This announcement expands the retail pharmacy price war over generic drugs, puts further pressure on pharmacy margins from cash-pay customers, and sets the stage for more cost-plus deals. More intriguingly, it portends an emerging strategic convergence between Walmart and CVS Caremark. Yes, you read that correctly.
My comments in Walmart Aims at PBM Profits still hold, so you may want to reread that post before reading further. Some additional observations:
- The price war expands. Retail pharmacies are engaged in a generic prescription price war that began when Walmart initiated its $4 generics program in September 2006. This price war has encouraged pharmacies, particularly supermarkets and other mass merchants, to sacrifice some margins from cash customers and payers in exchange for growing (or maintaining) market share. The big drug store chains have also joined in (CVS Escalates the Generic Price War), although they sometimes claim the opposite (Walgreens vs. Reality). For now, Walmart's mail expansion seems to be directed at the underinsured/uninsured customers that are the core of Walmart's low-cost generic program, which means…
- Goodbye to generous cash-pay margins. Pharmacies earn more from cash-pay customers, whereas the pooled negotiating power of third-party payers and PBMs limits the profitability of pharmacy prescriptions for consumers with insurance. As I show in Pharmacy Profits and Wal-Mart, consumer-paid prescriptions have average gross margins of 42.4%, which is more than twice as large as an independent pharmacy's margins for prescriptions covered by a third-party payer. (BTW, these economics partially explain the non-stop litany of complaints about PBMs from pharmacy owners.)
- Mail pharmacy enables more cost-plus deals. Walmart does not have full geographic coverage with its stores, which is one reason why Caterpillar added Walgreens to its cost-plus network. By expanding mail order, Walmart is positioning itself to pursue more cost-plus, direct-to-payer deals because mail order eliminates the geographic requirement to use a Walmart store. Presumably, this offering will augment all of the top-secret cost-plus clients that Walmart has allegedly signed up.
- Walmart is legitimizing mail pharmacy. Walmart's low-price home delivery service puts additional (albeit indirect) pressure on PBM mail margins. On the other hand, Walmart's mail order expansion could help PBMs by improving consumer perceptions of mail order pharmacy. Walmart is legitimatizing the concept, which could increase overall mail utilization.
If we extend Walmart's mail strategy to its logical conclusion, then we should expect cost-plus deals that designate Walmart as an exclusive pharmacy network provider. In other words, a payer would require consumers to get maintenance medications from either a Walmart retail pharmacy or via Walmart mail dispensing. This model would permit consumer choice of pharmacy channel (mail or retail), but would not provide choice of the specific outlet.
Yup, I just described how CVS Caremark's Maintenance Choice program works, although Maintenance Choice does not rely on cost-plus pricing for payers … yet. Ironically, Walmart and CVS Caremark (with Maintenance Choice) are now both pursuing strategies that eliminate the traditional out-of-pocket cost difference for consumers between mail and store-based pharmacy.
So, how long before independent pharmacists begin complaining to the FTC about Walmart's "anticompetitive" behavior?
The graphic above comes from the completely awesome Mental Floss t-shirt collection. Check it out!