While payers and providers argue over fees in the independent dispute resolution process, self-insured health plans need to focus on fair market value
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By Bruce Shutan
By Bruce Shutan
By Laura Carabello
By Laura Carabello
MESSAGE FROM THE CHAIRWOMAN
Amy Gasbarro, SIIA Chairwoman, President, ELMCRx Solutions
As SIIA’s Chairwoman this year, I want to begin by sharing how honored and energized I am to help lead this organization at such an important moment for the self-insured marketplace. You can expect to hear more from me throughout the year as we advance key initiatives, elevate SIIA’s visibility, and strengthen the value we deliver to our members and the broader industry. I look forward to engaging with you often as we continue shaping the future of self-insurance together.
SIIA enters this year with a renewed sense of purpose, clarity, and forward momentum. As the leading voice for the self-insured and captive insurance marketplace, SIIA has long played a critical role in shaping policy, elevating industry standards, and ensuring that employers, solution providers, and innovators have a strong, unified advocate. This year, we are expanding that commitment with a sharpened focus on visibility, education, and proactive engagement across every corner of the self-insured ecosystem.
STRENGTHENING OUR ADVOCACY AND GOVERNMENT RELATIONS
SIIA’s government relations efforts remain at the center of our mission. With regulatory and legislative activity accelerating at both the federal and state levels, our members need timely, actionable insight more than ever. This year, we are enhancing our cadence of updates, briefings, and member communications so that stakeholders can stay ahead of emerging issues, from stop-loss regulation to transparency requirements, specialty drug trends, and the evolving dynamics of employer-sponsored benefits. Our goal is simple: ensure that SIIA members are never surprised, always informed, and consistently represented in the rooms where decisions are made.
EXPANDING VISIBILITY AND MARKET EDUCATION
A major priority this year is bringing greater visibility to the value SIIA delivers to the self-insured marketplace. We are investing in a refreshed marketing and communications strategy designed to reach a broader audience, highlight the strength of our membership, and articulate the unique advantages of self-insurance in today’s healthcare environment. This includes a new series of white papers, thought leadership briefs, and educational content that will help employers, policymakers, and industry partners better understand the innovation, flexibility, and cost stewardship that define our sector.
LEVERAGING MEMBER FEEDBACK TO SHAPE OUR PATH
Our Diamond members, representing some of the most influential organizations in the industry, have provided invaluable feedback on how SIIA can continue to evolve. This year, we are using that input to evaluate additional ways to support our constituents, including new programming, expanded research, and enhanced opportunities for collaboration. Their insights help ensure that SIIA remains aligned with the needs of the marketplace and continues to deliver meaningful, high-value resources to all members.
RENEWED MARKETING AND COMMUNICATIONS EFFORTS
To support our visibility goals, SIIA is launching a more coordinated and modernized marketing strategy. This includes consistent messaging across channels, strengthening SIIA’s brand presence, and ensuring our communications reflect the sophistication and leadership of our membership. These efforts will help amplify SIIA’s voice and reinforce our position as the leading advocate for the self-insured community. Thank you for your continued engagement, leadership, and partnership across the self-insured ecosystem. We have an ambitious year ahead, and I’m excited for the progress we will make together. More to come. Stay tuned.
IDR’s Tug of War
FWhile payers and providers argue over fees in the independent dispute resolution process, self-insured health plans need to focus on fair market value
Written By Bruce Shutan
Faced with unintended consequences from one of the most significant U.S. healthcare reforms in recent years, the self-insured marketplace has been forced to innovate its way out of conflict.
Federal agencies vastly overestimated the ability of providers and insurers to amicably resolve payment squabbles as part of the independent dispute resolution process. IDR has generated at least $5 billion in total administrative and payment costs since being introduced in April 2022, with more than 10 times the number of disputes that were expected to be filed. This has created a heavy financial burden on group health plan sponsors.
The process was established by the No Surprises Act (NSA) to stop penalizing patients who inadvertently receive care from an out-of-network physician. While an independent, third-party arbiter is brought in to be as neutral as possible, both payers and providers have argued that the results favor the other side.
A payment formula for determining qualified payment amounts (QPAs) was introduced to capture the median of contracted rates for medical services in the same region and insurance market. But in the face of provider opposition, the IDR system was adopted when providers and insurers could not agree on payment amounts for out-of-network claims.
FOLLOWING THE MONEY
IDR intended to reduce transaction costs, improve the overall interaction between providers and payers, and protect patients who are no longer being balance billed, observes Scott Bennett, EVP of provider relations for The Phia Group. “But the process itself has created a significant number of issues,” he says.
One is the sheer volume of filings from providers who are asking for open negotiations. It’s easy to see why that’s happening: the simplicity of pursuing these actions has now made it part of a provider’s business processes. Another issue is that there’s no enforcement in open negotiations to resolve payment disputes, which was supposed to be a 30-day window, while additional guidance is clearly needed.
The biggest motivator is monetary gain. “There’s an incentive for the provider not to participate in open negotiations because IDR is better,” he explains. “There’s
an incentive to initiate IDR because the win rate is so high, and then there’s an incentive for IDR arbitrators to benefit providers, as providers are the initiating party most of the time and the initiating party chooses the IDR entity, and the entities want to be selected and essentially win the business.”
Bennett has seen awards handed out that were actually above billed charges, noting “odd logic” in not being able to consider the provider’s billed charges and award whatever amounts based on what the provider asked for.
“When NSA went into place, I was initially surprised by how much more savings there was compared to what payers were doing previously on this tranche of emergency, air ambulance and surprise billings – three different categories of claims,” observes Brian Wroblewski, executive vice president of sales and marketing for ClearHealth Strategies. “So, it doesn’t surprise me in the least that the providers are trying to do a grab strategy of, ‘I still need to try to recuperate what I can, and I’m going to fight this tooth and nail in whatever way I can.’”
One pitfall worth noting is that QPAs are full of nuance and prone to miscalculation unless a highly skilled expert is brought in to design a proper glide path method, he explains. Look no further than various medical procedure codes, sites of service involving an inpatient vs. outpatient setting and the type of discount applied to in-network claims (percentage off vs. per diem vs. DRG-based, etc.).
Another is health plans and employers not having the ability to manage open negotiations and IDR negotiations with their respective parameters at either a claim-type or dollar-size level before getting to an actual arbitration. “If you don’t have that robustness of configuration, you may run into additional problems,” he says.
While believing the focus on IDR losses is important, Wroblewski says it’s not tantamount to the issue at hand. In examining NSA claims as a whole, selfinsured health plans should still end up securing a reasonable discount in the 60% to 70% range, more than they had previously. Between a proper QPA and negotiation parameters at different levels, IDR wins and losses will often be blended for superior results compared to what was in place prior to the NSA.
Brian Wroblewski
Scott Bennett
Tug of War
Whatever falls through the funnel into an actual IDR arbitration, he says, there are limits to what can and can’t be used in terms of data industry or claim-specific data and no guarantee that most IDR cases will be won. “But you can still bring in important data, such as, for example, what an average allowed amount is for providers,” he adds.
In addition, he notes that a “go-out” rate or initial payment amount allows plans to determine their own basis for reimbursement, such as reference-based pricing (RBP). However, they must be willing to pivot back to the QPA when a provider wants to engage further, which adds another layer of complexity.
“This is where a lot of folks in our industry will get either confused or have a limited ability to manage it from an administrative perspective, systems or otherwise,” he explains.
EYEING PAYMENT INTEGRITY
The answer for avoiding IDR disputes in the first place may lie in payment integrity. At its core, this approach serves as connective tissue for price transparency, NSA compliance and a more thoughtful view of the QPA.
“It gets to how you look at payment dispute, IDR and defensibility of your methodology for the QPA process,” observes
Rob Gelb, CEO of Vālenz Health, who notes that no matter what methodology is used, providers can still balance-bill patients if they’re not getting what they asked for.
In 2019 and 2020, he noticed RBP was causing too much friction with 12% to 15% appeal and balanced-bill rates and served as a blunt force instrument to reduce health plan costs. In short, he saw the need for a more defensible strategy with regard to a providerreimbursement recommendation.
The tide began to turn in 2021 and 2022 when there was wider access to publicly available data around providers' charges, what they accepted as payment, published rates that were available for networks and how they reimbursed for certain procedures in and out of a hospital setting.
“We started turning that into an algorithm,” he reports.
Mindful that NSA regulations created a heavy burden for TPAs and their clients, Vālenz developed a market-sensitive repricing and compliance solution to generate defensible reimbursement rates that’s supported by extensive clinical data from multiple sources. Rather than use Medicare as the basis for this approach, it makes recommendations based on an analysis of provider data for specific services in a given region. The result is very low IDR appeal rates.
In responding to this trend, Bennett says self-insured employers can request that their TPA or other service providers follow meaningful benchmarks, identify service-level agreements to determine the value of services rendered, make viable good-faith offers and create a record. These steps will help lower payment amounts or influence a more favorable ruling.
“You’ve got to treat it as a quasi-legal function instead of an administrative function, and in doing that, No Surprises Act independent dispute resolution really should be recognized as its own standalone service, not a bolt-on to reference-based pricing or some other cost-containment piece,” he suggests. “It is its own special service, and it has a significant cost per unit.”
Rob Gelb
Tug of War
Having an ambiguous fair market value in regulations breeds disputes and seeds conflict, Bennett says, noting a need for more guidance on a direct metric – not a usual, customary and reasonable measurement. He uses California as an example of how, in the early 2000s, the state’s workers’ compensation system switched to the typical pricing metric used in contracts based on a multiple of Medicare, which reduced conflicts and arguments over fees.
“There’s never going to be an agreement on the right value, and that’s why we’re seeing awards at higher than bill charges,” he says.
Bennett cites studies by RAND and the Health Care Cost Institute that map Medicare multiples to contracts as the benchmark for resolving provider pay disputes. He also references workers’ comp cases in Texas, pegging fees to about 200% of Medicare for facilities and more than 100% for outpatient services, with a certain multiple layered on top of that.
JUDGING THE JUDGES
Another issue to consider is that those handling the IDR process are essentially independent businesses, and there isn’t enough transparency on who is making these determinations, what their qualifications are and whether those decisions are sound.
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As such, Bennett believes the selection of IDR arbitrators needs to be reformed. “The fact that the initiating party, the person who’s essentially suing, chooses the judge and then you have judges whose compensations are tied to being selected more for processing these because that’s how they get their fees, just seems like an odd process to me,” he says.
He would like employers to advocate for more transparency and accountability for IDR arbitrators. He has seen determinations come back within less than a day when the evidence that was submitted was “an absolute dissertation on a complex medical claim,” calling into question the integrity of the process and the possibility that the evidence could not have been fully reviewed in the time between submission and determination.
“There’s behavioral science to this and identifying the arbitrator by name and qualifications on the determination would encourage a higher level of review and accountability; arbitrators might feel embarrassed about a cursory and copy-and-paste decision that would not withstand scrutiny,” he says.
Christine Cooper, CEO of aequum, who sits on the SIIA Board of Directors, says there needs to be a substantial amount of redrafting of both the NSA and the Federal Arbitration Act to create an enforceable scenario, which has huge implications for every group health plan, regardless of whether it’s fully insured or self-insured. Her takeaway: plans have options depending on their risk tolerance, including not paying the awards until there’s legislative clarity on the IDR process.
“There is no private right of action to enforce any of these IDR awards,” she explains, noting that the U.S. Supreme Court recently refused to hear Guardian Flight et al. v. Health Care Service Corp., which means the Fifth Circuit Court of Appeals ruling on this highprofile IDR case still stands. A similar ruling was made in the Eleventh Circuit Court of Appeals involving REACH Air Medical Services LLC v. Kaiser Foundation Health Plan Inc. On top of that, she cites a New Jersey district court case on whether the IDR process represents a fair arbitration that will likely appear before the Third Circuit Court of Appeals, where the same outcome is expected.
Given these decisions, she says the Department of Labor, Health and Human Services and Centers for Medicare & Medicaid Services do not have any right to penalize a plan or insurer for not participating in the process and not making payment if there is an award.
“The courts are, in essence, undoing the IDR part of the No Surprises Act a little at a time. If the Supreme Court doesn’t take it up, then each one of these decisions are going to stay in place, and ultimately Congress is going to have to do something,” she says.
WAITING ON CLARITY
Penalties under the NSA have nothing to do with the IDR process or interplay between providers and plan sponsors, according to Cooper, who says “they only have to do with whether you’re providing the proper notices to plan participants and things of that nature.”
She says the IDR process lacks transparency, noting that providers don’t know how the QPA is being calculated. “To make the IDR process truly work and cut back on the number of claims that ultimately get filed, there has to be something more akin to a true arbitration. There has to be judicial review just like there would be for any other arbitration.”
Christine Cooper
Cooper believes RBP could help minimize IDR exposure because the process doesn’t apply to a pure RBP plan that cannot get to that median in-network contracted rate as defined by the statute.
“It really lifts that plan outside of the IDR process,” she observes. “We are still seeing even pure RBP claims going through the process. But I think on the back end, if there’s ever an enforcement that those would be grounds to overturn any decision that came out of it. Plus, the RBP experience throughout that IDR process is going to be lower in numbers because so many fewer claims will be covered.”
Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for nearly 40 years.
How to minimize costs and protect plan assets
Bruce Roffé, president and CEO of HHC Group and a licensed pharmacist, suggests several key strategies for self-insured employers to adopt when it comes to the independent dispute resolution (IDR) process. The following tips will help minimize out-of-network costs and protect plan assets:
1. Strengthen network contracting. That includes expanding narrow networks for high-cost specialties and implementing tiered networks to incentivize in-network utilization.
2. Pursue pre-emptive negotiation. The thinking is to engage early during the 30-day open negotiation window and use data-driven offers based on CMS QPA methodology and historical benchmarks.
3. Leverage IDR data. Arbitration trends should be analyzed by specialty and geography, while high-risk specialties (i.e., anesthesiology, emergency medicine, radiology) should be targeted for contracting focus.
4. Adjust plan design. He suggested adopting reference-based pricing tied to Medicare or transparent benchmarks and capping out-of-network liability to limit exposure.
5. Partner with cost-containment experts. It’s best to hire vendors skilled in NSA negotiations and IDR representation, as well as bundle services such as bill review, negotiation and IDR submissions.
6. Educate members. It starts with promoting steerage programs and incentives for in-network care and providing pre-service notifications for elective procedures.
7. Take action. Among the various additional steps that he recommends: audit out-of-network spending and IDR outcomes, identify high-risk providers and specialties, and engage a cost-containment partner for negotiation and IDR support.
— Bruce Shutan
Bruce Roffé
Rare Diseases Lurking in Your Workforce
WWritten By Laura Carabello
While some diseases are classified as “rare,” they are not uncommon. Unfortunately, most rare diseases are serious or life-threatening, leading to significant morbidity and mortality.
In the U.S., the National Institutes of Health defines rare diseases as those affecting fewer than 200,000 individuals, the majority of whom are children. With a greater understanding of disease genetics, experts agree that there are more than 10,000 rare diseases -- 80% of which are genetic.
But rare diseases are not just genetic and can also stem from infections, environmental factors, allergies or even rare forms of cancer. According to the organizers of Rare Disease Day, 1 in 5 cancers is classified as rare, touching lives with more than just medical concerns as they shape everyday life, work and education in ways that are often invisible. Individuals and families affected by rare diseases often experience problems, such as delays in obtaining an accurate diagnosis, difficulty finding a healthcare provider with expertise in their condition and a lack of access to treatments or ancillary services.
Source: Charles River Research
The impact of rare disease on employer health plans in 2026 will be significant, primarily the result of the high cost of new specialty drugs and gene therapies. With one-time costs of well over $2 million, these innovative, high-impact treatments --
though used by a small number of people -- contribute to a projected median 9% increase in overall healthcare costs for employers.
Estimates published in Drug Discovery Today project that by 2030, there may be over 63 FDA-approved Cell and Gene Therapies (CGTs) in the US. Despite these advances and increased understanding of the causes and mechanisms of many rare diseases, the Food and Drug Administration (FDA) reports that while more than 880 drugs and biologics have been approved for the treatment of rare diseases, 95% of rare diseases do not have an FDA-approved treatment.
One major challenge is that research on rare diseases is especially reliant upon global partnerships. With so few patients available to study in any one country, scientists are forced to search extensively to identify the causes and test potential treatments.
Source: Global Genes
EMPLOYERS CONFRONT MULTIPLE CHALLENGES
Plan sponsors face the soaring, high costs of specialty drugs, including CGTs for genetic disorders, complex conditions and rare cancers. This landscape is about to change as the FDA is expected to approve around 50 CGTs in 2026, many of which target these diseases. These
innovative treatments will impact the employer spend, with Deloitte projecting that employers with 7,500 employees have a 1 in 4 chance of experiencing a CGT claim by 2029.
While these therapies offer dramatic improvements in advancing optimal health outcomes, employers are grappling with how to make these groundbreaking but expensive treatments available. In response to these exorbitant costs, especially the multi-million-dollar specialty and rare disease drugs, employers are expected to implement tighter utilization controls and prior authorization requirements to mitigate the proliferation of high-cost claims.
BURDEN OF RARE DISEASE
In the workplace, employees and their families are dealing with delayed diagnosis, as the advocacy organization Global Genes reports that it takes an average of 7 years to get an accurate diagnosis for a rare disease – and in many cases, it may take much longer, or even a lifetime. This can lead to missed treatment opportunities and a prolonged impact on their work and personal lives.
The burdens of rare disease extend beyond the employee who has the condition. A worker may take on significant caregiving responsibilities – often for a child or relative -- imposing complex medical, social and economic challenges that affect on-the-job performance, productivity and retention. To address these issues, employers are beginning to focus on condition support services, escalating the number and scope of condition management and care coordination programs to better support employees and families with complex and chronic conditions, including rare diseases.
COST-CONTAINMENT OPPORTUNITIES
Many employers are also considering other tactics, such as increasing employee cost-sharing through higher deductibles and out-of-pocket maximums or utilizing risk-pooling strategies, where multiple health plans contribute to a shared fund for high-cost therapies, allowing them to distribute financial burdens more equitably. Mortgage models offer another approach, amortizing costs over time with subsequent payers assuming payments if members change plans.
These models can incorporate portability mechanisms, allowing the initial payer’s investment to follow the member. While each model has limitations, they aim to better align payer incentives with patient outcomes and therapy value. As employers reassess their benefit strategy, they remain sensitive to member needs for improved access to life-changing therapies and are partnering with Centers of Excellence (COEs) for complex conditions, like cancer.
The FDA reminds plan sponsors to align their coverage policies with FDA-approved indications. FDA reviewers carefully consider the scientific evidence and consistencies in disease process across different groups, as well as a drug’s overall benefits and risks, in determining the patient population appropriate for treatment.
These regulators advise all payers to uphold the FDA’s authority in determining the safety and efficacy of medical products, including accelerated approval drugs, and cover the entire population included in the gene therapy’s “indication and usage” section of the prescribing insert. They further recommend upholding physician authority in determining medical necessity as physician specialists are experts in their field, spending years in training, research and clinical practice. Health plan decision-makers should consult these experts in developing coverage policies to ensure alignment with therapeutic area understanding and clinical practice, and specialists should also be included in external reviews.
Source: Skyquest
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INNOVATIVE DATA AND TECHNOLOGY SOLUTIONS
To navigate this environment, benefit leaders are emphasizing data-driven strategies and evidence-based support to manage costs while doing the "right thing" for their employees. Advanced data analytics and new technology platforms answer the need for effective management of these conditions through more accurate forecasting and ensure measurable, valuable results.
“While healthcare overall remains a significant challenge for employers, rare diseases present an even more daunting one,” says Melinda Alba, M.D., chief medical officer, Evidium, a healthcare AI company. “They create a particularly unique challenge for self-insured employers, who are responsible for ensuring the right provision and care for their employees while managing significant uncertainty, all while maintaining the risk. That challenge is compounded because evidence is fragmented across guidelines, studies, and real-world data, and rarely structured in a way that supports transparent clinical and financial reasoning, so that the best clinical/financial decisions can be made.”
Dr. Alba points out that traditional analytics struggle when patient numbers are small and care pathways are complex, adding, “That’s where a computational approach matters. A technology platform should structure trusted medical evidenceincluding guidelines, published studies, and real-world observations - into computational models that represent clinical states and potential future pathways, all explicitly traceable back to the underlying evidence.”
Rather than treating rare disease as a black box, Dr. Alba says the technology platform should enable benefit leaders and their advisors to explore what is known, what is uncertain, and how different evidence-based scenarios affect utilization, treatment timing and cost exposure over time.
Arnav Saxena, Machine Learning (ML) Engineer, Evidium, explains, “Selfinsured stakeholders are often forced to make decisions without clear visibility into the prevalence of rare conditions within their employee population, how these conditions typically progress or where costs may concentrate. By integrating structured medical knowledge with claims and other data, the right platform helps stakeholders to reason more clearly about risk and make better-informed decisions.”
He says the result is a shared, traceable foundation for decision-making - one that supports more informed planning for rare disease therapies, including high-cost interventions, while aligning financial stewardship with responsible care.
Dr. Alba and Saxena invite self-insured employers to ask themselves these questions:
1. Are you familiar with the definition of rare disease in your employee population?
2. Do you know how many of your employees or their family members face the challenges of a rare disease?
Arnav Saxena
Melinda Alba
3. Are you addressing the education, utilization and coverage of therapies for rare diseases?
4. What impact do you anticipate rare diseases will have on your 2026 budget and beyond?
“To navigate this landscape, benefit and industry leaders are emphasizing real, data-driven strategies and evidence-based support to manage costs while doing the right thing for their employees over a longer period of time,” Saxena continues. “While there is trusted medical evidence for rare diseases, it's often harder to find.”
Together with their colleagues at Evidium, Dr. Alba and Saxena recognized the need for an AI platform based on computational knowledge and transparent reasoning to operationalize medical knowledge computationally and enhance the reliability of AI.
“Small patient numbers and low prevalence of rare disease mean there is greater reliance upon registries, case studies and real-world data (RWD) alongside traditional trials,” they state. “This is precisely where the introduction of a computational platform transforms reliable
medical evidence into precise, transparent and actionable intelligence that plan sponsors can trust. It is particularly valuable for rare diseases because the platform helps close the knowledge gap. A shared knowledge foundation that can be utilized by all stakeholders helps improve not only clinical insights but also the prediction of disease progression.”
Self-insured stakeholders are often left in the dark regarding the rare disease patient journey. A computational platform that ingests trusted sources of medical evidence, including clinical guidelines, published studies and care pathways specific to rare conditions and complex diseases, helps to drive better clinical and financial outcomes. It also enables data integration, allowing for the construction of dynamic, patientspecific models of current health states and future trajectories for rare disease progression, along with potential treatment pathways and associated financial impacts. Empowered with this robust ability, organizations can share transparent results and reasoning across their teams and advisors.
“For the first time, employers will no longer be hamstrung by simply guessing about what comes next for their employees and members facing the challenges of rare disease,” they conclude. “When it comes to risk management for rare disease, with probabilistic
forecasting and associated costs, there is now a transparent, traceable source of evidence-based medical and clinical knowledge, normalized, shareable and ready to power more precise predictions.”
AI COULD ENABLE FASTER RARE DISEASE DIAGNOSIS
David Talby, PhD, MBA, CTO of John Snow Labs, advises that rare disease symptoms often look like something ordinary – until years later. While the evidence was there, it was just scattered across years and specialties. He says rare diseases are not invisible, but the healthcare system often sees them through a keyhole:
Each visit is a snapshot. A lab result here, a symptom note there, maybe an MRI five years later – but never viewed together.
Different data lives in different systems. Your labs might be at one hospital, your imaging at another, and your genetic report in a lab portal no one checks twice.
The “common first” mindset. Because rare diseases are, by definition, rare, the odds seem stacked against them, until you realize those odds reset every time a new doctor starts from scratch.
What he suggests is a longitudinal, multi-modal patient record – one that brings together every clue across the years: blood tests, imaging reports, pathology results, doctor’s notes, even data from wearable devices. A unified, longitudinal approach doesn’t just speed up diagnosis — it changes, and in some cases saves,
lives. It gives clinicians the full canvas instead of a handful of puzzle pieces. And if it works as intended, it helps more patients hear their doctor say: “We finally know what this is and we can treat it.”
An AI-powered vision:
Connects the timeline. Pull together labs, imaging, procedures, and doctors’ notes into one unified patient journey.
Teaches the system what to look for. Build a digital “fingerprint” library of rare diseases – combinations of features that tend to cluster together over time.
Blends rules with learning. Some patterns come straight from medical literature (“bilateral carpal tunnel before 60 plus thickened heart walls – think ATTR”). Others can be learned automatically by algorithms scanning thousands of historical cases.
Keeps the human in the loop. Doctors still make the final call, but now they’re alerted to patients who deserve a second look.
GENETIC TESTING FOR RARE DISEASES
Employers are inundated with opportunities to conduct genetic testing as a wellness benefit, potentially identifying an individual’s genetic mutation and likelihood of developing a rare disease. However, employers should be aware of major ethical issues that may raise concerns for privacy breaches, data security and potential distrust about misuse of information.
Source: Cousin Tree – chart illustrating the different types of cousins, including genetic kinship marked within boxes in red, which shows the actual genetic degree of relationship (gene share) with 'self' in percentage (%).
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As with any workplace diagnostic initiative, genetic testing should not be done merely to satisfy patient curiosity – it should only be conducted when medically advised and clinically efficacious. Data from Business Group on Health’s 2026 Employer Health Care Strategy Survey reveals that 57% of surveyed employers already cover genetic testing based on family history for certain diseases, and another 7% are considering doing so for 2027/2028.
There are always issues associated with genetic testing, such as increased costs, unnecessary followup tests and procedures, undue mental hardship for patients and a potential for limited actionability. Employers should be judicious about coverage of genetic testing and insist upon evidence-based utilization for members who can benefit from it and receive appropriate navigation support.
Employers can select the appropriate vendor to manage various aspects of genetic testing, including their pharmacy benefit managers (PBMs), lab partners and some third-party partners such as lifestyle support programs and condition-specific solutions. Rather than making coverage decisions based on test categories for all genetic tests, it is a better course to determine the clinical utility of individual tests and evidencebased treatment guidelines. An important directive is to be aware of new-to-market, diagnostic genetic tests and remain mindful of prior authorization and utilization management requirements.
Finally, employers must also navigate the Genetic Information Nondiscrimination Act (GINA), which protects employees from discrimination based on genetic information and strictly limits how employers can acquire and use such information.
Genetic Testing Glossary of Terms
To make sound decisions about genetic testing, it is helpful to have some background knowledge.
· Genes: The basic unit of heredity transferred from parents to offspring, present in all cells.
· Genetics: The study of heredity and variation in characteristics of people based on their heredity.
· Genome/Genomics: The complete set of genes in an organism and the study of these genes.
· Genetic Testing: Analysis of a particular gene, or set of genes, which may indicate the presence of or increased likelihood of developing a disease.
· Pharmacogenomic (PGx) Testing: A type of genetic test that is used to predict an individual’s response to a given medication or therapy.
· Biomarker: A measurable indicator of a certain biological process or condition, often linked to an individual’s genes, which can be used by providers to help diagnose certain health conditions, track disease progression and predict the effectiveness of a particular treatment approach.
· Precision Medicine: Medical care that focuses on identifying approaches that would effectively treat a particular patient based on their individual genetic, environmental and lifestyle factors.
Sources: National Library of Medicine
Workplace genetic testing: which employees are likely to participate, what are their concerns with employer sponsorship, and which design features could reduce barriers and increase participation? - PMC
FINANCIAL IMPLICATIONS OF GENE THERAPY FOR RARE DISEASE
This year, employers can expect to learn of rapid advancements in gene therapy for rare diseases with more approvals, better diagnostic tools and increased collaboration for accessible, single-intervention, potentially life-saving cures. As of early 2025, the FDA has approved over, and industry experts anticipate 30-50 additional cell and gene therapy approvals by 2030. Forecasts from the National Bureau of Economic Research project that by 2026, annual spending on gene therapy products and patients in the U.S. is estimated to reach $25.3 billion.
Rare diseases are typically also ideal candidates for gene therapy research and development, as approximately 80% result from a single genetic mutation, according to American Gene Technologies. By correcting or compensating for this mutation, gene therapy has the potential to provide long-term, curative treatment, often with a single administration.
Source: Kaiser Permanente Business
At the end of 2025, for example, the notable approval of Waskyra for Wiskott-Aldrich Syndrome generated widespread awareness of increased research funding and faster regulatory pathways for personalized genetic medicines. New drug delivery systems are fueling precision editing for previously untreatable genetic conditions.
It’s also worth noting that genetic testing of newborns may result in increased prescribing of gene therapies. In mid-December 2025, the Department of Health and Human Services added.
Two rare genetic disorders, Duchenne Muscular Dystrophy and Metachromatic Leukodystrophy, were added to the federal newborn screening list to enable early treatment. As a result, employers should not be surprised by requests for coverage of ELEVIDYS, a prescription gene therapy used to treat ambulatory and non-ambulatory people with Duchenne muscular dystrophy who are at least 4 years old and have a confirmed mutation in the dystrophin gene.
Every day, employees may hear about new lifesaving treatments for their own or a family member’s rare disease. This is largely the result of multiple pharma companies collaborating with regulatory agencies to use a common approval pipeline to fast-track approval of therapeutics. Late last summer, a rare and aggressive type of brain cancer that often becomes fatal a year after its diagnosis in children and young adults now has its first FDA-approved therapy, a once-weekly capsule of the drug Modeyso. An estimated 2,000 patients in the U.S. are affected by this cancer each year.
Managing the costs of gene therapies - which can run into millions of dollars – remains the primary challenge to ensuring treatment accessibility. An analysis of 230+ health benefits executives from health plans, employers and unions conducted by the Pharmaceutical Strategies Group (PSG) reveals that more than 70% of employers and health plans expect affordability of gene therapy for their health plan members and workers will be a “moderate or major challenge” over the next 2 to 3 years.
Despite these results, most responders express low confidence in their understanding of the financial impact, and nearly 40% don’t currently rely upon any financial protection product to manage their financial risk related to cell and gene therapies.
Cost of Rare Diseases
· The total indirect and non-medical cost of rare diseases is estimated at $548 billion annually: $64 billion for children and $484 billion for adults.
· Absenteeism accounts for nearly $150 billion (27%), followed by presenteeism ($138 billion, 25%) and forced retirement ($136 billion, 25%).
· For adults, caregiver absenteeism costs match those of individuals with rare diseases ($64 billion vs. $60 billion), while for children, caregiver absenteeism costs may exceed those of the affected child ($89 billion vs. $60 billion).
· Broader impacts on quality of life when assessing the value of a gene therapy beyond what is included in traditional health technology value assessments: Parents or caregivers may be able to return to work, reducing lost productivity and increasing workforce participation.
· Healthcare system savings can be substantial due to reduced hospitalizations and long-term care needs.
· A lifetime of care for hemophilia (~67 years) can cost ~$12M.
Source: American Society of Cell and Gene Therapy; Journal of Molecular Therapy
ROLE OF STOP-LOSS
However, a growing number of plan sponsors are turning to their stop-loss partners for protection from unknown financial risk. BCS characterizes stop-loss for gene therapies as a standalone product that can be a great fit for larger employers above 3,000 employees that do not buy stop-loss coverage but want to be shielded from the frequency of expensive CGTs. For small to mid-size groups of 101 or more employees, they say gene therapy stop-loss sits alongside a traditional stop-loss policy, carving out the gene therapy ingredient cost risk from the traditional stop-loss policy.
A recent Mercer survey paints a different picture. When asked about gene-therapy-only stop-loss policies for employers that don’t otherwise purchase stop-loss, just 1% of survey respondents with 5,000 or more
employees purchase GT-only stop-loss. Mercer analysts conclude that, given the current low incidence of gene therapy claims, they may not feel compelled by the GT-only stop-loss products currently available. But this may change as more gene therapies reach the market.
Finally, Vickram Pradhan at Sopris Capital advises that stop-loss premiums are already increasing at a ~10% CAGR, and that’s with only 50-60% of stop-loss plans covering the few dozen approved CGTs. He says premium inflation could accelerate if 1) CGT coverage expands across carriers and/or 2) CGT approvals proliferate.
As reimbursement uncertainty continues with newly approved CGTs, many stakeholders are optimistic that meaningful changes can be made. One such change is in the development of innovative payment models, which 79% of the survey respondents thought would improve reimbursement and access challenges. In fact, implementing strategic initiatives between payers and manufacturers was a top development in a survey conducted by Cardinal Health.
Increased adoption of high-trust centers of excellence for specific treatments is becoming especially relevant when there are geographic barriers to accessing care. Milliman advises that less than half of patients with sickle cell disease have a treatment center in the region where they live.
Source: Kaiser
Regardless of which payment model or approach a stakeholder selects, there is a need to reexamine existing underwriting and cost containment tools to manage CGT expenses. Plan sponsors should also be aware of the trials and tribulations of certain approved gene therapies that have not met expectations.
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AT ISSUE: MEMBER ACCESS
Portability
For gene therapies in the rare disease space, patient portability is a key concern as individuals frequently change jobs with concomitant changes to their insurance plans and coverage. Plan eligibility through a family member differs, and purchasing plans on the marketplace is proving to be a challenge with regulatory changes. Therefore, an employer is unlikely to receive the full benefit of reduced total cost of care for covering a one-time gene therapy, an issue that is exacerbated due to the upfront cost and the expectation of health system savings over a patient’s lifetime.
Prevalence
Physicians at Kaiser Permanente/Georgia advise that even if a company has 1M employees, they are likely to only have a couple of people each year who would be considered for gene therapy. But the cost of a single employee or an employee’s family member who needs gene therapy could be substantial. Astute employers must consider strategies around gene therapies that can protect their employees and their plan’s financial performance.
Restrictive Coverage
Plan sponsors determine coverage policies using many different data sources, including clinical criteria recognized by the Centers for Medicare and Medicaid Services (CMS), clinical trial data and FDA prescribing information. Some adopt narrow clinical trial inclusion/exclusion criteria that were represented in the pivotal clinical trial vs. using the FDA-approved indication.
Varying Value-based Payment Models
Innovative payment arrangements impact the requirements for self-insured companies to cover the entire upfront cost of a gene therapy. This includes installment plans, subscription agreements, outcomesbased agreements (OBAs), and warranties. Mortgage models offer another approach, amortizing costs over time with subsequent insurers assuming payments if patients change plans. Tangential to all these arrangements is careful coordination of health services, medical management, healthcare data and specialty pharmacy expertise to provide a holistic approach to care management for rare diseases.
Many companies are also utilizing portability mitigation strategies: risk-pooling strategies, where multiple payers contribute to a shared fund for high-cost therapies, and can distribute financial burdens more equitably. These models can incorporate portability mechanisms, allowing the initial payer’s investment to follow the patient.
Inconsistent Payment Methodologies
The complex patchwork of payment systems, varied billing practices and reimbursement methods for rare disease gene therapies that vary by administration route requires extensive time and resources for members to navigate. These often pose unnecessary administrative barriers to accessing timely treatment and should be removed when possible.
Member Support Programs
Federal safe harbors reduce financial challenges for patients and their families, alleviating significant barriers to accessing these potentially curative but logistically complicated therapies. The creation of these provisions provides legal certainty that employers can allow drug developers to offer limited support programs, such as lodging or transportation, to patients and caregivers who must travel to specialized treatment facilities.
Travel for Treatment
Stem cell tourism has emerged as a fast-growing global phenomenon, with patients traveling across borders and potentially thousands of miles to seek treatments that may not be available or approved in the US. This form of medical tourism is particularly appealing to those suffering from chronic or terminal illnesses where conventional therapies have failed.
Employees may be lured to stem cell clinics worldwide. However, many authorities, such as the Harvard Stem Cell Institute (HSCI), warn against this option since some of these clinics offer unproven treatments with promises of miracle cures for conditions ranging from Parkinson’s disease to spinal cord injuries. While this choice offers hope, it also raises significant ethical, medical and regulatory concerns. There are some reports that these unproven treatments carry substantial risks, including tumor formation, tissue rejection, infection, permanent disability and death.
According to the HSCI, in the U.S., stem cell treatments are tightly regulated, and the only FDA-approved therapies are hematopoietic (blood) stem cells from cord blood for blood cancers and immune disorders, plus several specific CAR T-cell therapies (genetically modified immune cells) for certain cancers. But many other uses, such as for arthritis or Parkinson's, are still experimental, with the FDA cracking down on unapproved "regenerative medicine" clinics. Instead of encouraging travel for unproven treatments, employers are well-advised to focus on providing coverage for FDA-approved CGT within their existing health plans.
Moreover, there are legal and compliance issues for employers. For example, an employer could face significant legal risks if an employee suffers harm or complications from unapproved treatment in a foreign country. Furthermore, attorneys at Alston & Bird advise that offering medical travel benefits, even for a specific treatment, could cause the employer's health plan to be classified as a group health plan under the Employee Retirement Income Security Act (ERISA) and the Affordable Care Act (ACA). This could trigger complex compliance requirements and potential excise taxes for non-compliance.
GO-FORWARD COVERAGE DECISIONS
Coverage decisions for CGTs should not rest solely upon the current absence or prevalence of rare diseases in the workforce. By integrating CGTs into your health plans, employers can potentially provide:
1. Access to new, transformative treatment options: For certain diseases, when no other treatments exist, or current options are costly and only temporarily manage symptoms.
2. Slowed or halted disease progression: In some cases, CGTs may be able to halt disease progression entirely by addressing its underlying genetic cause.
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3. Reduced long-term healthcare costs: With the right price point and benefit structure, CGTs have the potential to prevent costly lifelong medical interventions and may offset the costs of long-term treatment.
4. Quality-of-life improvements: CGTs may offer improved function, reduced or eliminated pain and suffering, provide a psychological sense of well-being, and reduce strains on time and caregiving.
“Sun Life’s latest high-cost claim and drug trend analysis shows million-dollar claims have increased 29% over the prior year and 61% over the past four years, driven not just by cost but by rising frequency,” says Robert McCollins, chief community organizer, Employers Healthcare Alliance (EHA), a non-profit managed ‘employer built by employers for employers and their work families.' "The question for employers is no longer if a rare disease will impact their workforce, but when.”
Robert McCollins
McCollins, who leads the EHA to provide support for HR/Business Professionals who desire the best healthcare for their workplace through a peer community, educational programs and actionable resources and solutions that are easy to implement and use, attributes the success to optimizing outcomes requiring unencumbered access to data, early identification and intervention.
“This will only be accomplished with a benefits support team of the advisor, TPA, PBM, clinical risk managers and data analytics partners that are all aligned to support the patient and employer,” he continues. “Strategies such as centers of excellence, charitable and government programs with roll-up your sleeves, hands-on clinical advocacy can dramatically change outcomes.”
In one case, his team was able to involve a clinical expert in a particular rare disease to reduce a $1.7M patient drug spend by over $1M, providing access to a disease-specific center of excellence for enhanced care and oversight for the patient.
Source: Tufts University NEWDIGS
RISKS OF EXCLUDING COVERAGE
While the prospect of a multi-million-dollar expense can be a deterrent to coverage, there are stop-loss policies to protect a plan by transferring the risk of high-cost claimants. Moreover, the downside of not covering CGTs carries many risks, primarily compliance and negative public relations.
Lockton maintains that excluding coverage can trigger a disability-based discrimination claim, even if the exclusion is targeted at an employee’s dependent. If a plan amendment adding the exclusion is installed midyear because of an existing claim or impending claim, the amendment risks a HIPAA violation.
The advisory firm further states that if a self-insured employer chooses to exclude gene therapy, and then decides to make an exception to cover the treatment gene therapy due to extenuating circumstances (negative publicity, child of an executive needs the treatment, etc.), the claim will not be eligible for stoploss reimbursement because the service is not listed as covered in the underlying health plan.
Therefore, it is critical to align the terms of the underlying health plan and the stop-loss coverage to ensure stop-loss reimbursement of claims related to these expensive treatments. Some carriers/claims administrators will not allow excluding some or all gene therapies.
The consequences of exclusions may also result in adverse publicity since these treatments are often viewed as essential, particularly for children. Imagine the adverse publicity implications for not covering FDA-approved gene therapy for a child with a life-threatening condition with limited, if any, treatment options.
NEXT UP: COMMON CHRONIC DISEASES
Employers must be prepared for every eventuality since new technology is poised to bring CGTs to common chronic diseases. While expenses for treating not-so-common rare diseases were taxing health plan budgets, these new treatments targeting more common conditions, which are certainly “lurking” in the workforce, may become even more financially challenging.
New research from Penn Medicine reveals a safe delivery system of therapeutic DNA to cells, which could transform the treatments for common chronic diseases like heart disease, diabetes and cancer. This breakthrough overcomes the harmful, adverse effects of past attempts to treat chronic disease.
• In the pipeline, there are several gene therapies for various cardiovascular indications, including congestive heart failure, with some expected to file for Biologics License Applications this year.
• Gene-targeting approaches for Alzheimer's disease and related dementias are a major area of research focus, with grant programs specifically funding early-stage human trials for 2026 and beyond. A gene therapy for Huntington's disease is also showing promise in clinical trials.
• CGTs are already a significant part of cancer treatment, and there is continued expansion into solid tumors and new immunotherapies.
• Executives at Breakthrough T1D, formerly the Juvenile Diabetes Research Foundation, believe that novel cell therapies will transform T1D management and make them a reality.
Diabetes is certainly a key target, so be on the lookout for really promising treatments. Novo Nordisk and Aspect Biosystems recently announced they are entering a new phase of their partnership to develop transformative cell therapies toward clinical development and potentially generate a functional cure for people living with diabetes.
While this development could take years, it could be a gamechanger for employers. BSwift benefit administrators report that U.S. companies incur$413 billion annually in diabetes-related costs alone, and the yearly healthcare cost for an employee with diabetes is $20,000–six times higher than someone without. Roughly 6.4% to 8.2% of the employed U.S. adult population has diabetes.
As costs continue to rise, this annual figure is predicted to rise 20% year-over-year. Comorbid conditions like obesity, musculoskeletal (MSK) pain and depression often co-occur with diabetes, making health management more complex and further raising the stakes for workforce health management.
As with all new treatments, employers should be skeptical of products or therapies that promise a guaranteed cure for diabetes or any other condition. Any genuine cure will have undergone rigorous clinical trials and received approval from regulatory bodies, like the FDA. It is always prudent to consult with a healthcare professional before making significant changes to plan coverage.
About the Author
Laura Carabello holds a degree in Journalism from the Newhouse School of Communications at Syracuse University, is a recognized expert in medical travel and is a widely published writer on healthcare issues. She is a Principal at CPR Strategic Marketing Communications. www.cpronline.com
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55% of patients experience a change in diagnosis
82% see a change in treatment plan
PRIMARY ADVANTAGE
Advanced primary care emerging as the engine for value-based care
Written By Bruce Shutan
DDecades
of mounting dissatisfaction with fee-for-service medicine and fragmented care have laid the groundwork for a more coordinated, value-focused approach known as advanced primary care (APC), which is turbocharging self-insured health plans.
A Bain & Co. study suggests that APCs will be among the disruptors that could take over up to one-third of the traditional primary care market in the coming years. APC adoption is rapidly accelerating, with 76% of purchasers offering it or considering doing so within the next 1 to 3 years, according to the National Alliance of Healthcare Purchaser Coalitions.
Fortune 500 companies from JPMorgan Chase to 7-Eleven have turned to this model, which is credited with saving up to 30% of healthcare costs with the shift to value-based care. Organizations like the Primary Care Collaborative and the National Alliance of Healthcare Purchaser Coalitions have advocated for greater investment in comprehensive APC.
At the heart of this movement is a recommendation from leading researchers that primary care spending should roughly double, to 10% to 12% of total health spending, from about 5% to 7%. This thinking reinforces the old axiom that an ounce of prevention is worth a pound of cure, as patients schedule more regular checkups to ward off serious health problems.
MAXIMIZING OUTCOMES
APC began to take shape over the past decade amid a shift beyond traditional, volume-based care, according to Ed McNamara, executive vice president, business development strategy for Premise Health. He says this approach was built on comprehensive, team-based and value-based models and increased recognition of the role that primary care plays in improving health outcomes and reducing expenses.
“We know that investing in highquality, accessible primary care leads to healthier populations and lower total cost of care, and APC allows us to maximize outcomes and cost savings for the organizations we work with,” he says.
It’s easy to understand why APC has emerged in recent years. As much as 80% of primary care is owned by big entities such as insurance companies and hospital systems that answer to Wall Street rather than Main Street or local communities, notes William H. “Bill” Bestermann, M.D., president and chief medical officer for Epigenex Health, Inc.
As a result, he says PCPs are under pressure to see about 30 patients a day for 10 minutes
at a time because they’re paid based on patient volume. “The financial motivations are completely misaligned,” he adds.
Doctors, no doubt, are drawn to the APC model in hopes of establishing more meaningful patient relationships and helping improve outcomes without having to deal with care barriers and administrative matters involving insurance companies.
For physicians who practice APC, “it’s not just about the transactional visit that happens when a patient is in the health center,” explains Krista Beckwith, vice president of population health with APC provider Marathon Health. “It’s more about that proactive management that happens before, after and in between that visit.”
APC is rooted in the patient-centered medical home model in the early to mid-2000s, which originated in pediatrics, and both emphasized quality. However, “it never saved any money or improved care in adult medicine because it was mostly structural and administrative,” Bestermann explains.
He says nearly half the patients had few medical needs because they were younger and healthier, while about 60% had a chronic condition and accounted for 85% of the overall health spend. Mindful of these facts, he explains that the American College of Physicians created a concept called the advanced medical home whose focus was on the needs of patients with a particular condition. The best example of that in the U.S. was Kaiser Permanente in Colorado, where a collaborative coronary care service grew out of the HMO’s cardiac rehab program.
Like direct primary care and concierge care, both of which involve a membership-based model wherein they pay a monthly subscription for direct access to their own provider in lieu of traditional health insurance, APC offers more time with providers and increased access through both in-person and virtual visits.
“Where it differs is in its comprehensive, multidisciplinary care team and focus on population health and total cost of care,” McNamara says. “It brings together primary care, behavioral health, pharmacy, care management, care navigation and virtual primary care services to proactively care for members.”
Zaid Fadul
APC goes further than the medical home concept by prioritizing digital access, better use of data analytics and technology, and an increased emphasis on behavioral health and pharmacy access, he explains.
But there’s also a larger swath for improvement. Employers are trying to implement more APC metrics into their wellness plans, observes Zaid Fadul, CEO of Bespoke Concierge MD. Flagging serious illnesses at a younger age and preventing disease progression “makes it much easier to mitigate the downstream negative impacts of eye damage, kidney disease, erectile dysfunction or anything else like that if you intervene early,” he says, noting that those steps typically save about $1,200 to $1,500 a year per employee.
In APC, Bestermann says systems of care become standardized. He has come to believe over the past 30 years that all cardio-metabolic conditions and chronic diseases are related, driven by excess oxidant production and decreased antioxidant defense that happens as people age. “If we’re fat and smoking, it’s worse – so it all ties together,” he says.
WIDENING ACCESS
Bestermann also points to the need for a population health tool and patientengagement resources and education programs to help them understand their disease and what can be done about it, along with evidence-based care processes that are consistent with best practices. “Then you have to have the IT infrastructure to support providing and measuring that care,” he explains, noting that these elements are missing from the direct primary care model.
Self-insured employers can build APC into their plan design by focusing on access, affordability and engagement, McNamara suggests. Those steps include making APC low- or no-cost for members or integrating it into their network as a preferred provider. When members can easily access primary care, he says their healthcare shifts from reactive, episodic care to proactive care management. “Early detection and prevention methods are essential to avoiding costly complications, saving out-of-pocket expenses for both employees and employers,” he adds.
More organizations are exploring primary care-centered health plans to drive even greater engagement with APC and further improve overall outcomes, according to McNamara. In these plans, he says employers steer members to easily accessible primary care providers and incentivize preventive care like annual exams and vaccines, often at low or no cost. Members benefit from a seamless, coordinated experience, even when they do need to seek care from a specialist.
One example is Premise and Centivo partnering last year to launch a primary care-centered health plan for self-insured employers. A mutual client, which offered an alternative health plan for more than four years, noted that more than 70% of its population has enrolled. “Those receiving care from Premise providers are driving a 32% lower per member per month healthcare spend,” McNamara notes. “They’re also making 16% fewer emergency room visits and experiencing 28% fewer hospital admissions.”
With benefits such as sameday and next-day appointments, lower costs for both members and organizations, integrated behavioral and pharmacy services, and streamlined referrals, he says more employers are recognizing that APC can drive meaningful health outcomes and long-term savings.
In 2024, Premise Health reviewed claims data for more than 207,000 of its members using a methodology validated by Milliman that showed APC leads to better health and lower costs, with an average 30% reduction in total cost of care. “That’s about $2,434 savings per member each year,” McNamara reports. “And when organizations add more services like pharmacy or behavioral health, those savings nearly double for attributed patients.”
These results stem from the increased emphasis on preventive and primary care, with members being seen earlier. They show that members made 20% more routine, preventive and mental health office visits, visited the emergency room 17% fewer times and were admitted to the hospital 52% less often.
ON-SITE MEDICAL CLINICS
Bestermann has been collaborating for five years on an effort to create the infrastructure necessary to support APC teams in cardio metabolic disease, noting that the same model could be applied to other conditions.
William Bestermann M.D.
Accelerating Progress
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“The ideal place to do this is in a worksite clinic that a self-insured employer has serving their employees because generally that is run by a nurse practitioner or PA who is supervised by one physician,” he says.
The problem is that too many self-insured employers can’t afford a worksite clinic, and even large employers often don’t have one in place, he cautions. Also, many large employers have their employees scattered all over the country, but even within the same town, patients may be seeing multiple doctors, which makes it extremely difficult to manage.
However, he says medical problems can be managed remotely, noting that “you can measure your blood pressure at home, and that measurement is more accurate than the office measurement. You can also measure your blood sugar at home.”
Across half the U.S., Bestermann notes that nurse practitioners can practice on their own. Explaining that they’re trained in care paths and best practices, and are used to protocols and algorithms, he says, “they do fantastic work on advanced primary care and the systematic application of optimal medical therapy for cardio metabolic disease.”
Advocacy in Action
One approach that has proven to be effective is giving specially trained nurses or pharmacists, under appropriate supervision, the authority to make medication changes without consulting the physician as long as the changes fall within approved treatment algorithms, he says.
“It will remain difficult to improve diabetes outcomes very much unless the current medical care system can change to facilitate more frequent interactions with knowledgeable providers,” he explains.
Beckwith is sanguine about the prospect of expanding this model. “We are going to see more employers lean into not just value-based care, but also advanced primary care,” she predicts. Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for nearly 40 years.
ALL SYSTEMS GO
October 11-13, 2026
JW Marriott Desert Ridge
Phoenix, AZ
APC Provider Practices What It Preaches
One leading APC provider actually practices what it preaches to selfinsured employer clients.
“We drink our own Kool Aid,” quips Krista Beckwith, vice president of population health with Marathon Health, noting that the company’s employees and dependents are incentivized to use their in-house services to become healthier, which also has a positive impact on the bottom line.
More than 70% of the at-risk employee population who engaged in this APC offering reduced their overall healthcare risk in just one year. That buoyant participation has paid considerable dividends internally and externally.
One telling metric is that Marathon Health has generated an average net savings on claims trend that exceeds program costs with a 1.2 times return on investment after the first year that grows to 3.7 times by year five. ROI was driven by an 82% increase in primary care utilization from more engaged members who use more preventive services and less acute care, as well as 15% fewer ER visits, 31% fewer urgent care visits and 41% fewer inpatient admissions. The result is more than $1,100 in savings per member per year and nearly $1,300 per engaged member with a chronic condition.
Marathon Health partners with Garner Health, whose analytics are overlayed on top of payer data, so that the patient is always being referred in network. Then, within that network, those analytics and algorithms are used to drive patients to the highest quality, lowest cost provider in the network. “Our special sauce is that we partner with patients every step of the way so that they’re never taking on the burden of having to figure out things on their own or understanding what they need to do for follow-up,” she says.
Her company’s value-based care model features three key components: substantially quicker access, greater time commitment and proactive management of employee populations. Same-day and next-day appointments are available compared with 30, 60 and even 90-day lags with the traditional fee-for-service model. In addition, patient visits last 30 to 45 minutes on average, which is two to three times a standard primary care visit.
In a departure from fee-for-service medicine, Marathon Health doctors are compensated based on the value provided to patients vs. volume. “We take more risk with managing populations and managing them to outcomes and performance guarantees,” Beckwith explains.
“It’s not about how many patients you can see in a day, how quickly you can see them, and how we can get them more services to bill,” Beckwith says. “It’s about let’s make populations healthier and make sure we’ve got that right relationship.”
– Bruce Shutan.
Krista Beckwith
FOOD IS/AS MEDICINE – OPPORTUNITIES FOR SELF-INSURED EMPLOYERS AND OTHER STAKEHOLDERS
NowNWritten By Laura Carabello
more than a fanciful theory, Food Is/As Medicine (FIM/FAM) is a widespread movement that is gaining significant traction. Shifting from concept to reality with healthcare providers and self-insured companies, stakeholders in the industry increasingly use tailored nutrition to prevent and manage chronic diseases, like diabetes and hypertension. Driven by high healthcare costs and evidence that specific foods improve health outcomes, plan sponsors are supporting programs and services that advance implementation.
"Food is Medicine" (FIM) and "Food as Medicine" (FAM) are often used interchangeably.
· FAM emphasizes food as a complementary tool, like prescriptions or tailored groceries, which are provided in parallel to care for specific conditions. FAM is typically used with nutrition professionals and community organizations addressing food system issues, communicating “food and health” with diverse coalitions across sectors.
· FIM is a broader philosophy recognizing the power of food to prevent/treat disease, integrating nutrition into healthcare for better outcomes, cost savings, and health equity. This often involves systemic changes, highlighting food's therapeutic role. FIM is typically used with healthcare payers and systems for clinical partnerships and reimbursement.
These trends are gaining attention among the highest levels of government and throughout the private sector, although there are differing opinions about what constitutes a healthy diet. Across the country, Governors are driving a new phase of healthcare transformation—one that positions healthy food as a reimbursable, clinically relevant intervention to address chronic disease.
Source: 2026 National Governor’s Association
Now, the federal government is taking a stand, stating, “Better health begins on your plate – not in your medicine cabinet. “The United States Department of Agriculture (USDA)and the Department of Health and Human Services (HHS), both part of the Executive Branch, which jointly issue the Dietary Guidelines for Americans every five years, recently released a revamp of recommendations. Americans are now urged to eat more protein and less added sugar, and, for the first time, they are discouraged from consuming highly processed foods.
The new parameters do not eliminate warnings about saturated fats but do encourage eating “healthy fat,” which they say includes beef tallow and butter, as well as olive oil. They also include a new, inverted food pyramid, emphasizing the consumption of fruits and vegetables along with protein, dairy and “healthy fats,” to replace the MyPlate chart that had previously provided visual guidance for American diets. Conspicuously, whole grains are deemphasized.
These guidelines are drawing criticism for their lack of consistency in reflecting scientific consensus and the risk of leaving behind vulnerable populations. Clinical strategists at VIDA Health contend that while they provide a framework, certain areas still need nuance, clarity and practical context.
DEFINING FIM
The American Heart Association (AHA) defines FIM as the provision of healthy food —such as medically tailored meals, groceries or produce prescriptions—to treat or manage specific clinical conditions in a way that is integrated with and paid for by the healthcare system. A growing number of studies, including a scientific statement from the AHA, show associations between FIM programs and improved clinical or patient-reported outcomes (related to both physical and mental health), medication adherence, food and nutrition insecurity and even healthcare use and costs.
Did you know?
• Only 1 in 10 people in this country consume the recommended amounts of fruits and vegetables, reports the Centers for Disease Control and Prevention (CDC).
• According to the Economics Research Institute of the US Department of Agriculture, lower-income households consume less produce and are at a higher risk for food insecurity and diet-related diseases. Healthy eating habits can be hard to adopt or maintain for those living in food deserts or who have difficulty covering the higher costs of fresh, health-conscious foods.
• The number of Americans living with obesity is expected to rise by 19 million and affect nearly 126 million people by 2035, according to a new study published in the Journal of the American Medical Association. Researchers project that almost half of US adults will be living with obesity by 2035.
• Poor diet, exacerbated by food insecurity, is a leading cause of disease and death in the U.S., say professionals at the Nutrition Policy Initiative (NPI) at Tufts University. This includes heart disease, stroke, type 2 diabetes, obesity, hypertension and some cancers, with poor nutrition estimated to account for 500,000 deaths annually.
• NPI attests that poor nutrition is estimated to cost society $1.1 trillion in yearly healthcare spending and lost productivity, the same amount that the entire food sector contributes to the economy. This means that “our national ‘bill’ for diet-related disease is equal to all the money we currently pay for the food itself.”
PRO-ACTIVE SUPPORT FOR HEALTHY FOOD, BETTER HEALTH
From a payer perspective, it’s worth noting that the FIM National Network of Excellence establishes standardized approaches for integrating food-based interventions into healthcare systems and communities. Founded by the Tufts Friedman School of Nutrition Science and Policy and nonprofit health system Kaiser Permanente, the first members of the network include some of the most recognizable plans touching millions of lives—Blue Cross and Blue Shield of North Carolina, CVS Health, Devoted Health, Elevance Health, Geisinger, and Highmark Health. Complementing this program, the HHS launched various public-private initiatives with Instacart, The Rockefeller Foundation and Feeding America.
Another positive market signal is the uptake in training the next generation of physicians to embrace FIM as a foundational part of how they provide care. For example, in addition to 12 hours of dedicated nutrition education, the Kaiser Permanente Bernard J. Tyson School of Medicine has intentionally woven it throughout the curriculum to underscore its importance across health. This includes highlighting the connections to food when teaching about metabolic disorders, vitamin and mineral deficiencies, endocrine disorders, pregnancy, heart disease and many other topics. Their stated goal is to move past a model where physicians sound like chemists when discussing diet with patients, focusing on nutrients rather than providing practical counseling on meal planning and healthy eating.
Today, FAM is regarded as a foundational pillar of Lifestyle Medicine (LM), which emphasizes the interconnected roles of nutrition, physical activity, sleep, stress management, substance avoidance and social connection in promoting holistic health. Lockton says positioning FAM within the LM framework shows multinational employers how nutrition complements other lifestyle approaches, reinforcing cohesive messaging as LM gains influence across healthcare, policy and corporate wellness.
Extending this focus on LM, Lifestyle Spending Accounts (LSAs) now offer an option for self-insured employers to sponsor stipends and reimbursements where employees receive a fixed sum of money separate from their salary that they can spend or expense towards household costs, such as groceries. Monies are set aside as taxable income by the employer into an account that employees can use freely and then be reimbursed at a later date. LSAs might prove to be the impetus for employees to feed themselves better.
Source: Informa
claim-doc.com
Carmie Johnson Coding Auditor
It appears that more businesses are planning to consolidate stipends or adopt LSAs in 2026.
Compt annual Lifestyle Benefits Benchmark Reports
• 64% of Compt customers offered an all-inclusive LSA in 2025, making it the most common lifestyle stipend structure.
• 82% of multicategory LSAs include five or more eligible categories, signaling a preference for consolidation rather than one-off perks.
• 20% of employers now extend LSAs to international employees in 62 countries, simplifying lifestyle benefits with a single global structure rather than country-by-country programs.
Sequoia Benefits Benchmarking
• 10% of companies offer a Lifestyle Spending Account, and adoption has more than doubled since 2024.
• Among employers requiring full-time office attendance, 13% offer an LSA; this number is expected to rise to 48% in the next year.
EAT “HEART HEALTHY,” CONTAIN CARDIOLOGY CLAIMS
FIM may be especially important for cardiovascular disease (CVD), particularly in light of a new study in the Journal of the American College of Cardiology showing that half of Americans still have high blood pressure, unchanged from 2009 to 2023. Both diabetes prevalence and deaths are growing, particularly among younger adults and low-income populations, as upwards of 40% of adults are obese. In some areas of the country, CVD mortality is rising again, particularly among working-age adults and people who have historically faced barriers to care. Researchers report that CVD is shaped as much by where people live, work and eat as by what happens in the healthcare system.
From a cost standpoint, cardiology claims are a major expense for employers, ranking as the second costliest condition category after cancer, driven by complex procedures (CABG, TAVR) and chronic issues. Affordable FIM programs may result in ROI when exorbitant claims hit health plan budgets.
COST OF HEART DISEASE IN AMERICA
Source: American Heart Association
As Bruce Roffé, P.D., M.S., H.I.A., president and CEO of H.H.C. Group, explains recently in BenefitsPRO, “These high-cost procedures and chronic conditions lead to expensive treatments and multi-million dollar claims even in younger workers. Hidden billing abuses -- like inflated assistant surgeon fees-- exacerbate costs, stressing the need for proactive management and negotiation for self-funded plans. The key is to scrutinize cardiology bills for overcharges and billing abuses. Every inflated cardiology claim that goes unchallenged contributes to rising employer healthcare costs, higher stop-loss renewals and increased financial strain on self-insured plans.”
In the article, Roffé suggests that benefits professionals can help employers with self-funded plans fight the abuse by watching for three important red flags.
1. Assistant surgeons charging at primary surgeon rates
In surgical procedures, it's a standard industry practice for an assistant surgeon to receive only 16% to 20% of the primary surgeon's fee. However, many claims reveal that assistant surgeons are billing at rates far beyond this threshold. In some cases, they're nearly matching the primary surgeon's charges.
Assistant surgeon charges should be flagged and adjusted if they exceed 20% of the primary surgeon's fee. Claim review teams should be trained to apply industry-standard reductions before payments are processed. Additionally, direct negotiation with providers can help challenge these inflated charges, ensuring that self-funded employers pay only what is fair and reasonable.
2. Missing multiple-procedure discounts
When multiple cardiology procedures are performed during the same surgical session, standard industry guidelines require secondary procedures to be billed at a 50% discount. This reduction accounts for the overlap in resources and time, ensuring fair and reasonable reimbursement. However, many providers fail to apply this discount, instead billing every procedure at full price to maximize their reimbursement — at the direct expense of employers and their health plans. Every claim involving multiple procedures should be carefully reviewed to ensure the 50% reduction is correctly applied. And here, too, direct negotiations can defend employers against excessive charges.
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3. Bundling Manipulation
For many surgical procedures, some services and equipment should already be included in the primary cost and should not be billed separately. For example, the use of an operating microscope in cardiovascular procedures is considered incidental to the surgery itself. However, some providers unbundle these charges, billing them separately to increase reimbursement. Claim review teams can be trained to watch for this problem and compare the actual billing with national coding benchmarks.
Furthermore, new evidence now emerges that Alzheimer’s genetic risk may be effectively countered with diet. Here are the facts: People who carried the Alzheimer's disease APOE4 risk gene had a lower risk of developing dementia if they followed a Mediterranean diet, according to an observational study of healthcare professionals published in Nature Medicine. Greater adherence to the Mediterranean diet was associated with a lower risk of dementia and slower cognitive decline in the overall study population.
Reflecting on this issue, Dr. Will Clower, the founder & CEO of Mediterranean Wellness, shares, “Employee health programs have long searched for the right formula to improve outcomes. But after cycling through countless innovations, perhaps the best solution is to remember what we’ve forgotten.”
He says that as a culture, “We were healthier when we ate real food— not the ultra-processed products that now dominate our shelves. This isn’t nostalgia. It’s science. Decades of research on the Mediterranean diet show that eating whole, unprocessed foods can improve blood sugar, reduce inflammation, support heart health, and even protect cognitive function.”
For employers, food remains one of the most overlooked tools in longterm risk reduction, as Dr. Clower concludes, “Everyone eats—every day. Rethinking food not just as fuel, but as a daily intervention, opens the door to more sustainable, evidence-based health strategies. In tandem with tools like analytics and health coaching, food can become a powerful part of a broader wellbeing solution—already on the table, three times a day.”
Further validation emanates from solutions providers. “From health systems to insurers, the future of patient care is increasingly moving toward food-based solutions,” shares John Furton, president & COO, Sifter Solutions, a medically tailored grocery solutions for Food-asMedicine Programs. “To date, the challenge has been how to bridge the gap between what we eat and our health goals. General dietary advice usually breaks down in the grocery aisle, where it becomes confusing to understand product fit and tempting to veer off course.”
Furton’s company has developed technology to make it easy to transform grocery shopping into a platform for health. Backed by evidence-based nutrition standards of care, the cutting-edge technology is designed to make healthy food choices accessible, actionable and personalized—at scale.
“At the core of our business are hundreds of powerful algorithms that evaluate the universe of food products sold in US supermarkets based on thousands of health attributes—from chronic conditions like diabetes and heart disease to allergens and even medication interactions,” he explains. “This allows Sifter to provide personalized food prescriptions -- clinically validated food guidance—in real-time, for everyone from patients to healthcare providers.”
This technology powers a variety of food interventions, including prepaid food Rx benefit cards, medically tailored grocery ordering and virtual dietitian shopping apps that scan barcodes, ensuring dietary compliance and making grocery shopping easy and fun.
BEHAVIORAL HEALTH CONNECTION TO FIM
“FIM is increasingly recognized as a population-level strategy for addressing diet-related chronic conditions by targeting social drivers that influence health outcomes,” Dani Kimlinger, PhD, MHA, SPHR, SHRM-SCP, CEO, Mines and Associates. “From our perspective,
food insecurity, financial strain, stress, and competing life demands are closely linked to both physical and mental health risks and are consistently associated with higher medical and behavioral health claims. For self-insured plans, integrating FIM alongside Employee Assistance Programs and managed behavioral health services offers an opportunity to address these drivers earlier and more holistically.”
EAPs and managed behavioral healthcare play a critical role by identifying social determinants of health through intake and utilization patterns, supporting behavior change and helping members navigate barriers that affect adherence to nutrition-focused interventions.
“When paired with claims and utilization data, these insights can help identify high-risk populations, guide targeted outreach and reduce avoidable emergency department use and inpatient admissions,” continues Kimlinger. “Importantly, FIM approaches can advance health equity when designed to reach populations disproportionately impacted by food insecurity and chronic stress. Aligning nutrition access with behavioral health support strengthens engagement, improves stability, and supports sustainable outcomes across diverse employee populations.”
OPPORTUNITIES FOR SELF-INSURED EMPLOYERS
Food doesn’t replace medicine, but it has the potential to enhance health and well-being, counsel the advisors at Mercer. They acknowledge that many employers have programs in place to address obesity, which is associated with a number of chronic conditions and higher medical costs. With the rapid increase in utilization of GLP-1 medications and the high cost of coverage, they say food programs can play a part in a comprehensive strategy to support weight management.
Employers should also consider some healthy diet suggestions:
• Healthy cafeteria and snack options
• On-site cooking classes and lunch and learns, offering chef-inspired and dietitian-approved recipes that are easy to recreate at home.
• Nutrition education sessions with registered dietitian nutritionists
• Flexible work hours to support healthy lifestyle activities, including time for mindful eating
• Integrating nutrition support programs into existing EAP programs
• If financial barriers are identified, have the system tie in SNAP benefits information and SNAPeligible foods into meal plans and recipes.
Mercer consultants maintain that employers can potentially address food insecurity and nutrition insecurity by also considering a benefit to deliver and/or subsidize healthy food:
• Produce Prescriptions: Assist employees newly diagnosed with a medical condition.
Offer and/or discount healthy food, providing access to a dietitian to provide culinary education and medical nutrition therapy. Specific nutrients in foods can play a pivotal role in preventing and even managing a number of health conditions.
For example, the consumption of whole grains and vegetables has been associated with stopping hypertension, while eating a diet high in fresh fruits, vegetables, extra virgin olive oil, legumes and fish has been tied to the prevention of chronic diseases.
Produce prescriptions offer free or discounted produce to ambulatory patients based on a range of eligibility criteria, such as people who have a chronic condition, like diabetes, prediabetes, hypertension, obesity or heart disease, as well as people on low incomes and/or who are food insecure.
Retail-Led Produce Prescription Plans
These initiatives route healthcare dollars directly into produce departments, with retailers serving as the delivery system.
• Eat Well, managed by the non-profit Reinvestment Partners in Durham, NC, launched a pilot at Food Lion in 2016. The 1,100-plus store retailer, headquartered in Salisbury, NC, initially loaded fruit and vegetable funds onto its loyalty cards. Expansion led to a retailer-neutral restricted debit card accepted at major national chains, including Ahold Delhaize banners, Kroger, Albertsons, Walmart and Instacart.
Participants, most often individuals managing diet-related chronic disease, are enrolled through health plans, care managers, dietitians and community health workers. Monthly produce benefits range from $40 to $320, depending on program intensity. Funds are limited to fruits and vegetables — fresh, frozen, or canned without added ingredients.
• Giant Food’s Healthy Flexible Rewards program is a loyalty rewards program that gives more points for healthier purchases.
• Oscar offers $100 per year for healthy groceries for members with type 1 or type 2 diabetes who have an annual physical or wellness visit. Generally, these “prescriptions” come in the form of a voucher for fresh fruits and vegetables as described above.
• Medically Tailored Meals (MTMs): Support employees who are experiencing complex health issues by offering delivery of MTMs once the patient returns home from the hospital.
MTMs are fully prepared home-delivered meals designed by a registered dietitian to address specific medical needs. Highmark Health recently launched such a pilot for members with qualifying chronic health conditions who are at high risk for food insecurity.
A recent study published in JAMA found that national implementation of MTMs for high-risk individuals could produce a net cost savings of $13.6 billion annually ($2,500 per patient year). Adults with serious medical conditions who received 10 MTMs per week for an average of 9 months per year were 49% less likely to be admitted to the hospital and 72% less likely to be admitted to skilled nursing facilities — producing a 16% reduction in total healthcare costs, even with the cost of the MTM program.
While MTMs are not widely covered by public or private health insurance plans, pilot programs have shown a significant decrease in hospitalizations and overall improvement in chronic disease management, and some plans are taking steps in that direction.
Now, employers are leveraging employee discretionary spending programs to cover the costs. Mealdelivery service Trifecta is partnering with food-tech platform Prado, which connects prepared food businesses with healthcare professionals and other specialists to distribute medically approved meals that employees can pay for with their health savings account (HSA) or flexible spending account (FSA).
• Education and Information: Lockton says FAM is gaining global traction as a transformative approach to healthcare—one that multinational employers are uniquely positioned to champion.
This forward-thinking framework emphasizes the role of nutrition in preventing, managing, and even reversing chronic conditions. They maintain that the inclusion of FAM tactics has the potential to improve overall well-being while achieving long-term cost savings. Lockton’s U.S. National Benefits Survey indicates that 33% of self-funded plan sponsors offer intensive lifestyle programs that emphasize nutrition, physical activity and mental health.
Furthermore, FIM has particular relevance for reproductive health, as G. David Adamson, MD, FRCSC, FACOG, FACS, CEO, ARC Fertility, says, “ARC regards this as a good movement. Our infertility and fertility care program places significant focus on a healthy lifestyle, which is important for good reproductive health. This includes emphasis on diet as a critical factor in good health.”
Dr. Adamson believes strongly that self-insured stakeholders take action to integrate FIM into standard healthcare for better patient outcomes – especially for those members who are at risk.
“This is an absolute yes,” he emphasizes. “A healthy diet is absolutely essential to obtain better health outcomes, especially as diet is related to overweight and obesity. The ROI to companies for a good diet and resulting in better weight and reduced chronic conditions affecting the cardiovascular, metabolic, orthopedic and other systems is extremely high. FIM absolutely should lower the prevalence of chronic conditions and related expenses.”
INDUSTRY UPTAKE
United Healthcare is now offering medical nutrition therapy nationwide to UnitedHealthcare members who are pregnant, during postpartum, or with chronic conditions. In partnership with medical device company Aeroflow Health, the company is combining telehealth services with devices, such as breast pumps,
continuous glucose monitors (CGMs) and continuous positive airway pressure (CPAP) machines for sleep apnea, to bring physiological data into nutrition care. Virtual medical nutrition therapy (MNT) is available to patients enrolled in commercial plans, Medicare, and select Medicaid plans.
Just in from NationsBenefits®, a leading provider of supplemental benefit and healthcare fintech solutions, an announcement of a new retail integration with Tops Friendly Markets, the neighborhood grocer that operates 147 full-service supermarkets across Upstate New York, northern Pennsylvania, and Vermont. Through this partnership, health plan members can immediately use their NationsBenefits Benefits Mastercard® Prepaid Card at all Tops locations to purchase fresh produce, pantry staples, and over-the-counter wellness essentials with each transaction validated in real time by NationsBenefits’ Basket Adjudication Service.
Another program from SmartRise Health, a clinical consultancy and technology-enabled firm dedicated to advancing value-based care and population health outcomes, serves as an example for utilizing FAM programs to cultivate health activism and cultural vitality.
Vanessa Guzman, MS, ME, CPCHE, CEO & president, explains, “While Value-Based Care (VBC) has long provided the structural framework for quality, its true promise is realized when we infuse real, personalized value into the member experience. We believe that care plans achieve maximum impact when they move beyond clinical checklists to empower individuals as activists of their own health. By leveraging our platform, we integrate FAM as a tech-enabled clinical intervention that meets members exactly where they live and eat.”
Guzman affirms this approach transforms healthy eating into a precise treatment that respects cultural identity, ensuring that nutritional prescriptions resonate with a member’s heritage rather than feeling like a restriction.
“For employers, this cultural alignment is a powerful driver of population health outcomes: it addresses the root causes of chronic disease, provides a vital strategy to manage the escalating costs of treatments like GLP-1s, while fostering community transformation,” says Guzman. “When members feel seen and supported by culturally relevant care, they don't just improve their metrics -- they become catalysts for wellness within their families and neighborhoods.”
Throughout the healthcare ecosystem, one reality is becoming impossible to ignore: Nutrition is one of the most powerful tools we have to prevent, manage, and in some cases, even reverse chronic disease. As the FIM movement continues to gain momentum, organizations are asking important questions: How should we respond? How do we best integrate nutrition into care? And will it make a difference financially?
“At MedWatch, our answer is clear and already in motion,” explains Theresa Chickering,
BSN, RN, MedWatch, director of Population Health Management. “FIM is based upon evidence and supported by programs such as medically tailored meals, produce prescriptions, and clinically guided nutrition counseling, recognized for their ability to reduce chronic disease risks and improve patient outcomes.”
At MedWatch, a registered dietician works directly with the Disease Management (DM), Case Management (CM) and wellness teams, providing members with targeted, real-time support, including:
- Virtual nutrition education sessions
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- Evidence-based resources for chronic disease management
- Dietary assessments and recommendations based on chronic conditions
Chickering further explains, “Treating nutrition as a core clinical intervention, not a lifestyle choice, offers a powerful framework for managing chronic disease. By incorporating medically tailored meals and nutrition counseling, we can help reduce complications and stabilize high-risk patients. populations, and strengthen care coordination. As more healthcare systems and employers adopt FIM programs, we see a clear path toward addressing the root causes of disease while improving long-term outcomes.”
She provides a recent case example: A member with Crohn’s disease was experiencing recurrent flareups. MedWatch’s clinical staff reviewed eating patterns, identified potential trigger foods, and developed a personalized lower-residue meal plan to decrease bowel irritation. During remission, foods were gradually reintroduced to help. maintain nutritional balance. The dietitian also assessed the risks of nutrient deficiencies from malabsorption and provided guidance on supplement options and lifestyle adjustments.
The result: reduced symptom frequency, fewer disruptions to daily living, and an improved quality of life.
Proper nutrition guidance can create meaningful clinical and quality-of-life improvements, as Chickering attests to the value of FIM in showing that better nutrition can correlate with:
- Lower blood pressure
- Improved glucose control
- Reduced inflammatory episodes
- Fewer hospitalizations and emergency room visits
- More stable chronic disease management
- Decreased reliance on high-cost interventions
“When it comes to transformative dietary changes, many members simply need the right. tools, information and support, which make nutrition education a true preventive intervention,” she emphasizes. “MedWatch is working to embed FIM principles into its DM management program because improved access to nutrition supports, education and services can transform population health.”
When organizations embrace FIM ideals, Chickering says they have the opportunity to lower healthcare costs, reduce avoidable utilization, enhance member well-being, and shift toward a more preventative, population-focused model.
“We believe these programs are not only beneficial, but they’re also essential for the future of sustainable, effective healthcare,” she concludes. “FIM is transforming how people think about care, and MedWatch is proud to be helping lead that transformation.”
MEDICARE AND MEDICAID PROVIDE DOCUMENTATION
FAM initiatives are already active in Medicare Advantage and Medicaid programs, where nutrition counseling, medically tailored meals and grocery support are being used to help manage chronic conditions such as diabetes, cardiovascular disease and obesity.
“These programs are generating meaningful engagement,” reports Dr. Roman Kalista, CEO and cofounder of RxDiet, a New York-based health-technology company working with leading national payers on containing chronic disease costs using food and AI technology. “In our program, we had a 98% retention rate and sustained weekly app use averaging about 30 minutes. That level of ongoing interaction supports adherence to dietary guidance and chronic disease management plans. As employers look for more effective, prevention-focused benefits, these public-sector models provide useful evidence and a practical roadmap for integrating nutrition into population health strategies.”
He recommends that self-insured employers consider integrating FAM programs, particularly for at-risk populations, using a risk-stratified approach similar to emerging Medicare and Medicaid models.
“Fully funded nutrition benefits often deliver the clearest ROI for high-risk members, while mid-risk groups may benefit from subsidized programs with dietitian access and education,” says Dr. Kalista. “These approaches can also complement GLP-1 strategies: nutrition programs may support step therapy before prescribing, improve outcomes during treatment and help sustain habits if medications are tapered. While comprehensive programs can add cost alongside GLP-1s, ongoing digital tools and member grocery spend can support longer-term sustainability.”
Dr. Kalista points to the growing evidence that FAM programs can improve outcomes while helping control healthcare costs, particularly for high-risk populations.
“For example, California DHCS has reported medically tailored meals and supportive food programs associated with meaningful reductions in inpatient and emergency department utilization,” he states. “Clinical pilots also show promising economic impact. In our own diabetes intervention study, participants with uncontrolled Type 2 diabetes saw significant HbA1c improvement and estimated cost savings of about $48,000 per participant over six months, largely tied to reduced acute care use and better disease management.”
MORE DATA NEEDED
While there is enthusiasm for introducing programs and services, Vincent Esposito, CEO, Reflect Health, expresses the need for more data to support this direction.
“We are open to FIM but have not yet initiated,” he shares, noting that the company’s Benefits Hub integrates administration, network access, and a powerful marketplace of cost-saving solutions to enable its partners to manage costs more effectively, serve members better and grow stronger. “I’d also appreciate it if the stop-loss market validated some of this as preventive before we invest too heavily. Short answer – open-minded but won’t be the first on this.”
Esposito sees little downside risk here and thinks it is an opportunity, adding, “I think with more data, better outcomes may be the result. I believe that, for now, investing in collectible data that can validate the impact is worthwhile. My instinct is that it will have a positive impact and lower the cost due to prevention of care.”
EMPLOYER PATHWAYS TO ‘SMART EATING’
The phrase “you are what you eat” was first recorded in versions that date back over 200 years in the French and German literature, stating that the food one eats has a bearing on one’s state of mind and health. During the 1920s and 1930s, an American nutritionist, Victor Lindlahr, coined and popularized
the phrase in an advertisement, “Ninety per cent of the diseases known to man are caused by cheap foodstuffs. You are what you eat.”
It appears that the time-tested catchphrase has materialized into widespread publicity about the downsides of eating ultra-processed foods (UPFs), such as fast food, sugary snacks, and packaged convenience items. Today, people are alerted to the value of making lifestyle changes as junk foods make up more than half of the calories consumed in the US.
In a new study conducted by researchers from the Keck School of Medicine of USC, investigators explored how consuming UPFs affects the body’s ability to process glucose, which is a key indicator of diabetes risk. The study authors, who published their findings in the journal Nutrition and Metabolism, noted that an increase in UPF intake was linked to a higher risk for prediabetes.
The food industry is responding. Packaged food makers and fast-food restaurants may be forced to overhaul more of their products next year as newly approved, appetite-suppressing GLP-1 weight loss drugs become more available. Food companies are already dealing with shifts in consumer tastes toward higher protein and smaller portions:
What’s also prompting these changes is news that households using GLP-1 medications cut spending at grocery stores by 5.3% and fast-food restaurants by about 8% on average. According to a Cornell Research study recently published using purchase data collected by Numerator from about 150,000 households:
• French dairy company Danone, which makes Oikos Greek yogurt, stated that it is seeing doubledigit growth in its high-protein offerings, a trend that has accelerated with the adoption of GLP-1 medications.
• Nestle, the world's biggest food company, has also introduced new frozen meals that cater specifically to GLP-1 users, called Vital Pursuit.
• Fast-casual Mexican chain Chipotle on Tuesday added a "High Protein Menu" that features, among other items, a single cup of chicken or steak.
• Some restaurant chains, including Olive Garden, have added menu items for smaller, cheaper portions.
• Noodles & Company marketing head said menu additions were about offering guests “options that satisfy without going overboard.”
The FAM movement is actually quite simple and straightforward, as Brown & Brown advises: Use food to help better manage health. As one of the world’s largest insurance brokerages, How to Eat’s advisory states that employers can increase access, improve quality and remove cost barriers to nutritious foods. Helping to increase food security and making healthy food easily available ultimately decreases the risk and costs of chronic and other poor health conditions, which can lead to high-cost claims. Here are some of their recommendations:
• Vendors. Work with vendors such as Foodsmart, Season Health, or similar vendors to help remove barriers to nutritional counseling and increase access to nutritious food through discounted delivery services. Some of these vendors even help qualified individuals enroll in programs like SNAP and WIC. And depending on the health insurance carrier or TPA, these vendors may already be part of your ecosystem!
• Teaching Kitchen Programs. Implement an on-site Teaching Kitchen to help employees learn ways to eat, cook, move, and think more healthfully.
• Well-being Reimbursements. Offer a well-being reimbursement account, which helps reduce the financial barrier to accessing locally grown healthy produce.
• On-site Food. Offer healthy snacks throughout the office, at catered events and in on-site cafeterias. Make the healthy food choice the easy food choice for your employees.
NUTRITIONAL SUPPORT IS ESSENTIAL – NOT OPTIONAL
Across the board, current clinical evidence and obesity management guidelines advise that nutrition and lifestyle therapy are essential components of GLP-1–based treatment, supporting both therapeutic efficacy and tolerability. However, Registered Dietitian Michele Rager DCN, RD, LDN, FAND, director, Nutrition Programming at Weight Watchers, says, “In my experience leading clinical nutrition programs across health systems and telehealth platforms, most care pathways — and payers — still treat structured nutrition support as optional rather than essential.”
Source: Women’s Health / Viawomenshealthmag.com
Dr. Kalista suggests that information about FAM is increasingly available, highlighting, “The primary challenge isn’t awareness, it’s engagement and behavior change. Traditional evidence-based behavioral change interventions may demonstrate strong ROI in controlled settings, but adherence is frequently low, which limits their overall impact. Food-centered programs can change that dynamic: they create high engagement by meeting tangible needs while reinforcing healthier habits.”
He calls attention to programs that combine nutrition support with peer cohorts, coaching, and structured habit-building drive stronger participation and persistence, adding, “In clinical pilots with people managing Type 2 diabetes, pairing food-focused interventions with group support has improved adherence and produced real outcomes. We believe these approaches can deliver strong ROI at scale.”
From health systems to insurers, the future of patient care is increasingly moving toward food-based solutions, as John Furton shares, “To date, the challenge has been how to bridge the gap between what we eat and our health goals. General dietary advice usually breaks down in the grocery aisle, where it becomes confusing to understand product fit and tempting to veer off course.”
Furton has developed technology to make it easy to transform groceries into a platform for health. Backed by evidence-based nutrition standards of care, Sifter leverages cutting-edge technology to make healthy food choices accessible, actionable, and personalized—at scale.
“At the core of our business are hundreds of powerful algorithms that evaluate the universe of food products sold in US supermarkets based on thousands of health attributes—from chronic conditions like diabetes and heart disease to allergens and even medication interactions,” he explains. “This allows Sifter to provide personalized food prescriptions - clinically validated food guidance—in real-time, for everyone from patients to healthcare providers.”
This technology powers a variety of food interventions, including pre-paid food Rx benefit cards, medically-tailored grocery ordering, and virtual dietitian shopping apps that scan barcodes – ensuring dietary compliance and making grocery shopping easy and fun.
Bottom-line for employers: If you are hungry for a better way to help manage your employees’ health, remember to help them eat smartly.
About the Author
Laura Carabello holds a degree in Journalism from the Newhouse School of Communications at Syracuse University, is a recognized expert in medical travel and is a widely published writer on healthcare issues. She is a Principal at CPR Strategic Marketing Communications. www.cpronline.com
May 20 - 21, 2026
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NEWS FROM SIIA MEMBERS
SIIA boasts a very active and dynamic membership. Here are some of the latest developments from member companies and individuals powering the self-insurance industry.
Captive Resources Announces Executive Leadership Team Updates
Captive Resources, LLC, announced a series of executive leadership updates designed to further strengthen the organization’s long-term growth, alignment, and sustainability.
As part of these updates, Mike Foley has been named Vice Chairman. Foley previously served as Co-Chief Executive Officer and President and will continue to play an active role in shaping Captive Resources’ strategic direction and supporting the company’s senior leadership as it enters its next phase of growth.
John Pontin has been appointed President. Pontin previously served as Chief Growth Officer, where he led the expansion of Captive Resources’ Property & Casualty and Health Solutions businesses, strengthened broker partnerships, and helped advance the firm’s growth strategy across multiple markets.
Captive Resources also announced two additions to its Executive Committee (ExCo). Steven Gransbury, President of Health Solutions, and Mark Knipfer, Chief Strategy Officer, have joined the ExCo, reflecting the firm’s continued focus on leadership depth, strategic clarity, and enterprise-wide collaboration.
The Captive Resources’ ExCo now consists of:
-Nicholas Hentges, Chief Executive Officer
-Mike Foley, Vice Chairman
-John Pontin, President
-Donna Dreuth, Group Chief Financial Officer and Chief Administrative Officer
“These leadership changes reflect our continued focus on the long-term growth and sustainability of Captive Resources,” said CEO Nick Hentges. “As our organization evolves, it’s critical that our leadership structure evolves with it — ensuring we are positioned to serve our clients, brokers, and partners at the highest level for years to come.”
“I’m excited to continue working alongside this leadership team as we further invest in our people, strengthen our client relationships, and support the continued growth of both our Property & Casualty and Health Solutions businesses,” commented Pontin on his transition to President.
Berkley A&H Celebrates Milestones
Berkley Accident and Health, a Berkley company, announced two landmark achievements: celebrating its 20th anniversary and surpassing $1 billion in annualized premiums. These milestones underscore the business’s industry leadership, outstanding growth, and service to its policyholders, according to a company statement.
“Reaching our 20-year anniversary is a testament to the dedication of our employees, the trust of our customers, and the strength of our broker relationships,” said Brad N. Nieland, President and CEO of Berkley Accident and Health. “Crossing the $1 billion premium threshold reflects the value that our solutions bring to organizations seeking clarity, control, and long-term financial confidence. We’re honored to have earned our policyholders’ trust and built a reputation for integrity over the past two decades.”
Daniel Laroue Elevated to CEO at VBA
VBA, a leading provider of healthcare administration software and technology solutions, today announced a leadership transition designed to support the company’s continued growth, innovation, and long-term scalability. Daniel Laroue has been appointed Chief Executive Officer.
According to a company statement, the transition reflects VBA’s strategic focus on expanding its product capabilities, advancing its platform, and delivering greater value to customers as demand for flexible, modern solutions continues to grow.
Since joining the company as President and COO, Laroue has worked closely with the leadership team to accelerate product initiatives, support operational execution, and drive measurable growth across the business. As CEO, he will continue to lead the company’s efforts to expand its platform, invest in innovation, and help customers navigate an increasingly complex and dynamic healthcare landscape.
“I am very excited about the opportunity ahead for VBA, and our focus remains on building scalable solutions, innovating rapidly, and being a trusted long-term partner for our customers,” said Laroue. “We are committed to supporting our customers as their needs continue to evolve.”
Mike Clayton, who has served as CEO of VBA for 13 years, will retire from the role and continue supporting the business as a Senior Advisor. He will work closely with Laroue and the leadership team on key initiatives that support VBA’s customers and long-term strategy.
“I am incredibly proud of what this team has built over the past 13 years and am very confident in the company’s future,” said Mike Clayton. “I have thoroughly enjoyed working with Daniel over the last several months. He’s the right person to lead the company through the next stage, and this transition reflects the organization's strength and leadership. I’m looking forward to supporting Daniel and the leadership team in this next chapter. The best of VBA is yet to come!”
Assured Benefits Administrators Strengthens Sales Team with New Hire
Paul Joey Stone has been hired by Assured Benefits Administrators as its new vice president of sales. Stone joins the firm with more than 25 years of experience in the insurance and employee benefits industry. In his new role, he will focus on enhancing business growth for employee benefit consultants and developing strategic partnerships to expand alternative funding solutions.
Stone most recently served as regional vice president at Clear Point Health, where he specialized in medical stop-loss captives and alternative funding strategies. Prior to that, he spent over 7 years as a human capital management consultant and executive manager at OneDigital.
Commenting on his new role, Stone said: “I help benefit consultants reduce healthcare costs while improving transparency, sustainability and member experience through alternative funding strategies and cutting-edge point solutions. My work is disciplined, data-driven, and grounded in accountability, delivering solutions that stand up to fiduciary scrutiny and produce measurable results.”
Throughout his career, Stone has held several leadership positions, including serving as president of Third Era Benefits and as vice president at First National Brokerage Corporation. He also served as vice president at the Medical Society of Virginia Insurance Agency and was a principal at Strategic Employee Benefit Services.
Boon-Chapman President Featured in Authority Magazine
Kari L. Niblack, President of Boon-Chapman, was recently featured in Authority Magazine’s series focused on improving the U.S. healthcare system.
Niblack shares thoughtful insights on the structural and operational changes needed to create a more efficient, transparent, and patient-centered healthcare landscape. Drawing on her leadership experience in the self-funded healthcare space, she discusses opportunities to strengthen collaboration, modernize administrative processes, and improve outcomes while responsibly managing costs.
Her perspective reflects Boon-Chapman’s long-standing commitment to innovation, service, and practical solutions that support employers, brokers, and members navigating an increasingly complex healthcare environment.
Jesse Roberts Promoted at M3 Insurance
M3 is proud to announce the promotion of Jesse Roberts to Director of Business Development. In this expanded leadership role, Jesse will continue to serve as a key advisor to businesses throughout Wisconsin—bringing strategic guidance, risk insights, and a client first mindset to the organizations he supports.
Carbon Stop Loss Solutions Expands Medical Excess Team
Carbon Stop Loss Solutions (Carbon) announced the addition of a seasoned Medical Excess team to its growing Managed Care vertical. This thoughtful expansion reflects Carbon’s enduring commitment to client continuity, trusted relationships and the consistent delivery of high-quality valued services.
Brent Hoehne brings more than 25 years of U.S. Health experience and will be joined by Senior Underwriters Alex Schaffer and Connor Kalb. They will continue to be supported by both Chris Schmidt and Kim Ming Phun, both FSAs integral to the pricing process. Carbon is an established market leader in the Managed Care sector, offering in-house actuarial, claims, and cost-containment services.
“Our business is built on relationships and trust,” states Dan Bolgar, President of Carbon. “We are delighted to welcome this talented group to our tight-knit organization. Their experience and clientfocused philosophy align perfectly with what we stand for. We hope our collective offering of deep industry knowledge, actuarial expertise, and in-house cost containment services will continue to provide invaluable support to clients.”
Michael Brown to Head Risk Control Unit at Captive Resources
Captive Resources, LLC has announced the appointment of Michael Brown as senior vice president, risk control and unit leader.
Brown has more than eight years of experience within the firm. He most recently served as vice president of risk control services, a role he held since March 2019. He first joined the organization as assistant vice president of risk control services in November 2017.
In his new capacity, Brown leads risk control initiatives for the captive consultancy. Captive Resources provides oversight and development for member-owned group captive insurance companies, currently advising medical stop-loss group and 48 casualty captives with over US$5.2 billion in annual premium.
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2026 SELF-INSURANCE INSTITUTE OF AMERICA
BOARD OF DIRECTORS
CHAIRWOMAN OF THE BOARD*
Amy Gasbarro
President ELMCRx Solutions
CHAIRPERSON ELECT, TREASURER AND CORPORATE SECRETARY*
Mark Lawrence President
HM Insurance Group
BOARD MEMBER
Blake Allison
Chief Executive Officer
Employers Health Network
BOARD MEMBER
Christine Cooper CEO
aequum, LLC
BOARD MEMBER
Orlo “Spike” Dietrich Operating Partner
Ansley Capital Group
BOARD MEMBER
Jeffrey Fitzgerald
Managing Director, SRS Benefit Partners
Strategic Risk Solutions, Inc.
BOARD MEMBER
John Fries
Head Accident & Health NA
Swiss Re Corporate Solutions
BOARD MEMBER
Matthew Smith
Managing Director
Risk Strategies
BOARD MEMBER
Beth Turbitt
Managing Director
Aon Re, Inc.
VOLUNTEER COMMITTEE CHAIRS
Captive Insurance Committee
George M. Belokas, FCAS, MAAA President
Beyond Risk
Future Leaders Committee
Erin Duffy Director of Business Development
Imagine360
Price Transparency Committee
Christine Cooper CEO aequum LLC
Cell and Gene Task Force
Ashley Hume President
Emerging Therapy Solutions®
* Also serves as Director
SIIA NEW MEMBERS
CORPORATE MEMBERS:
Frank Aguilar Event Marketing Manager Pager Health New York, NY
Mackenzie Anderson Chief Executive Officer SA Benefit Services Helotes, CT
Jala Attia President Integrity Advantage Forest Hill, MD
Ben Baker Senior Advisor, Conference Sponsorships Evernorth Health Services St. Louis, MO
Kirstin Brinkhurst Director of Marketing PPi Verona, WI
Brandon Faresich Vice President Eir Partners Miami, FL
Charlie Hart VP of Growth Katch Brentwood, TN
Angela Holgate Senior Vice President Blue Sky Specialty Infusion Pharmacy Scottsdale, AZ
Noah Kaminer Co-Founder & CEO Korva New York, NY
Patrick Keavy Managing Director Bailey & Company Brentwood, TN
2026 BOARD OF DIRECTORS
Dani Kimlinger CEO & Partner MINES & Associates
Les Boughner Chairman Advantage Insurance
Rajiv Sood General Manager Evidium Inc. San Francisco, CA
Eric Sukalac CEO TPA Stream Shaker Heights, OH
Thomas Wagner CEO Zenith Risk Strategies Austin, TX
Kimberlie Young Director of Health Plan Operations Nice Healthcare Cedar Creek, TX
SILVER MEMBERS:
Andrew Jernigan Head of Insurance, North America Pliant New York, NY
Liz Midtlien Head of Large Claims Solutions BCS Financial Corporation
Matt Hayward Office President Ryan Specialty
Jonathan Socko President East Coast Underwriters, LLC
Nigel Wallbank SIEF Chairman Emeritus
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José faced more setbacks after receiving his new liver. Stop Loss helps protect his self-funded employer.
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