By Jake Velie, CPT, Founder, Chairman & CEO, National Integrative Health

The GLP-1 market has already changed. The real question now is not whether these therapies will keep growing. They will. The question is whether plan sponsors have a real strategy for managing them.¹ ²

Too much of the conversation is still framed the wrong way. It gets reduced to a yes or no coverage debate, cover it or exclude it, as if that alone settles the issue. It does not.² ³

Coverage alone is not a strategy. Exclusion alone is not a strategy either.

A plan sponsor can decide to cover GLP-1s and still lose control if there are no clear clinical criteria, no channel discipline, no oversight on duration of therapy, and no process for managing net cost. A plan can also choose to exclude them and still end up with pressure from members, employers, appeals, and market demand that does not go away.¹ ²

That is where the market is now. GLP-1s have moved past being a niche benefit question. They are reshaping employer conversations around pharmacy trend, specialty management, clinical governance, and fiduciary oversight.¹ ²

This split is already showing up in the market. PSG reported that nearly all plans now cover GLP-1s for diabetes, but only 40% offer them for obesity, and 49% of plans that do not cover obesity GLP-1s say they would not do so at any price. That tells you this is no longer a fringe benefits question. It is an active plan-design and cost-governance decision.³

That means the next step for plan sponsors has to be execution.

The first piece is clinical criteria. If a plan is going to cover these therapies, it needs a disciplined framework around who qualifies, under what conditions, with what documentation, and with what expectations for continued therapy. That includes diagnosis standards, prior therapy requirements where appropriate, prescribing oversight, and ongoing review. Without that structure, utilization expands faster than governance.² ³

The second piece is channel management.

Not every high-cost therapy should move through the same pathway without scrutiny. Plan sponsors need to know where a GLP-1 claim is being filled, what support programs may exist, what manufacturer assistance or patient advocacy pathways are available, and whether anyone is actively managing the lowest legitimate net-cost route. Too often, plans look at the claim only after the spend is already on the books.¹

That is reactive. It is not strategy.

We are also seeing what stronger GLP-1 discipline can look like in real plan modeling. In a de-identified jumbo-group analysis built on a U.S.-sourced formulary, NIH modeled a fixed all-in GLP-1 rate of $521 per utilizing member per month, 36% below the incumbent carrier’s standard estimate and 57% below its risk-managed estimate. That translated to projected annual savings of $11.5 million to $25.8 million, depending on member take-up.⁴ ⁵

Just as important, tighter guardrails did not raise the unit cost in that modeling. BMI thresholds, prior authorization, step therapy, and lifestyle-program requirements could be layered on without changing the price per fill. Under the incumbent’s rebate-based model, tighter eligibility raised the unit cost by 50%.⁴ ⁵

The third piece is net-cost discipline. This is where a lot of employers still stop too early. They may get more visibility into pricing, but visibility by itself does not solve the problem. Seeing spend is not the same as controlling spend. A report can tell you what happened. It cannot prove the plan used the best available pathway.¹ ²

That matters because GLP-1 demand is not slowing down. As more employers face pressure from utilization, workforce interest, and broader market normalization, the plans that do well will not be the ones with the loudest position. They will be the ones with the clearest process.¹ ³

That process should answer a few simple questions.

1. Who qualifies for therapy?

2. What clinical criteria must be met?

3. What channel should be used?

4. What cost-support options have been evaluated?

5. Who is accountable for the net result to the plan?

If a plan sponsor cannot answer those five questions clearly, it does not have a GLP-1 strategy yet.

This is also where employers need to be careful about confusing vendor activity with accountability. PBMs, TPAs, brokers, consultants, and clinical vendors may all play a role. But someone has to own the full picture. Someone has to be responsible for making sure access, clinical integrity, and financial stewardship are working together.

That is the gap I see in this market.

The conversation is finally catching up to the size of the issue. That is a good thing. But the next move cannot be more debate without operational discipline. Plans do not need another round of abstract opinions on GLP-1s. They need criteria. They need process. They need channel control. They need net-cost management.¹ ² ³

In short, they need a strategy.

Footnotes

1. Managed Healthcare Executive. “Growth of GLP-1 Therapies Has Reshaped the Market.” PBMI 2026, as summarized in AHIP Solutions SmartBrief, Sep. 15, 2026: GLP-1 therapies accounted for almost half of prescription drug sales growth, the diabetes market reached $98 billion, and weight loss treatments grew 75% year over year to $55 billion.

2. PLANSPONSOR. “Navigating the Current Landscape of GLP-1 Coverage.” Sep. 11, 2026. PLANSPONSOR NewsDash summary noting that attorneys from McDermott Will & Schulte reviewed the costs, benefits, and risks employers should evaluate when deciding how their benefits address GLP-1 medications.

3. PSG 2026 Trends in Drug Benefit Design Report webinar notes shared internally on Jun. 25, 2026: nearly all plans now cover GLP-1s for diabetes, 40% offer GLP-1s for obesity, and 49% of plans that do not cover obesity GLP-1s would not do so at any price.

4. National Integrative Health, de-identified GLP-1 coverage cost analysis for a jumbo labor health and welfare fund, Aug. 2026: modeled fixed all-in GLP-1 pricing at $521 per utilizing member per month, compared with incumbent estimates of $800 standard and $1,200 risk-managed.

5. National Integrative Health. GLP-1 Program Case Study, de-identified illustrative summary, 2026: projected annual savings of $11.5 million to $25.8 million depending on member take-up, with the same pricing holding under added utilization-management guardrails.

By Jake Velie, CPT, Founder, Chairman & CEO, National Integrative Health

Employers are getting squeezed from every direction on healthcare costs. That part is not new. What is changing is how they are starting to respond.¹ ²

For years, many plan sponsors treated high-cost healthcare as something to review after the fact. They got the renewal. They looked at the trend. They asked a few questions. Then they assumed the vendor stack had it covered.

That approach is breaking down.

U.S. healthcare costs have reached $5.7 trillion, more than $15,000 per person per year. At the same time, nearly 60% of surveyed employers told Marsh they plan to make benefits changes next year to help control costs.¹ ² That is not a minor adjustment. It is a signal that employers know the old model is not holding.

The conversation is also becoming more explicit about fiduciary duty. Plan sponsors are being pushed to understand and implement CAA provisions, meet fiduciary responsibilities, and build stronger processes aligned with ERISA requirements.³ This is not just a cost conversation anymore. It is a governance conversation.

That matters because the real problem is not only price. It is fragmentation.

The PBM may manage one piece. The TPA may manage another. The broker may see the problem but not operate the fix. The employer is left trying to connect the dots after the spend is already on the books.

That is why more employers are looking for partners who do more than administer benefits. They are looking for people who can help them act like fiduciaries.

High-cost claims make that need impossible to ignore. One outside analysis put it plainly: 80% of healthcare costs are driven by 20% of claimants, and 50% of healthcare costs are driven by 5% of claimants.⁴ When that much risk is concentrated in that few cases, passive oversight is not a strategy.

Pharmacy pressure only adds to it. Specialty medications now comprise nearly 80% of all new drug launches, and nearly half of those launches carry price tags above $150,000.⁵ Employers do not need more summaries telling them costs are rising. They need someone who can challenge the pathway before a bad default becomes a paid claim.

That is the shift happening now. Employers are asking harder questions. Where is spend concentrating? Which claims are being actively challenged? What alternatives were reviewed? Who owns the decision? How do we prove the plan bought well, not just processed correctly?

Those are fiduciary questions. And once employers start asking them, they usually realize generic oversight is not enough.

This is why specialized partners are getting more attention. Not because employers want another logo in the stack. They do not. They want control. They want accountability. They want a party that can step into the space between administration and outcome and actually manage the problem.

That does not require self-promotion to explain. It is simply where the market is headed. When costs rise, risk concentrates, and compliance expectations get tighter, employers move toward expertise that is operational, clinical, financial, and accountable at the same time.

The era of passive health plan oversight is ending.

And for employers who are serious about cost, that is a good thing.

Footnotes

1. Moving to Value Alliance, “Enough with the Blank Checks,” Sep. 15, 2026. Summary states that U.S. healthcare costs have reached $5.7 trillion, more than $15,000 per person per year, and frames a 12 to 24 month roadmap from passive payer to active fiduciary. Link shared by user: https://www.movingtovalue.org/enough-with-the-blank-checks?utm_campaign=7ebc36f3-b142-46b4-acf7-6228b99dc19c&utm_source=so&utm_medium=mail&cid=322adc3d-c936-40c5-815b-713c3ca416dd

2. PLANSPONSOR NewsDash, “Employers Gear Up for Biggest Healthcare Cost Spike in 20 Years,” Sep. 8, 2026. Summary notes that nearly 60% of surveyed employers told Marsh they planned to make benefits changes next year to help control costs.

3. PLANSPONSOR, “Your Health Benefit Fiduciary Roadmap Starts Here!,” Mar. 25, 2026. Invitation copy states the series would help plan sponsors and advisers understand and implement CAA provisions, confidently meet fiduciary responsibilities, and build robust processes aligned with ERISA requirements.

4. AHealthcareZ, Eric Bricker, MD, “#1 Cause of High Healthcare Costs is…,” Oct. 28, 2025. Summary states that 80% of healthcare costs are driven by 20% of claimants and 50% of healthcare costs are driven by 5% of claimants.

5. RxBenefits Team, “Take Control of Specialty Drug Costs,” Aug. 24, 2026. Summary states that specialty medications comprise nearly 80% of all new drug launches and nearly half of them carry price tags exceeding $150,000.

By Jake Velie, Chairman & CEO, National Integrative Health

When brokers start raising infusion carve-outs in renewal conversations, it is a sign that the old approach to medical-benefit drug spend is under pressure.

This is not a labeling exercise. It is about cost, accountability, and control.

In one recent NIH case, a broker managing over 70 self-funded groups asked whether an infusion carve-out could be put in place for a 10/1 renewal after reviewing claims that included Keytruda and other J and Q codes.¹ (Source note: Internal NIH case notes.) In another July case, a broker requested a deeper repricing analysis focused on site-of-care adjustments and Cyramza.² (Source note: NIH case notes on site-of-care repricing.) Those cases matter, not because two anecdotes prove a trend, but because they reflect where sophisticated intermediaries are starting to focus.

They are looking harder at provider-administered drugs billed through the medical benefit. They are asking what the plan actually paid. They are questioning whether the hospital outpatient department was the right setting. And they are recognizing that a standard renewal conversation does not answer those questions well enough.

What an infusion carve-out means in practice

An infusion carve-out is not a solution by itself, and it is not automatically the right answer.

At a practical level, it usually means separating some portion of infused and injected drug management from the default medical-claim workflow so the plan can evaluate a different mix of site of care, sourcing, prior authorization, clinical review, and network strategy. The point is not the carve-out itself. The point is to stop treating every infused claim as if its current pathway must be accepted.

That distinction matters.

Too many employers still approach infusions as though the only variable is the drug. In reality, the economics are shaped by at least four moving parts: the therapy selected, the place of service, the reimbursement structure, and the discipline of the people managing the claim. When those four variables go unmanaged, high-cost cases consistently flow to the most expensive channel.

Why brokers are raising this now

The broader specialty market is already telling employers that high-cost drug management cannot be treated as a rebate exercise. In PSG’s latest specialty trend discussion, gross specialty spend grew 10.8 percent in 2025 while cost per claim was nearly flat at 0.1 percent. Utilization grew 10.6 percent.³ (Source note: PSG specialty trend findings.) More members are using more high-cost therapies, across more conditions, for longer periods of time.

Figure 1: Specialty Spend Is Surging Because More People Are Using More Drugs, Not Because Drugs Cost More

That utilization dynamic is especially important in the infusion setting.

Once more high-cost therapies move through the medical benefit, the site of care starts to matter significantly. Magellan Rx Management has cited research showing that shifting infusions from hospital outpatient departments to clinically appropriate lower-cost settings such as physician offices, ambulatory infusion centers, or home infusion can reduce administration costs by 40 to 60 percent.⁴ (Source note: Magellan site-of-care optimization research.) That does not mean every infusion belongs outside the hospital. It does mean every routine case deserves scrutiny.

Figure 2: Shifting Infusions Out of Hospital Settings Can Cut Administration Costs by Up to 60%

That is why brokers are asking harder questions. They are seeing the same thing employers are seeing in their claims experience: infused drug spend is not something you can review once a year and set aside.

The problem is not just price. It is process.

The structural problem for many plans is that they do not have a clean answer to a simple question: who is responsible for proving that a high-cost infused claim was routed through the lowest reasonable net-cost path?

The PBM may not own it if the drug is billed through the medical benefit. The TPA may process the claim correctly without knowing to challenge the site. The broker may spot the problem without being aware how to operate the fix. The hospital has no reason to volunteer a lower-cost setting if the current one pays well.

That leaves the plan sponsor holding the financial risk and, increasingly, the governance burden. As the U.S. Department of Labor and Employee Benefits Security Administration continue to press for greater health-plan transparency and accountability, employers should assume they need a clearer record of how high-cost pharmacy-related claims are being evaluated and managed.⁵ (Source note: DOL and EBSA guidance on oversight and accountability.)

This is why infusion carve-out conversations keep reaching the renewal table. They are often less about replacing a vendor and more about creating a process that does not depend on passive default behavior.

What plan sponsors should evaluate before making a decision

A sound infusion strategy starts with diligence, not positioning.

Before a plan sponsor embraces or rejects a carve-out, there are several practical questions worth answering:

1. Which infused and injected therapies are driving the highest paid amounts today?
2. How much of that spend is occurring in hospital outpatient departments versus lower-cost alternative settings?
3. For the largest claims, does the plan know the true net paid amount after all credits, refunds, and adjustments?
4. Which cases are clinically appropriate for redirection, and which are not?
5. Is the plan evaluating biosimilars, site-of-care changes, and other cost levers together, or one at a time?
6. Who is documenting the rationale for the path chosen on the largest claims?

That is the conversation self-funded employers should be having.

A plan does not need an ideological view of carve-outs. It needs a disciplined view of whether the current structure is producing defensible outcomes.

What gets lost when this becomes a vendor conversation

The industry tends to turn real operating problems into marketing categories.

The important issue is not whether an employer adopts a vendor’s preferred label. The important issue is whether the employer can demonstrate that it understands where infused drug spend is landing, why it is landing there, and what alternatives were considered.

If a carve-out helps create that discipline, it is worth considering. If the same discipline can be achieved through other means, that is equally valid. But inaction is no longer a defensible position.

When high-cost infused claims continue to flow into expensive settings without a documented challenge process, the plan is not managing the trend. It is absorbing it.

What employers should do next

Do not wait until the next renewal to get clarity on infused drug spend.

Pull the high-cost claims. Identify the sites of care. Reconcile the true net paid amounts. Review which therapies could have been managed differently. Make sure someone can explain, in writing, why the current pathway was used on the largest cases.

Infusion carve-outs are getting attention because employers are finally confronting a simple reality: hospital-based drug administration is not just a clinical event. It is a purchasing decision, a network decision, and a governance decision.

The plans that take that seriously will be in a much better position than those still treating infused drug spend as an unavoidable cost of doing business.

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

Footnotes

1. Internal NIH case notes describe a broker with 70 groups seeking an infusion carve-out for a 10/1 renewing group after review of claims including Keytruda and other J/Q codes.¹²
2. NIH case notes describe a broker request for deeper analysis of site-of-care adjustments and Cyramza repricing.
3. PSG, 2026 Pharmacy Benefit Manager Customer Satisfaction Report. Internal notes summarizing 2025 specialty trend findings: gross specialty spend grew 10.8%, cost per claim was nearly flat at 0.1%, and utilization grew 10.6%.
4. Magellan Rx Management, Medical Pharmacy Trend Report: Site of Care Optimization. Shifting clinically appropriate infusions from hospital outpatient departments to lower-cost settings can reduce administration costs by 40 to 60 percent.
5. U.S. Department of Labor, Employee Benefits Security Administration. Used here to support the employer-accountability and documentation framework for pharmacy-related spend oversight.

By Jake Velie, Chairman & CEO, National Integrative Health

The 2027 Segal Health Plan Cost Trend Survey should change the conversation for every self-funded employer. The issue is not simply whether costs will rise. It is whether the same high-cost claim will become more expensive because of its site of care, its sourcing pathway, and its lack of active management, then show up again in the plan’s stop-loss economics.

Segal projects 2027 medical trend for open-access PPO/POS plans at 9.9 percent. Outpatient prescription drug trend is projected at 11.5 percent before PBM rebates. Specialty drugs and biologics are projected at 11.9 percent. Those are near double-digit projections and the highest medical projections Segal has reported in nearly 15 years.

Insurance Business Magazine’s August coverage places the same pressure in the context of employer health costs and billing practices. That is useful context, but it is not an action plan. Employers need to know where the pressure is entering the claim and what they can do before the cost becomes a renewal problem.

Figure 1. 2027 trend snapshot

The place of service is part of the claim

Segal’s SHAPE data warehouse, which tracks actual claims experience for a sample of large self-funded plan sponsors, found that medical trend reached 8.9 percent in 2025, up from 8.0 percent in 2024. Outpatient hospital expenses led the major service categories at 10.4 percent, compared with 5.8 percent for inpatient care and 8.2 percent for professional services.

That matters because many specialty biologics and infused therapies are administered through the medical benefit, often in outpatient hospital settings. Segal defines specialty drugs as generally high-cost therapies for rare conditions or drugs that require special handling, including products given by injection or infusion.

The clinical need may be the same, but the total cost can change materially based on where the therapy is administered, how the provider is reimbursed, and which sourcing channel is used. Segal reports hospital price inflation at 6.7 percent, compared with 2.4 percent hospital utilization. For physicians, the components are 3.5 percent price inflation and 4.0 percent utilization. The report defines hospitals here as inpatient and outpatient hospital services combined.

The point is not that every infusion belongs outside a hospital. The point is that every high-cost case deserves review. A clinically appropriate shift to an ambulatory infusion center, physician office, or home setting can materially change the cost of administration. Magellan Rx Management has cited research indicating that moving clinically appropriate infusions to lower-cost settings can reduce administration costs by 40 percent to 60 percent.

Figure 2. Site-of-care driver

Prescription drug trend is a mix and utilization problem

The 11.5 percent outpatient prescription drug projection should not be read as simple price inflation on existing products. Segal’s data points to a changing mix of therapies. Actual prescription drug trend increased from 10.4 percent in 2024 to 12.4 percent in 2025. New-to-market drugs launched within the previous five years accounted for 7.0 percentage points of that 12.4 percent, or almost 60 percent of actual 2025 trend.

That innovation is concentrated in oncology, immunology, rare disease, and cell and gene therapy, where costs are high and use is expanding. The practical question for employers is not whether innovation is valuable. It is whether the plan has a deliberate way to manage the mix, the channel, and the net cost as new therapies enter the benefit.

Figure 5. 2025 prescription drug mix

GLP-1s add another layer. Plans covering GLP-1s for obesity management experienced an 18.3 percent prescription drug trend in 2025, compared with 10.5 percent for plans that did not cover anti-obesity medications. Segal attributes 7.8 percentage points of the covered-plan trend to GLP-1s. This does not argue against coverage. It argues against treating coverage as the entire strategy. Employers need evidence-based criteria, clinical management, benefit design, and a clear access pathway for members and providers.

Figure 4. GLP-1 coverage gap

Stop-loss turns trend into a financing problem

In June 2026, Segal reported that medical stop-loss premiums had increased nearly 13 percent, driven by the high-cost claims that increasingly shape employer plan performance. The connection to the 2027 trend survey is straightforward: specialty drugs, biologics, and outpatient hospital claims are not only medical and pharmacy trend items. They are also part of the high-cost claim concentration that influences specific stop-loss exposure and renewal conversations.

Not every specialty claim will cross a specific deductible. But when high-cost claims are concentrated in expensive sites of care, employers can feel the impact in two places: the claim itself and the cost of transferring that risk. A sponsor that does not review the pathway for major infused claims is accepting both exposures without testing the alternatives.

Biosimilars show why active sourcing matters

Segal’s SHAPE data illustrates the difference between having a lower-cost option available and actually using it. In the fourth quarter of 2025, Humira’s average 28-day cost was $7,611. High-WAC biosimilars averaged $6,541. Low-WAC biosimilars averaged $1,229, an 84 percent reduction.

For Stelara, the reference product averaged $12,827 per 28-day cycle. A low-WAC biosimilar averaged $1,536, roughly 88 percent below the reference product. The J&J biosimilar averaged $4,097.

Those comparisons do not guarantee the same result for every plan. They show why availability is not the same as adoption. A sponsor needs to evaluate formulary positioning, clinical appropriateness, provider behavior, benefit design, and actual net paid amounts. A passive default will not answer those questions.

Figure 3. Specialty sourcing and biosimilar gap

Rebates are one variable, not the strategy

Segal reports that the median rebate among survey respondents represented 30 percent of projected 2027 prescription drug allowed costs. That is a meaningful number, but it is not the same as lowest net cost.

Segal also reports that federal PBM reform enacted in 2026 is expected to reshape rebate economics. Under the report’s description of the Consolidated Appropriations Act of 2026, covered group health plans and issuers will receive 100 percent of manufacturer rebates, fees, and other remuneration, along with enhanced disclosure and audit rights, although many commercial-market requirements do not take effect until 2028 to 2029. Employers should prepare for that shift, but they should not wait for regulation to solve the cost problem.

A serious review must look beyond the rebate line. Employers should understand administrative fees, specialty pharmacy charges, clinical program fees, affiliate arrangements, spread, and any other compensation that affects the amount the plan ultimately pays. Transparency tells you where the problem is. You still need a solution that works across the entire claim pathway.

What employers should do before 2027

Segal found that plan sponsors using multiple cost-management strategies tend to experience lower trends than sponsors taking a hands-off approach. Site-of-care steerage entered the top five medical cost-management strategies. On the pharmacy side, the top strategies include addressing diabetes and anti-obesity GLP-1 medications, managing specialty drugs, and controlling specialty drug mix through biosimilar strategies.

The practical work should start now:

1. Pull the highest-cost medical and pharmacy claims and reconcile them into one view.
2. Identify the place of service and site of administration for infused and injected therapies.
3. Compare actual net paid amounts with clinically appropriate alternatives, including biosimilars and lower-cost sites of care.
4. Review 340B pricing, Manufacturer Assistance Programs (MAP), clinical interventions, foundation and Patient Assistance Advocacy, and clinical trial program access where appropriate.
5. Document why the chosen pathway was clinically appropriate and financially defensible.

This work does not require employers to replace their partner ecosystem. Brokers connect sponsors to expertise. TPAs administer claims. PBMs process pharmacy benefits. Segal provides independent trend and actuarial perspective. An employer-side managed services layer can help evaluate the net-cost pathway across those channels. NIH is not the plan fiduciary. The employer retains that responsibility. NIH’s role is to help plan sponsors evaluate and execute a multi-channel approach across high-cost claims.

Documentation is not a promise of better stop-loss terms. It is evidence that the sponsor is actively managing the risk and gives the employer something concrete to bring into renewal and stop-loss discussions.

Do not wait for renewal

Segal’s conclusion is the right one: employers need coordinated action across plan design and networks, vendor and PBM accountability, and population health, all supported by strong analytics. The 2027 strategy should not be built around one lever, one vendor, or one renewal meeting.

The math is not complicated. Outpatient hospital trend is above 10 percent. Prescription drug trend is also in double digits. Specialty claims are shaping stop-loss economics. The question is whether employers will review the claim pathway before 2027 or keep paying hospital prices because that is where the claim happened to land.

Do not wait for renewal to discover what your high-cost claims are doing to the plan. Pull the data, challenge the pathway, and build the record now.

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.

Sources and footnotes

• 1. Segal, 2027 Health Plan Cost Trend Survey, 30th annual edition (2026), especially pp. 4–5, 8–12, 19–27. All Segal projections and SHAPE figures in this draft were checked against the supplied PDF.
• 2. Insurance Business Magazine, “Employer health costs near 15-year high as billing pressures mount,” August 2026. Direct article URL was not included in the supplied materials and should be added before publication.
• 3. Segal, “Medical Stop-Loss Premiums Increase Nearly 13 Percent,” June 2026. Direct article URL was not included in the supplied materials and should be added before publication.
• 4. Magellan Rx Management, Medical Pharmacy Trend Report: Site of Care Optimization, as cited in NIH’s prior source notes, for the 40 percent to 60 percent administration-cost reduction range.
• 5. National Integrative Health, About Us, for the NIH managed-services description.
• 6. NIH fiduciary clarification draft, internal source stating that NIH is not the plan fiduciary and that the employer retains that responsibility.

By Jake Velie, Chairman & CEO, National Integrative Health 

The National Alliance of Healthcare Purchaser Coalitions just released its 2026 Pulse of the Purchaser survey, and if you run a self-funded health plan, you should read it carefully.¹ 

Not because it says anything surprising about costs. Costs are up. Everyone knows that. The average employer expects a 7.7% increase before plan design changes, and one in three projects 9% or more. That has been the background noise for years. 

What makes this year’s data important is what it says about who actually does something about it, and why. 

The answer is not what most people assume. 

Cost Pressure Does Not Predict Action 

Here is the finding that should stop every benefits leader in their tracks: employers facing the steepest cost increases are not significantly more likely to have purchasing strategies in place.¹ 

Read that again. 

The employers getting hit hardest are not the ones doing the most. Employers paying above-average premiums are not doing more either. Neither cost level nor cost trajectory predicts whether an employer is actually managing spend. 

So, what does? 

Data access. 

Employers with complete claim-level access to their medical data are running an average of 11.9 high-value purchasing strategies. Employers without that access are running 7.9.¹ That is a four-strategy gap driven entirely by whether the employer can see what is happening inside its own plan. 

Across all 26 hospital and high-cost claim strategies measured in the survey, employers with complete claims data were more likely to be taking action. Every single one pointed the same direction. Twenty-one of the twenty-six differences were statistically significant.¹ 

This is not a minor methodological footnote. This is the central finding of the largest employer health purchasing survey in the country. 

The Gap Is Not Intent. It Is Information. 

Both groups of employers express similar levels of interest in managing costs. They are considering roughly the same number of strategies. The difference is that employers with data convert interest into action at dramatically higher rates. 

As one respondent put it: “Even if I did have access to our data, I don’t know that I have the capacity to review and make decisions.”¹ 

That quote is important because it captures both sides of the problem. Access is necessary but not sufficient. Employers also need the operational support to translate claims intelligence into purchasingdecisions. But without access, the conversation never starts. 

Roughly one in three employers in the survey report they do not have complete claim-level access to their medical data.¹ Only about three in five are confident they can audit their own complete files. And where the data is stored matters: three-quarters of employers keep claims with their health plan or TPA, and that group reports the lowest access rates. Employers using an independent data warehouse report access rates above 84%.¹ 

The practical implication is straightforward. If your claims data lives inside the same vendor relationship you are trying to evaluate, you are less likely to have unfettered access to it. And if you do not have access, you are less likely to act. 

Where the Money Goes 

For the first time, the survey asked employers to estimate how their healthcare dollars are allocated. The results confirm what many plan sponsors suspect but have not documented: 

Hospital and facility costs account for 30.5% of total spend.¹ Prescription drugs take 21.1%. Professional fees account for 19.1%. 

But here is the number worth dwelling on. The National Alliance estimates that when hospital-affiliated professional fees and physician-administered drugs billed through hospital systems are included, hospital services approach half of every dollar employers spend on healthcare.² That is not a fringe claim. That is the survey sponsor’s own analysis, and it aligns with what we see in high-cost claim reviews every week. 

If hospitals are consuming close to half the spend, and only 30% of employers regularly use hospital price and quality information to guide purchasing decisions,¹ the gap between problem and response is enormous. 

The most commonly reported barrier to using that information? Limited internal staff capacity.¹ Not lack of interest. Not disagreement with the approach. Capacity. 

The PBM Market Is Moving, and the Data Explains Why 

The survey documents a meaningful shift in PBM market share. Big Three PBM share of named pharmacy benefit managers fell from 63.4% in 2025 to 54.3% in 2026.¹ That is a nine-point decline in a single year. 

The shift came almost entirely from employers under 1,000 lives, where Big Three share dropped 26 points.¹ Small employers moved first because they can move faster. But 60% of Big Three clients with 10,000 or more employees are now considering a change, suggesting the next wave could come from the largest purchasers.¹ 

What is driving it? Contract terms and fiduciary confidence. 

On every contract protection measured except rebate pass-through, employers using non-Big Three PBMs report stronger terms: no spread pricing, disclosure of affiliated entities and compensation, and lowest-net-cost formulary design.¹ The gaps are consistent, ranging 16 to 18 percentage points. 

Big Three clients are nearly three times as likely to question the integrity of PBM administration (36% versus 13%) and the reasonableness of PBM compensation (35% versus 12%).¹ And employers without full pharmacy claims access are more than twice as likely to express concern about both measures. 

Opacity and distrust travel together. That is not speculation. That is what the data shows. 

This matters in the context of new federal law. The Consolidated Appropriations Act of 2026 will require PBMs to pass through 100% of rebates and other remuneration beginning with plan years starting 30 months after February 3, 2026.³ For calendar-year plans, that generally means January 1, 2029. Employers should be evaluating their PBM contracts now against what that timeline will require. 

Policy Engagement Is Rising Because Frustration Is Hardening Into Specific Asks 

The survey documents something subtle but important: employer threat ratings are falling while support for regulation is rising.¹ 

Drug prices as a significant threat fell from 93% in 2024 to 77% in 2026. Hospital prices fell from 82% in 2023 to 68%.¹ But over the same period, support for PBM reform rose 20 points to 88%, and support for hospital rate regulation rose 17 points to 83%.¹ 

Those two trends moving in opposite directions tell you something. Employers are not less worried. They have moved past alarm and into specific policy demands. Frustration has hardened into targeted asks. 

More than half of employers now engage in federal or state health policy, up nearly nine percentage points in a single year.¹ And once again, data access is the dividing line: employers with full pharmacy claims access are 22 percentage points more likely to participate in policy discussions.¹ 

The pattern is consistent. Data access predicts action. Data access predicts confidence. Data access predicts engagement. If you take one thing from this survey, it should be that the single most important investment a plan sponsor can make is ensuring unfettered access to its own claims data. 

What This Means for Plan Sponsors 

The survey identifies a clear hierarchy of what matters: 

1. Get complete access to your claims data. Medical and pharmacy, separately. Not aggregate reports. Not vendor-curated dashboards. Claim-level data with audit rights you can actually exercise. 

2. Store that data independently. Employers using independent data warehouses report access rates above 84%. Employers storing data with their health plan or TPA report rates near 59%.¹ Where the data lives determines whether you can use it. 

3. Use the data to evaluate, not just to report. Small employers use claims data for cost analysis. Large employers use it for vendor accountability, financial integrity review, and benchmarking.¹ Theprogression from tracking to governing is where value creation happens. 

4. Evaluate your PBM contract against the new federal standard. If your contract does not already include no spread pricing, full compensation disclosure, and lowest-net-cost formulary design, you are behind the market. The survey shows non-Big Three employers already have these protections at significantly higher rates.¹ 

5. Treat site-of-care strategy as a first-order purchasing decision. Hospital and facility spend is the largest single category. More than half of employers are already steering members to higher-value sites or using centers of excellence.¹ If you are not among them, you are absorbing costs that other employers are managing. 

The Uncomfortable Truth 

This survey confirms something that should make every plan sponsor uncomfortable: the system is designed to limit your visibility. 

Vendors who administer your claims also control your data access. PBMs whose compensation you cannot verify also design your formulary. Hospitals whose prices you cannot compare also dictate where care is delivered. 

The employers who break through that design limitation are the ones who insist on data access, exercise audit rights, evaluate contract terms, and treat purchasing as an active discipline rather than a passive administrative function. 

The 2026 Pulse of the Purchaser makes the case clearly: what separates employers who act from those who do not is not what they pay. It is what they can see. 

If you cannot see your data, you cannot manage your plan. And if you are relying on the same vendors whose performance you need to evaluate to give you the information you need to evaluate them, you have a structural conflict that no dashboard will solve. 

The question for every plan sponsor reading this is simple: do you have complete, independent access to your own claims data, and are you using it to hold every vendor relationship to account? 

If the answer is no, that is where to start. 

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 self-funded employer health plans. 

Footnotes 

1. National Alliance of Healthcare Purchaser Coalitions. “Pulse of the Purchaser: 2026 Survey Findings.” Fielded May-June 2026, 408 respondents representing employers across all 50 states and DC, covering approximately 3.7 million lives. https://www.nationalalliancehealth.org/resources/pulse-of-the-purchaser-2026-survey-results/ 

2. National Alliance of Healthcare Purchaser Coalitions. “Setting the Record Straight: A Challenge to Align Hospital Prices with Value.” 2026. The Alliance estimates that when hospital-affiliated professional fees and physician-administered drugs billed through hospital systems are included, hospital services approach half of every employer healthcare dollar. 

3. Consolidated Appropriations Act, 2026, H.R. 7148, 119th Congress, enacted February 3, 2026. Requires PBMs to pass through 100% of rebates and other remuneration beginning with plan years starting 30 months after enactment (August 3, 2028). For calendar-year plans, this requirement would generally begin January 1, 2029. 

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.

Stacey Richter makes the point directly in the title of her Relentless Health Value episode on this article: “The Sleeping Giants of Healthcare. Why Self-Insured Employers and Clinicians Keep Missing Each Other.”² 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.

As Richter puts it in the episode, Epic is not going to program a prompt that tells a clinician to find out whether the right site of care might be somewhere else. That would be programming network leakage, her term for what hospital systems call it when a patient leaves their network for care elsewhere, into a system whose primary customer is the hospital.²

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%.

By Jake Velie, Chairman & CEO, National Integrative Health

The most important sentence in some PBM paperwork is not buried in the pricing exhibit. It is not in the rebate schedule. It is not in the reporting package.

It is the disclaimer.

In one PBM pharmacy service agreement reviewed by our team, the language is direct: in providing services under the agreement, the PBM “is not acting as a fiduciary” under ERISA, and the client “shall not name” the PBM “as a plan fiduciary.”¹ That is not unusual. It is honest contract drafting. But it should get every self-funded employer’s attention.

Why? Because the plan sponsor still holds the liability, even while the PBM controls a huge amount of the machinery.

PBMs adjudicate claims. They build networks. They negotiate rebates. They issue reports. They manage specialty channels. They influence formularies and utilization patterns. But when it comes to fiduciary responsibility, many of them are telling employers exactly where they stand: not here.

What one PBM does well

To be clear, this is not a hit piece on any single company. The agreement and reporting package we reviewed show a PBM doing a number of operational things employers need done. 

The contract lays out claims processing, network administration, customer service, implementation support, audits, reporting, specialty pharmacy services, and rebate administration.² The fee schedule is straightforward enough to tell the client what it will pay for paid claims, prior authorizations, reporting requests, and other administrative functions.³ The agreement also states that the manufacturer’s rebate share to the client is 100%.³

The reporting itself is also the kind of visibility many employers say they want. The 2025 and Q1 2026 client summary reports show plan spend, member spend, rebates, net plan spend, generic utilization, specialty concentration, and other utilization markers.⁴ That is useful information. Employers need reporting. They need operational execution. They need a PBM that can keep the benefit running.

But here is the mistake too many plan sponsors still make: they confuse administration with alignment.

A clean report is not a fiduciary strategy. A rebate line is not a fiduciary strategy. A contract that spells out responsibilities is not the same as a partner taking fiduciary responsibility off your plate.

It does not.

The sentence employers cannot ignore

ERISA does not let a plan sponsor shrug and point downstream. The fiduciary standard follows the employer’s role in managing plan assets and plan decisions.⁵ If your PBM agreement says the PBM is not the fiduciary, believe it. 

That means the employer still owns the hard questions:

1. Are we paying the lowest net cost available for this drug?
2. Are rebate economics distorting our decision-making?
3. Are we overusing high-cost sites of administration?
4. Are there lower-cost biosimilar or therapeutic alternatives?
5. Are we using Manufacturer Assistance Programs (MAP), foundation support, and patient assistance opportunities where appropriate?
6. Do we have a documented process showing we evaluated those alternatives?
   

That last point matters more every year. The Consolidated Appropriations Act forced more disclosure into the pharmacy benefit system, but disclosure alone does not satisfy fiduciary duty.⁶ Transparency tells you where the problem is. You still need a solution.

Reporting does not equal optimization

The summary reports make the point for me.

In the 2025 report reviewed by NIH, specialty plan spend accounted for 71.6% of total plan spend.⁴ In Q1 2026, that figure rose to 88.1%.⁴ Those are not abstract numbers. That is concentration risk. That is exactly why employers cannot afford to look at pharmacy through a single-channel PBM lens.

Even with rebates reflected in the reporting, the employer still needs an independent strategy for where each claim should go and which levers should be pulled. If specialty utilization is dominating spend, the employer cannot be satisfied with getting a quarterly report and hoping the economics work themselves out.

At NIH, we take the opposite view. We assume every high-cost claim deserves to be challenged.

Where NIH changes the equation

National Integrative Health is not trying to become the PBM. We are the managed services layer that sits on the employer’s side of the table.

It is also important to be clear about what we are not. NIH is not the plan fiduciary. The employer still holds that responsibility. Our role is to help plan sponsors meet it with better oversight, better documentation, and better net-cost execution.

That matters because our job is not to protect a single channel. Our job is to drive the lowest net cost across all available channels.

That means looking at 340B pricing, biosimilar pathways, site of administration optimization, Manufacturer Assistance Programs (MAP), clinical interventions, foundation and patient assistance advocacy, and clinical trial access.⁷ ⁸ We are not dependent on a single regulatory outcome or a single vendor revenue model. We are focused on the employer’s result. 

So, when a PBM contract says, in effect, “we administer the program but we are not the fiduciary,” our response is simple: then the employer needs someone on its side who is actually waking up every day thinking like an owner. 

That is where NIH fits. 

This is a partner model, not a replacement fantasy 

Employers do not need to blow up their ecosystem to fix this problem. 

Brokers still matter. TPAs still matter. PBMs still matter. Auditors and consultants still matter. 

But each of those partners has a different role. 

Brokers connect plan sponsors to expertise. TPAs handle claims administration. PBMs process the pharmacy benefit and related operations. Auditors test the math and the compliance record. NIH helps the employer prove it asked the right questions, evaluated the right alternatives, and pursued the lowest net cost available.

That is the gap I see again and again in this market. Plenty of reporting. Plenty of vendors. Plenty of activity. Not enough employer-side orchestration.

Do not wait for the contract to save you 

If your PBM has already told you in writing that it is not the fiduciary, take that statement seriously. 

Do not wait for another lawsuit, another regulatory bulletin, or another renewal cycle to start building your fiduciary record. Start now. Review the contract language. Review the reporting. Review where specialty dollars are going. Then put a managed services strategy in place that proves you pursued the lowest net cost, not just the most convenient status quo. 

The employers who get ahead of this will not be the ones with the prettiest PBM dashboard. They will be the ones who can show they understood the risk, challenged the model, and acted. 

That is the standard now. And it should be. 

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. PBM pharmacy service agreement reviewed by NIH, effective April 1, 2017, Article VI, Section 6.2. Source material on file.
2. PBM pharmacy service agreement reviewed by NIH, effective April 1, 2017, Exhibit A, Scope of Services. Source material on file.
3. PBM pharmacy service agreement reviewed by NIH, effective April 1, 2017, Exhibit B, Administrative Fee Schedule, including claims processing fee and manufacturer rebate share to client. Source material on file.
4. 2025 and Q1 2026 client summary reports reviewed by NIH. Source material on file.
5. Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002(21)(A), defining fiduciary functions under ERISA.
6. Consolidated Appropriations Act, 2021, Pub. L. No. 116-260, Division BB, Title II, establishing prescription drug cost reporting and related transparency obligations for group health plans and issuers.
7. National Integrative Health, “About Us,” describing NIH’s managed services model for prescription drug cost optimization. https://nationalintegrativehealth.com/
8. Magellan Rx Management, “Medical Pharmacy Trend Report: Site of Care Optimization,” describing savings potential from shifting infusion administration to lower-cost settings.

By Jake Velie, Chairman & CEO, National Integrative Health

The momentum toward pharmacy benefit manager transparency just got a significant boost. As reported by Allison Bell in BenefitsPro on July 17, 2026, DOL Secretary nominee Keith Sonderling told the Senate Health, Education, Labor and Pensions (HELP) Committee that drafting new PBM transparency regulations is a priority for the Department of Labor.¹ The full hearing is available on the Senate HELP Committee’s website for anyone who wants to hear it straight from the source.²

“That’s going to save billions and billions of dollars for health care plans, which is going to drive down the cost of health care plans,” Sonderling stated during the hearing. He added that employers have “never been armed with information about what they’re paying for” and that “for the first time, they’re going to have that information.”¹

This is exactly the fight we’ve been in for years at National Integrative Health.

Why This Matters to Employers Right Now

For too long, PBMs have operated behind a curtain of complexity, profiting from spread pricing, rebate retention, and opaque formulary steering that costs plan sponsors billions annually. Sonderling’s commitment to transparency validates what we at NIH have built our entire model around: giving employers real visibility and real options to reduce their prescription drug spend.

This isn’t a new fight at the federal level. The Consolidated Appropriations Act of 2021 first cracked open the door by requiring group health plans to report prescription drug cost data and mandating PBM disclosure of rebates and fees.³ The DOL’s Transparency in Coverage Final Rule further required machine-readable pricing files from plans.⁴ And earlier this year, new federal PBM transparency laws created a collision with the DOL’s draft regulations that were already in motion, slowing the rulemaking process.⁵

Sonderling, who was confirmed as deputy secretary of Labor in March 2025 and became acting secretary after Lori Chavez-DeRemer resigned in April 2026,⁶ has now made it clear these regulations are back on the front burner. His oversight of the Employee Benefits Security Administration (EBSA), the agency that writes and enforces ERISA health plan rules, gives him direct authority to make this happen.⁷

At National Integrative Health, we don’t rely on a single strategy or hope that regulation will eventually fix the system. We deploy a multi-lever approach to achieve the lowest net cost on every claim, for every member:⁸

1. 340B Pricing: Access to the lowest U.S. source pricing available across all 50 states
2. Biosimilars: Therapeutic equivalents delivering 60–80% savings over brand medications
3. 503B Manufacturer Direct Contracting: Direct relationships with 503B outsourcing facilities for compounded specialty medications at a fraction of brand pricing
4. Proprietary 50-State Infusion Network: Our nationwide site of administration network redirects infusion and injection therapies from high-cost hospital outpatient settings to lower-cost, clinically equivalent alternative sites of care, saving plans 40–60% per administration⁹
5. Variable Copay Programs: Direct-to-manufacturer programs for GLP-1s and specialty medications
6. Clinical Interventions: Therapeutic substitutions, patient assistance programs, and provider coordination
7. Clinical Trial Program Access: Connecting eligible members to manufacturer-sponsored clinical trials, providing access to cutting-edge therapies to patients and large savings to plans in qualifying circumstances

This multi-channel model means we’re never dependent on any single regulatory outcome. If one lever faces headwinds, we pivot to the next-best option for the plan and the patient.⁸

Transparency Is Necessary, But Not Sufficient

While I applaud the DOL’s direction, employers shouldn’t wait for regulations to take action. Bell’s reporting notes that new draft or final regulations “may not come out in the next few weeks,” and that the department’s efforts have been slowed by the intersection of new congressional PBM transparency laws and existing draft regulations.¹ ⁵ When Sen. Bill Cassidy asked about a timeline, the best Sonderling could offer was, “We are working very hard on it.”¹

The reality is this: transparency tells you where the problem is. You still need a solution. That’s where a managed services organization like NIH comes in. We sit on the same side of the table as the employer, armed with clinical expertise and pricing intelligence across multiple channels, to ensure every dollar spent on pharmacy benefits is optimized.⁸

The Bigger Picture

As Sonderling moves through his confirmation process, his oversight would extend to ERISA-governed health plans, ACA employer provisions, and any new PBM legislation.¹ ⁷ These are the very regulatory frameworks that shape how employers structure and manage their health benefits. Having a Labor Secretary who views PBM accountability as a core priority signals a meaningful shift.

Sonderling also expressed enthusiasm at the hearing for creating benefit solutions for gig workers, programs that could let multiple platforms contribute to a worker’s benefit account without triggering employee classification under the Fair Labor Standards Act.¹ This signals a DOL that’s thinking creatively about expanding access to benefits, not just regulating existing ones.

At National Integrative Health, we welcome any effort to bring sunlight into the prescription drug supply chain. Transparency paired with actionable, multi-lever solutions is how we drive real savings for employers and better outcomes for their members.

The information age is finally reaching pharmacy benefits. It’s about time.

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 Bell, Allison. “DOL Secretary Nominee Calls PBM Transparency a ‘Priority.'” BenefitsPro, July 17, 2026. https://www.benefitspro.com/2026/07/17/dol-secretary-nominee-calls-pbm-transparency-a-priority/

² U.S. Senate HELP Committee. “Nomination of Keith Sonderling to Be Secretary of Labor.” Hearing recording. https://www.help.senate.gov/hearings/nomination-of-keith-sonderling-to-be-secretary-of-labor

³ Consolidated Appropriations Act of 2021, Pub. L. No. 116-260, Division BB, Title II (Transparency provisions requiring PBM disclosure of rebates, fees, and prescription drug cost reporting by group health plans).

⁴ U.S. Department of Labor, Department of Health and Human Services, and Department of the Treasury. “Transparency in Coverage Final Rule,” 85 Fed. Reg. 72158 (Nov. 12, 2020).

⁵ Bell, Allison. “Brand-New Federal PBM Laws Fuel Fight Over DOL Transparency Regulations.” BenefitsPro, Feb. 4, 2026. https://www.benefitspro.com/2026/02/04/brand-new-federal-pbm-laws-fuel-fight-over-dol-transparency-regulations/

⁶ Bell, Allison. “DOL Secretary Resigns, New Acting Head Has Been Active on Benefits.” BenefitsPro, Apr. 21, 2026. https://www.benefitspro.com/2026/04/21/dol-secretary-resigns-new-acting-head-has-been-active-on-benefits/

⁷ U.S. Department of Labor, Employee Benefits Security Administration (EBSA). https://www.dol.gov/agencies/ebsa

⁸ National Integrative Health. “About Us.” https://www.nationalintegrativehealth.com/

⁹ 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%. https://www.magellanrx.com/medical-pharmacy-trend-report/

By Jake Velie, CEO & President, National Integrative Health

Caribou Systems recently published a piece that every self-funded plan sponsor should read: “You’re the Fiduciary. Can You Prove It?” It’s a direct, uncomfortable question, and that’s exactly why it matters.¹

Their argument is simple and correct: ERISA fiduciary compliance isn’t about outcomes. It’s about process. Specifically, can you produce an independent, time-stamped trail showing you were actively verifying your pharmacy benefit spend, catching errors, and acting on what you found? For most plans, the answer is still no.
 

What Caribou Does 

What Caribou Systems does is rare in this industry: they tell plan sponsors the truth about their exposure and then give them the tools to close the gap. Their re-adjudication engine audits 100% of pharmacy claims (not a statistical sample), they conduct 75+ pre-implementation audits annually, and they process over 200 million claims per year.² That’s not a compliance checkbox. That’s a real oversight infrastructure.

Their emphasis on independence is critical. As they correctly point out, PBM-provided reporting, however detailed, is not independent verification. The Consolidated Appropriations Acts of 2021 and 2026 gave plan sponsors the legal standing to demand raw claims data and expanded audit rights, but having data is not the same as having a defensible fiduciary record.³ ⁴ Caribou builds that record.

Where National Integrative Health Fits

At NIH, we view organizations like Caribou as natural allies. Our work operates on a parallel track: while Caribou ensures your PBM is billing correctly, disclosing rebates fully, and applying benefit terms accurately, NIH ensures you’re achieving the lowest possible net cost on every claim in the first place.⁵
 

We deploy a multi-lever approach: 340B pricing across all 50 states, biosimilars delivering 60–80% savings, site of administration optimization reducing infusion costs by 40–60%, variable copay programs for GLP-1s and specialty medications, clinical interventions, and clinical trial program access.⁵ ⁶

These aren’t competing strategies. They’re complementary layers of a complete fiduciary posture. Caribou asks: “Is your PBM doing what they said they’d do?” NIH asks: “Is the PBM model even the best structure for this claim?” Both questions must be answered.

The Litigation Environment Demands Both

Caribou’s article flags the ERISA lawsuits filed against Johnson & Johnson, Wells Fargo, and JPMorgan over health benefit mismanagement.¹ What those cases reveal is that courts don’t just want to see that you caught billing errors. They want to see that you exercised the care of a knowledgeable professional across the entire pharmacy benefit, including whether you explored alternatives to the traditional PBM markup model.
 

A plan that can show both an independent claims audit trail and evidence that it pursued the lowest net cost through multiple sourcing channels is in a fundamentally different position than one relying solely on PBM-provided reports and a broker’s annual review.

Don’t Wait for Regulation

DOL Secretary nominee Keith Sonderling has made PBM transparency a stated priority, and new regulations are in motion.⁷ But as I’ve said before: transparency tells you where the problem is. You still need solutions. The smartest plan sponsors aren’t waiting for regulators to hand them a playbook. They’re building their fiduciary record now, with partners like Caribou handling the audit and verification layer, and organizations like NIH driving the actual cost optimization.

Caribou Systems is doing important work. If you’re a self-funded plan sponsor and you can’t answer the five questions in their article, start there. Then call us to make sure the dollars flowing through that system are optimized from the ground up.

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 Caribou Systems. “You’re the Fiduciary. Can You Prove It?” MyHealthGuide, July 16, 2026.

² Caribou Systems. Company overview: audits 200 million+ pharmacy claims annually, conducts 75+ pre-implementation audits per year, and provides 100% claims re-adjudication for independent fiduciary documentation. https://www.caribousystems.com

³ Consolidated Appropriations Act of 2021, Pub. L. No. 116-260, Division BB, Title II (Transparency provisions requiring PBM disclosure of rebates, fees, and prescription drug cost reporting by group health plans).

⁴ Consolidated Appropriations Act of 2026 (Expanded audit rights and regulatory obligations for self-funded plan sponsors to act on pharmacy benefit data).

⁵ National Integrative Health. “About Us.” NIH is a managed services organization that deploys a multi-channel approach to achieve the lowest net cost on every pharmacy claim for employer health plans. https://www.nationalintegrativehealth.com/

⁶ Magellan Rx Management. “Medical Pharmacy Trend Report: Site of Care Optimization.” Shifting infusion administration from hospital outpatient departments to lower-cost settings can reduce per-administration costs by 40–60%.

⁷ Bell, Allison. “DOL Secretary Nominee Calls PBM Transparency a ‘Priority.'” BenefitsPro, July 17, 2026.