vol. 1, issue 20

Greetings,

It occurred to me recently while I stood in line at my local CVS to purchase a box of syringes for new medication I must take through intramuscular administration as part of my recent autoimmune disease diagnosis, that my mistrust of CVS goes back to 2007 when it started issuing its electronic “Care Cards”. I was not pleased to know there was a database over which I had no control and which would be tracking indefinitely all my purchases. How cute, I know. Remember those days when we used to take privacy largely for granted?

At the time, I didn’t realize that the data tracking cards and the buying spree of vertically related companies was the thin edge of the wedge in CVS’s campaign to become the lords of American healthcare. This Seattle Times piece chronicles it nicely up to 2015. I have mapped the rest of its purchases for you in this article from back in June where I ask do you want Socialism or CVS.

Standing there annoyed because, through no fault of my own the purchase of said syringes had taken over a month to complete, I ruminated on that data capture.

I recalled a conversation I had last year while attending the Wall Street Journal’s Health Care Summit at the Four Seasons Hotel in Georgetown. As a trade journalist for Mergermarkets hoping to break scoops about the frenetic activity in healthcare, I was only this squinchy much higher than persona non grata among the likes of Aetna CEO Mark Bertolini and other C-suiters (many, if not all, of whom had body guards tracking their every move) and healthcare illuminati. That’s why I was alone as I munched on swanky crudites with exotic dips and sipping a San Pelligrino, praying to the Gods of Journalist Intel, when another loner asked if he could share my table.

Ask the universe for a break, and look what happens!

He looked like he’d had a hard day on his feet and would rather head back to where he was from in the upper Midwest so he could relax with a little ice fishing. Why was he here, I asked. Turns out, he managed some pretty hefty data processing contracts for all the major healthcare companies. Including — especially — the US government, particularly the Centers for Medicare and Medicaid Services (CMS).

Did the government have a chance of making our electronic health data actually synch properly (currently it does not) such that we would benefit as a nation from all the money being spent on it, much to the heartache of many a physician?

Uh. No.

Oh, shocker. But I bet CVS is ahead of the curve on that now that they look like they will have everything they need to own the doctors and the patients, I said.

Yup.

The details of that conversation boil down to this: Medicare data. Boomers are where the bucks are, and if CVS can own the majority of that demographic’s spending habits on drugs, and know how to predict and even shape those habits, CVS will literally own the healthcare market and control trends.

“All along, it has been about the data,” my new friend told me. “They want to control as much of it as possible. The more they do, they more control they have. And they have a lot of data.”

For more on that, see the article I wrote in June and especially this one I wrote in the inagurual issue of docu-mental back in February. Meanwhile, because they’ve been investing in their healthcare IT infrastructure since the mid 2000’s, this is what they presented to investors back in June:

I am still looking for a good graph issued by CMS that shows they are capable of this and already implementing it. I believe, based on my conversations with him, that Health and Human Services Secretary Alex Azar dreams about it happening one day, if only on his watch. For now, I could only find enormous ZIP files of ponderous charts likes this one to explain how that dream of seamlessness between the patient experience, physician efforts, and data capture are to function:

Yeah, you’re not alone rolling your eyes there. Doctors are as thrilled with all this mumbo jumbo as you might suspect. As in, they hate it. Does it even work? It might except that your favorite president and legislators can’t walk in a steady healthcare policy line long enough to make anything meaningful happen.

Which brings me back to where I was, standing not at the cafe table in the posh Four Seasons but in the not posh (and not private at all) CVS, thinking that if the behemoth’s elegant and simple graph created for investors is true, I almost wouldn’t mind CVS managing my data and my healthcare experience. I like efficiency. The government is not efficient. Spoiler alert! Efficient, seamless government-run healthcare won’t happen in my lifetime or yours either.

So, why do I grouse?

Because for all its power over the healthcare system, CVS still escapes being featured in the tiresome healthcare debates we seem addicted to. Meanwhile, as legislators fixate on Medicare-for-all, CVS is steadily making in-roads to be the obvious choice for efficiently delivered healthcare, and the only ones really taking notice are Jeff Bezos, Jamie Dimon, and Warren Buffett with their own slowly rising healthcare empire.

I believe CVS should absolutely be a factor in our healthcare debates. The company has the power to change the playing field, and by not acknowledging that in any of their debates or stump speeches, political candidates are being disingenuous at best, displaying their ignorance at worst.

The difference between CVS and CMS is not their IT, it’s that shareholders have the power, not American citizens. They are profiting off of the purchase of our personal data, and yet are not subject to our desires for what they do with it. There is HIPAA to protect our privacy, but that is like a cheap first aid kit bandage on the way that CVS as a pharmacy benfits manager is using our data to shape the market by controlling what prescriptions doctors in their plans can prescribe, or once Aetna has fully merged with it, even determining which physicians we will see.

It’s all there. They are telling us this is what they are doing. These are publicly available slides, and if you’re Alex Azar or Bernie Sanders, aren’t you just about to cry when, taking these numbers at face value, you see how well CVS is already delivering healthcare?

Consider that together with Aetna, that is now plus this:

Which by the way, is boosted by Aetna already doing this:

Notice that they collect population health data. That means they can make granular connections between their population of customer who have type 2 diabetes, for example, and who is costing their insurance plans more money, and so start flagging them if they purchase too many Twinkies. Maybe CVS/Aetna will send these customers a friendly reminder that too much processed food and sugar is directly linked to diabetes. That’s good. Maybe CVS will start refusing to sell these consumers certain foods implicated in type-2 diabetes, or they will make it more expensive for them to purchase those items. Well, now we’re getting into some squishy territory, aren’t we? Profiling. Discrimination. What amounts to the controversial “sin taxing” of sugary drinks, cigarettes, and alcohol.

These hypotheticals might point to free market solutions to our vexing healthcare woes, and they might even be protective of our health and effective in the economy, but CVS and its shareholders are in control, not us. Doctors and other personnel are increasingly working for one employer (and it’s not the government, which everyone who abhors Medicare-for-all is so scared of), and the federal government is only tangentially involved in setting policies. I think it sounds terrific!

Except.

Except that I was standing there in the line to get the certain-sized syringes after a month of not having them for the injections I am meant to have weekly because the pharmacist at first didn’t have them because they aren’t typically stocked by CVS, or so he told me then, although no one from his staff, including himself, had bothered to call and tell me that ahead of time.

Nor did they call my specialist. There went one week. When the syringes were ordered, no one called me to say they were in, so they sent them back after a few days. There went two weeks. Then I was out of town. There went three weeks. Then they had to re-order them. Another week. And on it went. Eventually, they blamed me for not having given them my phone number. It took them four visits for them to tell me this. So much for effective data management.

In a market-driven economy, I would normally go elsewhere rather than put up with mediocre service, but since most of the independent pharmacies in the area have closed in the last few years since CVS has taken over the marketplace, it would have been more difficult to do.

This is the type of concern that has hung the deal up in court.

The reason why CVS as the bully on the block bothers me is because no one is watching it become so big it can control my data, but not necessarily serve my healthcare needs.

Doesn’t it sound like the big, bad government take-over of the healthcare system we’re being told will kill a fifth of our domestic economy by those vehemently opposed to Medicare-for-all?

Big is as big does. Government isn’t bad. Corporations aren’t bad. Too big is bad.

The reason CVS can do give me crap service is because they are watching me but no one apparently is watching them. What could possibly go wrong as they continue to grow, I wonder. The days of “too big to fail” come to mind, but I don’t want to ruin your supper.

I am not advocating for a federal single-payer system, not yet anyway. But if we’re going to discuss Medicare-for-all as part of our national healthcare debate as we run up to the next presidential election, then we need to also discuss how this kind of single-payer one-stop-shop is already happening and what it can already teach us about whether such a system would work, and if so, how.

Thanks for reading.