Over the past two decades, consolidation in the US healthcare sector has increased, with mergers and acquisitions of domestic players at multiple levels of the supply chain, including pharmacies. The pharmacy market is undergoing major changes, with vertical and horizontal consolidation, independent pharmacies facing increasing challenges, growth of specialty pharmacies, and the exponential presence and influence of pharmacy benefit managers (PBMs). increase. The situation is complex, with conflicting views and theories about the impact of these market shifts and whether they are driving up costs and out-of-pocket costs for cancer patients.

Walgreens, by contrast, also expanded, but remained primarily in the pharmacy market. Walgreens, the second-largest pharmacy chain in the United States after CVS Health, is working to eliminate competition by integrating other chains and related e-commerce into its brands. In the past decade, Walgreens has acquired New York City-area chain Duane Reed. Drugstore.com and Beauty.com; Alliance Boots; USA Drug, Super D Drug, May’s Drug, Med-X, and Mid-South drugstore chains operating under the Drug Warehouse banners. Finally, his Rite-Aid at the drugstore chain.

However, some argue that these acquisitions may have little impact on cancer patients. “While retail pharmacy consolidation may create inconvenience for patients, pharmacy consolidation is not expected to have a significant impact on cancer care in community settings,” said Ann Johnson, Pharmacy Healthcare Solutions, Pittsburgh, PA, USA) said. “Pharmacy consolidation will not increase prices for consumers because the costs that patients pay for medicines, such as co-payments, are set by health insurance and PBM, not by the pharmacy itself. Similarly, the pharmacy perspective. From now on, the amount pharmacies will be reimbursed is established in the PBM Network contract.”

Anticancer drugs have traditionally been administered in medical settings, but the advent of oral anticancer drugs has changed that trend. Some patients obtain their medicines at retail pharmacies, but most use specialty pharmacies or receive them by mail order. Oral anticancer drugs can be dispensed at pharmacies during consultations. Far more threatening to the integrity of cancer care is the integration of insurance companies, doctors, and other types to which his PBM is all connected, says Nicolas Ferreyros (Community Oncology Alliance, Washington, D.C.). , USA) said.

One area of ​​concern is vertical integration between insurers and physicians, with insurers providing their own practitioners, Ferreyros said. An example of this he is UnitedHealthcare. UnitedHealthcare is the largest health insurer in the United States and the nation’s largest single physician employer. His OptumCare, a subsidiary of UnitedHealth Group, has about 43,000 affiliated or employed physicians. Optum Healthcare subsidiaries also include MedExpress emergency care facilities, Surgical Care Affiliates ambulatory surgery centers, HouseCalls home visits, behavioral health and care management, and Rally Health wellness and digital consumer engagement. “They can manage primary care referrals, they can manage prescriptions, they are a fully integrated entity and they can keep everything in the network,” he says. “Decisions are not always made in the patient’s best interest or best value.”

Ferreyros explained that PBM is likely to drive branded drugs as opposed to generics and biosimilars. PBMs often receive rebates calculated as a percentage of the manufacturer’s list price, so they receive larger rebates for more expensive drugs as opposed to drugs that cost less and offer better value. . “Patients with higher deductibles or copayments based on the drug’s list price may have higher copayments,” he said.

The consolidation of PBM is even more of a concern given the intractable levels of control and influence a small number of companies have over the healthcare system. There are dozens of his PBMs in existence, but all three of his PBMs, which are the largest by market share, are vertically integrated with large downstream insurers. Caremark with CVS/Aetna, Express Scripts with Cigna, and OptumRx with United. The largest PBM not owned by a single health insurer is Prime Therapeutics, owned by 14 Blue Cross and Blue Shield health insurers.

“This is not good for any patient,” says Matthew Seiler (National Community Pharmacists Association, Alexandria, VA, USA). “PBM integrates upstream with insurance companies and downstream with pharmaceutical companies, which creates access issues.”

Seiler said patients may not be able to use their pharmacy of choice because it is “unconnected” and may be directed to an integrated pharmacy. “For example, you may need to use mail order instead,” he says Seiler. “This can lead to delayed drug availability and higher prices. Patients have no choice and no cost transparency.”

Lina M. Kern (FTC, Washington, DC, USA) said in a statement, “Many people have never heard of pharmacy benefit managers, but these powerful intermediaries wield tremendous influence over the U.S. prescription drug system. “This study sheds light on the practices of these companies and their impact on pharmacies, payers, physicians and patients.”

The Community Oncology Alliance notes that access and cost are two of the main problems with community practices being lost. For example, when rural clinics are closed, access issues arise because patients may have to travel great distances for treatment. This access issue can pose particular difficulties if the patient has mobility or locomotion problems.

The increasing integration of PBM and pharmacy, together with the steady disappearance of independent oncology practices, may pose more barriers to accessible and affordable cancer care. Healthcare mergers and acquisitions continue at a steady pace, but they can adversely affect the cost, quality, and accessibility of cancer care.