Mark Cuban, co-founder of Cost Plus Drugs Co., and Optum CEO Patrick Conway, MD, sparred over drug prices, pharmacy benefit managers and a range of other healthcare issues during a Dec. 16 conversation in Washington, D.C. hosted by Johns Hopkins University.
There was very little common ground to be found among arguably two of the most influential executives within the broad pharmacy services industry, though both acknowledged the other’s contributions to improving drug affordability.
The hour-long discussion, moderated by Ge Bai, PhD, an accounting and health policy professor at Baltimore-based Johns Hopkins, touched on rebate pass-through policies, contract transparency, and independent pharmacy reimbursement.
Dr. Conway and Mr. Cuban diverged on a number of issues throughout the conversation, nowhere more clearly than in how they would each rewrite national healthcare policy.
“Break up the big insurance companies,” Mr. Cuban said. “Can’t own PBMs. Can’t own providers. Can’t own their own technology. Make them all independent companies.”
Dr. Conway pushed back on claims about how many physicians Optum controls, noting that the company employs 10,000 to 12,000 physicians directly, while the remaining 88,000 are contracted. Optum parent UnitedHealth Group is the nation’s largest healthcare company, encompassing the largest insurer and PBM, data analytics firm Change Healthcare, and a sprawling provider subsidiary portfolio of homecare companies, ASCs and medical clinics.
For his part, Dr. Conway said he would focus on tackling high hospital and pharmaceutical costs.
“The underlying issue, just to be super clear about it: We have amazing, high-level care, and it is not distributed evenly in this country,” he said. “We’ve got a cost problem. When you ask regular Americans what’s the problem, it’s cost.”
Dr. Conway, who has led Optum since May, previously served as CEO of UnitedHealth Group’s PBM Optum Rx, president and CEO of Blue Cross Blue Shield of North Carolina, and held several top positions at CMS under the Obama administration. He framed Optum Rx as a “clinically-driven organization” that negotiated more than $50 billion in discounts or rebates on behalf of its more than 5,000 employer, health plan, union and government clients last year.
“When you look at our client base on new clients, we had a net promoter score of 100,” Dr. Conway said. “I haven’t seen an NPS of 100 on almost anything. The actual people we’re providing services to, employers, unions, governments, etc., including on transparency, choice, and affordability — we provide them that.” He also cited a 98% client renewal rate and said Optum Rx is growing faster than competitors.
Mr. Cuban was quick to challenge those claims, at one point asking Dr. Conway to name one of Optum Rx’s biggest customers “so I can call them and see if they love you guys.”
“Feel free to call any of our customers,” Dr. Conway responded.
Mr. Cuban argued that employers lack the information needed to evaluate their PBM contracts. His claims come amid a wider and recent trend of large employers suing health insurers and PBMs in an effort to access their complete medical claims data.
“The reality is there’s an information asymmetry,” Mr. Cuban said, pointing to his discussions with employers. “When I go talk to CEOs, I have a list of things that I ask them. One of the first things is, ‘Do you control all your claims? Do you get access to all your claims?'”
Mr. Cuban co-founded Cost Plus in 2022 with radiologist Alex Oshmyansky, MD, PhD. The company launched with about 100 generic drugs and now offers more than 6,000 medications, including brand-name medicines and biosimilars. It operates on a transparent “cost plus” pricing model that bypasses traditional PBMs.
The rebate debate
Much of the discussion, which grew tense at times, centered on PBM rebates and how they affect what patients ultimately pay at the pharmacy counter.
Dr. Bai explained the core issue: “There’s a gross-to-net price bubble because of the rebates. The PBMs get manufacturer rebates. The rebates become the difference between the gross price and net price. The patient’s cost-sharing is based on the gross price, not the post-rebate net price.”
Dr. Conway said Optum Rx has committed to passing 100% of rebates through to its clients. The company announced in early 2025 that it would complete the transition by the end of 2028, up from the 98% it says it already passes through.
He also defended the rebate system itself, warning that its complete elimination would benefit drug manufacturers at the expense of employers and health plans.
“If you had no rebates today and snapped that wand immediately, which some states are debating, you would transfer hundreds of billions of dollars from employers and health plans to pharma companies,” Dr. Conway said.
Mr. Cuban, visibly eager to counter throughout the discussion, was unconvinced by Dr. Conway’s argument, pointing to what he sees as a fundamental flaw in the U.S. drug pricing system.
“There’s a reason why we’re the only country that has PBMs and our prices are higher than brands everywhere else,” he said.
Network access and price transparency
When asked whether employers could add Cost Plus to their Optum Rx pharmacy networks, Dr. Conway responded with a firm ‘yes,’ another notion disputed by Mr. Cuban.
“We say yes to Cost Plus. We say yes to Amazon,” Dr. Conway said, linking what he described as Optum’s “fundamental principle” of collaborating with new entrant pharmacies to its growth.
“You’ve developed a company trying to solve a challenge,” Dr. Conway said to Mr. Cuban about Cost Plus. “We welcome innovation in the marketplace. You have a niche solution, largely in generics, where you’re trying to find a lower-cost individual drug at a point in time. We have a comprehensive solution that, for employers or unions or whoever else we represent, for their entire population, we negotiate the lowest net price. We deliver those savings to them. We have clinical programs.”
In 2024, Cost Plus committed to publishing its contracts with customers publicly in a push for greater transparency. The company has more than two dozen partnerships with pass-through PBMs and expanded its biosimilar offerings this year. It is also partnering with TrumpRx, a federal website launching in 2026 that will connect consumers with prescription drugs at discounted prices.
Though a much larger organization, Optum Rx has also been overhauling its pharmacy payment practices. In December, the company said all community and independent pharmacies in its network have transitioned to a cost-based reimbursement model. It’s also rolled out drug price comparison tools for consumers and automated prior authorization tools for health systems that reduce approval times to seconds. The PBM also eliminated prior auth requirements for 180 medications this year, all in an effort to reduce system friction, according to Dr. Conway.
“We don’t think we can solve everything in the system,” he said. “What I would hope we could do in these forums and others, as opposed to finger-pointing or other things, is how do we collectively solve the issue?”
Despite the shared appreciation for innovation, the two executives disagreed sharply on what drives high drug prices in the U.S.
Mr. Cuban pointed to PBM rebates as the primary obstacle to affordability. Dr. Conway disagreed, arguing that pharmaceutical list prices set by manufacturers are the bigger problem.
“It’s actually very clear what the data shows,” Dr. Conway said. “The primary issue in the U.S. is hospitals and health system costs and pharmacy costs.”
He pointed to GLP-1 drugs as an example of manufacturer pricing that far exceeds what other countries pay. His comments echoed those of former UnitedHealth Group CEO Andrew Witty, who in 2023 said U.S. list prices for weight loss drugs were “running at about 10 times the level of prices paid in Western Europe.”
The Trump administration has since negotiated deals with Eli Lilly and Novo Nordisk to bring GLP-1 drugs under a most-favored-nation pricing model. Starting in 2026, Medicare will cover these drugs with a monthly price capped at $245. State Medicaid programs will also have access to the same prices. Cash-pay customers will see prices fall to around $350 per month through TrumpRx, down from more than $1,000.
Despite the federal policy changes, the two industry leaders remained divided on how to address systemic issues within the wider pharmacy supply chain. Mr. Cuban acknowledged Optum’s contributions while directly questioning whether the company’s incentives align with patient affordability.
“I appreciate all you’ve done,” he said. “Between [UnitedHealthcare] and what you guys do, you’re not going to not help people — I get that. But there’s a reason why having 15 straight years of increased earnings, then having that streak stop, and then the CEO gets fired or leaves, that there are incentives that seem to be misaligned with offering the best price for patient care. It appears to me, anyways, that it’s very obvious.”
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