Recent moves to consolidate insurance customers under one corporate structure could lead next to carriers acquiring hospital networks.
The continued market consolidation and efforts to create an “all-in-one” approach to healthcare insurance customers may lead to carriers acquiring large hospital networks, particularly if the CVS-Aetna transaction proves to be successful and profitable, one analyst says.
The mergers and acquisitions in the insurance industry over the last year is the preamble for what will happen over the next two years, says CEO of Tom Borzilleri of InteliSys Health, a company aimed at bringing greater transparency to prescription drug prices, and the former founder and CEO of a pharmacy benefit manager (PBM).
The effort will ramp up to include hospitals if health plans start seeing financial rewards from the recent moves, he says.
"We are seeing carriers acquiring PBMs, as with Cigna/Express Scripts, and pharmacy chains/PBMs acquiring carriers, like CVS/Aetna, in search of cost efficiencies to increase earnings," he says. "One may view these mergers and acquisitions as a favorable strategy to delivering both cost savings and patient convenience, but this strategy also has the potential to produce a serious negative effect on other critical stakeholders like doctors, hospitals, clinics, and others."
In the past, many carriers managed their pharmacy benefits internally and found that it would be more cost-efficient to outsource that function to third-party PBMs, Borzilleri notes.
"As the PBM industry grew significantly over the last decade, allowing PBMs to gain market share and buying power for the millions of lives they managed, it opened the door for PBMs to methodically profiteer at the expense of both the carriers and their insured through the vague and complicated contracts for services the carriers were forced to sign," he says.
Borzilleri continues, "In essence, the carriers really didn’t know what they were paying for at the end of the day for these services. As the market began to change with the onset of a movement and demand within the industry for more price transparency, carriers began to realize that they would be better served to bring the PBM function back in-house to reduce costs and increase earnings."
Creating a Closed Loop
Borzilleri explains that a merger like the CVS-Aetna acquisition provides the insurer the ability to:
- Control drug costs by eliminating the profits that the PBM formerly enjoyed
- Realize cost efficiencies to dispense medications at the pharmacy level
- Directly employ the providers that can treat their members at a cost much lower than the reimbursement rates they currently pay their network doctors
- Create a brand-new revenue stream from the retail products sold in these stores
That brings a ton of reward to CVS-Aetna, but not to anyone else, Borzilleri says.
"This type of closed-loop network will limit patient options to everything from who will be treating them, where they will be treated, and how much they will be forced to pay for services and their prescriptions," he says.
Gregory A. Freeman is a contributing writer for HealthLeaders.