Are your PBM's incentives aligned with yours?
For regional health plans and health systems, pharmacy benefit management is often treated as a procurement problem: negotiate harder, improve rebates, tighten guarantees, and push for better unit economics.
But the more important question may be structural:
What happens when the company managing your pharmacy benefit is also competing with you?
The largest PBMs are increasingly part of vertically integrated healthcare enterprises that also own health plans, specialty pharmacies, mail-order pharmacies, provider assets, and other healthcare services. That means your PBM may not simply be a vendor. Its parent company may also be competing for members, patients, pharmacy volume, provider relationships, and market share.
Vertical integration changes the PBM relationship.
Consider a health system that operates its own specialty pharmacy. It may have invested heavily in pharmacists, accreditation, clinical workflows, financial assistance, and patient support.
But if its PBM also owns a specialty pharmacy, the PBM may have a financial incentive to direct prescriptions toward its own asset.
The same issue can arise with mail order and other pharmacy services.
These decisions do not have to be malicious to create a conflict. They are the predictable result of organizational incentives.
For health systems investing in specialty pharmacy, infusion, ambulatory pharmacy, or medication management, PBM strategy should reinforce those investments rather than compete with them.
Are you getting the PBM's best economics?
Vertical integration raises another question for regional health plans:
If your PBM’s parent company owns a competing health plan, are you receiving the same economics it provides its own affiliated business?
A vertically integrated healthcare company has a rational incentive to optimize economics across its entire enterprise. That does not necessarily mean outside customers receive poor pricing, but it does mean regional plans should understand whether the best economics are being preserved internally.
Traditional PBM contracts can make that difficult to see.
A contract may include aggressive rebates, discounts, and guarantees while still providing limited visibility into where value ultimately accumulates across the pharmacy supply chain.
The goal should not simply be the largest rebate or most attractive discount. It should be the lowest total pharmacy cost, while preserving transparency, clinical flexibility, and strategic control.
Your data and dollars are strategic assets.
PBMs sit at an important intersection of healthcare data. They can see prescribing patterns, utilization, specialty trends, provider activity, and member behavior.
For regional health plans and health systems, that data is strategically valuable.
So are the dollars flowing through the pharmacy benefit.
When a regional organization directs significant pharmacy spend through a vertically integrated national healthcare company, some of that economic value may ultimately support an enterprise expanding its own health plan, pharmacy, provider, or healthcare services businesses.
In effect, a regional organization can find itself providing both the data and economic fuel that strengthen a national competitor.
Executives should ask not only, “What are we paying?”
They should also ask, “What are we enabling?”
Who controls pharmacy utilization?
One of the clearest examples of incentive misalignment is pharmacy steering.
A health system may spend years building a retail or specialty pharmacy, only to find that its PBM contract determines where prescriptions can be filled.
Network rules or specialty pharmacy requirements can direct utilization toward PBM-owned pharmacies rather than the health system’s own assets.
The consequences extend beyond pharmacy margin. They can affect patient experience, care coordination, access to clinical data, and the health system’s ability to manage complex patients across the continuum.
The strategic question is simple:
Who controls where pharmacy utilization goes?
An aligned PBM should support the organization’s strategy. If a health system wants eligible specialty prescriptions directed to its own pharmacy, the infrastructure should support that.
A New Model - Own the PBM and the Strategy
Replacing one vertically integrated PBM with another may improve pricing or contract terms, but it doesn’t change the underlying incentive structure.
There is another option: the independent, aligned PBM model.
That is the model NeosRx has developed.
NeosRx is designed to give health plans and health systems greater control over pharmacy economics, claims routing, and utilization, without requiring them to contract with a competitor to manage their pharmacy benefit.
NeosRx gives health plans and health systems greater control over pharmacy economics, claims routing, and utilization without requiring them to contract with a competitor to manage their pharmacy benefit. Organizations can use NeosRx as an independent PBM partner, create a private-label PBM experience under their own brand, or structure deeper ownership and joint venture models that keep more strategic and economic value within their organization.
The result is more than a different vendor relationship. It is an opportunity to own more of the pharmacy strategy, share value created, and transform pharmacy spending from an expense into a strategic enterprise asset.
PBM Strategy is Enterprise Strategy
Pharmacy intersects with some of healthcare’s biggest strategic priorities: specialty drug growth, affordability, patient retention, ambulatory care, data, population health, and margin.
That means PBM strategy can no longer be viewed only as a procurement decision.
Boards and executive teams should be asking:
- Does our PBM or its parent company compete with us?
- Where does our pharmacy spending create revenue for affiliated businesses?
- Who controls specialty, mail-order, and retail pharmacy routing?
- Can we direct appropriate utilization to our own pharmacy assets?
- When we reduce pharmacy costs, does our PBM benefit alongside us?
These questions reveal something a spreadsheet of rebates and guarantees cannot:
Alignment.
Regional health plans and health systems do not have to contract with a competitor to manage one of their largest and most strategic areas of spending.
An independent PBM model offers another path—one designed to support the organization’s strategy, preserve control, and turn pharmacy from an expense into an enterprise asset.
