When we helped build the modern pharmacy benefit model, we believed in its purpose: to bring order, scale, and affordability to a fragmented market. Over time, the system became burdened by the very complexity it set out to solve. Gross-to-net distortions, opaque routing, and patient abandonment at the counter have eroded trust on all sides.

Now, as EVERSANA, a company combining commercialization expertise with Waltz Health’s technology-driven marketplaces, we have a simple conviction: reform will not come from government-mandated price controls. It will come from how we, as an industry, choose to work together. That starts with how pharma and pharmacy benefit managers (PBMs) coexist.

Why price controls miss the mark

Government price controls make for good headlines but bad health policy. They are static solutions to a dynamic problem. Drug affordability challenges shift daily across benefit designs, channel markups, and inventory costs, yet price controls lock the system in place.

Price controls also risk unintended side effects: throttled innovation, delayed launches, and fewer therapies making it to market. Specialty manufacturers feel it most, especially when early-stage therapies depend on predictable returns to fund future R&D.

Instead of ceilings on price, we need a floor of transparency: real-time visibility into net pricing, contracting, and patient cost share. When data flows freely across stakeholders, competition can do what regulation rarely does: lower prices faster while preserving innovation.

PBMs still matter when they modernize

Despite the criticism, PBMs still perform critical functions. They aggregate buying power, manage formularies, and optimize use of cost-effective options. The issue is not their existence; the issue is
their evolution.

Modern PBMs, or PBM-like functions, should operate with full line-of-sight to net price and patient outcomes. Full line-of-sight means audit-ready pricing, transparent administrative fees, and data-driven measurement of access
and affordability.

At EVERSANA, we think of this as functional transparency: bringing core PBM capabilities into the open so pharma, payers, and patients can all benefit. It is not about dismantling PBMs. It is about rewiring the system to compete on the metrics that matter:

• Net price versus list price
• Time to fill
• Patient out-of-pocket cost
• Abandonment and persistence rates

When those measures become the standard, the incentives shift. PBMs that modernize around transparency and performance will thrive, while those that resist will lose ground to more agile, technology-enabled competitors. The market is already rewarding partners who are willing to show their math
and compete on total value, not just rebate volume.

If PBMs evolve in that direction, they can remain vital partners in helping patients access the medicine they need: faster, more affordably, and with better support along the way.

Compete on the fill: Where marketplaces make the difference

The next generation of cost control is happening at the transaction level, not the formulary level. Technology now allows dynamic routing that sends each prescription to the pharmacy or channel that delivers the best total value: lowest net cost, fastest turnaround, strongest adherence, and optimal healthcare outcomes.

That is the logic behind competitive drug marketplaces. They let pharmacies and PBMs compete on clinical, service, price, and performance. We are already seeing this model work with health plans and employers that use marketplaces to process specialty prescriptions in real time.

When pharmacies and fulfillment partners compete, the market self-corrects—prices drop, fill rates increase, outcomes improve, and the data loop between pharma and payer tightens.

For manufacturers, this model means cleaner rebate and chargeback accounting, fewer abandoned scripts, and better insight into therapy performance post-launch. For payers, it means affordability without added administrative layers. For patients, it simply means faster access at a lower cost.

A coexistence playbook for pharma

Pharma does not need to wait for legislation or litigation to drive reform.
The opportunity is to shape coexistence—to engage PBMs and payers as partners in transparency.

1. Contract for transparency. Move beyond rebate-only economics to contracts that reveal net price movement across the supply chain. Disallow duplicate discounts and revenue leakage that distort affordability metrics.
2. Co-design benefit pathways. Work with payers and PBMs to test lower out-of-pocket models for high-impact therapies, especially in specialty categories like obesity or oncology. The goal is to align clinical value with financial access.
3. Route with intent. Place therapies in marketplaces that can steer fills dynamically, rewarding partners that deliver the best total-value performance. Require real-time reporting on cost, service, and adherence.
4. Measure what matters. Insist on shared dashboards that track abandonment, time to therapy, and total cost of care. Tie a portion of service fees to measurable outcomes.
5. Pilot, then scale. Start small—one region, one therapy, one payer. Publish results and expand. Demonstrations will do more to reform the system than declarations ever will.

The private sector path beats policy paralysis

Regulatory pressure on PBMs is at an all-time high, and it is warranted. But change through legislation moves at the speed of politics, not patients. In contrast, the market is already moving. Employers are experimenting with direct-to-payer models. Health plans are embracing transparent marketplaces. Manufacturers are testing new contract structures that reward value instead of volume.

Coexistence does not mean capitulation. It means recognizing that PBMs—modernized, accountable, and transparent—can remain essential partners in the affordability equation. The private sector has both the technology and the incentive to fix what is broken faster than Washington can.

At EVERSANA, we see this play out every day. When stakeholders share data and incentives align, costs fall and adherence rises. The Serve You Rx collaboration, for instance, reduced specialty spend by double digits and improved patient access timelines, not through regulation, but through smarter routing and aligned incentives.

A new kind of middle

The pharmaceutical marketplace does not need fewer stakeholders; it needs better alignment among them. Pharma brings innovation. PBMs bring scale. Marketplaces bring competition. When those three forces operate in sync, patients win, and so does every participant in the value chain.

As someone who has led organizations on both sides of the equation, I believe reform will come not from eliminating the middle, but from reinventing it. We can coexist, and in doing so, deliver lower net prices, faster access, and better clinical outcomes for the people who matter most: the patients counting on us.

This is the commitment we are building toward every day: to connect manufacturers, payers, and pharmacies through transparent, data-driven infrastructure that rewards value, not volume. Because the path to lower drug costs and better outcomes is not about who controls the middle, but rather, it is about how the middle works.

That is the work ahead, and it is happening now.

About the Author

Mark Thierer is the CEO of EVERSANA.