Drug Channels News Roundup, April 2026: PBM Specialty Pharmacy Steering, MLR Profit Shifting, Hospitals’ Fake Prices, and a Peek Behind the Scenes at DCI

Spring has officially arrived at Drug Channels' worldwide headquarters in beautiful downtown Philadelphia. (Photo proof at right.) So, dive into this month’s curated crop of noteworthy news:

• The patient experience at PBM-affiliated specialty pharmacies

• New evidence of profit shifting in vertically integrated Part D businesses

• The growing gap between non-profit hospitals’ public mission and financial reality

Plus: Behind-the-scenes at DCI

P.S. Join my nearly 70,000 LinkedIn followers for links to neat stuff, along with unfiltered commentary from the DCI community.

How PBMs’ Vertically Affiliated Pharmacies Shape Access Pathways for Oncology and Autoimmune Patients, IQVIA

This new IQVIA data shows striking differences in the patient experience at PBM-affiliated pharmacies compared with non-affiliated pharmacies.

Here’s our summary of the data.

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As you can see, for patients starting a new brand-name drug:

• Oral oncology: 84% approval at PBM-affiliated pharmacies vs. 70% at unaffiliated pharmacies
• Autoimmune: 63% vs. 61%

But the pathway matters:

• First-fill approvals are far higher at PBM-affiliated pharmacies (42% vs. 14% in oncology; 29% vs. 8% in autoimmune)
• At unaffiliated pharmacies, many patients only get approved after switching (14% oncology; 20% autoimmune)

Bottom line: PBM-affiliated pharmacies capture a disproportionate share of specialty volume. 

IQVIA also found that patients who overcome initial rejections get approved faster at PBM-affiliated pharmacies, e.g., 16 vs. 32 days in immunology.

The data are unambiguous, but the mechanism remains unclear. Is this (1) an efficiency of vertical integration, or (2) behind-the-scenes efforts to steer patients to affiliated pharmacies?

Click here to check out the DCI community’s lively debate on this question from LinkedIn.

Profit Regulation and Strategic Transfer Pricing by Vertically Integrated Firms: Evidence from Health Care, NBER

A new (not yet peer-reviewed) study offers compelling evidence that vertically integrated insurers strategically shifted profits within the Medicare Part D program.

The mechanism: Transfer pricing between insurers and their affiliated pharmacies in response to Medical Loss Ratio (MLR) constraints.

The authors compare price changes for the same drug and the same insurer across affiliated vs. non-affiliated pharmacies.

Key findings:

• Prices paid to affiliated pharmacies rose about 9.5% more per claim than at non-affiliated pharmacies

• The effect is stronger among insurers with lower MLRs, i.e., tighter profit constraints

• This behavior increased gross Part D drug spending by an estimated $1.2 billion from 2014 to 2016

Bottom line: Vertical integration may enable insurers to shift margins internally, potentially undermining the intent of MLR regulation introduced by the Affordable Care Act.

The figures are dated, but the methodology and results are worth a closer look.

ICYMI, we highlighted MLR research in our October 2025 and mid-April 2026 news roundups. Also, my colleague Bryce Platt posted a useful illustration of this paper.

Hospitals & Their Fake Prices, Claim Denied

Whoa. This is a must-read. Anthony DiGiorgio delivers a hard-hitting perspective on nonprofit hospitals and the growing gap between their public mission and financial reality.

He lays out the extensive subsidy ecosystem supporting hospitals:

• Property and sales tax exemptions

• Public funding (DSH payments, GME, research support)

• 340B Drug Discount Program revenues

• Market power–driven pricing from consolidated health systems

…among others

Then comes his key question: “After all of those subsidy streams, what exactly is still unfunded?”

I can’t resist quoting a big chunk of his answer:

“If hospitals truly need additional support to cover public obligations, then they owe the public a real accounting. Show us the net Medicaid shortfall after supplemental payments. Show us the value of the tax exemption. Show us where 340B revenue goes. Show us executive compensation, administrative headcount growth, capital expansion, reserves, acquisitions, lobbying, and political spending.

Show us the books.

Nobody is saying poor and sick patients should be abandoned. Hospitals do perform some genuine community functions. Trauma care, standby capacity, teaching, and care for vulnerable patients are real obligations. But if those functions require public support, then subsidize them directly, transparently, and in a form that can be audited. Do not launder those subsidies through routine MRI bills marked up to absurd levels and then pretend the public is confused for noticing.”

A strong, provocative piece.

Behind the scenes of a Drug Channels Institute webinar, Bryce Platt on LinkedIn

Earlier this month, DCI presented PBM Industry Update 2026: Trends, Challenges, and What’s Ahead—a live webinar featuring three members of our team: Adam, Tyler, and Bryce.

We snapped this fun picture to capture our prep.

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In the post linked above, Bryce shares his observations on how we developed the event.