Forty Years In. Here's What I Keep Coming Back To.

March 3, 1986. I walked a resume into an independent TPA and had no idea what TPA even stood for. A gentleman named Kent Bruce recognized me, hand carried my resume to Steve Lewis and said we need to hire this guy. That was the beginning of forty years in employee benefits.

I have been thinking about what to say to mark this. Forty years is a long time. My daughter had just turned 1 and now she is 41. I celebrated her birthday with the annual bouquet of yellow roses (41…one for each year) and somewhere in there I lost a full head of hair. Bald Guy Bob would not exist without the experiences of those four decades, so I have made peace with it.

But what really occupied my thoughts on a recent flight was not the personal milestones. It was the industry itself, and a pattern I keep seeing. A lot of what gets called "new" and "innovative" today is actually quite old. It was disruptive once before. We dealt with it, moved past it, and somehow circled back to calling it revolutionary again.

Let me walk through four examples.

Direct Primary Care

There is a lot of energy right now around DPC, bringing back the primary care physician, smaller patient panels, real access, little or no cost to be seen. Employers are excited about it. Advisors are pushing it. And it is a good idea.

It is also basically an HMO from the late 1980s and early 1990s. Brick and mortar. A physician who knew you. Imaging on site. Medications dispensed. The quarterback of your care, coordinating everything, accessible and affordable. We called them "doc in a box" back then, and they were considered innovative. DPC is the same concept with better branding and thirty years of distance from the managed care backlash that killed the first version.

Transparency and Data Access

Employers today are frustrated that they cannot get their claims data from their carrier. It is proprietary, they are told. You cannot have it. This is driving a real movement toward independent TPAs and self-funded arrangements, and for good reason.

Here is what is interesting. The independent TPA model was largely built for this exact reason in the late 1980s and early 1990s. Self-funded employers wanted their data so they could make better decisions on medical management and pharmacy costs. The carrier would not give it to them. Sound familiar? The problem has not changed. The vocabulary around it has.

Fiduciary Responsibility

The word "fiduciary" gets treated right now like it just arrived. There are conferences on it. Consultants specialize in it. Advisors lead with it.

ERISA was signed in 1974. The fiduciary standard, the responsibility to act in the best interest of your plan participants and do your due diligence with vendors, has been federal law for over fifty years. The concept is not new. The attention being paid to it might be, which is fine, but let's not pretend we invented it.

Reference Based Pricing

RBP has a reputation for being aggressive, disruptive, and hard to sell. Employees push back. Providers push back. It is the three-letter term a lot of people would rather avoid.

Forty years ago, the same function existed under the name Usual, Customary, and Reasonable. UCR was the standard basis for benefit payments. Eighty percent of UCR was a common benchmark for self-funded employers. The primary reference point for establishing that UCR standard? Medicare. The same reference point RBP uses today. Same concept, same math, different name, and for some reason a completely different political problem.

None of this is meant to dismiss real advancement. Healthcare delivery has changed enormously. The clinical tools available to patients today, the quality of care, what is possible for people living with serious conditions, that progress is real and genuinely worth celebrating. As a patient with my own electrical problem, I appreciate it personally.

But the foundational questions, how do employers get their data, how do they pay fairly for care, how do they give their people real access to a primary care relationship, how do they meet their legal obligations to their workforce, those questions have not changed much in forty years. We keep rediscovering them and acting surprised.

Forty years in, I am not done. I am honestly just now hitting my stride. The next ten years matter more to me than the last forty, because I think we are at a real inflection point for people who actually want to change how employer healthcare works. There are advisors out there doing serious, consultative work. There are HR professionals asking harder questions. There is a genuine appetite for something better. There is a community “committed to making healthcare more affordable by improving access to high-quality healthcare for American working families and their employers because that’s who we are and that’s who we care about.”

A lot of what is new is very old. But the people trying to get it right, those feel new to me, and that is reason enough to keep going.