The U.S. healthcare delivery model is undergoing dramatic changes - how should pharma plan for the changes ahead?

The below post is an excerpt from our white paper Beyond the PBM: A New Order for Healthcare Delivery.

The turn of the year highlighted the rapid transformation and stakeholder role expansion within the modern-day healthcare industry, such as:

  • A flurry of vertical integration activity during the first week of December, including the announcement of two major deals – CVS’s $69 billion acquisition of Aetna and Optum’s $4.9 billion purchase of DaVita Medical Group – signaling a marked acceleration in the evolution of the PBM competitive landscape.
  • Several health systems announcing their partnership with the US Department of Veteran Affairs to form a generic drug company to address supply shortages and reduce costs for patients – thereby cutting out intermediaries in the healthcare value chain.
  • Amazon, Berkshire Hathaway, and JPMorgan Chase publicizing plans to form an independent not-for-profit healthcare company for their US employees, a sure signal amidst the many speculations on how Amazon might disrupt the healthcare value chain.

Such changes have been a long time coming. PBMs continue to face pressure from all sides, not least from pharma companies who question their transparency and value, namely whether drug discounts are being passed through the system to enhance patient access and affordability. Meanwhile, payers and providers are looking for services to support the trend towards value-based care.

This healthcare model evolution brings a variety of threats and opportunities for pharma companies.

What key questions should companies be asking as they navigate the changes ahead?

  • Where should you place your bets for ground-breaking R&D innovation to differentiate? Which metrics will be most meaningful to payers, and how can you build outcomes data into clinical development to best demonstrate that value?
  • Are there opportunities to improve and streamline the clinical development process by getting input from payers earlier and more often?
  • Which customers matter most for your business, and which ones are going to be impactful from a product access standpoint? How can you best engage, show value, and collaborate with payers, PBMs, hospitals and other key organizations?


  • Does your reimbursement model need to evolve with the changing market? Are there scenarios for bypassing intermediaries in the system, such as applying one-time discounts up front vs. handing out rebates and co-pays on the backend?
  • Should you invest more in evaluating value-based contracts with payers directly to build brands on the real value of treatments? How can you set up the right target, deal structure, and benchmarking for risk-sharing?
  • Where should you implement pay for performance models to differentiate in competitive markets and reduce payer uncertainty?
  • How should you leverage real world evidence data to show value and effectiveness, and best communicate this to critical stakeholders?
  • Are there opportunities to partner with technology and consumer-focused companies to optimize care and improve outcomes? Which types of digital tools and platforms could move the needle in patient care?


Download the full report to learn more about healthcare delivery evolution and implications for pharma, payer, providers, and patients.


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