By Jake Velie, Chairman & CEO, National Integrative Health

The New England Journal of Medicine just published an article calling self-insured employers “A Sleeping Giant of Health Care Affordability.”¹ The authors, Dr. Suhas Gondi and Dr. Zirui Song, wrote it because most physicians do not know that a self-insured employer sits behind that carrier card their patient walks in with.

That is not a minor knowledge gap. That is the root cause of a dysfunction that costs plans millions and leaves patients stuck in the middle.

I want to add something the article implies but does not say directly: there are two sleeping giants here, not one. Employers and clinicians both hold enormous latent power over healthcare costs and outcomes. Neither has historically used it well. And the reason is simple. They do not talk to each other.

The GLP-1 Case Study That Should Make Employers Uncomfortable

Dr. Gondi laid out a scenario on the Relentless Health Value podcast that every self-funded plan sponsor should hear.²

A physician and patient decide together that a GLP-1 is clinically appropriate. The patient confirms coverage with their employer. The physician writes the script, completes the prior authorization, sends it to the pharmacy. Everything is done correctly.

Then the claim is denied at the counter. Out-of-pocket cost: list price. Patient walks away without the medication.

What happened? The employer made a reasonable decision to cover GLP-1s only through a third-party vendor that wraps in health coaching, lifestyle management, and clinical oversight. That vendor is the sole covered prescriber under the plan. The employer did this because GLP-1 spend was increasing plan pharmacy costs by double digits and adherence without wraparound support is dismal.

But nobody told the prescribing physician. There is no feedback loop from the pharmacy back to the clinic. The doctor does not find out until the three-month follow-up. The patient is frustrated. The physician is frustrated. The employer thinks it did the right thing and never gets credit for it.

That is not a technology failure. That is a coordination failure. And it is exactly the kind of failure that keeps compounding across the system when the two parties with the most at stake never communicate directly.

Site of Care Is Not a Coverage Denial. It Is a Routing Problem. 

Dr. Gondi’s second example is one I see constantly in our work at NIH, and it illustrates the problem even more starkly.

A member is diagnosed with cancer. The oncologist at a large academic health system prescribes first-line therapy. The prior authorization is denied. Both the physician and the patient are stunned.

The employer did not deny the drug. The employer denied the site of administration. The same medication administered at the hospital-owned infusion center costs 40 percent more than it would at a physician office or home infusion setting.³ The employer implemented a site-of-care program. The oncologist had no idea.

This is where good intentions collide with poor execution. The employer’s goal is legitimate. Site-of-care economics are real and well documented.³ But a denial without navigation is not a site-of-care strategy. It is a coverage barrier wearing a cost-containment label.

The difference between a plan that steers effectively and one that just generates friction is whether someone is doing the work of connecting the physician, the patient, and the employer-side strategy before the denial hits. That means provider communication, member navigation, and clinical coordination. Without those, site-of-care programs create exactly the dysfunction Dr. Gondi describes.

Why This Gap Persists

Dr. Gondi makes a critical observation: electronic medical records are billing instruments designed to optimize revenue for health systems.² They are not designed to help clinicians understand plan economics, site-of-care alternatives, or employer coverage strategies.

Epic is not going to build a prompt that says, “Hey, your patient’s employer covers this drug but only at a lower-cost infusion site down the street.” That would be programming network leakage into a system whose customer is the hospital.

So the information gap persists by design. The employer makes a smart cost-containment decision. The physician never hears about it. The patient bears the friction. And everybody involved thinks the other party is the problem.

This is why the gap between employer strategy and clinical reality matters so much. If no one is translating coverage decisions into provider-facing communication, the system defaults to denial and confusion. The patient gets caught in the middle, and both giants remain frustrated with each other instead of working together.

What Plan Sponsors Should Learn From This

The pattern in both of Dr. Gondi’s examples is the same. The employer made a defensible decision. The clinician was never informed. The patient absorbed the fallout.

That pattern will keep repeating until plan sponsors treat provider communication as a core part of benefit design, not an afterthought. Every coverage change that alters how a clinician’s order gets fulfilled should include a communication plan for the prescribing community. That is not optional. It is the difference between cost containment and cost confusion.

It also means that whatever partners an employer relies on, whether a PBM, TPA, consultant, or managed services organization, those partners need to be evaluated on whether they are actually closing the loop between employer intent and clinical reality. If your vendor’s version of site-of-care optimization is a prior authorization denial with no navigation, no provider outreach, and no member support, that is not optimization. That is a barrier dressed up as a strategy.

The Real Takeaway for Plan Sponsors

Dr. Gondi’s advice is sound: employers with local presences should engage directly with local providers when making significant coverage changes.² Do not assume the information will travel through the PBM or TPA to the prescriber. It will not.

But communication alone is not enough. You need an operational discipline that treats provider awareness as part of plan design. When you implement a new coverage pathway, build the prescriber communication into the implementation timeline. When you add a vendor, make sure the vendor’s workflow includes closing the loop with the treating physician. When you steer site of care, make sure a navigator is doing the work before the denial letter lands in a patient’s mailbox.

If your plan has implemented site-of-care steering, GLP-1 vendor requirements, biosimilar step therapy, or any other cost-containment measure that changes how a clinician’s order gets fulfilled, ask yourself one question: does my physician network actually know about it before the denial hits?

If the answer is no, you do not have a cost-containment strategy. You have a friction generator. And your members are the ones paying for it.

The two sleeping giants do not need to keep missing each other. But somebody has to build the bridge. That is the work.

Jake Velie is Chairman & CEO of National Integrative Health, a managed services organization headquartered in West Des Moines, Iowa, specializing in prescription drug cost optimization for employer health plans.

Footnotes

¹ Gondi, Suhas and Song, Zirui. “A Sleeping Giant of Health Care Affordability—Self-Insured Employers.” New England Journal of Medicine, 2026. https://www.nejm.org/doi/full/10.1056/NEJMp2517872

² Richter, Stacey. “Episode 523: The Sleeping Giants of Healthcare. Why Self-Insured Employers and Clinicians Keep Missing Each Other.” Relentless Health Value, 2026. Interview with Dr. Suhas Gondi. https://relentlesshealthvalue.com/blog/transcript-for-ep523-with-suhas-gondi

³ Magellan Rx Management. “Medical Pharmacy Trend Report: Site of Care Optimization.” Research shows that shifting infusion administration from hospital outpatient departments to physician offices, home infusion, or ambulatory infusion centers can reduce per-administration costs by 40–60%.