Making Drug Spend Visible in Value-Based Care
If you ask a health system leader how much they spend on pharmacy, they might give you a number. Ask them where that number lives, who manages it, or how it connects to clinical strategy, and the answers get fuzzier.
The Visibility Problem
In value-based care (VBC), pharmacy spend should be visible, actionable, and strategically aligned. Too often, it’s not. It’s carved out, separately contracted, buried in fee-for-service logic, or treated as a black box passed between vendors. Meanwhile, drug therapies are central to chronic condition management, cost avoidance, and patient outcomes. So why the disconnect?
Legacy Structures, Fragmented Oversight
One reason: legacy financial structures. Another: pharmacy benefits are often administered with operational logics designed for transaction management, not clinical value. And sometimes, the challenge is simply that pharmacy isn't viewed as part of the core clinical infrastructure, even when it clearly is.
How CMS Models are Raising the Stakes
This is exactly what new CMS models like ACO REACH and AHEAD are beginning to expose. Participants in these models are now accountable for total cost of care, and that means dealing with pharmacy spend as something more than a line item. The AHEAD model in particular emphasizes improved medication management for chronic disease, which creates clear pressure to understand and manage pharmacy costs at the population level. The ACO REACH model, as of 2025, requires participating ACOs to manage total cost of care, which explicitly includes pharmacy expenditures. Recent CMS evaluations highlight the need for integrated pharmacy data to support these goals. Meanwhile, PBMs are increasingly being pushed toward transparency and value-based contracts.
What Leading Systems are Doing Differently
The good news? Systems are starting to fix this. We’re working with organizations embedding pharmacists in primary care teams, standing up dashboards to track drug utilization in real time, and linking pharmacy data to risk adjustment and quality performance. Others are revisiting how drug costs are booked internally, creating internal accountability for pharmacy strategy, and folding pharmacy into cross-functional clinical operations.
Where the Work Gets Technical, but Valuable
We’ve seen systems run parallel financial reconciliations to untangle what they're actually paying PBMs versus what they think they're paying. We’ve supported clinical teams trying to manage adherence while having no visibility into fill data. And we’ve worked through re-architecting data feeds to get around payer portals that weren't designed for any of this.
It’s not flashy work. But visibility is the first step to strategy. And strategy is what gets you from "pharmacy as a cost center" to "pharmacy as an asset."