The Pharmacy of the Future Will Not Compete on Dispensing. It Will Compete on Value.

The short version: a pharmacy built on dispensing volume is easy to exploit and hard to defend, and enforcement actions and CMS quality measures already reward outcomes over counts. The pharmacy of the future will be paid for moving patients successfully through therapy, through benefits navigation, adherence support, care coordination and real-world evidence. Dispensing alone will price like a commodity.

Pharmacies have been measured by prescriptions filled, and that measure is now working against them. It is easy to exploit, hard to defend, and it describes none of the work that actually keeps a patient on therapy. Reimbursement is already moving toward the work that does.

As our industry pushes toward greater pharmacy independence, increased transparency, and reduced vertical integration, I believe we are asking an important question. For years, pharmacies have largely been measured by prescriptions filled. I do not believe that is enough anymore.

A Volume Model Is Easy to Exploit

Start with the uncomfortable part. When the unit of value is the prescription rather than the patient, the system becomes straightforward to game, and a small number of actors do exactly that. In June 2026, the Justice Department announced its largest coordinated health care fraud action by participation in the department's history. Four hundred fifty-five defendants were charged across 56 federal districts and 45 states and territories, involving more than $6.5 billion in alleged false claims, with 50 state Medicaid Fraud Control Units taking part. Ninety of the defendants were licensed medical professionals, pharmacists among them. The prior year's takedown had alleged $14.6 billion in intended loss. The pharmacy-specific allegations are worth reading closely, because every one of them describes a dispensing transaction detached from a patient outcome. These are allegations, and they describe a small minority of an industry where the overwhelming majority of pharmacists do difficult work with integrity. That is not my point. My point is what the cases have in common. Prosecutors built them by comparing claims data against drug purchases, inventory, prescriber patterns, and proof of delivery. Every scheme lived in the gap between a billed prescription and a treated patient. A model that pays for units moved will always have that gap. A model that pays for patients successfully treated has nowhere to hide.

Extraction Is Not Always Criminal

The larger issue is not fraud. It is that value can be extracted from a dispensing-based system entirely lawfully. The FTC's second interim staff report on pharmacy benefit managers examined 51 specialty generic drugs dispensed between 2017 and 2022. It found that the three largest PBMs marked up numerous drugs at their affiliated pharmacies by hundreds and in some cases thousands of percent above estimated acquisition cost. One pulmonary hypertension generic was marked up more than 7,700 percent for commercial payers in 2022. Across the set, affiliated pharmacies generated over $7.3 billion in dispensing revenue above acquisition cost, growing at a 42 percent annual rate, with an additional $1.4 billion attributed to spread pricing. The share of specialty generic dispensing revenue going to affiliated pharmacies rose from 54 percent in 2016 to 68 percent in 2023. CVS has disputed the analysis, calling it a selective reading of outliers and noting that specialty generics were under 1.5 percent of its clients' total drug spend across the period. Take the dispute at face value and the underlying point survives. When margin depends on which pharmacy fills the script and at what markup, the economics reward capturing the transaction. Nothing in that structure rewards whether the patient started therapy, stayed on it, or got better.

Dispensing Alone Is No Longer a Differentiator

If the pharmacy of the future does not create measurable value for patients, providers, manufacturers, and payers, we will continue to see the market evolve toward alternative models. Direct-to-patient distribution. Manufacturer-supported fulfillment. Cash-pay channels, wherever they offer a better experience. Dispensing medication alone is becoming less of a differentiator. Creating a better patient journey is.

What the Pharmacies That Thrive Will Actually Do

The pharmacies that thrive will be those that become active partners in healthcare, by helping to:

They will not simply move products. They will move patients successfully through therapy.

That is where I believe the opportunity lies.

This Is Not a Prediction. It Has Already Started.

Here is the part I think gets underweighted in this conversation. Value-based payment tied to pharmacy performance is not something the industry is waiting on. It is already the single largest lever in Medicare Advantage plan economics. CMS Star Ratings include three Part D medication adherence measures, covering diabetes medications, blood pressure medications, and statins. Each has historically been triple-weighted, carrying three times the influence of an ordinary measure. Together they have accounted for roughly a third of a plan's Part D summary rating. Plans reaching four stars overall become eligible for a five percent quality bonus payment. Read that again in commercial terms. A plan's bonus payment turns substantially on whether patients have their medication on hand at least 80 percent of the days they should. That is not a dispensing metric. It is a patient journey metric. And the pharmacy is the entity closest to it.

The Debate Is Not Independent Versus Integrated

As someone who has spent nearly two decades working across commercialization, patient access, and healthcare finance, I do not think the future debate is about independent pharmacy versus integrated pharmacy. It is about which pharmacy models create the greatest value. The enforcement data shows what a volume model invites. The FTC data shows what it rewards even when everyone stays inside the law. The Star Ratings data shows that the alternative is already funded and already scored. Pharmacies that can prove they moved a patient from prescribed to persistent will be able to price that. Pharmacies that can only prove they moved a box will be priced like a box.

That is the future I believe our industry should be designing. And the infrastructure to pay for it already exists.

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Sources and Notes

The views expressed are my own and are not made on behalf of any current or former employer. All trademarks belong to their respective owners.