The Sleeping Giants of Healthcare—Why Self-insured Employers and Clinicians Keep Missing Each Other, With Suhas Gondi, MD, MBA. EP523

Why Self-Insured Employers and Clinicians Keep Missing Each Other, With Suhas Gondi, MD (EP523) Dr. Suhas Gondi, MD, MBA, chief medical officer at Health Strategy and an attending physician at Massachusetts General Hospital, co-wrote a New England Journal of Medicine article — "A Sleeping Giant of Health Care Affordability—Self-Insured Employers" — because most clinicians, he found, have little idea a self-insured employer, not an insurance carrier, is the one actually paying for their patients' care. Talking with Stacey Richter, Dr. Gondi argues that self-insured employers and clinicians are both "sleeping giants," each holding real power over cost and access, who rarely communicate directly — leaving patients caught in the gap. WHAT YOU'LL LEARN ✅ Why Dr. Suhas Gondi and his NEJM co-author, Zirui Song, MD, PhD, wrote for clinicians who, they found, have little sense that a self-insured employer — not the carrier name on the card — actually pays for a patient's care ✅ How a GLP-1 prescription can get denied at the pharmacy counter even after a clinician verifies coverage, because the employer has quietly moved GLP-1 coverage exclusively through a single third-party prescribing and coaching vendor ✅ Why GLP-1 spending alone can push a self-insured employer's pharmacy costs up 9% to 20% in a year, and why the roughly eight-year payback period employers are counting on assumes patients stay adherent far longer than most actually do ✅ How oncology site-of-care steering — an employer declining to pay a roughly 40% premium for infusion at a hospital-owned center instead of a physician's office — can look to the patient and oncologist like a denied cancer drug ✅ Why Dr. Gondi says EHRs like Epic are built to optimize revenue for hospital-system customers, not to surface a lower-cost site of care for patients or plan sponsors ✅ Dr. Gondi's advice for closing the gap: clinicians and employers should communicate directly, especially before a coverage change lands on patients, rather than assuming direct contracting is the only fix WHY THIS MATTERS Roughly half to 60% of the US population has commercial insurance, and nearly three-quarters of large employers self-insure that coverage — yet most clinicians have no visibility into the plan-level decisions those employers make, and most employers have no channel to explain those decisions to the doctors whose patients are affected. Both sides, Dr. Gondi says, usually believe they're doing the right thing — covering the GLP-1, covering the cancer drug — and the patient still gets lost in between. Closing that gap doesn't require full direct contracting, he argues, just employers and local provider groups actually talking to each other before a coverage change lands on a patient, not after. MENTIONED IN THIS EPISODE Study: New England Journal of Medicine article, "A Sleeping Giant of Health Care Affordability—Self-Insured Employers," by Suhas Gondi, MD, MBA, and Zirui Song, MD, PhD EP406 with Lauren Vela: Apple Podcasts | Spotify | Other Apps EP519 with Lisa Rosenbaum, MD: Apple Podcasts | Spotify | Other Apps EP509 with Patrick Nelli: Apple Podcasts | Spotify | Other Apps EP494 with Sarah Emond: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP468 with Matt McQuide: Apple Podcasts | Spotify | Other Apps Article: Acquired's episode on how Epic quietly powers American healthcare === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 00:35 A big thank you. 06:22 The conversation with Dr. Suhas Gondi. 07:08 Why Dr. Suhas Gondi and his coauthor wrote their article. 09:24 Why the affordability of care and the decisions self-employers are making about coverage matter to clinicians. 12:12 What the term "sleeping giants" implies and how that reflects the reality of healthcare. 14:31 A case study. 21:24 How the patient can still get lost even when both the employer and clinician think they're doing the right thing. 22:52 An example from the oncology space. 28:47 Dr. Suhas Gondi's advice to clinicians. 30:55 The communication gap between clinicians and employers. 33:30 Why the presence of middlemen should not prevent communication between clinicians and employers.