From Transparency to Compliance: Key Issues Shaping the Future of Employer Health Plans

The health insurance landscape is at a crossroads as renewal conversations continue to put pressure on employers to weigh managing costs with thoughtful, meaningful benefit offerings for employees and their families. From how employees access care to how plan sponsors oversee the efficacy of administration, the playbook is morphing quickly. Advisors continue to be uniquely positioned to consider emerging strategies, tightening regulations, and challenges to the status quo. 

Let’s explore some of the hot topics in benefits today— they’re signposts of where the industry is heading and provide insights into how employers can adapt. 

Direct Primary Care (DPC)

Ask around about people’s experience with their primary physician, and you will start to hear some common themes—not being able to get an appointment for weeks, not enough doctors taking new patients, short appointment times, or perceived lack of care and attention from their doctors. The typical patient experience doesn’t align with what primary care physicians want to provide, yet the disconnect persists. 

DPC offers a different approach. Instead of billing insurance for each visit like we are used to in the mainstream “fee-for-service” model, patients pay a flat monthly membership fee that unlocks unlimited access to the physician. This structure allows primary-care doctors to focus more on patient care and less on administrative backlog and insurance billing, fostering faster appointment times (often same- or next-day), more personalized, longer visits, and easier accessibility through text and email communication.

Starting January 1, 2026, DPCs are compatible with high-deductible health plans (HDHPs) and health savings accounts (HSAs). This is a massive win for those benefiting from HSA tax savings, as they can see their DPC without restriction, and there is no cost other than the monthly membership fee.

Health Care Navigation

You have probably heard that staying in network guarantees the lowest out-of-pocket cost, but it is not always that simple. Various facilities and providers often charge different amounts for the same procedure—even when they’re all in the same network. Insurance carriers that negotiate their own rates with each provider add more complexity, compounding the variation in pricing. In fact, prices can vary anywhere from 50% to 200% for the same service, depending on where you go and what insurance you have. 

What used to be a hazy maze of hidden pricing has evolved into something more straightforward. Transparency in Coverage regulations mandate that negotiated rates are made public, paving the way for private companies and app developers to compile massive sets of data into digestible formats. Health care navigation tools and concierge services combat this, flagging price gaps and supporting employees toward informed decisions about their care and the cost.

Getting in the habit of shopping for your health care can also save real dollars without sacrificing quality. Research shows no correlation between higher prices and better care. In fact, the opposite is often true.

Pharmacy Spending

This would not be an article about benefit trends without acknowledging the ballooning costs of pharmaceuticals in the United States. Notably, the average annual cost of specialty medications has nearly tripled in the last 10 years, rising from roughly $18,000 in 2015 to more than $52,000 today. 

People need their medications, so what can be done? Carving out pharmacy is a great first step. To take it one further, consider pharmacy benefit managers (PMBs) who guarantee transparency, both in terms of full access to claims data as well as their drug acquisition costs. 

Where a PBM makes their money is equally important – is it through spread pricing, where they mark up the cost of medications, or through administrative fees? Does the PBM pass through 100% of manufacturer rebates, or keep some for themselves? All valid and prudent questions are asked while in the selection process. 

Cost containment continues to be a hot and evolving topic, with many PBMs offering overlay programs that reduce costs for employees through copay assistance, patient assistance programs, and even international sourcing. It is essential to thoroughly vet PBMs to ensure they are at the forefront of developing solutions that comply with all applicable laws and regulations. 

Fiduciary Responsibility

Though it is nothing new, the reality of fiduciary duty on the plan sponsor’s part is becoming common knowledge, due in part to lawsuits waged against large companies, like Johnson & Johnson and Wells Fargo. To date, both cases have fizzled on technical grounds, but the spotlight lives on.

Employers offering health benefits and/or retirement benefits are subject to The Employee Retirement Income Security Act (ERISA) fiduciary standards. The ERISA establishes a legal duty to act in the best interest of plan participants, which entails numerous requirements. Vetting vendors and advisors, ensuring compensation is reasonable, determining conflicts of interest, and documenting prudent decision-making are all duties handled by the plan sponsor.

By default, fiduciary responsibility falls to the employer’s governing body, most often a board of directors. Creating a well-rounded committee that oversees various components of benefit plan execution is key. Members of such a committee might include those with financial oversight roles focused on wrangling costs, HR professionals tuned in to the employee experience, and executive leaders who ensure offerings are consistent with business objectives and employee needs. 

Ultimately, establishing clear fiduciary processes and governance reduces legal risk. It also creates a framework to help ensure benefits are managed proactively and with the same level of accountability as any other core business function.

Claims Adjudication

An often-overlooked drain on health care resources is fraud, waste, and abuse (FWA).  It is estimated to cost us tens of billions of dollars each year—anywhere from 3% to 10% of our annual health care spending. The result is increased costs via higher premiums and out-of-pocket maximums, which weaken employers’ bottom lines and contribute to wage theft as employees are forced to spend more out of their own pockets on health care costs. 

FWA can look like billing for services not rendered or charging for more expensive procedures than were actually performed. It also includes providing medically unnecessary services to increase insurance payments or unbundling and billing each step of a procedure as separate line items.

Adjudication processes and outdated technology also contribute to FWA—roughly 80% of received claims are adjudicated automatically. Notably, carriers are often both the adjudicator and the payer of claims. This situation poses an inherent conflict of interest as carriers are tasked with balancing motivations to protect their provider networks, keeping administrative costs low, and ultimately, profiting from higher premiums.

Exploring independent third-party administrator (TPA) relationships or working with claim-audit firms that remove bias can help hold carriers accountable to plan terms and flag improper payments. 

Taking Control

The thread tying these five trends together is control. Control of costs, of compliance, and of the data that drives actionable insights. Each is a lever, and we must possess the curiosity and drive to thoughtfully create value and drive down costs.  Being more intentional and thorough in these areas not only protects against unnecessary spending but also allows recuperated resources to be reinvested back into employees through stronger programs and compensation. In other words, these shifts align with a more sustainable strategy for long-term growth.