How Will Insurer-PBM Deals Affect Health Costs?

It may take awhile, but the recent mergers of health insurers and pharmacy benefits managers could meaningfully mitigate the costs of care.
David McCannOctober 11, 2018
How Will Insurer-PBM Deals Affect Health Costs?

It’s anyone’s guess how the ongoing consolidation of the health-care industry will ultimately affect group health-care costs.

Companies, for their part, appear to be skeptical that the cost outcome will be positive. But some key observers smell the potential for game-changing efficiencies in the delivery of medical services and drugs — over the long term, at least.

No one is expecting big changes soon, following the Justice Department’s approval on Wednesday for CVS Health’s $69 million acquisition of Aetna. That federal green light followed another one in September for Cigna’s purchase of Express Scripts, a leading pharmacy benefits manager (PBM) and a primary competitor of CVS.

“From the surveys we’ve done, employers do think these deals matter and will have an impact on their overall health ecosystems,” says Tucker Sharp, global chief broking officer for Aon Health Solutions, which provides consulting, brokerage, actuarial, and strategic services for corporate clients.

“But they’re not building that into any budgets, even for the long term,” he adds. “They’re going to be watching to see what happens, but there are no predictions or confidence about knowing the actual financial impact.”

That could change, though.

Most consolidations in the health-care space in recent years have been horizontal — for example, health-care systems buying up other health-care providers to gain scale and negotiating leverage with suppliers.

However, the two major deals approved since last month are vertical in nature, with two of the three largest U.S. health insurers joining forces with the two largest PBMs. “These vertical mergers are about changing the delivery of health care,” says Sharp.

The combination of CVS and Aetna is particularly intriguing. According to the company, 82% of Americans live within 10 miles of a CVS retail location.

So, a big payday could come from the combined company creating health-care clinics at retail locations offering a wide range of services. To make it work, there would have to be incentives — in cost, quality, convenience, or some combination — for people to use the clinics instead of emergency rooms and other traditional medical providers.

With respect to employer-sponsored health plans, plan sponsors could install disincentives for not using such retail facilities.

But how much will that change people’s behavior? “It’s an interesting bet CVS is making,” Sharp observes.

The potential implications of the deals go far beyond retail health-care delivery, however. The main game-changer could be the opportunity for health insurers and PBMs to finally start sharing information.

“A PBM is focused only on managing an employer’s drug spend, without any regard for the impact on the total cost of care,” notes Brian Marcotte, CEO of the National Business Group on Health (NBGH), a coalition of some 420 large employers. “But it’s very possible for an increase in pharmacy spend to lower the employer’s total cost of care.”

How so? When pharmacy costs are managed in a silo, the PBM might leave a high-cost drug — that could, for example, allow optimal management of a potentially costly chronic condition — off the employer’s drug formulary.

“If that drug is able to manage that condition to the extent where someone is not going to the hospital, the overall costs for that person’s care may be less,” Marcotte points out. “That should be factored into the equation as to whether a certain drug is going to be covered.”

That’s more likely to happen when a health insurer and a PBM are under the same roof and sharing information. It’s a big-ticket item, to say the least, considering that 86% of the nation’s $2.7 trillion in annual health-care expenditures are for people with chronic conditions.

Additional advantages could come from integrating medical and pharmacy data and bringing transparency to the point of prescription-writing.

“They could potentially enable a physician to understand the full price of the drug, the patient’s obligation, and the efficacy of that drug vs. others,” Marcotte says. “Physicians have never been in a position to have those conversations with patients.” It should be noted, though, that NBGH’s member organizations may not be quite as enthused about the insurer-PBM combinations as Marcotte is. Indeed, for the most part, they’re skeptical (see chart).

To be sure, Marcotte knows that a lot of pieces must fall into place for his vision of a potentially more efficient health-care system to materialize into reality.

For one, he reiterated comments he made to CFO in August about the need to significantly alter the current pharmaceutical supply-chain model, which he characterizes as “broken.”

Also, much more progress needs to be made toward evolving to new physician-reimbursement models and service-delivery models.

“In those models where the physician has the responsibility for costs within their health system, giving them information about what things cost, and alternatives, and efficacy would be very helpful in trying to drive down a path of efficiency,” Marcotte says.