Geled the director of the center for pharmaceutical policy and prescribing at the university of pittsburgh and also an associate professor of medicine and Health Policy and here to help walk us through the impact of the proposed merger between c. V. S. And aetna. Thank you so much for joining us today. A pleasure. Ood morning. Host good morning. Cvs changed its name three years ago some say to reposition itself as a Health Company rather than just a drug store. Of about the significance a major drug store chain merging with a Health Care Insurance provider. Guest yeah. It is almost like this transition has been happening for decades. Cvs started in the 1960s as a single store and has been expanding its footprint since that time. The Minute Clinics opened about a decade ago. Then it joined with a pharmacy benefits manager to do other things and then it added some longterm care services. Some infusion services. Then it changed its name and got rid of tobacco. It has really been the evolution of the pharmacy. You said it. This is what makes it so unique is that this has been a pharmacy which is probably the first time this has happened in integrating pharmacy more into the structure of how health care was paid for. Host talk a little bit more about what you think cvs is trying to achieve with this merger. Guest only they know. Your imagination can fly in terms of what could be possible. It could be incremental changes. It could be what they talk about which is a fundamental transform ags of how health care is delivered. Understand youre asking about what cvs is and for most people its the pharmacy around the corner but it also has the Minute Clinic, the benefit management services, infusion services. You can imagine a fundamentally different way that health care is delivered. I think that is what cvs talks about and the goal. In fact, its something that farmsists have been talking about for a long time is finding a way to put pharmaciests and pharmacy more at the center of how health care is delivered. We are talking with dr. Walid gel add about the oposed merger between cvs if you are in the mountain or cific regions call 202748800 1. In gel add gellad, cvs its press release gave insight into what they believe the merger will do with top bullet points saying it will combine the unmatched local presence and clinical capabilities with aetnas benefits, provide better integration of care empowering consumers and their Health Professionals make more informed decisions and the transactions expected to generate significant synergy for Share Holders and benefits for customers. Certainly putting this in a light of something that is really going to help its customers. Is it really . Guest yeah. Those are a lot of grand things that could happen but it really will, really can do all those things they talked about. It can also do none of those things. When you talk about cvs, which is present, there are 10,000 stores. The statistics i read, 80 of americans, 8 in 10, live within 10 miles of a cvs and 70 live within three miles. Cvs is just everywhere. Its not hard to imagine the kinds of things theyre talking about if you, for example, if you have an issue where you might normally call your pcp or try to go to the Doctors Office if you can go around the corner and see someone then its just going to be a lot simpler. Imagine, take it a step further where not only do you go to cvs and see someone but there may be Telehealth Services and you can telehealth to see someone, to see a specialist. Theres all kinds of possibilities. And remember, cvs is not just that pharmacy but Home Infusion services. Think about instead of going to the Doctors Office to get infusions of whatever medicine it might be, imagine if they do it at home. They wont have to pay the facility anymore. They dont have to pay the doctor. It can all be kept internally. I think this is the kind of synergy they talk about and when they talk about the opportunities for the consumer its what happens when you can get these things done around the block or a few miles from your house or the same place you bought bread or milk or sunglasses or whatever it is. Thats the potential revolution. Host ok. Rudy is on the line calling from chicago. Youre on with dr. Gellad. Caller good morning and Merry Christmas to you all. This merger is nothing but the competitive battle between walgreens and cvs. There are several areas in neark have medical in america that have medically under served areas with all of the medical specialties. This merger doesnt talk about how theyre going to generate that kind of professionalism within our medical schools because at the university of illinois there is the Largest Medical School in america and also the university of chicago is the largest Public Research center in america. , s merger has no documented unmet needs to address areas that are medically under served in terms of Public Health sues or dealing with opiates outside every major city. Along with the whole question of accessing care, i know in chicago cvs is relatively new to the market. This Competitive Edge is doing nothing to curb some of the major problems like immunizations, school physicals, the kinds of services you need to have for trauma, the kinds of services you need in a major metropolitan area. Host ok. Rudy, i want to give dr. Gellad a chance to address that. Gaveragets lot of the problems with guest he has outlined a lot of the current problems with the Health Care System. If i were cvs i would say that again if you have a store within three miles or around the corner you have the opportunity to bring a lot of services to communities that didnt have them using new technology. And k thats a reality the way the system is going in terms of Telehealth Services and other kinds of clinicians who can take on more of the care. In some way you can imagine this increasing access. Maybe it will let hospitals focus on other things or expand in other ways. But your a he totally right. In terms of the walgreens issue, i think that, you know, that may be part of it again. Pharmacies are finding a way to compete and to become more central in the Health Care System. And cvs has done an amazing job spreading, it is now cvs has taken over target pharmacies nd who knows what is left . There are a lot of problems with Health Care System and this is a business decision but there are aspects to expand given the proximity to stores where people live. Host we are joined by the doctor and professor of Health Policy and management at the university of pittsburgh and he is helping us break down the proposed merger between cvs and aetna. The question i have and some of the viewers may is how does this impact consumers down the road. Say the cvs is the closest pharmacy to me but i am not an aetna customer. Will it make it harder and will my drug costs be higher . Guest yeah. Those are the questions everybody is asking and they are good questions. There is no answer. It depends how things are implemented. Weve already seen limitations n what pharmacy you can go to. Aetna already uses cvs and most people with aetna probably have a preference to go to cvs anyway. The concern is obviously that this will become more of an issue for consumers. You could easily imagine, and this already happens, much higher costs if you go to another pharmacy. You can even imagine much higher costs if you go to a different Urgent Care Center than the Urgent Care Centers in cvs. So it is going to be variable depending on what consumers need from cvs, the person just walking into the pharmacy may not notice any difference. Any time you have consolidation like this and integration there is always a concern that it will decrease the choices available to consumers. Say on the flip side, again, the flip side argument is that this is going to help us manage costs. Its going to help reduce costs for employers. Its going to make premiums less. It will provide benefits for consumers. It is always this tradeoff between costs and then the ability to go anywhere you want. Host weve talked a lot about the motivation of cvs and perhaps other drug stores to do this. What about on aetnas side . What is the motivation of Health Insurance providers in partnering and merging with drug stores . Guest yeah. Thats an excellent question. Aetna has been, they tried to merge previously and it didnt go through. This is a slightly different merger. But there is a trend in health care of trying to integrate payors and providers. And its happening all over the place. You saw United Health care doing the same thing with buying providers. The issue insurers have is things are really expensive and theyre trying to make money. Anything they can do to lower the price of services they have to pay for they will make more money. One of the best ways to lower the price is to be able to do things in a setting that is less expensive. So you can imagine a lot of things that currently happen, for example in the hospital or in the Doctors Office, that could be less exensive done in other set ks. And this arrangement really will facilitate that. Aetna could make deals with cvs but when they are under the same parent the presumption is there will be less barriers. They can do pilot programs. They can see how this works. And if it does work, you can imagine the kinds of customers they would get. Aetna has a lot of business in medicare and medicaid and if they can show theyre able to improve satisfaction, lower costs, whatever it might be that is an opportunity to really grow their business. Host bill is on the line from georgia. Good morning. Caller good morning. Id just like to say that i disagree with everything dr. Gellad has said. Number one, in markets where its not where there is not enough money and especially rural medicine, there will be more physicians. Plus the fact is a physician is a professional. And provides a service. And his Main Customer is his patient. For cvsaetna there is no professionalism there. The patients will be forced to use aetna products and they may not be the best for that particular patient. So we lose that bond between physicians and patients. You know, i have one question for dr. Gellad. I know hes not really thought about that issue about rural medicine but is he a paid consultant with any pharmaceutical companies. I appreciate hearing his answer. Guest yeah. Thanks for those questions. No, im not a consultant for any Pharmaceutical Company or any pharmacy or any company. But i appreciate that question. That is an excellent question. And im a doctor. So i completely get what youre saying. There is a special bond and relationship and this does have the potential to disrupt that. I dont want to minimize that. I dont want to minimize that at all. So let me get to that and thent issue about rural areas. Theres been a trend, because you brought up a lot of issues, theres been a trend about services leaving the primary care Providers Office and practice and all these things disrupt the relationship and weve seen the mini clinics and Retail Clinics which disrupts care a little bit, all of the specialization of care. It as chael eng. It as challenge. But on the other hand, we have a market and this is the way the market is going. And it can be tough for patients but ultimately costs are the issue. If its not the most Cost Effective way to see care thats whats going to happen in a market that we have. I mean, any it is obvious you brought up the issue about who is the customer. You are absolutely right that these are two large for Profit Companies and the big concern is that, like any for Profit Company we might see shareholder value, prioritized at least in the short term over patients. I mean, that can happen. And you dont want to minimize that. That would be a problem for patients. Ultimately its a balance between having the market we ave and trying to keep the doctorpatient relationship and the patient provider relationship. Another point you brought up, let me just make two more quick points about this issue around professionalism, you know, i think pharmacists would argue vehemently, maybe, contrary to what you said in terms of the professionalism that might be present in the pharmacy. They really viewed their relationship with patients in a very professional light and they have been again pushing for more of a role in the care of patients. They view it very seriously i think. You know, the reality is all of this is happening and as a primary care doctor i think about this all the time. The reality is what can doctors do to provide the best service to patients and demonstrate their value in this new market place . The last thing about rural care, it is a huge issue. Hospitals are closing in rural areas. Maybe this is a way to access care. I think the issues around telehealth and the expansion of access through technology really is one way to address the rural health problem. Host ok. We are talking to dr. Walid gellad at the university of pittsburgh about the proposed etnacvs merger. Ruth is on the line from atworth, georgia. Good morning. Caller good morning. I have a question. I would like to address the medication you receive from cvs when you have to do the mail rder care. The medicine that you receive has hurt me really bad, really, really bad. My legs have swollen till the skin breaks. My feet im hurt all over. Now ive had a heart attack because the medicine that my doctor snends for them, they get sends in to them they get it from india or someplace else and i have a terrible reaction to it. How do you address things like that . If thats the only place that you can go get your medicine and not have to pay full price for it . Guest yeah. I think that is an excellent question. I think the argument, first of all, i think you should talk to your doctor about all these things. But the argument i guess to make, that cvs would make is that if you have all these issues with your medicines, then you could come into the pharmacy, talk to the pharmacist, a pharmacist, you would have more of a regular interaction with, and then they help you address some of these concerns without med about medicines. But the issues, i dont think this is going to change dramatically all of the issues you talked about in terms of where our medicines come from, how theyre delivered. In fact, it may accelerate all those things. The argument is that when youre having problems with medicines you can go around the corner, go back to cvs and discuss this with a pharmacist or someone who can help you address these things. Host can you talk about what this might portend for the future . For example there is amazon. Com is exploring selling medicine. Might we see more of this kind of Cross Section or combination of Different Industries sort of getting into the medical Delivery Business . Guest yeah. Everybody has speculated on that. Some people have said this is about amazon. Some people have said this is nothing about amazon but just the progression of what cvs has done for a long time. My own opinion is that the pharmacy as the place where medicines are dispensed has been dying for years. You know, theres mail order and mail order pharmacies. Theres other ways to deliver medicines. You are no longer getting maybe getting longer supplies. So pharmacies have been trying to find ways again to incorporate themselves more essentially into health care. And so you might think if amazon goes on to deliver prescriptions this is just yet another way that the dispensing medicine part of the brick and mortar pharmacy will become less important but, yet, the pharmacy is a location. And cvs as a mail order pharmacy which is what it is will become more important. In fact, you saw cvs, i cant remember how long, a few months ago, promise to have next day delivery of prescriptions and same day delivery in certain markets, which people said was a response to amazon. But i think amazon, if amazon were to come into the market it will compete on mail order prescriptions and it will that is something it will compete with cvs for but cvsaetna would be a payor for these prescriptions and a location where care is delivered which would give them a Competitive Edge they would argue against just having a mail order place like amazon. Host all right. Steve is on the line from henderson, nevada. Good morning. Caller good morning. My question is the ive used the Minute Clinics before and they do take a number of insurance groups but i was concerned whether having aetna tied with cvs would that create a conflict of interest . Guest yeah. I guess im going to avoid any specific legal arguments. Im not a lawyer. What it will what will happen is that it will be an ssue for other insurers if aetna and cvs are merged. T may be that other insurers will not want you to go to cvs clinics and will contract with other Retail Clinics, whether med express, some of which are owned by united now. In the same way we are seeing payors and providers merge and that if you are a payor you dont really want your patients youre taking care of to go to a facility owned by another payor provider it is probably the same thing with the urgent care clinics. If you have aetna they will most likely rather you go to a Minute Clinic than some other Retail Clinic and will either do that by not paying for other places that you go to or they will make you pay more if you go to other places or pay less if you go to Minute Clinics. Theyll incentivize you to go to their ow