Beyond Shared Savings: The New Playbook for Specialty Care Procurement

For years, specialty care purchasing centered on three priorities: access, navigation, and reported savings. These were the metrics that mattered. When evaluating a new partner, employers would ask: Can employees get to the right providers? Are they being guided toward quality care? How much are we saving?

That conversation is changing.

Increasingly, benefits, finance, and procurement leaders are asking a different set of questions—ones that go deeper than reported outcomes and into the structural economics of how specialty care is purchased in the first place. How are savings calculated? What fees are embedded in the model? What financial exposure exists beneath the surface? Can these arrangements withstand fiduciary scrutiny?

What was once viewed solely as a healthcare purchasing decision is now increasingly being viewed as a financial and governance decision as well.

Why scrutiny is increasing

This shift isn’t happening in isolation. A combination of litigation, regulatory pressure, and growing employer sophistication is drawing specialty care purchasing models into sharper focus.

On the legal front, ERISA-related health plan litigation has accelerated significantly. In 2025, plaintiff law firms filed a near-record 155 ERISA fiduciary class action lawsuits. 39 (25%) involved health plans, the largest subcategory outside of defined contribution plans. The allegations span a wide range:

• Lewandowski v. Johnson & Johnson and Stern v. JPMorgan Chase (filed 2024–2025): Both cases allege that plan fiduciaries failed to prudently manage prescription drug benefits, allowing their pharmacy benefit managers to charge excessively inflated prices, resulting in significant financial harm to plan participants.
• Hecht v. Cigna (settled late 2025 for $5.7 million): Plaintiffs alleged that Cigna maintained inaccurate provider directories, steering members to out-of-network providers without their knowledge. A federal court found that “repeated and systematic failures” were sufficient to constitute a plausible breach of ERISA’s duties of loyalty and prudence—reframing what had long been considered an administrative issue as a fiduciary one.

A “prohibited transaction” under ERISA—the legal concept at the heart of many of these cases—refers to any arrangement between a health plan and a provider where the compensation paid cannot be demonstrated to be reasonable. Until recently, plaintiffs faced a high bar to bring such claims. That changed in April 2025, when the Supreme Court issued a unanimous ruling in Cunningham v. Cornell University that significantly lowered the pleading standard for prohibited-transaction claims. The Court held that plaintiffs need only allege the basic elements of a transaction, not preemptively disprove every available exemption. Under the ruling, the burden of demonstrating that a vendor arrangement qualifies for an exemption now falls on the plan sponsor, not the plaintiff.

The Consolidated Appropriations Act of 2021 (CAA) has also played a central role. The law significantly strengthened ERISA’s requirements by requiring brokers, consultants, and other covered service providers to disclose all direct and indirect compensation to the employer in writing—before a contract is signed. Employers, in turn, have a corresponding duty to review those disclosures and determine whether vendor compensation is reasonable. Failing to receive, review, and evaluate those disclosures can itself constitute a breach of fiduciary duty and a prohibited transaction.

Beyond litigation, employers are encountering practical friction in their relationships with specialty care vendors. Disputes over how savings are calculated, questions about fees embedded in shared savings arrangements, and vendor contract terminations driven by financial disagreements have all contributed to a broader reckoning with the way these models are structured. When the economics of a relationship cannot be independently verified, such disputes become harder to avoid and resolve. While individual cases rarely become public, the pattern is consistent: when the price isn’t established upfront, disagreements over what was actually saved—and what the vendor is owed—are nearly inevitable.

The signal isn’t coming from one direction. It’s coming from several at once. And the tone is not one of alarm; this is a natural maturation of how employers approach healthcare as a category of enterprise spend.

The bigger issue isn’t litigation—it’s visibility

It would be easy to frame this as a story about lawsuits. But the core issue runs deeper.

Many specialty care purchasing models share a structural characteristic: they are built around retrospective calculations. Under shared savings arrangements, for example, employers aren’t provided with a defined price before care occurs. Instead, value is demonstrated after the fact, once care has been rendered and the bill arrives. The employer’s ability to independently verify or validate that value often depends on benchmarks set by the vendor and on methodologies that may not be fully transparent.

This creates a fundamental challenge. The true cost of care—and the true economics of the vendor relationship—cannot be fully understood before a purchasing decision is made. Fees can be embedded within savings calculations. Benchmarks can shift based on assumptions. Financial outcomes can be difficult to independently validate. And under ERISA, the employer is still responsible for demonstrating that the arrangement was prudent and that compensation was reasonable, regardless of whether the vendor made that easy to verify.

As scrutiny increases, employers are realizing that the ability to defend a purchasing decision matters just as much as the promise of savings itself. That’s a meaningful shift in how healthcare is being evaluated at the organizational level.

What employers are beginning to demand

The natural response to structural opacity is a demand for structure. And that’s precisely what’s emerging across the market.

Employers are increasingly prioritizing:

• Defined pricing established upfront, before care is rendered and before commitments are made
• Transparent vendor economics, with fees that are visible and clearly separated from any savings calculation
• Verifiable financial outcomes that can be understood and validated in advance, not interpreted after the fact
• Governance and fiduciary alignment, ensuring that purchasing decisions can be documented, defended, and held to the same standards applied across the enterprise

The question is shifting from “How much could we save?” to “How is value actually defined, measured, and validated?” That’s not a retreat from value-based thinking. It’s a more rigorous application of it.

The shift toward responsible purchasing

These emerging standards have a name: responsible purchasing.

Responsible purchasing is best understood not as a product category, but as a framework. It’s a response to the governance pressure, financial ambiguity, and increasing scrutiny now shaping how employers evaluate specialty care.

The framework starts with a straightforward premise: the price must be known before care occurs. From that foundation, it establishes that vendor economics should be fully transparent, and that financial outcomes should be verifiable before a commitment is made—not estimated after.

Models built on upfront pricing, transparent economics, and defined accountability avoid many of the disputes and uncertainties that are now drawing employer attention. They also provide a defensible foundation for the fiduciary obligations that plan sponsors carry under ERISA, which are only becoming more consequential as litigation expands and regulatory expectations rise.

The market is signaling what comes next

The most important signal isn’t the lawsuits themselves. It’s what they represent: employers asking harder questions, applying greater scrutiny to purchasing models, and raising their expectations for financial transparency and accountability.

This is a maturation of the market—one that was always going to happen as healthcare spending grew and as employers became more sophisticated purchasers. The legal and regulatory environment has accelerated the timeline, but the direction was already set.

As specialty care continues to evolve, one principle is becoming increasingly clear: the price must come first.

We explore the full Responsible Purchasing framework—including the financial, governance, and fiduciary implications driving this market shift—in our executive brief.

Download the Responsible Purchasing Executive Brief