A Merger and a Turning Point for Pharmacy Practice?

The federal government agreed on October 10 that the Aetna and CVS Health merger can be consummated. That deal came with the caveat that the sale of Aetna’s Medicare part D business to WellCare is finalized.

Internal relationships between managed care plans and pharmacy benefits managers are not new. In fact, United Healthcare spawned Diversified Pharmaceutical Services, one of the first PBMs some 40 years ago. That PBM was eventually bought by Express Scripts. Today, OptumRx is United’s PBM. Today, CIGNA is closing its deal to purchase Express Scripts. Other regional or national health plans have established relationships with PBMs, for at least one valuable service: negotiating drug pricing with manufacturers. However, over the course of time, they have also taken advantage of several of the available services the PBM provided, like pharmacy network development, mail-order pharmacy, specialty pharmacy, and claims administration. This side of the Aetna and CVS Health merger is less inspiring.

One of more interesting aspects of the arrangement is not the PBM side of CVS but rather Aetna’s opportunity to leverage the community-based health clinics that CVS drugstores offer nationally.

Most people realize that flu and Herpes zoster vaccinations are available through community pharmacies. Generally, the drugstore has a partitioned area in which patrons can receive their flu shots. Like other large drugstore chains, CVS has built such a network—its Minute Clinic® within select locations. (These facilities may vary in terms of services offered or personnel on site. For example, according to CVS Health’s website, my local CVS pharmacy is supposed to offer Minute Clinic services, but it has no private area nor have I ever seen nurse practitioners or physician assistants onsite.)

The idea behind CVS Health’s strategy is largely embraced today. People need alternatives to the long appointment waits for routine care that may be evident through primary care practices. Urgent care clinics somewhat fill this gap, but the convenience of local drugstores cannot be topped (outside of access to full telemedicine services, which is years away).

Furthermore, the overhead associated with pharmacy-based clinics may be lower than facilities, particularly considering the menu of services they offer. In this model, access to pharmacy services is as good as in a hospital or integrated delivery network setting.

The only problem with this strategy is a familiar one—the limited workforce of healthcare providers. CVS Health states that its Minute Clinics are staffed with nurse practitioners and physician assistants.

The idea of using clinical pharmacists to collaborate with prescribers in the course of providing basic medical care has been around for decades. Beyond their utility in medication therapy management, a practice that has experienced slow growth since the early 1990s, clinical pharmacists can be a very useful resource in limited care settings. A major barrier to expansion of these services has been a lack of reimbursement from payers. Organizations like the Academy of Managed Care Pharmacy, American Pharmacists Association, and the American Society of Health-System Pharmacists have supported the expanded use of clinical pharmacy.

However, Aetna is a major payer. If Aetna is considering more fully integrating the community pharmacy–based clinic model into its provider networks, it may also be wise to plan for wider use of clinical pharmacy services. These services may be cost effective, help improve patient access to care, and result in high patient/member satisfaction. To achieve these outcomes, Aetna will have to align reimbursement for these services.

As fascinating as the scenario offered by Aetna and CVS Health merger seems, there may also be a more tantalizing opportunity: Beyond significantly growing the use of medication therapy management services, might this also serve as an initial step towards pharmacist-provided direct patient care supported by a national payer?

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