Federal Pharmaceutical Proposal: The Next Step in Healthcare Pricing Reform

Carrying forward the momentum of the Transparency in Coverage (TiC) Schema 2.0 rollout, the U.S. Department of Labor has proposed a new rule aimed at another opaque corner of healthcare finance: Pharmacy Benefit Managers (PBMs). While the initial deployment of TiC ruling was aimed at medical reimbursement transparency, this new proposed rule targets the pharmaceutical side of healthcare.

How PBMs Fit in the Greater Healthcare Landscape

At first glance, this may seem like an isolated effort; however, in practice it touches nearly every specialty. From oncology and endocrinology to cardiology and primary care, medication access, cost-sharing, and formulary decisions directly shape clinical outcomes and patient behavior.

Currently, PBMs fit into the current prescription supply chain for employer-sponsored self-insured group health plans , affecting approximately 90 million Americans today. While these functions influence both cost and access, the underlying financial arrangements are often difficult for plan sponsors and fiduciaries to evaluate.

Proposed Updates to the Current Transparency Initiative

Outlined in the proposal, are three main requirements:

  1. Rebates and other payments from drug manufacturers.
  2. Compensation received when the price paid by the plan for a prescription drug exceeds the amount reimbursed to the pharmacy.
  3. Payments recouped from pharmacies in connection with prescription drugs dispensed to the plan.

Direct Effect on Provider Organizations

Although this rule is directed at plan fiduciaries, the downstream effects extend to providers. Pharmacy benefit design directly influences medication affordability, adherence, and treatment access, which in turn affect utilization patterns, outcomes, and total cost of care. Greater transparency into PBM economics may ultimately shape formulary strategy, reimbursement structures, and employer purchasing decisions, creating ripple effects across clinical practice and care delivery.

Trek Health’s Role

Trek is closely monitoring the PBM proposal and preparing our data infrastructure to support rapid adoption should the rule be finalized, ensuring organizations can interpret new disclosures as soon as they become available. This potential integration of data contributes to greater visibility of the entirety of commercial reimbursement.

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Federal Pharmaceutical Proposal: The Next Step in Healthcare Pricing Reform

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From Transparency to Prediction: Quantifying the Drivers of Physician Reimbursement Variation

This analysis uses Transparency in Coverage data to model how payers behave, not just what they pay. By linking reimbursement rates to physician characteristics, we uncover the patterns behind payment variation and transform transparency data into predictive intelligence. The result: a predictive view of rate dynamics that helps stakeholders anticipate trends and negotiate with data-driven confidence.

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Q3 2025 State of Commercial Reimbursement: Trek Health’s Quarterly Market Intelligence

Trek Health’s Quarterly Reimbursement Brief highlights emerging variability in commercial payment rates across U.S. payers, specialties, and geographic markets. With some segments experiencing double-digit growth and others notable declines, contracting performance is increasingly shaped by real-time payer behavior rather than historical norms. Through validated reimbursement trend analytics, contract intelligence, and policy monitoring, Trek equips provider organizations to anticipate market shifts, protect revenue, and negotiate with measurable leverage.

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Q4 2025 State of Commercial Reimbursement: Trek Health’s Quarterly Market Intelligence

Trek Health’s Q4 2025 Quarterly Market Intelligence report analyzes quarter-over-quarter commercial reimbursement movement across national payers, physician specialties, and U.S. states. While overall reimbursement improved following earlier declines, rate changes remained uneven—highlighting payer selectivity, persistent specialty outliers, and shifting geographic leverage. This report moves beyond static benchmarks by tracking real-time reimbursement changes, giving provider organizations actionable insight to identify negotiation risk early, protect rate parity, and respond proactively to evolving payer behavior.

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Reimbursement and Reality: The Economics of Breast Cancer Treatment

While breast cancer awareness efforts often focus on screening and treatment, one critical factor remains overlooked: how care is reimbursed. Payment structures shape far more than provider margins; they influence access, equity, and patient outcomes.

In this analysis of payer rates, Trek Health uses its Transparency Platform to analyze how reimbursement for breast cancer care varies across geography, commercial payer behavior, and public policy. The findings reveal a system that rewards disease burden rather than prevention which creates inequities that ripple through the entire care process.

Inside you’ll learn:

  • How reimbursement rates differ dramatically by state and payer
  • Why higher disease burden correlates with higher payment, but prevention does not
  • What these trends mean for provider strategy, patient access, and equity

Download the full analysis to see how transparency data can help reshape breast cancer care—turning financial insight into fairer outcomes.

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The Payer Paradox: When Higher Rates Don’t Mean Higher Reimbursement

This analysis uncovers a critical paradox in commercial healthcare financing: the payers offering the highest contracted rates often deliver the lowest realized reimbursement once denials and administrative friction are accounted for. By introducing the Payer Generosity Index (PGI) and adjusted PGI (aPGI), Trek Health reveals how payer performance varies not only across insurers, but across specialties and service lines. These findings equip healthcare organizations with a clearer, data-driven framework for contracting, revenue optimization, and strategic planning in an increasingly complex reimbursement landscape.

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The Private Practice Playbook: Rate Negotiation Index Rankings for Specialty-Specific M&A Strategy

Physician economics are shifting as private equity and independent platforms redefine the workforce landscape. Trek Health’s Rate Negotiation Index Report quantifies the return on physician labor across states and specialties in a new lens: combining commercial reimbursement, physician salary, malpractice risk, and provider density into a single metric. This data driven foundation for smarter M&A strategy identifies the most economically sustainable opportunities across the U.S. for physician recruitment and network expansion.

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Published on

February 3, 2026

Written by

Jordan Kassab

Carrying forward the momentum of the Transparency in Coverage (TiC) Schema 2.0 rollout, the U.S. Department of Labor has proposed a new rule aimed at another opaque corner of healthcare finance: Pharmacy Benefit Managers (PBMs). While the initial deployment of TiC ruling was aimed at medical reimbursement transparency, this new proposed rule targets the pharmaceutical side of healthcare.

How PBMs Fit in the Greater Healthcare Landscape

At first glance, this may seem like an isolated effort; however, in practice it touches nearly every specialty. From oncology and endocrinology to cardiology and primary care, medication access, cost-sharing, and formulary decisions directly shape clinical outcomes and patient behavior.

Currently, PBMs fit into the current prescription supply chain for employer-sponsored self-insured group health plans , affecting approximately 90 million Americans today. While these functions influence both cost and access, the underlying financial arrangements are often difficult for plan sponsors and fiduciaries to evaluate.

Proposed Updates to the Current Transparency Initiative

Outlined in the proposal, are three main requirements:

  1. Rebates and other payments from drug manufacturers.
  2. Compensation received when the price paid by the plan for a prescription drug exceeds the amount reimbursed to the pharmacy.
  3. Payments recouped from pharmacies in connection with prescription drugs dispensed to the plan.

Direct Effect on Provider Organizations

Although this rule is directed at plan fiduciaries, the downstream effects extend to providers. Pharmacy benefit design directly influences medication affordability, adherence, and treatment access, which in turn affect utilization patterns, outcomes, and total cost of care. Greater transparency into PBM economics may ultimately shape formulary strategy, reimbursement structures, and employer purchasing decisions, creating ripple effects across clinical practice and care delivery.

Trek Health’s Role

Trek is closely monitoring the PBM proposal and preparing our data infrastructure to support rapid adoption should the rule be finalized, ensuring organizations can interpret new disclosures as soon as they become available. This potential integration of data contributes to greater visibility of the entirety of commercial reimbursement.