Even before the DaVita deal, about 30,000 doctors were affiliated with OptumCare. They treat UnitedHealth’s members, as well as clients of rival health insurers. The company doesn’t own pharmacies, but its pharmacy benefit director serves 65 million people–compared with 90 million members at CVS’s PBM. UnitedHealth’s profits and share performance have outpaced those of many other big health companies in recent years.
” The path here has been led by UNH/ Optum ,” Matthew Borsch, an analyst at BMO Capital Markets, said in a research note about the CVS-Aetna plan.” We watch a bold strategy to match( and maybe leapfrog) the health-care/ PBM consolidation strategy .”
The integration is part of a wide-ranging effort by health insurance companies and the federal government to shifting care away from paying for each service and toward paying the physicians and hospitals for taking better care of patients and keeping them healthier. The approach, known as value-based care, challenges the industry’s traditional reimbursement models.
Putting different aspects of care under the same roof also can remove perverse incentives from the system. For example, some critics have said that PBMs contribute to narcotic cost hikes because they benefit from back-end rebates and fees extracted from pharma companies. Stimulating them part of the same company that delivers care and offers health insurance can ensure it doesn’t happen, says Craig Garthwaite, a professor of strategy at Northwestern’s Kellogg School of Management. When different parts of the system blend,” everyone’s earning motives are aligned at providing care that leads to good outcomes ,” he says.
CVS and Aetna say they’ll be able to reduce costs by directing some patients to lower-cost sites of care in CVS stores, keeping them out of emergency rooms and hospitals. About 70 percent of the U.S. population lives within 3 miles of a CVS location, according to David Larsen, an analyst at Leerink Partners.
” This is going to be appealing to a huge number of people ,” says Ingrid Lindberg, chairman of Kobie Marketing Inc. and a former chief customer experience officer at health insurer Cigna Corp.” There’s a large majority of people who are truly driven by ease and convenience when it comes to their care .”
Ateev Mehrotra, a professor at Harvard Medical School, says his research has found that retail clinics, by making care more convenient and accessible, actually raise health-care expenses because people go to them more often. That’s bad news if you’re also an insurer.” The majority of visits we watch at retail clinics represent new utilization ,” he says.” Because of that, in contrast to the people who have said retail clinics would reduce health-care spending, we’ve seen it increase health-care spending .”
Debating such outcomes could remain an academic workout if the CVS transaction doesn’t gain government approval. Courts and regulators tend to go easy on “vertical” mergers, such as CVS-Aetna, which combine companies at different levels in the render chain, such as manufacturers with retailers. The logic is that the combining can improve efficiency and lower costs for consumers. Authorities tend to worry more about “horizontal” mergers, which combine companies at the same stage of production. In January a federal tribunal blocked Aetna’s proposed horizontal merger with Humana Inc ., a fellow health insurer.
In weighing the CVS-Aetna deal, the Department of Justice or the Federal Trade Commission could try to determine” whether there is a long-term economic benefit to a strategy that harms challengers even if it means a short-term hit to gains ,” says Jennifer Rie, a senior analyst at Bloomberg Intelligence.
CVS won’t get a free pass. In November the Justice Department sued to stop the merger of AT& T Inc. and Time Warner Inc ., also a horizontal consolidation. The CVS-Aetna dealmakers are constructing the lawsuit that their combination would bring new services to the market, such as the planned pharmacy clinics. That could persuade regulators to give the proposal a chance. In contrast to AT& T-Time Warner, says Jonathan Rubin, an antitrust lawyer and partner at MoginRubin LLP,” it’s a more believable story that the vertical consolidation is related to invention .”
The buyout remainders on an untested strategy, however, and some on Wall Street question whether the companies can persuade enough consumers to switch to their in-house services. Says John Schroer, a health portfolio director at Allianz Global Investors:” Health care is a very difficult business, and it’s not so easy to say it’s a new world and merely do it this style .” —