Choosing employee benefits can feel overwhelming. There are more options than ever, rising costs, and constant changes to laws and regulations. The challenge for employers is not offering everything, but rather offering benefits that actually support employees as their lives change, while still making sense for the organization.

Looking at benefits through a life-stage lens can help. Instead of grouping employees by age or job title, this approach focuses on what people need at different points in their lives. It also recognizes that employees don’t move through these stages neatly—someone might be growing their career while caring for a parent or starting a family all at the same time. Benefits should be flexible enough to keep up while balancing cost, compliance, and operational impact.

Early Career and Entry Level Employees

Employees early in their careers are often enrolling in benefits for the first time while also navigating work-life balance and the challenges of a new workplace. While nearly all employers offer health coverage, many younger employees do not fully understand how to use it or what it costs them.

At this stage, affordability and simplicity matter. Employees tend to value preventive care, mental health support, and basic financial tools that help with budgeting, emergency savings, and student loan repayment. Clear education is critical, as communicating benefits is often rated poorly by employees, which directly affects utilization.

Time off also plays an important role. Flexibility to manage personal needs helps early career employees build healthy work habits and reduces the risk of burnout or early turnover in an already competitive labor market.

Employees in the Family Building and Caregiving Stage

As employees progress in their careers, many begin juggling work with caregiving responsibilities. More than one in six U.S. workers provides unpaid care to a family member, and most caregivers report difficulty balancing those responsibilities with their jobs.¹

Healthcare and leave benefits become especially important at this stage. Coverage often expands to include partners and dependents, along with increased use of maternity care, fertility services, pediatric care, and postpartum support. Leave programs are critical, and employers face the added challenge of ensuring employer-sponsored leave coordinates appropriately with federal, state, and local mandates.

Without adequate support, employees are more likely to reduce hours, postpone advancement, or leave the workforce altogether. Additional benefits such as dependent care, flexible scheduling, resource navigation, and financial planning support can help employees remain engaged and productive. Manager awareness is also key, since employees often turn to their direct manager first when life events arise.

Mid-Career Employees

Mid-career employees often hold deep institutional knowledge and occupy key leadership or technical roles. Losing them can be expensive, with turnover costs estimated at roughly one-third of an employee’s annual salary, factoring in hiring, training, and lost productivity.²

Benefits at this stage often center on balance and long-term health. Preventive care, screenings, condition management, and strong benefit navigation tools help employees manage growing responsibilities inside and outside of work. Time off remains important, whether for caregiving, family needs, or rest.

Retirement planning also becomes more significant. Access to education and financial guidance can help employees make informed decisions about both their careers and their future financial security.

Employees Entering Late Career and Retirement Planning State

As employees approach retirement, healthcare usage typically increases, and coverage becomes more important than cost alone. Strong provider networks and condition management are common priorities.

Most U.S. workers have access to employer-sponsored retirement plans, but participation often lags behind access, highlighting a need for better education and guidance.³ Financial counseling, retirement readiness programs, and phased retirement options can support smoother transitions while helping employers plan for workforce changes.

What Matters At Any Stage

Some benefits are important regardless of career stage. Flexible work arrangements, family care support, and professional development consistently rank among top workforce priorities.⁴ Technology also plays a major role: benefits that are difficult to understand or access are less likely to be used effectively.

Ongoing communication is essential. When education occurs only during open enrollment, employees are more likely to feel confused and make rushed decisions. Year-round education in multiple formats improves understanding and utilization.

Making Practical Decisions

Rising healthcare costs and benefit expenses require difficult decisions each year. While most employers view health benefits as a top priority, offering too many options can overwhelm employees and increase costs without improving outcomes.

A life-stage approach helps employers focus on what delivers the most value, regardless of where employees are in their careers. Investing in preventive care, wellness programs, financial education, comprehensive leave offerings, and clear communication can reduce long-term costs and turnover. At the same time, staying compliant remains essential as leave laws and healthcare requirements continue to change.

A benefits strategy built around real-life needs, not just demographics, is more sustainable and more impactful for both employees and employers.

¹Caregiver Statistics: Work and Caregiving, Family Caregiver Alliance, https://www.caregiver.org/resource/caregiver-statistics-work-and-caregiving/
²Average Turnover Rate by Industry (2026 Update), Corporate Navigators,  https://www.corporatenavigators.com/articles/recruiting-trends/average-turnover-rate-by-industry-in-2024/
³Worker Participation in Employer-Sponsored Pensions, https://www.congress.gov/crs-product/R43439
⁴30+ Employee Benefits Statistics in the U.S. (2024/2025), https://high5test.com/employee-benefits-statistics/

To attract and retain top talent, employers continue to invest heavily in comprehensive employee benefits programs. While offering a wide range of health and well-being options is well-intentioned, an unintended consequence often emerges: choice overload. Employees may appreciate having options, but without the time, expertise, or clarity to evaluate them, navigating benefits can quickly become overwhelming.

This is where care steerage and smart navigation come into play. Together, these strategies are designed to simplify healthcare decision-making, improve the benefits experience, and help employees access high-quality, cost-effective care with greater confidence.

What Is Care Steerage?

Care steerage is a benefit design strategy that guides employees toward higher-quality, more cost-effective providers and care settings based on objective measures, such as quality outcomes, cost efficiency, and an individual’s specific healthcare needs.

Rather than leaving employees to navigate complex provider networks on their own, steerage uses data and structured pathways to support better decisions. At a high level, steerage typically falls into two categories.

Active Steerage

Active steerage involves real-time, personalized support. Employees may interact with nurse navigators, care concierges, or trained benefits coordinators who engage employees by phone, chat, or online portals. These experts help identify appropriate providers based on medical history, new diagnoses, upcoming procedures, and geographic preferences.

Passive Steerage

Passive steerage empowers employees with self-service tools, including online provider directories, mobile apps with cost and quality transparency, and provider and facility comparison tools. By making pricing and quality data more visible, employees are better equipped to make informed choices independently.

Why Steerage Matters

The primary goal of care steerage and smart navigation is to encourage quality-based and cost-conscious healthcare decisions that improve outcomes while reducing unnecessary spending. Many benefit plans reinforce these choices through design features such as tiered provider networks that highlight high-value options, lower copays or out-of-pocket costs for preferred providers, and incentives for using primary care or outpatient settings rather than higher-cost inpatient care.

For employees, this often translates into lower costs, better care experiences, and greater confidence in using their benefits.

Common Features of Smart Navigation Programs

Smart navigation complements care steerage by leveraging technology, often enhanced by AI, to make benefits easier to understand and use. Common design elements include:

1. Personalized communications that deliver targeted guidance based on life events, care needs, or upcoming decisions.
2. Digital decision-support tools, such as mobile apps and online platforms with cost calculators and provider comparison features tailored to individual and family needs.
3. Value-based plan integration, where navigation tools are embedded within Tier 1 or value-based networks that reward employees for choosing high-quality, cost-effective care.

Benefits for Employees and Employers

When smart navigation and care steerage work in tandem, they deliver meaningful benefits for both employees and employers. For employees, these programs help reduce search fatigue and the frustration that often comes with trying to find the right healthcare resources. With access to expert guidance through personal concierge services and decision-support tools, employees are better equipped to make informed healthcare decisions and identify lower-cost providers that still deliver high-quality care.

For employers, this approach can drive stronger returns on investment, help control unnecessary and wasteful claims spending, improve overall benefits engagement, and positively impact employee recruitment and retention, ultimately contributing to a healthier and more satisfied workforce.

Sources:
– Wellness360 Blog, Benefits Navigation: Simplifying Healthcare with Technology, September 2025
– 10 Best Benefits Navigation Platforms for 2026, Recruiters Lineup, October 2025
– Best Employee Benefits Navigation Companies, CBINSIGHTS

What is Nurse Navigation?

A nurse navigator is a registered nurse who guides patients through the often complex healthcare system, coordinating care and serving as an advocate. Navigating healthcare independently can be overwhelming, time-consuming, and costly, particularly for employees managing chronic conditions, complex treatments, or new diagnoses.

Nurse navigation provides personalized, end-to-end support—from diagnosis and treatment planning to recovery—by unifying benefit utilization, provider coordination, and cost-efficient clinical care. This approach ensures employees receive the right care, at the right time, at the right place, while reducing confusion and delays.

Employer adoption is growing rapidly. Currently, 37% of self-insured employers implement a healthcare navigation solution, helping employees access the most appropriate care and resources. ¹

The Role of a Nurse Navigator

Nurse navigators offer a variety of services tailored to patient needs:

Education

• Helps employees understand diagnoses, treatment options, and benefits, bridging gaps in healthcare literacy.

Fast-Tracked Care

• Streamlines the care process by handling prior authorizations, scheduling appointments, coordinating labs and tests, and ensuring all prerequisites are met for timely care.

Advocacy

• Acts as the employee’s primary point of contact and advocate, providing guidance and support throughout the care journey.

Care Logistics

• Assists with travel arrangements (car services, hotels, flights), financial or insurance issues, and access to other support resources.

Emotional Support

• Provides empathy and guidance, offering a trusted relationship for patients and their families to navigate fears, questions, and concerns.

Why Nurse Navigation Matters

Healthcare is increasingly complex, and employees often face multiple challenges when trying to access care. Navigating between multiple providers, understanding specialty networks, and deciphering benefit structures can be confusing and time-consuming. Rising deductibles and out-of-pocket costs add financial stress, while care gaps, particularly for chronic or high-acuity conditions, can lead to delays, complications, and unnecessary expenses.

Nurse navigation addresses these challenges by providing personalized, proactive support throughout the healthcare journey. By coordinating care, assisting with benefit utilization, and guiding employees through complex treatment plans, nurse navigators reduce barriers and ensure employees receive the right care at the right time. Clinical evidence demonstrates the effectiveness of this approach. For example, patients with advanced pancreatic cancer who had access to a nurse navigator had a 104% higher probability of survival after one year compared to those without navigation support. ² Similarly, oncology patients using nurse navigation services reported an increase in satisfaction from 66.5% to 87.4% and a drop in no-show rates from 3.8% to 0.4%. ³

Beyond clinical outcomes, nurse navigation also improves employee engagement and benefits utilization. Employees are more likely to understand their coverage, attend necessary appointments, and make informed care decisions when they have a dedicated resource guiding them. This support not only improves health outcomes but also generates measurable value for employers through reduced unnecessary spending and higher ROI on benefits programs.

Different Models of Nurse Navigation

Employers have several options when implementing nurse navigation:

1. Standalone point solution vendors – specialized navigation services that can be added to existing benefits.
2. TPA-integrated navigation – larger third-party administrators offer nurse navigation as part of their platform, creating seamless integration with claims, wellness, and leave management.
3. Hybrid approaches – combining internal case management with external navigation support to meet the needs of specific employee populations.

Choosing the right model depends on the population served, plan structure, and organizational goals.

How Nurse Navigation Supports Employers

Nurse navigation is more than a benefit perk; it is a strategic tool for addressing key employer challenges. By proactively coordinating care, nurse navigators help manage rising medical costs, increase engagement, and reduce fragmentation in the healthcare system. Employees experience better outcomes and higher satisfaction, while employers benefit from reduced unnecessary spending and improved ROI.

Employers considering nurse navigation should assess their current plan offerings, population needs, and integration options to ensure the solution complements their existing benefits ecosystem without disruption.

As the healthcare landscape becomes more complex, nurse navigation has emerged as an essential solution for modern employers. Providing employees with expert guidance, care coordination, and emotional support reduces barriers to care, improves outcomes, and increases engagement. Whether implemented as a standalone solution or integrated into existing plans, nurse navigation delivers measurable value for both employees and employers.

¹State of Healthcare 2024, Employee Benefit News (EBN) National Employer Study, sponsored by Quantum Health, which found 37% of employers are offering healthcare navigation services to support employee access to care. https://www.businesswire.com/news/home/20240410953008
²Cruz, Z. (2025, September 15). Impact of nurse navigation on overall survival and timeliness to care in patients with pancreatic cancer in advanced stages. Journal of Oncology Navigation & Survivorship. https://www.jons-online.com/issues/2025/september-2025-vol-16-no-9/impact-of-nurse-navigation-on-overall-survival-and-timeliness-to-care-in-patients-with-pancreatic-cancer-in-advanced-stages
³Strengthening oncology patient navigation enhances outcomes and access to care. Oncology Nurse Advisor. (2025, May 13). https://www.oncologynurseadvisor.com/reports/strengthening-oncology-patient-navigation-enhances-outcomes-treatment/

When we think of travel, many of us envision picturesque beaches, historical sites, or national parks. For others, travel is driven by healthcare needs, often combining treatment with tourism activities or recovery time. This practice is commonly referred to as medical tourism.

The prevalence of medical tourism is difficult to quantify, but the American Association for Physician Leadership (AAPL) estimates that approximately 1.4 million Americans travel abroad each year for medical care. ¹ For employers, this does not indicate that their health plans are misaligned with benchmarks, nor is it something to control. However, it is a growing reality that benefits from education and proactive navigation. The opportunity is to frame your approach not as cost-cutting, but as an access and risk management consideration. Without thoughtful planning, organizations may face hidden costs, care gaps, and employee dissatisfaction, particularly when complications arise after an employee returns home and seeks care under an employer-sponsored plan.

Why Employees Seek Care Abroad

Risks for Employer-Sponsored Plans

Because most medical tourism occurs outside of employer-sponsored benefit plans, it typically involves no preauthorization, limited quality vetting, less structured follow-up care, and reduced cost predictability for unplanned complications. While participants generally assume these risks while abroad, employers often absorb downstream impacts once employees return home. These may include postoperative complications such as infections, additional surgeries, extended recovery periods, and related leaves of absence.

One of the most significant challenges is the lack of coordination with domestic providers, including limited sharing of medical records before and after procedures performed abroad. As Renée-Marie Stephano, JD, Chief Executive Officer of Global Healthcare Accreditation, explains,

“When patients arrange medical travel independently, without involving their primary care provider, physicians may be left out of the loop. That makes it difficult to review the treatment plan, ensure it aligns with the patient’s medical history, and properly manage follow-up care once the patient returns home.” ²

Establishing a Philosophy Around Medical Tourism

Rather than implementing rigid policies that aim to discourage or restrict international care, employers may benefit from establishing a philosophy, not a policy, regarding medical tourism. This approach focuses on governance, education, and equity rather than enforcement. Many organizations currently take a passive approach, addressing complications only after employees return home. While this requires minimal oversight, it can result in unintended inequities and inconsistent employee experiences.

In developing a philosophy, employers may consider factors such as equity and access, employee experience, cost transparency, and organizational risk tolerance. Often, the most effective approach involves modeling scenarios across health plans, disability programs, and time-off policies for employees seeking care domestically and internationally. Practical steps may include adding educational resources about risks, clarifying coverage expectations, planning for post-travel care coordination, and aligning leave and disability benefits with health benefits.

Looking Ahead

Medical tourism is expected to continue growing in the coming years. According to Forbes, the global medical tourism market is projected to grow at a compound annual growth rate of about 25.2% through 2030, reflecting rising demand as more individuals combine travel with healthcare services. ³ While medical tourism may not present immediate challenges today, establishing a clear foundation and philosophy now can help employers better manage risk as participation increases.

As with other benefits decisions, employers should apply the same attraction and retention principles when considering medical tourism. Rather than viewing it as a perk to promote, it should be treated as a plan governance consideration. While employers cannot prevent medical tourism, thoughtful planning can help reduce risk, manage complications, and support better outcomes for employees, dependents, and employer-sponsored plans.

¹American Association for Physician Leadership (AAPL), medical tourism estimates
²Physician Leadership Journal, “Medical Tourism — Who, What, and Where,” Renée-Marie Stephano, JD
³Forbes, 5 Tips Business Leaders Can Learn From The Rise In Medical Tourism, noting that the global medical tourism market is expected to grow at a CAGR of 25.2% through 2030.

We are proud to announce Spring and our consultants have been recognized for multiple awards from Captive Review’s Cayman Awards 2025. We look forward to continuing to do excellent captive work in all domiciles, including but not limited to the Cayman Islands.

Spring has been awarded for:

Obesity is not a choice or a moral failing. It is a chronic, multifactorial disease with metabolic, behavioral, psychological, and environmental underpinnings. As employers, benefits managers, and health plan stewards, you must ask: Do you have all the pieces you need to manage obesity effectively? Offering a single tool will rarely suffice.

What Is a Weight Management & Metabolic Health Program?

A weight management and metabolic health program is a coordinated intervention set designed to address obesity and its underlying metabolic irregularities over time. These programs typically combine:

• Clinical evaluation of metabolic markers (for example, insulin resistance, lipid profiles, inflammation) ¹
• Nutritional counseling customized to metabolic needs
• Frequent and ongoing monitoring, follow-up, and adjustment
• Behavior change support, including coaching and psychological or mental health resources
• Physical activity and exercise guidance to preserve muscle and improve metabolism
• Medication support when clinically appropriate (including GLP-1 or including obesity GLP-1 agonists and other weight loss agents) ³

A high-performing program does not treat obesity simply as excess weight. Instead, it views obesity as a chronic disease that requires continuous management and adaptation.

Direct Primary Care

Obesity affects more than 40 percent of U.S. adults and is a major contributor to type 2 diabetes, cardiovascular disease, nonalcoholic fatty liver disease, certain cancers, osteoarthritis, and sleep apnea¹. Recognizing obesity as a disease rather than a behavioral failure shifts the paradigm. It demands a coordinated multi-pronged strategy, not a simplistic “eat less, move more” approach.

The causes of obesity are complex. Genetic predisposition, hormonal dysregulation, gut microbiota, psychosocial stressors, sleep disruption, food environment, and socioeconomic factors all play roles². Because of this complexity, no single solution such as a pill or injection can resolve the disease in isolation.

GLP-1 medications such as semaglutide and tirzepatide have demonstrated promising results in clinical trials for weight loss and improvements in metabolic health markers³. However, real-world adoption, drug discontinuation, and weight regain remain significant challenges. One analysis found that more than 50 percent of patients using GLP-1s for weight management stopped treatment within 12 months³. After discontinuation, biological adaptations lead many to regain much of the lost weight within a year. These patterns underscore that GLP-1s are powerful but only one piece of a broader strategy.

The Cost and Employer Dilemma

Employers contemplating coverage for GLP-1s face a difficult tradeoff. On one hand, these medications are expensive and can significantly increase pharmacy spending. A recent survey indicated employers are rethinking their strategy and many employers covering these medications today are considering a change. High discontinuation rates and uncertain long-term value make ROI calculations complex.

On the other hand, effective obesity management and improved metabolic health can reduce downstream costs associated with diabetes, cardiovascular disease, joint issues, and productivity loss⁴. Employers must decide whether to cover GLP-1s, and if they do not, how else to invest in comprehensive wellness and chronic condition management programs.

Benefits to Patients and Providers

For Patients

• Improved metabolic outcomes, including better insulin sensitivity and blood pressure
• Sustainable weight loss when combined with behavioral interventions
• Reduced risk of obesity-related comorbidities
• Enhanced quality of life, mobility, and mental well-being
• Lower likelihood of requiring invasive procedures such as bariatric surgery

Programs that integrate behavioral and psychological support help patients address emotional eating, stress, and motivation, which are often critical to long-term success.

For Providers

• Structured care pathways for chronic obesity management
• Data and feedback loops that allow for continuous monitoring and early intervention
• Clearer alignment with evidence-based best practices
• More efficient coordination between primary care, nutritionists, and behavioral specialists

Providers participating in holistic programs are better positioned to support patients in achieving sustainable outcomes rather than focusing solely on short-term weight loss².

Key Questions for Your Point Solution

When evaluating or designing a weight management and metabolic health program, consider the following questions:

1. Does the program address underlying metabolic dysfunction rather than just weight loss?
2. Are healthy behaviors supported over time, not only during initial engagement?
3. Is psychological or behavioral support part of the design?
4. If medications such as GLP-1s are offered, are they integrated within a structured clinical framework?
5. Does the program emphasize preservation of lean muscle mass through physical activity and nutrition?
6. Is there flexibility to adapt the program as patient needs and results evolve?
7. Do providers have sufficient training and resources to sustain engagement?
8. Is there a clear cost-benefit analysis and a defined measurement strategy for ROI?

Takeaways & Recommendations

Effectively addressing obesity requires viewing it through the same lens as other chronic diseases, with a long-term management strategy rather than a quick fix. Employers, providers, and health plan leaders must recognize that no single intervention can succeed in isolation. A comprehensive weight management and metabolic health approach combines medical treatment, behavioral support, nutrition, and ongoing engagement. While GLP-1 therapies have shown promise, they are only one component of a multifaceted solution. Without lifestyle changes and behavioral health integration, the long-term success of these medications is limited. Employers evaluating whether to cover GLP-1s should consider both the financial implications and the broader care framework necessary for success. Those that do offer coverage can maximize outcomes by ensuring these medications are paired with coaching, nutritional counseling, and continued follow-up. For those unable to include them, investing in alternative wellness initiatives and chronic condition management programs can still demonstrate support for employee health. Ultimately, effective obesity management depends on aligning all available tools (clinical, behavioral, educational, and organizational) to create a system that promotes sustainable metabolic health over time⁵.

¹FAIR Health. (2024). Obesity and GLP-1 Drugs: A FAIR Health White Paper. Retrieved from https://s3.amazonaws.com/media2.fairhealth.org/whitepaper/asset/Obesity%20and%20GLP-1%20Drugs%20-%20A%20FAIR%20Health%20White%20Paper.pdf
²McKinsey Health Institute. (2025). The Path Toward a Metabolic Health Revolution. Retrieved from https://www.mckinsey.com/mhi/our-insights/the-path-toward-a-metabolic-health-revolution
³American Journal of Clinical Nutrition. (2025). GLP-1 Clinical Trial Findings. Retrieved from https://ajcn.nutrition.org/article/S0002-9165%2825%2900240-0/fulltext
⁴Cigna/Evernorth. (2024). Employer Strategies for Sustainable GLP-1 Coverage. Retrieved from https://newsroom.cigna.com/employer-strategies-for-sustainable-glp1-coverage
⁵Luminare Health. (2025). GLP-1s and the Cost of Obesity. Retrieved from https://www.luminarehealth.com/site/media/Files/LH-3270-White-Paper_GLP-1s.pdf

High-cost claims, and the claimants incurring those expenses, are arguably the biggest cost pressure self-insured employers face within the healthcare ecosystem. Solutions are complicated, multi-faceted, and ideally implemented before a claim occurs. Although these solutions only impact a small percentage of the population, their overall effect is significant, and once established, the savings compound.

Employers should begin by defining high-cost claims for their organization and verifying the clinical drivers. From there, solutions can be considered that will directly impact current claims and future cost mitigation.

Defining High-Cost Claimants

The definition of high-cost claims is not uniform. Many employers use a targeted dollar threshold (for example, $100,000) to pinpoint high-cost claims, which are embedded in the insurance model through stop-loss contracts. While that benchmark makes reporting consistent, it is often more practical to consider plan size and risk tolerance when defining high-cost claims.

The National Alliance of Healthcare Purchaser Coalitions (2024), of which our client edHEALTH is a member, estimated that 1.2% of health plan members are high-cost claimants, making up approximately 33% of total healthcare spend. These individuals absorb 29 times the average member cost, with an average of $122,382 per claimant. By stratifying data, employers can start to pinpoint which individuals are high-cost claimants now, and who may become one in the future, and implement solutions to mitigate spend.

Clinical Drivers

When examining data across our book of business at Alera Group, oncology and specialty pharmacy conditions, such as rare diseases, are the top diagnoses associated with high-cost claims. Other common drivers are cardiovascular disease, newborn and infant care, and musculoskeletal disorders.

According to Sun Life’s 13th Annual High-Cost Claims and Injectable Drugs Trend Analysis (2024), cancer again tops the list as the most frequent and costly condition, nearly three times the cost of the second-leading condition, cardiovascular disease.

Employers should start by analyzing their own data and focusing on where they can make the most impact. Industry data, assuming the sample is broad, can serve as a helpful benchmark when developing a strategy, but understanding internal data is critical to success. In nearly all cases, specialty care is where savings will be found, and following the path of comorbidities often leads to the best outcomes. In addition, employers should implement broad market shifts and tactical actions that work together to address current costs and reshape future spending.

Cost Saving Through Broad Market Shifts

Self-insured employers seeking opportunities for savings related to high-cost conditions, claims, and claimants should consider the following broad shifts in thinking:

• Ownership of Plan Governance:
  Self-insured employers govern their plans but often do not build an internal structure, instead relying on vendor partners. Employers looking to target innovative solutions should maintain ownership of plan rules and understand the flexibility of their partners.
• Oversight of Steerage and Utilization Management:
  Plan management is complex, and vendor partners frequently revise rules related to steerage, utilization review, and care management. Understanding where flexibility exists allows employers to manage emerging therapies and carve-outs in the best interest of the plan.
• Value-Based Specialty Arrangements:
  Value-based arrangements create aligned goals and greater transparency, though they are less common in specialty care. Contract language should be carefully reviewed.
• Specialty Medication Solutions:
  Employers and their vendor partners must begin having detailed conversations about specialty medications, especially as the pipeline for these treatments expands beyond rare diseases.
• Partnering with Aligned Vendors:
  Some vendor partners may not have goals that align with employers. Those serious about managing high-cost claims should find partners willing to focus on value-based care, centers of excellence, and network management.
• Data and Analytics:
  Understanding plan data is a fundamental requirement for managing high-cost claims. It starts with utilization and baseline information but must extend to member-level analysis and predictive reviews that consider demographics and comorbidities. The goal is to establish protocols before claims are incurred so they can be proactively managed.

Tactical Actions Targeting High-Cost Claimants

At a tactical level, employers must be focused on opportunities that deliver savings at the condition level and continuously monitor results. This can be done with a partner, but if incentives are not aligned, methodology and key performance indicators should be established in advance.

Key first steps often include:

• Stop-loss design
• Prior authorization for top cost drivers
• Vendor contracting
• Centers of excellence
• Disease-state initiatives focused on prevention, care navigation, and overall management (for example, oncology, infusion site of care, cardiology, prenatal/neonatal, behavioral health, musculoskeletal, and others)

High-cost claims will continue to be a defining challenge for self-insured employers in higher education and beyond. Addressing them effectively requires a balanced approach that combines strong governance, meaningful data analysis, and proactive partnership with vendors and providers. Employers who invest the time to understand their data and align their strategies accordingly are best positioned to control costs while improving outcomes for their members. The goal is not only to manage high-cost claims when they arise but to build a framework that anticipates and prevents them wherever possible.

Sources:
National Alliance of Healthcare Purchaser Coalitions. High-Cost Claims Report, 2024.
Sun Life. 13th Annual High-Cost Claims and Injectable Drugs Trend Analysis, 2024.
Kaiser Family Foundation. Employer Health Benefits Survey, 2024.

Primary care providers—originally general practitioners who would later specialize into modern internal and family medicine physicians—served as lone practitioners for much of the 20th century, playing a central role in both the healthcare system and their local communities.¹ After World War II, the prominence of PCPs declined as specialty care expanded, influenced by changes in medical education, reimbursement models, technology, and public demand². Today, rising healthcare costs, workforce shortages, and systemic pressures have highlighted underinvestment in primary care. The market is seeking solutions that remove barriers, enhance education, and support population health management³.

Shifts in Primary Care

Primary care remains a core component of all health plans, but fee structures and market pressures have changed the patient–provider relationship. Patients often face rushed appointments, long wait times, low reimbursement rates, and high administrative burdens. These factors contribute to burnout among PCPs and have led the Association of American Medical Colleges (AAMC) to project a shortage of 17,800 to 48,000 primary care physicians by 2034⁴. Insurance requirements, market consolidation, and operational pressures limit PCPs’ ability to deliver optimal care. Patients are also demanding broader access, digital solutions, self-service options, and hybrid care models. In response to these growing challenges, Spring Consulting Group’s client edHEALTH, a captive health coalition serving educational institutions, is proactively pursuing primary care solutions to meet the evolving needs of its member schools. Direct primary care (DPC) has emerged as a strategic tool for employers seeking to improve access, enhance preventive care, reduce avoidable acute care utilization, and generate a return on investment⁵.

Direct Primary Care

At the core, direct primary care provides patients with unlimited access to a primary care team for a flat monthly fee, typically outside of traditional health plan coverage. Most DPC solutions guarantee same-day or next-day appointments, longer visit times, higher patient satisfaction, and bundled care for preventive, chronic, and acute conditions⁶.

DPC models vary depending on vendor capabilities and employer priorities. Options include onsite or near-site clinics, virtual-first networks, retail clinics, preferred-access arrangements, navigation and concierge support, digital tools such as AI and wearables, incentives for engagement, and plan design levers to drive utilization. Providers include retail brands, technology-driven platforms, and employer-focused businesses leveraging onsite, near-site, and virtual-first care models.

DPC emphasizes relationship development and improved access rather than gatekeeping. It positions primary care as a strategic entry point, controlling downstream utilization, referrals, and chronic disease management. Separating primary care from traditional insurance networks may allow patients to access the best available care, facilities, and providers. DPC models can also incorporate risk-based approaches, including capitation or partial-risk arrangements.

Patients increasingly expect convenience, engagement, and integrated behavioral health. DPC partners are responding with retail-style access, care navigation, and satisfaction-focused services. Employers can align DPC partnerships with broader human resources initiatives, such as curated networks, direct contracting, and programs addressing social determinants of health.

Virtual-First Primary Care

In addition to DPC, other access models such as virtual-first primary care and urgent care clinics are shaping the future of healthcare delivery. Virtual-first primary care models are increasingly being adopted as a complementary approach to in-person care. These models prioritize digital access by encouraging patients to connect with their care team through telehealth visits, chat, or app-based platforms before turning to in-person appointments. Virtual-first care can improve access, reduce wait times, and support patient engagement, particularly for populations who may struggle with transportation or scheduling barriers.

When integrated effectively, virtual-first models can serve as a gateway to coordinated care by addressing routine concerns, managing chronic conditions, and promoting preventive health measures. However, challenges such as continuity of care, patient trust, and integration with existing electronic health records must be carefully managed to ensure quality outcomes. For employers, virtual-first networks can complement direct primary care by expanding access and helping to balance costs without sacrificing patient experience.

Market Shifts and Employer Considerations

Employers, particularly self-funded ones, must increasingly shape their healthcare strategy to maximize value. Primary care represents a relatively small portion of overall healthcare spend, and immediate savings may be limited. However, long-term investment in DPC can yield measurable benefits over three to five years. Successful DPC implementation requires attention to challenges such as geographic coverage gaps, referral coordination limitations, regulatory uncertainty, and member education. Employers should prioritize integration with existing health plan solutions, coordinate utilization and data tracking to ensure savings are captured accurately and deploy clear communication and engagement strategies.

When implemented effectively, DPC models shift the healthcare narrative toward value-based care, improve access, strengthen care coordination, and enhance patient satisfaction, ultimately supporting both employee health and organizational objectives.

¹Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. The Milbank Quarterly, 83(3), 457–502.
²Bodenheimer, T., & Pham, H. H. (2010). Primary care: Current problems and proposed solutions. Health Affairs, 29(5), 799–805.
³Petterson, S., Liaw, W. R., Tran, C., & Bazemore, A. W. (2015). Estimating the residency expansion required to avoid projected primary care physician shortages. Annals of Family Medicine, 13(2), 107–114.
⁴Association of American Medical Colleges. (2023). The complexities of physician supply and demand: Projections from 2023 to 2034.
⁵Rosenthal, T. C. (2012). The medical home: Growing evidence to support a new approach to primary care. JAMA, 308(21), 2335–2336.
⁶Direct Primary Care Coalition. (2022). What is direct primary care? Retrieved from https://www.dpcare.org/

The political landscape has seen significant developments in healthcare reform, notably with the enactment of the One Big Beautiful Bill Act (OBBBA) on July 4, 2025¹. This legislation introduces changes that may reshape healthcare policies, employee benefits, and overall benefits packages. Understanding these changes is crucial for employers to navigate the evolving landscape effectively¹,².

What Is the “Big Beautiful Bill”?

The “Big Beautiful Bill,” officially known as the One Big Beautiful Bill Act, is a substantial piece of legislation encompassing tax, spending, and healthcare provisions¹,³. The law focuses on deregulation of healthcare, expansion of private insurance options, tax incentives for both employers and employees, and modifications to certain provisions of the Affordable Care Act (ACA)¹,⁴. At its core, the law aims to increase competition and choice in healthcare, with the objective of reducing premiums and expanding access³.

How Will the Bill Impact Employee Benefits?

Changes to ACA Compliance

The OBBBA includes provisions that modify certain aspects of the ACA²,³. While the law does not eliminate the ACA, it introduces changes, such as new reporting requirements for certain Medicaid enrollees and restrictions on federal financial assistance for those enrolled in the ACA Marketplace². Employers offering health insurance may encounter fewer regulatory requirements around employee health plans but could face challenges if employees opt out of company-sponsored coverage due to more affordable individual insurance options or if employees lose government-sponsored coverage³.

Expansion of Health Savings Accounts (HSAs)

The law expands Health Savings Accounts (HSAs) by broadening the definition of a high-deductible health plan (HDHP) to include bronze and catastrophic plans²,³. This allows taxpayers to save and invest more money tax-free for healthcare expenses². For employers, these expanded accounts present an opportunity to provide more customizable healthcare benefits, potentially reducing administrative costs while empowering employees to manage healthcare expenses more effectively³. The OBBBA also designates Direct Primary Care arrangements as qualified medical expenses eligible for HSA coverage within limits².

Shift Toward Private Insurance

The legislation includes adjustments to Medicaid and changes to the ACA marketplace, which may result in fewer individuals relying on government-run plans²,³. This shift encourages employers to refine benefit packages to provide more personalized private insurance options that better align with employee needs³. Increased competition among private insurers may also influence employer-sponsored insurance premiums².

Tax Incentives for Employers

The OBBBA introduces new tax provisions, including a permanent increase to the standard deduction¹,². While healthcare-specific tax incentives for employers are not as clearly detailed as individual tax changes, the general focus on tax relief and cost reduction is intended to encourage companies to reassess benefit offerings and consider new ways to support employee health and well-being².

Potential Impact on Wellness Programs

The law’s emphasis on individual choice and competition may encourage employers to invest more in wellness programs²,³. Health and wellness incentives, such as gym memberships, mental health services, and preventative care, could become more prevalent as employers aim to improve employee health outcomes and reduce long-term healthcare costs³. These programs can also enhance employee engagement and satisfaction².

What Can Employers Do to Prepare?

Given the significant changes brought by the OBBBA, employers should remain informed and proactive. Key strategies include:

1. Stay Updated on Legislation:
   Employers should regularly monitor updates on the law, particularly regarding ACA regulations, HSA contributions, and tax incentives²,³. Joining professional organizations or subscribing to policy newsletters can help employers stay current.
2. Review Employee Benefits Packages:
   Employers should evaluate current healthcare offerings and consider adjustments to remain competitive and cost-effective, particularly with expanded HSAs and private insurance options²,³. Supplemental private plans or partnerships with brokers may help diversify options for employees².
3. Communicate with Employees:
   Transparent communication is essential. Employers should educate employees on changes to benefits, HSAs, and wellness programs, and explain potential impacts on premiums or out-of-pocket costs²,³.
4. Consult with Benefits Advisors and Legal Counsel:
   Navigating healthcare reform is complex. Consulting advisors and legal counsel ensures compliance and appropriate plan design under the new law²,³.
5. Prepare for Tax Adjustments:
   Employers should reassess benefits strategies to maximize available tax incentives, adjust structures as necessary, and ensure overall compensation remains competitive¹,².

The Road Ahead for Employers

The One Big Beautiful Bill Act has introduced substantial transformations to the healthcare landscape¹,². Its impact on employee benefits is becoming clearer as provisions are implemented. Healthcare is likely to become more individualized, with greater responsibility falling on employers to navigate benefits packages effectively²,³. By staying informed, reassessing offerings, and planning proactively, employers can adapt to the evolving regulatory environment while continuing to support employee health and well-being²,³.

¹Congress.gov. (2025). H.R.1 – One Big Beautiful Bill Act 119th Congress (2025-2026). https://www.congress.gov/bill/119th-congress/house-bill/1
²Ballard Spahr. (2025, July 14). The OBBBA’s impact on employee benefits and executive compensation. https://www.ballardspahr.com/insights/alerts-and-articles/2025/07/the-obbbas-impact-on-employee-benefits-and-executive-compensation
³McDermott Will & Emery. (2025, July 7). Employee benefits provisions of the One Big Beautiful Bill Act. https://vitacompanies.com/blog/employee-benefits-provisions-of-the-one-big-beautiful-bill-act
⁴Johns Hopkins Bloomberg School of Public Health. (2025, July 30). The changes coming to the ACA, Medicaid, and Medicare. https://publichealth.jhu.edu/2025/the-changes-coming-to-the-aca-medicaid-and-medicare