More than 10,000 attendees visited Las Vegas last week for Asembia’s ASX26 Summit. Along with meeting with clients and hosting the Specialty Pharmacy Patient Choice Awards, MMIT representatives attended many excellent sessions on the state of the industry. In one session after another, patients’ ability to afford and access their medication was front and center.
As we know, the healthcare ecosystem is undergoing a significant policy-driven reset, with affordability, access, and transparency taking center stage. From the IRA’s negotiated Maximum Fair Price (MFP) to the rebate pass-through requirements stipulated in the 2026 Consolidated Appropriations Act, federal policies are increasing scrutiny on pricing and reimbursement models. At the same time, state-level activity and increased regulatory pressure on PBMs are reinforcing the need for greater accountability across the system.
Many Asembia sessions discussed the implications of U.S. administrative priorities, from Most Favored Nation drug pricing to the launching of CMS’s Medicare GLP-1 Bridge demonstration, which provides weight-loss drugs at a low copay. Together, these policy changes and administrative forces are pushing the industry toward more comprehensive, scaled solutions—requiring organizations to demonstrate outcomes in a more transparent, patient-centric way.
The Need for More, Broader Value-Based Care Initiatives
While we usually hear about the negatives of vertical integration, Lisa Gill, Head of Healthcare Services Research at JPMorgan, offered a compelling defense of the trend in the session Pharmacy and Health Benefits at a Crossroads. Payers have accumulated so many assets over the years that they have nearly as much revenue on the provider and services side as the insurance side. Given the scope of these umbrella organizations, she said, it makes sense to strive for better management of a patient’s entire healthcare journey.
“One of the things that went into play with Medicare Advantage is you had to have an MLR of 85%. So 85 cents of every dollar had to be spent on medical care, which reduced your opportunity for a margin in MA plans. However, you could take that 85 cents and you could capitate it to your own entity, take care of that patient for less than 85 cents on the dollar and create a better margin opportunity,” said Gill. “Is that better for the patient? Yes, because they have a choice every single year…If they’re not happy with that primary care doctor, if they’re not getting the services that they want and need, they’re going to vote with their feet.”
In response to a question about how the healthcare system can work better for patients, Gill discussed the evolution of value-based care, from the gatekeeper model of the 1990s to the fears of the post-Affordable Care Act era that specialists would overcharge the system. To truly move the needle on patient care, Gill said, “We really need a value-based care system that is paying on outcomes, not on volumes. And the problem is that our whole healthcare system today is predicated on volumes . . . If we can really pay for outcomes in pharmacy, in hospitalization and surgical procedures, I think that’s really where we need to go.”
Many other presenters concurred, calling for a broader value-based care approach. “If AI does what it’s supposed to do, we will shorten the pipeline to getting drugs to market . . . and actually escalate the number of expensive drugs that we’re talking about today,” said John Wig, Chief Clinical Officer at Optum. “AI is likely going to increase utilization access. There’ll be programs without adherence, and there’ll be easier ways for patients to get medications, but unless you also have that coupled to disease regression and curative therapies, you’re going to open up an aperture for a lot of drugs that are coming to market without a system that knows how to pay for them.”
The Rise of New Risk Models for Cell and Gene Therapies
Several sessions discussed the rise of cell and gene therapies in diverse therapeutic areas, from cardiovascular disease to oncology to rheumatoid arthritis. Given the exceptionally high cost of these potentially curative therapies, speakers agreed that such therapies require different risk models to help payers and patients afford treatment. A few presenters noted that the industry is already seeing great strides in value-based purchasing and outcomes-based agreements for gene therapies in sickle cell disease, many of which are based on the CMS Cell and Gene Therapy (CGT) Access Model.
According to Bethanie Stein, PharmD, Segment President at Humana, “The way to balance innovation and affordability is not to slow access. Our infrastructure was not built for this type of innovation, and together we are going to have to figure out ways to redesign it. The key to doing that is to engage early . . . We have conversations with manufacturers in Phase II and III that enable us to construct various interventions, whether it’s in specialty pharmacy, retail, or with employers.”
In a session entitled The $400B Question: What Does It Take to Win in Market Access Over the Next 3-5 Years, the panelists discussed the fact that 2026-2030 is projected to mark the steepest innovation curve in modern history. Traditional medications will no longer offset the inflation of specialty products, which will be driving 80% of that growth, led by new oncology, neuroscience, obesity and cell and gene therapies.
The panelists discussed the need for a true ecosystem approach to cell and gene therapy in particular, and addressed the difficulties faced by purchasers as well as providers. Health plans and self-insured employers find it hard to even contemplate spending three million dollars on a therapy, even if that therapy offers immense value over the patient’s lifetime. At the same time, providers cannot predict volume, nor when they might be paid. Several panelists said that payers need to pay providers upfront for these therapies, so providers don’t have to take a massive risk on their balance sheet. To create a sustainable environment, payers need to clarify what kind of volume providers can expect—and they also must stop negotiating single case agreements.
On the positive side, one panelist pointed out that the curative aspect of these therapies offers hope from a risk management perspective. “These therapies purport to cure conditions, and that changes the calculus. If you have an outcome that’s binary, yes or no—did it work? This is really different, frankly, than the 42 value-based contracts we had in Humana . . . with manufacturers who were all well-intentioned. . . but it was hard to get around the measures and the methods,” said Dr. Will Shrank, CEO of Aradigm. “Now, I think we can do better. If you’ve got a drug in a binary outcome and the drug costs $3 million, we should be able to put a contract together that actually captures value in a meaningful way.”
Specialty Products and Direct-to-Patient Platforms
Several sessions discussed how to effectively manage the emergence of more direct-to-consumer or direct-to-patient (DTP) models. Panelists stressed the importance of having providers and pharmacists as part of any DTP ecosystem to help avoid any unintended consequences. Others noted that while employers are eager to provide employees with the opportunity to take popular products that aren’t covered by their plan—such as GLP-1s—the logistics of contracting with so many separate manufacturers are a significant barrier. As a result, employees are paying out-of-pocket for these therapies without any plan oversight.
In one session, State of Direct-to-Patient for Specialty, presenters from IntegriChain argued that the DTP pricing model will become an attractive option for many specialty products in the near future. With approximately $230 billion of specialty products set to lose exclusivity by 2030, the presenters posited that many manufacturers will embrace not just one pricing model but three: government, commercial and self-pay.
Brands facing a loss of exclusivity (LOE) may opt not to pour more money into rebates to try to keep on formularies and block the generics, as AbbeVie did with Humira. Instead, they may decide to compete by offering a self-pay option for patients. Rather than the DTP model used now for drugs like GLP-1s, DTP platforms for high-cost specialty drugs might focus instead on providing greater access to specialists, which may be especially beneficial to patients living in rural communities.
The presenters noted that 10 of the 78 products on TrumpRx are specialty drugs, including Humira for $950/month (an 86% discount). For brand-loyal patients on high-deductible health plans, paying even a relatively high cost for a few months of a prescription may even be an attractive proposition, as it will allow them to meet their deductible early in the year while staying on their chosen therapy.
For many drugs, the manufacturer’s gross-to-net ratio is worse with commercial insurance than it is with self-pay models due to the prevalence of rebates and discounts, distribution and services costs, and the utilization management tactics that make access difficult. According to Bill Roth, SVP of Consulting and Advisory Services at IntegriChain, “The units of a cash sale are not subject to inducement, they’re not subject to anti-kickback, and they’re not reportable for government pricing. They can fly in a whole different industry that runs side by side, parallel, without the controls of any puppeteer. It’s beautiful.”
How AI-Driven Advancements Will Help Center the Patient
Many sessions focused on how rapid technological advancement is redefining how care is delivered and accessed. Many presenters were optimistic about the role of AI-driven technology in simplifying the patient journey and easing access to therapies. Several pharmacists discussed how technology has already enabled them to spend more time with patients by streamlining behind-the-scenes processes.
In the Future of Pharmacy in America, panelists talked about deploying AI for foundational issues, such as preventing fraud, waste and abuse or optimizing call center operations. “As we move into the future, what’s exciting is that AI is really beginning to predict and pre-predict adherence [and help us] look at ways to mitigate side effects and to understand and model consumer engagement and behavior, all with obviously a provider, a physician or pharmacist as part of that,” said Optum’s John Wig.
Other panelists discussed how technology is poised to revolutionize pharmacy operations, enabling community pharmacists to spend more time clinically interacting with patients rather than just dispensing medications. “The North Star that we’re trying to achieve is, can we get specialty pharmacies to a 24-hour turnaround time?” asked Lucile Accetta, SVP, Chief Pharmacy Officer and Head of CVS Specialty, CVS Health.
Wig also discussed the concept of a ‘living and breathing formulary’ driven by AI-informed wearables and diagnostics. “If I see that a patient’s phosphorus level is up, I give them their medication and provide them with dietary advice. But then there’s an AI component that makes sure they recheck their blood work; maybe there’s an algorithm that changes the type of drug dosing….As we get better data interoperability and better AI, you could see a pharmacy that changes based on someone’s life, which could be a really interesting product when you think about how to mitigate drug treatment.”
To better understand market access from the perspectives of payers, PBMs, providers and IDNs, learn more about MMIT’s Payer and Provider Insights solutions.
