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Walking the aisles of a CVS drugstore, there are piled paper towels, stacked cereal boxes, and neat lines of nail polish. In the back, there’s the pharmacy.

For years, that approach has remained essentially unchanged despite a creeping reality: Every time a customer hits “Add to Cart” on, the pharmacy chain’s thousands of square feet of retail floor space get a little less valuable. Meanwhile, the money Americans spend on health services keeps growing.

That’s why the back of the store is front and center as CVS Health Corp. gets ready to combine with health insurer Aetna Inc.

The $67.5 billion merger announced Dec. 3 will bring together 9,700 CVS stores and Aetna’s 22 million customers. A central plank of the deal is transforming the stores into health hubs where consumers can get care, pick up their drugs, buy some milk, and stay out of the hospital.

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“Together, we plan to build an entirely new health care concept based on the principles of making care easier to use and more affordable,” CVS Chief Executive Officer Larry Merlo said on a Dec. 4 call with investors.

There are serious challenges to CVS’s proposal. Revamping the stores could cost several billion dollars. The company will have to change how millions of customers see a doctor or nurse. And it will have to fight decades of health care economics and patterns.

Drab But Busy

CVS is already the leader in drugstore-based clinics. At a CVS in Springfield, New Jersey, an unlit MinuteClinic sign in the store’s window is hard to see from the road after dark. The waiting area is four plastic chairs pressed up against the store’s back wall, near greeting cards and nail products. There are exam rooms off a short hall behind.

Despite the drab look, it’s busy. An hour before closing time, three women were waiting for appointments on a recent Tuesday evening. A couple who came in with their school-age daughter turned away after seeing a display on the check-in kiosk next to the pharmacy, which read: “We’ve got a full schedule today.”

While many stores are polished and inviting, revamping others will require significant overhauls, and CVS has said it may redirect some of its $2 billion in annual capital spending to the task. The company is also testing out vision and hearing services in a handful of locations and may eventually offer nutrition services.

The Aetna deal offers little in the way of traditional synergies, and whether it succeeds will depend on managing customers’ health, using in-store clinics and hubs to care for patients in lower-cost settings or stay on top of costly diseases.

As the companies envision it, individuals with a chronic disease like diabetes could get blood tests drawn or see a nutritionist in a store while picking up their medication. If they need it, they could then be guided to see a specialist or told when to return for a follow-up.

Most CVS clinics now are staffed by a single nurse practitioner at a time. Frances Prado, a nurse practitioner who previously worked at MinuteClinics in the Walnut Creek, California, area, said she had to do everything from ordering supplies and cleaning up to dealing with a customer’s insurance information.

Access Gap

Stef Woods made her first trip to a Washington, D.C., MinuteClinic when her four-year-old daughter Roya came down with a cold. Hoping to get a quick test for strep throat, Woods, a lecturer at American University, took Roya to a CVS on a Saturday morning, buying her a drink and a coloring book in the store as they waited.

“CVS is trying to fill a void,” she said. “There’s such a gap in access to care.”

While the clinics are convenient, there’s evidence that may come at a cost for the health care system. According to one study, patients take advantage of the convenience to use more services. Instead of waiting out a cold or the flu, they go see a clinician.

“In contrast to the people who have said retail clinics would reduce health care spending, we’ve seen it increase health care spending,” said Ateev Mehrotra, an associate professor at Harvard Medical School.

The study doesn’t account for the “the long-term benefits of receiving preventive care,” CVS spokeswoman Carolyn Castel said.

Clinic nurses try to coordinate with patients’ doctors when they have them. If patients don’t have a physician relationship, the clinicians try to connect them with one, said Castel.

Drawing Customers

For now, the clinics likely account for less than 1% of CVS’s annual revenue, estimates Adam Fein, president of Pembroke Consulting, which focuses on drug distribution. The clinics also don’t bring in many customers — only about 1% of all drugstore visits are made primarily to visit a clinic, according to research firm Kantar Retail.

CVS, based in Woonsocket, Rhode Island, doesn’t disclose financials for its clinics and declined to comment on the estimates.

Jeff Goldsmith, who runs the health care consulting firm Health Futures Inc., is skeptical of the strategy behind the deal, calling it “flat-out baffling.” He says the MinuteClinics, or what he calls the “nurse in a broom closet” model, lack the clinical acumen or trusting relationships with patients to effectively manage care.

“I don’t see it generating new customers for either the acquirer or the acquiree, or leverage to lower health costs,” he said.

More of the recent growth in “convenient care” has come from standalone urgent-care centers. Those facilities, typically staffed by doctors and serving a wider array of illness and injury, are expanding quickly, as much as 15% a year, according to Tom Charland, founder of industry tracker Merchant Medicine. Some of the biggest are backed by major corporations, such as UnitedHealth Group Inc.’s MedExpress chain.

Slower Growth

In-store clinics are growing more slowly. CVS has 1,100 out of about 2,000 industrywide, according to data from Merchant Medicine.

CVS’s rivals have stayed back, by comparison. Walgreens Boots Alliance Inc. has about 400 in-store clinics, while Rite Aid Corp. has 43 RediClinics in its pharmacies. Wal-Mart Stores Inc. has more than 4,600 pharmacies in its stores, but just 19 clinics. The company says it isn’t planning to add more.

CVS has made deals to transform its business before. In 2007, it acquired prescription benefit manager Caremark. Seven years later, CVS broke ranks with the rest of the drugstore industry and removed tobacco products from its shelves. Today, only 11% of CVS’s sales come from non-pharmacy sources, according to Kantar Retail analyst Brian Owens.

With Inc. threatening every traditional retail business, including CVS, Owens said now’s the time try something new.

“They’re already moving away from a drugstore to a health care company,’’ Owens said. “That means they can take risks that other retailers can’t.’’

—Read CVS Aims to Remake Health Care With Aetna Deal  on ThinkAdvisor.

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Copyright 2017 Bloomberg. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

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