PODCAST: Amazon Pharmacy VS. GoodRx Drug Prices

A HEAD-2-HEAD COMPARISON

By Eric Bricker MD

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AMAZON’S New Move in Health Care

By Health Capital Consultants, LLC

Amazon, the largest e-commerce company in the world, has made large, strategic moves over the past several years to make a place for themselves in healthcare.

This article will review Amazon’s most recent advancements in the industry, including those related to Amazon’s voice-controlled personal assistant, Alexa, and Amazon’s employee healthcare system, Amazon Care, and how this non-healthcare company is changing the industry.

LINK: https://www.healthcapital.com/hcc/newsletter/03_21/HTML/AMAZON/convert_amazon_moves_healthcare_3.25.21.php

RELATED: https://medicalexecutivepost.com/2018/09/07/investors-have-misdiagnosed-amazons-push-into-the-pharmacy-business/

MORE: https://medicalexecutivepost.com/2018/03/07/how-amazon-could-lose-its-health-care-bid/

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AMAZON Buys “One Medical”

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By Neal Freyman [Morning Brew]

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Amazon turned and coughed up $3.9 billion to buy One Medical, a primary care provider, in its biggest push yet into health care. It may not be long until your Prime membership comes with a complimentary physical.

What’s One Medical? A company that operates more than 180 medical offices across 25 US markets, offering both in-person and virtual medical services. When it went public as a unicorn in January 2020, it followed a similar trajectory of other high-flying startups: A huge spike when telehealth was in feverish demand, then an equally huge crash to fall well below its IPO price.

The deal for One Medical represents Andy Jassy’s first major acquisition as CEO of Amazon, showing that he’s willing to make bets on growth in certain areas even as he reins in costs in others.

So why is health care a priority?

As you know all too well from every time you pay a medical bill, health care is a massive industry. With a market size of $4 trillion, it accounts for about 20% of the entire US economy. And as Amazon looks to grow outside of its core areas, it sees potential in sending a digital shock wave through a medical industry that’s entangled in a complex web of insurance companies and government regulations.

Not that it’s even clear what a “core” area of Amazon is anymore. Besides its e-commerce marketplace, Amazon has tentacles in cloud services, grocery stores, entertainment, and many other sectors. Basically, we’re about to live in a world where one company owns the James Bond franchise…and also medical clinics.

But Amazon’s infatuation with health care isn’t new. It acquired the online pharmacy PillPack in 2018, and launched its own on-demand health care services one year later. Some projects, like its buzzy joint venture with Berkshire Hathaway and JPMorgan, collapsed, illustrating the challenges for anyone—even Bezos and Buffett—to break into the medical realm.

Those stumbles won’t stop Amazon, or Big Tech in general, from trying. Just this week, Apple released a 60-page report outlining why health care will be a major focus for the company going forward.—NF

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BUSINESS MEDICINE: https://www.amazon.com/Business-Medical-Practice-Transformational-Doctors/dp/0826105750/ref=sr_1_9?s=books&ie=UTF8&qid=1287563112&sr=1-9

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PODCAST: High Per-Capita Metropolitan Healthcare Costs

SPUR INNOVATION

The Dallas Morning News Reported that Healthcare Costs Per Capita in the Dallas-Fort Worth Metro Area are Higher than New York City, Houston, Miami, Chicago, Atlanta and Washington, D.C.

By Eric Bricker MD

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Citation: https://www.r2library.com/Resource/Title/0826102549

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Amazon’s New Moves in Health Care

Amazon’s New Moves in Healthcare

By Health Capital Consultants, LLC

Amazon, the largest e-commerce company in the world, has made large, strategic moves over the past several years to make a place for themselves in healthcare. This article will review Amazon’s most recent advancements in the industry, including those related to Amazon’s voice-controlled personal assistant, Alexa, and Amazon’s employee healthcare system, Amazon Care, and how this non-healthcare company is changing the industry. (Read more…)

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Small Companies Get Tax Breaks, Too!

How can this possibly be fair?

By Rick Kahler MS CFP®

An April 29th headline in The New York Times got my attention: “Profitable Giants Like Amazon pay $0 in Corporate Taxes. Some Voters Are Sick of It.” My immediate reaction was outrage. Amazon had a 0% tax rate. My company’s overall tax rate was 24%, and its net profit was less than 0.000025% of Amazon’s. How can this possibly be fair?

The Times article, by Stephanie Saul and Patricia Cohen, gave few specifics but left the impression that Amazon simply gets out of paying taxes on its profits because of a legal, but unfair, manipulation of the tax code afforded only to wealthy corporations, leaving the heavy lifting to the rest of us poor saps.

I wanted to know how Amazon did it, so I did some research

First, let’s put the $11.1 billion profit into perspective. The past 18 months are the first time Amazon has shown any meaningful profit since 2011. Many of those years saw them losing billions of dollars.

The total value (market capitalization) that shareholders have invested in Amazon is $954 billion as of April 29, 2019. That means the 2018 profit of $11.1 billion represents an earnings yield of 1.16% return on investors’ money. The average earnings yield on a large US company is 4.5%, significantly higher than Amazon’s. While $11.1 billion sounds like a lot of money in dollar terms, when viewed in the amount of money it takes to generate those profits, Amazon’s financials are significantly subpar.

Amazon reduced their taxes to zero by primarily doing four things:

  1. They reinvested their profits in equipment and buildings, and were able to deduct a portion of these expenses. They will have to repay the taxes they deferred on these purchases when they sell the equipment or property. And the money spent was not available for distribution to their shareholders.
  2. They received a tax credit for spending on research and development. This credit is an incentive for any company to help offset the high risk of the up-front costs of developing new ideas, not all of which pay off.
  3. They paid some employees in the form of stock, rather than cash. While still a real cost to the company, this is used to minimize cash outflows, while giving employees an opportunity to reap the rewards of their hard work in future profits.
  4. In their start-up years, Amazon lost billions of dollars. Out of fairness, the tax code allows any business to carry losses over into future years to offset profits, when and if they ever materialize. This type of “write off” is real money that was lost.

The article cited a carpet layer who had a profit of $18,000 and paid more in taxes than Amazon. He was so upset at this injustice that he joined the Socialist Party.

The article failed to mention that many of the same write-offs used by Amazon were available to him, too. If his business was incorporated, the tax bill on his profits was probably 21%, or $3,780. If he had reinvested his profit in a new carpet cleaning machine, had losses from previous years to carry forward, spent money on developing a new type of carpet cleaner, or paid his employees in stock, he would have paid nothing in taxes.

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Assessment

Critics of big corporations might say such strategies would not be realistic for a one-person company. Yet I have seen many small business owners use them, particularly carrying forward losses that result from the essential start-up costs. The corporate tax code generally applies equally to all businesses and is meant to encourage small companies as well as large ones to take the risks necessary to create new jobs.

Conclusion

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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How Amazon could lose its health-care bid

 While drug distributor stocks win

By Vitaliy Katsenelson CFA

Amazon.com has been one of the most innovative and disruptive companies of this century, with incredible success in areas that lie outside of what has been historically perceived as its core business (book selling).

Thus every announcement or speculation that Amazon will enter into a particular industry sends stocks of that industry into a tailspin. Investors sell first and ask questions later. When Amazon announced its purchase of Whole Foods, grocery stores declined as much as 30%. Even Tesco separated by an ocean from Whole Foods, was down on that news.

A big part of Amazon’s success has come from not being taken seriously by its competition. Amazon was able to create a huge lead in AWS (Amazon Web Services) because the competition (Alphabet and Microsoft did not give Amazon enough respect. Competitors thought, “what does a book seller know about the cloud?” Well, according to Amazon CEO Jeff Bezos, such thinking gave Amazon a much bigger lead over its rivals. Today, everyone takes Amazon seriously. Indeed, fear of Amazon is reaching paranoia levels.

McKesson

McKesson shares, for example, took a 20% dive during the fourth quarter of 2017 on speculation that Amazon would start distributing pharmaceuticals in the U.S. As McKesson shareholders, my firm took this speculation seriously, but upon further investigation, it became evident that such concerns were overblown. After the market cooled off from fourth-quarter worry about Amazon, McKesson shares recovered.

Then in late January, news that Amazon, JPMorgan Chase, and Berkshire Hathaway will join forces to drive down U.S. health-care costs hit health-care sector stocks, including McKesson.

How big of a punch could this be? McKesson is the largest distributor of pharmaceuticals in the U.S. Its 2018 sales are on track to exceed $210 billion. It is important to point out that McKesson is not a retailer but a distributor. It is one of three railroads for drugs in the U.S. McKesson distributes drugs to thousands of independent pharmacies, as well as giants like CVS Health, Rite Aid and Walmart McKesson operates two distinct distribution businesses: branded and generics. Though these businesses may look similar on the surface, the economic models of branded and generic businesses are quite different.

In the distribution of branded drugs (about 70% of McKesson’s revenue and 30% of profits) McKesson has a fee-for-service model. Pharmaceutical companies want to be involved in high-value activities: chiefly, inventing and manufacturing drugs. Getting drugs to thousands of pharmacies on a timely basis and collecting accounts receivable is not the business they want to be in. They don’t have the scale and distribution know-how of McKesson, Cardinal Health, and AmerisourceBergen — that collectively control 90% of drug distribution in the U.S. Thus the likes Pfizer and Bristol-Meyers Squibb pay drug distributors a small “fee for service,” and pharmaceutical companies (not distributors) negotiate prices with pharmacies.

More than 90% of McKesson’s profit in this segment is driven by volume, while just 10% is linked to changes in drug prices. Pfizer, for instance, despite its might, would still have higher distribution costs than McKesson because it doesn’t have McKesson’s scale and focus on distribution efficiency. So Pfizer is happy to pay McKesson this service fee and not think about drug distribution.

In its generic drug distribution business (about 30% of sales, 70% of earnings), McKesson uses its enormous buying power to buy drugs at low prices from generics manufacturers and sell at higher prices to pharmacies. Since it can source the same drug from various manufacturers, it leverages better prices from the likes of Mylan and Teva Pharmaceuticals Industries. Drug distributors are a significant deflationary force in generic pricing — good for consumers, not great for Teva or Mylan.

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Moats

So McKesson has a wide protective moat, which includes the distinct possibility that Amazon’s adventure into drug distribution could lead to miserable failure. Here’s why:

1. Amazon cannot match McKesson’s buying power or negotiating power when it comes to generics. Current Amazon sales of pharmaceuticals are somewhere between zero and slightly above zero. McKesson’s sales are pushing $210 billion, about $65 billion of which comes from generics. Walmart is the fourth-largest pharmacy in the U.S., with sales of $20 billion. It had distributed drugs, but in 2016 it signed a distribution deal with McKesson. Walmart realized it could get better prices for generics through McKesson. Amazon, with near-zero sales, doesn’t stand a chance.

2. Amazon has no structural advantage. In the fight against Barnes & Noble and Best Buy, Amazon could charge lower prices than brick-and-mortar retailers because it had a structural advantage — it did not own stores and have all the extra costs associated with them. On one of his conference calls, McKesson CEO John Hammergren said his company was Amazon before Amazon was Amazon. Indeed. McKesson has highly specialized warehouses designed to distribute drugs. It can get any drug to any pharmacy in the U.S. within hours.

3. McKesson’s pretax margins are just 1.7%. If Amazon is looking to cut fat in the pharmaceutical industry, this is not where the fat is.

4. Distributing and selling drugs is not like selling or distributing most anything else. First, some drugs require refrigeration and others are controlled substances. Distributing them puts an extra regulatory (and self-policing) burden on distributors. McKesson has paid fines and recently received plenty of negative publicity from “60 Minutes” for distributing opioid pain medications to legal pharmacies who illegally sold the medicine on the black market.

Next, unlike in almost any other industry, pharma consumers are price-insensitive. If you are on Medicare, Medicaid, or a copay/low-deductible private insurance plan, you really don’t care if you are paying the lowest price because you don’t see the price (other than for copay). For this group of drug consumers, which constitutes the bulk of the U.S. population, lower drug prices are not an incentive to switch.

Moreover, let’s say Amazon starts an online pharmacy and self-distributes. Internet-savvy millennials are not the ones consuming most of the drugs in the U.S. Their parents and grandparents are. This demographic still has brick-and-mortar habits that are less likely to be broken anytime soon. Also, major pharmacies already have mail-order operations. It would be logical for Amazon to try to get into the almost-trillion-dollar pharma business, but its success here will be limited, and it will take decades to gain a meaningful market share

5. Suppose Amazon opens an online pharmacy and succeeds. It would probably take five to 10 years to reach sales of, let’s say, $10 billion (half of Walmart’s current drug sales). Let’s assume that Amazon self-distributes and will not use McKesson, or that it decides to employ the services of Cardinal Health. This would steal less than a year of current growth from McKesson, in five to 10 years.

Put simply, the laws of economics still apply — even to Amazon. Drug distributors are strong financially and have great scale and a tremendous purchasing-power advantage. Distributors’ stocks may take a dive but their business will be fine in the long run. The only competitive advantage Amazon has against drug distributors is that Wall Street completely ignores its profitability and focuses only on revenue growth.
McKesson is one of the U.S. stock market’s most interesting investments. Its business is future-proof. The demand for its product is not cyclical and is likely to continue to grow as the U.S. population ages. Higher or lower interest rates, recession or no recession, inflation or deflation, McKesson’s earnings power will continue to march ahead for a long time.

McKesson has a conservative balance sheet; it can pay off its debt in less than two years. McKesson pays a lower dividend than its competitors, but it has purchased a third of its shares over the last decade. Expected earnings of about $13 a share this year could grow to $15 in 2019. At a conservative 15 times earnings, McKesson is worth about $225 a share.

Assessment

However, McKesson has spun off its technology business into Change Healthcare, which could go public in 2019. McKesson owns 70% of Change Healthcare, and my firm estimates McKesson’s interest is worth about $25-$30 a share. Thus, a conservative estimate of McKesson’s value is about $250.

Conclusion

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Regulator Floats Idea of Merging Banks and Commerce

On the Bank of Amazon? Wal-Bank, Face-Bank, etc.

https://www.bloomberg.com/news/articles/2017-11-08/banking-commerce-divide-may-be-unnecessary-u-s-regulator-says

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, urls and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements.

https://medicalexecutivepost.com/dr-david-marcinkos-bookings/

Contact: MarcinkoAdvisors@msn.com

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Why Amazon will NOT kill this business!

Why Amazon Will Not Kill This Business

By Vitaliy Katsenelson CFA

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, urls and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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Why I Love Amazon.com but Won’t Buy Its Stock

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By Vitaliy Katsenelson CFA

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You should look at your portfolio and want to throw up a little — this is how one value manager described what a true, die-hard value investor’s portfolio should look like. The two stocks I wrote about in my latest article — American Eagle and Aéropostale — have a tendency to elicit that unpleasant reflex in many investors today.I’m not writing this article as a pitch for those stocks (though, to be clear, my firm does own them) but to reinforce the lesson I have learned from past indecisions. If you want to buy a retailer selling clothes and shoes — items that are subject to fashion and weather risks — you want to buy them when they have missed their latest trend, when their financials look ugly and when the risks have already played out. One thing I like about these apparel retailers is that teens will shop there for just a few years. If a retailer screws up with one crop of kids, they get a second chance, because there is another crop coming right along. (The JCPenney crowd is not as forgiving. See “What I Learned from the JC Penney Fiasco .”)Also, unlike for the Best Buys and RadioShacks of the world, the Internet is not a significant threat to teen clothing retailers. Parents get sick of their kids driving them crazy at home on weekends — plus, let’s be honest, when your kids get to be teenagers, you are definitely not cool anymore. There is, however, an amicable solution: Drop the kids off at the shopping mall — a large, relatively secure enclosed space with video cameras and security personnel, with a movie theater, inexpensive fast food and a lot of retailers.

As I am writing this, I’m realizing that this is a quintessentially American phenomenon. The public transportation system is not really well developed in the U.S., and distances are large. Dropping off your kids at the mall pretty much ensures that they’ll still be there when you come back for them. And before the movie but after they have filled their bellies with French fries … you guessed it, the kids go to Aéropostale or American Eagle. Kids go there to kill time.

stock-exchange-

Growing up in Russia, which in many respects was a lot like Europe, we walked (there were wide sidewalks along the streets) and took public transportation. These were the times before the nightly news was allowed to talk about real local crime, and my parents were not really worried about safety on the streets, though if I was really, really late coming home, my mom still called the hospitals. I don’t know if Russian parents still feel the same way about letting their kids roam the streets today.

On a separate but related topic, for the past year, since we got Amazon Prime, I’ve been hooked on shopping on Amazon.com . I have bought things there that I never thought I would. We just bought a bunk bed for the kids. I read all the positive and, most important, the negative reviews. The bed was delivered to my door, and I did not have to pay for shipping. If I had bought it at Ikea, I would have had to either pay for delivery or load and unload boxes into and out of our minivan. But what is amazing about Amazon is how easy it is to deal with them and return things that don’t work out.

A few weeks ago we bought a foam mattress. It was vacuum-sealed, so when we opened it and removed the plastic it expanded to double the size of the original packaging. However, the mattress had an unpleasant smell that had not gone away after a week of airing. So I had a mattress that I couldn’t stuff back in the original box to return. I went on Amazon’s website — I didn’t even bother calling them but hit the “chat” button. Ten minutes later my problem was solved. A service truck (not UPS or FedEx) would pick up my mattress as is, without the original packaging, and it would not cost me a dime.

My wife was not very happy with me for buying this mattress and having to return it. But I reminded her to just imagine how much money and time we’d have wasted if we’d bought at a traditional retailer — we would have had to pay for delivery (a cost we wouldn’t recoup) and then pay again for delivery back to the store.

Amazon Prime is an ingenious idea. For a bit less than $100 a year, I receive free shipping on any item — no limits or constraints. This also buys my loyalty to Amazon. (Yes, my loyalty is that cheap!) I don’t even think about checking prices with other retailers — I know that with them I won’t get free shipping (both ways), incredible selection, the reviews of other buyers, absolutely pain-free customer service and competitive prices. Also, Amazon already has my work and home addresses and my credit card information. So Amazon Prime has done something that you wouldn’t think is possible: It has created online loyalty.

This new loyalty presents me, as an investor, with an interesting dilemma: What do I do about Amazon’s stock? Answer: absolutely nothing. It is incredibly difficult to value Amazon shares. Today they trade at 90 times next year’s earnings. I can definitely see how Amazon’s sales will grow over time, but because the company is not focused on making money, I have no idea whether that bright future is already priced in or not. Investors are forgiving Amazon for not making money today because at some point it will start to. It will stop investing in new product categories, it will raise its prices, and customers will be forgiving. So they may have a workable strategy.

But here is what I have learned over the years. You don’t have to own all the great companies. You can just enjoy their products and services until they stumble. They always do. Wall Street love affairs are like Hollywood marriages; they’re not forever. Look at Apple . I have always loved their products (I have owned every single iPhone), but I waited until I could buy the stock on my own terms, when I could value it and have a margin of safety. The same applies to electric car–maker Tesla Motors. My next car will probably come from them, but I’ll wait patiently for Tesla’s stock to become reacquainted with the concept of gravity.

ABOUT

Vitaliy N. Katsenelson, CFA, is Chief Investment Officer at Investment Management Associates in Denver, Colo.
 

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners(TM)

BOOK REVIEW

This is an excellent book. It is all inclusive yet easy to read with current citations, references and much frightening information. I highly recommend this text. It is a fine educational and risk management tool for all doctors and medical professionals.

DR. DAVID B. LUMSDEN; MD, MS, MA

[Orthopedic Surgeon-Baltimore, Maryland]

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