Six ways to augment payer, pharmacy benefit manager and drug manufacturer partnerships | Viewpoint

The relationship between payers (insurers/employers), pharmacy benefit managers (PBMs), drug manufacturers and hospital systems is complex and often misaligned. This interconnection often results in friction over pricing, network access and overarching goals.

Hospital-owned specialty pharmacies face challenges in competing with large national specialty pharmacies. Success depends on understanding payer, PBM and manufacturer requirements, which include operational and clinical standards and intentionally positioning their pharmacy to meet those expectations.

Demonstrating the value of a hospital specialty pharmacy

A hospital-owned specialty pharmacy can be viewed as a positive asset by payers, PBMs and drug manufacturers when the value is articulated appropriately.

Working with manufacturers and payers often feels like circular discussions about access. Manufacturers require hospitals to demonstrate payer volume thresholds and defined clinical needs for access to a limited distribution drug (such as an oncology medication). At the same time, payers may focus on existing limited distribution access and question whether additional network participation is necessary.

If a hospital is already receiving medications through contracted or central fill pharmacies, the payer may view the hospital as already having network access. In these situations, the hospital leaders must clearly differentiate the value of an embedded, in-house specialty pharmacy model compared to external fulfillment options.

To improve the case for network inclusion, the focus should be on the following:

Conveying patient care value through a healthcare delivery model focused on positive patient health outcomes. Hospitals can demonstrate this value through a continuity of care model where longitudinal care of patients can be fully managed by the health system through an on-site pharmacy team. This reduces fragmentation, improves adherence monitoring and enables the clinical team to manage adverse events proactively.

Aligning pharmacy services with clinical outcomes. Health systems are uniquely positioned to connect dispensing data with real-world clinical outcomes, strengthening discussions with both payers and manufacturers.

Building relationships beyond the portal submission. Network access is not achieved through paperwork alone. Transparent communication, executive engagement and clearly defined value propositions are critical to long-term partnership success.

When a specialty pharmacy is fully integrated within a hospital, improvements in patient care, adherence and total cost of care can benefit all parties.

Healthcare payer, PBM and drug manufacturer strategies

An effective strategy to strengthen payer, PBM and manufacturer partnerships should focus on six core capabilities.

1. Comprehensive data reporting

Data is key to credibility. Hospitals and health systems must be able to articulate their value proposition using analytics. Analyzing data to identify targeted growth opportunities and prioritize efforts based on volume, therapeutic alignment and financial impact is a key first step. More and more, manufacturers are expecting real-world clinical insights through data sharing. This data includes utilization trends, persistence and adherence data, adverse events, discontinuation rates and other measurable clinical outcomes. Connecting dispensing data to patient outcomes can position a hospital-owned pharmacy as a strategic partner. Executive leaders should ensure their organizations have access to meaningful data and the expertise needed to analyze, present and take action on it effectively.

2. Specialty pharmacy accreditation

Accreditation is the prerequisite for obtaining network participation. The Utilization Review Accreditation Commission (URAC) and the Accreditation Commission for Health Care (ACHC) are the two most recognized accreditations demonstrating a seal of quality for pharmacy operations and patient management services. Accreditation signals to payers and manufacturers that the pharmacy meets rigorous performance expectations related to patient management, safety, quality improvement and regulatory compliance. Because the accreditation process is detailed and resource heavy, health systems should dedicate a focused internal team or partner with an experienced specialty pharmacy organization to ensure readiness and sustainability.

3. Alignment with clinical performance standards

Beyond accreditation, pharmacies must consistently meet the clinical performance standards required by URAC, ACHC and PBMs. Policies, workflows and documentation should be regularly evaluated to ensure alignment to evolving standards. This includes defined clinical program guidelines, 24/7 patient access to care, documented care plans, cold-chain integrity validation and quality assurance monitoring.

4. Operational excellence

Embedding pharmacists and pharmacy liaisons within ambulatory care teams enables seamless coordination with providers, faster medication access and proactive resolution of barriers. Through longitudinal medication therapy management and adherence monitoring, pharmacy teams can reduce therapy interruptions and improve persistence. This integrated model improves clinical outcomes for patients.

5. Strategic contract negotiation

Once a payer target is identified as a good fit for a hospital or health system, an extensive application process is required where supporting documentation is necessary to meet requirements. Industry timelines often extend 120 days or longer and delays can be common. Maintaining a good rapport with medical payers and pharmacy benefit managers is beneficial; however, it is important to note that most communication occurs upfront during contract negotiations. Listening, being open and honest, as well as working with teams to gather necessary information before moving forward can help to set the team up for success. Also, be mindful that once approved, ongoing re-credentialing is required to ensure sustained network participation.

6. Wholesaler coordination

A deliberate wholesaler strategy can materially impact cost structure and margin sustainability. Health systems should evaluate wholesalers based on therapeutic focus, distribution access and pricing alignment with specialty pharmacy programs. Often multiple wholesaler agreements will be required to manage the full patient population. Being transparent with the wholesaler supports the negotiation process and enhances long-term alignment on pricing.

Deliberate clinical preparation, operational readiness and relationship management are required to improve payer, PBM and manufacturer partnerships. While the landscape is complex, hospitals and health systems that intentionally build on these six capabilities will be better positioned to expand access to limited distribution medications, improve patient outcomes and lower overall costs for all stakeholders.

Derek Dennis, PharmD, is senior vice president of client services for Clearway Health.