Self-Funded Will PBM Reform Actually Happen? | Last Month In Healthcare
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Mar 13, 2026 They unpack recent moves to curb PBM and insurer power, including an FTC settlement and a bill targeting vertical integration. They cover the FDA limiting compounded GLP-1s and debate privacy questions around ChatGPT Health. There is a playful segment comparing monthly drug costs to luxury car payments. They also discuss what headcount is needed to go fully self-funded in 2026.
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Medicare Part D Reforms Only Scratch The Surface
- Medicare Part D will require PBM rebate pass-through and delink PBM compensation from list prices.
- Spencer Harlan Smith notes this applies only to Medicare Part D and leaves two-thirds of Americans in the commercial market unaffected.
FTC Settlement Forces Net Price Basis For Insulin Costs
- The FTC settlement with Express Scripts forces patient out-of-pocket costs to be based on net price, not inflated list price.
- Spencer Harlan Smith explains PBMs previously pocketed rebates and had incentives to raise list prices and favor high-rebate drugs on formularies.
Proposed Break Up Of Vertical Integration Faces Long Odds
- The Break Up Big Medicine Act would ban common ownership of insurers, PBMs, and provider MSOs to curb vertical integration.
- Spencer Harlan Smith and Nathaniel agree the bill likely faces heavy lobbying and probably won't pass despite addressing clear conflicts of interest.