The State of Pharmaceutical Care: Challenges and the Road Ahead in 2025

The prescription medication sector in 2024 has been characterized by escalating costs, increased demand for specialty drugs, and persistent drug shortages. Contributing to this trend are manufacturer price hikes, greater utilization of brand-name drugs, and the introduction of costly new products. Additionally, the U.S. is experiencing an unprecedented scarcity of hundreds of different medications, including essential treatments like asthma medications and chemotherapy agents.

These challenges underscore the need for innovative solutions to enhance affordability, accessibility, and transparency in the prescription medication sector as we look to improve pharmaceutical care in 2025.

Bridging the Cost Gap and Overcoming Systemic Barriers for Access

The cost burden of medications has grown unsustainable for many. In 2024, out-of-pocket expenses for patients surpassed $91 billion, reflecting a $5 billion increase from the prior year. This rising cost is not just a financial challenge but also a barrier to adherence. A staggering 98 million new therapy prescriptions are left unfilled or abandoned at the pharmacy annually due to affordability issues for patients. One of the root causes lies in the limited access to full manufacturer rebates and patient assistance programs. These funds, which can significantly offset costs, often fail to reach patients and payers. Addressing this gap is critical to making healthcare more equitable and reducing abandonment rates.

The current model is riddled with restrictions—formularies and prior authorization processes dictate which drugs are accessible and which providers patients can use. These limitations often prevent patients from obtaining the medications they need at competitive prices. Advocates for change believe that increasing access and fostering transparent price competition are keys to improving outcomes. When patients and payers have visibility into all available prices and access to 100% of manufacturer rebates and assistance dollars, affordability improves, and adherence follows suit. Transparency and access are not just aspirational goals—they are necessities for a functioning healthcare system.

Moving Toward New Models: A Shift from Exclusivity to Competition

Historically, pharmacy pricing models have relied on scale and consolidation to negotiate better prices. While effective for generic drugs—responsible for 90% of dispensing—this model falls short for specialty drugs, which represent 54% of overall pharmacy costs. Specialty drugs often have little to no competition, further driving up costs.

The inefficiencies of the current system are stark. A recent Wall Street Journal article highlighted that a single medication could have over 2,200 different prices, illustrating the incremental costs and limited access to the best prices. Moving forward, the focus must shift from rigid rules and restrictions to consumer-driven solutions.

By leveraging artificial intelligence (AI) and technology, healthcare systems can customize the “next best action” for each patient, improving care while reducing costs. Competition, rather than exclusivity, is the key to achieving better prices in both pharmacy and broader healthcare settings.

Embracing Technological Advances

One of the greatest obstacles to innovation in pharmacy care lies in outdated technology. Claims systems, for example, are built on fixed inputs such as static drug lists, limited pharmacy networks, and rigid formularies. These systems are ill-equipped to support the dynamic, patient-focused demands of modern healthcare. System conversions aimed at upgrading these technologies are often costly, time-consuming, and disruptive—especially when involving the three dominant players in the pharmacy benefit management space. Yet modernization is essential to meet the current realities of pharmacy operations, electronic medical records (EMRs), payers, and claims systems.

To truly manage pharmacy processes effectively, stakeholders must work beyond the “lowest common denominator” and embrace systems that enable flexibility and innovation. By integrating AI-driven insights and creating seamless interoperability, the industry can lay the groundwork for a more efficient, patient-centered future.

Looking to 2025: A Vision for Change

The prescription medication landscape in 2025 will build upon the shifts already underway. As costs continue to rise and drug shortages persist, the need for affordable, accessible, and transparent solutions become crucial. Innovative models that prioritize competition over exclusivity will pave the way for better outcomes.

By addressing the inefficiencies of outdated models and championing competition, Waltz Health isn’t just reducing costs; we’re changing the very fabric of how patients, payers and providers interact with the pharmacy ecosystem. We currently support over 9 million patients and touch 80 million pharmacy transactions annually and are tracking to save over $100 million annually for our payers and their patients. Our configurable solutions can be connected at multiple points in the existing pharmacy and PBM eco-system to help deliver increased affordability, increased access for patients, and leverage new technologies and AI to micro-personalize better care and improve costs.

The opportunities for transformation in 2025 are immense. With the right solutions, the healthcare industry can evolve into a system that not only addresses current inefficiencies but also anticipates and adapts to the needs of the future.

Contact Waltz Health to discover how our innovative solutions can help your organization reduce costs, expand patient access and leverage AI-driven insights to improve care.