QUOTE AND NEWS
New York Times  Dec 9  Comment 
Express Scripts says that nearly half the people who took opioids for more than 30 days in the study’s first year were still using them three years later.
Insurance Journal  Nov 26  Comment 
Steve Miller is waging war on high- priced medicine, guiding decisions to ban drugs from the health plans of millions of Americans and sending companies reeling in a $270 billion market. He and his colleagues at Express Scripts Holding Co....
Benzinga  Nov 25  Comment 
Below are the health care plans stocks on the NYSE and the NASDAQ in terms of revenue. The trailing-twelve-month revenue at CVS Health (NYSE: CVS) is $135.14 billion. CVS Health's profit margin for the same period is 3.40%. The...
Jutia Group  Nov 14  Comment 
[Reuters] - Warren Buffett's Berkshire Hathaway Inc disclosed a new stake in healthcare management company Express Scripts Holding Co and shed its stake in agricultural equipment maker Deere & Co, among several changes in its stock investments...
Reuters  Nov 14  Comment 
Warren Buffett's Berkshire Hathaway Inc disclosed a new stake in healthcare management company Express Scripts Holding Co and shed its stake in agricultural equipment maker Deere &...
Jutia Group  Nov 5  Comment 
[PR Newswire] - ST. LOUIS, Nov. 5, 2014 /PRNewswire/ -- Express Scripts (Nasdaq: ESRX) announced that it will present at the Credit Suisse Annual Healthcare Conference on Tuesday, November 11, 2014 at 9:30 a.m. MST (11:30 ... Read more on this. ...




 
TOP CONTRIBUTORS

Express Scripts (NASDAQ: ESRX) is one of North America's top five Pharmacy Benefits Management (PBM) companies measured by prescriptions sold.[1] Express Scripts' clients are health insurers and employers which hire ESRX to manage prescription drug benefit plans for their members and employees. [2] In addition to administering prescription drug plans, ESRX negotiates volume discounts with pharmacies and drug companies on behalf of its clients, and sells drugs at a discount through its mail-order pharmacy.

The merger of CVS and Caremark has increased competition in the PBM market.[3] The merger will likely increase CVS's consumer base. ESRX's revenues will be significantly negatively impacted if CVS increases its consumer base by luring away clients or potential clients from Express Scripts. [4] The Medicare Part D law helps individuals pay for prescription drugs through private providers and has increased the competitive landscape of the PBM market. [5]

ESRX benefits from Baby Boomer aging, who require more medical services as they get older.[6] Also, the key patent expirations on widely used drugs benefit PBMs because they can save money when generic substitutes become available. This is especially true for ESRX, which has the highest generic dispensing rate of all PBMs.[7]

Company Overview

Express Scripts is one of North Americas largest PBMs measured by prescriptions sold. More than 50 million Americans rely on Express Scripts for information and treatment to stay healthy.

Business & Financial Metrics[8]

In 2009, Express Scripts generated a net income of $827.6 million on revenues of $24.75 billion. This represents a 6.6% increase in net income on a 12.6% increase in total revenues from 2008, when the company earned $776.1 million on revenues of $21.98 billion.

Business Segments[9]

  • Pharmacy Benefits Management (94.8% of total revenues): The "PBM" segment is third largest in the US as measured in prescription sales. ESRX buys pharmaceuticals in bulk and resells it to clients at smaller volume and higher price. ESRX distributes pharmaceuticals through a network of third-party retail pharmacies and its own home delivery pharmacies.
  • Emerging Markets (5.2% of total revenues): This segment distributes pharmaceuticals, medical supplies, and fertility services to medical suppliers, physicians, clinics, and hospitals in emerging markets.[10]

IMAGE:EXRS-Segments2009.jpg[9]

Clients

ESRX clients are not the recipients of the drugs it distributes, but rather health maintenance organizations (HMOs), health insurers, third-party administrators, employers, union-sponsored benefit plans, workers compensation plans, primary care physicians, renal dialysis clinics, and government health programs. The business-to-business model spares ESRX the need to market to millions of customers. It also makes the company more vulnerable to the purchasing decisions of individual clients, which each represent a larger portion of sales.

The company has a diverse client base with no single client accounting for over 10% of consolidated revenues the past three years. The top ten retail pharmacy chains account for only 56% of the retail stores in ESRX'S largest retail network. [11] PBM clients generally have a three-year contract, so just one-third of its clients are at risk in renegotiations each year.[12]

Other Services

ESRX's PBM segment offers the following other services to its clients:

  • Benefit Design Consultation.
  • Patient Care Contact Centers
  • Formulary development
  • Information Reporting and Analysis Programs
  • Rebate Programs
  • Electronic Claims Processing System
  • Consumer Health and Drug Issues[13]

Trends and Forces

Medicare

The Medicare Part D program lets retirees choose their own prescription medication plans. This has the potential to reduce the number of end users for ESRX's services if employers stop providing their own PBM coverage through ESRX to retirees and instead let retirees pick their own plans. ESRX also faces competition from other PBMs and other healthcare companies, some of which have units that specialize in these Medicare Part D plans. [14] There is also a longer term risk that Medicare might expand and engulf some of the services ESRX provides. This has become more likely as polls suggest that November's elections will yield a House of Representatives, Senate, and White House all under Democratic control.

Demographic Change/Aging Baby Boomers

The PBM sector is positioned to benefit as the aging "Baby-Boomer" population increases the demand for medical services. [15] In 2025, 35 million Americans are expected to be aged between 65 and 74 years old with 26 million over age 75. [16]

According to a study by the Kaiser Family Foundation, there is a direct correlation between prescription drug use, and spending, age, and the prevalence of chronic, acute, and complex health issues. [17] ESRX will likely benefit from a larger client base and more claims as more people will need pharmaceuticals and as pharmaceutical use per patient increases.

Wal-Mart

Wal-Mart has also begun competing with retail pharmacies as it seeks to increase its market share of pharmaceutical sales. On May 5, 2008, Wal-Mart announced phase III of its $4 prescription drug plan; in addition to offering a month's supply of generic drugs for $4 as it had before, Wal-Mart will offer $4 over-the-counter drugs and a 90-day supply of around 350 generic drugs for only $10. However, Wal-Mart offers only a limited selection of drugs, typically, older, generic drugs like ibuprofen, and not all of the drugs that ESRX supplies its customers. This limited offering, Wal-Mart's lack of home-delivery pharmacies, and other strong barriers to entry have prevented Wal-Mart from competing much with ESRX.[18] The other barriers to entry include, but are not limited to, formulary expertise and large networks of retail pharmacies.[19] Still, Wal-Mart's massive buying power and retail stores would create serious competition if it seeks to enter the market against ESRX.

Legislation

States have tried to prohibit health plans from using economic incentives to persuade their members to use home delivery pharmacies. Some states also require that health plans (like those provided by PBMs) cover specific drugs if they are prescribed by a physician. This type of legislation raises costs for PBMs.

Lawmakers and regulators are also considering, or have adopted, changes that would weaken ESRX's ability to negotiate discounts from its network of third-party pharmacies. For example, states have enacted "most-favored nation" legislation that requires pharmacies to give the state the same lowest price it makes available to third-party plans. These requirements hamper ESRX's ability to take advantage of cost savings when it buys drugs in bulk.[20]

The state of Maine and the District of Columbia have enacted statues that declare PBMs to be a fiduciaries with respect to their end users. This means that they must act in the best interests of their clients; for instance, in Maine, ESRX must disclose to its clients the rebates it receives from drug manufacturers. Residents of the states had complained that PBMs were keeping rebates rather than passing them on to their customers. [21]

Competition

As a PBM, ESRX operates in a competitive market against three types of competitors. One type is the independent PBM, such as MedcoHealth Solutions or Catalyst RX. The second type is the PBM owned by a managed-care organization, such as Wellpoint Pharmacy Management or Cigna. And the final type is the PBM owned by a retail pharmacy chain, such as CVS CareMark or Long's Drug Stores.

  • Medco Health Solutions -- A PBM traded on the NYSE. It competes with ESRX through mail-order and other traditional PBM services. It has the largest market share in prescriptions sales of any PBM and is the nation's leading PBM based on net revenues. It operates a mail-order pharmacy and it has a Specialty Pharmacy segment operating under the name Accredo Health Group, which was the largest in the US based on revenues. Medco is an active participant in the Medicare Part D benefit program.[22]
  • HealthExtras (HLEX) -- HealthExtras's PBM segment operates under the brand name Catalyst Rx HealthExtras. Its retail pharmacy network includes over 60,000 pharmacies. It provides many of the same services that ESRX does to similar clients.[23]
  • CVS/Caremark -- CVS is the largest provider of prescriptions and related healthcare services in the US. The March 2007 merger of CVS and Caremark promotes more competition in the PBM sector, especially over time as CVS/Caremark deals with integration problems relating to the companies' merger. CVS operates two segments: retail pharmacy and pharmacy services. The latter is in direct competition with ESRX. This segment provides mail-order pharmacy service, specialty services, plan design, and other services that ESRX also offers.[24]
  • Longs Drug Stores -- Longs Drug Stores operates as both a retail drug store and as a PBM, the latter through its Rx America subsidiary. Longs' retail stores have historically been located on the West Coast of the US. Its PBM segment offers prescription drugs under Medicare Part D. It provides many of the same services as ESRX, including mail-order drugs and a retail network of pharmacies (its own). Its PBM segment has a small share of the market.[25]

References

  1. ESRX Annual Earnings Release (10-K) 2007, P. 36-39
  2. Reuters report on ESRX
  3. [Morningstar analyst report on Express Scripts]
  4. Forbes: Caremark Approves CVS Merger revenues.
  5. Medicare Part D
  6. [Jefferies & Company, Inc. report on ESRX]
  7. [Morningstar analyst report on Express Scripts]
  8. ESRX 2009 10-K pg. 27  
  9. 9.0 9.1 ESRX 2009 10-K pg. 67  
  10. ESRX 2009 10-K pg. 33  
  11. ESRX Annual Earnings Release (10-K) 2007, P.4
  12. Welpoint Annual Earnings (10-K) 2007
  13. ESRX Annual Earnings Release (10-K) 2007, P.11
  14. ESRX Annual Earnings Release (10-K) 2007 P. 21
  15. Why to Buy Express Scripts
  16. National Institute on Aging: US population Aging 65 years or older
  17. [Jefferies & Company, Inc. report on ESRX]
  18. Walmart Press Release
  19. WSJ Should PBM Investors Worry About Wal-Mart?
  20. ESRX Quarterly Earnings Release (10-Q) Q1 2008
  21. The future of PBMs -- a work in progress
  22. Medco Annual Earnings (10-K) 2007
  23. HLEX Annual Earnings (10-K) 2007
  24. CVS Annual Earnings (10-K) 2007
  25. Longs Drug Stores Annual Earnings (10-K) 2007
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