5 key takeaways for benefits leaders from Bloomberg's Vanguards of Health Care Podcast.

For benefits leaders navigating the complex and rapidly evolving PBM landscape, here are the five biggest takeaways from the podcast to help you stay informed—and ahead. 

1. Pharmacy benefits are confusing by design. 

The PBM market is incredibly complex. “Pharmacy benefits have become so complicated that expecting anyone to understand them—unless it’s their full-time job—is just unrealistic,” says Feldman.

But that complexity isn’t accidental. Traditional PBMs have built a system riddled with jargon, convoluted pricing models, and rebate schemes, which leaves employers to navigate a foreign language of terms like AWP, spread pricing, and gross-to-net gaps, while member experience is sidelined in favor of profits. The result is a perverted marketplace where confusion breeds complacency—and the status quo stays firmly in place.

2. Employers are fed up with point solution overload. 

The proliferation of digital health point solutions has created “a monstrosity to no one’s benefit,” says Feldman. Many of these tools suffer from low levels of engagement, low levels of retention, and low levels of customer satisfaction and loyalty, too. Today, Feldman sees that employers are shifting toward fewer, more integrated solutions that address foundational needs like medical, pharmacy, and behavioral health.

3. Navigation alone can’t fix a broken system. 

Care navigation is important—but, as Feldman realized—without the support of an aligned PBM, it hits a ceiling. “Every time we tried to help a member shop for a drug, optimize for lowest net cost, or think about therapeutic equivalents, there was essentially no partnership on the PBM side,” said Feldman. 

“We couldn’t just be this information and navigation layer on top of a fundamentally misaligned system,” Feldman realized. The lack of transparency and cooperation from traditional PBMs made it nearly impossible to deliver meaningful results. To truly support members and control costs, Rightway had to rebuild the pharmacy benefit to work with, not against, navigation. 

4. Regulation and litigation are forcing employers to pay attention. 

While federal reform may be slow to reach the employer market, state legislation—like Arkansas’s ban on PBM-owned pharmacies—is beginning to chip away at industry practices. But it’s litigation that’s truly shifting behavior. Recent lawsuits are making benefits leaders question the safety of sticking with the legacy PBMs. According to Feldman, “It’s taken some of the conservatism out of the benefits decision to say, ‘Maybe by just renewing, we don’t protect ourselves against this risk, so we could try something new.’”

5. Specialty drugs and GLP‑1s are driving unsustainable cost growth. 

Rising spend on specialty medications and weight loss drugs like GLP‑1s is straining pharmacy budgets. “There are companies spending $50, $100, $150 million on these drugs,” says Feldman, “and they’re saying, ‘I’m not seeing the corresponding decrease in medical costs. I’m certainly not seeing my overall PMPM pharmacy spend come down.’”

Many employers lack visibility into whether these high-cost drugs are being used appropriately, or at all. The industry is now being forced to ask not just “are we covering these drugs?” but “are we managing them well?”

To see how a transparent, integrated PBM and care navigation solution actually works, book a demo with Rightway today.