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 th...

“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 1...

"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....

"[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'...

"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 fir...

"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 treatm...

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, beca...

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-par...

"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 ac...

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 t...

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 br...

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...

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...

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...

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...

My guest this week is Billy Potter, now CEO of Snellings Walters, and we spend this episode on "the Switch," his firm's process for moving employers from fully insured to self-funded. Billy explains why he thinks it has almost nothing to do with insurance and everything to do with changing who a business trusts to lead them. We get into why "does that make sense?" is the wo...

"Generic drugs are not the costly drugs. A 100% increase on a relatively inexpensive generic may not even be noticeable." In this episode of Last Month in Healthcare, Producer Nathaniel and I sat down with Sean McGowan of Centivo to break down the biggest healthcare news stories of July 2026. We started with the proposed tariffs on generic drugs - 100% in 2028, 200% in 2029 - and what th...

"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 developmen...

"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 happenin...

"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...

"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 Spe...

"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 underwrit...

"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 a...