COMMENTARY

CVS-Aetna Deal Turns Up the Heat on Physicians

Melissa Walton-Shirley, MD

Disclosures

January 18, 2018

I imagine a word game between me and the father of medicine, Hippocrates. "Instructor. May I say three words and you say the first thing that comes to mind"? I ask.

"Very well," replies the ultimate teacher.

"Acquisition," I say, expectantly.

"Entrenchment," he replies. Hmm...interesting.

"Merger," I say.

"Prohibition," he replies emphatically. I look confused. "Against competition," he explains. I hesitate, carefully choosing my last offering of the game.

"Monopoly," I say. At this point he tires of the back and forth and asks, "What does this game have to do with the practice of medicine, relief of suffering, and the provision of comfort?"

"Monopoly," I say again. "Exclusion," he says, wisely. He does not know why I've chosen these three words. I do not reveal that I'm from the future, where medicine, the sacred profession he holds dear, has become a business, and I'm ashamed to say that these three words now govern everything.

A Year of Reversal

In January 2017, the US District Court for the District of Columbia ruled Aetna's attempt to purchase Humana in a $34 billion dollar deal a violation of antitrust law. In a victory for the US Department of Justice (DOJ), the competition among Medicare Advantage providers was deemed a protected entity.

By year end, CVS, the owner of almost 10,000 pharmacies and 1100 retail clinics announced its purchase of Aetna in a $66 billion deal. This new merger, which pits scores of pharmacy-based outpatient clinics against US hospital-based emergency departments and private physicians offices, has thus far failed to garner any formal action from the DOJ. Their silence tacitly pronounces it fair competition. This expensive shell game is touted as an efficient avenue to lower the price of pharmaceuticals, improve access to care, and provide convenience to consumers, but others see it differently.

In a recent Forbes article titled The CVS-Aetna Merger Is a Mortal Threat to US Hospitals,[1] Bruce Japsen wrote that the merger "is designed to keep patients out of the hospital for as much as possible" in order to "capture patients in lower cost settings." He quoted CVS CEO Larry Merlo as saying that the move is filling the "unmet need" of "convenience and coordination." Merlo neglects to mention the glaring lack of supervision, expertise, and experience that may occur when more than 22 million health plan members move into the hands of nurse practitioners (NPs) with whom they've had no prior professional relationship.

The Demise of the Last Jedi of Medicine

There are good doctors and bad doctors, just as there are good and bad NPs and physician assistants. I have had the great privilege to practice alongside great ones. I have found them compassionate, competent, and caring. Many spent years in critical care units, on hospital wards, and in physician's offices under direct supervision prior to becoming nurse practitioners. I have expressed grave concern regarding new pathways for education, particularly the accelerated pathway to a bachelor's of science in nursing (BSN). My NP friends and acquaintances share my concerns. To meet the demands of these new "customers," CVS-Aetna may be forced to acquire a large number of such healthcare providers quickly. Furthermore, there may be a near-complete disruption in continuity of care for many.

Accelerated BSN candidates may achieve a bachelor's degree in any area and then study in an intense nursing pathway for 12 to 20 months. Students are required to pass a board exam and do 2 to 3 years of NP courses, and then they can practice. By email, Robert Rosseter, chief communications officer of the American Association of Colleges of Nursing, wrote, "If you are fresh out of high school, you need a 4 year BSN followed by 2-3 years to become an NP."

He referred me to Newhouse and colleagues' review of multiple studies that " show comparable outcomes between APRN [advanced practice registered nurse] and physician care."[2] These studies, however, do not include patients who were managed by NPs who trained under accelerated BSN programs. I reached out to Aetna for comments, but they said they would be unable to get back to me in a timely fashion. I predict that the argument will be made that most practitioners are well trained and have not graduated from an accelerated BSN program as part of their earlier training. Hopefully this may start a conversation regarding the quality of care to be offered.

Consumer Choice?

Patients can see the healthcare provider (HCP) of their choice? Sound familiar?

I'm certain it will be emphasized that it will be a matter of choice for an Aetna patient to see an MD, NP, or physician's assistant with whom they have enjoyed a long -term relationship. I suspect that choice will narrow over time. I further suspect that most patients caught up in this phagocytosis of Aetna will have to walk by shelves of fiber supplements and do-it-yourself pregnancy kits to access a clinic for their primary care.

Any complaint may then be rendered worthy (or not) of further assessment by someone with little insight into their medical history. That is indeed a dangerous and slippery slope for a country that claims to have excellent healthcare. At the very least, this merger may be viewed as a lingering embrace of mediocrity in medicine.

Physicians Are Our Own Worst Enemies

Physicians who say we are "too busy" to adequately assess the downside of new trends or legislation in this pharmacy–insurance company merger should consider the frog in the pot brought slowly to boil. Our colleagues in primary care may be the first victims. The minute the CVS clinics open, drive-through healthcare will be instantly and forever the norm for a large slice of our US population…unless we create our own brand of disruption.

Medical associations need to do more. They should advertise experience and education as a counter distinction from what is offered in the pharmacy walk-in clinic. We physicians need to give up routine 3- and 6-month follow-ups where appropriate to make room for more walk-ins.

Patients need ready access to all test results and medical records so they are informed about their status and can have a more efficient conversation with their providers. That means providing hard copies for elderly patients who aren't computer savvy or offering access for their family members and advocates. We need to sit down, look patients in the eye, touch them, answer questions, and demonstrate that we care.

Hospitals and Corporations Missed Opportunities

Patients and physicians have lamented costly emergency department visits for years. It is the Achilles heel in the medical industry that has led to this merger. Hospitals had the capability to streamline care and cut costs, but they didn't. They could have proposed legislation and funding of education for our young to understand the difference between wellness and illness, but they didn't.

While the number of physicians in the work force remained relatively flat, hospitals employed more and more clipboard-carrying administrative personnel.[3] According to Physicians for a National Health Program, between 1975 and 2013 the number of physicians grew 150%, an expected rise based on population growth, whereas the number of hospital administrators grew by 3200%.

Take a moment to digest those figures and the impact on the cost of US healthcare.

Insurance conglomerates bonus their CEOs with multimillion-dollar checks, while patients go without necessary testing. According to Securities and Exchange Commission filing acquired by the Hartford Courant, Mark T Bertolini, the chief executive of Aetna, received almost $28 million in compensation in 2015, including over $3 million in salary, bonuses, and perks.[4] Contrast this with the many hours physicians and office staff sit on the phone daily, begging for coverage of a stress nuclear test or echocardiogram. How many patients could stay with their own HCPs for that amount of cash, not to mention for the amount that other executives and administrators are earning?[5] In other words, don't blame doctors for most of what's wrong or too expensive in medicine today.

Is There an Upside to the CVS-Aetna Merger?

I value the role that HCPs and even lay people can play in healthcare. Recall the study about a blood pressure cuff in a barbershop? [6] Blood pressure control improved when someone offered blood pressure monitoring at a place where humans go most often. Nutrition and exercise training can shut down the metabolic factories that produce illness and drive costs. We need more education in that regard, but it can't replace experienced physicians and HCPs who can diagnose and treat illness.

Perhaps the most popular Hippocrates quote "Healing is a matter of time but it is sometimes also a matter of opportunity" is telling with regard to the CVS-Aetna merger. I fear there will be far less opportunity for the detection and therefore the healing of serious medical illnesses. I fear that by the time specialists see some patients, their illnesses will be advanced because of delays in diagnosis.

Another worrisome trickle-down effect will be that far fewer humans will choose to spend the 4 years of premed, followed by 4 years of medical school and the 3 to 6 years post-residency to practice our trade. Who will be willing to sacrifice so much of their lives to deliver care if a few years after a French degree we may be called "Doctor" by the lay public just as easily?

God help us frogs. The bubbles are starting to rise to the surface already.

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