The self-insurance industry isn't usually described as "glamorous," but if you spent any time in Phoenix for the SIIA National Conference 2025, you know the energy felt different this year. It wasn't just the usual networking over lukewarm coffee. There was a genuine, almost frantic pulse underneath the sessions. Why? Because the middle market is currently getting crushed by traditional insurance carriers, and people are finally fed up.
Self-insurance used to be the playground of the Fortune 500. Not anymore.
Small to mid-sized employers are moving into the space in record numbers. This year’s gathering of the Self-Insurance Institute of America (SIIA) proved that the "alternative" market is becoming the primary market. If you missed it, you missed the blueprint for how companies are going to survive the next five years of healthcare inflation.
The Captive Explosion and Why It’s Not Just a Buzzword
Everyone at the SIIA National Conference 2025 seemed to have "captive" on the tip of their tongue. It's become the industry's favorite tool, but the nuance is where things get interesting. We aren't just talking about single-parent captives anymore. The real heat is in group captives.
Think about it this way. A 50-person manufacturing firm has zero leverage against a massive blue-chip carrier. None. They take the 15% renewal increase and they cry about it. But when you bundle fifty of those manufacturing firms together into a member-owned captive? Now you have the scale of a 2,500-employee corporation. You’re the boss. You own the profit that the insurance company used to keep.
One of the most intense debates in the hallways—not just the sessions—was about the "domicile" wars. For years, Vermont was the undisputed king of captives. But Tennessee and North Carolina have been aggressive lately. They’re making it easier, faster, and cheaper to set up shop. The 2025 conference highlighted that the choice of domicile is becoming a strategic chess move rather than a clerical box to check.
Stop-Loss Carriers are Getting Picky
The stop-loss market is the backbone of self-insurance. If you don't have a good stop-loss partner, one catastrophic claim—like a $2 million premature birth or a specialized gene therapy treatment—can bankrupt a small plan.
At the SIIA National Conference 2025, the vibe from the carriers was... cautious.
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They’re seeing the same thing everyone else is: the "laser." For the uninitiated, a "laser" is when a carrier excludes a specific high-risk individual from the general deductible, forcing the employer to take on more risk for that one person. It’s a brutal practice. The conversation this year shifted toward "No-Laser" renewals. Brokers are fighting harder for these contracts because employers are tired of being penalized for having one sick employee. It's a fundamental shift in how we view the "social" aspect of insurance.
The $3 Million Drug Problem
We have to talk about GLP-1s. Honestly, you couldn't walk ten feet at the conference without hearing about Ozempic or Wegovy. It is the single biggest headache for plan sponsors right now.
Employers are caught in a vise. On one side, employees are demanding coverage for weight-loss drugs. On the other side, the cost is absolutely nuking the plan’s pharmacy spend. Some experts at the SIIA National Conference 2025 argued that if you don't cover them, you'll pay for it later in heart disease and diabetes claims. Others pointed out that at $1,000 a month per person, the math simply doesn't work for a small business.
There isn't a consensus yet. That’s the truth.
But some of the more innovative Third Party Administrators (TPAs) are starting to bake "lifestyle management" requirements into their plans. You want the drug? Great. You have to check in with a health coach and log your nutrition. It sounds invasive to some, but it’s the only way companies are finding to keep the plan solvent. It’s about accountability, not just writing a check to Big Pharma.
Transparency and the CAA: The Law is Finally Catching Up
The Consolidated Appropriations Act (CAA) of 2021 is finally growing teeth. For a long time, it felt like a "paper tiger." Nobody was really following the transparency rules because there was no enforcement.
That changed in 2025.
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The Department of Labor is starting to look at whether plan sponsors—the employers themselves—are fulfilling their fiduciary duties. This was a massive wake-up call at the conference. If you are an HR director or a CFO, you are legally responsible for making sure you aren't overpaying for healthcare with your employees' money.
Basically, if your broker is taking "hidden" commissions from a carrier and you didn't know about it, you’re the one on the hook. The SIIA National Conference 2025 provided a lot of "defensive" strategies for this. We’re seeing a rise in "fee-only" consultants who refuse to take carrier overrides. It’s cleaner. It’s safer. It’s the future.
Artificial Intelligence in TPA Land
Technology was everywhere, but it felt more practical this year. Less "sci-fi" and more "how do we fix this broken process?"
TPAs are using AI to catch billing errors before the check is even cut. You’d be shocked—actually, maybe you wouldn't be—at how many hospitals accidentally (or "accidentally") double-bill for the same procedure. Or how many times a code for a simple office visit gets "upcoded" to something more expensive.
AI doesn't get tired. It looks at every single line item on a 50-page hospital bill in three seconds. The speakers at the SIIA National Conference 2025 were clear: if your TPA isn't using some form of automated claim scrubbing, you are leaving 10% to 15% of your spend on the table. That’s just pure waste.
The Cultural Shift: Why Direct Primary Care (DPC) is Winning
One of the coolest parts of the conference was seeing the growth of Direct Primary Care.
DPC is basically a subscription to a doctor. The employer pays $70 a month per employee, and that employee gets unlimited access to a physician. No copays. No insurance forms. No three-week wait for an appointment.
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When you integrate DPC into a self-insured plan, the "downstream" savings are massive. Because people actually go to the doctor when they’re just "sorta" sick, they don't end up in the Emergency Room at 2:00 AM for something that could have been handled with a quick check-up. The SIIA National Conference 2025 highlighted several case studies where companies saw a 20% reduction in total claims spend just by adding a DPC option. It’s the ultimate "win-win" in a sector that rarely has them.
Realities of the Reference-Based Pricing (RBP) Model
Reference-Based Pricing isn't for the faint of heart. It’s the "disruptor" model. Instead of using a traditional network (like a PPO), the plan pays a percentage above what Medicare would pay—usually 140% or 170%.
It saves a ton of money. But it causes friction.
Hospitals hate it. Sometimes they "balance bill" the employee for the difference. The 2025 discussions moved away from "how do we save the most money" to "how do we protect the member from getting harassed by hospital billing departments." Member advocacy is now the most important part of any RBP plan. If you don't have a team of advocates ready to jump in and fight those bills for your employees, your RBP plan will fail because your employees will hate you.
What’s Next for You?
The SIIA National Conference 2025 made it obvious that the status quo is dead. You can't just "renew and pray" anymore. If you’re a business owner or an HR leader, here are the moves you need to consider right now:
- Audit your broker's compensation. Ask for a written disclosure of every penny they make off your plan, including "contingent" or "bonus" commissions from carriers. If they hesitate, find a new broker.
- Evaluate a captive feasibility study. You might be smaller than you think and still qualify for a group captive. It’s worth the $5,000 to $10,000 to find out if you could be saving six figures.
- Look at your GLP-1 data. Don't just ignore it. Work with your TPA to create a clinical management program so these drugs don't bankrupt your pharmacy budget.
- Consider Direct Primary Care. It’s the easiest "bolt-on" to improve employee satisfaction and reduce ER visits.
- Check your fiduciary "hygiene." Make sure you have a process for reviewing claims and ensuring you aren't overpaying. The DOL is watching.
The world of self-insurance is getting more complex, but the rewards for doing it right have never been higher. The SIIA National Conference 2025 proved that the tools are there—you just have to be brave enough to use them. It's about taking control of your largest "uncontrollable" expense. And honestly? It’s about time.