Express Scripts (ESI) is the largest pharmacy benefit manager (PBM) in an industry where scale is a competitive advantage. It has been able to compound earnings, free cash flow, and free cash flow at very high rates (over 20%) over the past ten years. Fundamentally, I believe that Express Scripts’ returns are mostly driven by its CEO, George Paz, who has held the position since 2005. In the past, ESI never had the benefit of scale. Its success was driven by the quality of its management. In the future, ESI will begin to see advantages and disadvantages from its larger size.
On the other hand, the PBM industry has some dubious practices that creates regulatory risk. The PBMs are rarely transparent with their customers and have often taken kickbacks from drug manufacturers. There is a chance that future government intervention will target such practices.
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