Every week in clinics across Arkansas, physicians watch patients perform painful calculations in anticipation of the pharmacy counter: groceries or prescriptions, rent or insulin, a needed inhaler or a child's winter coat. As physicians, we can diagnose disease and adjust medications, but we are often powerless against a system that inflates prices and obscures who is paid, how much, and why. That confusion is embedded in a business model that profits from complexity rather than patient care.

Pharmacy benefit managers (PBMs) were intended to negotiate savings and streamline benefits.

Instead, the marketplace has become consolidated and opaque. Just a few PBMs control the vast majority of U.S. prescriptions, and most are vertically integrated with large insurers, group purchasing organizations (GPOs), specialty pharmacies, and mail-order operations. Often, the same parent corporation owns the insurance plan that sets premiums, the PBM that designs the formulary, the GPO that negotiates manufacturer contracts, and the pharmacy that dispenses the drug. This allows that one insurance company to write the rules and collect revenue at every stage of the transaction.

When insurers and PBMs operate under one roof, decisions about formularies, rebates, and cost-sharing can be driven by internal profit strategies rather than patient affordability. Rebates may lower premiums on paper while leaving patients with high deductibles tied to inflated list prices. Independent pharmacies are reimbursed at unsustainable rates, even as affiliated pharmacies are favored.

Arkansas has been forced to act. In many rural communities, the local pharmacy is the front door to the health-care system. When those pharmacies close, patients lose access not only to medications but also to counseling and trusted relationships. Families deserve to know that savings negotiated in their name reach them directly, and that local providers can compete fairly.

In 2023, Arkansas enacted "Share the Savings" legislation (Act 333), requiring manufacturer rebates to be passed through to patients at the pharmacy counter. The state also protected patients from accumulator programs that prevent copay assistance from counting toward deductibles or out-of-pocket maximums. These reforms reflect meaningful progress and a patient-first approach. But state-by-state fixes cannot fully address a system dominated by national, vertically integrated corporations operating across state lines and within federal programs. Durable reform requires strong federal standards and sustained oversight.

Fortunately, Congress has recently taken steps to strengthen PBM transparency and curb spread pricing in federal programs. That progress matters and is cause for optimism. Arkansas' congressional delegation deserves thanks for its commitment to PBM reform and for helping ensure these provisions crossed the finish line in February.

However, transparency alone will not realign incentives in a marketplace structured around consolidation. As long as insurers, PBMs, GPOs, and pharmacies remain vertically integrated, the incentive for self-dealing persists.

The consequences are visible in exam rooms across Arkansas. When formularies favor drugs with higher rebates over lower net costs, patients pay more at the counter. When independent pharmacies are squeezed, rural patients are forced to travel farther or rely on mail order. When prior-authorization policies are shaped inside the same corporate structure, physicians spend hours navigating administrative barriers instead of caring for patients.

These are not abstract policy debates. When medications become more challenging for patients to access, chronic diseases worsen and preventable complications multiply. Vertical integration in the health-care marketplace concentrates decision-making far from the bedside and shields it from meaningful competition.

If policymakers are serious about making health care more affordable, they must look beyond incremental adjustments and confront the insurance marketplace that enables this structure. Insurance reform that includes stronger oversight of vertically integrated entities, enforceable standards for fair reimbursement, and policies that promote genuine competition is essential to restoring balance. Without addressing consolidation directly, reforms risk treating symptoms while leaving the root causes intact.

Patients should not have to navigate corporate ownership charts to access the medication prescribed by their provider. Physicians should not have to fight opaque formularies to prescribe appropriate therapy. And rural communities should not lose their pharmacies because vertically integrated corporations can shift profits internally while squeezing local providers.

Dr. Samuel A. Moore, D.O., is an osteopathic physician and board-certified orthopedic surgeon and a practice partner at Bowen Hefley Orthopedics. Dr. Moore is also the president of the Arkansas Osteopathic Medical Association.

© Arkansas Online