A Founder’s Perspective on Value-Based Pharmaceutical Management and the Future of Benefit Strategy

Employers, consultants, and healthcare purchasers have reached a breaking point with the traditional Pharmacy Benefit Management (PBM) model. What was once considered standard practice is increasingly incompatible with the realities of managing pharmaceutical spend across both prescription and medical benefits.

For too long, healthcare purchasers have been forced to choose between controlling costs and improving patient outcomes—a tradeoff that is both artificial and unsustainable, created by misaligned incentives and fragmented decision-making across pharmacy and medical benefits.

Incremental improvement will not solve this problem—it requires a fundamentally different approach.

At Ventegra, we call that approach Medical Benefit Management (MBM)—a model designed to manage how medications are utilized, priced, and delivered across both the prescription and medical benefits to achieve the best outcomes at the lowest net cost—unlike traditional PBMs, which focus primarily on pharmacy transactions.

For years, plan sponsors have had to navigate opaque pricing structures, retained rebates, undisclosed spread pricing, hidden margins, conflicts of interest, contractual complexity, and vertically integrated ownership models that obscure the true flow of pharmaceutical dollars. These challenges have intensified as specialty medications have become the fastest-growing driver of drug spend and overall healthcare costs—and are now being challenged by employers and policymakers alike who are demanding transparency, auditability, and aligned incentives across the pharmaceutical supply chain.

In response, the market has begun to embrace “transparent” PBM models—an evolution we welcome, as greater visibility is helping to move the industry in the right direction.

But transparency alone is not enough. Without structural alignment, these approaches risk reinforcing the very dynamics they aim to correct.

A healthcare system cannot achieve affordability when intermediaries financially benefit from higher drug costs—even when those economics are disclosed. Nor can it build trust or long-term sustainability when transparency is mistaken for alignment, and business models prioritize revenue extraction over clinical and financial stewardship.

This is the critical distinction: transparency reveals the problem—alignment solves it.

Achieving the level of alignment required to resolve these issues is not possible within the constraints of the traditional PBM model.

This is precisely why Ventegra moved beyond the traditional PBM construct to advance a model, formally recognized by the pharmaceutical industry in 2014 as something new and unique. At Ventegra, pharmacy benefits are not treated as isolated financial instruments. Under our MBM model, drugs are managed based on clinical appropriateness and cost-effectiveness—regardless of where they are billed—integrating site-of-care decisions, care coordination, and total cost to optimize outcomes and long-term sustainability.

This requires structural change, prioritizing stewardship, and these key elements:

• Full pass-through of all pharmaceutical discount value (not just rebates)
• No ownership conflicts across the drug supply chain
• Consistent, transparent pricing methodologies
• Direct manufacturer contracting with full reconciliation and auditability
• Performance-based contracts with clear exit rights and flexibility
• Governance aligned with public benefit, not profit extraction
• Upfront transparency of contractual commitments

Increased focus on transparency is a positive step—but it risks becoming a diluted concept when applied to legacy structures without meaningful change.

At Ventegra, we refer to these approaches as “Transparent In Name Only” (TINO)—because without alignment or structural change, they simply become a more transparent version of the same legacy model—a PBM built to extract value for its shareholders.

The broader industry conversation is now catching up. Employers are demanding auditability and enforceable protections, regulators are increasing scrutiny, and consultants are reevaluating long-held assumptions. Most importantly, purchasers are asking a more fundamental question: Who is truly aligned with our best interests?

The future of healthcare will be defined by those willing to answer that question clearly—and act on it.

Long before transparency became a market expectation, Ventegra built its model on a simple premise: the management of pharmaceuticals—whether delivered through the prescription or medical benefit—should function as a societal good, not a financial arbitrage opportunity. That distinction remains critical because transparency alone does not eliminate the underlying conflicts embedded within traditional PBM economics.

The next evolution is not simply a more transparent or better PBM—it is a different model. It is Medical Benefit Management, where pharmacy and medical benefits are fully aligned for better pharmaceutical management, bringing together clinical integrity, financial stewardship, and a commitment to community.

This transformation will require employers willing to demand better alignment across pharmacy and medical benefits, policymakers willing to insist on accountability, and industry leaders willing to rethink legacy economics that no longer serve patients or purchasers.

We welcome that challenge.

Healthcare does not need another intermediary optimizing revenue flows. It needs aligned stewards committed to redesigning the system itself.

If your organization is reevaluating its pharmacy and medical benefit strategy and looking for more effective ways to manage drug spend, the Ventegra model offers a path to greater alignment, true transparency, and long-term value. I welcome the opportunity to connect and continue the conversation.

Robert T. Taketomo, PharmD, MBA
President & CEO of Ventegra, Inc.
President & CEO, and Chairman of the Board of the Ventegra Foundation