Self-Funded

“Rebates, I’ll go out on a limb and say, they’re almost inherently evil... Your sickest employees are paying for that rebate.” - Steve DittoPBM 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 members cover the cost.Steve spent 30 years as a healthcare consultant before the wrong $100,000 infusion put him in the ICU and made him a patient advocate. He explains why buying drugs on a lowest-net-cost basis beats chasing rebates, why the PBM is the easiest place for a self-funded employer to start, what to ask about an advisor’s compensation, and how Nautilus Health Institute’s free model contract language and Contract X-Ray tool help plans get a better deal. His new book, The Middleman’s Cut, is available on Amazon.If you’re advising self-funded employers on pharmacy, 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: Rebates Are Almost Inherently Evil(00:00:16) From Consultant to Patient(00:04:40) Jim, Maria, and Rationing Medications(00:09:46) Why the Sickest Members Pay for Rebates(00:17:09) Steve’s Path Through Healthcare Consulting(00:19:40) Quality, Stop-Loss, and Specialty Drugs(00:27:37) Nautilus and Free PBM Contract Tools(00:32:54) Where Self-Funded Employers Should Start(00:38:55) Direct Primary Care and Direct Contracting(00:43:00) Navigation and the Right Diagnosis(00:52:04) Are Carrier Networks Obsolete?(00:56:51) Closing ThoughtsKey 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 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, WellGenieMany 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 ThoughtsKey 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/

“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 GroupType 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 ThoughtsKey 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/

"He went from injury Friday night to in front of the correct surgeon on Monday afternoon." - Dr. Tom Weber, MD OrthoMost 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 ThoughtsKey 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/

"[AI] absolutely is an arms race, and this is what we're dealing with on a daily basis." - Stephen Carrabba, ClaimInformaticsIn 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