Lydia Ramsey

Moderna Therapeutics just started trading, after the biggest initial public offering in biotech history.

The stock slid 5.7 percent to $21.65 in its trading debut on Friday, after pricing at $23 late on Thursday night.

Moderna sold more than 26 million shares late Thursday, <a id="57357b16-b253-3980-ae51-3c9d2d62b0cf" href="https://investors.modernatx.com/news-releases/news-release-details/moderna-announces-pricing-initial-public-offering"> raising $604 million </a> , a biotech record. The company trades under the ticker "MRNA."

Moderna is developing medical treatments based on messenger RNA, and the company is still in the <a id="32e2ebc1-3ad0-3400-a1f4-4e40d3f9717c" href="https://www.modernatx.com/pipeline/clinical-trials"> early days of human trials </a> for its treatments, which include cancer treatments as well as a vaccine for cytomegalovirus, or CMV.

Read more: <a id="495dd34f-2414-3038-aa48-ba82c7ab34b8" href="https://www.businessinsider.com/top-biotech-ipos-of-2018-2018-9?utm_source=intl&amp;utm_medium=ingest"> The market for biotech IPOs is red hot — here are the top 10 of 2018 </a>

It's been a big year for biotech IPOs. In October, the early-stage cancer biotech Allogene became the then-biggest biotech IPO ever. It raised $324 million in an IPO that valued the company at more than <a id="7cfaca2c-2b3a-3478-af67-7f44dffe491f" href="https://www.bloomberg.com/news/articles/2018-10-11/allogene-makes-trading-debut-as-largest-biotech-to-ipo-since-09"> $2 billion. </a>

Excluding Moderna, there have been 56 biotech IPOs that have raised a total $5.5 billion in 2018, according to Renaissance Capital. It's the highest total since 2014, when there were 71 biotech IPOs that raised <a id="807e84f8-faed-31bd-afaa-3c5bd43d5aa0" href="https://www.renaissancecapital.com/review/2015USReview.pdf"> a combined $5.2 billion. </a>

Morgan Stanley,Goldman Sachs and J.P. Morgan were the joint lead bookrunners on the deal.

<ul><li> Read more: </li><li> <a href="https://www.businessinsider.com/biotech-moderna-prices-initial-public-offering-2018-12?utm_source=intl&amp;utm_medium=ingest">Moderna just priced the biggest IPO in biotech history, valuing the startup at $7.5 billion</a> </li><li> <a href="https://www.businessinsider.com/biggest-investors-in-moderna-before-initial-public-offering-2018-11?utm_source=intl&amp;utm_medium=ingest">When Moderna goes public in what might be the biggest IPO in biotech history, it should be very good for these 7 people and investors</a> </li><li> <a href="https://www.businessinsider.com/moderna-president-stephen-hoge-compensation-revealed-in-ipo-filing-2018-11?utm_source=intl&amp;utm_medium=ingest">The president of the company headed for the biggest IPO in biotech history has a surprisingly large pay package</a> </li><li> <a href="https://www.businessinsider.com/bankers-on-healthcare-ipos-and-deals-2018-11?utm_source=intl&amp;utm_medium=ingest">Top healthcare bankers from Morgan Stanley and Bank of America see a slowdown ahead after a record year for deals and IPOs</a> </li></ul>

NOW WATCH: <a id="e93aad8f-1700-302e-a39e-1f2e83114afa" href="https://www.businessinsider.com/harvard-scientists-oumuamua-interstellar-object-alien-spacecraft-solar-sail-2018-11?utm_source=intl&amp;utm_medium=ingest"> Why Harvard scientists think this interstellar object might be an alien spacecraft </a>

<ul><li> <a href="https://www.businessinsider.com/biotech-moderna-prices-initial-public-offering-2018-12?utm_source=intl&amp;utm_medium=ingest">Moderna just priced the biggest IPO in biotech history, valuing the startup at $7.5 billion</a> </li><li> <a href="https://www.businessinsider.com/novartis-ceo-vas-narasimhan-on-ma-and-taking-earlier-risks-on-new-technology-2018-12?utm_source=intl&amp;utm_medium=ingest">The CEO of $230 billion pharma giant Novartis explains why he's not scared of buying biotechs at an earlier — and riskier — stage</a> </li><li> <a href="https://www.businessinsider.com/glaxosmithkline-tesaro-agree-to-51-billion-deal-2018-12?utm_source=intl&amp;utm_medium=ingest">Pharma giant GSK just made a $5.1 billion bet on a cancer-drug maker</a> </li></ul>

Moderna is sliding in its Wall Street debut after the biggest IPO in biotech history

Walgreens is getting deeper into the prescription-delivery wars.

On Thursday, the pharmacy giant said it partnered with FedEx to do national, next-day prescription delivery. At the start, the service will be available at 7,100 of Walgreens' 9,560 pharmacies. Same-day delivery is available in Dallas, Chicago, New York City, Gainesville, Miami, Tampa, and Fort Lauderdale.

Walgreens is up against stiff competition for customers, facing off against <a id="7b77e37f-f0a3-3d9f-a806-7aa33c73b385" href="https://www.businessinsider.com/amazons-plan-to-get-into-prescription-drug-pharmacy-industry-2018-6?utm_source=intl&amp;utm_medium=ingest"> Amazon, </a> which is getting into the pharmacy business through its <a id="6f40b398-7661-3316-ab18-809db185497b" href="https://www.businessinsider.com/how-to-use-pillpack-amazon-pharmacy-service-2018-7?utm_source=intl&amp;utm_medium=ingest"> acquisition of the online pharmacy PillPack </a> ; <a id="4bed56ed-a72a-32fc-a4f1-957c2acf3fd8" href="https://www.businessinsider.com/cvs-health-offers-prescription-delivery-2018-6?utm_source=intl&amp;utm_medium=ingest"> CVS Health </a> , which is making a big bet on the healthcare aspect of its business through the acquisition of the insurer Aetna; and of course the retail giant <a id="d4d70302-dd5c-3c37-a99e-18fd1126b8f1" href="https://www.businessinsider.com/walmart-medicare-ambitions-2018-4?utm_source=intl&amp;utm_medium=ingest"> Walmart </a> . Next-day delivery will cost customers $4.99. A Walgreens spokesman said same-day delivery fees will vary, but will be priced competitively. In the past, Walgreens has offered delivery, though typically not as quickly. It's also had a relationship with FedEx in which Walgreens set up counters in its stores where customers can drop off and pick up packages.

Customers who opt into getting texts from Walgreens will get an alert when a prescription is ready, and then can decide to have it delivered instead of coming into the store.

Read more: Take a look inside Walgreens' futuristic store where it's plotting new ways to take on Amazon and CVS

CVS Health is taking a similar approach. In June, CVS said it would offer next-day delivery, with pharmacies in some cities like New York and San Francisco providing a same-day delivery service. One-to-two day service, <a id="75f163cf-9605-38db-aae3-325c98605bcd" href="https://www.businessinsider.com/cvs-health-offers-prescription-delivery-2018-6/?utm_source=intl&amp;utm_medium=ingest"> CVS said </a> , would cost $4.99, while same-day costs $8.99.

The move came right before Amazon <a id="78774a2d-56fc-37ee-af1a-3d82d11a461e" href="https://www.businessinsider.com/how-to-use-pillpack-amazon-pharmacy-service-2018-7?utm_source=intl&amp;utm_medium=ingest"> acquired PillPack </a> . PillPack <a id="59de4560-2461-33e5-a688-edcf26b0c658" href="https://www.businessinsider.com/how-to-use-pillpack-amazon-pharmacy-service-2018-7?utm_source=intl&amp;utm_medium=ingest"> mails prescriptions that are packaged together based </a> on when they need to be taken, putting it in a good spot to handle prescriptions for elderly people who tend to have more prescriptions.

<ul><li> Read more: </li><li> <a href="https://www.businessinsider.com/alto-pharmacy-raises-50-million-2018-12?utm_source=intl&amp;utm_medium=ingest">A startup that could be Amazon's next takeover target just raised $50 million to help people manage their prescriptions</a> </li><li> <a href="https://www.businessinsider.com/how-independent-pharmacists-survive-against-amazon-cvs-2018-11?utm_source=intl&amp;utm_medium=ingest">Amazon is threatening the future of independent pharmacies. Here's how they're fighting back.</a> </li><li> <a href="https://www.businessinsider.com/why-high-deductible-health-insurance-plans-dont-work-2018-11?utm_source=intl&amp;utm_medium=ingest">A top healthcare executive pointed out what's broken about America's health-insurance system in a single sentence</a> </li><li> <a href="https://www.businessinsider.com/walgreens-humana-may-takes-stakes-partnership-2018-11?utm_source=intl&amp;utm_medium=ingest">Walgreens is reportedly looking to strengthen its relationship with one of the largest players in a lucrative part of healthcare</a> </li></ul>

NOW WATCH: <a id="bfb8c50b-e4ea-39af-a0ed-753c50c070b0" href="https://www.businessinsider.com/how-far-sneeze-cough-germs-can-travel-2018-10?utm_source=intl&amp;utm_medium=ingest"> This animation will make you think twice before going to work sick </a>

<ul><li> <a href="https://www.businessinsider.com/alto-pharmacy-raises-50-million-2018-12?utm_source=intl&amp;utm_medium=ingest">A startup that could be Amazon's next takeover target just raised $50 million to help people manage their prescriptions</a> </li><li> <a href="https://www.businessinsider.com/how-independent-pharmacists-survive-against-amazon-cvs-2018-11?utm_source=intl&amp;utm_medium=ingest">Amazon is threatening the future of independent pharmacies. Here's how they're fighting back.</a> </li><li> <a href="https://www.businessinsider.com/why-high-deductible-health-insurance-plans-dont-work-2018-11?utm_source=intl&amp;utm_medium=ingest">A top healthcare executive pointed out what's broken about America's health-insurance system in a single sentence</a> </li></ul>

Walgreens CEO Stefano Pessina at the 2018 Forbes Healthcare Summit

Walgreens is teaming up with FedEx to defend its turf from Amazon and CVS (WBA)

The Food and Drug Administration on Monday took an unconventional approach to approving a new cancer drug.

The drug, Vitrakvi, was developed by Loxo Oncology. It's the company's first drug to get approved.

Loxo's approach is to develop drugs that act on cancerous genetic mutations rather than the type of cancer a person has. For example, Vitrakvi, has been <a id="69d410e1-0914-36aa-acc5-846080bc0f78" href="https://ir.loxooncology.com/press-releases/2372560-Loxo-oncology-announces-larotrectinib-clinical-update-in-patients-with-trk-fusion-cancers-at-the-european-society-for-medical-oncology-2018-congress"> tested in patients </a> with lung, colon, breast and thyroid cancer among others.

The drug comes with a high price tag of $393,000 a year. Bayer said in a statement that there's between 2,500 and 3,000new patients with this mutation a year. The company set a lower price of $132,000 a year for the liquid form used in pediatric cases. Bayer said it will offer financial assistance to help patients afford the drug, reducing the out-of-pocket cost to $20 a month for most patients.

"Today’s approval marks another step in an important shift toward treating cancers based on their tumor genetics rather than their site of origin in the body," FDA Commissioner Scott Gottlieb said in a news release Monday.

In 2017, the drugmaker struck a <a id="1a1b6e61-6815-3b98-afb4-ebebabafaaa0" href="https://www.businessinsider.com/loxo-oncology-partnership-with-bayer-for-genetic-cancer-drugs-2017-11?utm_source=intl&amp;utm_medium=ingest"> $1.5 billion deal </a> with pharma giant Bayer to commercialize and develop two of Loxo's drugs, including Vitrakvi.

<h1> Targeting a genetic mutation instead of cancer type </h1>

Building a treatment that's specific to a genetic mutation is a new approach to treating cancer. Most companies develop treatments for specific types of cancer, like lung cancer or melanoma, and seek approval just for that one kind of tumor at first, before setting up more trials to see how the drug does in other types of cancer.

Scientists have <a id="a022c382-8367-392b-a30e-839bfeb400a4" href="https://cancergenome.nih.gov/"> seen genetic patterns across cancer types </a> for years, but the topic started attracting more attention in 2013 after <a id="05a2804f-fa87-33c3-ab1b-405ef17be4c6" href="https://www.nytimes.com/2013/05/02/health/dna-research-points-to-new-insight-into-cancers.html?_r=1"> the discovery </a> that endometrial cancer was genetically similar to forms of ovarian and breast cancer.

In May 2017, <a id="8d002fe2-8514-32e4-abce-d79b0037e2ab" href="https://www.businessinsider.com/fda-approves-cancer-drug-based-on-genetic-markers-2017-5?utm_source=intl&amp;utm_medium=ingest"> the FDA approved a drug </a> based on genetics rather than tissue type for the first time, paving the way for others including Loxo.

Loxo's drug works in cancer patients with a mutation called a "TRK gene fusion."

The company had <a id="69b670e4-cc76-32b5-aba4-a42e65d81b4c" href="https://www.businessinsider.com/r-loxos-targeted-drug-helps-variety-of-advanced-cancers-in-small-study-2017-6?utm_source=intl&amp;utm_medium=ingest"> seen promising results </a> in its human trials. In a recent presentation at the European Society for Medical Oncology, Loxo said that out of 109 patients, 81% had an overall response rate, meaning their tumors shrank. In 17% of the cases, the patients had a complete response, meaning their tumors went away entirely.

NOW WATCH: <a id="d69e90ab-a12d-3e2e-a514-4eec2c76dcd2" href="https://www.businessinsider.com/right-way-blow-nose-blowing-wrong-2017-11?utm_source=intl&amp;utm_medium=ingest"> You've been blowing your nose all wrong — here's how you should do it </a>

<ul><li> <a href="https://www.businessinsider.com/is-it-safe-to-eat-romaine-lettuce-2018-4?utm_source=intl&amp;utm_medium=ingest">An E. coli outbreak from romaine lettuce has sickened 65 people — here's how to avoid getting sick</a> </li><li> <a href="https://www.businessinsider.com/facebook-google-portable-mini-mri-see-inside-body-brain-animal-testing-openwater-2018-11?utm_source=intl&amp;utm_medium=ingest">A superstar ex-Facebook and Google exec is trying to upend a $24 billion industry with devices that spot disease sooner — and she's already testing it on animals</a> </li><li> <a href="https://www.businessinsider.com/how-long-you-can-go-without-sleep-2018-11?utm_source=intl&amp;utm_medium=ingest">Sleep deprivation can be dangerous — here's how long you can hold off sleep without life-or-death consequences</a> </li></ul>

The FDA just approved a drug that targets cancers based on DNA, rather than where the tumor is in your body

Loneliness has reached epidemic levels in the US.

In May, <a href="https://www.businessinsider.com/cigna-loneliness-study-americans-millennials-lonely-2018-5?utm_source=intl&amp;utm_medium=ingest" id="3992be6b-7e7b-3758-a4b0-8c0954764b4c"> health insurance company Cigna published results </a> from a survey that found most American adults are considered lonely. Younger people, like millennials and Generation Z, are the loneliest.

The company used a questionnaire based on the UCLA Loneliness Scale, which is the <a href="https://public.psych.iastate.edu/ccutrona/uclalone.htm" id="d6a365e3-0ce0-30ce-a74b-55fed4039975"> measure most widely used by researchers </a> .

To help the rest of us get a sense of how lonely we might be, Cigna on Wednesday released a <a href="https://app.snapapp.com/LonelinessSurvey" id="666133c4-f6a8-3e86-ab66-73b3fac6e7e3"> 10-question version </a> of the questionnaire used for the UCLA Loneliness Scale in partnership with Dr. Daniel Russell, who created the initial scale.

Being lonely can have a big impact on your health, from <a href="http://www.sciencedirect.com/science/article/pii/S0277953612000275" id="671e3491-3709-3115-a62e-beae4a9b1046"> disrupting sleep </a> and increasing <a href="https://static1.squarespace.com/static/531897cde4b0fa5080a9b19e/t/555601d9e4b0849a888ed857/1431699929973/toward-a-neurology-of-loneliness.pdf" id="e2323d50-40f9-3c57-a656-b93e2b8f6363"> stress </a> , to weakening a <a href="https://www.washingtonpost.com/national/health-science/loneliness-grows-from-individual-ache-to-public-health-hazard/2016/01/31/cf246c56-ba20-11e5-99f3-184bc379b12d_story.html" id="4c88cca5-27e4-3aea-a103-bc30ba94ed31"> person's immune system </a> . It's also <a href="http://psychology.oxfordre.com/view/10.1093/acrefore/9780190236557.001.0001/acrefore-9780190236557-e-122" id="4d5682c4-6a2a-3f31-a1d4-6ba32eb63a76"> associated with </a> cognitive decline, heart disease, and greater frailty later on in life. And recent research has found that it has such a significant effect on mortality rates that <a href="https://www.businessinsider.com/loneliness-greater-public-health-hazard-than-obesity-2017-8?utm_source=intl&amp;utm_medium=ingest" id="4333bcff-54ed-3975-aa33-db431675b97a"> loneliness could be considered a public health threat </a> that's more harmful than obesity and about as <a href="http://journals.sagepub.com/doi/abs/10.1177/1745691614568352" id="ec376944-9337-370a-a3d0-dc993dc0a216"> bad as smoking </a> .

Read more: <a href="https://www.businessinsider.com/cigna-loneliness-study-americans-millennials-lonely-2018-5?utm_source=intl&amp;utm_medium=ingest" id="1bc5df52-4ceb-3bf0-a70e-43e4b30c7776"> Loneliness may be a greater public health hazard than obesity — and experts say it has hit epidemic levels in the US </a>

"Loneliness is a normal feeling," Dr. Doug Nemecek, chief medical officer of behavioral health at Cigna told Business Insider. Everybody will feel lonely at some point in their lives. The key is to figure out who might be chronically lonely, which is what can have a negative impact on people's health, he said.

The test runs though questions such as "How often do you feel isolated from others?" and "How often do you feel that you have a lot in common with the people around you?" with options to answer "never," "rarely," "sometimes," or "always."

Starting in February, Cigna along with research firm Ipsos surveyed 20,000 US adults aged 18 or older to assess the state of loneliness using the UCLA questionnaire.

Possible loneliness scores ranged from 20 to 80 in the scale, with anything above 43 qualifying as "lonely." The average score was a 44, making most Americans qualify as lonely.

Just under half of respondents reported sometimes or always feeling alone or left out. About 27% of Americans said they feel that people rarely or never understand them. One-fifth of respondents said they rarely or never feel close to people, and just under half said they didn't have meaningful relationships or felt isolated.

Young people in particular reported high rates of loneliness, with rates gradually decreasing with age.

Kevin Loria <a href="https://www.businessinsider.com/cigna-loneliness-study-americans-millennials-lonely-2018-5?utm_source=intl&amp;utm_medium=ingest" id="bcd86aa4-6f29-311f-a6ad-83ca9f12c46a"> contributed </a> reporting.

NOW WATCH: <a href="https://www.businessinsider.com/right-way-blow-nose-blowing-wrong-2017-11?utm_source=intl&amp;utm_medium=ingest" id="d69e90ab-a12d-3e2e-a514-4eec2c76dcd2"> You've been blowing your nose all wrong — here's how you should do it </a>

<ul><li> <a href="https://www.businessinsider.com/fda-approves-loxo-oncologys-larotrectinib-vitrakvi-2018-11?utm_source=intl&amp;utm_medium=ingest">The FDA just approved a drug that targets cancers based on DNA, rather than where the tumor is in your body</a> </li><li> <a href="https://www.businessinsider.com/ketamine-for-depression-medical-centers-where-get-infusions-2018-11?utm_source=intl&amp;utm_medium=ingest">A 'party drug' with potential to be the next blockbuster antidepressant is edging closer to the mainstream, but it could set you back $9,000</a> </li><li> <a href="https://www.businessinsider.com/why-high-deductible-health-insurance-plans-dont-work-2018-11?utm_source=intl&amp;utm_medium=ingest">A top healthcare executive pointed out what's broken about America's health-insurance system in a single sentence</a> </li></ul>

SEE ALSO: The man who predicted that Amazon would buy Whole Foods now expects the tech giant will soon be the world's fastest-growing healthcare company

DON'T MISS: Amazon is threatening the future of independent pharmacies. Here's how they're fighting back.

Being lonely can be as bad for you as smoking. Now you can take a quiz to find out if you're at risk.

It was only a matter of time before tech giants got interested in health because the industry is massive and ripe for disruption.

At Business Insider's <a id="b966db22-2ca6-3941-ad55-399cd0993276" href="https://www.businessinsider.com/category/ignition-2018?utm_source=intl&amp;utm_medium=ingest"> IGNITION 2018 </a> conference, New York University marketing professor Scott Galloway laid out which of the four tech giants — Facebook, Google, Apple, or Amazon — will do the best in healthcare.

At the top of his list is Amazon, which he said will soon be the "fastest-growing healthcare company in the world."

Galloway has been known for his predictions when it comes to Amazon, <a id="4505c93b-4f4f-3583-a5ba-8b32ad43efd9" href="https://www.businessinsider.com/amazon-hq2-will-be-new-york-or-dc-scott-galloway-predicts-2018-2?utm_source=intl&amp;utm_medium=ingest"> first predicting it would acquire Whole Foods and more recently correctly calling which cities Amazon would pick as its headquarters, </a> which gives his analysis here some clout.

For Facebook, the answer was clear.

"No one's going to tell Facebook about their diabetes or STDs," Galloway said.

Google, for its part, is looking at more moonshots, Galloway said. Alphabet, Google's parent company, has a number of bets in healthcare, ranging from Verily, its life-sciences arm that's developing everything from glucose-monitoring contact lenses to surgical robots, to Calico, its <a id="82443aea-6997-3af3-a4e3-76c637ee16d5" href="https://www.businessinsider.com/ancestry-google-release-first-genealogy-study-longevity-aging-genetics-2018-11?utm_source=intl&amp;utm_medium=ingest"> life-extension spinoff. </a>

Galloway said he'd expect most people to choose Apple, but he said he'd place it as second.

"I think we over-inflate the value of wearables," Galloway said, adding that the only true wearable is your phone.

But it's Amazon that has a good shot at taking on healthcare, in Galloway's opinion. Unlike Apple, Amazon investors are more comfortable with investments that are capital intensive in the short term, like healthcare.

"Amazon knows how healthy you are," Galloway said.

The company has data on your eating habits, as well as on your relationship status and whether you have kids, all of which can be used to determine your health.

Read more : <a id="df8779be-db25-357f-a40e-f67f2debd902" href="https://www.businessinsider.com/how-to-use-pillpack-amazon-pharmacy-service-2018-7?utm_source=intl&amp;utm_medium=ingest"> We tried PillPack, the pharmacy startup Amazon acquired for $1 billion, and we can see why it has big pharmacies terrified </a>

Galloway said Amazon's also good at determining which businesses to get into and which to outsource.

"This is the perfect fulcrum for an entry into healthcare, to decide which businesses you want to be in, which you don't, and they'll have the best dataset on not only two-thirds of households which now have Prime, but also on the healthiest households," Galloway said.

Amazon for its part <a id="c7205508-0876-3686-a2f7-c59bd186d9f4" href="https://www.businessinsider.com/how-to-use-pillpack-amazon-pharmacy-service-2018-7?utm_source=intl&amp;utm_medium=ingest"> acquired online pharmacy PillPack </a> this year and is working with JPMorgan and Berkshire Hathaway on a <a id="df830f2d-1b0b-3e13-aef9-4293b7cde5c9" href="https://www.businessinsider.com/amazon-jpmorgan-and-berkshire-hathaway-health-joint-venture-ceo-pick-2018-6?utm_source=intl&amp;utm_medium=ingest"> joint healthcare venture </a> aimed at lowering healthcare costs for the companies' employees.

See who's speaking now — check out the livestream of Business Insider's IGNITION 2018:

NOW WATCH: <a id="e10fec68-7f34-3a3e-a169-57f2d6a31371" href="https://www.businessinsider.com/cancer-13-year-old-teen-invented-treatment-award-pancreatic-2018-10?utm_source=intl&amp;utm_medium=ingest"> This 13-year-old scientist invented a safer way to treat pancreatic cancer, and he hasn't even started high school yet </a>

<ul><li> <a href="https://www.businessinsider.com/ketamine-for-depression-medical-centers-where-get-infusions-2018-11?utm_source=intl&amp;utm_medium=ingest">A 'party drug' with potential to be the next blockbuster antidepressant is edging closer to the mainstream, but it could set you back $9,000</a> </li><li> <a href="https://www.businessinsider.com/why-high-deductible-health-insurance-plans-dont-work-2018-11?utm_source=intl&amp;utm_medium=ingest">A top healthcare executive pointed out what's broken about America's health-insurance system in a single sentence</a> </li><li> <a href="https://www.businessinsider.com/cvs-health-and-aetna-will-close-69-billion-merger-2018-11?utm_source=intl&amp;utm_medium=ingest">CVS officially completed its $70 billion deal with Aetna almost a year after it was announced, creating a new kind of healthcare company</a> </li></ul>

The man who predicted that Amazon would buy Whole Foods now expects the tech giant will soon be the world's fastest-growing healthcare company

Mitchell Brin has a license plate that says "Botox."

Brin's been researching Botox since 1984 and is currently the chief scientific officer of Botox at the drug company Allergan. It's one of many Botox-related license plates he owns, including some more scientific nods like one that says "Snap-25." That's a reference to a protein affected by botulinum toxin A,leading to smoother foreheads when used in the right doses.

"Botox is a big component of my life," Brin told Business Insider.

Brin is one of the scientists who saw Botox through from its early days as a potential treatment for muscle disorders to what it is today — a blockbuster pharmaceutical drug best known for cosmetic uses like smoothing out wrinkles on patients' faces.

Here's <a id="17d68f21-0184-3d7f-a1ba-36eb87b1b2fc" href="https://read.bi/2O0k97t"> the story </a> of how a poisonous toxin became a blockbuster treatment for everything from wrinkles to migraines.

<h1> Researchers had been looking into whether botulinum toxin, a neurotoxin that works by paralyzing parts of the body, could be used as a treatment for muscle-related conditions starting around the 1970s. </h1>

<h1> Yes, its a toxin — the deadliest on Earth even. Botulinum toxin is a byproduct of the bacteria clostridium botulinum, the same one implicated in canned food gone bad. </h1>

Source: <a id="72a55b42-221e-3605-add2-d79272698dfe" href="https://theconversation.com/handle-with-care-the-worlds-five-deadliest-poisons-56089"> The Conversation </a>

<h1> In the 1980s, Vancouver-based ophthalmologist Jean Carruthers was treating people with a tight eyelid condition with Botox injections when one patient got angry with her. She wanted to know why Carruthers hadnt given her an injection near her inner brow. Carruthers explained it was because she wasnt spasming there, but the patient was insistent. "Every time you treat me there, I get this beautiful, untroubled expression," she told Carruthers. </h1>

<h1> Carruthers took the information from that visit home with her to her husband, Alistair, who worked in dermatology. She told him she might have a solution for his patients who were struggling with their frown lines. He was skeptical, but curious to see it at work. The next day, they tested it out on their receptionist. </h1>

<h1> Jean was next to try it. The result? "Jean hasnt frowned since 1987," Alistair told Business Insider. </h1>

Courtesy Jean and Alistair Carruthers

<h1> Over the next decade, the Carruthers went on to research and publish on the cosmetic use of Botox. Botox grew so popular that at one point in 1997, the US had run out of its supply, inciting panic for those who used the treatment monthly to reduce wrinkles. </h1>

Source: <a id="bac90f7a-7d3d-355b-a45f-26ba9d98aa7e" href="http://www.nytimes.com/1997/12/14/style/pulse-drought-over-botox-is-back.html"> The New York Times </a>

<h1> On the other side of North America, Brin was finding the same results in the patients he was treating for an involuntary muscle contraction condition. After more than a decade of researching the use of Botox at Columbia University and Mount Sinai, he joined Allergan in 2001. </h1>

<h1> Botox didnt immediately catch on within Allergan, the company that owned the drug. That started to change when David Pyott became CEO in 1998. </h1>

<h1> It took until 2002 for cosmetic Botox to officially get the FDAs stamp of approval. Since then, its become a blockbuster drug for Allergan. In 2017 alone, the drug made $2.2 billion in revenue for both its cosmetic uses and medical uses. </h1>

<h1> Today, its used to treat everything from crows feet to migraines to overactive bladder. Its currently being studied in the treatment of depression. </h1>

Source: <a id="e73c3519-e976-3ddd-a381-d08ab1492e54" href="https://www.allergan.com/News/News/Thomson-Reuters/Allergan-Reports-Topline-Phase-II-Data-Supporting"> Allergan </a>

<h1> Facing competition, Allergans plan to stay ahead and grow the Botox market is to make getting the treatment as common as getting your eyebrows waxed or your hair dyed a vibrant hue. The plan also relies on the millennial generation taking up medical aesthetics regimens, leading Allergan to launch a campaign that asks the question, "Are you bo-curious?" </h1>

Source: <a id="3a27b10e-1f8d-3aa5-a89b-d194296b8f40" href="https://www.businessinsider.com/allergan-ad-campaigns-targeting-millennials-2018-9?utm_source=intl&amp;utm_medium=ingest"> Business Insider </a>

<h1> To hear more about how Botox became a go-to way to change expressions and appearances,listen to "Household Name,"a new podcast from Business Insider. Subscribe for free on Apple Podcasts, Stitcher, or your favorite podcast app. </h1>

<a id="1b4d21ce-e750-3259-a6bc-1680622fa1c2" href="https://read.bi/2O0k97t"> Subscribe here. </a>

<ul><li> <a href="https://www.businessinsider.com/how-independent-pharmacists-survive-against-amazon-cvs-2018-11?utm_source=intl&amp;utm_medium=ingest">Amazon is threatening the future of independent pharmacies. Here's how they're fighting back.</a> </li><li> <a href="https://www.businessinsider.com/microbiome-gut-bacteria-test-forgotten-organ-future-medicine-ubiome-photos-2018-11?utm_source=intl&amp;utm_medium=ingest">I tried a test that let me peek inside my microbiome, the 'forgotten organ' that scientists say is the future of medicine — and what I learned shocked me</a> </li><li> <a href="https://www.businessinsider.com/cvs-health-and-aetna-will-close-69-billion-merger-2018-11?utm_source=intl&amp;utm_medium=ingest">CVS officially completed its $70 billion deal with Aetna almost a year after it was announced, creating a new kind of healthcare company</a> </li></ul>

SUBSCRIBE TO: Business Insider's "Household Name" podcast

Botox is made from the deadliest toxin on earth. Then we started injecting it in our faces.

<a id="047dc48b-724f-35a6-a709-b3a78742a1b6" href="https://markets.businessinsider.com/stocks/gsk-stock?utm_source=intl&amp;utm_medium=ingest"> GlaxoSmithKline </a> is getting deeper into cancer drug development.

On Monday, the UK-based pharma giant said it had agreed to acquire Tesaro, a cancer drugmaker with a treatment for ovarian cancer, for $5.1 billion.

<a id="99b0307c-b1c6-35c2-a305-d141c62d5f44" href="https://markets.businessinsider.com/stocks/tsro-stock?utm_source=intl&amp;utm_medium=ingest"> Tesaro </a> was up 60% on the news before markets opened Monday while <a id="a271b7fc-39df-329b-a219-7f6acb48da66" href="https://markets.businessinsider.com/stocks/gsk-stock?utm_source=intl&amp;utm_medium=ingest"> GSK </a> was down 6%.

GSK has been working to refresh its research-and-development strategy. In 2017, GSK brought on Hal Barron, a former Genentech and Calico executive, as its chief scientific officer and president of R&amp;D.

As part of that, the company made a <a id="a431da0c-dd1d-3ffd-a742-d97acf891c5c" href="https://www.businessinsider.com/why-gsk-invested-300-million-in-23andme-genetic-drug-discovery-collaboration-2018-7?utm_source=intl&amp;utm_medium=ingest"> $300 million investment in the consumer-genetics company 23andme </a> . GSK also <a id="c6566551-ad74-39b6-a0d0-17fbb58331f6" href="https://www.businessinsider.com/why-gsk-invested-300-million-in-23andme-genetic-drug-discovery-collaboration-2018-7?utm_source=intl&amp;utm_medium=ingest"> said in July </a> that it planned to focus its research efforts on developing new treatments that act on the body's immune system.

Read more: <a id="340d97dc-4896-305e-a4d7-17b06f33b0ac" href="https://www.businessinsider.com/why-gsk-invested-300-million-in-23andme-genetic-drug-discovery-collaboration-2018-7?utm_source=intl&amp;utm_medium=ingest"> Why pharma giant GSK just made a $300 million bet on 23andMe's approach to finding new medicines </a>

"Our strong belief is that PARP inhibitors are important medicines that have been under appreciated in terms of the impact they can have on cancer patients," Barron said said in a press release. "We are optimistic that Zejula will demonstrate benefit in patients with ovarian cancer beyond those who are BRCA-positive as front-line treatment."

Tesaro makes a cancer drug called Zejula, which is used to treat ovarian cancer.

Zejula is a pill that's taken once a day, and it's part of a group of cancer drugs called PARP inhibitors. Essentially, they block a particular enzyme that's used by our cells to <a id="a91d6009-d235-33a1-a828-e14c40e96a12" href="https://www.facingourrisk.org/research-clinical-trials/research-findings/parp-inhibitors.php"> repair DNA </a> . In certain kinds of cancer that repair system is broken, allowing cancer cells to thrive, so <a id="38a9af08-d572-3cba-a12b-1e04d63031fe" href="https://www.dana-farber.org/Newsroom/Publications/PARP-inhibitors-on-trial.aspx"> blocking it is critical </a> .

Zejula isn't the only PARP inhibitor out there: Pfizer <a id="f0ebcdbc-89bd-30ea-ac07-c8d0c6b5c705" href="https://www.businessinsider.com/medivation-talks-up-its-experimental-cancer-drug-2016-7?utm_source=intl&amp;utm_medium=ingest"> acquired one </a> in its deal for Medivation, Clovis Oncology makes Rubraca, and AstraZeneca has Lynparza

<a id="a41f671c-c9e4-3bd5-aeb6-564fa99aefdb" href="https://www.businessinsider.com/goldman-analyst-jami-rubin-joins-pjt-partners-2018-11?utm_source=intl&amp;utm_medium=ingest"> PJT Partners </a> and Bank of America Merrill Lynch advised GSK, while Citi and Centerview advised Tesaro on the deal.

NOW WATCH: <a id="87791aa9-bbf6-3d79-a829-4c0165ceb686" href="https://www.businessinsider.com/time-lapse-videos-satellite-images-china-infrastructure-change-2017-7?utm_source=intl&amp;utm_medium=ingest"> Beautiful time-lapse videos show how much China has changed over the years </a>

<ul><li> <a href="https://www.businessinsider.com/fda-approves-loxo-oncologys-larotrectinib-vitrakvi-2018-11?utm_source=intl&amp;utm_medium=ingest">The FDA just approved a drug that targets cancers based on DNA, rather than where the tumor is in your body</a> </li><li> <a href="https://www.businessinsider.com/bankers-on-healthcare-ipos-and-deals-2018-11?utm_source=intl&amp;utm_medium=ingest">Top healthcare bankers from Morgan Stanley and Bank of America see a slowdown ahead after a record year for deals and IPOs</a> </li><li> <a href="https://www.businessinsider.com/ap-ap-exclusive-first-gene-edited-babies-claimed-in-china-2018-11?utm_source=intl&amp;utm_medium=ingest">A Chinese scientist claims he used a controversial gene-editing tool to alter the embryos of twin girls that were just born</a> </li></ul>

Pharma giant GSK just made a $5.1 billion bet on a cancer drugmaker (GSK, TSRO)

Roger Paganelli's business in the Bronx is bustling.

Mt. Carmel Pharmacy stands at the corner of Beaumont Avenue and 187th Street, near the Bronx Zoo and Fordham University.

On a rainy Tuesday morning, shoppers are running errands, and employees, speaking Spanish and English, are helping patients pick up their prescriptions at the counter.

Behind the counter the operation is just as busy.

"It's controlled," Paganelli said. "I wouldn't even call it controlled chaos. I'd just call it controlled."

Orders are going out on delivery to other areas in the Bronx, to Fordham's campus, and even beyond New York City, into Westchester. All in, there are 40 employees working in close quarters.

Paganelli, a third-generation pharmacy owner, would like to keep things busy. But plenty of outside forces — retail behemoths such as Amazon and health giants like <a id="0b779834-94d3-3ab2-a60d-2c2743b6e369" href="https://www.businessinsider.com/cvs-aetna-cigna-express-scripts-deals-pass-doj-2018-10?utm_source=intl&amp;utm_medium=ingest"> CVS </a> , among others — are putting pressure on independent pharmacies. Amazon and CVS are two of the top 10 companies in the Fortune 500 list.

It's not just that consumers can buy paper towels, toilet paper, and milk online now. Healthcare, too, is going digital, with <a id="3d4d7059-8c14-33e1-a922-f27229a84647" href="https://www.businessinsider.com/how-to-use-pillpack-amazon-pharmacy-service-2018-7?utm_source=intl&amp;utm_medium=ingest"> Amazon acquiring an online pharmacy </a> that can send pills straight to your door.

Meanwhile, middlemen known as pharmacy benefit managers, or PBMs, are gaining leverage by teaming up with health insurers, which threatens to put even more pressure on payments to independent pharmacies.

CVS, the largest pharmacy chain in the US and also a PBM, agreed to acquire <a id="5a2447c8-7a22-332a-a290-164456a24ec9" href="https://www.businessinsider.com/cvs-health-buys-aetna-2017-10?utm_source=intl&amp;utm_medium=ingest"> health insurer Aetna </a> in a $69 billion deal, while health insurer <a id="8200a9e5-c50a-38e7-a9fd-1410321f229c" href="https://www.businessinsider.com/cignas-67-billion-express-scripts-acquisition-changes-pharma-industry-2018-3?utm_source=intl&amp;utm_medium=ingest"> Cigna is buying the pharmacy benefit manager Express Scripts for $67 billion </a> .

<h1> Getting paid for more than just dispensing pills </h1>

Business Insider spoke with more than a dozen independent pharmacists about the challenges their businesses are facing. Pharmacists, including Paganelli, say they're getting paid less and less for the prescriptions they're dispensing, while losing customers to mail-order systems they say their patients feel pressured to join.

To survive, pharmacists are getting creative, looking to get paid for providing healthcare to their customers, rather than solely for the pills they dispense.

Paganelli, for instance, is working to get health plans to pay him to help care for their patients.

He's already helping to strike a similar deal in Brooklyn, as part of his work with a group called the Community Pharmacy Enhanced Services Network.

Under that arrangement, independent pharmacists will help make sure that patients leaving the hospital are getting the right doses of their medications, and ensure that their medical support outside the hospital is looped in.

In the Brooklyn deal, the hospital is paying the pharmacists. The hope is to do more such deals around the city, and eventually at his own pharmacy.

He already does a lot of work to keep his patients healthy that he doesn't get paid for.

Mt. Carmel follows up with patients if they haven't come in for a refill. It has employees on the phone all day working to help patients sync up their prescriptions, so that instead of coming in for refills a few times a month, they might have to come in only once or twice.

That also helps the pharmacy get a better picture on the medications they've stopped taking or switched off of.

All of the work is integral to keeping the lights on at the pharmacy.

Still, thanks in part to competition from massive retail chains and prescriptions directed through mail services rather than getting picked up in person, the number of independent pharmacies is declining.

According to the National Community Pharmacists Association, there were <a id="ab5c474d-bc04-3b30-a197-ed6f9c8c4225" href="https://www.cardinalhealth.com/en/essential-insights/the-state-of-community-pharmacy-from-the-2017-ncpa-digest.html"> 22,041 independent </a> pharmacies like Paganelli’s around the US in 2016, down about 1,000 since 2011.

Randy McDonough who runs Towncrest Pharmacy, in Iowa City, Iowa, isn't a stranger to competition from retail pharmacies. The store sits across from a CVS and around the corner from a Walgreen's. There's a grocery store with a pharmacy inside just across the parking lot too.

"Someone asked me once, 'Aren't you concerned it's awfully crowded?' And I said, 'Well, it must be a good location for pharmacy," McDonough told Business Insider.

The truth of the matter is that being forced to compete with the likes of CVS and Walgreens has given McDonough a head start on preparing for the changes shaking up pharmacies, particularly small independent shops like his own.

McDonough was a professor of pharmacy at the University of Iowa until 2005. Just four days after getting tenure, he left to start Towncrest, and put into practice the ideas he was teaching.

McDonough worked to renovate the pharmacy, automating in areas he could, and synchronizing prescriptions so that patients wouldn't have to come in as often. He delegated work to technicians so that he could focus on taking care of the patients who came in for prescriptions.

But in 2013 he faced a big problem. The largest insurer in the state, Wellmark Blue Cross Blue Shield, lowered its reimbursement rates for prescription drugs by 50%. The pharmacy lost <a id="b69ea4e7-9642-37e6-a8ae-a36c42f9a578" href="https://join.healthmart.com/clinical-performance/create-new-revenue-streams/"> thousands </a> on the prescriptions it was filling. Briefly, McDonough considered finding a new job.

Instead, he wrote a letter to the CEO of <a id="6c8a2063-5ad5-326b-a42f-c99485e7268e" href="https://join.healthmart.com/clinical-performance/create-new-revenue-streams/"> Wellmark </a> , arguing that the insurer needs to treat community pharmacies differently. When that CEO looked into Towncrest Pharmacy, he noticed that was the pharmacy was treating a sicker group of patients at a lower cost than other pharmacies around the state.

So, the two struck up a pilot program to see if Towncrest could keep the health plans' members healthier while saving money on healthcare costs. By the end of it, McDonough and his colleagues were able to show that the patients seen at his pharmacy were more likely to take their medications, and ultimately saved the health plan $300 per member each month.

Wellmark has since expanded the program into a three-year trial that kicked off in April 2017. Towncrest is participating as part of a group of 72 pharmacies — independent and regional chains alike — in South Dakota and Iowa.

Matt Hosford, Wellmark's chief pharmacy officer, said the program's seen success in managing high cholesterol by making sure patients are on the right dose of their medication, and in helping patients with mental health issues byensuring they're taking their antidepressants and that side effects from those medications are under control.

<h1> What pharmacists are up against </h1>

Declining reimbursement rates from health insurers and the middlemen, the pharmacy benefit managers, are a constant problem for pharmacists. For patients who have insurance, the pharmacists agree to contracts that stipulate how much they'll be reimbursed by the insurer or PBM for dispensing that medication.

If the insurers or PBMs set those rates too low, it's hard for pharmacists to push back. If a pharmacist turns down a contract, they stand to lose a big chunk of business because patients won't be able to use their insurance at the pharmacy.

For example, on one prescription, Paganelli asked for a health plan to pay him back $203 for dispensing a drug. In the end, the pharmacy was paid $6.75 for a prescription of 90 tablets.

That's not enough, Paganelli said. He figures that it costs his pharmacy at least $11 to fill a prescription. Anything less than that and he's losing money.

In Mt. Carmel's computer system, prescriptions where the reimbursements don't cover the costs to fill the prescription are colored red. And there's a lot of red on the computer screen.

"We see these all day long," Paganelli said.

Independent pharmacists have very little leverage to push back on reimbursement rates from giant PBMs and insurers. Even big pharmacies can struggle. Nearly a decade ago, Walgreens and Express Scripts cut ties in a dispute over reimbursement rates. Ultimately, the two came to an agreement, but analysts estimate the dispute cost Walgreens <a id="a6326293-3620-303a-ab3e-626017c1c083" href="https://www.nytimes.com/2012/07/20/business/walgreen-and-express-scripts-settle-their-dispute.html"> $4 billion in annual revenue </a> .

To alleviate these pressures, pharmacists in retail stores are seeking to get paid more like doctors or nurses, and less like sales clerks.

Here's the thinking: You might see your doctor a few times a year. But you probably pop into your local pharmacy once a month, if not more. So why not check in on your health there instead of setting up a separate appointment with your doctor? The visit won't be as comprehensive as a full yearly physical, but could help fill in the gaps in between visits.

Already, when pharmacists dispense medications, their job is not just to put the pills in the tube. It's also to check whether the prescription will mix poorly with any other drugs a patient might be taking, counsel a patient on how to take the medication, and answer any outstanding questions they may have thought of on their way from the doctor's office.

Pharmacists are heavily trained to do the work. They tend to go to school for <a id="4f855bf6-9afd-3438-aa53-4d6c22adfd0a" href="https://pharmacy.oregonstate.edu/pharm-d-frequently-asked-questions"> four additional years </a> after college to obtain their Pharm.D, the same duration as medical school.

Right now, though, pharmacists who work in retail stores typically don't get directly paid for that medical work.

"Pharmacists can't be dispensers; they need to be healthcare service providers that happen to dispense," said Troy Trygstad, executive director of the Community Pharmacy Enhanced Services Network.

CPESN, as its known, aims to help pharmacies reach deals with health plans to care for their patients. The group estimates that there are almost 2,000 pharmacies working under that type of arrangement. Trygstad said the number of pharmacies in CPESN's network has been growing at a rate of about 100 pharmacies a month for the past 18 months. McDonough and Paganelli are both members of CPESN.

The US population is growing older, and we're facing a shortage of <a id="443686bd-e6f1-3024-a042-aa65a586e2fb" href="https://www.businessinsider.com/us-primary-care-physician-shortage-solutions-2018-9?utm_source=intl&amp;utm_medium=ingest"> primary-care doctors </a> . Pharmacists could be key in helping patients and their doctors stay on the same page.

There are a growing number of pharmacists in the US, though many work in hospitals, not retail stores. According to the Bureau of Labor Statistics, there were 312,500 pharmacists in the US in 2016, a number that's projected to grow to 329,900 by 2026.

"I think remunerating pharmacists for helping to manage care is a great idea," Carolyn Long Engelhard, a public-health expert and professor at the University of Virginia School of Medicine, told Business Insider.

That could ultimately reshape the role of pharmacists in the next few years.

The addition of health services is something on the minds of big pharmacies as well. CVS Health, <a id="df784a12-d9f4-3025-afa0-6e650fd6499e" href="https://www.cnbc.com/2018/11/06/cvs-to-test-stores-with-more-health-services-after-aetna-deal-closes.html"> after its acquisition of Aetna </a> , plans to add more health services to its pharmacies, including chronic disease management as well as primary care services. The company already has more than 1,000 in-store clinics, typically staffed by nurse practitioners.

Not everyone is convinced this will work. Owen Sullivan, who owns Sullivan Drugs in Carlinville, Illinois, a town of about <a id="b9d89be3-be67-3c9d-a1ad-251113d2d9a4" href="https://blackburn.edu/parents-families/about-carlinville/"> 6,000, </a> has been making less and less money over the past few years from reimbursements for the prescriptions he dispenses.

Now, the money he's paid back in reimbursements no longer covers the cost of the medication he dispenses.

As the Bronx pharmacist Paganelli sees it, the transition from getting reimbursed based on the volume of prescriptions to getting reimbursed for services that keep patients healthier has to happen.

The transition period will be rocky.

"It has to be the way of the future because reimbursement can't do it," Paganelli said. "Reimbursement alone can't do it, but we're in a transition phase and we can't get the paid-for services up to speed fast enough to cover for the losses on the pharmacy side."

When asked how bad the pressure of lower reimbursements is getting, Paganelli answered: "catastrophic."

Are you a pharmacist with a story to tell? Email the author at lramsey@businessinsider.com.

<ul><li> <a href="https://www.businessinsider.com/is-it-safe-to-eat-romaine-lettuce-2018-4?utm_source=intl&amp;utm_medium=ingest">An E. coli outbreak from romaine lettuce has sickened 65 people — here's how to avoid getting sick</a> </li><li> <a href="https://www.businessinsider.com/see-inside-the-walgreens-pharmacy-of-the-future-2018-11?utm_source=intl&amp;utm_medium=ingest">Take a look inside Walgreens' futuristic store where it's plotting new ways to take on Amazon and CVS</a> </li><li> <a href="https://www.businessinsider.com/turkeys-twice-size-weight-2016-11?utm_source=intl&amp;utm_medium=ingest">The turkey you're about to eat weighs twice as much as it did a few decades ago</a> </li></ul>