It is not unusual for people to drift into the insurance industry. What is unusual is to arrive with such clarity of purpose, so quickly, and to act on it so decisively.
Talia Carbah (pictured) grew up familiar with the world of property casualty insurance through work alongside a grandparent. But it was a move in 2020, from Montana to Georgia with her then-fiancé, both of them in their early twenties and "figuring everything out," that brought her to a genuine crossroads. On the same day, she received two job offers: one from a property casualty firm, and one from an employee benefits agency. She thought it through carefully.
"I am a very active person who wants to be out and about talking to as many people as I can," she explains. "In property casualty, a lot of it is sitting in an office, waiting for the phone to ring. I wanted something that was going to be a little more free."
She chose benefits, and entered the industry in the most traditional of fashions: as a 1099 contractor, working on commission, knocking on employers' doors and sitting with employees during open enrollment to walk them through their health insurance, life insurance, and everything in between. Business came in waves. Fourth quarters were strong. Other months required every ounce of energy just to keep the bills paid.
It was through a conference in Atlanta, BenPro, that her trajectory began to shift. She connected with a community of women in insurance, including a group organized by the well-known industry figure Susan Combs, whose Wonder Woman Mastermind brings together agency owners and professionals from across the spectrum of the industry. It was there that Carbah encountered Chelsea Ryckis: younger in the industry, innovative, and, as Carbah puts it, someone who "really had her act together" in every sense.
She did what she readily admits most people would not: she sent a cold email. "I said, 'You don't really know me, but I've seen you on a couple of these calls and I think you are the bee's knees. If you have the time and the space, I would love for you to take me on as a mentee.'" Ryckis, who was simultaneously building a business, releasing documentaries, and writing books, said yes. They worked together on a monthly basis for roughly two and a half years.
By then, something else had been growing: unease. Commission-based consulting, Carbah had come to understand, creates structural pressure that even the most well-intentioned advisor must constantly fight against. "On the spreadsheet, you have six different options," she says, "and internally, everyone has the one where it's like, if they go with this one…" The sentence does not need finishing. She wanted her compensation to be "a direct result of the value I was creating for people and not just because they had to pay more money. That's not helping anybody."
When Chelsea Ryckis offered her a place at Ethos Benefits, the firm Chelsea leads alongside her husband and founder Donovan Ryckis, Carbah did not hesitate. "Once you know better, you should do better," she says simply.
Fiduciary. It is a word that, in the context of employee healthcare, still makes many in the benefits industry uncomfortable. Carbah uses it constantly, fluently, and with the conviction of someone who has thought through every corner of its implications.
Under ERISA, the federal law governing employer-sponsored benefit plans, employers themselves are already fiduciaries. They are legally required to act in the best interest of their plan participants. The people they hire to advise them, however, are held to a considerably lower bar. The only standard of care required of brokers and consultants in the healthcare space is that their recommendation be "suitable," and suitable, in practice, means little more than legal.
"Insurance carriers have to get all of their products approved by the state in order to be sold in any particular area, and that makes them suitable," Carbah explains. "So whether it's the best plan on the market or something that's really lacking a lot of value, it doesn't really matter. It's legal to be sold, which means I could recommend it and that is a suitable recommendation."
The parallel to the securities world is exact and instructive. During the 2010s, a wave of lawsuits forced a reckoning in that industry: advisors had been making recommendations based on commission structures, and anything legally sellable was considered suitable. Regulators stepped in and imposed fiduciary standards on securities advisors. "And that is now starting to translate over onto the healthcare side," Carbah says, pointing to a growing body of litigation targeting brokers and consultants for undisclosed conflicts of interest.
Ethos did not wait for regulators. From its inception, the firm has operated under a voluntary fiduciary standard, written directly into every consulting agreement it signs. "It wasn't required by anybody," Carbah notes. "It wasn't a regulatory obligation, but it was an obligation we wanted to make."
In practice, that means Ethos does not accept medical carrier commissions. Compensation is fee-based, entirely aligned with the value created for employer clients. The firm has built a fiduciary framework validated by an independent third party, backed by rigorous documentation, so that every decision an employer makes can be traced and defended. It also means Carbah's book does not include a quiet internal favorite on any given spreadsheet.
The results are, by any measure, compelling. Ethos clients on average perform 10 to 40 percent better on both financial and health outcomes compared to organizations of similar size and risk profile. "Solely because we're looking at it from a fiduciary standpoint," Carbah says, "and not from solely the traditional or safe-option standpoint."
The architecture of Ethos is best understood through its founder. Donovan Ryckis came from the securities side of financial services, where fiduciary thinking was already becoming embedded after years of litigation and regulatory pressure. A client of his, facing a 30 percent increase on their employer health plan, asked for help.
Ryckis spent a couple of weeks immersing himself in healthcare. The proposal he brought back did not simply soften the renewal increase. It came in 12 percent below the client's existing rates. His reflection on that outcome has since become something of a founding philosophy for the firm: "I thought to myself, I'm not smarter than all of these other people who are out here doing this. I just did it with the fiduciary mindset."
He also saw what was coming. More than a decade before the healthcare benefits lawsuits now making headlines, Ryckis predicted that the industry's structural conflicts of interest would eventually face legal scrutiny of the kind that had already reshaped the securities world. He moved entirely into healthcare, brought Chelsea on as a partner and, eventually, as his wife, and built a firm around the principle that good ethics and good business outcomes are not competing interests but the same thing.
"We believe that we will be rewarded for doing good work," Carbah says, articulating the firm's philosophy, "and that our compensation should be in direct alignment with the value we're creating for employers and not with the value we're creating for an insurance carrier."
Ethos has now been operating on this model for between 10 and 15 years. "We're now starting to see more and more brokerages take this framework and make it their own," Carbah observes. She welcomes it. "A rising tide will lift all boats."
Understanding what Ethos actually does for its clients requires understanding how a health plan is structured, because most employers, and many of their employees, do not.
Every employer-sponsored health plan, regardless of how it appears on the surface, has four parts.
Provider Network – This determines which doctors, hospitals, and healthcare providers members can use, where they can receive care, and how much they will pay for those services.
Administrative Fees – These include both broker fees and Third-Party Administrator (TPA) fees. The TPA is responsible for administering the plan, including processing and adjudicating claims.
Pharmacy Benefit Manager (PBM) – This component manages prescription drug benefits and costs.
Stop-Loss Insurance – This is an insurance product that protects the plan sponsor from catastrophic or unexpectedly high claims costs. It provides financial protection when claims exceed the amounts the plan sponsor has projected or is reasonably able to retain.
On a traditional fully insured plan, all four of those components are typically owned by the same parent company. Blue Cross, United, Cigna, Aetna: these are not simply insurers but vertically integrated conglomerates with ownership across the network, the pharmacy, the claims administrator, and often the hospital systems and pharmacy chains that employees use. The result, as Carbah describes it, is a closed box. "It's a really good way and a really easy way to pass money back and forth between entities when it's all flowing upward to the same parent company, the same shareholders, the same people who are making those decisions."
Ethos breaks that box open. It shops each component independently, driving genuine competition among stop-loss carriers, third-party administrators, and pharmacy benefit managers who are not sheltered by dominant market share. "Blue Cross or Cigna, 300 lives is not going to make or break their profit margins for that year," Carbah points out. A specialist stop-loss carrier, by contrast, will negotiate hard, offer better contract terms, and deliver faster service because that business genuinely matters to them.
The firm's vendor vetting process is exacting. Every contract is reviewed in full and redlined. Clauses that are standard in traditional carrier agreements but entirely hostile to employer interests, such as restrictions on data access, prohibitions on third-party auditing, and limitations on how claims data can be used in future decision-making, are identified and challenged. "They sound ridiculous when you say them," Carbah says of such clauses, "but we see them every single day."
If there is a single area where the financial distortions of the current system are most visible, it is prescription drugs.
Carbah's explanation of how pharmacy pricing operates in the traditional model is a masterclass in how legal arrangements can produce outcomes that serve almost no one but the intermediary. A pharmacy benefit manager can charge a health plan $75 for a drug it sourced for $5. Drug manufacturers can pay to have their products placed at a lower formulary tier, meaning a branded drug with a $5 copay for the employee may be costing the health plan thousands of dollars, while the generic equivalent at a $25 copay costs the plan next to nothing.
"Any person who wants to be a wise consumer is going to choose the $5 option," Carbah notes. "What they don't know is on the back end, that $5 medication is being charged to the health plan $5,000. And that $25 would cost the health plan $150."
The real-world numbers can be extraordinary. A recent Ethos client had almost $100,000 of annual spend on a single prescription medication for one plan member. The drug was administered four times a year, at $25,000 per dose. An independent, fiduciary pharmacy benefit manager priced the same medication at $4,000. The client's spend on that one drug dropped from $100,000 to $16,000 in a year: an $84,000 saving from four claims for one person.
"It's the same medication," Carbah says plainly, "the same formula from the same manufacturer. It just is being paid for in a reasonable way."
Solutions such as Mark Cuban's Cost Plus Drugs, which lists the actual cost of medications alongside a transparent markup and allows both direct individual access and integration through fiduciary-aligned pharmacy benefit managers, represent exactly the kind of competition-driven alternative that Ethos actively incorporates into client plans. International sourcing programs, which allow medications to be brought in from countries such as the United Kingdom or Canada as personal imports, are also part of the toolkit, albeit one that Carbah acknowledges sits in a regulatory gray area that advisors and clients must navigate carefully.
Ethos operates primarily in the mid to large employer market, working with organizations of 100 insured and above. Their largest engagements have involved organizations with 20,000 to 25,000 employees. There is no current ceiling.
For smaller employers, Carbah is clear that the same principles and many of the same solutions are accessible through advisors who specialize in that segment. What matters most, across every size of organization, is that employers understand the leverage they actually hold.
"Most employers did not get into whatever business they're in because they wanted to be health insurance companies," she observes, "but unfortunately they have to be." Benefits spend is, for the overwhelming majority of employers, among the top three line items on the profit and loss statement. And yet many have signed away their data rights, accepted renewal increases as inevitable, and assumed that the familiarity of a well-known carrier logo is equivalent to value.
It is not. And the assumption that a large, long-established brokerage will have more market leverage than a leaner, fiduciary-aligned firm is equally mistaken. "If anything," Carbah says, "there is a good chance that they're more ingrained in the system." The voluntary benefits lawsuits that emerged in December 2025 named a number of such brokers, with allegations of undisclosed conflicts of interest and compensation structures that effectively transferred consulting fees onto employees without their knowledge.
Her practical counsel to employers is direct. Access your data, and insist on that access as a contractual right. Around 80 percent of medical bills contain billing errors, from duplicate charges to surgical procedure codes that are billed twice over in different line items. "We need someone to catch the mistakes," Carbah says. Reference-based pricing, which anchors reimbursement to hospitals and facilities at Medicare and Medicaid rates, is another increasingly viable tool that can meaningfully reduce employer outlay without compromising employee access to care.
On the question of plan structure, her advice is equally clear. Fully insured plans transfer all risk to the carrier, but offer no upside in years when claims run well. "With a level-funded or self-funded program, if you have a good year, that money's going to come back to you in some form or fashion. You're paying for claims as they incur, not for what could possibly happen plus a profit delta."
And when employers already have a broker relationship they value? "Ask them to go fee-based. Ask them to take a fiduciary standard of care and see what happens. The worst they can say is no." The best outcome is that they do it, and the industry shifts a little further in the right direction.
Employers looking to find fiduciary-minded consultants can start with the Validation Institute, which maintains a directory of individuals operating under a more fiduciary-aligned framework. For contract benchmarking, Mark Cuban's Cost Plus Wellness has published sample contracts that reflect what good vendor agreements should look like. Carbah notes, with a practical candor that is characteristic of her throughout, that AI tools can now be used to compare existing contracts against those benchmarks in a matter of minutes.
"We are small in numbers but we're mighty in force," she says of the fiduciary consulting community. "And we will become more."
It would be easy to assume that someone who talks about healthcare reform with Carbah's intensity carries it home every evening. She does think about it in her personal time, she admits freely, "because it is such a monstrous task to accomplish." But she is equally deliberate about compartmentalization.
Carbah lives back in Montana now, and she means it when she says the landscape helps. Rivers, creeks, streams, waterfalls and trails: the state offers an outdoor life that she takes full advantage of. She is also, she notes with some pride, the mother of four dogs and three cats, all of whom have opinions about the schedule.
Beyond the outdoors, her leisure pursuits have a breadth that verges on the impressive. She crochets, reads voraciously across fiction and nonfiction, bakes sourdough and has recently added pottery to a schedule that also includes violin practice.
"If you ask me to go tie-dye on a mountaintop tomorrow," she says, "I am probably going to be there."
It is, perhaps, not an entirely different instinct from the one that led her to send a cold email to a stranger at a conference, or to walk away from a commission structure that many in her position would simply have accepted. The willingness to reach for something better, even when nobody else is requiring it, appears to be a consistent trait. The healthcare industry, one suspects, will be hearing more from her.
