Five things pharmacy leaders are actually talking about

On August 18, pharmacy leaders from health systems across the Inneo Alliance spent an hour and a half in a moderated conversation. There was no agenda deck, no presentation, and nothing was sold — Inneo convened and moderated the session, and the discussion belonged to the room. They came from systems in Ohio, Virginia, South Dakota, Louisiana, Washington, and California, ranging from single-region systems to a 38-hospital network.

They were asked one question to open: what is consuming your attention right now.

Five things came up, and they came up in almost every answer. In each one, the leaders furthest along had built something the rest of the room could use.

Why are health systems rethinking where infusion happens?

Because the reimbursement math has changed, and the systems reworking their footprint now are the ones that will have options later.

The 2027 OPPS cuts, the 340B rebate pilot, and manufacturer contract pharmacy restrictions are arriving together. One system in the room found that only a minority of its top drugs will reimburse above 340B drug cost. Another is carrying negative margin on every infusion of a single advanced heart failure drug, with volume climbing.

No one offered a single system-wide answer, and the group agreed there does not need to be. The decisions are being made drug by drug and disease state by disease state, and the room had a working list: shift to home infusion, clear bag through specialty into the Part D benefit, move volume to non-HOPD sites, use specialty GPO programs to work around orphan drug exclusions, and reconsider which settings infusion belongs in.

The bigger opportunity is the one nobody has built yet — a way to evaluate a patient at intake against contracts, payer, drug, and site of care, then route them to the setting where the patient receives the best care while the organization protects margin. Every leader in the room wanted it. One offered to sit on the board of whoever builds it.

What does the 340B reimbursement gap actually cost?

More than the published rates suggest, which is why the systems modeling it themselves are ahead of the ones waiting for guidance.

One health system walked its executives through the numbers. While non-drug outpatient reimbursement increased to offset repayments from 2018–2022, 340B reimbursement continued to decline, pushing the recoupment rate from 0.5% to 3%. When these changes were aggregated across DSH, Sole Community, Critical Access, and Rural Referral facilities, the overall financial impact remained negative.

As one participant put it, the stated intent to reimburse near 340B acquisition cost is a sentiment rather than a fact. Knowing that early is what lets a system plan around it rather than absorb it.

Why don’t pharmacy leaders know what they were paid?

Because remittance can take six to eight months to materialize, underpayments frequently go unnoticed. Most denials processes are built to catch missing payments, not payment inaccuracies.

This drew more agreement than anything else in the conversation. One director described asking repeatedly what a drug was reimbursing, getting no answer, and learning a year later that it had been running deep in the red, with patients already scheduled six months out.

The recommendation that gained the most support was a structural one rather than a technical fix: ensuring pharmacy has a seat on the denials committee. One system did exactly that, and found the committee was built to catch denials but not underpayments. The question being asked was whether a claim was paid, not whether it was paid correctly. Billing unit and HCPCS coding issues decide the difference between those two answers.

The room had more to trade here than anywhere else. Several leaders described practical steps already in place: tracking first-pass denials as an early signal of payment problems, moving an analyst from the pharmacy system team into a dedicated margin reporting role, and building automated flags for any drug where expected reimbursement falls below acquisition cost. One system borrowed a rule from its surgical service line — if an authorization is not approved 24 hours ahead, the case pauses for a joint call with site and service line leadership.

Earlier visibility, better decisions, fewer surprises — and a clearer picture of what a service line is actually earning.

Is AI working in prior authorization yet?

In at least one organization, yes, and by a wider margin than anyone else in the room expected.

One system had recently acquired another and learned on the introductory call that the acquired group had gone from 25 people processing prior authorizations to a single person working alongside AI.

That number reset the ceiling for everyone else on the call. Most are still reviewing every AI-generated letter by hand and are being deliberate about it. Appeals remain the harder problem, where guideline interpretation has to be right every time. Several are waiting on their EHR vendor rather than buying a point solution, on the reasoning that a third-party tool can erode a meaningful share of the margin it was purchased to protect.

Nobody thought the demos looked bad. The open question is timing, and it is worth noting how fast this moved: two years ago the same leaders described these tools as far too early.

What makes cell and gene therapy hard to operationalize?

The contracting, not the clinical protocol — which means the fix is a process, and a process can be built once.

Manufacturers are pushing qualified treatment center agreements — six to twelve pages, requiring full legal and finance review — ahead of PADUFA dates. One system now waits for actual FDA approval before opening those discussions, after spending cycles on products that never cleared. Using Microsoft Teams and Power Automate, another health system created a centralized workflow that tracks every milestone, from initial referral and payer approval through treatment, billing, and payment collection.

The advice that drew agreement in the room: stop writing drug-specific protocols. You will run one case and then not see another for four or five years. Build the process instead, and bring in a project manager to map stakeholders at the start, because the list of departments this does not touch is shorter than the list it does.

That workflow is reusable, and most of the room left planning to build their own version of it.

What connected all five

While the issues ranged from denials to site-of-care optimization, they all pointed to a shared need for better insight into reimbursement and margin performance. Pharmacy leaders are being asked to drive financial stewardship while navigating increasingly complex payment models — and the ones furthest along are building the visibility that makes stewardship possible.

The most useful thing said in the ninety minutes was not a tactic. One leader described presenting to their CEO council with a multimillion-dollar case for new specialty revenue — from a central refill operation built to handle 80% of retail scripts, specialty pharmacy expansion, and MSAT rolled out across retail. What surprised them was not the number. It was that the C-suite asked more questions than it ever had, and started treating pharmacy as something to invest in rather than a cost to manage down.

The difference between that conversation and a harder one elsewhere came down to whether anyone had done the work of putting a number on it.

Why the room matters

Two participants ended the session trading contact details over a specialty pharmacy question. That is the entire reason the forum exists.

Every problem raised in those ninety minutes had already been worked through by somebody else on the call. One system’s answer to reimbursement visibility was another’s open question. The cell and gene therapy workflow one leader had spent a year building was exactly what two others were about to start from scratch. None of that gets shared in a conference session or a vendor webinar, because none of those settings let a leader say plainly what is not yet working.

That is what this room is for: a small, closed group of peers, no competitive overlap, nothing recorded, and nothing sold. The shortcut is in the room, and it only works if people can speak freely.

The next pharmacy forum is being planned. If there is something you want on the agenda, tell us.

Based on a moderated roundtable of nine pharmacy leaders from health systems participating in the Inneo Alliance, held August 18, 2026. Participants and their organizations are not identified. Inneo is owned by non-profit health systems and runs the Alliance as a free resource for member and participating systems.

Inneo (formerly The Innovation Institute) is owned and managed by a nationwide group of nonprofit health systems. We run innovation programs for our members across clinical innovation and business services, embedding with their teams at no charge. Inneo identifies the partners best aligned with each system’s priorities, negotiates terms on their behalf, and reinvests the resulting vendor fees into the program. That flywheel sustains the innovation lab without additional capital calls on members. We are your ally. We are Inneo Alliance.