How the proposed CVS-Aetna merger may increase prices, limit entry

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Whereas the U.S. Division of Justice might not have plans to problem the $69 billion mega-merger of CVS and Aetna, sufferers and physicians ought to achieve this at each flip. The acquisition of the nation’s third largest insurer by the nation’s largest pharmacy profit supervisor couldn’t solely enhance health-care prices, however limit entry to look after hundreds of thousands of insured People.

CVS and Aetna declare their union — which can mix a medical health insurance payer, pharmacy profit supervisor (PBM), and nationwide retail pharmacy community underneath one roof — may streamline inefficiencies, scale back the worth of prescribed drugs and reduce down on physician and emergency room visits by permitting sufferers to obtain primary scientific care at walk-in CVS MinuteClinics.

The merger might increase income for each firms however may severely restrict affected person selection in the case of seeing a health care provider or filling a prescription, and can nearly definitely enhance health-care prices by offering even much less transparency into the already murky world of prescription drug costs.

For instance, Aetna may restrict selection by requiring sufferers to go to a CVS MinuteClinic earlier than, or as a substitute of, seeing their very own physician, although common, seemingly routine visits to a major care doctor have been proven to be essential for sufferers, particularly for wanted preventative care. Aetna may additionally require sufferers to fill their prescriptions solely at CVS pharmacies, severely limiting affected person choices for the place and the way they get their drugs. Requiring Aetna prospects to make use of CVS pharmacies may additionally sound the dying knell for impartial pharmacies and trigger drug costs to rise, significantly in underserved communities.

With even much less value transparency, sufferers can anticipate decreased selections. Insurer and PBM confidentiality agreements already make it nearly not possible to know precisely what prescribed drugs truly price as a result of payers and PBMs negotiate costs behind closed doorways. These secret agreements and drug rebate “kickbacks” are largely answerable for greater drug costs within the first place, as a number of class-action lawsuits have alleged. If rivals like Aetna and CVS are allowed to merge, you could be certain value negotiations would change into much more opaque and prescriptions much more costly.

Each CVS and Aetna declare that housing a payer, retailer, and PBM underneath one umbrella would make managed care cheaper and extra environment friendly. However, even when consolidation improved effectivity, it’s unlikely that any price financial savings can be handed to sufferers. Aetna already has a historical past of prioritizing income over sufferers by intentionally blocking entry to care. A former Aetna medical director just lately admitted that he by no means checked out sufferers’ medical data when deciding to approve or deny claims, a revelation that resulted in a number of states launching investigations into Aetna’s claims overview course of. A pediatric doctor group just lately filed swimsuit in opposition to the insurer for “improperly interfering with medical care,” alleging that Aetna executives “don’t concern themselves with the precise care being delivered,” even for “justified and life-saving care,” however are solely “motivated by a need for ever-increasing income.”

The rising development of proscribing sufferers’ entry to care shouldn’t be restricted to Aetna. A latest report discovered that as much as 53 million People might lack entry to prescribed remedies for persistent sicknesses as a result of their insurer wouldn’t cowl the fee.

What ought to fear insured People much more is CVS-Aetna merger may set off a wave of different acquisitions, additional consolidating the health-care sector underneath the management of some highly effective firms. Insurance coverage big Cigna already has an settlement to amass PBM Categorical Scripts, and there are rumors of a potential Walmart-Humana acquisition. In response to the American Medical Affiliation, such mergers will additional limit entry, scale back high quality, and make care much less inexpensive, even whereas rising premiums and increasing the out-of-pocket prices for prescribed drugs.

Amongst these urging the DOJ to dam the deal is California’s Insurance coverage Commissioner, who argued the sheer measurement of the merger “will possible result in elevated costs and decreased high quality” and “have important anti-competitive impacts on American shoppers, well being care and medical health insurance markets.”

Well being care is getting too far out of attain for many People, even with insurance coverage. Reforms should begin with value transparency and eradicating boundaries to look after sufferers, not trying the opposite approach when the business’s largest and strongest gatekeepers be a part of forces to spice up their income and market share. Lawmakers and the Division of Justice should intervene to forestall these so-called vertical health-care mergers and forestall much more consolidation that might enhance prices, scale back selection and restrict entry to look after hundreds of thousands of insured People.

Theresa Rohr-Kirchgraber, MD, is the previous president of the American Medical Girls’s Affiliation and a founding member of the Physician-Affected person Rights Mission.

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