CVS-Aetna combination faces still business challenges

Walking the aisles of a CVS drugstore, there are piled paper towels, stacked cereal boxes and neat lines of nail polish. In the back, there’s the pharmacy.

For years, that approach has remained essentially unchanged despite a creeping reality: Every time a customer hits “Add to Cart” on, the pharmacy chain’s thousands of square feet of retail floor space get a little less valuable. Meanwhile, the money Americans spend on health services keeps growing.

That’s why the back of the store is front and center as CVS Health gets ready to combine with health insurer Aetna.

The $67.5 billion merger announced December 3 will bring together 9,700 CVS stores and Aetna’s 22 million customers. A central plank of the deal is transforming the stores into health hubs where consumers can get care, pick up their drugs, buy some milk and stay out of the hospital.

Customers exit a CVS Health Corp. store in Chicago, Illinois, U.S., on Sunday, Nov. 6, 2016. CVS Health Corp. is scheduled to release earnings figured on November 8. Photographer: Christopher Dilts/Bloomberg

“Together, we plan to build an entirely new healthcare concept based on the principles of making care easier to use and more affordable,” CVS CEO Larry Merlo said on an early December call with investors.

There are serious challenges to CVS’s proposal. Revamping the stores could cost several billion dollars. The company will have to change how millions of customers see a doctor or nurse. And it will have to fight decades of healthcare economics and patterns.

While many stores are polished and inviting, revamping others will require significant overhauls, and CVS has said it may redirect some of its $2 billion in annual capital spending to the task. The company is also testing out vision and hearing services in a handful of locations and may eventually offer nutrition services.

The Aetna deal offers little in the way of traditional synergies, and whether it succeeds will depend on managing customers’ health, using in-store clinics and hubs to care for patients in lower-cost settings or stay on top of costly diseases.

As the companies envision it, individuals with a chronic disease like diabetes could get blood tests drawn or see a nutritionist in a store while picking up their medication. If they need it, they could then be guided to see a specialist or told when to return for a follow-up.

Most CVS clinics now are staffed by a single nurse practitioner at a time. Frances Prado, a nurse practitioner who previously worked at MinuteClinics in the Walnut Creek, Calif., area, said she had to do everything from ordering supplies and cleaning up to dealing with a customer’s insurance information.

Stef Woods made her first trip to a Washington, DC, MinuteClinic when her four-year-old daughter Roya came down with a cold. Hoping to get a quick test for strep throat, Woods, a lecturer at American University, took Roya to a CVS on a Saturday morning, buying her a drink and a coloring book in the store as they waited.

“CVS is trying to fill a void,” she said. “There’s such a gap in access to care.”

While the clinics are convenient, there’s evidence that may come at a cost for the healthcare system. According to one study, patients take advantage of the convenience to use more services. Instead of waiting out a cold or the flu, they go see a clinician.

“In contrast to the people who have said retail clinics would reduce healthcare spending, we’ve seen it increase healthcare spending,” said Ateev Mehrotra, an associate professor at Harvard Medical School.

The study doesn’t account for the “the long-term benefits of receiving preventive care,” CVS spokeswoman Carolyn Castel said.

Clinic nurses try to coordinate with patients’ doctors when they have them. If patients don’t have a physician relationship, the clinicians try to connect them with one, said Castel.

For now, the clinics likely account for less than 1 percent of CVS’s annual revenue, estimates Adam Fein, president of Pembroke Consulting, which focuses on drug distribution. The clinics also don’t bring in many customers—only about 1 percent of all drugstore visits are made primarily to visit a clinic, according to research firm Kantar Retail.

CVS, based in Woonsocket, R.I., doesn’t disclose financials for its clinics and declined to comment on the estimates.

Jeff Goldsmith, who runs the healthcare consulting firm Health Futures, is skeptical of the strategy behind the deal, calling it “flat-out baffling.” He says the MinuteClinics, or what he calls the “nurse in a broom closet” model, lack the clinical acumen or trusted relationships with patients to effectively manage care.

“I don’t see it generating new customers for either the acquirer or the acquiree, or leverage to lower health costs,” he said.

More of the recent growth in “convenient care” has come from standalone urgent-care centers. Those facilities, typically staffed by doctors and serving a wider array of illness and injury, are expanding quickly, as much as 15 percent a year, according to Tom Charland, founder of industry tracker Merchant Medicine. Some of the biggest are backed by major corporations, such as UnitedHealth Group’s MedExpress chain.

In-store clinics are growing more slowly. CVS has 1,100 out of about 2,000 industrywide, according to data from Merchant Medicine.

CVS’s rivals have stayed back, by comparison. Walgreens Boots Alliance Inc. has about 400 in-store clinics, while Rite Aid has 43 RediClinics in its pharmacies. Wal-Mart Stores has more than 4,600 pharmacies in its stores, but just 19 clinics. The company says it isn’t planning to add more.

CVS has made deals to transform its business before. In 2007, it acquired prescription benefit manager Caremark. Seven years later, CVS broke ranks with the rest of the drugstore industry and removed tobacco products from its shelves. Today, only 11 percent of CVS’s sales come from non-pharmacy sources, according to Kantar Retail analyst Brian Owens.

With threatening every traditional retail business, including CVS, Owens said now’s the time try something new.

“They’re already moving away from a drugstore to a healthcare company,’’ Owens said. “That means they can take risks that other retailers can’t.’’