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Comment by allenz | Hacker News Reader

I see this as a move towards providing cheap basic medical care. This is timely now that it's possible that the individual mandate will be repealed. Millions of uninsured people could be treated for rashes or flus by nurses at CVS cheaper and faster than at doctor's offices.

More competition in healthcare could be a good thing--many say it's bloated and overpriced. The risk is that poor people get basic care while rich people get full care, widening health disparities.

It's unclear what the new healthcare economics will look like. Currently, minor procedures are profit centers for doctor's offices and hospitals. They subsidize complicated patients (often elderly with multiple chronic diseases like diabetes or COPD) who are riskier and take more time to treat. If CVS is taking that money, then hospitals may need to do some cost-cutting.

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How does CVS buying Aetna allow for "more competition"? I'm a lot more concerned that before we know it non-Aetna insurance customers will have difficultly or increased cost fulfilling a prescription at CVS stores.

I'm not sure what Aetna brings to the table in regard to a future where nurses fill CVSes, either. That seems like it would be a far bigger operation than buying Aetna, and the two would be only tangentially related.

I agree that CVS wants to stave off Amazon and mail order pharmacies. But a buyout is an expensive way to secure a fraction of the market.

Buying Aetna makes it easier to expand the new Minute Clinic business model. CVS no longer has to worry about getting paid less than a hospital for treating a cough or fever. Aetna could even charge zero copay for nurse visits. It's more competition in the "basic healthcare" space (if it happens).

The "Caremark/CVS" insurance that I have for prescriptions allows me to go to Target/CVS for covered medications, but I also have the option to mail-order (from them, of course). I also have Aetna Health Insurance just by chance (we have a choice of 3 companies @work).

Amazon is going to buy drugs in major bulk (Walmart, or Mail-order-pharmacy style), and likely will charge low "dispensing fees" (because robots will do most thigs). CVS is looking to be the "other other Walmart" of pharmacies. I have worked (as an intern) in many pharmacies, and I've seen several buyouts. At this point in time, I'm very happy that I made the leap from PharmD to SRE/DevOps about 11 years ago. Pharmacists will be robots in <5 years IMHO.

>Amazon is going to buy drugs in major bulk (Walmart, or Mail-order-pharmacy style)

All pharmacies, electronic and brick-and-mortar, go through one of 3 wholesalers: Cardinal, AmerisourceBergen, or Mckesson. It's, "which retailer can drive distribution?"

Speaking from the US, it's too bad that pharmacists are so disempowered here. I was just in France, and my friend came down with an eye infection. He went to a pharmacist, who just gave him antibiotics and told him to come back in three days if it didn't go away.

We both agreed it would never have been so easy in the states.

While I agree that kind of ease of access to an Rx that would have otherwise required a doctor’s office visit sounds great, antibiotics is probably a bad example. Over-prescription of antibiotics is a known problem. Was your friend seen by a PA or nurse or something? Maybe that model makes sense but I hesitate to give pharmacists the added power of diagnosis.

If Amazon enters the pharmacy business is there any reason they couldn't bypass the wholesalers and buy directly from pharmaceutical companies?

No. To be clear, I don't make these regulatory decisions, I'm just relaying the reality of the situation. It's very difficult to have these discussions with people that don't even know the basics about the industry under discussion.

Is it even legal to dispense drugs without a pharmacist? The same way that a nurse practitioner is only legally permitted to do so much before a doctor is required.

The pharmacist “supervises” te process. Mail order has been doing this for 20 years. There used to two big ones... Caremark and Express Scripts. Now CVS, the Comcast of drugs, swallowed both up.

Hospitals do this too. In some cases 2-3 pharmacists can cover 10-12 hospitals for off shift dispensing needs.

With the black horse cavalry running the country, we’re going to see lots of M&A activity like this.

Pharmacists must directly supervise dispensing. Many hospitals use a central-fill pharmacy where the prescriptions are filled for many hospitals.

The problem with these mergers is they allow health plans that further disadvantage other pharmacies or providers. Once those other options are eliminated we’ll see prices rise. Do people actually want the Home Depot’s of healthcare rather than the equivalent of the local hardware store? We’ll see I guess.

Optical insurance has been like this for a long time. For example, EyeMed is owned by Luxottica, who owns the majority of eye wear retailers in the USA.

Evidence suggests that they've used their monopoly to artificially inflate prices quite dramatically.

No, it isn't. I worked for CVS for about 8 years, though not as a pharmacist. Some of this information could be Indiana-specific, however:

A brick and mortar pharmacy must have a pharmacist on-site to dispense drugs. Not only are they supposed to do a final check on prescriptions filled, but they must be available for patient question and sometimes medicine requires advice from a pharmacist before it can be dispensed. In addition, there are some stricter laws for certain controlled medications and these checks must be done by a pharmacist. If the pharmacist gets sick or in a car accident on the way to work, the pharmacy can't legally open (they can section the pharmacy off with its own locks to keep the convenience store open).

>The risk is that poor people get basic care while rich people get full care, widening health disparities.

In my experience, that's already the situation. Actually, reality is worse. The rich (meaning, upper middle class and not sick) get full care and even excessive care, while the poor get basic or no care, often emergency only.

If you go to a hospital for an emergency procedure, the level of care and follow up care depends on your insurance. When the hospital thinks they probably won't be paid for services they choose to not offer them. So, the poor get basic care... while rich people get full care.

This may have been true pre-ACA, but it isn't the reality now.

It's now a system where wealthy, government employees, and the poor (i.e. subsidized) have access to full care, and most of the middle class just goes without.

In the past 5 years, I've gone from a decent $20 copay to a employer-sponsored high deductible to currently a fully out of pocket deductible of $2k before insurance pays a cent.

I've begun rationing my prescriptions and simply skip the doctor unless it's a true life-or-death situation.

The deductible for co-workers with a kid or two is something like $5k. That's on top of probably $10k in premiums a year.

Right, it is worse to have some money then none. But still, if you are super poor receiving free care, you do not get anywhere the same level of care as people with good insurance. But at least you're not paying tons of money for it or getting none (massive deductibles) like the middle class.

> treated for rashes or flus by nurses

I sometimes think that's one of the things that's kept health care so expensive. Nursing salaries aren't cheap. A lot of the home health and basic clinic stuff could be handled by an LPN/LVN or even a Paramedic in many cases. Not everything needs an RN. There are plenty of available telemedicine options to put a provider in touch with a higher level of care if necessary.

"Professional Extenders" are everywhere, and it hasn't caused anything to become cheaper. If you show up at an urgent care, just expect that you will be treated by a LPN and a PA or a NP. A Family Practice physician's salary is about comparable to a Sr. Engineer at many tech companies (~160k), and they can have significant malpractice insurance overhead and insane hours. A PA or NP still makes 6 figures, so the "savings" just aren't there.

If you've ever had to attend something like Physical Therapy, you'll see the actual PT (a MS/Doctorate level professional aka DPT) about twice. Once for an eval, and once for a discharge. An "aide" will guide you through all the other exercises, and they make very significantly less than a PT.

The savings are mysteriously gone, even adding lower-salaried professional extenders.

> “Professional Extenders" are everywhere, and it hasn't caused anything to become cheaper.

This needs the caveat of “to American consumers”. The NHS seem to be heavily moving in that direction, and I suspect “cheaper” is no small part of that

"professional extenders" are often "profit extenders", as the supervising physician can enable his / her practice to see more volume and better match revenues and costs (ie have lower cost labor do lower revenue / acuity work). the "savings" from this often end up accruing to the owner of the practice. increasingly this owner is a large hospital system, but they take this delegation a step further, using lower cost primary care as a way to increase volume to higher acuity / reimbursed hospital procedures.

The Minute Clinics are staffed by nurse practitioners and physician assistants

https://www.cvs.com/minuteclinic/why-choose-us/our-practitio...

To expand their services to all of their stores, they'd be looking at hiring 5 or 10 percent of the NPs and PAs in the country.

Or...the publically signaled demand for those relatively high paying jobs would encourage more people to seek training for those opportunities.

These aren't easy roles to get into. The educational requirements are pretty high (MS or PhD) and the courses are rigorous. The educational requirements are close enough to an MD that I'm sure most people considering being an NP from the onset also debate just getting an MD.

The minimum requirements of a RN is an Associates degree and successful completion of the NCLEX -- though, many hospitals require a person to also obtain a BSN after a few years to continue being employed. That's a big educational jump to make.

I don't think pay is a big motivator for nurses. There are so many better paying jobs out there that are easier to get, and don't involve dealing with the figurative and literal shit nurses deal with daily.

Or, the high price may be from administrative costs:

http://www.nejm.org/doi/full/10.1056/NEJMp1209711

Do a search for "McKinsey health costs" and browse the report. It breaks down category spending in the US vs. other western countries. Yes, admin cost more in the US, but it doesn't add much to the overall costs. The biggest driver of US healthcare spending are out-patient care. The US just does a shit-ton more of it then most countries.

I've seen at least one healthcare economist claim that admin costs account for roughly 25% of spending. Is this in line with what you see there?

'Even' a paramedic?

While we might cost about the same, our scope of practice is a lot broader than an LPN's...

Nursing unions and trade groups are generally very opposed to the 'paramedic practicioner' or 'community paramedicine' model.

There's no reason to believe that a return to pre-ACA will make the market behave differently than it did pre-ACA.

ACA without the individual mandate is not the same as no ACA. Plus, lots has changed in the meantime: a growing shortage in physicians, even higher healthcare costs, an expanding role for nurses. The healthcare market is not static.

ACA without the individual mandate means that the insurers can't make the exchanges work causing their collapse. One benefit for the insured of millions fewer insured is that it will aliviate the shortage of doctors and nurses, probably to near pre-ACA levels.

Sounds more like building a moat by aligning formularies with insurance requirements.

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