Drug reimbursement has never been more complex or more consequential for providers.
Turquoise Health and ZS’s Drug Reimbursement Trends Report analyzes millions of hospital- and payer-reported drug rates to uncover how reimbursement actually works across today’s most expensive therapeutic areas.
Examining seventeen medical benefit products across four high-cost categories, the report reveals that reimbursement outcomes are driven less by list prices and more by local payer–provider contracting dynamics. While many providers are reimbursed near Average Sales Price (ASP), hospitals, particularly under commercial contracts, frequently secure rates three to five times ASP, with outliers reaching up to ten times ASP for certain biosimilars.
These differences aren’t theoretical. They translate directly into meaningful revenue variation across providers, sites of care, and regions. In some cases, reimbursement deltas across products can exceed $100,000 per patient per year, creating material implications for margin, access, and care strategy.
The findings underscore a growing reality: reimbursement performance is a strategic lever. Providers with greater negotiating leverage, often large hospital systems and regionally dominant organizations, are better positioned to command premium rates, while specialty groups and national payers face tighter constraints. Powered by Transparency in Coverage (TiC) data, this report offers providers an early look at a future where healthcare pricing is more visible, more comparable, and more competitive. For organizations navigating tightening margins and increasing scrutiny, understanding reimbursement variation is no longer optional—it’s essential.
Key Findings
Drug reimbursement is heavily influenced by local payer–provider control and contracting dynamics
Hospitals are ~3× more likely than specialty groups to secure rates above 200% of ASP
Regional payers face higher reimbursement exposure than national payers due to local provider leverage
Product-level reimbursement variation can drive revenue differences exceeding $100K per patient annually
