If you have been waiting for the right moment to have a different conversation with your employer clients, Justin Fallein (pictured) has a message for you: that moment has arrived and if you are still waiting, someone else is already having it.
Fallein is VP of Business Development at Healthcare Highways, the Frisco, Texas-based company behind the Centrus Health Direct network. He has nearly 25 years in the group benefits industry behind him, having worked as a carrier employee, a general agency producer, and a TPA sales leader before landing where he is now. He has seen this market from every angle, which is probably why he speaks about it with such clarity.
"Brokers that are sitting idle and continuing to quote and spreadsheet and not really having strategic conversations about how to get employers to a better place, that's not going to last much longer," he said, without a great deal of ceremony.
He is not wrong.
Healthcare Highways builds what Fallein calls intentional high-performance networks, contracting individually with hospitals and health systems in a given geography rather than rolling out a standardized national product. The goal is savings of up to 20 percent on medical claims compared with broad Blue Cross and Blue Shield, UHC, Cigna, and Aetna networks on the same claims, same providers.
The reason providers are willing to engage with this model comes down to a simple and uncomfortable truth about how the big payers actually treat hospitals. Fallein tells the story of one of his current hospital partners who renegotiated a contract with a dominant payer in the Kansas City market. On paper, they were set to receive a 6 percent reimbursement increase in 2025. When the numbers were actually crunched, it netted out to less than 1 percent.
"There's a very contentious relationship between the big payers and the hospital systems," he said. "It stems from those payers continually putting pressure on the providers and utilizing various contract provisions to reduce payment."
That dynamic, repeated across thousands of claims every day, is why providers are increasingly receptive to commercial arrangements that sit entirely outside the big-payer system. Three of the largest health payers in the country are also among the biggest US corporations by revenue, generating billions in profit administering the employer-sponsored plans that most US workers depend on. "That's counterintuitive for employers that are trying to save money," Fallein noted, with admirable understatement.
This is where the conversation shifts from benefits administration to benefits strategy. Many employers, and even some advisers, spend far more time evaluating plan design than examining the mechanics of network access and reimbursement. Yet provider utilization patterns, network strategy and the contractual provisions that govern complex, high-cost care can be some of the most influential drivers of a plan's financial performance.
It is also an area where technical expertise can make a measurable difference. Fallein argues that the underlying provisions within network and reimbursement agreements deserve far greater attention, as they can materially affect an employer's healthcare spend and the long-term sustainability of a plan.
In practice, that can mean employers paying more when their most expensive claims arise. An intentional network, he says, addresses those issues upfront by negotiating more favourable terms from the outset. Healthcare Highways also conducts a geo-access analysis, using zip-code-based mapping to assess how closely a network footprint aligns with where an employer's workforce actually lives. It is the kind of detail, Fallein believes, that separates a plan that performs well in the real world from one that simply looks good on paper.
The structural threat to the traditional brokerage model, in Fallein's view, is fiduciary liability exposure. Employer lawsuits are growing, and they are testing a straightforward question: are advisors presenting all available options, or only the ones that generate the highest commission? The Department of Labor's (DOL) Employee Retirement Income Security Act (ERISA) fiduciary framework has already tightened the lens. The legal community is now following through on what the regulations imply.
"For a long time, the industry has approached healthcare spend in largely the same way," Fallein said. "Employers receive data, advisers analyze the results, and then everyone prepares for the next renewal cycle. We're beginning to see a shift in thinking, but many organizations are still operating within a framework that hasn't materially changed the trajectory of rising healthcare costs. Sometimes the opportunity isn't to work harder within the existing model, but to look at the problem differently."
It is not a comfortable question, but it is the right one. Younger consultants entering the industry without legacy ties to the bundled model, he says, are already answering it, approaching benefits as a problem to solve rather than a product to sell.
His advice to everyone else is practical. Find an independent, non-BUCA TPA. Sit down with them. Learn how an unbundled program actually comes together. "If you're a broker and you're not at least familiar enough to talk intelligently about unbundled programs, somebody else is going to come in and do it. That's just how it is right now."
And the idea that self-funded is only for larger groups? "We've got groups that came on last year with under 100 employees that did a full self-funded program." Once employers make the move, they stay there. "Groups don't go unbundled and then go back to the traditional setting. They go unbundled and then they tweak and they continue to change and customize and make it fit their organization."
"I don't recall a time in my career where there's been more interest and more engagement from employers around doing something different. I just don't recall a time."
When the working day finally ends for Justin Fallein, the man who spends his hours challenging billion-dollar corporations and their systems closes his laptop, heads home to his family, picks up a golf club when he can, and by his own admission just tries to live grateful. There is something quietly compelling about that, a person who sees the industry's flaws as clearly as anyone, fights hard to change them, and then goes home and counts his blessings. Perhaps that perspective is exactly what makes him so effective at work.
"I'm just trying to live grateful, be thankful for everything we have, because we're absolutely very blessed."
In an industry that can grind people down, that is no small thing.
