How Layers of Intermediaries Disconnect Patients from Healthcare Costs

Ken Kemker
Sep 22
2 min read

Healthcare has evolved from simple patient-provider relationships into a complex web of intermediaries:

Insurance pays on patient's behalf (third party)
Employer contracts with insurer (fourth party)
PBM manages benefits for insurer (fifth party)

This structure has removed patients so completely from cost decisions that a member may never discover their specialty drug costs $8,000 per month because they are only paying $100 copays. Even physicians prescribing these medications often don't know their true costs.

Consider Humira: prescribed widely despite 50% of users experiencing less than 10% efficacy, at $6,000 to $12,000 per prescription. This exemplifies a system where cost and clinical value have become separated.

How Traditional PBMs Profit from Confusion

Traditional PBMs have built their business model on complexity and spread pricing. Here's a typical scenario:

Pharmacy charges $10 for a prescription
Member pays $5 copay
PBM tells you the drug costs $300
You pay $295 ($300 minus the $5 copay)
PBM keeps $285 in undisclosed profit

The pharmacy earns a few dollars, the PBM extracts hundreds, and nobody except the PBM knows what actually happened. This spread can reach thousands of dollars per prescription.

Reconnecting Healthcare to Its Purpose

The current PBM system didn't evolve to serve patients or employers. It developed to maximize profits for intermediaries. The complexity isn't accidental; it's the foundation of a business model built on opacity.

Your organization deserves a PBM partner that puts your interests first, not one that profits from confusion. DisclosedRx proves pharmacy benefits can work differently: with Full Disclosure, fiduciary accountability, and a commitment to serving people at sustainable costs.

🎙️We spoke about this issue in detail (and more!) on Craig Gottwal’s podcast recently.

Check it out on Substack here: https://gottwals.substack.com/p/pharmacy-deep-dive-with-disclosedrx

You can also find the episode on the BenefitsPRO website here: https://www.benefitspro.com/2025/07/22/pharmacy-deep-dive--with-zack-robinson/