CVS, Aetna and REM: It’s The End Of The {Healthcare} World As We Know it

This week, it was announced that two of the largest players in the American healthcare market have agreed to merge in a deal worth nearly 70 billion dollars.  This merger represents a departure from the traditional way in which doctors, patients, insurers and pharmacists have interacted for decades.  In the past, insurers and pharmacies have existed in separate silos.  As I discussed in a recent Op Ed, this old system was far from perfect.  Pharmacy benefit managers (PBMs) have taken advantage of patients, doctors and drug manufacturers and have served to raise the cost of medicines through demanding kickbacks known as “rebates”.  As bad as PBMs have been for healthcare, this new merger may actually be WORSE.  Now, mergers such as the CVS/Aetna deal will essentially bring the “Soprano-like” PBMs in house.  In addition, in the last several years, CVS has ventured into the healthcare provider market as well—staffing primary care “clinics” with pharmacists and nurse practitioners in retail stores (note the glaring absences of physicians in the CVS care model).  While CVS argues that the combination of a health insurance company and a pharmacy (that provides primary care services) will streamline patient care and lower costs, I believe it is likely to do just the opposite.

What IS the Likely  Impact of the Insurance Company/Pharmacy/Clinical Services Mega Store on Healthcare?

If this merger is allowed to proceed, all players (except for the mega CVS/Aetna conglomerate) in the US healthcare system will suffer negative consequences.

  1. Diminished Choice

Currently, many patients have limited access to drugs due to the role in which PBMs play in negotiating prices and determining what is on “formulary”.  This less than transparent process basically involves a system of bids from manufacturers where the highest bidder (for a rebate that is pocketed by the PBM) wins the preferred formulary status.  In addition, the PBMs can require patients to deal with a process of “step therapy” where they are forced to use less expensive (and potentially less effective drugs) than originally prescribed by their physician prior to being allowed to take the intended therapy.  If this acquisition is allowed to proceed, we will see even less choice.  Now, an insurer (who is motivated financially to prohibit access to more expensive therapies) will be partnered with a pharmacy who can potentially decide to only stock certain medications.  Price fixing may become the norm—if you are an Aetna customer, you may be only allowed to purchase your medications from CVS—even if there are cheaper options for you elsewhere.

  1. Rising Costs

When there is less competition, the consumer always suffers.  If we allow CVS and Aetna to merge, we are likely to see costs rise.  Healthcare consumers will not be allowed to shop around for less costly purchasing options.  I foresee a system where Aetna is able to dictate that ALL covered medications must be purchased from CVS.  If

  1. The Demise of the Doctor Patient Relationship

Medicine is defined by the way in which doctors and patients interact.  Trust is built over years of interactions—not in a minute clinic.  By removing the physician from the healthcare equation (as this merger is likely to do), patients will no longer be able to bond with a provider who can help them make difficult healthcare choices as they age.  Minute clinic staff tends to be more transient that physicians that work in long standing practices and medical groups.  While minute clinics can certainly be a great way to triage and treat simple, common primary care issues such as colds and flu, it is not a great venue for long term care of chronic disease.  Highly trained physicians who have completed between 3 and 10 years of Residency and Fellowship training AFTER the completion of their medical degrees are better equipped to make difficult diagnoses and manage complex diseases over time.  As a for profit entity, CVS is focused on cost containment—and Nurse Practitioners are far cheaper staff than board certified physicians.  In an ideal world, NPs and physicians work together and co-manage patients as each professional brings a unique perspective and a unique skill set to the clinical arena.

  1. Poorer Outcomes

When we focus purely on the economics of healthcare rather than evidence based medicine for therapy choice, outcomes will most certainly be less favorable.  If the CVS/Aetna merger is allowed to proceed, I expect all clinical decisions by CVS minute clinic staff will be based on treatment protocols and algorithms that are developed to contain cost.  Let’s be realistic—CVS and Aetna are in this to make money for their executives and their stockholders—the patient is really not their top priority.  Care delivered only by a Nurse Practitioner in a minute clinic is not the same as the care delivered by a Residency and/or Fellowship trained physician in a continuity clinic.

Ultimately, it is my hope that regulatory bodies in Washington DC will recognize this planned acquisition for what it is—an assault on the way in which medicine is practiced in the United States.  We continue to allow for profit corporations to dominate the decision making when it comes to healthcare policy.  WE must act to change this paradigm and PUT PATIENTS FIRST.  As Michael Stipe of the rock band R.E.M. wrote in his song, “world serves its own needs , don’t mis-serve your own needs”  If we do not act, this merger will be the first of many and will likely be “The End of  The {Healthcare} World As We Know It”





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