New claims research from Medefy, a care navigation platform, cuts through one of the more persistent budget-season assumptions: that Q4 health plan costs run hot because of inflation. Across four self-funded employer health plans representing more than 11 million claim lines, the data shows otherwise. Between 40% and 55% of total medical spend on each plan was fixable, averaging 47% across all four.
Medefy produced the research and sells cost containment software to self-funded employers and their advisors. Three of the four plans analyzed are not Medefy clients.
The fixable share is not catastrophic claims, cancer treatment, emergency admissions, or trauma. Those categories, which the report explicitly sets aside, represent spending that no benefits strategy can meaningfully redirect without stepping into clinical decisions. What is fixable is scheduled care, including imaging, labs, outpatient procedures, infusion, and elective surgery. The same service costs significantly less at a different site already inside the plan’s existing network.
The core mechanism is a price gap that shows up consistently across all four plans. The same procedure cost an average of 48% less at a lower-cost site than at a standard facility, with both options in the same plan’s network and members paying nothing out of pocket in either case. A CT scan of the abdomen and pelvis ran $592 at a lower-cost site against $1,585 at a standard facility on the plan Medefy has worked with for six years. A colonoscopy showed a gap of 30% to 47% across three of the four plans, in three unrelated markets.
This is not a contracting failure. One of the plans had negotiated better than 50% off billed charges. The contracted rates were not the problem. The problem was where members were going. Across the three non-client plans, 80% of imaging dollars landed at the most expensive type of facility, as did more than half of lab, infusion, and surgery spend. In two of those three plans, a lower-cost alternative was already under contract. Almost no one was sent there.
Independent research on site-of-care price variation supports the pattern. An April 2026 issue brief from the Health Care Cost Institute found that imaging prices at hospital outpatient departments ran two to four times higher than at physician offices for the same procedures, based on commercial claims data from employer-sponsored plans.
The Q4 finding is where the report connects most directly to the renewal conversations advisors are having now. Across all four plans, two years in a row, plan-paid medical spend ran approximately 20% higher in the fourth quarter than the Q1-to-Q3 average. The instinct is to book that as inflation. The claims say otherwise.
About half of the Q4 jump is mechanical: once members meet their deductibles, the plan picks up a larger share of the same bills. That half cannot be steered. The other half is behavioral: claim volume rose 2% to 5% and cost per claim rose 6% to 7%, as members with their deductibles met fit in more care and chose higher-priced sites. That half can be steered, and Q4 is precisely when steering saves the plan the most because the full differential between a standard and a lower-cost site lands entirely on the plan once the member’s out-of-pocket is gone.
Three specific procedures drove the Q4 volume rise across all four plans: laparoscopic hysterectomy, cataract surgery, and chest X-rays. The first two are scheduled, carry wide price gaps between sites, and can be redirected. The third follows respiratory season and cannot. Advisors who pull each client’s scheduled Q4 procedures before October, rather than analyzing the spike after the fact at renewal, have the data to intervene before the most expensive quarter begins.
Employer health benefit costs are projected to rise 8.2% per employee in 2027, the steepest increase since 2003, according to Marsh’s 2026 National Survey of Employer-Sponsored Health Plans. Many employers entering that renewal cycle say they cannot explain where last year’s money went. The Q4 spike is part of that answer, but only if it is read correctly. An employer that books the fourth-quarter jump as inflation sets next year’s budget against the wrong baseline and goes looking for solutions in the wrong half of the spend.
