RICHARD J. LEON, United States District Judge.
The United States of America ("the Government") filed this lawsuit to challenge CVS Health Corporation's ("CVS's") acquisition of Aetna Inc. ("Aetna") as a violation of Section 7 of the Clayton Act, 15 U.S.C. § 18. It now moves to resolve the case through entry of a negotiated consent
That determination in this particular case, however, is no small matter. Industry players, consumer groups, and state regulatory bodies have all raised concerns about CVS's acquisition of Aetna. The merger combines two healthcare giants. Its effects, for better or worse, will be felt by millions of consumers. As I explained to the parties near the outset of this case, with so much at stake, the congressionally mandated public interest inquiry must be thorough. Indeed, if the Tunney Act is to mean anything, it surely must mean that no court should rubberstamp a consent decree approving the merger of "one of the largest companies in the United States" and "the nation's third-largest health-insurance company," Compl. ¶¶ 15-16 [Dkt. # 1], simply because the Government requests it!
My determination of whether the Government's proposed final judgment is in the public interest will, of course, be based on the existing record, which has been meaningfully supplemented by the briefs and testimony presented by the parties and amici curiae ("the amici").
On October 10, 2018, the Government, along with the States of California, Florida, Hawaii, Mississippi, and Washington, sued to enjoin CVS's sixty-nine-billion-dollar acquisition of Aetna. See Compl. ¶¶ 1, 41. According to the Government's complaint, "CVS ... is one of the largest companies in the United States." Id. ¶ 15. Indeed, it is currently listed as number eight in the Fortune 500 list, see Fortune.com, Fortune 500, CVS Health, https://fortune.com/fortune500/2019/cvs-health, and "operates the nation's largest retail pharmacy chain; owns a large pharmacy benefit manager called Caremark; and is the nation's second-largest provider of individual [Medical Part D prescription drug plans ("PDPs")], with over 4.8 million members," Compl. ¶ 15. By acquiring Aetna, CVS purchased "the nation's third-largest health-insurance company and fourth-largest individual PDP insurer." Id. ¶ 16. Both companies earn billions of dollars in annual revenue. See id. ¶¶ 15-16. The Government alleged in its complaint that their merger would "lessen competition substantially in the sale of individual PDPs" in sixteen of the geographic regions
As soon as the complaint was filed, however, the Government submitted a notice attaching a proposed consent judgment that would settle the case. See U.S. Explanation of Consent Decree Procedures at 1 [Dkt. # 2]. To comply with the proposed judgment, Aetna would have to divest its individual PDP business to an independently owned competitor, WellCare Health Plans, Inc. ("WellCare"). The Government describes its proposed remedy as having five primary components:
Mot. for Prop. Final J. at 2-3.
Because this is a civil antitrust suit brought by the Government, the proposed consent judgment is subject to the Tunney Act. See 15 U.S.C. § 16(b). That statute requires the Government to take several procedural steps before moving for entry of its proposed judgment.
In addition to these procedural steps, the Tunney Act "requires that before a proposed consent judgment" is "approved by the Court, the Court must determine that `the entry of such judgment is in the public interest.'" United States v. Airline Tariff Pub. Co., 836 F.Supp. 9, 11 (D.D.C. 1993) (quoting 15 U.S.C. § 16(e)). To establish that its proposed judgment meets this standard, the Government incorporated its response to the comments received during the sixty-day notice and comment period into its motion for entry of final judgment. See Mot. for Prop. Final J. at 4-5. To say the least, that response left much to be desired. It is rife with conclusory assertions that merely reiterate the Government's confidence in its proposed remedy, but shed little light on the reasons for that confidence. Indeed, the Government's perfunctory response to the public comments was particularly disappointing in light of the volume and quality of the comments to which it was responding!
For example, the AMA's comments criticized the Government's proposed divestiture remedy because the buyer—Well-Care—relies on CVS for pharmacy benefit management
Rather than risk an uninformed public interest determination that relied too heavily on responses like these from the Government, I decided to hold hearings on the Motion to Enter the Proposed Final Judgment. The hearings were designed to assist the Court in evaluating the public record. The parties and the amici were given the opportunity to propose up to three witnesses who could be called to testify. The Court alone would decide which of those witnesses it believed would be most helpful to its analysis and how much time would be allotted to each witness. In the end, the amici were allowed to call a combined total of three witnesses who were permitted to testify for a total of four hours. CVS and the Government were allowed the same combined total of witnesses and the same combined total number of hours of testimony. To reinforce my repeated emphasis that the hearings were not a trial, cross-examination was not permitted. Only the Court was allowed to ask follow-up questions during the direct examination of each witness.
At the hearings, which lasted two days, the AMA examined Dr. Neeraj Sood, a college professor who is an expert on health policy. Consumer Action and U.S. PIRG jointly examined Dr. Diana Moss, an economist who is president of the American Antitrust Institute. And the AIDS Healthcare Foundation elicited factual testimony from the Foundation's Chief Medical Officer, Dr. Michael Wohlfeiler.
After amici's testimony, the parties to the case were permitted a rebuttal presentation. I heard testimony from Dr. Alan Lotvin, CVS's Executive Vice President and Chief Transformation Officer, and from Dr. Lawrence Wu, an expert in economics offered by CVS. Thereafter, the Government and CVS jointly designated Terri Swanson, Vice President for Medicare Part D products at Aetna, to testify about the PDP assets Aetna sold to WellCare.
The Tunney Act provides that, when making a public interest determination, "the court shall consider":
15 U.S.C. § 16(e)(1).
The public interest inquiry is "not... `a de novo determination of facts and issues.'" United States v. Newpage Holdings Inc., No. 14-2216, 2015 WL 9982691, at *5 (D.D.C. Dec. 11, 2015) (quoting United States v. Western Elec. Co., 993 F.2d 1572, 1577 (D.C. Cir. 1993)). The Court need "only ... confirm that the ... settlement is within the reaches of the public interest." United States v. Microsoft Corp., 56 F.3d 1448, 1460 (D.C. Cir. 1995) (quotation marks, citation, and italics omitted).
But neither is the inquiry a mere formality or judicial rubberstamp. If, for example, a proposed consent "decree is ambiguous, or the district judge can foresee difficulties in implementation," the decree should not be entered until the problems are fixed. Microsoft, 56 F.3d at 1462. "[I]f third parties contend that they would be positively injured by the decree, a district judge might well hesitate before assuming that the decree is appropriate." Id. And no "judge is ... obliged to accept [a consent decree] that, on its face and even after government explanation, appears to make a mockery of judicial power." Id.
Throughout this case, the Government has repeatedly asked this Court to dismiss out of hand many of amici's objections to its proposed final judgment. Relying for the most part on United States v. Microsoft Corporation, 56 F.3d 1448 (D.C. Cir. 1995), the Government argues that consideration of harms that were not alleged in the complaint would "aggravate... `constitutional difficulties that inhere'" in the Tunney Act. U.S. Resp. to Order to Show Cause at 2 [Dkt. # 32] (quoting Microsoft, 56 F.3d at 1459). To avoid this purported aggravation, the Government contends that the Court must ignore all evidence regarding "harm outside of the individual PDP market," "theor[ies] of harm that the United States did not allege," and "efficiencies" gained from the
To say the least, these arguments severely understate the permissible scope of a Tunney Act review. The "constitutional difficulties" our Circuit Court addressed in Microsoft were implicated because a court "reach[ed] beyond the complaint to evaluate claims that the government did not make." 56 F.3d at 1459 (first italics added). Courts cannot, of course, "force the government to make [a] claim." Id. at 1460. The Government, alone, chooses which causes of action to allege in its complaint.
But Microsoft never says that allegations in the complaint are the only harms courts may consider in a Tunney Act review.
The Microsoft Court recognized this very point. It explained that the Tunney Act reflects Congress's understanding that "a consent decree might well do unexpected harm to persons other than those `alleging specific injury from the violations set forth in the complaint,'" so "district court[s] might ponder those sort of concerns in determining whether to enter [a proposed] judgment." Microsoft, 56 F.3d at 1459 (quoting 15 U.S.C. § 16(e)(2) (1988), now codified at 15 U.S.C. § 16(e)(1)(B)). The Microsoft Court went on to specifically identify three examples of when complaint allegations do not circumscribe a Tunney Act inquiry. Courts, it said, may review whether a "decree is ambiguous, or ... difficult[] [to] implement[]," whether "third parties ... w[ill] be positively injured by the decree," and whether entry of a decree would "make a mockery of judicial power." Id. at 1462. Adequately reviewing any of these potential harms to the public interest could require a court to look beyond the four corners of the Government's complaint. But none constitute the "evaluat[ion of a] claim[] that the government did not make." Id. at 1459 (italics omitted). All, therefore, are fair game. See id. at 1462; BNS Inc., 858 F.2d at 462-64.
The Government's suggestion here—that by narrowly drafting a complaint
Thus, based on a correct reading of Microsoft and the Tunney Act, the potential harms to the public interest raised by the amici in this case fall within the permissible scope of this Court's review. As such, notwithstanding the Antitrust Division's protestations to the contrary, a judicial evaluation of those alleged harms raises no constitutional issue.
Amici's testimony and briefs alleged a variety of harms to the public interest that the final judgment would cause if it were entered by the Court. While those concerns shed a healthy light on this merger, the amici did not substantially undermine the parties' public interest position by persuasively demonstrating that their concerns currently exist or are likely to develop. This was especially so in light of the rebuttal presentations by CVS and the Government. A review of the amici's major concerns should be sufficient.
Principal among amici's concerns were the following three contentions: (i) Aetna's divestiture to WellCare will not effectively remedy the harm to the PDP market alleged in the complaint; (ii) the proposed final judgment's failure to address effects in markets adjacent to the PDP market—like the market for PBM services—will undercut the effectiveness of the divestiture remedy and harm the public; and (iii) entry of the proposed final judgment without modification will harm HIV and AIDS
First, amici, contend that the divestiture to WellCare mandated by the proposed judgment will not remedy the competitive harm to the PDP market alleged in the Government's complaint. Amici argue that, according to the Herfindahl-Hirschman Index ("HHI"),
In response, CVS and the Government provided a more persuasive rebuttal. Terri Swanson, the Vice President in charge of Aetna's Medicare Part D products prior to the divestiture, was the hearing witness most familiar with the PDP market and the PDP assets that WellCare purchased. See Hr'g Tr. at 336:24-337:16, 338:10-16, 339:9-22 (June 5, 2019 P.M.). Her testimony focused on how the PDP market is already highly competitive. See id. at 342:22-344:5. She described CMS's Medicare Plan Finder tool, which allows PDP customers to compare plans in granular detail. See id. at 343:16-344:5. Using CMS's tool, customers can see "the price of a specific drug at a specific pharmacy for a specific plan" before purchasing a PDP plan. Id. CMS also makes it "very easy for [customers] to switch" PDP plans online or over the phone. Id. at 344:6-14. Ms. Swanson explained that, because PDP plans can be easily compared and swapped, variables like brand recognition are far less important to maintaining PDP market share than simply offering the drug coverage customers want for a couple of dollars less than competitors. See id. at 346:17-348:11.
She also emphasized that WellCare has been a successful competitor in these very conditions. Prior to Aetna's divestiture, WellCare "added around half a million" new members—growing from "about 1.1 million members" to "about 1.6 million members"—by underselling Aetna "a dollar or two" on "similarly situated plans." Hr'g Tr. at 340:8-342:3, 346:17-347:20 (June 5, 2019 P.M.). WellCare did so despite being smaller than Aetna. See id. at 342:4-11. It also did so while both competing against CVS in the PDP market and contracting with CVS for PBM services. See id. at 360:17-361:7; Hr'g Tr. at 228:9-228:19; 251:10-19 (June 5, 2019 A.M.). WellCare thus showed, before the divestiture, that it could attract customers from larger competitors under conditions similar to those it faces now. It stands to reason that, notwithstanding amici's concerns, WellCare can and will continue to compete post-merger, after its market share has been bolstered by the purchase of Aetna's assets.
With respect to amici's other concern—PDP market concentration—CVS's expert, Dr. Lawrence Wu, emphasized that amici's HHI analysis shows that the PDP market is "moderately," as opposed to "highly," concentrated under the Government's guidelines. See Hr'g Tr. at 272:23-273:24 (June 5, 2019 A.M.). According to the Government, the HHI scores at issue here merely indicate potential competitive concerns, not a presumption of market power.
In the final analysis, PDP customers do have numerous options when picking a plan, and many of the plans are offered by major healthcare players, including United Healthcare, Humana, Cigna, and Rite Aid. See Hr'g Tr. at 342:22-343:15 (June 5, 2019 P.M.). The moderate concentration in the PDP market has neither prevented Well-Care from competing in the market, nor prevented price competition from driving premium prices down, in recent years.
Amici next argue that the proposed judgment's failure to address the merger's effects in PDP-adjacent markets—such as the market for PBM services—threaten the success of the Government's proposed remedy and potentially harm third parties and the general public. How so?
CVS is a major player in the PBM market. It accounts for close to a quarter of PBM market share, and with the two other top PBMs, CVS is part of "the big three" that control about 70% of the market. See Adam J. Fein, The CVS-Aetna Deal: Five Industry and Drug Channel Implications, Drug Channels (Dec. 5, 2017), https://www.drugchannels.net/2017/12/the-cvs-aetna-deal-five-industry-and.html.
Amici argue that CVS can leverage this power in the PBM market to disadvantage companies that compete against its newly expanded health insurance business. They theorize that CVS could, for example, raise the price of its PBM services when selling
But again, CVS presented more persuasive evidence that substantially undermines amici's theory. Notwithstanding CVS's significant market share, the evidence showed that CVS must compete vigorously to retain its PBM customers. Dr. Wu explained that CVS's PBM competes on two fronts. First, rival PBMs try to underbid CVS. See Hr'g Tr. at 222:15-224:1 (June 5, 2019 A.M.). Indeed, Dr. Wu concluded, based on a review of bid data, that CVS "lose[s] bids all the time." Id. In fact, it "lost business to more than ten different PBM competitors" in 2017. Resp. to Comments, Ex. TC-003 at 133. Second, CVS's PBM oftentimes competes against its own customers. See Hr'g Tr. at 263:3-264:9 (June 5, 2019 A.M.). After all, health insurance companies can move PBM services in house when and if they consider CVS's price for contract services too high. See id.; Hr'g Tr. at 324:20-326:7 (June 5, 2019 P.M.).
Moreover, PBM customers have ways of ensuring that they receive the best deal the market can offer. Clients, for example, "demand market checks, which means, even if you have a 3-year contract, ... during the contract[,] ... that PBM client will have the right to take the business back out for a market check." Hr'g Tr. at 326:8-22 (June 5, 2019 P.M.). PBM clients also negotiate directly with pharmaceutical manufacturers to confirm that their PBM is providing the lowest available price for the manufacturer's drugs. See id. at 325:2-7.
This evidence combined strongly suggests that, if CVS were to raise its PBM prices, customers like WellCare could simply switch to a less expensive PBM or stop contracting for those PBM services altogether. Were CVS to raise PBM prices in this scenario, it would risk losing PBM market share without disadvantaging WellCare or other competing insurers at all. To say the least, that would be an enormous risk for CVS to take.
Indeed, Dr. Lotvin addressed that very problem when he testified that focusing CVS's business only on its health insurance customers "would be economic suicide." Hr'g Tr. at 328:15-329:3 (June 5, 2019 P.M.). CVS's PBM business covers about 90 million lives. See id. Its pharmacies
As such, the record here did not persuasively establish amici's contention that the proposed final judgment's failure to address the PBM market will likely result in harm to the public interest.
Finally, amici argue that the proposed final judgment will harm certain HIV and AIDS patients. Dr. Michael Wohlfeiler, of the AIDS Healthcare Foundation, testified about the importance of comprehensive, HIV-and-AIDS-specific treatment programs in addressing those conditions. See Hr'g Tr. at 107:9-113:17 (June 4, 2019 P.M.). Success in treating HIV and AIDS can often turn on patients' adherence to complicated medicinal regimens. See id. at 109:4-110:2. Those adherence rates increase when specialists remain in frequent contact with patients. See id. at 110:13-112:10. And even simple procedures, like flu shots, can be fraught with danger when a patient with HIV or AIDS receives treatment from someone who lacks specialized training. See id. at 127:9-24. Dr. Wohlfeiler's testimony demonstrated that, if the proposed final judgment were to cause patients to leave HIV-and-AIDS-specific treatment providers for providers that are unequipped to treat those conditions, the judgment could cause harm.
For the reasons already discussed, however, the record did not establish that the proposed final judgment will likely result in CVS gaining the ability to steer patients away from their current healthcare providers. Indeed, that reasoning applies with even more force to patients receiving healthcare from the AIDS Healthcare Foundation because it embeds its own pharmacies in its clinics and contracts with MedImpact, one of CVS's competitors, for PBM services. See Hr'g Tr. at 103:8-15 (June 4, 2019 P.M.); Hr'g Tr. at 224:9-10 (June 5, 2019 A.M.). Put simply, if the record did not establish that CVS will be likely to steer customers away from WellCare, which relies on CVS for PBM services, it certainly did not establish that CVS will be likely to steer patients away from the AIDS Healthcare Foundation, which uses a different PBM and maintains its own pharmacies. As such, the potential harm to this segment of the public was not
Although amici raised substantial concerns that warranted serious consideration, CVS's and the Government's witnesses, when combined with the existing record, persuasively support why the markets at issue are not only very competitive today, but are likely to remain so post-merger. Consequently, the harms to the public interest the amici raised were not sufficiently established to undermine the Government's conclusion to the contrary.
As such, for all of the above reasons, I have concluded that the proposed settlement is well "within the reaches" of the public interest and the Government's Motion to Enter the Proposed Final Judgment [Dkt. # 57] should therefore be GRANTED. See Microsoft, 56 F.3d at 1460 (In the final analysis, "the court's function is not to determine whether the resulting array of rights and liabilities is the one that will best serve society, but only to confirm that the resulting settlement is within the reaches of the public interest." (quotation marks and citations omitted)). An Order consistent with this decision and an executed version
15 U.S.C. § 16(b).