For decades, independent community pharmacies have been anchors of patient care, particularly for people battling complex conditions like cancer. But in 2025 those pharmacies find themselves at a crossroads, squeezed by low reimbursements, powerful middlemen and a regulatory maze that makes it harder—not easier—to get life‑saving medications into the hands of patients who need them.
A recent report in Pharmacy Times describes medically integrated dispensing (MID) pharmacies as being at a “critical crossroads.” These pharmacies, which combine oncology practice with medication management, face unsustainably low reimbursement rates, restrictive pharmacy benefit manager (PBM) practices, new interpretations of anti‑kickback rules that limit their ability to deliver oral cancer drugs, and financial headwinds tied to the Inflation Reduction Act. Each factor on its own would be burdensome; together they threaten to upend a care model that keeps patients on therapy and out of hospitals.
PBMs were originally designed to negotiate drug prices on behalf of insurers. Today three of them control nearly 80 % of U.S. prescription claims: CVS Caremark, Express Scripts (Cigna) and OptumRx (UnitedHealth). This consolidation has tilted the market in their favor. Independent pharmacies must accept ever‑lower reimbursements to stay in networks, yet those reimbursements often fail to cover the cost of expensive oncology drugs and the personalized services MIDs provide. An analysis by the American Economic Liberties Project found that at least 326 pharmacies, most of them independent, closed in the ten weeks after Congress abandoned bipartisan PBM reforms. Patients in underserved areas are now traveling farther for care or going without.
Federal rules are compounding the problem. When the public‑health emergency ended in May 2023, the Centers for Medicare & Medicaid Services reinterpreted the Stark anti‑kickback law to forbid independent physician practices from delivering oral cancer medications via mail. Patients who once could get oncology drugs delivered now must travel long distances or rely on PBM‑affiliated specialty pharmacies. Meanwhile, the Inflation Reduction Act, designed to cap patient out‑of‑pocket costs, is prompting PBMs and manufacturers to adjust contracts in ways that could lower reimbursements further.
People on the ground see the effect up close. Dimple Lagdiwala has spent his career straddling pharmacy operations and entrepreneurship. The New Jersey‑based consultant and real‑estate investor, who once ran his own pharmacy, describes himself as a “pharmacy consultant, real‑estate investor and philanthropist,” with a personal mission to improve access to affordable, high‑quality treatments for underserved communities. In his view, the fight isn’t about matching the scale of national chains. “Competing on size is neither feasible nor desirable,” he says, echoing themes from a recent commentary he wrote about “precision over scale.” Instead, he argues that independent pharmacies should leverage their agility to provide tailored services such as point‑of‑care counselling, medication synchronization and help navigating financial assistance programs, while banding together to advocate for fair reimbursement.
Pharmacy advocates share those concerns. Organizations such as the Community Oncology Alliance and the National Community Pharmacists Association are lobbying for PBM transparency, equitable reimbursement and a repeal of the Stark delivery interpretation. Proposed legislation, from the Pharmacists Fight Back Act to the Patients Before Monopolies Act, would require PBMs to reimburse pharmacies fairly and prohibit spread pricing. State lawmakers are also exploring their own reforms, from banning fees on Medicare Part D claims to mandating prompt payment.
Behind the policy jargon are real patients. MIDs often serve people undergoing chemotherapy who need rapid access to oral oncolytics, anti‑emetics and supportive medications. Low reimbursements and delivery prohibitions mean some clinics can no longer stock or dispense certain drugs, forcing delays in treatment initiation and medication adherence. When small oncology practices close, vulnerable patients are left navigating complicated mail‑order systems or traveling hours for refills.
An equitable path forward will require collaboration across the supply chain. PBMs and insurers must recognize the value MIDs provide in keeping patients out of expensive hospital settings. Regulators should revisit interpretations that inadvertently hurt patient access. And independent pharmacies must continue to innovate, adopt technologies such as AI‑enabled inventory management and automated dispensing, and work collectively to make their voices heard.
Lagdiwala remains cautiously optimistic. “Opportunities don’t happen, you make them,” he says. With thoughtful policy reform and a recommitment to patient‑centered care, independent pharmacies can continue to play their vital role in the cancer‑care continuum.
