"If you're expecting to pay $50k, but it hits an outlier clause, you could be paying upwards of three, four, five, six hundred thousand dollars."

What if the single biggest driver of your high-cost claims isn't your discount, your network, or your utilization, but a contract provision almost nobody in this industry has ever read?

My guest this week is Ryan Bojrab, who leads new solution development at Aon and came into this business through a channel almost nobody uses: he started his career as a clinician with a doctorate in physical therapy, treating patients inside a federally qualified health center.

When carriers started dictating how many visits he could give a patient, he began pulling the thread, and hasn't stopped since.

Ryan and I spend this episode discussing the outlier clause: the provision buried in hospital-carrier contracts that flips your negotiated discount once billed charges cross a threshold. Expecting a 50% discount on an open heart surgery? Once the trigger hits, you may be paying 70% of billed charges on the entire episode of care, and watching a $50,000 claim become a $500,000 one.

Ryan calls it the casino's high roller table, and it's where hospitals make their money. It also produces one of the most perverse incentives in American healthcare: the longer you're in the bed, the worse your discount gets.

If you've ever put two networks side by side, seen a massive pricing delta, and couldn't explain why - tune in.

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 https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.

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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 Best Kept Secret in Network Contracts
(00:05:59) From Clinician to Consultant: On the Receiving End of Every Vendor Pitch
(00:10:46) Why Indiana Became a Self-Funding Powerhouse
(00:16:00) What Is an Outlier Clause? The Casino's High Roller Table
(00:21:00) The Hospital's Defense and the Inverted Discount
(00:27:43) What You Can Actually Do: RFP Language and Direct Contracting
(00:35:12) Prompt Pay Providers and the Death of Spec Advance
(00:41:17) A Quarter-Million-Dollar Claim With No Checks and Balances
(00:47:39) Decoupling Primary Care From Insurance
(00:53:36) The Four Buckets of Quality
(00:58:53) Tiering and Steering at National Scale
(01:05:36) Closing Thoughts: Contract Terms Are the Next Frontier

Key Links for Social:

@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded

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Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286

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