Michael Gaffney’s throat was scratchy for days, and lemon tea was not helping. So he dropped into a MinuteClinic above a CVS store in Midtown Manhattan on a lunch break. Within minutes, a nurse practitioner tested him for strep throat (negative), suggested lozenges and a regimen (ample fluids, no spicy food), collected a co-payment ($25 cash) and sent him on his way.
“That was quick,” said Mr. Gaffney, 26, an account executive for Indeed.com, who, like millions of Americans, does not have a primary care physician, even though he is covered by health insurance. He has been meaning to find a doctor since moving to New York last year, but his sore throat did not seem serious enough to warrant what was sure to be a time-consuming search and a long wait for an appointment.
The CVS MinuteClinic, on the other hand, was just blocks away from his office. “I waited longer for my bagel this morning,” he said.
Jessica Chung, a nurse practitioner, examined Mike Gaffney last month at a CVS clinic in Midtown Manhattan, where patients check in on a touch-screen kiosk and generally have short waits. Credit Brian Harkin for The New York Times
With 7,800 retail stores and a presence in almost every state, CVS Health has enormous reach. And while shoppers might think of CVS as a place to pick up toothpaste, Band-Aids or lipstick, it is also the country’s biggest operator of health clinics, the largest dispenser of prescription drugs and the second-largest pharmacy benefits manager. With close to $140 billion in revenue last year — about 97 percent of that from prescription drugs or pharmacy services — CVS is arguably the country’s biggest health care company, bigger than the drug makers and wholesalers, and bigger than the insurers.
Even before the Affordable Care Act created millions of newly insured customers in the almost $3 trillion health care industry, CVS saw that there were more profits to be made handling prescription drugs than selling diapers. But while its transformation from drugstore to health care company began a decade ago, CVS has more recently taken on a new advocacy role, that of a public enemy of cigarettes.
Its stand against smoking has allowed CVS to make alliances with health care providers and rebrand itself fully as a health care company. But with smoking rates on a steady decline, and cigarettes sales slumping, CVS also saw that future profits lie not with Big Tobacco but in health and wellness.
Taking the high road for health has its challenges. For one thing, it means new competitors in a rapidly changing industry. And, for a major retailer with tens of thousands of products on its shelves, it leads to an uncomfortable question: If we cannot sell cigarettes, what does that mean for potato chips?
Road to Growth
The Consumer Value Store started as a scrappy discount health and beauty outlet in Lowell, Mass., in 1963. Four years later, the small chain opened its first in-store pharmacies, and those became the core of the company — and its growth — for years. Larry Merlo, the chief executive, is a pharmacist by training and came into the company when it bought People’s Drug, a drugstore chain based in a suburb of Washington.
Helena B. Foulkes, below, leads CVS’s retail business. which is starting to change to better fit the company’s health care focus. Credit Ryan Conaty for The New York Times
In a phone interview, Mr. Merlo spoke mostly in corporate platitudes, but when the conversation turned to the subject of pharmacists, he spoke passionately about pharmacists’ role in delivering health care.
“Hypertension, diabetes, osteoporosis,” he said. “It’s the same story — people don’t take their medication as prescribed.”
Pharmacists, who see patients more frequently than doctors do, can make sure patients stay on their drug regimens, he said, keeping them out of the hospital and saving the health care system billions of dollars down the road.
“I think back to my own personal experience,” he said. “Sometimes, it’s as simple as answering questions to get people to stay on their prescription therapies.”
Mr. Merlo said the company stood out in the breadth of products and services it offered: Its MinuteClinics diagnose and treat patients, and its pharmacies dispense medicine to more than two million prescriptions a day. It negotiates the price of medicines and helps 65 million people navigate drug coverage under their insurance plans.
The shift toward health care started in 2004, when CVS acquired Eckerd Stores and Eckerd Health Services, giving CVS a foothold in administering drug benefits to employees of big corporations and government agencies. Two years later, CVS acquired MinuteClinic, a pioneering in-store health clinic chain that was offering treatment for routine illnesses, basic screenings and vaccinations. CVS also expanded its very profitable specialty pharmacy business, which focuses on expensive drugs to treat complex or rare diseases like cancer or H.I.V.
Then in 2007 came the $21 billion merger between CVS and Caremark, which gave birth to the country’s leading pharmacy benefits manager. Three years ago, CVS struck a deal with the medical products distributor Cardinal Healthto form the country’s largest generic drug sourcing operation. It followed up with a $2.1 billion acquisition ofCoram, a business that allows CVS to dispatch technicians to patients’ homes to administer pharmaceuticals through needles and catheters.
The acquisitions keep coming. In May, it paid $12.7 billion to acquire Omnicare, which distributes prescription drugs to nursing homes and assisted-living operations. Just weeks later, CVS announced it would buy Target’s pharmacy and clinic businesses for $1.9 billion and left open the possibility of pursuing further deals. Once the Target deal closes, CVS will operate about 9,600 retail stores, or about one out of seven retail pharmacies, according to Pembroke Consulting. Last year, the company changed its name from CVS Caremark to CVS Health.
The growth of CVS comes at a time when the way Americans get access to and pay for health care is evolving quickly. Surveys show that many of the estimated 30 million people who gained insurance coverage last year under health care reform do not have a primary health care physician or do not use one. Many, too, opted for high-deductible health plans and are expected to become picky with the dollars they spend, and less tolerant of the opaque pricing that is still the industry’s norm. And consumers in general are starting to demand more convenient, on-demand access to health care, closer to home.
In that fast-changing world, CVS’s strategy is to be a one-stop shop for health care.
“Say you have diabetes, and you go into a pharmacy to get your insulin, how great is it if, in the same aisle, there’s a cookbook for people with diabetes?” said Ceci Connolly, managing director of PwC’s Health Research Institute. “And maybe there’s some foods that are already approved for you, and a place to check your feet, and a clinician to check your eyes,” she said.
“Consumers are saying: I want all of that at a place near my house that’s open on Saturdays, when it’s convenient for me. I want that place to post prices. It’s in CVS’s interest to pull in more and more pieces of that puzzle.”
A typical CVS clinic staffed by nurse practitioners sees 35 to 40 patients a day; those patients pay $79 to $99 for minor illnesses and injuries, and most insurance plans are accepted. Analysts estimate each clinic typically brings in $500,000 a year, representing just a fraction of CVS’s revenue. Still, the clinics are an important part of the company’s health care proposition.
Other retailers are also getting into the business. The number of retail clinic sites grew to 1,800 locations nationwide in 2014 from 200 in 2006, though they still represent just 2 percent of primary care encounters in the United States, according to a report published this year by Manatt Health, a health advisory practice, and the Robert Wood Johnson Foundation. But CVS is by far the leader. Walmart, which charges just $40 a visit, has fewer than 100 clinics, compared with the more than 900 in CVS’s portfolio. Walgreens, the second-largest, has half as many clinics as CVS. And CVS plans to add more, reaching 1,500 by 2017, the company has said.
Whether these clinics provide the best kind of care is a question sometimes raised by doctors in more traditional practices, like Robert Wergin, president of the American Academy of Family Physicians and a doctor in Milford, Neb.
“These retail clinics, they’re run by competent folks, and they probably have some role to play,” he said. “But you’re being seen at a clinic next to the frozen food section by a stranger. And if you go back for a follow-up, you’re going to get seen by someone else.”
For employers and insurers, however, the clinics offer a way to reduce costs for noncritical conditions. A study by researchers at the RAND Corporation estimated that more than a quarter of emergency room visits could be handled at retail clinics and urgent care centers, creating savings of $4.4 billion a year.
Reducing health care spending, however, may turn out to be complicated.
“You might imagine that they keep people out of E.R., so that’s one way you could save money,” said Martin Gaynor, professor of economics and public policy at Heinz College, Carnegie Mellon University. “On the other hand, just because they’re more convenient, people might go and obtain care in circumstances where they otherwise would not have sought care.”
CVS might have more sway reducing health care costs in its role as a middleman between drug companies and patients with drug benefits. The company is expected to start shifting the balance between end users on one hand, and drug manufacturers and wholesalers on the other.
CVS and other large dispensing pharmacies — Walgreens, Express Scripts, Rite Aid and Walmart — made up about 64 percent of prescription-dispensing revenue in the United States in 2014, according to Pembroke Consulting. That year, CVS was also the leading provider of specialty drugs in North America, with $20.5 billion in revenue, representing 26 percent of the total market.
“Scale is a big factor in pharmacy,” said Joseph Agnese, senior equity analyst at S&P Capital IQ. “There’s a lot of pricing pressure from drug manufacturers and one way for retailers can come back at them is to become larger, and become a more significant purchaser of drugs.”
Dr. Gaynor of Carnegie Mellon said, however, that cost reduction varied greatly by type of drug. “If there’s a drug that is very important for CVS to carry, and there are no alternatives, they aren’t going to have a lot of negotiating power,” Dr. Gaynor said. “But of course, the bigger CVS gets, the more they can move product, the more important it becomes.”
The company’s size also creates significant competition issues, says David A. Balto, an antitrust lawyer and former policy director at the Federal Trade Commission who often represents independent pharmacies. CVS’s ownership of Caremark could restrict consumers’ access to rival pharmacies, he said, and CVS’s acquisition of Omnicare, already a dominant player in long-term care, could reduce competition in that industry.
“There are tremendous concerns when you see someone becoming so terrifically large,” Mr. Balto said. “The acquisitions might conceivably be efficient, but whether those efficiencies are passed on to consumers really depends on the level of competition in the market.”
Helena B. Foulkes, who leads CVS’s retail business, swept past the sales counter at a newly renovated CVS in downtown Manhattan. Where cigarette packs once lined up in neat rows, now there were nicotine gum and patches to help smokers quit. (There are no e-cigarettes either, much to the chagrin of that industry, which had hoped CVS would embrace its products as a lower-risk alternative.)
Ms. Foulkes, who lost her mother to lung disease, leads the retail business, which is starting to change to fit the company’s health care bent better.
The move to forgo $2 billion in annual tobacco sales has bolstered CVS’s health care bona fides. The White Houselauded CVS’s move. “Thanks @CVS_Extra, now we can all breathe a little easier,” Michelle Obama wrote in a Twitter post. The praise seemed to give Mr. Merlo a jolt of confidence. At a TEDx talk this year in Winston-Salem, N.C., he declared: “CVS kicks butts across the U.S.”
“When we exited the tobacco category, it was the most important decision we’d made as a company,” Ms. Foulkes said. “That decision really became a symbol both internally and externally for the fact that we’re a health care company.”
It also made economic sense. Adult smoking rates have dropped to 18 percent in 2014, from 43 percent in 1965, according to the Centers for Disease Control, and experts predict that rate to dip below 10 percent in the next decade. Ditching cigarettes allows CVS to trade a small — less than 2 percent of revenue — and shrinking part of its business for an instant enhancement of its credentials in the faster-growing health and wellness space.
In October, CVS announced that its Caremark arm would require some of its customers to make higher co-payments for prescriptions filled at pharmacies that still sold tobacco products — in effect driving more traffic to the now tobacco-free CVS pharmacies. While that move encourages pharmacies to quit selling tobacco, it also raised the ire of an antitrust law research firm, which called the announcement “a smokescreen” that masks higher costs for those who fill prescriptions at competing pharmacies.
“CVS’s use of its market power to bludgeon consumers and rivals into ending tobacco sales is not a legitimate form of competition,” the American Antitrust Institute said in astatement. It has urged the Federal Trade Commission to investigate.
In general, CVS’s new anti-tobacco stance has helped it forge affiliations with regional hospitals. Before CVS went tobacco-free, negotiations with local health systems were awkward, Mr. Merlo said during a recent analyst conference call.
“That question would always come up — ‘You guys sell tobacco products, don’t you?’ — and that literally sucks all the energy out of the room,” Mr. Merlo said. But since the company stopped selling tobacco, he said, “We’ve been able to accelerate partnerships with leading health systems across the country.”
A new partnership with Rush University Medical Center in Chicago will involve patient referrals and shared electronic health records. Anthony Perry, vice president for ambulatory care and population health at Rush, said that traditional health care providers and companies like CVS could be natural allies.
“Take people with high blood pressure. That’s the type of thing you manage steadily over time, and you work on things like diet and exercise, and lifestyle changes, and if those things don’t work, you get into the world of medications,” he said. “What we asked was: If we’re going to do a series of visits with somebody, might they be able to do some of that closer to home?”
The flip side, he said, is that CVS can refer people with more serious ailments, but no primary care doctor, to Rush. “So CVS can now say: You need to see a primary care doctor, and we can connect you.”
The anti-tobacco stand has had other effects. Notably, the company has had to start thinking about other unhealthy items on its shelves. If it is a company that promotes health, can it also sell sugary sodas and candy bars?
The downtown Manhattan store where Ms. Foulkes walked the aisles is one of 500 locations that CVS is remodeling to emphasize healthy fare.
“I was in Long Island the day after the tobacco announcement, and I ran into a store manager who said: ‘I’m so proud of the company,’ ” she recalled. “But he also said, ‘I’m hearing customers now saying, why don’t you have healthier food?’ ”
“Customers quickly made the leap. They expected more from us,” she said.
Ms. Foulkes pointed to a prominent snack corner at the front of the store.
“What you’ll see in our stores are brands that convey healthy without being overly edgy. It’s Chobani yogurt, it’s Kind bars, it’s lots of proteins and nuts,” she said. “Health for the masses.”
At this point, there are no plans to stop selling high-fat or high-sugar snacks, still a big part of CVS stores’ sales. But they might be harder to spot.
When asked where the Oreos were, she smiled. “You’ll find them, but you’ll have to look for them.”