Your Premiums Went Up Again. Somebody Got a Raise.
I was playing golf a few weeks ago with a good friend of mine who owns a small business here in town. Somewhere around the back nine he told me he pays north of a million dollars a year in health insurance premiums for his employees. Suffice it to say, the rest of my round didn’t go well due to the instant nausea.
Then he told me he'd asked his team how the plan was working out for them, and mostly got shrugs. A few of them admitted they hadn't seen a doctor in years.
Sit with that. He is writing a check the size of a house (a very, very nice one) every single year for something his employees are going out of their way to avoid using.
And they're not avoiding it because they're healthy. They're avoiding it because using it is miserable. Call the office, sit on hold, get an appointment three weeks out, take a half day off work, sit in a waiting room, get seven minutes with someone who has never met you, walk out with a lab order and a prescription, then get a bill six weeks later for an amount nobody warned you about.
So they wait. And they keep waiting, until the infection or the chest pain or the blood sugar gets bad enough that it turns into a Saturday urgent care visit, or an ER visit.
That care gets used. It just costs everybody four figures more than it needed to.
His number isn't even unusual, which is the part that should bother you. KFF's most recent employer survey puts the average annual premium at just under $27,000 for family coverage and $9,325 for single. Run that across a 50 person company with a typical mix of single and family enrollment and you land somewhere around $900,000 a year. For fifty people. Family premiums rose 6% last year and 7% in each of the two years before that. And 2027 is projected to be worse. Aon is forecasting a 9.5% jump, which would push average employer cost past $19,000 per employee and make it the fourth straight year of increases approaching double digits. That is one of the longest sustained runs of healthcare inflation employers have faced in decades.
Nobody is coming to fix this for you.
Premiums follow claims
Every lab, every office visit, every scan, every prescription your team runs through the plan is a data point. That pile of data points is what your renewal gets priced against.
So the interesting question isn't "how do I get a better rate at renewal."
It's "how do I stop generating claims in the first place."
That's what we do. Not as a marketing angle, as a structural consequence of how we're built. Simplicity Health does not bill insurance for anything. Not one thing. Every visit, every lab, every in-office procedure, every prescription out of our pharmacy happens completely off your plan.
Which means none of it ever becomes a claim. Anywhere. It does not exist.
What that looks like in actual dollars
Routine bloodwork. One of the large hospital systems here in town publishes its patient price list. As of January 2026, here is what a standard set of labs runs at their standard rate:
Comprehensive metabolic panel: $278
Lipid (cholesterol) panel: $250
Hemoglobin A1c: $278
CBC: $115
TSH: $188
Drawing the blood: $37
That's $1,146 for one morning of ordinary labs. Not exotic testing. This is the stuff we check on a middle-aged guy with high blood pressure and a family history. And we don't check it once and call it a career. Depending on what we're managing, that's once or twice a year, every year. Call it $2,292 for one employee, on the routine stuff alone.
At our office those labs are included in the membership. Your employee pays nothing, and your plan never sees the claim.
An MRI. We've negotiated direct cash rates with independent imaging centers in the area. Our patients typically pay $350 to $400. That same MRI at a local hospital usually runs $3,000 to $4,000. It's also faster, because we're not waiting two weeks on a prior authorization that might get denied anyway. CT works the same way.
A blood pressure medication. I once stood in a retail pharmacy line and watched a young man get quoted $144 for a month of his BP medicine through his insurance. The pharmacist then found it for $36 on GoodRx. That exact prescription is about $5 for a three month supply through our office. We buy at wholesale and we pass it straight through.
An ER visit that never happens. Call it $10,000 in claims. One. An employee with their physician's cell number calls us at 8pm on a Tuesday instead of driving to the emergency department, and the entire event never occurs.
Now run that across a team of 50 people for a year. The panels, the scans, the refills, the sick visits, the handful of ER trips that got handled by phone instead. That is not a rounding error. That is a large share of your claims history that simply stopped existing.
I've tried to hand them the savings. They won't call me back.
Let me tell you something that took me a few years to understand.
I have reached out, repeatedly, to the biggest benefits brokerages in this town. Not to sell them anything. I don't pay referral fees and I wasn't asking for one. I just wanted to show them the math. Here is what your clients' employees are getting billed for a morning of routine labs. Here is what those same labs cost at my office. Here is a $3,500 MRI for $375. Here is what happens to a group's claims volume when thirty of their people stop generating claims.
I sent emails. I followed up. I sent more emails.
Nothing. Not a no. Not a "we looked at it, it isn't for us." Not a single reply.
For a while I assumed the problem was me. Maybe my email was too long. Maybe it went to spam. Maybe direct primary care still sounds like a gimmick to somebody who has been selling group health plans since the Carter administration. I gave them every benefit of the doubt I could think of.
I don't anymore.
Because here's the thing about the offer I was making. It was pure upside for their client and it cost them nothing. Any advisor whose actual job is lowering their client's healthcare spend would have at minimum taken a fifteen minute call. Not one did.
So I stopped wondering about it and went and looked at how they get paid.
Follow the money and it stops being confusing
Here's something most business owners have never been told.
The standard way a health insurance broker gets paid is a commission from the carrier, calculated as a percentage of your total premium. Usually somewhere in the range of 3 to 6%.
Run that against a $900,000 premium bill. Somebody is collecting $27,000 to $54,000 a year on that one account.
And here's the part that should make you put your coffee down: because the commission is a percentage of premium, that number goes up when your premium goes up. Your renewal increase is your broker's raise.
Now go back and read my unanswered emails again. I was offering to shrink the thing their paycheck is calculated on. Of course nobody called me back. I wasn't bringing them a solution, I was bringing them a pay cut.
And then renewal comes around and the client gets the same performance every year. The sympathetic head shake. "Those darn insurance companies raised the premiums again." Delivered with real feeling, like it happened to them too.
It didn't. They just got a raise.
It doesn't stop at commissions. A 2019 ProPublica and NPR investigation documented the layer underneath: carriers paying brokers bonuses on top of commissions for volume and retention. Health Net offering bonuses of up to $150,000 per employer group signed. Blue Cross Blue Shield of North Carolina calling its bonuses, in an email to a broker, the "cherry on top." Cigna offering top sellers a trip to Bermuda. One broker told ProPublica his bosses would email the team pushing a particular plan because the agency was close to hitting a bonus threshold, and said flatly that none of it got disclosed to the employers.
Those bonuses aren't charity. They're built into the premiums. You are paying for the Bermuda trip.
A University of Colorado bioethicist called it what it plainly is: a classic conflict of interest.
Congress eventually noticed. The Consolidated Appropriations Act of 2021 now requires benefits brokers to disclose to employers what they're being paid by carriers and vendors. That's real progress. But the disclosure requirement doesn't change the incentive, it just documents it. And most employers have never asked to see it.
I want to be fair here, because plenty of brokers are decent people who genuinely care about their clients. The problem isn't that they're villains. The problem is that they're operating inside a compensation structure that pays them more when your costs go up, and nobody ever sat you down and explained that.
So ask. You are allowed to ask your broker, in writing, exactly what they make on your account and from whom. Watch how they answer. That answer tells you almost everything.
What "Health Rosetta" means, and why it matters
There's a national organization called Health Rosetta that certifies benefits advisors who agree to work differently.
The core requirement is transparency about money. To carry the credential, an advisor has to disclose all of their direct and indirect compensation, commissions, bonuses, consulting fees, override payments, and who exactly is paying it, to the employers they advise. They sign a code of conduct built around transparency, expertise, and aligned incentives. Many of them move to flat fees paid directly by the employer instead of taking carrier money at all.
Put simply: a Health Rosetta advisor has agreed in advance to show you the thing the industry has spent decades not showing you.
There aren't many of them in Ohio. One is Christina King at C&A Benefits Group, a Health Rosetta Associate Advisor who has been in the benefits business for over twenty years.
Let me be clear about what this is and isn't. This is not a sales pitch. We get nothing for sending you her way, there's no arrangement between us, and I'd say the same about any advisor who works this way. She's just somebody we know won't jerk you around.
The difference in practice? A fully insured plan is a cookie cutter product. The carrier has a handful of plan designs built for a company roughly your size in roughly your industry, and the broker's job is to pick one off the rack and hand it to you. Nobody looks at what your specific people actually use. Nobody asks why your pharmacy spend looks the way it does. You get the box that fits.
Christina's team does the opposite. They go into your actual claims and utilization data and build the plan around what is genuinely happening inside your company.
The numbers on her published case studies are worth your time. An Ohio city government with 120 employees was on a $5,000 deductible plan and got handed a 50% renewal increase, on top of a 45% increase the year before. C&A took over as broker, contracted directly with the regional hospital system, and brought in local direct primary care, a prescription advocacy program, and four independent pharmacies with $0 generic copays. The result: $800,000 saved, and employees who went from a $5,000 deductible to $0 deductibles and $0 copays for local care. A separate client, a 60 person nonprofit, cut premiums 35% while moving to $0 copays for primary care, specialists, mental health, and generic medications.
Read that twice, because it's the whole argument of this article in one paragraph. The employer saved a fortune and the employees got dramatically better coverage. At the same time. That is what becomes possible when somebody actually opens your data instead of handing you a box.
Self-funded, level-funded, and why it matters for a business your size
This is the part that determines how much of the savings actually reaches you, so it's worth understanding.
Fully insured is what most small employers have. You pay a fixed premium to a carrier. The carrier takes on all the risk and keeps whatever it doesn't pay out in claims. If your team has a wonderfully healthy year, the carrier keeps the difference. You don't see a penny of it.
There's a catch worth knowing: under the ACA, groups of 50 or fewer in Ohio are community rated. Your own claims experience is not what sets your rate. So if you're a fully insured small group, the "cut your claims and watch your renewal drop" argument does not apply to you cleanly, and any broker who tells you otherwise is either confused or selling.
Self-funded means your business pays employee claims directly out of its own pocket, and you buy stop-loss insurance to cap your exposure if someone has a catastrophic year. You hire an administrator to process claims. Now every claim your team avoids is money that stays in your account instead of the carrier's. You also get to see your own claims data, which fully insured employers usually cannot.
Level-funded is the bridge, and it's where a lot of small and mid-sized businesses land. You pay a fixed monthly amount that looks and feels like a premium, but it's split into three buckets: a claims fund, administrative costs, and stop-loss coverage. If your team's claims come in under the projection, you get a refund of the surplus at the end of the year. You get budget predictability like a fully insured plan, but you stop donating your good years to the insurance company.
Here's why this matters. DPC and self-funded or level-funded design are made for each other. Under a fully insured plan, you're cutting claims for a carrier that keeps the savings. Under level-funded or self-funded, every avoided lab, every $375 MRI instead of a $3,500 one, every ER trip that turned into a phone call, is money that comes back to your business.
That's the whole play. Restructure how the plan is funded so your savings belong to you, then add a benefit that dramatically reduces what gets claimed. One without the other leaves money on the table.
This is exactly the conversation a Health Rosetta advisor is built to have with you, and exactly the conversation a commission-driven broker has no financial reason to bring up.
What your employees get for $99
$99 per employee, per month. That's it.
That's our Diamond tier, our most comprehensive membership, at roughly half of what an individual pays retail. Spouses are $99. Kids under 18 are $49.
For that:
Appointments that run 30 to 60 minutes. Not seven.
Same day or next day scheduling for basically everything.
Their physician's actual cell phone number. Text, call, email, nights and weekends.
No copays, no deductible, no cap on how often they come in.
In-house lab draws at member pricing.
Our own pharmacy at close to wholesale. Plenty of common generics run a few dollars for 90 days, and they walk out with the bottle instead of standing in a line.
Cash imaging rates at independent centers, without the prior auth circus.
We've been doing this in Centerville since 2020. Four physicians, around 1,500 patients, our own lab and our own pharmacy under one roof.
Fifty employees at $99 a month is $59,400 a year. Against a $900,000 premium bill, that's under 7%.
You decide who's covered, by the way. Some businesses sponsor everyone. Plenty start with owners, leadership, and a few key people and expand from there. Some split the cost with employees. All of that works.
What this does not do
DPC is not insurance and it does not replace insurance. It doesn't cover hospitalization, surgery, specialists, or anything catastrophic. Your people still need real coverage for real emergencies, and I would never tell a business to drop major medical and hand out memberships instead.
What it does is absorb the 80 to 90% of medical care that's routine, the colds and infections and blood pressure and diabetes and physicals and refills and "hey doc is this normal" texts, and handle all of it for a flat monthly fee. Insurance stays right where it belongs, for the big stuff.
I also can't promise you a specific insurance renewal number, and you should be suspicious of anybody who does. What I can tell you is that the $1,146 in labs and the $3,000 difference on the MRI are real money that somebody was going to pay. Your plan, or your employee's deductible, or your employee's credit card. When those numbers go to $0 and $375, that money stops leaving the building. Where it lands depends entirely on how your plan is funded, which is why the two halves of this post belong together.
Where to start
You can sign up on our employer page and someone from our office will evaluate your company’s specific needs.
Fifteen minutes. Tell us about your business, roughly how many people you're considering, and what your benefits look like now. If it isn't a fit, we'll tell you.
We work with businesses in Centerville, Kettering, Springboro, Oakwood, Bellbrook, Miamisburg, Beavercreek, and across the Dayton area.
Your premiums are going to keep climbing. What you actually control is how much of your team's care ever becomes a claim, and who's getting paid when it does.
$99.
Charlie Opperman, MD, FACP
