Political debate over cancer drug prices often overlooks a quieter system — specialty pharmacy rules, utilization controls, and rebate arrangements — that plays an equally large role in whether patients can access treatment. In this editorial, Paul Pruitt, Chief Growth Officer at SHARx, argues that pharmacy benefit managers have become powerful gatekeepers in oncology care, and that closing this transparency gap is essential to ensuring innovation actually reaches patients.
Key Takeaways
- Oncology spending is projected to rise from ~$99 billion (2023) to $180 billion (2028), yet pricing debates rarely address the specialty pharmacy systems shaping actual access.
- PBMs now influence which cancer drugs are covered and dispensed, with Federal Trade Commission (FTC) findings citing nearly $1.6 billion in added revenue from steering just two drugs through affiliated pharmacies.
- Opaque cost structures contribute to treatment delays and financial toxicity, with real consequences for patient outcomes.
- Pruitt calls for greater transparency, scrutiny of vertical integration, and incentives aligned with patient outcomes rather than administrative complexity.
If cancer drugs become less expensive, will patients actually gain faster access?
Cancer treatment has entered a remarkable era of innovation. Precision therapies, immunotherapies, antibody-drug conjugates, and targeted treatments continue to expand options for patients facing some of the most difficult diagnoses in medicine. Yet as policymakers focus on lowering prescription drug prices through initiatives such as TrumpRx, a growing question remains: if cancer drugs become less expensive, will patients actually gain faster access to them? For many patients, the answer is: not necessarily.
The United States spent approximately $99 billion on anticancer therapies in 2023, and spending is projected to reach $180 billion by 2028. While much of the public debate focuses on drug manufacturers and list prices, the reality of cancer care is increasingly shaped by a less visible system of specialty pharmacy requirements, utilization controls, rebate arrangements, and coverage decisions that stand between patients and treatment. The result is that oncology access is becoming as much a supply chain challenge as a clinical one. [1][2]
The Real Challenge Is Not Just Drug Prices
The political appeal of lowering drug prices is easy to understand. Cancer therapies are among the most expensive medications in healthcare, and rising costs place significant pressure on patients, employers, health plans, and government programs. However, focusing exclusively on price risks overlooks a larger structural issue.
Many oncology therapies are classified as specialty medications, placing them within a segment of the pharmaceutical market that operates under a unique set of rules. These therapies often require prior authorization, specialized distribution channels, restricted pharmacy networks, and ongoing utilization management oversight. As a result, treatment access is frequently influenced by organizations that are not directly involved in clinical care.
Over the past two decades, pharmacy benefit managers (PBMs) have evolved from administrative claims processors into powerful gatekeepers within the specialty drug ecosystem. Today, the largest PBMs influence which drugs are covered, which pharmacies may dispense them, how reimbursement is structured, and what financial incentives exist throughout the supply chain.
For oncologists and patients, these decisions can affect not only what treatment is available but also how quickly it can be obtained.
Specialty Pharmacy Has Become a Control Point
The specialty pharmacy market was originally developed to support complex therapies requiring clinical monitoring, patient education, and coordinated care. In many cases, that model serves an important purpose. The challenge emerges when specialty designation becomes intertwined with ownership structures and financial incentives.
The Federal Trade Commission (FTC) has increasingly scrutinized the role of vertically integrated PBMs and affiliated specialty pharmacies. Recent findings showed that the largest PBMs generated nearly $1.6 billion in additional revenue from just two cancer drugs by steering prescriptions through affiliated specialty pharmacies. Other FTC findings showed significant markups on specialty generic medications, including therapies used to treat cancer and other serious conditions. These findings raise broader questions about transparency.[3]
When the same organization influences coverage decisions, specialty pharmacy requirements, reimbursement arrangements, and dispensing channels, it becomes increasingly difficult for employers, plan sponsors, physicians, and patients to understand the true drivers of cost.
The issue is not simply whether profits are being earned. The issue is whether stakeholders have sufficient visibility into how treatment decisions are being made and whether incentives remain aligned with patient outcomes.
The Cost of Opacity Extends Beyond Dollars
The consequences of these dynamics extend well beyond healthcare spending. Cancer treatment is often time-sensitive. Delays in therapy initiation can affect treatment effectiveness, disease progression, patient anxiety, and overall outcomes.
At the same time, financial toxicity continues to emerge as a significant challenge within oncology care. Research increasingly shows that high out-of-pocket costs contribute to treatment nonadherence, delayed care, and poorer health outcomes.
Recent surveys suggest that a growing number of Americans are making difficult financial tradeoffs to afford healthcare. Many report delaying treatment, stretching prescriptions, or cutting spending in other areas of life to pay for medical expenses. For patients facing a cancer diagnosis, those choices become particularly consequential.[4]
The challenge is compounded when costs are difficult to predict, as patients may struggle to understand how specialty pharmacy requirements, formulary placement, copay assistance programs, and rebate structures ultimately affect what they owe. Access becomes a moving target.
Innovation Requires Transparency
The oncology community has every reason to celebrate scientific progress. New therapies continue to extend survival, improve quality of life, and create treatment options where few previously existed. However, innovation achieves its intended value only when patients can access it. That reality places increasing importance on transparency throughout the specialty drug supply chain.
Physicians need greater visibility into treatment pathways and coverage requirements. Employers and plan sponsors need a clearer understanding of the true cost drivers behind specialty drug spending. Patients need predictability regarding affordability and access. Policymakers need a more complete understanding of how incentives operate throughout the specialty pharmacy ecosystem. Without transparency, efforts aimed solely at reducing list prices risk addressing only part of the problem.
A Better Path Forward
Improving oncology access requires more than another debate over drug pricing. It requires examining how specialty drugs are procured, reimbursed, distributed, and approved throughout the healthcare system. Several opportunities deserve greater attention.
- Increase transparency around specialty drug reimbursement. Stakeholders should be able to understand how specialty medications are priced, reimbursed, and routed through the system.
- Evaluate the impact of vertical integration. As insurers, PBMs, and specialty pharmacies become increasingly interconnected, policymakers should continue assessing how those relationships affect competition, pricing, and patient access.
- Align incentives around patient outcomes. Financial arrangements should reward timely access, clinical effectiveness, and affordability rather than complexity or administrative friction.
- Expand direct access models. When clinically appropriate therapies can be provided through direct-to-employer or direct-to-patient arrangements, stakeholders should explore models that reduce unnecessary intermediaries, simplify access, and improve affordability while preserving continuity of care.
The Next Chapter in Cancer Care
The future of oncology will undoubtedly include more sophisticated therapies, more personalized treatment strategies, and continued scientific breakthroughs. What remains uncertain is whether the systems surrounding those therapies will evolve at the same pace. Lower drug prices may help some patients. But for many individuals navigating cancer treatment, the greatest obstacle is not necessarily the price of the medicine itself. It is the complexity of the system determining whether that medicine reaches them in the first place.
As policymakers continue pursuing affordability reforms, the next conversation should focus not only on what cancer drugs cost, but also on who controls access to them, how those decisions are made, and whether the system is truly serving the patients it was built to help.
References
[1] Jazowski SA, Nayak RK, Dusetzina SB. The high costs of anticancer therapies in the USA: challenges, opportunities and progress. Nat Rev Clin Oncol. 2024 Dec;21(12):888-899. doi: 10.1038/s41571-024-00948-1. Epub 2024 Oct 4. Erratum in: Nat Rev Clin Oncol. 2024 Dec;21(12):903. doi: 10.1038/s41571-024-00958-z. PMID: 39367130; PMCID: PMC11848938.
[2] Jazowski SA, Nayak RK, Dusetzina SB. Author Correction: The high costs of anticancer therapies in the USA: challenges, opportunities and progress. Nat Rev Clin Oncol. 2024 Dec;21(12):903. doi: 10.1038/s41571-024-00958-z. Erratum for: Nat Rev Clin Oncol. 2024 Dec;21(12):888-899. doi: 10.1038/s41571-024-00948-1. PMID: 39478104.
[3] Goldman M. PBMs made more than $7B marking up specialty generics: FTC. Jan 14, 2025. Axios. Online. Last accessed on September 13, 2026
[4] Late M. Americans Cut Care, Ration Medications as Health Costs Climb. March 22, 2026 PHW | Public Health Watch. Online. Last accessed on September 13, 2026
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