Under fire. That is the best way to describe the current state of the proposed $29 billion mega-merger of two of the nation’s three largest pharmacy benefit managers, and the fierce resistance it is drawing from pharmacy and consumer groups. If the plan is approved, Express Scripts will emerge as a PBM giant with a network covering some 135 million members.
Appearing before a Sept. 20 House Judiciary Subcommittee hearing called to explore potential antitrust issues related to the proposed merger, Express Scripts and Medco executives made their case. The deal, said Express Scripts chairman and CEO George Paz, “will help make prescription drugs more affordable for seniors, people with disabilities and working families. It will also help small businesses and large employers ... to rein in their medical costs.”
Medco chairman and CEO David Snow told the House panel that PBM clients still would have “plenty of competitive choices post-merger, and the combined Express Scripts and Medco will be fully subject to the competitive pressures that will ensure value-based pricing and service.”
In fact, according to Express Scripts spokesman Brian Henry, the PBM sector “is a very dynamic, competitive marketplace. There [are more than] 40 PBMs in the marketplace, and 10 different companies servicing the Fortune 50 companies,” he told Drug Store News.
However, the true competitive picture appears far less robust. According to research conducted by Barclay’s Capital analysts, once you carve out the new ESI-Medco’s 41% share of total U.S. prescriptions filled, Caremark’s share (about 28%), and OptumRx (about 14%), that leaves seven companies fighting over about 15% of the pie. Factor out Catalyst Health and Prime Therapeutics — each about 5% of the market — and that’s five companies left to fight over the remaining 5% or so.
Then there’s the grip the new company would have on the mail-order business (about 60%), and more so, the rapidly growing and highly costly specialty pharmacy market (more than 50%).
Expressing “grave concerns,” Dennis Wiesner, senior director of privacy, pharmacy and government affairs at H-E-B — who spoke on behalf of the National Association of Chain Drug Stores during the Sept. 20 hearing — told House members that the deal, if approved, “would be a tipping point in PBM consolidation, harming patients, as well as government and private health plans and employers.”
In particular, Wiesner drew lawmakers’ attention to what he called the “opaque manner” under which PBMs operate. “There is no proof that [PBMs] pass along their purported savings to health plans, employers or consumers. In fact, the PBM industry has been fraught with allegations of extensive deceptive and fraudulent practices,” such as accepting manufacturer rebates for placing higher-priced medications on drug formularies, switching customers to those medicines and benefiting from both, he said.
Amplifying Wiesner’s message was Pennsylvania-based independent pharmacist Joe Lech. “ESI and Medco say that this merger will drive out so-called ‘waste’ in the healthcare system,” said Lech, who spoke on behalf of the National Community Pharmacists Association. “Frankly, these are just code words for squeezing my pharmacy reimbursement as far down as they can and trying to shift as many of my patients as they can to their own mail-order facilities,” he added. “My pharmacy has no leverage. ... In my pharmacy, this merged company will pay for more than half of the prescriptions filled.”
Lech also attacked the two PBMs on generic utilization — which “everyone knows is the fastest way to reduce drug costs,” he said. “The generic rate at the ESI mail facility is 60%. It is 62% at the Medco facility. By contrast, community pharmacies dispense generics on average 72% of the time,” he said.
Meanwhile, both sides tried to amplify the message for all Beltway influentials to hear and see during the week of the Sept. 20 hearing. A NACDS-sponsored ad (which can be heard at DrugStoreNews.com/audio) played on radios throughout the Capitol. And ESI and Medco ran print ads that appeared in important D.C. papers like The Hill and Politico that week. “We protect consumers from the rising cost of prescription drugs,” the ESI-Medco ad promises.
Yet, for all of that “protection,” you can say that five of the biggest consumer interest groups in America just aren’t feeling it — Consumers Union, Consumer Federation of America, the National Consumers League, U.S. PIRG and the National Legislative Association on Prescription Drug Prices have all come out against the merger.
Other groups also have expressed opposition, including the National Coordinating Committee for Multiemployer Plans, the Independent Specialty Pharmacy Coalition, the Food Marketing Institute and the California Pharmacists Association. Representing some of those groups is David Balto, a Washington-based attorney and former FTC policy director.
“The mere fact that the FTC has issued a second request, that they’re conducting dozens of interviews and that they’ve been joined by numerous state attorneys general, shows that the law enforcers believe that this merger is not business as usual, and it’s not going to get a quick-glance approach,” Balto told DSN.
Although the deal could impact how pharmaceuticals reach the market, the industry group Pharmaceutical Research and Manufacturers of America has not taken a position on the merger. Still, even without PhRMA piling on, the arrows are flying from seemingly every direction.
According to ESI’s Henry, both companies still are as confident as ever that the deal will close, and are sticking with the original second quarter 2012 timeline.