"There’s no bad risk, there’s just mispriced risk... we helped one carrier achieve a 29.1% improvement in their loss ratio just through better risk selection."

How do stop-loss carriers and self-funded employers accurately predict which groups are going to run well and which ones are about to see skyrocketing claims?

My guest this week is Ali Panjwani, Founder and CEO of Merit Medicine. Ali transitioned from a career in biotech and pharmaceutical public policy, where he helped price and launch complex, rare-disease drugs, to solving one of the biggest problems in self-funded healthcare: predicting catastrophic risk before it happens.

In this episode, we dive into the evolution of predictive analytics and medical underwriting. Ali explains how Merit Medicine uses AI and access to a massive database (covering 95% of commercial claims in the US) to project a group's healthcare spend using just a simple census file. We discuss why a group that ran poorly last year might actually be a great risk this year, how to prevent underwriters from "playing on tilt," and the ongoing debate over how to finance multi-million-dollar cell and gene therapies.

If you are a benefits consultant, an MGU, or a stop-loss carrier trying to understand how technology is fundamentally changing the way healthcare risk is predicted and priced, 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: The Evolving Landscape of Healthcare Risk
• (00:04:28) Ali's Background: From Biotech to Public Policy
• (00:09:47) The Complexity of Launching & Pricing New Drugs
• (00:13:30) Shifting Focus: Who Actually Pays for Healthcare?
• (00:16:34) The Data Access Problem for Self-Funded Employers
• (00:19:50) How Merit Medicine Predicts Risk with Just a Census File
• (00:23:24) Why Merit Looks Backwards to Predict the Future
• (00:26:27) How Stop-Loss Carriers & MGUs Use Predictive Analytics
• (00:29:41) "There Is No Bad Risk, Only Mispriced Risk"
• (00:33:04) The Danger of Underwriting "On Tilt" (Past vs. Future Claims)
• (00:37:37) Can Predictive AI Help Apply Specific Lasers?
• (00:40:10) The Evolution of Underwriting Tech
• (00:45:04) Proving the Model: A 29.1% Loss Ratio Improvement
• (00:49:10) The Cell & Gene Therapy Debate: Public Pools vs. Financing
• (00:55:14) Closing Thoughts: The Future of Predictable Premiums

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/

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/