What’s Actually Driving Your Pharmacy PPD Up—And Why No One Has Given You a Straight Answer

Over the last six months, CFOs and CEOs have been unusually candid about one issue: the numbers on their pharmacy spend no longer make sense.

Not just “prices are rising”—but rising in ways that feel untethered to clinical reality. Hospices tell us they’re seeing drug classes—anticonvulsants, psychotropics, analgesics—swing wildly in price week to week. National shortages have turned drugs that were once clinical workhorses into unpredictable line items. And behind the scenes, many PBMs continue to rely on spread pricing: a model where the PBM benefits financially from the very price increases that strain your budget.

One CFO put it bluntly:

“It’s hard to trust a partner who makes more money when our spend goes up.”

Layer onto that the growing number of after-hours retail fills—which carry higher costs, higher delivery fees, and a higher risk of unnecessary ER utilization—and the PPD trend line starts to feel inevitable.

But PPD isn’t rising because hospices are overprescribing. It’s rising because systems and incentives around you are breaking down.

And then there’s the other pressure point: fulfillment delays. Hospices report 2–4 hour waits for routine fills and even longer delays for night/weekend orders. Pharmacies are shortening their hours. Delivery drivers are scarce. Some PBMs push mail-order by default, even when a patient needs comfort meds now, not in two days.

The financial impact is obvious, but the clinical impact is worse: avoidable suffering, panicked families, and nurse burnout.

These aren’t logistics problems; they’re system design problems in an industry increasingly shaped by investor cycles instead of patient needs.

The financial strain hospices are feeling right now isn’t the result of a single bad month, a few expensive drugs, or a temporary wave of shortages. It’s structural. It’s embedded in how pricing is set, how orders move through fragmented systems, and how much of the med-management ecosystem is now driven by forces that don’t sit inside your organization.

That’s why the smartest leaders we talk to aren’t simply asking, “How do we lower PPD?” They’re asking harder questions:

• Are our pharmacy delays a logistics issue—or a symptom of our PBM’s delivery model?
• Do our rising costs reflect clinical complexity—or spread pricing and retail leakage?
• Are we building our budgets around predictable workflows—or propping up processes that only work on paper?
• Do our partners share our financial incentives—or quietly benefit from every price spike we absorb?

These aren’t academic questions. They determine whether you’re managing the problem or being managed by it.

If your current answers feel unclear—or if your gut tells you the numbers aren’t adding up—you’re not alone. Many hospices are discovering that the biggest financial risks aren’t coming from utilization; they’re coming from the unseen dynamics around how meds get priced, fulfilled, and delivered.

And this is where leadership matters. The organizations that stay ahead will be the ones willing to interrogate the assumptions they’ve outgrown… and start demanding a medication strategy built for the realities of today, not the systems of ten years ago.