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It wasn’t long ago that CVS Health seemed poised to become a heavyweight in the US healthcare sector. The country’s largest drugstore operator owned Caremark, the pharmacy benefits manager and a reliable profit center.

In 2017, the company entered the insurance sector, purchasing Aetna for $78 billion, including debt. The company then spent nearly $20 billion on healthcare providers Signify Health and Oak Street Health.

The idea was that CVS stores would become a one-stop shop and benefit from synergies by bringing so many parts of the healthcare chain under one roof.

It didn’t work out that way. CVS lowered its full-year profit outlook in August for the third time this year. Its market value of $80 billion is less than what it spends on acquisitions.

Net debt has risen to $50 billion – three times this year’s expected Ebitda. It has caught the attention of hedge fund Glenview Capital Management.

CVS’ board is reportedly considering its options. But a breakup would probably incur a lot of bank fees, but little else.

Take the health care business. An attempt to enroll more seniors in Aetna Medicare Advantage plans failed.

New customers led to a surge in medical claims – just as the government began cutting reimbursement rates. ​​

The medical performance ratio – i.e. the proportion of the premiums collected that is paid out to the service providers – was 89.6 percent in the second quarter, compared to 86.2 percent in the previous year.

In normal times, a standalone insurance company could command a higher valuation. Market leader UnitedHealth trades at nearly 20 times forward earnings, compared to CVS at 9 times.

But Aetna’s problems have hit CVS shares. Given the uncertainty surrounding Medicare payment rates, premium assessment appears unlikely.

The situation is similar in healthcare. This unit, which includes Caremark, is CVS’s largest and accounts for about half of the group’s sales and operating income.

But U.S. regulators are suing it — and two other PBMs — for allegedly inflating insulin drug prices. CVS said the allegations were “simply false.” However, a regulatory overhang could dampen enthusiasm for a PBM-focused stock.

Then there is the old drugstore. This sector is in secular decline. Amazon and rival retailers like Walmart have scaled back sales of front-of-store offerings like candy and toothpaste. Falling reimbursement rates and cheaper generics are squeezing prescription drug margins.

Still, CVS’s retail business has held up better than Rite Aid, which is now bankrupt, and Walgreens Boots Alliance, which is shrinking sharply. This is thanks in part to Caremark, which has helped drive patients to its pharmacies. A breakup would end this relationship. Not all complaints require radical surgery.

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