As soon as news surfaced last week about the potential merger ofCVS Health and Aetna, all eyes turned to thelooming threat from Amazon.

The online retailer’s flirtation with the pharmacy business is a factor, no doubt. But many industryexperts say CVS and Aetna have another huge competitor on theirminds: UnitedHealth Group.

UnitedHealth is best known as the nation’s largest healthinsurer, with more than 45 million members in the U.S. But behindthe scenes, it has extended its reach deep into America’s medicine cabinets, operating rooms and doctoroffices.

Its Optum unit fills more than 100 million prescriptions permonth as a pharmacy benefit manager, poaching big customers fromrivals CVS and Express Scripts. UnitedHealth owns more than 400surgery centers and urgent-care clinics and runs medical practicesfor about 22,000 physicians across the country.

“People have gotten carried away with Amazon,” said Ana Gupte, ahealth care analyst at Leerink Partners. “CVS and Aetna is an Optumwannabe. UnitedHealth is the winning business model, and Optum isshowing the way.”

UnitedHealth’s expansion into dispensing prescription drugs andtreating patients has put the company on track to reach $200billion in annual revenue this year and profits for the first nine months of 2017 already topped $7billion.

UnitedHeath is admired on Wall Street for its dependable resultsand diverse stable of businesses, which helps insulate it fromrough patches in the insurance sector. However, the prospect offurther industry consolidation alarms some consumer advocates andhealth policy experts. And they say UnitedHealth hasn’t always beena good role model.

In 2009, U.S. Senate investigators said the company built an industrywidedatabase that deliberately understated what insurers should pay forout-of-network care, exposing consumers nationwide to hundreds ofmillions of dollars in extra charges.

More recently, patients have accused the company’s prescriptiondrug business, OptumRx, of overcharging for routine medications inorder to pocket a pharmacy “clawback”that boosts profits. The company has denied any wrongdoing inresponse to lawsuits over the drug pricing.

Employers, lawmakers and consumer groups accuse the threelargest pharmacy middlemen — Express Scripts, CVS and UnitedHealth— of keeping drug prices high and pocketing too many of thediscounts they negotiate with pharmaceutical companies.

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This story was produced by Kaiser Health News, whichpublishes California Healthline, aneditorially independent service of the California Health CareFoundation.

Consumer advocates also are concerned about the prospect ofcompanies mining a vast supply of consumer data to maximize profitsrather than improve care.

“It is hard to find instances where these very large companiesused their market power for the good of consumers, rather than fortheir shareholders,” said Lynn Quincy, a consumer advocate anddirector of the Healthcare Value Hub at the Altarum Institute, anonprofit think tank. “The lack of transparency at these reallylarge companies is appalling. That’s why we’re skeptical it willmake things better.”

In a statement, UnitedHealth said it’s committed to “helpingpeople live healthier lives” and its Optum unit is trying to makethe entire health system work better.

In the past, company executives have said they’re fighting onbehalf of employers and consumers against high costs, as well aspoor outcomes and mind-boggling complexity. Before the merger news,executives at Aetna and CVS had already hinted at working togetherto tackle many of the same issues through the retailer’s vastnetwork of stores.

Last week, The Wall Street Journal broke the news about the potentialmerger between CVS and Aetna, which could be worth more than $66billion. CVS and Aetna say they won’t comment on market rumors orspeculation.

In general, these companies are trying to address problemsfamiliar to most Americans: poor coordination of care. Doctorsrarely talk to each other. It’s incredibly hard to share medicalrecords among providers or even with patients. Despite a lot oftalk about linking pay to performance, a surprising amount ofmedical care is still reimbursed under the old-fashionedfee-for-service model that rewards quantity over quality.

For some experts, CVS and Aetna are well-positioned to fix manyof those issues and that might make their deal more likely to passmuster with antitrust officials.

UnitedHealth, which has reached into everything from home healthcare to billing technology, has won praise for some of its efforts.One 2015 study published in Health Affairs found that the company’suse of house calls helped reduce costly hospital admissions forMedicare patients by 14 percent.

“One of the big failures of the U.S. health care system has beenfragmentation, and these vertical mergers are trying to cure thatproblem,” said Thomas Greaney, a former federal antitrust lawyerand now a professor at the University of California’s HastingsCollege of the Law in San Francisco.

“You want to encourage efficiencies and integration that helpspromote better care and lower costs. But you don’t want that toturn into a local monopoly,” he added.

Farzad Mostashari, a former official in the Obama administrationwho has studied health care competition, said it’s too soon to tellwhether a CVS-Aetna deal would be good or bad for consumers. ButMostashari, who now heads Aledade, a tech start-up that works withdoctors, said it warrants intense scrutiny of the more subtle waysit could put rivals at a disadvantage.

“These vertical mergers can create competitive challenges whereyou use your dominant market position to tip the ball to yourselfin another area,” he said.

This story was produced by Kaiser Health News, whichpublishes California Healthline, aneditorially independent service of the California Health CareFoundation. KHN’s coverage of prescription drug development,costs and pricing is supported in part by the Laura and John ArnoldFoundation.