Healthcare does not work that way. They do.

This is the last piece of the renewal story, and it is the one that is actually personal. Everything in these letters, the increases you cannot explain, the vendor pay you have never seen, the “you’re too small,” the pharmacy games, the duty you did not know you carried, all of it comes down to one thing. Someone convinced you this cost center was different. That your leverage stopped at the door. That you should hand over a fortune every year and accept whatever comes back.

You built something worth protecting. Every dollar a misaligned vendor pulls out of your plan is a dollar off what you created, for your employees, your successors, the culture you spent years building. This is not an HR conversation. It is a stewardship conversation. The plan is part of the legacy, whether anyone framed it that way for you or not.

Here is the good news the whole season points to. The employers who take this room back are not doing anything heroic. They ask for the math. They ask what their advisor gets paid. They control the pieces they were told they could not touch. They run the plan like they run everything else. The same instincts that built the company, finally pointed at the one cost center that dodged them.

What to do this fall: walk into the renewal like it is any other negotiation, because it is. Bring the same expectations you bring to every vendor. Refuse the shrug. You have earned the right to run this, and you have always had the leverage. Someone just told you that you did not.

You built this business. You should run this plan.

Ready to take that room back? Let’s talk.

Once in the premium. Again in the productivity you lose while people stress about it and still choose wrong.

Here is the connection owners miss. Benefits are not just a cost line, they are how your people reach care, or fail to. A confusing plan with bad access means employees delay care, guess at coverage, land in the wrong setting, and carry the worry into work. That shows up as your claims next year and as output this year. Healthcare access, or the lack of it, walks into your building every morning whether it shows up on a report or not.

Now the renewal tie-in. A plan you cannot explain to yourself is a plan your HR team cannot explain to 300 people. Or 50. The same opacity that hides your costs guarantees a miserable enrollment. Fix one and you fix the other, because a plan built in daylight is a plan people can understand.

I have watched this pay off in hard numbers. One employer recovered $267,000 in lost productivity by making care easy to reach through an onsite clinic. Not a wellness poster. Real access, and it showed up on the P&L. Their health plan is running at 82% of budget for the second year in a row. An onsite clinic is not the answer for every employer, some are too small or too spread out for it. The principle holds everywhere though: make care easy to reach and the productivity comes back.

What to do this fall: sit through your own open enrollment as if you were a confused employee. Can you understand it? Can your people reach care without a treasure hunt? A no there is not an HR failing. It is a design you can change.

Your people carry your business. What they carry to the doctor, or cannot, comes back to you either way.

Want an enrollment that does not make everyone sick? Let’s talk.

Renewal season is when that blind spot sends you a bill.

Run the math the way you run everything else. Industry forecasts put 2027 health costs up around 9 to 10% (Aon says 9.5%). At $15,000 or more per employee, all in, that is real money on your second largest expense. Compound a double-digit increase for three or four years and it does serious damage to EBITDA. You would never let another major cost grow like that unmanaged. This one you were told to accept.

Now run it the other way. A $100,000 cut in your health spend, at a 10% margin, is worth the same as a million dollars in new revenue. You would chase that million. You would build a sales plan around it, hire for it, lose sleep over it. This one you can capture by reading a contract.

And the market number is only the average. The midsize employers I see without leverage land higher, some well past 20% in a single year. A cost line moving 20% with no model behind it is not a benefits issue. It is a capital allocation problem wearing an HR costume.

Here is what changes when you treat it like capital. In the plans where we control the pieces and see the claims, the number is not just lower, it is knowable. I can show a CFO what drove it and what next year likely looks like. That is what a finance leader actually wants. Not a smaller surprise. A smaller surprise you can forecast. Predictability is worth as much as the savings.

What to do this fall: put your health plan in the model. Ask for a real projection, claim drivers and trend, the way you would demand from any other line this size. A plan nobody can forecast is a plan nobody is managing.

You optimize every dollar of capital in this business. This is $15,000 and up per employee, every year, running on autopilot. Take the wheel.

Want your benefits spend modeled like the capital line it is? Let’s talk.

Most owners have no idea. Renewal season is a good time to fix that, because this is the cost center now drawing the lawsuits.

Here is what fiduciary means in plain English. You have a legal duty to run the plan in your employees’ best interest and to make sure what it pays is reasonable. Not the carrier’s duty. Not the broker’s. Yours. The same way you are on the hook for the 401(k), you are on the hook for the health plan. Employees have started suing employers over health plan fees, the same wave that already hit retirement plans years ago. The class-action bar is circling, looking for the next plan that never checked its own costs.

Sit with that at renewal. Accept a number you cannot explain, from vendors whose pay you have never seen, and you are not just overpaying. You are signing off, as the fiduciary, on costs you never checked. That is the exposure. Not a letter from a regulator. A duty you did not know you were carrying.

The good part is that the fix and the savings are the same move. A fiduciary-run plan is a transparent plan. You see the fees, you see the vendor pay, you see the claims, you document that you asked. That is exactly the plan that also costs less, because sunlight drives out the waste. Doing right by your duty and doing right by your budget point the same direction here.

What to do this fall: ask for every fee in the plan, in writing, and ask your advisor to show you how they know your costs are reasonable. Keep the paper. That paper is both your savings trail and your defense.

You would never sign a contract this large without reading it. You already did. Renewal season is your chance to actually read it.

Want to see what you are on the hook for? Let’s talk.

You were right to do the double take. It is exactly as backwards as it sounds.

Here is the machine behind it. Between you and the pharmacy sits a pharmacy benefit manager, the PBM, the company that runs your drug plan. They negotiate prices, decide how much of the manufacturer rebates flow back to you, and set what your plan pays. Sometimes the cash price a stranger off the street gets is lower than the “discounted” price your plan pays. The spread does not come back to you. It stays in the middle, with the PBM.

Now put that next to your renewal. Prescription drugs are one of the biggest forces pushing your 2027 number up. GLP-1 medications alone, the weight and diabetes drugs everyone is talking about, are exploding. Filled prescriptions nearly doubled in a year, and nearly eight in ten employers now name them as a top cost driver. Specialty drugs pile on top. A big share of your increase is pharmacy, and a big share of your pharmacy spend is structure you cannot see.

This is where control changes everything. In the plans where we pick the pharmacy manager separately and read the actual contract, we see the spread, we shut down the games, and drug costs come down without touching a single employee’s copay or medication. Same drugs. Same people. Lower cost. In the bundled plans, that math stays hidden on purpose.

Your employee noticing the cash price is not a fluke. It is a crack of daylight into a system built to be confusing.

What to do this fall: ask who your pharmacy manager is, how they get paid, and whether your contract is transparent. A shrug or a word salad is the finding. The people making money on the confusion are counting on you not asking. Want to read the contract yourself? We built an AI prompt that shows you exactly what to flag. Download The Benefits Contract Review Prompt Pack

The pharmacy counter is where your whole plan shows its hand. Read it.

Want to know what your drug plan is really costing you? Let’s talk.

They were wrong. And this renewal season is proving it in my own book.

I have two kinds of midsize clients right now. One kind is fully insured, the standard setup most brokers sell, and they are getting hammered, some north of 20% this year. The other kind is self-funded and unbundled, meaning we chose each piece of the plan separately and can see inside all of it. Same size. Same headcount. Same lousy market. Their renewals are calm.

Size was never the problem. Structure is.

Now the honest caveat. Sometimes fully insured is the right answer. For a smaller group, or one with very high claims, it can be the smart, safe call. That should be a conclusion you reached by looking at the math, not a default someone handed you because looking was inconvenient for them.

Most owners never hear this part. A company your size can self-fund and cap its risk with stop loss insurance, a policy that catches the catastrophic claims so one bad year does not blow up your budget. You keep the savings in the good years. You see every dollar of claims and every vendor’s cut, the whole engine. The big carriers rarely mention this, because their model runs on you not knowing. Telling you “you’re too small” is easier than proving what your options actually are.

The reaction I watch land on people is not relief about the money, though the savings are real. It is closer to anger. “Why did nobody show me this existed?” They are right to be angry.

What to do this fall: before you sign another renewal, ask one question. “What would this plan look like if I could see inside it?” Ask what self-funding and stop loss would mean for a company your size. An advisor who says you’re too small just handed you your answer, and it is not about your size.

You built a company big enough to have this problem. You are big enough to fix it.

Want to see what your plan looks like with the lid off? Let’s talk.

That gap costs you at renewal, because part of the increase you are about to absorb may be their paycheck.

This is what surprises owners. Broker pay often rides inside your premium and the plan’s vendor contracts. Base commission, of course, but also bonuses, overrides, an extra cut on your stop loss coverage, sometimes a per-fill fee on every prescription your people run through the plan. Some of it is disclosed. A lot of it is not. And the incentives do not always point at your lowest cost. Sometimes they point the other way.

You already know how this feels, because you fixed it everywhere else. You made your retirement advisor disclose in real numbers. Your benefits broker probably handed you a line that reads “we may earn other income that does not affect your cost.” That is not a disclosure. That is a shrug in legal font. And it is not even true, because that income can absolutely affect your cost.

The Consolidated Appropriations Act, a 2021 law, gives you the right to the real number. Your broker owes you a written accounting of what they get paid, from every source. Most owners have never asked. Most have never seen it.

Sit with what that means at renewal. The person advising you on a 15% increase might get paid more when your premium goes up. That is not a conspiracy. That is how a percentage commission works. And how is that working?

What to do this fall: ask for the disclosure in writing. Every dollar, every source. Not “roughly.” In writing. Then go read the contracts, the fully executed ones, and when you don’t have them (it happens more than you’d think), get them and read them. We built a set of AI prompts that walk you through exactly what to look for. Download The Benefits Contract Review Prompt Pack

I disclose my compensation and certify the document. Every client, every year. That is how we run. Not because I am a saint, but because you would demand it from anyone else touching this much of your money, and you should demand it here.

You hold every other vendor accountable. Renewal season is the moment to hold this one too.

Curious what your broker actually makes off your plan? Ask them, then let’s talk about the answer.

Here is a test. Picture any other vendor in your business raising their price 20% and answering “that’s just the market” when you ask why. You would want the math. You would get the math, or you would get a new vendor.

Health insurance is the one line where owners accept the shrug. The renewal shows up like weather, you brace, you pay, you move on. The big benefits consultants are forecasting somewhere around 9 to 10% for 2027 (Aon says 9.5%, pushing the average cost past $19,000 per employee). That is the market average. Midsize employers without leverage routinely see worse.

The average is not the story. Whether you can see the math is the story.

I have fully insured clients this year staring at increases north of 20%, a few north of 40%. I also have self-funded clients, same size, same headcount, whose renewals are barely moving. Same market. Same year. Wildly different letters. The difference is not luck and it is not size. One group can see exactly what their claims did and why the number moved. The other gets a number and a shrug.

That is the whole game. A renewal you can explain is a business decision. A renewal you cannot explain is a bill someone handed you. Claims run high in a plan we can see into, and the increase makes sense. The client can plan for it. An increase that arrives with no visible math is not a market problem. That is a visibility problem, and it is fixable.

What to do this fall when the letter comes: do not ask “can we get it down.” Ask “show me the math.” Ask what drove the number. Ask what you are paying for and who gets paid inside it. A blank stare at any of those questions is the real problem, and it is not the market.

You negotiate every other number in this building. This one is not weather. It is a decision someone made, and you paid for it.

Want to know what your renewal is actually telling you? Let’s talk.

A number of health systems around the country have started billing for certain types of messages, largely ones that are involved in clinical assessments or medical history reviews that take more than five minutes. Those costs will be passed on to health plan enrollees — likely in the form of copays or coinsurance — and insurers.

Online and app-based portals have become increasingly popular, particularly since the onset of the COVID-19 pandemic, as more people grow accustomed to not seeing their doctor face to face for every visit. Often these portals will allow the health plan enrollee to ask their care team questions, and that’s when providers say they are not being paid for their time.

Is a new trend starting?

Patient portals were seeing little usage prior to the pandemic, which spurred demand as patients and providers needed a solution that didn’t require in-person interactions. Studies have shown that more than 80% of patients used telehealth at least once since the start of the pandemic, up from about 10% prior to 2020.

These portals also sometimes obviated the need even for a tele-visit with a doctor and opened the door for patients to message their doctor directly.

The issue recently came to the fore when Cleveland Clinic and a handful of other medical centers started charging for this service. 

Cleveland Clinic in November 2022 said it would start billing patients’ insurance companies for messages requiring at least five minutes of health care providers’ time to answer.

What will it cost?

Sending messages could cost as much as $50 per message depending on the time and skill necessary to answer the request. According to the announcement, people with individual or employer-sponsored group health insurance may be billed an average of $33 to $50 for each message taking more than five minutes. 

In announcing the new charges, Cleveland Clinic wrote: “Over the last few years, virtual options have played a bigger role in our lives. And since 2019, the amount of messages providers have been answering has doubled.”

According to a report in Becker’s Health IT, seven more large health systems around the country have also started billing for some patient portal services: Northshore University Health System in Evanston, Illinois; Northwestern Medicine in Chicago; Chicago-based Lurie’s Children’s Hospital; San Francisco-based UCSF Health; Renton, Washington-based Providence; and UW Medicine and Fred Hutch Cancer Center, which both have their headquarters in Seattle.

These hospitals say they will only bill for certain messages, such as those concerning:

• Changes to a patient’s medications.
• New symptoms the patient may be experiencing.
• Changes to a long-term condition.
• Check-ups on long-term condition care.
• Requests to complete medical forms.

Messages may provide information on a treatment plan or recommend that the patient get a test done or schedule an appointment with a specialist. Doctors may often refer to the patient’s medical history and review their records for these communications, for example.

The providers say that other services on portals will remain free, such as:

• Scheduling appointments.
• Getting a prescription refilled.
• Asking a question that leads to an appointment.
• Asking a question about an issue the patient saw their provider for recently.
• Checking in as a part of follow-up care after a procedure, such as a colonoscopy.
• A patient giving a quick update to their doctor.

Experts predict that as more health services gravitate towards providers’ portals, hospitals and doctors will look to generate revenue from these services.