Buried in the National Alliance of Healthcare Purchaser Coalitions’ 2026 Pulse of the Purchaser survey is a trend line moving in a direction nobody predicted. Employer concern about the reasonableness of hospital charges as a fiduciary matter has fallen from 68% in 2023 to roughly 33% today. Concern about hospital billing integrity dropped by a similar amount. Concern about PBM compensation fell from 43% to 24%.
On its face, that looks like progress. It is not. Over the same three years, the same employers’ support for PBM reform rose about 20 points and support for hospital rate regulation rose 17. Purchasers did not stop believing something is wrong with what they pay. They stopped believing it is their job to police it.
For a benefits advisor, that gap between falling vigilance and rising frustration is the most important client conversation of the year. Here is why.
Calm is not the same as safe
The survey’s authors offer three possible explanations for the decline:
- Genuine improvement
- Normalization of high prices
- Attention shifting elsewhere
Only the first would justify relaxing, and nothing else in the data supports it. Costs are projected to rise 7.7% before plan design changes. Hospital and facility care still consumes the largest share of the healthcare dollar. Nearly one in four Big Three PBM clients admitted they are not sure what is in their own contract, roughly twice the rate of employers using other PBMs.
Meanwhile, the legal environment moved the opposite direction. CAA 2021 made fee reasonableness and compensation disclosure an enforceable plan sponsor duty, and participant litigation against household-name employers has turned that duty from theory into discovery requests. Federal law enacted this February will require PBMs to pass through 100% of rebates and other remuneration, phasing in beginning in 2028 and, for calendar-year plans, generally taking effect in 2029. A pass-through mandate is only as strong as the plan’s ability to verify it. Verification is now the whole game.
You cannot verify what you cannot see
The survey shows what separates confident fiduciaries from anxious ones, and it is not plan size or premium position. It is data access. Employers without full pharmacy claims access were more than twice as likely to question both PBM compensation and the integrity of PBM administration. Employers who could independently review their own claims reported materially higher confidence in their vendors.
That is the fiduciary loop in one finding. Opacity breeds doubt, doubt without data has nowhere to go, and a sponsor who cannot audit cannot demonstrate prudence. A fiduciary process that depends entirely on the vendor’s own reporting is not a process. It is a testimonial.
The advisor’s opening
Here is the uncomfortable part of the survey for our channel: concern about the reasonableness of broker and consultant fees barely registered, under 10% among all employer groups. Advisors are not under scrutiny today. Anyone who watched PBM scrutiny build over the past five years knows how quickly that changes, and CAA disclosure rules already put advisor compensation in the file.
The advisors who win the next cycle will be the ones who moved first, who walked into the renewal meeting and said: your concern went down, your obligations went up, and here is the verification process that closes the gap. That conversation repositions the advisor from product placer to fiduciary architect, and it is very hard for an incumbent competitor to counter, because countering it requires producing the data access they never secured.
