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Bigger means cheaper
It took eight months and more than 200 interviews. But on April 2nd America’s Federal Trade Commission (FTC) decided, in a three-to-one vote, to let Express Scripts acquire Medco. The two firms are America’s second-biggest and biggest pharmacy-benefit managers. Eventually, they may change the way Americans take drugs.
Despite an intolerably dull title, pharmacy-benefit managers (PBMs) are important. America is the world’s biggest drug market; in 2010 it spent more than $307 billion on prescription medicines. PBMs are the middlemen that manage drug costs for employers and insurers. Together, Express Scripts and Medco will control more than 40% of the market.
Express Scripts announced the acquisition in July 2011. Medco was a good company that had had a bad year, and so looked cheap. It had lost about 30% of its business in a few months as some of its largest clients ended their contracts. For both firms, bigger ought to mean better. With scale would come the power to negotiate fatter discounts on drugs, lowering costs for employers and insurers.
Pharmacists felt sick when they heard the news. PBMs encourage consumers to fill their prescriptions through the mail instead of going to a costly pharmacy. PBMs, pharmacists fret, will crush their fees for dispensing drugs. Worse, PBMs will demand that drugmakers give them exclusive deals for new, complex medicines. Competitors and consumers will suffer, the pharmacists argue.
The FTC disagreed. The merged firm is unlikely to squeeze pharmacies’ fees for dispensing drugs, it ruled. There remain plenty of lively, smaller PBMs. John Kreger of William Blair, an investment bank, says there is enough turmoil—thanks both to the merger and to Express Scripts’ continuing fight with Walgreens, a big pharmacy—that smaller PBMs may snatch new business in the next year. The small fry may also benefit if the pharmacy lobby’s lawsuit against the merger moves forward.
The combined firm will have $91 billion in revenue in 2012, estimates Lawrence Marsh, an analyst at Barclays Capital. It is so big that it could shape a new era for America’s drug market. As more drugs lose their patents, consumers will increasingly fill their prescriptions with generics. If Express Scripts has its way, they will also fill their prescriptions by post. Medco recently acquired a firm that compares the efficacy of different drugs. This may prove useful when America begins to see cheap copies of complex drugs, called biosimilars, which will be tested against the originals. The new Express Scripts may also play a role on Barack Obama’s new insurance exchanges, working with insurers to court individuals shopping for health care.
Most intriguingly, the new Express Scripts could push Americans to buy the right medicines and take them at the right time. For years PBMs have tested ways to urge consumers to buy cheaper, effective drugs. For example, if a patient wants a branded pill rather than a generic, he must pay for more of it himself. Experiments will probably scale up and become more sophisticated. Eventually, they might even spread to Medicaid, the public programme for the poor. Health reform (unless the Supreme Court strikes it down) will add 16m new members to Medicaid by 2019, a 27% jump. PBMs such as Medco and Express Scripts have so far spent little time chasing the Medicaid market. That may change.
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