Self-Funded

Ali Panjwani, Founder and CEO of Merit Medicine, builds ML models on massive claims data to forecast and price employer healthcare risk. He explains predicting spend from simple census files. Conversation covers how better risk selection improved a carrier’s loss ratio, avoiding biased underwriting, data tokenization and privacy, and financing high-cost cell and gene therapies.

If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Each month on Last Month In Healthcare, producer Nathaniel joins me to discuss the previous month's podcasts, headlines, and listener-submitted questions.This month, we're joined by Jeff Bak from Imagine360!Together, we react to the latest headlines from March, including the new CMS rule enforcing actual dollar amounts in hospital price transparency files. We also discuss Medicare expanding coverage for GLP-1s to treat obesity, Roche's massive $65M investment in NVIDIA AI chips for drug discovery, and the Department of Labor's new PBM fee disclosure rules. Plus, we react to the shocking story of two insurance executives sentenced to 20 years for a $233 million ACA enrollment fraud scheme.Then, Jeff and I play a game of "Blind Ranking" where we have to rank the worst practices in health insurance (like PBM spread pricing, ER upcoding, and surprise balance billing) without knowing what is coming next. Finally, we answer a listener question about the viability of ICHRAs (Individual Coverage HRAs) as an alternative to brutal fully-insured renewals in 2026.Thank you to our sponsor, Walk On Clinic! Visit walkonclinic.com to learn more about their on-site health clinics.Chapters:0:00 - Intro & Live Show Announcement3:08 - CMS Enforces Dollar-Amount Price Transparency6:54 - Medicare Expands GLP-1 Coverage to Obesity12:15- Roche Buys $65M in NVIDIA AI Chips for Drug Discovery15:45 - The DOL Proposes New PBM Fee Disclosure Rules19:40 - Insurance Execs Sentenced to 20 Years for $233M ACA Fraud22:20 - Game: Blind Ranking the Worst Practices in Health Insurance30:41 - Ask Spencer: Are ICRAs a Smart Option After Huge Renewals?

Mark Galvin, serial tech entrepreneur and CEO of Talon who built shopping and repricing tools from claims and machine-readable files. He talks about obtaining statewide claims data, creating a true cash-pay shopping tool, inventing a Universally Acceptable Payment Amount for providers, and building in-app repricing plus employer shared-savings to drive consumer-driven healthcare.

Rob LaHayne, co-founder of Leap Health who shifts specialty infusion care into home and infusion centers. He breaks down how J&Q infusion codes hide massive hospital markups. They discuss taking over the supply chain, zero-margin drug pricing, using claims triggers to find high-cost patients, and big savings from moving care out of hospitals.

They unpack recent moves to curb PBM and insurer power, including an FTC settlement and a bill targeting vertical integration. They cover the FDA limiting compounded GLP-1s and debate privacy questions around ChatGPT Health. There is a playful segment comparing monthly drug costs to luxury car payments. They also discuss what headcount is needed to go fully self-funded in 2026.

Vinny Esposito, CEO of Reflect Health and former hedge fund professional, leads a TPA reinvented as a claims technology platform. He discusses building a centralized marketplace to beat point-solution fatigue. Topics include infusion drug carve-outs, dynamic deductibles and tiered networks, and a vision for frictionless, point-of-service claims paid instantly.

Norm Volsky, Managing Partner at DRI and founder of MVP Growth Partners, is a former executive recruiter turned VC investor in digital health and employer benefits. He discusses why investors are backing companies that carve high-margin services out of big insurers. Short takes cover radiology and fertility carve-outs, crowdsourced deal due diligence, at-risk pricing, and why incumbents resist lowering costs.

Pramod John, former Silicon Valley entrepreneur turned healthcare innovator focused on drug management and transparent market solutions. He exposes why current PBM economics inflate prices, explores how tiny patient cohorts drive most drug spend, and argues for data-driven, open-market transaction models and point-of-fill checks to cut waste and realign incentives.

William Steelman, a board-certified internal medicine DO and founder of a direct primary care practice, left hospital medicine after COVID-driven burnout. He explains how DPC shrinks patient panels for longer visits, restores work-life balance, and uses lifestyle and ketogenic approaches to treat metabolic and mental health. They also cover pricing transparency, employer partnerships, and using AI to cut admin time.

If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Each month on Last Month In Healthcare, producer Nathaniel joins me to discuss the previous month's podcasts, headlines, and listener-submitted questions.This month, we’re joined by John Kountz from Frost Insurance! We react to the record-breaking lobbying spend by drugmakers in 2025 and discuss the historic slump in Hospital M&A activity. We also cover the rising cost of medical real estate forcing doctors into co-working spaces, the critical decline in nursing home capacity, and the consolidation of federal lawsuits linking GLP-1s to vision loss.Plus, we play a game called "Real or Fake Medical Codes," where John and I try to guess if ICD-10 codes like "Struck by Turtle," "Sucked into a jet engine," or "Burned due to water skis on fire" are actually real. Finally, we answer a listener question about what a successful Q1 looks like for a new broker in the benefits industry.I'm also thrilled to announce that Last Month In Healthcare is now sponsored by Walk On Clinic! We are excited to partner with a team that is redefining primary care access.Chapters:0:00 - Intro0:37 - Drugmaker Lobbying Reaches Historic Highs4:30 - Hospital M&A Slump & Financial Distress7:39 - Doctors Moving to Co-Working Spaces10:05 - The Decline in Nursing Home Capacity11:57 - GLP-1 Vision Loss Lawsuits15:41 - Game: Real or Fake Medical Codes?21:41 - Ask Spencer: Successful Q1 for New Brokers