Disease Is the Enemy; The Patient Is Waiting

John OBrien

SUMMARY. This paper describes the mutual origins and shared history of pharmacy and the pharmaceutical industry. Pharmacists had major roles in the origin of todays pharmaceutical companies, and many industry professionals have held leadership roles in pharmacy associations and helped build the profession. As the relationship evolved, published accounts describe conflict between the two parties, often over their respective responsibilities to stakeholders. It can be argued, however, that the conflict often revolves around competing payment incentives and artifacts of a system of health care delivery and financing recognized as inefficient. Instead, pharmacy and industry should be fighting the real enemy, disease. Efforts should focus on innovating care and aligning payment and recognition incentives with new prescription medicines and pharmacist services. doi:10.1300/J058v18n02_08 [Article

copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> 2007 by The Haworth Press. All rights reserved.]

John OBrien, PharmD, MPH, was formerly a Senior Director of PhRMA and Manager of Medical and Scientific Affairs and Manager of Government Affairs at Sankyo Pharma (now Daiichi Sankyo) and is currently a consultant to PhRMA. He is President of Responsible Health, LLC. Address correspondence to: John OBrien, PharmD, MPH, 5225 Pooks Hill Road, Suite 1827N, Bethesda, MD 20814 (E-mail: jobrien@responsiblehealth.com). The inspiration of the pharmacy association and PhRMA executives, drug company leaders, and academicians and historians from whom Dr. OBrien has been lucky enough to learn is acknowledged.
[Haworth co-indexing entry note]: Disease Is the Enemy; The Patient Is Waiting. OBrien, John. Co-published simultaneously in Journal of Pharmaceutical Marketing & Management (Pharmaceutical Products Press, an imprint of The Haworth Press) Vol. 18, No. 2, 2007, pp. 75-89; and: Pharmacy and the Pharmaceutical Industry: Healing the Rift (ed: David A. Holdford) Pharmaceutical Products Press, an imprint of The Haworth Press, 2007, pp. 75-89. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: docdelivery@haworthpress.com].

Available online at http://jppm.haworthpress.com 2007 by The Haworth Press. All rights reserved. doi:10.1300/J058v18n02_08

75

76

Pharmacy and the Pharmaceutical Industry: Healing the Rift

KEYWORDS. History of pharmacy, pharmaceutical industry, pharmacists

Dr. Ernest Mario recently received the 2007 Remington Medal, an honor awarded by APhA since 1918 to recognize a lifetime of distinguished service on behalf of American pharmacy and to honor the significant contributions of pharmacist, professor, volunteer leader, and pharmaceutical manufacturer Joseph P. Remington. Dr. Mario is a pharmacist graduate of the only school of pharmacy in New Jersey, a state well known for being home to some of the worlds leading pharmaceutical and biotechnology companies. He ultimately went on to hold several important positions in the research-based pharmaceutical industry, including Deputy Chairman and Chief Executive Officer of Glaxo Holdings, the worlds second largest pharmaceutical company, and several senior management positions at the company named for pharmacist, physician, and manufacturer Edward Robinson Squibb, who for a time mentored a young pharmacist named Joseph P. Remington. Thats quite a career by anyones measure, although pharmacys rich history proves anything is possible for those who have the caring nature and scientific acumen to attend pharmacy school, complete a rigorous education thats as service-oriented as it is science-based, and gain the confidence to fight disease on the front lines of American health care. Pharmacists not only ensure the safety of the dispensing process in community, hospital, or long-term care facility pharmacies but also care for hospitalized or ambulatory patients as a member of an interprofessional team. Pharmacists also use population-based models of evidence-based decision making and health beliefs to help individual patients understand both their health risks and the value of medicine, increase self-efficacy, and provide reminders or cues that improve adherence to treatment and attainment of outcomes. Pharmacy graduates conducting research, completing residency training, or pursuing another professional degree may work at an academic medical center, a college of pharmacy research facility, or a pharmaceutical company. All of these provide opportunities to help patients make the best use of medicines, to improve the quality of consumer health outcomes that are affected by pharmacy, and to be true to their professional calling to practice pharmacy by remembering once a pharmacist, always a pharmacist (1). The careful reader may recognize the mission of the American Society of Health-System Pharmacists and the American Pharmacists Asso-

John OBrien

77

ciation Foundation and the title of former PhRMA Chairman Joe Dalton Williamss 1980 Remington medal address in the sentence above. Williams was a World War II submarine veteran and pharmacy student of 1947 Remington medalist Dean Rufus Lyman at the University of Nebraska. He joined drugmaker Parke-Davis as a sales representative after graduation and after 20 years was named Executive Vice President of the company formed by the merger with Warner-Lambert. He ultimately served as President for 18 years (12 as Chairman and CEO). He was Chairman of the Pharmaceutical Manufacturers Association (now PhRMA), chaired PMAs Pharmacy Relations Committee, chaired the International Federation of Pharmaceutical Manufacturers, and was a board member of Eckerd Drug, J.C. Penney, AT&T, Exxon, and Therapeutic Antibodies, Inc., before retiring 50 years after his decision to become a pharmacist. This special issue of the journal asks if a rift exists between pharmacy and pharmaceutical manufacturers and seeks to evaluate the severity, causes, and fixes of a relationship illustrated by what some may describe as accounts of egregious hostilities and contentious relationships. Williamss 1980 Remington medal address describes a natural tendency to focus on mutual finger-pointing during the previous two decades to the detriment of two centuries of common origin and working together. He describes Americas world pharmaceutical leadership as not only influenced by science flowing from the APhAs Academy of Pharmaceutical Scientists but also supported by additional industry expertise in technology, production, management, and marketing. His account of APhA President Mary Munson Runges attendance at the PMA annual meeting early that week compliments her support of drugmakers and request for cooperation to ensure the economic survival of both pharmacy and drugmakers alike. His address was delivered against a backdrop of economic recession and a recent history of state and federal legislation, including social programs like Medicare and Medicaid; oversight of the manufacture, sale, and distribution of prescription and OTC medicines; the practice of medicine and pharmacy and the role of doctors and pharmacists in medication use; and many other areas where pharmacy and the industry overlapped. His address highlights an increased recognition of both pharmacy and drugmakers, including the selection of 1992 Remington medalist Jere Goyan as the first pharmacist to become FDA Commissioner and his role in the Orphan Drugs Act, thanks those APhA presidents suggesting he facilitate better relationships between pharmacy and drugmakers, and acknowledges mutual problems and mutual opportunities to work

78

Pharmacy and the Pharmaceutical Industry: Healing the Rift

together to serve patients. His address mimics many other Remington lectures and published accounts highlighting the success and failures, opportunities and threats, and allegations of all aspects of what can be defined objectively as a mutual origin and shared history. A FASCINATING, OPEN-ENDED STORY Prolific pharmacy historian Dennis Worthen chronicles the evolution of American pharmacy and Americas drugmakers in a foreword to APhAs published collection of Remington medalist addresses and other publications describing not just individual success earned by hard work, scientific discovery, and innovations in health care that improve human life, but also the perceived rifts, threats, and opportunities that leaders in industry and pharmacy have both condemned and capitalized on to propel their organizations forward (2, 3). He highlights that pharmacy and pharmaceutical manufacturing originate from the same DNA and describes the public threat of unsafe imported drugs and pharmacys demand for quality assurance as at least partly responsible for the birth and growth of an industry. Before laws regulated the manufacture, sale, or use of drugs, devices, or even leeches, American consumers in the mid-1800s looked by name for medicine made by pharmacists named Wyeth, Warner, or Dohme or by physicians named Abbott or Upjohn. The competition of pharmacists making and selling the same products, save for the name on the bottle, ultimately led to innovations in science meeting the needs of doctors and patients, such as sugarcoated pills, friable tablets, or hyperpotent specifics containing elements of the whole plant rather than alcoholic fluidextracts. For example, one company formed with a focus on producing specifics yet still had a fluidextract portfolio nearly twice as large as Parke, Davis and Companys by 1885. The entrepreneurial spirit of three pharmacists developing individual expertise in research, marketing, and financial operations, making medicines specifically meeting the needs of physicians and their patients, built a business sold in 1960 for $4 million. Founder and pharmacist John Uri Lloyd, who left one drug company to start another with his brothers, also received the 1920 Remington medal and is among the 40% of Remington medalists with drug company career experience. These and other stories make it incredibly tempting to present examples from the last 150 years of history and cite the individual or shared successes and failures in science, business, and politics, quote key lead-

John OBrien

79

ers and activists of the period, and attempt to tease out or prove why any aspect of the relationship between pharmacy and pharmaceutical companies is the way it is today. Using the personal accounts of history told by award-winning pharmacists and published in pharmacy textbooks and journals may be biased, and the bigger flaw in such a research design is the difficulty in defining pharmacy or pharmaceutical companies. Accurately labeling the many practitioners who have been paid for making, dispensing, and counseling of patients about a materia medica that has included juniper berry juice and vaccines effective against cancer-causing viruses is one challenge, as is deciding in what year these services are correctly labeled pharmacy practice or pharmaceutical manufacturing. A greater challenge may be subjectively deciding whether pharmacy includes the pharmacists who owned a pharmacy they practiced in, the pharmacists who owned a business operating many pharmacies, and/or the pharmacies owned in the late 1800s by nonpharmacists cited in history books as at least one reason for the development of state practice acts and pharmacist licensure. Other challenges include properly evaluating key stakeholders in history and the organizations defining their mission and their membership categories in response to the changing needs of the day and reconciling the statements of both as personal beliefs or the official policy of the companies or organizations they may have been involved with over their careers. If a reliable mechanism or agreeable definition rendered these challenges moot, more bias may arise when choosing the years defining the sampling frame. The changes in health care over the last 150 years are both longitudinally significant and markedly punctuated by key events in a handful of years. The retrospective long view describes an evolution in stakeholder responsibility, although published descriptions of the interaction between individuals and organizations in pharmacy or the industryhowever they may be defineddo not always correspond to the descriptions or expectations of individuals currently representing either entity. A 20-year retrospective analysis would find some in pharmacy seeking to repeal Medicare laws preventing the government from interfering with the negotiations of pharmacies, PBMs, and drugmakers and the same organization opposing pharmacy technician education and certification as creating additional bureaucracies in the delivery of pharmacy services (4). Looking back 200 years would find industry policy regarding the professional services of pharmacists conflicting with the published lectures of Squibb himself, declaring that a pharmacist is not

80

Pharmacy and the Pharmaceutical Industry: Healing the Rift

a druggist. . . . The pharmacist . . . is an educated qualified practitioner of the art of pharmacy. He is a dealer in substances used to prevent and relieve distress. . . . The druggist is a merchant like the grocer, the dry goods dealer, etc. (5). Even accounts found in government publications include stories subject to interpretation. For example, the 1937 story of the antibiotic Elixir Sulfanilamide found on the Food and Drug Administrations Web page describes a drug company chief chemist and pharmacist, a salesman . . . report[ing] a demand for a drug with dramatic curative effects . . . used safely in one dosage form, the development of a new dosage form satisfactorily tested for flavor, appearance, and fragrance but not toxicity, and the unfortunate death of more than 100 people (6). The FDA itself was merely six years old, and while selling toxic drugs was, undoubtedly, bad for business and could damage a firms reputation, it was not against the law. The story describes physicians, pharmacists, and drug company employees alike participating in, hiding from, or even obfuscating the response to a public health crisis that included government agencies, professional associations, and a news media limited at the time to radio, newspapers, and telegrams. The medical literature, news articles, and Remington speeches or other testimony from that time include acknowledgment of blame; finger-pointing; and demands for reforms in professional education, practice standards, and drug lawall of which may be selectively chosen to praise, motivate, question, or damn any of the participants. Seventy years later, as health care stakeholders attempt to manage chronic disease more effectively; prepare for pandemics caused by human behavior and new strains of infectious disease; evaluate innovations in health care effective against societys most serious unmet health needs; and reform the way federal agencies, health professionals, and businesses provide, pay, or receive payment for all aspects of human health, what is the best way to use the shared learning of the last 200 years? Should they debate whether the new dosage form was meant to improve medication adherence or increase profits; whether health professionals did their best or failed the public in their acceptance of a new product to fight disease; or whether more regulation of industry, educational, or professional practice standards at the state or federal level is necessary to encourage informed decisions about how patients take responsibility for their health? Is there, as Henrik Ibsen asked in his 1882 open-ended public health politics thriller, a true Enemy of the People?

John OBrien

81

DISEASE IS THE ENEMY The last five years have seen organizations representing pharmacies, pharmacists, drug companies, and patients evaluate, debate, and seek to influence the passage and implementation of state and federal laws reforming Medicare, Medicaid, and how to care for those who arent offered, cant afford, or choose not to purchase health insurance. These laws have significant impact for pharmacists, pharmacies, and drug companies; determining the actual impact and the best course of action is the subject of significant debate. In many ways, the landscape resembles a continent where the neighboring countries lack a common language or currency, and significant resources and opportunities are lost to misunderstanding, competing incentives, and other issues lost in translation. The shared history previously described suggests focusing on the patient offers the best opportunity to overcome these translational and transactional barriers. Evaluation of the Medicare program alone reveals nearly all of the recent Medicare spending growth is the result of a 25% increase in the 50% of Medicare beneficiaries with 5 or more chronic diseases in a year (7). Chronic conditions are a leading cause of illness, disability, and death among Medicare beneficiaries and account for a disproportionate share of health care expenditures. For example, about 14% of Medicare beneficiaries have congestive heart failure but account for 43% of Medicare spending. About 18% of Medicare beneficiaries have diabetes, accounting for 32% of Medicare spending (8). These diseases often combine with other risk factors to cause serious complications requiring expensive surgeries and further reduce patient quality of life. Yet, only one-third of people with high blood pressure are managed as recommended by professional guidelines, and less than 12% of people with diagnosed diabetes meet the recommended goals for blood glucose, blood pressure, and cholesterol (9-11). Unlike the public health crises caused by the threat of infection at the turn of the last century for which no cure was available, these diseases and their sequelae are manageable with changes in diet and exercise and the use of prescription drugs. While the attention provided by some health care stakeholders focuses on reforming how Medicare (and ultimately Medicaid, the lowincome or working uninsured, and others) purchases drugs, research suggests only 8% of people with Medicare prescription drug coverage will pay out of pocket after spending $2,250 and reaching the coverage gap (12). These patients likely have spending attributable to three or more chronic diseases, and the literature suggests these and other costs

82

Pharmacy and the Pharmaceutical Industry: Healing the Rift

incurred by people with Medicare and the Medicare program may be the result Americas other drug problems: low health literacy, poor adherence to physician or provider instructions, or medication errors and preventable adverse drug events (7, 13, 14). For example, over 500,000 medication errors occurred in Medicare patients prior to 2003, costing the Medicare program $887 million (in 2000 dollars) (15). The cost of nonadherence alone has been estimated at over $100 billion nationwide, and preventing nonadherence is perhaps even more important in the vulnerable Medicare population (16). These discussions are also relevant to people with Medicaid and private insurance and to the uninsured, suggesting, as PhRMA President and CEO Billy Tauzin stated at the 2006 PhRMA Annual Meeting: Disease is indeed our only enemythat it is the pain and the cost of disease which burdens us all, rather than the price of hope which our medicines bring. We are demonstrating that we are willing to work with everyone who is willing to help us in this monumental battle against disease which we fight for all of mankind. We have begun to address the serious problem of the uninsured in America, especially those who, for the lack of resources, end up missing out on the promise of better health and longer lives. We have come to understand that our medicines do no good for those who have no access to them, and that is why we remain so committed to a robust enrollment of our senior population into the right drug insurance plan for each of them under the new Medicare Prescription Drug Act, and why we cannot stop there, when over 22 million working Americans remain uninsured. The members of PhRMA are, of course, not alone in their commitment to fight disease. All of the organizations representing pharmacy professionals have ongoing initiatives demonstrating the value of pharmacists helping patients more effectively manage chronic disease. Pharmacy journals are rich with evidence of pharmacists improving adherence, improving outcomes, and reducing overall health care costs. Hospitals, managed care organizations, and physician group practices are recognizing the value of pharmacists services. However, these activities are often limited to practice settings with the financial resources to invest in pharmacists and generate a return via future savings resulting from less use of more expensive services. The dominant trend for most employers or payers (including Medicaid) seeing a disproportionate increase in the pharmacy budget relative to other services has been

John OBrien

83

to seek demand-side cost controls such as higher copays and formulary restrictions or to reduce spending via lower pharmacy dispensing fees or lower prices for drugs. For many reasons, the potential for drugs to improve health is not realized, and more money is spent on increased visits to providers, hospitals, or long-term care institutions. Recall that the Medicare program prior to 2003 had no outpatient drug coverage and had inpatient hospitalization, nursing home, home health, and end-of-life care exceeding 60% of total program spending (17). Prior to the Medicare Modernization Act, the costliest 5% of beneficiaries enrolled in Medicares fee-for-service (FFS) sector accounted for 43% of total spending, while the costliest 25% accounted for fully 85% of spending (8). The costliest 5% of non-Medicare beneficiaries accounted for 55% of national health spending in 2001 (18). Yet, the current system of health care financing rewards providers for increased utilization rather than paying for preventive services or disease management shown to save money by improving health, and state and federal lawmakers are once again proposing or implementing reforms based on the same incentives. The human and financial costs of poorly managed health, and the political pressure and public perception of the rising costs of poorer health, underscore the importance of identifying parallel activities with similar goals, establishing partnerships that highlight and complement each others value, and aligning incentives rewarding better health, quality of life, and future cost savings. The APhA Foundations Asheville Project and Diabetes Ten City Challenge are examples of paying pharmacists to educate and motivate patients, improving the way they use prescription medicines to manage their disease, achieving better outcomes, and lowering overall health care costs. The participating self-insured employers and drug company sponsors are recognizing that an increase in drug spending can lead not only to lower health care costs but also to happier and healthier employees who miss work less and produce more when they are present (19, 20). For many years, the foundation has also offered intense education about pharmacist management of metabolic syndrome, the constellation of the preventable or manageable diseases of high blood pressure, high cholesterol, and diabetes, which is implicated in the high health care costs of Medicare beneficiaries with chronic disease. Pharmacists graduating from these programs often return to their communities to partner with providers and patient groups to increase the recognition of the enhanced danger of multiple chronic conditions and to establish innovative programs like peer-coaching sessions that empower patients to

84

Pharmacy and the Pharmaceutical Industry: Healing the Rift

get well or stay healthy. These drug company supported programs are merely one example of what industry-pharmacist collaboration can achieve, and innovative pharmacies like Kerr Drug are developing new models to support pharmacist-provided disease management. However, disease management organizations often rely on call centers staffed by other health professionals, and the National Institutes of Health and others have begun to recognize the ability of nontraditional community providers such as barbers and beauticians or community health educators to improve health literacy, medication compliance, and disease management (21). While pharmacy has long been aware of its valuable role as a trusted community health professional and accessible source of health information, it has struggled with seeking the same recognition outside of the pharmacy community. The historical experience of drug companies perhaps assuming their value and importance to human health equated to being valued and seen as important by the public may provide an important example of the need for others to tell pharmacys story. Partnerships between state pharmacy associations and those representing drug companies have revealed community demand for pharmacists willing to adopt churches or community leaders either to provide health education or to train the trainers best suited to translate reliable health information into culturally competent communication. Community recognition of pharmacy school initiatives partnering students, faculty, and community groups to reduce health disparities and provide service learning experience highlights fertile ground for meaningful, awareness-generating partnerships. These partnerships also resemble an educational initiative at the Rensselaer Polytechnic Institute during Robert A. Hardts 1955 presidency of the American Pharmaceutical Manufacturers Association (one of two groups merging in 1958 to become what is now known as PhRMA). Against a backdrop of Congressional investigation of industry monopolies, the first published account of where drug company profits ranked among other industries, and state/federal considerations of the role of doctors and pharmacists in choosing or influencing the medicines used by patients, over 1,000 social studies teachers attended a 3-day conference sponsored by APMA and organized by Hardt to learn the civic value of pharmacists serving the nation (22). THE NEW PhRMA As a pharmacist with training as an association executive and public health professional, and as a former employee of the pharmaceutical

John OBrien

85

heritage that put statins and glitazones on the shelves and cherry trees and their spring blossoms on the Tidal Basin, the author has long believed that there has never been a better opportunity for pharmacists and pharmaceutical companies to work together. Recent experience working with PhRMA, state and national pharmacy associations, and community or advocacy groups developing community campaigns to change the behaviors causing poor health; aggressively target chronic disease with information, motivation, and innovation; and preserve an environment supporting the discovery of new products to improve human health may well replace the authors n of 1 observation with multicenter controlled evidence highlighting the effectiveness of working together. These examples provide a snapshot of the many ongoing and planned initiatives for pharmacists and drug companies to overcome the entrenched health beliefs and perverse incentives standing in the way of a patient-centered twenty-first-century health care system. With the support of its members, PhRMA has become a patient-focused organization recognizing that a medicine that sits on the shelf helps no one, and the organization is working to reestablish its role as a trusted partner in health that listens to its partners and offers help before asking for it. A member company work group of pharmacy affairs executives, experienced not only in pharmacy practice, education, and association management but also marketing, communications, and government affairs, meets regularly to advise staff and support outreach activities. An in-house clinical team relies on physician, nursing, and pharmacist expertise every day to seek or develop policies, initiatives, and partnerships to fight chronic disease. The team is led by a servant-leader who discusses his life-threatening experience as a cancer patient more than his lengthy experience as an effective legislator, and his conversations with PhRMA members and staff, pharmacists, educators, and association executives often include the personal impact of problems pharmacists could have prevented. The door is open to build future partnerships to fight disease, reduce errors, and otherwise improve the medication use process, as well as work with other health care stakeholders that should better appreciate the value of pharmacy. THE PATIENT IS WAITING The title of an earlier section references a moving speech given by PhRMA President Billy Tauzin, and this article could have borrowed

86

Pharmacy and the Pharmaceutical Industry: Healing the Rift

even more heavily from the numerous lectures by leaders in pharmacy and industry citing the dual value of pharmacists and prescription medicines, the role they have served in the past, and the opportunities for better use of both in the future. For example, the 1967 Declaration of Independence delivered by former APhA Executive Vice President and CEO William Apple describes the World War II era as the end of the what you do period and the beginning of the what you know period, challenges both pharmacists seeking high markups for product dispensing and proud pharmaceutical heritages masquerading behind promotional names and marketing gimmicks, and alludes to the beginning of pharmacist-provided drug therapy management as the emancipation of the profession of pharmacy (23). This article ends hoping more robust interaction to help the patient begins between those representing pharmacists, pharmacies, or drug companies, a hope inspired by the 1998 Harvey A. K. Whitney Lecture delivered by Dr. John Gans, Executive Vice President and CEO of the American Pharmacists Association (24, 25). It is among the best of the Remington and Whitney lectures, all of which are suggested reads for anyone considering the future of health policy and must-reads for those in a position to influence it. Nearly 50,000 pharmacy students in 100 colleges nationwide are working toward a Doctor of Pharmacy degree. Last year, nearly 500 graduatesa 28% increase from the previous yearreceived a PhD from the 65 schools offering pharmacy or pharmaceutical sciences programs to over 3,500 currently enrolled, full-time graduate students. Professional and graduate programs alike have seen an increase in female and underrepresented minority students mindful of the growing attention on health care disparities (26). These graduates will know the science behind the most recent discoveries and understand people well enough to improve their use of medicines discovered decades ago. The potential for drugs to play a greater role in treatment is inevitable, how the health care system adapts to more drug spending is a serious question. Fifty years from now, Asia may offer a less expensive home for manufacturers, and automated dispensing machines may have the same impact on pharmacists as automated tablet production did on the corner drugstore. Asias growing commercial enterprise and consumer population may also become a new source of demand for an American health care system known for improved health and lower costsand provided by an industry and a profession focused on quality and effective against disease. Higby, Sonnendecker, and Worthen have identified the importance of 1902 as a turning point for pharmacy (27). The availability of more

John OBrien

87

pharmaceutically elegant products less reliant on the services of pharmacists and the decisions made soon after by pharmacists, physicians, or other health care stakeholders about how patients should get, pay for, and use medicines, are among the examples offered to explain 100 years of history between 2 entities that only 50 years prior were one and the same. The Remington medalists from pharmacy, drug manufacturing (or both) may have not only described the past but predicted the future, so accurate are their many predictions about the current health care landscape. Whether theyve described a rift or an opportunity is perhaps best left to others to define, although Remington himself might share how Squibb signed for the quality of each prescription he made as a Navy surgeon or recall his Congressional testimony that in the case of medicine quality is more important than the lowest cost (28). Squibb inspired Remington to serve the sick, to promote the value of quality and innovation, to never keep his important work secret, and to be willing to battle those perceived as thwarting standards of quality (28). Whether these beliefs arose from being the apprentice of a pharmacist and trustee of Americas first college of pharmacy or from being an inventor and industry leader in the era of Edison, Ford, and Bell, they forged Remingtons belief in drug quality, his passion for pharmacists, and his confidence in their future. As pharmacists and drug makers hear from candidates making health care their primary focus 12 months before primary season, they should proudly tell future political leaders about a nineteenth-century heritage that can deliver a twenty-first-century promise. Disease is the enemy, new medicines and models of pharmacy practice can reduce the costs of disease, and the patient is waiting. REFERENCES
1. Williams J. Once a pharmacist, always a pharmacist. In: Griffenhagen G, Bowles G, Penna RP, Worthen DB, eds. Reflections on pharmacy by the Remington Medalists 1919-2003. 2nd ed. Washington, DC: American Pharmacists Association; 2004. 2. Worthen DB. Joseph Price Remington. In: Griffenhagen G, Bowles G, Penna RP, Worthen DB, eds. Reflections on pharmacy by the Remington Medalists 1919-2003. 2nd ed. Washington, DC: American Pharmacists Association; 2004. 3. Worthen DB. Pharmaceutical industry (1852-1902). Pharmaceutical industry (1902-1952). Pharmaceutical industry (1952-2002). In: Higby G, Stroud E, eds. American pharmacy (1852-2002): A collection of historical essays. Madison, WI: American Institute of the History of Pharmacy; 2005.

88

Pharmacy and the Pharmaceutical Industry: Healing the Rift

4. Anon. New board brings national tech certification one step closerAmerican Pharmaceutical Association, Pharmacy Technician Certification Board, American Society of Health-System Pharmacists; pharmacy technician certification. Drug Store News. 1995; (Feb 20). findarticles.com/p/articles/mi_m3374/is_n3_v17/ai_16541611 (accessed 2007 Jul 5). 5. Wimmer CP. The College of Pharmacy of the City of New York, included in Columbia University in 1904. New York: The College of Pharmacy of the City of New York; 1929. 6. Ballentine C. Taste of raspberries, taste of death. The 1937 Elixir Sulfanilamide incident. www.fda.gov/oc/history/elixir.html (accessed 2007 Feb 10). 7. Thorpe KE, Howard DH. The rise in spending among Medicare beneficiaries: The role of chronic disease prevalence and changes in treatment intensity. Health Aff. 2006; 25(5):w378-w388 [Web exclusive]. doi: 10.1377/hlthaff.25.w378. 8. US Congress. Congressional Budget Office. High-cost Medicare beneficiaries. May 2005. www.cbo.gov/showdoc.cfm?index = 6332&sequence = 0 (accessed 2007 Feb 26). 9. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC-7 report. JAMA. 2003; 289:2560-72. 10. Rosamond W, Flegal K, Friday G. Heart disease and stroke statistics2007 update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115(5):e69-e171. circ.ahajournals.org/cgi/ content/full/115/5/e69 (accessed 2007 Jul 5). doi:10.1161/CIRCULATIONAHA.106. 179918. 11. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA. 2004; 291:335-42. 12. PriceWaterhouseCoopers. Significance of the coverage gap under Medicare Part D. 2006; June 8. www.hlc.org/HLC_Coverage_Gap_Research_Report_FINAL. pdf (accessed 2007 Jul 5). 13. Kutner M, Greenberg E, JinY, Paulsen C. The health literacy of Americas adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: US Department of Education, National Center for Education Statistics; 2006. (NCES 2006-483). 14. Carmona RH. Health literacy: A national priority. J Gen Intern Med. 2006; 21:803. 15. Institute of Medicine of the National Academies. Preventing medication errors. Washington, DC: National Academies Press; July 2006. www.iom.edu/Object.File/ Master/35/943/medication%20errors%20new.pdf (accessed 2007 Jul 5). 16. Sokol MC, McGuigan KA, Verbrugge RR, et al. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005; 43:521-30. 17. Medicare Payment Advisory Commission. Healthcare spending and the Medicare program. Washington, DC: MEDPAC; June 2006. www.medpac.gov/publications/ congressional_reports/Jun06DataBook_Entire_report.pdf (accessed 2007 Jul 5). 18. Berk ML, Monheit AC. The concentration of health care expenditures, revisited. Health Aff. 2001; 20:9-18. content.healthaffairs.org/cgi/reprint/20/2/9.pdf (accessed 2007 Jul 5).

John OBrien

89

19. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: Long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003; 43:173-84. 20. More information about the Asheville Project, Diabetes Ten City Challenge, and related programs is available at www.aphafoundation.org/programs (accessed 2007 Feb 26). 21. Effectiveness of a barbershop-based program to improve high blood pressure control and awareness in black men. Trial identifier NCT00325533. www.clinicaltrials. gov (accessed 2007 Feb 26). 22. Griffenhagen G, Bowles G, Penna RP, Worthen DB, eds. Reflections on pharmacy by the Remington medalists 1919-2003. 2nd ed. Washington, DC: American Pharmacists Association; 2004. 23. Apple WS. Declaration of independence. J Am Pharm Assoc. 1968; 51(NS8):8. 24. The Harvey A. K. Whitney Lecture Award is sponsored by the American Society of Health System Pharmacists and is recognized as the highest award in health-system pharmacy. 25. Gans JA. The patient is waiting. Am J Hosp Pharm. 1988; 55: 1675-9. 26. American Association of Colleges of Pharmacy. Academic pharmacys vital statistics. July 2006. www.aacp.org/Docs/MainNavigation/InstitutionalData/6676_2005-03. pdf (accessed 2007 Jul 5). 27. Higby G, Stroud E, eds. American pharmacy (1852-2002): A collection of historical essays. Madison, WI: American Institute of the History of Pharmacy; 2005. 28. Worthen DB. Edward Robinson Squibb (1819-1900): Advocate of product standards. J Am Pharm Assoc. 2006; 46:754-8.

doi:10.1300/J058v18n02_08