Looking for an Acquisition – Speculation

With the stock market handsomely rewarding the PBMs especially Medco and Express Scripts, they have cash and stock value to go on the acquisition path. Express Scripts has grown through acquisition over the years leading up to its acquisition of several specialty pharmacy companies a few years ago. In the St. Louis Business Journal, David Myers (VP, Investor Relations) is quoted as saying “Acquisitions are Express Scripts ‘No. 1 priority for our strong cash flow'”.

[By the way, as I have previously disclosed, I own no ESRX stock or other stocks individually. I only invest in mutual funds…and do very well with it.]

Although it’s been out for a week, I just read it this morning so before I run into anyone there I want to have fun guessing what Express Scripts might acquire. Usually, all I hear about is speculation of who might buy them. It typically is either a retailer like Walgreens or Wal-Mart or occasionally a managed care company. I don’t see them getting bought with the valuation so high. And, there are very few payor other than United Healthcare (which is tied to Medco) or WellPoint that could swallow such an acquisition. And, I am sure Walgreen’s won’t do anything until they see what the CVS/Caremark deal looks like, but if it works, they would have to make a bid for Medco or Express Scripts to compete.

1. Buy one of the many regional PBMs that exist. This would be the easy play. It could be integrated. There is lots of synergy. But, people still go to the regional players for a reason, and you may lose a lot of the lives. Now, buying Walgreen’s PBM might be an interesting play and create a sticky relationship with them to align against CVS/Caremark.
2. Buy a niche PBM in an area such as Worker’s Compensation. Not a bad strategy. They used to have about 20% marketshare in this space. They could also go after the Third Party Billers here although I think that market space may collapse.
3. Buy another specialty PBM. I hope not. They have the assets already to be successful here. All you would be doing here is buying lives for people committed to one particular pharmacy. I think the premium would be too high.
4. Go into a related space like dental or vision, but they tried vision before and it never really took off.
5. Go into the data (e.g., IMS) or IT space (e.g., Ingenix), but they have also tried this and it never took off.
6. Continue to acquire in the consumerism space. They recently bought ConnectYourCare. There are lots of companies out there doing interesting things in this space and with the projected growth here there are lots of opportunities. The problem is valuation of these companies, maturity of the business model, their risk in going into this business, and their focus on the traditional PBM model.
7. Buy a technology company like an e-prescribing company (e.g., Prematics where Barrett Toan (founder of ESI) is an advisor) or a Physician Practice Management company (e.g., Pat McNamee the Chief Administrative Officer came from Misys which I believe was for sale) or healthcare IT company like Cerner or a pharmacy automation vendor like ScriptPro or a Personal Health Record company (like Aetna bought ActiveHealth).
8. Buy a disease management company. Medco has a 10-year (I think) deal with Healthways which I would assume is a “try and buy” type relationship (i.e., let’s try this out and if it works we will buy you at a pre-determined price). ESI has worked with LifeMasters in the past, but I assume there are lots of players out there with interesting models.
9. Follow Medco and buy in the disease space and DME (durable medical equipment) space. Medco bought PolyMedica earlier this year as part of their strategy to develop disease specific pharmacies called Therapeutic Resource Centers. This would probably be the most logical extension. It seems to be working for Medco.
10. Buy into the international health
    space. This would probably be the most adventuresome with the biggest upside (if it could work). There is a lot of opportunity outside the US, but with limited investment, no managed care companies or PBMs have ventured too far. Express Scripts has a company in Canada. I know a few others have explored and/or tried small ventures.
11. Buy into the generic manufacturer or distribution space. This would probably be the most lucrative. They have a huge distribution channel. Why not buy a portion of an existing generic manufacturer, open a distribution company (like McKesson, Cardinal, or AmerisourceBergen), and create a single source relationship with the Express Scripts pharmacy and give the retail pharmacies a different reimbursement rate if they used them.
12. They could always try to become a retailer or go into the clinic business. There is something here, but it is a very different model and given the “training” they have done with the street over the past decade to focus on ROIC (return on invested capital), I don’t think they could do this.

Now, the two things I would suggest if I were still there would be:

1. Invest in IT. Look at how to automate more workflow activities. Look at technologies that drive patient self-service. Look at things that drive patient behavior (online tools, educational programs, incentive systems). Build out mass customization and personalization based on integrated data – medical and lab – so that no one can catch them. (But, if you are waiting to sell, don’t spend the money to overhaul the system.)
2. Create some mad money in a Venture Capital type relationship with someone like Google or Microsoft that are trying so hard to get into the healthcare space and would welcome the relationship to jumpstart.

Who knows? I certainly don’t know what they will do, but it is a fun position to be in. You have money. The market is at an inflection point. You want to be a catalyst. You have driven incredible results for a decade. What next?