“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 October 2026.

We started with Mark Cuban’s argument in Fortune that healthcare costs, not AI, are the real job killer. His fix is to break up the vertically integrated insurers and make provider contracts public. Sebastian sees employers starting to revolt against the system from the ground up. My take is that both can be true: if you replace someone with an AI tool, you don’t have to pay for their health plan either.

We also dug into KFF’s annual survey. Family coverage now averages $28,303, up 5%, while the worker’s share rose 9% to $7,471. At firms with fewer than 200 employees, nearly a third of workers pay $12,000 or more in premiums alone. Sebastian explains what those numbers look like to an hourly employee.

Plus, Amazon, Google, Meta, Oracle, and Axon pledged to speed up electronic prior authorization. A new bill from Rep. Frank Pallone would scrap No Surprises Act arbitration, which researchers say has added more than $22 billion in costs since 2022. And doctors’ offices owned by hospital systems are billing routine visits at hospital rates, sometimes 10 times more for the same care.

To cap it off, we played a Halloween edition of our fewer-ingredients game, and I answered a listener question about how to tell a client their plan is fine without looking like you’re not doing your job.

Thank you to Walk-On Clinic for sponsoring this episode. Visit walkonclinic.com to learn more.

Chapters:

(00:00:00) Intro: Sebastian Sanchez and Walk-On Clinic
(00:01:52) Mark Cuban: Healthcare Costs, Not AI, Kill Jobs
(00:04:39) KFF Survey: The $28,303 Family Premium
(00:08:00) Big Tech’s Prior Authorization Pledge
(00:10:09) A Bill to Scrap No Surprises Arbitration
(00:13:30) Doctors’ Offices Billing as Hospitals
(00:17:05) Game: Halloween Candy, Fewer Ingredients
(00:23:38) Ask Spencer Anything: When the Plan Is Fine

“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 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 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/

“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/