Managing the Exploding Costs of Specialty Drugs | with Jake Velie

By Spencer Smith – In this powerful conversation with Jake Velie of National Integrative Health, the discussion breaks down how smarter pharmacy management, infusion redirection, and clinical oversight can create real savings without sacrificing member care. "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." Read Full Article...

HVBA Article Summary

1. Hospital Markups and Site-of-Care Shifts Drive Major Cost Differences: The episode highlights how facility-based infusions often carry significant markups compared to home-based alternatives. By redirecting patients away from hospital outpatient departments to home infusion settings, employers can meaningfully reduce plan spend without changing the underlying medication. National Integrative Health has built a 50-state network specifically to facilitate these transitions. The discussion frames site-of-care management as one of the most practical levers for self-funded employers to control specialty costs.

2. Specialty Drugs Dominate Pharmacy Spending: Specialty medications are described as accounting for roughly 90% of total pharmacy spend for many plans, making them the primary driver of escalating costs. The conversation explores how J-codes and Q-codes, along with unmanaged biologics, can inflate claims when left unchecked. NIH positions itself as an independent pharmacy solution that actively manages these high-cost categories. The emphasis is on proactive oversight rather than reacting after large claims have already hit the plan.

3. Formulary Enforcement, GLP-1 Management, and Sourcing Strategies Matter: The episode addresses challenges around GLP-1 adherence and explains why the organization avoids 90-day fills for weight-loss medications to reduce waste and misuse. It also details how employers can transition patients from high-cost biologics like Humira to lower-cost biosimilars such as Yusimry through firm formulary enforcement. Additionally, the conversation touches on international drug sourcing and related safety considerations. Together, these strategies are presented as part of a broader specialty drug cost-containment framework for self-funded plans.

4. Three ways to Watch. Tune in through the links below:

   • APPLE PODCASTS

   • SPOTIFY

   • YOUTUBE

Opaque PBM definitions leave room for excess fees, consultant warns

By Allison Bell – What, really, is a specialty drug? Ben Link, a pharmacy benefits expert, says the answer may be something that a pharmacy benefit manager will use to squeeze more compensation out of an employer's prescription drug plan. Link appeared as a speaker on a PBM contracting webinar organized by the National Alliance of Healthcare Purchaser Coalitions, a group for health benefits groups. Link warned the employee benefits managers watching the webinar that policing PBM contract language is critical. "Be very clear about what definitions are in your contract," Link said. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Contract Definitions Can Shift Financial Outcomes: The article highlights how pharmacy benefit managers (PBMs) can define terms such as "specialty drug," "generic drug," and even "generic specialty drug" in ways that affect pricing and compensation. These definitions may not align with common-sense or industry-standard understandings. Because contract language governs reimbursement and fees, seemingly technical wording can materially change an employer’s drug spending. Employers that overlook these definitions may inadvertently allow PBMs to increase their compensation.

2. Retrospective Pricing and Rebates Create Risk: Link warns that rebate structures and retrospective pricing mechanisms can obscure the true value flowing back to employer-sponsored plans. Manufacturers may pay rebates tied to prescriptions, but the amount ultimately received by employers can differ due to contractual terms and timing. Longer reconciliation periods give PBMs more discretion over calculations and adjustments. Tightening rebate timing to the point of sale and limiting adjustment windows could reduce opportunities for revenue leakage.

3. Policy and Oversight Efforts Are Expanding: The National Alliance of Healthcare Purchaser Coalitions has issued new guidance to help employers negotiate clearer PBM contracts, with Link contributing to the effort. The group has also been involved in shaping transparency provisions in recent federal legislation and proposed Labor Department regulations. These initiatives aim to standardize reporting and reduce ambiguity in PBM arrangements. Still, employers are encouraged to secure strong audit rights and focus on net plan costs rather than headline rebate figures.

US healthcare affordability hits 5-year low: Gallup

By Kristin Kuchno – Healthcare affordability among U.S. adults fell to its lowest level since 2021, according to a June 18 article from Gallup. The findings are based on surveys of 5,660 U.S. adults conducted by the West Health-Gallup Center on Healthcare between Oct. 27 and Dec. 22. Read Full Article...

HVBA Article Summary

1. Fewer Americans Are Financially Secure in Healthcare: Only 49% of U.S. adults were classified as “cost secure,” meaning they can afford necessary care, medications and access to quality services. Meanwhile, 41% were considered “cost insecure,” and 10% were labeled “cost desperate,” reflecting multiple affordability and access challenges. The cost-secure share has dropped 7 percentage points since 2021 and peaked at 61% in 2022 before declining in subsequent years. An estimated 2.8 million Americans fell out of the cost-secure category between 2024 and 2025.

2. Young Adults and Women Face Steeper Affordability Declines: Adults ages 18 to 29 experienced the sharpest deterioration, with the share considered cost secure falling from 46% in 2021 to 32% in 2025, the lowest among age groups. Gender disparities also widened in 2025, as 42% of women were classified as cost secure compared to 57% of men. The gap increased from the prior year, when 48% of women and 55% of men were cost secure. These shifts indicate growing affordability pressures concentrated among younger adults and women.

3. Rising Anxiety Over Future Healthcare Costs: Concerns about affording care and medications intensified in 2025. About 42% of respondents said they were worried about paying for prescription drugs, up from 36% in 2024. Similarly, 51% expressed concern about covering healthcare services, compared to 44% the year before. The data suggest that financial strain is not only affecting current access but also shaping expectations about future affordability.

Employees Show Skepticism Over AI Benefits Technology, Employers Optimism

By Valentina Baez – Employer enthusiasm for artificial intelligence is outpacing employee willingness to use the technology as a tool as part of their benefits programs. The second installment of Prudential Financial Inc.’s 2026 Benefits & Beyond study found that 83% of employers surveyed were interested in using AI to help workers better understand their benefits. Only 58% of employees surveyed said they would use AI for that purpose, and just 24% said they were currently doing so. Read Full Article...

HVBA Article Summary

1. Trust and Privacy Concerns Are Slowing Adoption: While employers and employees both cite privacy and security as top concerns, employees are significantly more skeptical overall. Workers are more likely to question the accuracy, ethics and potential job impact of AI tools, signaling deeper unease beyond data protection alone. This trust deficit appears to be a central barrier preventing broader employee adoption of AI-powered benefits tools. Employers may need to address transparency and governance issues before usage rates rise.

2. Generational and Workforce Differences Shape AI Attitudes: Skepticism varies notably across demographic groups, with Generation X and Baby Boomers reporting higher levels of distrust and privacy concerns. Millennials tend to express fewer reservations, while Generation Z raises distinct concerns about AI’s environmental impact. Unionized employees and certain decisionmakers are already using AI tools at higher rates than other worker segments. These differences suggest that communication and rollout strategies may need to be tailored to specific employee populations.

3. AI Expansion Extends Beyond Benefits Amid Compliance Questions: Separate research indicates that many organizations plan to expand AI use in compliance functions within the next year. At the same time, a substantial share of professionals view AI as a major regulatory challenge in the coming years, with divided opinions on whether new regulations or clearer existing rules are needed. Regional differences further complicate adoption, as firms in different geographies cite varying primary obstacles. Together, the findings show that organizations are moving forward with AI initiatives, but regulatory clarity and governance frameworks remain critical considerations.

Why employers are pivoting to hybrid life and long-term care plans

By Richard (RAE) Egleston and Marty Traynor – The long-term care marketplace can be confusing to employers and their employees. There are many options, beginning with a fundamental design choice: should the product offered be a hybrid life/LTC plan or a standalone LTC plan? It's very easy to get into the technical details and nuances of the coverages, but, to an employer, the essential questions are whether the product offered can be easily understood by employees, relevant to the needs of employees and their families, and affordable. All too often, the application or customer experience are overlooked. These details are critically important to customers. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Hybrid plans simplify the purchase experience: The authors argue that hybrid life/LTC products are generally easier for employees to understand because they bundle a familiar life insurance benefit with long-term care coverage. Application processes for hybrid plans are typically streamlined through employer systems, while standalone LTC policies often require extensive underwriting and longer approval timelines. This simplicity can improve participation and reduce friction during enrollment. Employers may see higher engagement when the buying process feels predictable and integrated into existing benefits platforms.

2. Administration and ongoing management favor hybrid designs: Hybrid products are commonly administered through payroll deduction and standard HR or benefits administration systems, making billing and recordkeeping more seamless. In contrast, standalone LTC policies are often direct billed and managed outside employer systems, increasing administrative complexity for employees. Hybrid policies may also offer features such as cash value access and easier coverage increases. These structural differences can reduce employer workload and create a more consistent ownership experience for employees.

3. Claims experiences highlight structural differences: Hybrid policies include a traditional life insurance death benefit, providing a clear payout if long-term care benefits are not used. Both hybrid and standalone plans require medical certification and documentation for LTC claims, but the emotional and administrative burden can be significant in either case. The article emphasizes that claims navigation support and proper legal planning, such as powers of attorney, are crucial to avoiding delays. Overall, the authors suggest that hybrid products provide broader, more flexible protection while maintaining a more familiar claims framework.

Cigna Said No. His Doctors Said It Could Save His Life.

By Wendell Potter – Keaton Herzer’s year-and-a-half-long fight against a rare form of cancer could supply the plot for a TV drama series. Along the way, Herzer, a 35-year-old Colorado software engineer and new dad, accumulated a lot of followers on social media sites like TikTok, with videos about his struggle – not just with the cholangiocarcinoma attacking his liver, but also with Cigna, the insurance giant managing his health plan. Read Full Article...

HVBA Article Summary

1. Insurance Denials Delayed Critical Cancer Care: Herzer was diagnosed with Stage 4 intrahepatic cholangiocarcinoma, a rare bile duct cancer affecting roughly 8,000 to 10,000 Americans annually. After identifying a promising targeted therapy for his specific genetic mutation, his insurer denied coverage because the drug was not yet approved for his exact cancer type. He and his wife paid more than $77,000 per infusion out of pocket while pursuing appeals. Only after persistent internal and peer-to-peer reviews did the insurer reverse its decision and approve coverage.

2. A Life-Saving Transplant Required Another Battle: Following significant tumor shrinkage from the new therapy, specialists at leading cancer centers deemed Herzer eligible for a liver transplant, the only potentially curative option. Despite covering the extensive pre-transplant testing, the insurer initially refused to authorize the surgery, setting additional tumor-size criteria. Herzer mounted a coordinated campaign that included formal appeals, outreach to executives, and public advocacy. Approval came shortly after his social media posts criticizing the denial gained widespread attention.

3. The Case Highlights Broader Concerns About Prior Authorization: Herzer’s experience underscores how complex prior authorization processes can demand extensive time and resources from seriously ill patients. He spent hours each day navigating insurer communications and discovered that a physician outside his specialty had reviewed at least one denial. The article also cites industry data showing that only about 1% of patients appeal denials, even though many appeals succeed. His story illustrates how persistence, public visibility, and personal resources can influence outcomes that may be out of reach for less-equipped patients.

Health benefits spending soars, but employee confusion persists

By Jimmy Nesbitt – Employers are now spending nearly $20,000 a year per employee on health insurance, yet many workers still don't understand what they're getting in return. Often, that's because companies are not communicating the right benefits, said Dan Thompson, chief benefits officer at Vensure, an HR and payroll outsourcing provider. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Employees Face Growing Challenges Despite Rising Healthcare Spending: Employer-sponsored health insurance costs increased approximately 7% in 2026, yet many employees continue to struggle with understanding and accessing their benefits. High deductibles, premiums, and out-of-pocket expenses can make employees feel "functionally uninsured," causing some to delay care, skip medications, or seek alternative healthcare solutions outside traditional insurance networks. The interview suggests that employers have been slow to modernize benefits education and enrollment processes despite significant investments in healthcare coverage.

2. Low Benefit Utilization Signals Opportunities for Improvement: Several commonly offered benefits, including supplemental insurance products, employee assistance programs (EAPs), and telemedicine services, are often underutilized by employees. The discussion highlights concerns that employees may not fully understand available benefits or may enroll in products that do not meet their needs. Employers are encouraged to evaluate utilization rates, review benefit offerings regularly, and ensure employees receive clear information about how and when to use available programs.

3. Year-Round Communication and Technology Can Enhance Engagement: The interview emphasizes that annual open enrollment is no longer sufficient for supporting today's workforce. Employers may improve engagement by providing ongoing communications, multilingual resources, personalized decision-support tools, and AI-powered platforms that help employees navigate benefit options throughout the year. More consistent education and support could help increase benefit utilization, employee satisfaction, and overall awareness of available healthcare resources.

HCSC unveils Easify Edge plans as alternative employer option

By Paige Minemyer – With employers seeking new solutions to address rising healthcare costs, Health Care Service Corporation is rolling out its Edge health plans, a new alternative option aimed at simplifying the member experience. Read Full Article...

HVBA Article Summary

1. Simplified Plan Design With Predictable Costs: HCSC’s Edge plans are built around a proprietary design called Easify that eliminates deductibles and coinsurance for in-network care. Instead, members pay straightforward copays, which the company says are intended to make benefits easier to understand and use. The plans also maintain access to a broad PPO network, positioning them as an alternative to more restrictive models. This structure is meant to reduce confusion around cost-sharing and improve the overall member experience.

2. Incentives and Digital Tools to Guide Care Choices: The insurer is pairing the new plans with digital tools and personalized support to help members compare providers and anticipate costs. Members can see estimated copays for in-network and out-of-network care and identify potential rewards for choosing certain high-quality providers. The company said it also incorporated artificial intelligence to enhance the experience, while maintaining call center support so members can speak with a representative who can walk through the same digital interface. The approach aims to balance technology-driven navigation with human assistance.

3. Employer Demand Driving Alternative Offerings: HCSC executives said the launch reflects growing employer interest in products that reward high-quality, cost-effective care and offer clearer financial transparency. The plans are a revamped version of an existing offering and are scheduled to be available Jan. 1, with expectations of significant employer interest. Company leadership noted that competitors, including UnitedHealthcare with its Surest plans, have seen traction with similar models. HCSC has also outlined a multi-year roadmap to expand personalization and provide employers with deeper insights into employee engagement and early health risk indicators.

Millions in U.S. travel abroad for cheaper dental care

By Maya Goldman – Nearly 9.6 million American adults may have traveled abroad to get dental care, according to a new report from CareQuest Institute for Oral Health. Read Full Article...

HVBA Article Summary

1. Cost differences are driving dental tourism: Oral health procedures in the U.S. are often significantly more expensive than in other countries, prompting some Americans to seek treatment abroad. For example, a root canal that can cost up to $1,500 out-of-pocket in the U.S. may be priced under $350 in Mexico. In a nationally representative survey of 9,450 adults conducted last year, 4% said they had traveled outside the country for dental work. Among those respondents, 58% cited lower costs as the primary reason for going abroad.

2. Dental tourism spans income and insurance statuses: The CareQuest survey found no significant differences in participation based on education level, employment status or income. More than a quarter of those surveyed reported not having dental insurance, which may contribute to decisions to seek care elsewhere. The findings suggest that affordability concerns cut across demographic lines rather than affecting only specific socioeconomic groups. Lack of comprehensive dental coverage in the U.S. appears to be one structural factor influencing these choices.

3. A growing global market with potential trade-offs: The global dental tourism market is projected to exceed $65 billion by 2033, with destinations such as Mexico, Thailand and Hungary attracting patients. However, the report notes that obtaining care abroad can complicate follow-up treatment if problems arise after patients return home. Quality of care may also vary depending on the provider and location. These factors present potential risks alongside the financial savings.