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?

"We are in a $5 trillion US healthcare consumer market with no consumer in it... I basically decided we had been surgically removed from the US healthcare system."

My guest this week is Mark Galvin, a serial entrepreneur who successfully funded his own company's healthcare by pairing a $10,000 High Deductible Health Plan with a fully funded HSA and HRA - saving his company 32% and his employees 50%. When he realized that brokers, carriers, and even the state insurance department were financially disincentivized from sharing this strategy, he decided to force transparency into the market himself.

In this episode, Mark shares the incredible story of how he secured a DVD containing 100% of New Hampshire’s post-adjudicated claims data and built the first true shopping tool for medical procedures. We discuss his meetings at the White House that helped shape the Transparency in Coverage Rule, the absurdity of $68,000 knee replacements, and his new platform that calculates a "Universally Acceptable Payment Amount" (UAPA) for every provider in the country.

If you are an employer, broker, or patient who is tired of flying blind and wants to understand how true cash prices are finally coming to healthcare, this episode is a must-listen.

Thank you to our 2026 sponsors!

ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit ParetoHealth.com/Spencer to learn more.

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

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

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

Chapters:

(00:00:00) Intro: Aligning Financial Incentives in Healthcare

(00:02:41) Mark's Background: Voice Over IP to Healthcare Tech

(00:04:47) The Early Days of Direct Primary Care (DPC)

(00:09:08) Hacking the HDHP: Saving 32% on Premiums

(00:11:28) Why Brokers & Carriers Hate Cost-Saving Strategies (The MLR Problem)

(00:18:33) Discovering the All-Payer Claims Database (APCD)

(00:21:49) The $1,600 vs. $6,800 Nuclear Stress Test

(00:26:00) Building a Commercial Solution to Fight Lobbyists

(00:29:40) The "Proficiency Score": Why Price Does Not Equal Quality

(00:31:48) Scraping EOBs to Build a National Price Database

(00:33:27) The White House Meetings & The Transparency in Coverage Rule

(00:43:03) Inventing "Transparency 2.0" and the UAPA (Cash Pay)

(00:51:13) Shared Savings Rewards: Paying Employees to Shop

(00:53:56) The Future: In-App Repricing and "Tap-to-Pay" at the Doctor

(00:57:52) Can We Shop for 70% of Healthcare?

(01:04:18) Using UAPA as a Full Network Replacement

(01:11:19) The Path to an "Amazon-Like" Healthcare Market

(01:15:19) Closing Thoughts: Why 12% of Shoppers Can Change the System

Key Links for Social:

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

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

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

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

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

"I've got a patient in Washington state. He's traveling 100 miles every other week to receive an infusion. We moved this patient into the home and saved the plan $700,000 on this one patient...on gout treatment."

Why are infusion drugs quietly destroying your health plan's budget?

This week, my guest is Rob LaHayne, Co-Founder of Leap Health. We pull back the curtain on one of the most overlooked and expensive categories in healthcare: Specialty Infusion Care. Because these drugs are administered by a medical professional, they are billed through the medical plan under "J&Q Codes" - subjecting them to massive hospital markups and "buy-and-bill" margin games.

In this episode, Rob explains how Leap Health is solving this by taking over the supply chain, procuring the drugs transparently without margin, and redirecting patients to their own homes or convenient infusion centers. We discuss how these J&Q codes are often the hidden culprit behind breached stop-loss deductibles and skyrocketing renewals, and why shifting the site of care is a win for both the employer's budget and the patient's quality of life.

If you're a benefits consultant trying to figure out why your client's medical spend is out of control, or an employer tired of paying massive hospital markups for necessary medications, you need to understand J&Q codes.

Thank you to our 2026 sponsors!

ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit ParetoHealth.com/Spencer to learn more.

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

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

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

Chapters:

(00:00:00) Intro: The Hidden Problem of J&Q Codes

(00:04:13) Rob's Background & The Genesis of Leap Health

(00:08:24) Why Hospital "Buy-and-Bill" Margins Drive Up Costs

(00:13:22) How Leap Health Provides Transparent, Zero-Margin Pricing

(00:16:31) Shifting Site of Care: The Power of Home Infusions

(00:23:44) Overcoming Headwinds: Patient Engagement & Plan Design

(00:27:01) Taking Over the Supply Chain to Bypass the "BUCA" PBMs

(00:32:51) Stop-Loss Renewals: Why Identifying J&Q Codes is Critical

(00:37:04) Saving $700,000 on a Single Gout Patient

(00:41:39) The Future: Unbundling the Health Plan & "Point Solution Fatigue"

(00:45:41) Closing Thoughts: Why Consultants Must Request J&Q Code Data

Key Links for Social:

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

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

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

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

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