Preferred Provider Organizations (PPOs) are the most prevalent type of commercial health plan in the United States. However costs and service have been in question lately. According to the Kaiser Foundation, employee health care premiums have risen 47% and deductibles have risen 68% in the past decade, compared to an only 31% increase in wages. The American Public Journal of Health has reported that approximately 530,000 families file for bankruptcy each year because of medical bills.

However, nearly 50-year-old ERISA laws have allowed plan sponsors to change and set up the way they provide health or benefit plans. One such method are reference-based pricing (RBP) plans, which allow sponsors to set the pricing model (sometimes based on Medicare) that will be reimbursed to plan participants as opposed to the typical "charge master-down" model discount that is typical in most of the carrier-based models.

As time has passed, more weight has been placed on the fiduciary to make sure they are operating a plan in the interests of their own responsibility, but also of their employees. Fast forward to 2010 when the Affordable Care Act was enacted and many of the top carriers changed how they began measuring costs, which has affected employer costs. Tom Wittik, Senior Vice President, Growth, Imagine360, says there have been increases of as high as 30% year-over-year, which is why RBP is becoming of more interest to employers.