I recommended both CVS and ESRX in my post about PBMs here. In my opinion, the market action on 8/6/2014 for Walgreen (WAG), Rite Aid (RAD) and CVS Caremark (CVS) demonstrated the strength of CVS’s vertically integrated model – i.e combining PBM with retail pharmacy. On that day both WAG and RAD fell off a cliff, while CVS prices remained relatively flat.
Why CVS stock held steady as WAG and RAD sufferedWAG crashed not just because of no tax inversion in its Alliance Boots deal, but also because it adjusted guidance downward. Specifically, WAG cited reimbursement rate pressures and generic cost inflation – these happen to be headwinds that RAD is also facing (and discussed extensively in the last earning call). On the other hand, CVS actually came out a few days earlier saying that these headwinds are models and already built into their guidance.
To understand why CVS can better handle the issues that its peers are facing, it’s important to understand what “reimbursement rate pressure” means. First, RAD’s FY1Q15 transcript specific attributed reimbursement rate pressures from PBM’s “MAC” lists and plan mixes (emphasis mine).
“We're always dealing with a competitive reimbursement rate environment. Things that can develop differently than our plans would include just a mix of business amongst and within plans, so migration to narrow networks and business moving between different types of plans can have an impact on reimbursement rates. We also still have certain contracts that are not in a kind of guaranteed rate. We call those MAC contracts. So those can be a little bit more volatile”
And later on:
“…So I'll go back to kind of two basic examples. The first one would be around some contracts, we saw more volatility than we expected. So we might have a contract where on generic drugs, there is a proprietary MAC list that PBM uses. They don't often provide us their proprietary MAC list. And so they have some flexibility to adjust generic drug cost as they go. So sometimes we have a little bit difficulty getting good insight as to how that's going to behave over time…”
“Another situation would be we might have a contract with a PBM where we're in different plans. One is a very narrow plan. One is a medium plan and one is the broad plan. And we might see as we come through into the fiscal year gradually as there's utilization that the PBM has migrated patients from the broad plan, which has the highest reimbursement rate, to either the middle plan or the lowest reimbursement rate plan. And we call that a change in plan mix. And so we saw some of that activity as well. Those things tend to develop over time. “
For background, MAC (Maximum Allowable Cost) contracts basically allow PBMs to arbitrarily define pricing to their benefits. Note that Rite Aid said they’re not even privy to PBM’s MAC lists! Given the lack of transparency I can see how pharmacies would be hurt by this type of contracts. Here are a couple good links on the topic.
Let’s move on to Walgreens. WAG also referred to reimbursement pressure from these MAC prices in its June call:
David Larsen - Leerink Swann & Company: “Hi. With respect to the reimbursement pressure, aren't the generic rates typically set at a max price, and aren't those fixed so that the pressure is really the cost of the generic at the higher inflated rate and the difference between that and the fixed mac price or do those prices actually shift around or are they fixed? Thanks.”
Greg Wasson - President and CEO: “So, every contract is different. But you’re right, it's kind of a general abstraction that’s more or less true, but the thing is that I guess the key thing I alluded to earlier is that the indexes that those are based on don’t always immediately reflect the changes in that inflation, and so that’s the disconnect. But again I think we’re working this from many different angles.”
In the WAG/Alliance Boots call on 8/16/2014, Walgreen also attributed reimbursement rate pressure to Medicare Part D business (“Med-D”).
“…probably most significant impact was the negotiation and the reimbursement in the fiscal or calendar 2015 Med-D books of business. Those plans have really, really challenged us. We are in preferred positions with Part D plans. We think it's a strategic investment to grow market share with a lucrative senior market. But there were significant margin step-downs in the Med-D contracts beginning in 2015. Combine those two and that's what we're looking at and trying to be realistic as we forecast out the next couple of year
Note that Medicare Part D businesses usually run through a PBM, either because a payer hires a PBM or the PBM directly manages the plan (both Express Scripts and CVS have their own PDP plans). While a big part of Part D reimbursement pressure comes from the government, PBMs/plan sponsors further control prices with preferred pharmacy networks.
So here it is. The reimbursement pressures that hit RAD and WAG, whether it's the MAC contracts and PDP plans, are tied to pressures that PBMs exert on the pharmacies. CVS, on the other hand, runs one of the largest PBMs. Lisa Gill from JPM got to the crux of the issue in WAG’s call:
“And then, kind of a bigger question, as we look into your largest U.S. competitor, they own a PBM, they don't seem to have the same reimbursement pressure that you're having today, any thoughts around perhaps owning a PBM in the future?”
At which point Walgreen basically avoided the question.
Well hedged exposure to increasing drug usage
The above discussion highlights how CVS has a supply chain “hedge” between its PBM and retail pharmacy business. There’s more. CVS is a winner no matter how customers access their drugs and even healthcare services. Its Maintenace Choice and Specialty Connect offerings both provides retail and mail access, while the MinuteClinic shifts services between hospital, clinics, and pharmacies.
So CVS has a portfolio of product and services that makes them channel agnostic (mail order vs retail, PBM vs pharmacy, clinic vs pharmacy or even home service). In another words, a well hedged exposure to increasing drug usage.
Valuation reasonable but not particularly attractive
CVS trades around $76-78/share (~17.7x 2014E and 15.7x 2015E earnings). Here are the consensus expectations for CVS. Earnings per share are supposed be grow at over 10% CAGR but the underlying revenue and net income are only growing mid-single digits. This is because CVS boosts earnings per share with capital management actions. I think valuation is reasonable as a defensive play, but investors who simply look at EPS growth and argue for a higher multiple are effectively treating share buybacks as free lunch.
Sources: 2014 investor day, Bloomberg.
Finally, a word of caution about MinuteClinics. Although the service generates lots of excitement in the market, it is not yet contributing to the bottom line. Minute Clinic is a great idea but Walgreens and Rite-Aid are already copying this. Walmart actually goes even further and tries to offer primary care. I suspect that customers will be the main beneficiaries as opposed to shareholders. Let’s say someone just moved out of the city where they were frequent customer of CVS MinuteClinic. In the weekends are they going to commute into the city just to be a loyal CVS fan? Or would they go to the nearest Rite-Aid? I believe the latter. For this reason the rapid expansion of MinuteClinics can turn into an arms race just to maintain competitive positioning. In other words, MinuteClinic can turn out to be maintenance capex as opposed to growth capex.