And in news just in….health care premiums will be going up by 13% in 2004, according to a Corporate Research Group survey. The "good news" is that the increase will be slightly lower than the last two years. The real news is that as premiums go up, business will force more costs onto employees, or simply drop coverage, and no new model is in sight to deal with this. Even the big purchasing "thugs" of the mid-1990’s seem unable to halt these increases. And some are losing their clout, like CalPERS. Of course the worse this continues to get, the greater the political and market reaction will be down the road. When it will happen I don’t know, but personally I’m looking forward to a replay of 1991-5. But not everyone reading this might share that opinion.
The perils of being mid-market big Pharma
When I first got into health care a little over a decade ago, the first lesson I learned about big drug companies was that they were very profitable. The second lesson was that a huge company might have only one or two profitable drugs. When I first looked at the Fortune 500 I found that Merck, then the big Kahuna of big pharma, had a market cap the same size as companies with ten times its sales, reflecting that profitability. Pfizer, which is now the big Kahuna, has a market cap of over $250 billion (here’s a list of the top pharmas) with net income of $9 billion on sales of $32 billion. For comparison GE has net income of $14 billion on revenues of $131 billion. (GE’s market cap is around $315 billion).
However, behind the numbers, the pharma industry, despite all its dalliances with PBMs, care management, and genomics, over the years still operated by simple rules. So what a big pharma company did was to somehow develop a profitable drug and market it to doctors (and more recently patients). But there wasn’t a concentration in the industry like there is in automobiles, or steel, because the products were company-specific and of course patent-protected.
So the rules of the game are, if you’re a pharma company and you can’t develop a profitable drug, then license one in. If you can’t license one in then buy the company that makes it — even if it’s a huge company. Pfizer’s purchase of Pharmacia was $60 billion spent largely to get hold of one drug — Celebrex. Since the early 1990’s Pfizer had successfully played a strategy of marketing drugs when others (especially Merck) were distracted by managed care, buying PBMs and generally cutting back on their sales forces. That gave Pfizer the marketing clout to license in other drugs, even from big companies. For instance, they were already co-marketing Celebrex before they bought Pharmacia. And eventually it gave them the scope to have a full portfolio of drugs by acquiring other companies. Other big pharmas, notably GlaxoSmithKline — the combination of Glaxo, Burroughs-Wellcome, Smithkline-Beckman, Beecham (and a few I’ve probably missed), which were all largely "one-drug" companies at the start of the 1990s — followed suit by getting bigger to get both marketing clout and more comprehensive portfolios.
The other side of this coin is what happens when you don’t have the first part of the equation; the blockbuster drug. Schering-Plough’s new CEO Fred Hassan (ex-Pharmacia by the way) gave a talk this morning about the problems of his company. Schering has been hit by the loss — more like the evaporation — of its main allergy products Claritin and Nasonex, as well as in the Hepatitis C market. Schering has been unable to replace these losses with new brands, and also has had manufacturing and regulatory problems. It has been therefore unable to jump from being a one (or two)-drug company to being a serious heavyweight. Astra-Zeneca, a mid-size player that became big on one drug, Prilosec, looks like it is making that jump with Crestor — its new statin.
Usually the companies in that situation sell out/merge with others around the same size, rationalize their sales forces, and wait for new blockbusters to emerge. However, its been more than a year since we saw the end of the last round of pharmaceutical mergers — last one was Pfizer-Pharmacia — and it may be that the really big guys don’t need the medium size guys any more. In that case we might see the slow withering of the medium-sized pharmas, especially those without strong pipelines. And as I mentioned in last week’s post about biotech, there’ll be more continued interest from the big guys in cutting deals with interesting small research companies to keep that pipeline stocked.
Cigna settles — The end of “Managed Care” in sight?
Cigna has now joined Aetna in settling with the physicians who have sued it for downcoding. Essentially the suit promises that no longer will Cigna automatically downcode claims from providers, and will go as far as to allow "questions of medical necessity for services…be decided by doctors" and "to jointly decide (with the doctors) how to handle experimental and investigational treatments". Cigna’s "system for processing doctors’ claims will become more transparent by allowing doctors to e-mail Cigna, using the Internet to spread news about policy changes, limiting changes in reimbursement rates to once a year instead of monthly and creating a method for independent claims appeals". In many ways this is the corollary of Tenet, Columbia/HCA and others upcoding on their Medicare billing, and then settling with the government.
When I learned about managed care at the feet of Alain Enthoven, he correctly explained that all this gaming back and forth was an inevitable result of having payers and providers in conflict in a fee-for-service system. His solution was to give them shared incentives to deliver population-based cost-effective medicine, such as he saw in the Kaiser system, within a framework of "managed competition". Of course for the rest of the world outside Kaiser, "managed care" was never about that. Instead US Healthcare (later Aetna) and others used managed care as a battering ram to a) risk select against unhealthy individuals and groups, b) exclude high-cost providers, and c) operate as what Ian Morrison calls "virtual single payers" to cram down on providers’ fees.
But America’s doctors and hospitals were only going to take that for so long. The hospitals merged like crazy to increase their market power. Physicians couldn’t successfully do that, so they started a campaign in every examining room in America–my doctor used to call Prucare "Zoocare"–that reached its height in the scene in the movie As Good As It Gets when Helen Hunt slagged off HMOs for stopping her son going to the emergency room. As HMOs don’t actually have much say about what goes on in ERs, this was a great case of Hollywood getting the mood of the nation right while getting the facts of the matter wrong. The backlash against managed care as measured by Harris grew steadily until about 2000, when even Al Gore noticed and tried to incorporate it in his campaign. Humphrey Taylor’s quip was that "it doesn’t manage and it doesn’t care". The net result was that health plans threw out any attempt to do real care management along with the removal of any serious attempt at cost control. Double digit premium increases have been the result.
Now Cigna and Aetna have settled these provider law suits, and made their subsequent mea culpas, it puts pressure on the rest of the managed care pack to follow along. The others still being sued are Anthem, Coventry, Foundation, Humana, PacifiCare, Prudential, United and Wellpoint.
Enthoven would correctly argue that we haven’t tried managed care or managed competition in the way that he meant it. He also used to argue, although he backed off this position in the mid-1990s, that you couldn’t have managed competition without universal insurance. Bob Evans and Maurice Barer (with a little help from me) have forever argued that you can only cut costs effectively if you have a unified budget (which tends to mean a single national insurance system, although not necessarily as it doesn’t in Germany or Japan) and that, by necessity, means covering everyone with some type of community rating. But in the US we are not going–there barring Dennis Kucinich winning the Presidency and pigs flying.
So if the suit settlement is the last act of a play that we’ve been watching for a long while, the question becomes, what comes next after 1990’s style managed care? The overriding issue is that while costs go up, things haven’t been as bad for employers or the government while the economy was good, and their revenues have gone up as fast as their health costs. Now things are not so good. We have a growing Federal deficit, states cutting their health spending desperately and employers moving costs onto employees. And still health care cost growth is only matching pace with the overall economy. The challenge of delivering cost-effective health care looks to be well beyond any of the constructs being put forward by the private sector. So do we just end up paying more? And how long before the payers squeal again as they did in the early 1990’s, which created "managed care" as we knew it?
Drug companies political contributions in the limelight
The New York Times has a long and generally factual article about the impact of contributions from drug companies in the 2000 and 2002 elections, and it’s relation to the Medicare prescription drug coverage bills that are now in conference between the House and Senate. The industry, via its trade association PhRMA and in direct lobbying/contributions from individual companies, contributed $50 million in campaign contributions– almost all to Republicans–following the "Flo" TV commercials in 1999, which starred an old lady asking to "keep Big Government out of my medicine cabinet".
So with that anti-government stance, how come we have a prescription drug bill almost ready to be passed? Well the answer is that, like the AMA and AHA in the 1960’s, the industry has cut a medium term deal with the government. Given the costs of drugs to consumers, especially the elderly–and the near elderly "aging in" to Medicare by 2010–a government Rx program is inevitable at some stage. So PhRMA figured better one that has no price controls now, rather than one that comes with them immediately. Eventually, any government program that buys drugs will develop some type of budget restraint. But that can be left for future Congresses to pass and for future senior executive teams in the pharma industry to suffer through. After all, Medicare was introduced in 1965, and it took until 1983 before DRGs were introduced in a first attempt to restrain hospital costs. 19 years of an unrestrained government program with millions of new price-unconscious consumers probably looks good to the industry right now. OK, they won’t be that lucky, but you understand their position!
WebMD – An old nugget gives indigestion
WebMD was and remains the most remarkable company of the eHealth era. It was remarkable for the incredible feeding frenzy it set off in the eHealth world when Healtheon bought the then privately held WebMD in 1999, making Jeff Arnold a very rich young man, and getting Jim Clark out of the business of competing with Microsoft (who were about to come after Healtheon using WebMD as a vehicle). The original concept of the end-to-end eHealth company that could do all the varied gazillions of transactions in health care by putting them all into the Internet "cloud" was a very seductive concept. However, as the bubble grew larger and larger, the decision to jump start the process by buying traditional health care IT companies like Medical Manager and Envoy (using the absurdly inflated stock of 1999 values) proved too tempting. Here’s a list of some of the companies they bought.
As soon as the acquisition spree took place, the old idea (catalogued by Michael Lewis who’s now off writing about baseball) of creating a "New, New" company was dead. Furthermore, all the internal machinations ended up costing way too much in organizational terms. When I was at i-Beacon we negotiated with 5 separate sets of WebMD/Healtheon employees to sell them a version of our consumer health record. It was a clusterf**k every time. This may be sour grapes but WebMD never got it together on those negotiations and instead 18 months later (after we were out of business) they ended paying $18m in 2002 cash for Wellmed and their health record. Nothing wrong with Wellmed’s but they could have had ours (or all of us) for much less in Yr2000 stock, methinks, and it would have been a tremendous product well before they paid to get Wellmed. (Wellmed had raised about $40m in Venture capital in 2000, and its investors were lucky to get some of their money back, given what happened to most eHealth companies).
WebMD meanwhile ended up being "reverse" taken-over by Marty Wygod of Medco fame — he was the one who’d originally bought Medical Manager. By the time he started running the show for real in 2001, Wygod essentially stripped it down to the three parts of claims processing (Envoy, MedEAmerica & Kinetra), medical software (Medical Manager) and consumer and doctor online (WebMD, Medscape, Wellmed & everything else). The first two parts made money, the last one never has (well it eked out a small profit last year but it lost $75m the year before). (WebMD also has a medical plastics business via Wygod’s old plastics company Synetics which it’s never got rid of). Revenue size-wise WebMD at Year end 2002 looks like this:
a) Transactions $466m
b) Medical software & services $275m
c) Portals $80m
d) Plastics $120m
Meanwhile the PE ratio–as of two days ago–is around 23 whereas those of other diversified medical technology and services companies like Cardinal Health (CAH) are closer to 18. So the web technology spin is still helping WebMD’s stock price even if it hasn’t really been helping transform health care the way we were promised by Jim Clark back in 1997.
The recent news is that something was fishy in the accounting at Medical Manager before Synetics bought it. Medical Manager itself was a merger of several regional medical office software companies, and had to restate its earnings (and nearly went under) in 1999. So yesterday (Sept 4) the FBI went into raid mode, and trading in WebMD stock was halted, opening today about 15% lower.
Is the raid and subpoenas a fuss about nothing, as the company says? More than likely as it’s about old news. But a serious restatement of earnings for just that sector of the business could be a big drag on the stock, and if it’s PE was at parity with Cardinal’s, the stock price should be closer to 8 rather than 10. This of course all serves to take WebMD even further away from being the dominant health care company technology of the 21st century that never was. And boy do we need one (or two or three….).
Caremark/AdvancePCS Follow up
Today’s New York Times confirms what I said yesterday. Caremark is paying a bit too much for AdvancePCS, but is doing so to get into the Medicare scrum as in the NYT’s words "large drug benefit managers jockey for position in hopes of handling the potentially huge Medicare drug program that a House-Senate conference in Congress is drafting for 40 million elderly and disabled Americans." Meanwhile, Express Scripts shares have headed down to meet the percentage loss in Caremark’s since yesterday (Sept 3) morning’s deal, although there’s no clear reason why and ESRX already has a lower PE ratio than the other two. Caremark has gone down because a) they are paying too much (especially as they are debt-free and Advance still has $400m debt left over from its purchase of PCS a while ago) and b) they were growing revenues at 30% per year (and profits more so) and won’t be able to do that if they merge with as big a player as AdvancePCS — unless of course:
a) they convert many of Advance’s customers onto their mail-order pharmacy sooner than you’d expect, and/or
b) all PBMs get an amazing deal out of the Medicare Rx coverage negotiations. I’d say that’s unlikely unless the entire bill is held up and we get an even more Republican-leaning Senate in 2005 and they don’t notice that we have a eensy teensy problem with a thing called a deficit.
I’m back alive online
OK. My site is up and hopefully you are reading this by getting here via matthewholt.net or via thehealthcareblog.com, (or via .org and .net both of which get you here. (I describe the experience later when I’ve calmed down a bit). I have also fixed a way via bloglet of having you give your email address to get new postings emailed to you. I’m still figuring out whether it’s most useful for you to get, via email, the whole post, just the first few words as a teaser, or just the fact that there is a post. I’m also figuring out RSS and comments (and am nearly there with those). So please email me and let me know if you have any opinions about how you want to see this blog and what you want to see here. Thanks and please keep coming back. Matthew
PBMs again — Caremark buys AdvancePCS
For serveral weeks the odd rumor that PBM Caremark was going to buy AdvancePCS showed up in the Yahoo ADVP message board. While you shouldn’t usually trust what those boards say, this time they were right. Caremark announced a roughly $5 billion agreed bid for AdvancePCS, which sent Advance stock up from $40 to $47 and Caremark’s down from $24 to $22. On the face of it, with a newly freed Medco the big gorilla in the marketplace, this is a decent consolidation move. Caremark is stronger in mail-order and more profitable, AdvancePCS has more lives, especialy in the health plan world, and has probably made a little more progress in the eHealth and DSM world. However, the price thay are paying is some 35% higher than AdvancePCS has ever traded on the open market, which is quite a premium — hence the decline in Caremark’s stock. Longer term it leaves three big PBM players for whatever role for PBMs comes out of the Medicare Rx bill, now in negotiations between the house and the Senate.
Welcome back from the Labor day break. I’m still working on re-establishing my site, so please keep your browser pointed at thehealthcareblog.com and in the meantime I’ll keep posting! When it’s safe to go back to matthewholt.net I’ll let you know here!
So a funny thing has been happening in the small and medium cap Biotech market. (And by that I’m lumping in virtually any company that is developing pharma products but doesn’t sell them yet). After getting somewhat swept up in the dotcom fever of 1999 and early 2000. Biotech’s woes grew over the next two years, and by the time of the Iraq war several small biotech companies were selling for close to the value of their cash on hand. Now the Burrils Biotech Indicies have all shot skywards for this year. In particular their Select biotech index is up over 55% (to end July) compared to the NASDAQ’s 33% improvement so far in 2003. The small cap biotech market which tracked by the Burrils index was 84 at the end of 2002 and fell to 68 (down 18%) by the end of February as war loomed. It was 113 at the end of July, up 34% on the year and up roughly 66% since its war-induced lows. Finally we are beginning to see possible signs of life in the Biotech IPO market. For instance Cancervax filed for an IPO in mid-July, albeit selling some insurance stock to current investors in case it doesn’t get out the door.
This tells you a couple of things. Given that the science hasn’t changed too much in 7 short months, this market remains very, very volatile. After all , we’re talking about a market for drugs that usually have several years of testing to go through before they are ready for the nod from the FDA. But it also tells you that at least some investors believe that there will be a market for these new and usually very expensive drugs in the medium-term future. So while the major pharmaceutical companies continue to have their problems, the pipeline of new biotech offerings looks to be in good enough financial shape that the rest of the healthcare system will be getting the benefits, and of course the costs, of these drugs in years to come!
And in the interests of full disclosure, I own stock in one small-cap biotech company Pain Therapeutics (PTIE). I just wish I’d bought a hell of a lot more back in March!
I have had a very bad experience with domain theft from a terrible company called primesource-hosting.com. So until I can get my domain back, the blog will appear here. This should be sorted out in a week or so. Please keep coming back! Matthew