Old-School Pharmacy Hand Delivers Drugs

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Grubbs PharmacyIf House Speaker Paul Ryan comes down with the flu this winter, he and his security detail will not be driving to the closest CVS for Tamiflu, a little-known perk for the powerful members of Congress. 

Instead, he can just walk downstairs and pick up the pills, open to every member of Congress, from Ryan and Majority Leader Mitch McConnell down to the newest freshman Democrat or Republican.

Nearly every day, for at least two decades, pharmaceutical drugs have been brought by the carload to the Capitol — an arrangement so under the radar that even pharmacy lobbyists, who regularly pitch Congress in their industry, are not aware.

The deliveries arrive at the secretive Office of the Attending Physician, an elaborate medical clinic where Navy doctors triage medical emergencies and provide basic health care for lawmakers who pay an annual fee of just over $600. Every medicine comes from Washington’s oldest community pharmacy, Grubb’s.

Mike Kim, the reserved pharmacist-turned-owner of the pharmacy, says he has become familiar with knowing the most sensitive details about some of the most famous people in Washington.

“At first it’s cool, and then I realize, I’m filling prescription drugs that are for some serious health problems (i.e. diabetes and Alzheimers). And these are the people who are running the country,” Kim says.

“It makes me kind of sit back and say, ‘Wow, they’re making the highest laws of the land and they might not even remember what happened yesterday.’

Kim’s tiny pharmacy — which, at its busiest, sends as many as 100 prescriptions to members in a day — is nestled among Capitol Hill’s stateliest row houses, less than four blocks from the Capitol building. Founded in 1867 and named for a previous owner, the pharmacy predates penicillin, the American health insurance system, and even the Lincoln Memorial.

The two-story nostalgic shop, with its bay windows and wood counters, is reminiscent of the past, though the computer systems and supplements inside are not far removed from a typical Walgreen’s or CVS counter — if all the inventory in a pharmacy of today were placed into the nooks and crannies of three small aisles and labeled with individual stickers. At Grubb’s, staff will even scoop Hershey’s ice cream into cones from a small counter in the corner, a modern-day nod to the marble-topped soda fountain once popular with the neighborhood kids.

The pharmacy mostly serves the staffers, lobbyists, and families who make their home in the quiet, leafy neighborhood just east of the Capitol building, though Grubb’s five drivers will deliver prescriptions across the entire city. Some 800 prescriptions leave its doors every day, filled by three dozen pharmacists, technicians, and support staff.

The relationship between Grubb’s and the Capitol has gone nearly unchanged for decades, even as congressional leaders have pushed again and again to overhaul the nation’s broader health care system.

For the most part, lawmakers get the same prescription delivery service as any other customer of Grubb’s. The pharmacy still bills each lawmaker’s insurance plan. Grubb’s keeps credit card information on file for co-pays and other purchases. There are no discounts, Kim says. No special treatment.

“The Capitol takes somewhat of a precedence just because of who we are servicing,” Kim says. “The member might be calling to say, ‘I’m about to leave in five minutes, where’s my drug? So [the clinicians at the Capitol] get into panic mode. I wouldn’t say they’ve ever become frustrated with us, but it’s a concern, ‘Oh my gosh, the member just called asking about their drug.’

Those busy moments are much more prevalent in winter, when lawmakers have been in session for a while and when they might be facing more late-night vote sessions, Kim says. During August recess, the Capitol pharmacy business — like much of Washington’s economy — slows considerably.

Most lawmakers know far more about the Office of the Attending Physician than about Grubb’s or its arrangement with Congress. In a STAT survey of two dozen House and Senate members from both parties, only one knew about the single pharmacy that delivers all their drugs: Congress’s only pharmacist, Rep. Buddy Carter (R-Ga.).

“It’s a great opportunity for us, as pharmacists, to showcase what we do because what we do is take care of patients,” Carter told STAT. “This is another example of how we go above and beyond our call of duty to help people in health care.”

Others were quick to praise the Navy doctors and nurses in the Office of the Attending Physician, which has at least one pharmacist and several technicians on its staff.

Lawmakers describe the Office of the Attending Physician as a modern space much like a regular doctor’s office — though the $3.7 million budget it enjoyed for 2016 suggests a relatively well-furnished space. It’s strictly off-limits to reporters.

The office is not without controversy. Its services — and the relatively low fees that members must pay for access — were thrust into a harsh spotlight in 2009, as Congress began to debate the Affordable Care Act and as reporters began to ask how lawmakers’ own care might color their perspectives on policy. The central issue is the cost: In 2016, lawmakers paid $611 for annual membership — a fee that, unlike most health care prices, has risen much slower than inflation. In 1992, the first year the office charged a fee, it was $520.

The Office of the Attending Physician itself was formed in 1928, after three members of Congress died in their offices within months of one another — more than 50 years after Grubb’s first opened its doors.

But the pharmacy services at the Capitol may go back even further — a 1911 text on senatorial privileges describes an “assortment of drugs and viands, tonics and recuperatives” on hand and “readily accessible” for lawmakers. Back then, reportedly, senators took tablet after tablet and vial after vial of quinine, pepsin, and calomel, “endless supplies of cough drops,” and something described as “dandruff cure.”

It’s not clear how long Congress has contracted with Grubb’s to provide private prescriptions, but a 1992 review of the OAP — hastened after one senator threatened to make his colleagues pay market prices for the free care they got at OAP — decreed that prescription pharmaceuticals for lawmakers should be obtained through private pharmacies and paid for by the lawmakers themselves, according to a memo shared with STAT by the Senate historian.

It’s not clear, either, just how many drugs the OAP keeps on hand, whether for members or emergencies. But Dr. Lee Mandel, a retired Navy physician who spent several years working for OAP in the 1980s, remembers a well-stocked pharmacy just off the main corridor under the speaker’s office.

“We provided some pretty comprehensive service, to keep the members doing their jobs so they didn’t have to go look for a doctor,” he told STAT. “As far as all medications, I don’t know — maybe the more exotic ones we didn’t — but we probably did stock [most drugs] on their behalf.”

Kim, 47, knows only that the OAP’s relationship with Grubb’s has existed since at least 1997, when he joined the staff part-time as he finished his training at Howard University.

Not much has changed since then, though enhanced security protocols after 9/11 ended the pharmacy’s practice of driving each prescription to an individual member’s office and collecting cash in-person. Now, the drivers — all of whom have undergone a Capitol Police background check — head straight to OAP.

After 20 years at Grubb’s, Kim himself is not nearly so starstruck by the lawmakers. Even when they stop by the shop in-person, he says they’re just like any other customer.

“I still remember John Kerry — it was literally the day after he lost [the 2004 presidential election], he came in and was just standing in line with everybody else,” Kim recalled. “I just remember seeing him standing in line and almost feeling sorry for him — one day he’s a superstar, he’s got his entourage and security detail, and the next day he’s just by himself, picking up his prescription.”

Though Kim himself is active in the National Community Pharmacists Association that lobbies on behalf of the industry, he said he usually does not push lawmakers to talk shop when they are in line as customers.

Although he isn’t lobbying Congress, Kim is still working to improve his relationship with OAP. He desperately wants the office to use an electronic system to route prescriptions to the pharmacy, rather than having their physicians call them in every time.

The “back to back” calls are slowing down the rest of his business, and he thinks it’s important to have a clearer record of what prescriptions are ordered than a phone call can provide.

Those frustrations aside, however, Kim is proud of the work he does for the powerful figures who dominate Washington’s attention.

“It’s definitely a special arrangement that no other pharmacy in the country has,” he says. “In other states, [a community pharmacy] may fill prescriptions for maybe one or two members. But at this location, we are servicing almost every member from all across the country. It’s very cool.”

Popularizing Prescription Drugs

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rx-bottle-and-cashLaura Ries was moved to action when she saw a TV commercial portraying a woman happily sharing time with her grandchildren after taking Lyrica, a prescription medication, for diabetic nerve pain of which her elderly mother suffers.

“The ad showed someone who was enjoying life again,” said Ries, president of a marketing strategy firm in Atlanta, who then researched the drug and spoke with her mother’s doctor. “This was very related to what my mom was experiencing.”

Her reaction was precisely the aim of ‘direct-to-consumer’ advertising: getting patients or their family members to remember a drug’s name and ask the doctor for a prescription.

Spending on such commercials has grown 62 percent since 2012, even as ad spending for most other product types was flat.

“Pharmaceutical advertising has grown more in the past four years than any other leading ad category,” said Jon Swallen, chief research officer at Kantar Media, a consulting firm that tracks multimedia advertising. It exceeded $6 billion last year, with television picking up the lion’s share, according to Kantar data. Major network evening news and daytime drama programs are heavy with drug ads.

But the increase of drug advertisements has generated new controversy, in part because the ads inevitably promote high-priced drugs, some of which doctors say have limited practical utility for the average patient-viewer. For example, 60 capsules of Lyrica costs about $400 [the drug Ries asked about for her mother].

Critics, including the American Medical Association who called a ban in 2015, say ‘direct-to-consumer’ advertising inflates demand for new, more expensive drugs and encourages patients to ask their doctors for often marginal — and sometimes inappropriate — drugs that are stimulating high health care costs.

Such prohibition is unlikely. Previous efforts to push such an outcome have stalled, generally on free-speech arguments by the powerful drug lobby who declare that such ads provide valuable information to patients about treatment options.

Spending Zooms

One thing is certain: ‘direct-to-consumer’ advertising is big. And, as nearly everyone who watches TV knows, it’s getting bigger.

Some programs — the nightly news and sitcoms aimed at older Americans — get most of their advertising from drug companies. A Kantar analysis shows 72 percent of commercial breaks on the “CBS Evening News” have at least one pharmaceutical advertisement. Commonly, the ads target a range of conditions that generally affect this demographic. Sixty-two percent of commercial breaks during “General Hospital” include a drug ad.

“A lot of these ads target the caregivers and the children of older people,” said consultant Tom Lom, a former managing partner of Saatchi & Saatchi Consumer Healthcare, which has created ads for pharmaceutical giants.

Drug companies were on track to spend an estimated $6.4 billion on ‘direct-to-consumer’ advertising in the U.S. last year, up 5 percent from 2015, according to Kantar. In 2012, spending for pharmaceutical TV ads was the 12th-largest category. By last year, drug ads were sixth.

While substantial, the spending was less than the amount spent by automakers, retail and restaurants. Networks — ABC, CBS, NBC — along with cable channels like CNN — draw a lot of the pharmaceutical advertising.

According to Swallen, the effect of the ban on networks would be a daunting, 8 percent loss of total ad revenue, and its impact would be most evident for programming popular with viewers older than 60 ­— for instance, evening news shows. Similarly, cable networks such as the Hallmark Channel, which draw viewers from this demographic, would feel the pinch because they work on lower budgets.

Why Some Drugs Are Advertised

For years, the ‘direct-to-consumer’ industry was mostly focused on drugs that relieved chronic, typically non-fatal afflictions like heartburn (Nexium), allergies (Claritin) and high cholesterol (Lipitor).

More recently, Lom said, advertising has focused on more serious illnesses affecting seniors, such as Alzheimer’s disease. Ads for drugs that target constipation caused by other drugs — opioids — hit the scene last year, reflecting the large numbers of people taking painkillers.

In 2016, the top three ads based on total spending were Lyrica, $313 million; Humira, $303 million; and Eliquis, $186 million, according to Kantar Media.

The reasons why some drugs are advertised more than others vary, with drug companies evaluating which products are most likely to bring them the most revenue.

Drugmakers do not care “whether it’s a rare, expensive drug or a popular cheap drug,” said Amanda Starc, associate professor of strategy at Northwestern’s Kellogg School of Management. “They’re looking at the marginal return on advertising. A small number of customers spending a lot or a big number spending a little.”

How Advertising Plays To Consumers

The United States is one of two countries — the other is New Zealand — that allows ‘direct-to-consumer’ advertising, a long-standing practice that became more common in the mid-1980s after the FDA issued new rules. Most advertising was in print. But more television advertising began appearing when some of the rules were relaxed a decade later.

Lom said the ads give consumers a “head start” on knowing about drugs that might be available for their ailments, speeding up the consumer education process.

Surprisingly, 62 percent of physicians, for instance, said they would or might prescribe a harmless, even placebo, treatment to a patient who does not need it but demands it, according to a 2016 poll conducted by Medscape, an online physician education website.

Current rules require that if a drug is named in an ad, information must be included about side effects and adverse reactions. That makes it even more important that drug advertising be visually captivating — if not surprising, say consultants.

Meanwhile, the side effects are glossed over. “The ads describe the risks and at the same time play pleasant music — or show happy images — which helps to distract people from getting the message,” says Dr. Aaron Kesselheim, associate professor of medicine at Harvard Medical School.

Those that do advertise, however, appear to have a handle on the market. Ries, the brand consultant, says it wasn’t just the ad that helped her to remember Lyrica, but the name, too, which was easy to spell and pronounce.

Reis said her mother did take the Lyrica “and it’s helped.” That’s a good thing, says the brand guru who takes pride in looking out for her mother. “The ad spurred the conversation.”

But whether the advertising empowers patients or leaves them vulnerable is debatable.