Cost pressure dominates the renewal conversation, but the sharpest concerns aren't the ones employers are raising, a new study finds. The 2026 Phia Group Broker Survey Results & Analysis, surveyed 124 benefits brokers and advisors and found that only 12% are very confident their clients have adequate fiduciary processes in place.
Employers are leading with rate increases and pharmacy costs, while fiduciary oversight barely registers as a client question. That disconnect matters because around three-quarters of brokers (76%) report their book of business has shifted toward self-funded plans over the past 12 months.
Under the Employee Retirement Income Security Act of 1974 (ERISA), those plan sponsors carry a legal obligation to act in participants' best interests, monitor vendors, and document plan decisions. When that obligation isn't well understood, the exposure doesn't disappear - it goes unmanaged.
Brokers who surface the documentation and oversight conversation ahead of a client's first audit are doing something clients cannot initiate on their own. That positioning has taken on more weight as ERISA litigation targeting health plan oversight has intensified. A January analysis by law firm Willkie Farr & Gallagher described 2025 as a year of "expanding theories of fiduciary liability" and "intensifying health plan-related challenges," with 2026 expected to see further activity.
On No Surprises Act (NSA) and recovery, the survey data is equally pointed. Seventy-eight percent of brokers have no working visibility into their clients' NSA and independent dispute resolution (IDR) performance. Forty-four percent say they don't know their clients' key NSA statistics, and 34% say NSA/IDR isn't applicable or exposure is limited.
On the recovery side, 62% describe client visibility into subrogation and recovery as limited or very little. Only 4% report strong visibility into recovery opportunities and dollars retained.
Georgetown University researchers, writing in Health Affairs in August, found that the NSA's IDR process has generated $22.4 billion in total costs since 2022, with dispute volume rising 77% in 2025 alone. Those numbers illustrate what low visibility into NSA/IDR performance can leave unexamined.
"If you don't have visibility into a part of the plan, you can't really evaluate whether it's working," said Adam V. Russo, co-founder and CEO of The Phia Group, a Canton, Massachusetts-based firm specializing in health plan cost containment and compliance. "Employers should be asking their vendors and service providers not only what they are doing, but what results they are producing and what data the employer can actually see."
Seventy percent of brokers report that most clients are seeing or expecting double-digit renewal increases in 2026. Pharmacy has moved beyond an expense category. Among brokers surveyed, 27% identified pharmacy benefit manager (PBM) transparency and rebate questions as a leading client concern, while 18% named pharmacy and specialty drug costs as their single biggest pressure point.
Employers are also increasingly looking beyond the sticker price of prescriptions toward how pharmacy spending is structured, contracted, and managed. Separate Gallagher data from a survey of 3,717 US organizations polled in early 2026 found that nearly half of employers cite rising specialty pharmaceutical costs as a top challenge.
That scrutiny now has a regulatory dimension. The Consolidated Appropriations Act, 2026, signed February 3, requires PBMs to pass through 100% of rebates to ERISA-governed employer health plans and eliminates spread pricing. Most provisions take effect for plan years starting January 1, 2029.
The survey asked what tools would help brokers advise clients more effectively over the next six to 12 months. Fiduciary oversight checklists topped the list, selected by 54% of respondents. Better claims and cost-driver analysis ranked second, followed by more transparent vendor and third-party administrator (TPA) reporting.
The responses point consistently toward the same need. Tools that help brokers make a specific, documented case to a client rather than a general argument about risk. Most mid-market employers have never evaluated their health plan funding structure, and advisers who raise that question first have a narrowing window before the next renewal forces it.
"The broker's role is changing," Russo said. "It's not enough to tell a client that healthcare costs are increasing. The more valuable conversation is helping the client understand what is driving those costs, what the plan can see, which vendors are performing, what decisions need to be documented and where there may be opportunities to improve performance."
The Phia survey also found that 44% of brokers regularly use AI in advisory work, with another 26% using it occasionally. Fifteen percent say accuracy, privacy, or compliance concerns have slowed adoption. AI came up in open-ended responses as an extension of the same oversight question. Vendors and third-party administrators are deploying AI across claims administration and coverage decisions, and employers with no visibility into those processes face the same gap the survey documents everywhere else.
