EP377: Specialty Pharmacy, PBM, Hospital, Employer, and Pharma Strategic Maneuvering, With Mike Baldzicki, CRCM

The Strategic Chess Match Over Who Profits From Specialty Pharmacy, With Mike Baldzicki. Specialty Drugs Are 2% of Members but 30% of Costs—Here's Who's Fighting Over That Money. Episode 377.

Stacey Richter talks with Mike Baldzicki, chief brand officer at AscellaHealth, about how self-funded employers, hospitals, PBMs, and pharma are all maneuvering to capture (or avoid overpaying for) specialty pharmacy dollars—and why outcomes-based contracts remain more talk than practice.

WHAT YOU'LL LEARN

✅ Why specialty drugs represent about 2% of a typical employer's population but can consume up to 30% of total cost of care

✅ Why no employer or plan should pay more than acquisition price plus a reasonable professional fee, even though many do

✅ How employers who move specialty pharmacy business away from the "Big Three" or "Big Five" PBMs are actively steering members and managing benefits differently

✅ Why hospitals that lose buy-and-bill revenue often respond strategically by standing up their own specialty pharmacy or infusion center network

✅ How data insight—or the lack of it—determines whether an employer can actually negotiate plan language and coverage requirements effectively

✅ Why so few pharma outcomes-based contracts exist in practice, despite the "pay for value, not volume" logic applying just as well to drugs

WHY THIS MATTERS

Every stakeholder in the specialty pharmacy chain—hospitals, PBMs, pharma, employers—is maneuvering to either capture the outsized margin on these drugs or avoid getting stuck paying for someone else's markup, and most employers don't have the data insight to know which side of that fight they're actually on. Baldzicki's view from inside a specialty pharmacy company gives plan sponsors a map of the maneuvering so they can make deliberate choices instead of accepting default PBM arrangements.

MENTIONED IN THIS EPISODE

EP365 with Scott Haas: Apple Podcasts | Spotify | Other Apps

EP337 with Olivia Webb: Apple Podcasts | Spotify | Other Apps

EP370 with Erik Davis and Autumn Yongchu: Apple Podcasts | Spotify | Other Apps

EP369 with Keith Hartman, RPh: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

04:27 Is it a conflict of incentives to worry about the cost of million-dollar pharmaceuticals?

06:24 "Really, does it make sense to carve up my specialty pharmacy benefit … away from my typical PBM model?"

06:48 What's the trend line with moving away from the big PBMs?

07:53 How does a small PBM contract with Pharma?

11:32 "We're still lacking the overall insight to data."

12:15 "When you have insight and good data, then you can start really driving the plan language and cover requirements."

13:07 "It is a frustrating game because … the large PBMs that have traditionally managed an employer's spend … doesn't give them the data that's needed."

13:48 What's going on with outcomes-based contracts?

14:16 What's the importance of aligning reimbursement around value instead of volume?

14:57 "The issue is, how real is the data?"

20:36 Are hospital-based specialty pharmacies teaming up with big PBMs?

22:01 "It's market ownership."

30:43 "These are real scenarios that are happening in the self-insured planned sponsor market."

30:59 "Employers really should start recognizing organizations that take more of an integrated and thoughtful approach."