Cigna’s $67 billion bid for pharmacy benefits manager Express Scripts could give the insurer better tools to manage patient healthcare and more clout to negotiate lower prices with drugmakers — but health economists caution that the main beneficiaries could be shareholders rather than patients.

“In some sense, this was inevitable, with the other major insurance companies being integrated with a PBM — Cigna doesn’t want to be at a competitive disadvantage,” said Sam Richardson, a health economist at Boston College.

Health economists predicted more consolidation after Aetna and CVS announced plans to merge last year. The prospect of Amazon entering the pharmaceutical market, and the joint pledge from Amazon’s Jeff Bezos, Warren Buffett and JPMorgan Chase chief Jamie Dimon to find ways to drive down healthcare costs, provide an imperative for players across the industry to contain costs and improve the quality of care patients receive.

Cigna CEO David Cordani described the current healthcare market as "not sustainable" in a CNBC interview on Thursday. "The market demands more affordability, the market demands more personalization,” he said.

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By undergoing a vertical merger that brings an insurer and benefits manager under one umbrella, Cordani said patients as well as employers would benefit from better coordination and more efficiency in providing care. “"This combination accelerates our movement to deliver more value," he said.

Will Sneden, practice leader of U.S. Health and Benefits at Aon, said the merger would give Cigna more data and better insight into the total scope of healthcare people get, reducing the fragmentation that can lead to less effective or duplicative care. “It gives a broader scope of capabilities for the organization. It could be another choice for more integrated medical and pharmaceutical solutions,” he said.

“I see this as a strategy for accelerating the accountable care space. By having an in-house PBM capability, it will make the data integration that much more readily available,” Sneden said.

Exactly who will benefit from that value, though, remains to be seen.

“On one hand, there probably are going to be gains from coordinating care between the insurer and PBM… those will probably have benefits for employers and patients, but on the other hand, it changes the incentive structure for the entities,” said Matthew Eisenberg, an assistant professor of health policy and management at Johns Hopkins University. With a benefits manager in-house, Cigna might not negotiate as vigorously for lower drug prices, or might not pass savings along to patients.

“The challenge is that, as the industry consolidates, [will it] have an effect on prices?” said Jason Shafrin, a senior director of policy and economics at Precision Health Economics. He pointed out that CVS is already experimenting with more flexible delivery models, such as a plan to improve costs and care for rheumatoid arthritis treatment.

"Do those negotiated rebates get passed on to the consumer?"

While this can lower insurer costs, though, Shafrin said the wrong incentive structure could sacrifice patient care, expressing concern that greater negotiating leverage could be wielded to restrict patient access to new or experimental treatments in pursuit of keeping costs down.

And patients might not even see the results of those savings, Shafrin said. “A question is, do those negotiated rebates get passed onto the consumer? In the past, the answer was largely no,” he said.

If a marketplace develops where fewer, larger insurers extract better concessions from pharmaceutical companies but don’t pass those savings along, patients will suffer, especially those whose jobs offer high-deductible health plans that shift more of the cost to the employee.

“Consumers would acutely feel these higher prices. That’s the worry,” Eisenberg said.