Pharmacy leaders say 2026 is shaping up to be a year defined by financial volatility, regulatory pressure and workforce strain — all intensified by upcoming federal drug pricing reforms. Across organizations, the challenges are stacked.
Drug pricing reforms are reshaping the financial landscape
The most widespread concern is the combination of Inflation Reduction Act provisions, 340B program changes and Medicare pricing reforms — all of which alter how and when health systems see savings.
Eric Balotin, director of retail and specialty pharmacy services at Upstate Medical University in Syracuse, N.Y., said his team is focused on managing cash flow as Inflation Reduction Act and 340B rebates begin in 2026, with additional medications entering the model the following year. Fred Yingling, vice president and chief pharmacy officer at Adena Health in Chillicothe, Ohio, called the shift to rebate-based 340B savings the organization’s top headwind because it removes up-front pricing advantages.
Kisha Gant, PharmD, regional director of pharmacy for Slidell (La.) Memorial Hospital, echoed those concerns, noting that HRSA’s shift to a 340B rebate model will create significant cash-flow pressures and add substantial administrative complexity — from vendor contracting to detailed claims submissions. She said her team is prioritizing proactive planning, strengthening partnerships and advocating for policies that protect patient access and long-term financial sustainability.
Several leaders underscored how destabilizing this transition is for hospitals serving rural and vulnerable communities. Neil Creasey, PharmD, system director of pharmacy services at Holzer Health System in Gallipolis, Ohio, said the 340B program is already a “moving target,” and adding rebates creates “yet another fiscal challenge” as payers report record profits. Donna Feild, chief pharmacy officer at PeaceHealth in Vancouver, Wash., pointed to the combined administrative burden and cash-flow disruption caused by both Medicare and 340B rebate programs.
Seth Gazes, associate vice president of strategy and planning in pharmacy at Geisinger in Danville, Pa., said the Health Resources and Services Administration’s 340B rebate model introduces administrative and denial-risk concerns. He also noted that Medicare drug price negotiations require planning for 2027 IRA-designated drugs, affecting specialty, retail and mail-order revenue streams.
Coverage losses and reimbursement pressure are tightening margins
Leaders also pointed to declining reimbursement environments and shifts in patient coverage that are adding financial strain.
Mr. Gazes cited Medicaid redeterminations and shrinking reimbursement as key pressures. Ms. Feild said decreases in Medicaid coverage — paired with rises in uninsured patients due to reductions in ACA subsidies — will further challenge hospital stability.
Arlene Johnstone, PharmD, director of pharmacy at MarinHealth in Greenbrae, Calif., described a broader financial picture of falling operating margins and rising non-labor costs. Her team has launched a multidisciplinary review of medication spending, formulary optimization and drug contract renegotiation to get ahead of the pressure.
Regulatory volume and payer requirements are accelerating
Federal and state policy activity is expected to surge in 2026, and leaders said the pace itself is becoming a headwind.
Danielle Sestito, PharmD, assistant vice president of pharmacy services at Northwell Health in New Hyde Park, N.Y., said the “sheer volume” of legislative and policy proposals will profoundly affect both practice and financial integrity. She emphasized that navigating this environment is a strategic imperative, not just a compliance exercise.
Matt Webb, PharmD, director of pharmacy at Sanford Health in Sioux Falls, S.D. — who oversees operations for the Northern Minnesota division — said his system is preparing for increasingly intricate payer requirements alongside federal and state regulation. His team is investing in proactive compliance strategies and updated infrastructure.
Workforce shortages persist — and leaders are turning to AI and pipelines
Almost every leader referenced workforce challenges as demand for clinical services grows.
Mr. Webb said recruiting and retaining pharmacists and technicians remains difficult, so his organization is strengthening career pathways and positioning itself as an employer of choice. Don Gruntowicz, PharmD, senior director of pharmacy services at Providence in Renton, Wash. — part of the Providence-Swedish division — said workforce well-being and retention are central to the system’s ability to stay flexible amid future industry change.
At the same time, leaders are evaluating automation and AI to augment capacity. Mr. Gazes said AI solutions — both in house and vendor based — are helping address pharmacist shortages and improve efficiency across centralized and in-clinic teams. Mr. Balotin said his organization is actively selecting an AI vendor for prior authorization management.
Supply chain vulnerabilities and high-cost therapies add complexity
Supply chain stability remains a foundational concern heading into 2026. Mr. Gruntowicz said his team is continuing efforts to diversify sourcing and strengthen revenue strategies while maintaining evidence-based therapy management.
Rita Shane, PharmD, chief pharmacy officer at Cedars-Sinai in Los Angeles, pointed to cell and gene therapies — along with uncertainty around drug pricing and the future of the 340B program — as areas with significant implications for systems caring for complex patients.
