"There's no reason why I should be able to do an infusion for 50% of the cost of what it's currently being allowed at. We've seen allowed amounts between $57,000 and $80,000 for Keytruda. I typically can have that in the home at $29,000."

My guest this week is Jake Velie, CEO and co-founder of National Integrative Health (NIH). After spending the first half of his career in the clinical "meat grinder" of value-based care on the provider side, Jake realized the only way to truly fix the system was to control the dollars on the commercial plan side. Today, NIH acts as the ultimate watchdog and independent pharmacy solution for self-funded employers, actively managing J-codes, specialty drugs, and clinical coordination.

In this episode, we unpack the exorbitant markups hospitals charge for infusions and how NIH has spent years building a 50-state network to redirect patients to safe, comfortable, and massively discounted at-home infusion care. Jake also breaks down the brutal reality of GLP-1 adherence, why his team refuses to fill 90-day prescriptions for weight-loss drugs, how they enforce formularies to switch patients from expensive biologics like Humira to low-cost biosimilars like Yusimry, and the absolute truth about the safety of international drug sourcing.

If you want to know how to stop the bleeding on your pharmacy and medical claims while actually improving the white-glove customer service your employees receive, this is a masterclass in specialty cost containment.

Thank you to our 2026 sponsors!

ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.

Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.

Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.

Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.

Chapters:

(00:00:00) Intro: Moving Keytruda to the Home Setting

(00:01:47) Defining True Value-Based Care

(00:03:20) The Genesis of NIH and Leaving the Provider "Meat Grinder"

(00:07:01) Building a 50-State Home Infusion Network

(00:09:22) Why Specialty Meds Drive 90% of Pharmacy Spend

(00:14:53) Demystifying J-Codes and Q-Codes

(00:17:01) Exorbitant Hospital Markups and Hidden Fees

(00:24:59) The Mechanics of Redirection: Mandatory vs. Voluntary

(00:30:27) Coordinating Carve-Outs with Stop-Loss Carriers

(00:34:08) Enforcing Formularies: Converting Humira to Yusimry

(00:41:12) The Reality of International Sourcing and the FDA

(00:47:35) Managing GLP-1s and the Danger of 90-Day Fills

(00:51:48) The Ideal Employer Profile for NIH

(00:58:04) Overcoming Healthcare's Terrible Customer Service

(01:02:05) The Future: Oncology, Cell, and Gene Therapies

Key Links for Social:

@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded

Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02

Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286

Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/

Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"We did this survey with a third-party consulting group who talked to 2,000 brokers. Their perception was that 25% of bills are going to be balance bills; it's actually 3%."

Is Reference-Based Pricing (RBP) still something that just creates endless problems for HR?

My guest this week is Jeff Bak, CEO of Imagine360. Jeff brings 30 years of healthcare and private equity experience to the table, and he's leading the charge to rebrand and evolve RBP from a defensive "pay and defend" model into a comprehensive, full-stack alternative health plan.

In this episode, we tackle the persistent broker misconceptions surrounding RBP, dissecting exactly why the actual balance bill rate is closer to 3% while plan savings average over 20%. We also explore how Imagine360 blends RBP with strategic direct hospital contracts (like Baylor and Northwestern) to give employees a seamless "PPO-like" experience without the inflated PPO price tag. Jeff also breaks down the reality of the No Surprises Act (NSA) and Independent Dispute Resolution (IDR) process, and why hospitals are currently winning the majority of those arbitration cases.

If you are a benefits consultant or an employer looking to truly break away from the traditional "BUCA" networks, while ensuring your employees aren't stranded with unmanageable balance bills, this conversation is the reality check you need.

Thank you to our 2026 sponsors!

ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.

Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.

Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.

Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.

Chapters:

(00:00:00) Intro: Dispelling Broker Myths Around RBP

(00:03:52) Jeff's Background: From the NFL to Healthcare CEO

(00:10:15) Defining Reference-Based Pricing (Cost-to-Charge vs. Medicare)

(00:14:22) Why Traditional Plans are Like Buying a Ford F-150 Every Year

(00:16:19) The Evolution from ELAP's "Pay and Defend" to Imagine360

(00:20:09) Blending RBP with Direct Hospital Contracts

(00:26:01) Unpacking the Broker Survey: Perceived vs. Actual Balance Bill Rates

(00:34:19) Building an Integrated, Full-Stack Health Plan

(00:39:11) How to Transition a Workforce to RBP (Dual Option & Slice)

(00:45:34) Managing Single Case Agreements & Redirection

(00:50:16) Navigating the NSA and the IDR Arbitration Process

(00:54:26) The Ideal Employer Profile for an Alternative Health Plan

(00:59:37) The Future of RBP & Price Transparency

(01:04:57) Closing Thoughts: The "Barbecue Sandwich" Margin

Key Links for Social:

@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded

Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02

Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286

Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/

Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"The average marketplace deductible grew by about $1,000 per person in 2026. Premium payments increased by an average of 58%... We might be seeing the death throes of the fully insured market."

Welcome back to Last Month in Healthcare! This month, Spencer, Nathaniel, and special guest Jonathan Lopez break down the most impactful healthcare headlines and regulatory shifts from May 2026.

The episode kicks off with a discussion on the sudden resignation of FDA Commissioner Dr. Marty Makary following reported clashes with the food, tobacco, and pharmaceutical industries. From there, the guys dive into the shocking 58% premium hikes and 37% deductible increases hitting the ACA marketplace as carriers like Cigna exit the space.

Finally, Spencer and Jonathan play a World Cup-themed game guessing the cost of medical procedures across different North American cities and answer a listener question about Cost Plus Drugs and the rise of direct-to-consumer pharmacy models.

If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.

Thank you to our sponsor, Walk On Clinic. This month, we shared a tragic reminder to our listeners on the critical importance of early cancer detection and proactive primary care.

To hear Chris's brother-in-law's music, tune in here: https://open.spotify.com/artist/1SKw4DO9FNLjcZDb5Q81q4?si=Dwpuz2wOTRawhMDfR5NIsA

Episode Chapters:

(00:00:00) Intro: The Importance of Early Detection & Walk-On Clinic

(00:02:30) Dr. Marty Makary Resigns as FDA Commissioner

(00:04:37) ACA Marketplace Premiums Skyrocket by 58%

(00:07:51) HR 8163: Stopping the Squeeze on Physician Reimbursements

(00:12:34) Harvard Study: AI Outperforms Doctors in ER Triage

(00:14:53) The FDA's Push for Hospital-at-Home Devices

(00:17:18) Game: Guess the Procedure Cost (World Cup Edition)

(00:21:22) Ask Spencer Anything: Cost Plus Drugs & D2C Pharmacies