How the proposed CVS-Aetna merger could boost costs, restrict access

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Whereas the U.S. Division of Justice could not have plans to problem the $69 billion mega-merger of CVS and Aetna, sufferers and physicians ought to accomplish that 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 prohibit entry to take care of thousands and thousands of insured Individuals.

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

The merger could increase income for each firms however may severely restrict affected person selection relating to seeing a physician or filling a prescription, and can nearly actually 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, despite the fact that common, seemingly routine visits to a major care doctor have been proven to be vital 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 loss of life knell for unbiased pharmacies and trigger drug costs to rise, significantly in underserved communities.

With even much less worth transparency, sufferers can anticipate diminished selections. Insurer and PBM confidentiality agreements already make it nearly not possible to know precisely what pharmaceuticals really price as a result of payers and PBMs negotiate costs behind closed doorways. These secret agreements and drug rebate “kickbacks” are largely chargeable for increased drug costs within the first place, as a number of class-action lawsuits have alleged. If opponents like Aetna and CVS are allowed to merge, you may be positive worth negotiations would change into much more opaque and prescriptions much more costly.

Each CVS and Aetna declare that housing a payer, retailer, and PBM beneath 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 could 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 lately admitted that he by no means checked out sufferers’ medical information when deciding to approve or deny claims, a revelation that resulted in a number of states launching investigations into Aetna’s claims evaluate course of. A pediatric doctor group lately filed go well with towards 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 pattern of proscribing sufferers’ entry to care will not be restricted to Aetna. A current report discovered that as much as 53 million Individuals could lack entry to prescribed therapies for power diseases as a result of their insurer wouldn’t cowl the fee.

What ought to fear insured Individuals much more is CVS-Aetna merger may set off a wave of different acquisitions, additional consolidating the health-care sector beneath 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 doable Walmart-Humana acquisition. Based on the American Medical Affiliation, such mergers will additional prohibit entry, cut back high quality, and make care much less inexpensive, even whereas growing premiums and increasing the out-of-pocket prices for pharmaceuticals.

Amongst these urging the DOJ to dam the deal is California’s Insurance coverage Commissioner, who argued the sheer measurement of the merger “will seemingly result in elevated costs and decreased high quality” and “have vital 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 Individuals, even with insurance coverage. Reforms should begin with worth transparency and eradicating limitations to take care of sufferers, not trying the opposite method 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 stop these so-called vertical health-care mergers and forestall much more consolidation that may enhance prices, cut back selection and restrict entry to take care of thousands and thousands of insured Individuals.

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 Undertaking.

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