Every day, Priscilla Watson needs 12 drugs to manage high blood pressure, diabetes, allergies and other health problems. Like thousands of other poor people in the District, she can't afford them.
But she stays well by getting all her prescriptions filled free through a social services agency that taps individual drug companies' indigent care programs and arranges for product donations to eligible patients.
Since last fall the Pharmaceutical Resource Center, a city-funded service of Catholic Charities of the Washington Archdiocese, has obtained $2,878 worth of free medications for Watson, 61, who gratefully picks up three-month supplies from her regular clinic. The center said it has helped about 600 elderly or disabled patients by arranging for $1.7 million worth of drugs in the past year.
Officials said Watson, a Medicare beneficiary and former nursing home worker, saves perhaps $450 a month. She said she otherwise would be desperate because she lives on a modest monthly disability check. "I would be a homeless person," she said. "This is a blessing from God."
Other needy residents aren't as lucky as Watson. They are unable to navigate a confusing array of patient assistance programs run by the drug companies, individual clinics, pharmacy benefit managers and the District government.
Specialists say that figuring out the system is difficult. When it comes to dispensing life-saving prescription drugs for the poor, they say, the District's situation is fluid and volatile.
"The District is in no way in a bigger mess than anywhere else in the country, but the reality is that people . . . can't get their medicine," said Sharon Baskerville, executive director of the D.C. Primary Care Association, an advocacy group for charity clinics. "To get their medicine, people have to wend their way through lots of craziness. The most vulnerable people don't make it through. They can't get the drugs they need and end up in emergency rooms or in the hospital needlessly. Or they die prematurely."
In a federally funded study released last week, researchers reported that middle-aged and older patients with heart disease who cut back on their prescribed medications because of cost were 50 percent more likely to suffer heart attacks, strokes or angina than patients who did not ration their drugs at levels below their prescribed dosages and frequency.
The decline in patients' health was monitored over two to three years, suggesting to researchers that economic barriers to prescription drug use may cause problems quickly, not just in the long term, according to the lead author of the study, Michele Heisler of the Veterans Affairs Ann Arbor Healthcare System in Ann Arbor, Mich.
The hodgepodge of prescription drug and patient assistance services in the District is uncertain these days. In May, the Pharmaceutical Research and Manufacturers of America launched Rx4DC, a service similar to that provided by the resource center. The main differences are that it has no limit on how many people it can serve and that patients are on their own in managing the substantial paperwork.
But like the resource center, it faces an unknown future. It could last for years, or its reach could change abruptly, depending on what happens on Capitol Hill.
The $217-billion-a-year pharmaceutical industry's move to set up Rx4DC came days after Mayor Anthony A. Williams (D) signed Access Rx, a law requiring drug companies to sell medications to the District at discount rates, and to disclose pricing, marketing and contracting data. The city would make the drugs available to seniors and the uninsured and pass the savings along to them.
This week the D.C. law came under legal attack. The Pharmaceutical Care Management Association, the trade group for the nation's pharmacy benefit management companies, filed suit in U.S. District Court to block the part of the law that forces those firms to reveal all financial arrangements between them and drug makers. Benefit managers administer prescription drug plans for more than 200 million Americans with drug coverage in their health plans.
The association has a similar suit pending in Maine, whose law was a model for the District's Access Rx law. A federal judge there has issued a preliminary injunction against enforcement of that state's law until a trial is held in 2005.
Experts say elements of the drug industry have sued in every state where such laws have been passed and have succeeded in delaying them.
The D.C. law has not taken effect because it is still being studied by a city interagency task force that has a monumental challenge: The law regulates drug purchases for every kind of government program. It does not apply only to low-income people. The litigation won't change anything, officials said.
"We're trying to implement the bill, and we're trying not to let anything [the pharmaceutical industry] is doing get in the way of that," said Gina Lagomarsino, a senior health policy adviser in the city administrator's office.
Rx4DC is a public relations ploy, said Sidney Wolfe, head of the Public Citizen Health Research Group. "The pharmaceutical industry is doing everything possible to do things to make people hate it less, and generally it is not working," he said.
"If you're poor, and there is no other alternative, we are not saying don't take advantage of the programs," Wolfe said. "But it really doesn't solve the larger problem. . . . Even Medicare beneficiaries with a reasonable income can easily be wiped out by having to spend up to $10,000 a year on prescription drugs. The companies are charging whatever the market will bear."
According to Public Citizen, a liberal public interest group, the drug industry spent a record $108.6 million on federal lobbying in 2003 -- mostly to make sure that Medicare changes adopted in November did not impose price controls on drugs for the 41 million Medicare beneficiaries.
Some low-income patients have come up with surprising health maintenance methods when they can't obtain their prescription drugs.
George Wallace, a 72-year-old Medicare patient who lives in Northeast D.C., said that when he could not afford blood pressure medication, he regularly mixed a glass of water with a teaspoon of vinegar to control his hypertension. "It's been helping me -- I'm serious," said the retired janitorial service worker. "But the medication is better."
Donald W. Cole, 78, a retired chauffeur who lives in Northeast on about $9,000 a year in Social Security payments, said he could not afford his three regular prescriptions before enrolling at the Catholic Charities resource center.
"There were times when [the clinic pharmacy was] not going to give me medicine without my paying full cost," he said, so he visited the clinic administrator. "I just got hysterical. I thought what would happen to me had I not had the funds to continue taking these medicines. I must have babbled like a little baby."
The clinic got him a free supply of the drug, but later he switched to another provider, and now the resource center is helping him. "It's like they give me my breath," Cole said.
The Medicare prescription drug program is to begin in earnest in 2006, and that will put more wrinkles into the everyday decisions of low-income people who need prescription drugs.
Also in recent months, the federal government launched its Medicare drug discount card program, which gives a $600 credit to certain low-income Medicare beneficiaries. There has been much criticism of the program, especially by people who say it's too confusing.
No one knows how assistance programs will evolve, which ones will survive and whether patients who can't navigate a complex system will continue winding up in hospitals recovering from health crises that could have been prevented with medications.
Lagomarsino and top officials at Catholic Charities say it is possible that the city in October will not renew the $140,000, nine-month grant it made this year to Catholic Charities for the resource center. Lagomarsino said she is trying to see that the resource center survives.
In June, meetings were held with officials of the resource center, the District government and the pharmaceutical manufacturers group about merging the activities of the resource center and Rx4DC. Former D.C. Health Director Ivan C.A. Walks attended the meeting on behalf of the pharmaceutical group.
In an association survey, 80 percent of enrollees reported that their health had improved after joining the resource center, 58 percent said their financial picture had gotten brighter and 98 percent said they would recommend the center to someone in need of prescription drugs.
But there are problems with the resource center, too. It often takes two months to process new prescription requests; the drugs are delivered to doctors, not patients; and there is no assurance that the funding will continue, the primary care association said.
Suzanne H. Jackson, director of the Health Insurance Counseling Project at George Washington University, said many people will only be frustrated by the programs.
"There is no one-stop shop for people in the city," she said. "Until they enact a health care ombudsman program, people will struggle to find the services they need."
The drug makers' group on May 27 opened the Rx4DC call center and Web site for low-income District residents; it matches the more independent patients with the industry charity programs. The group offers the same kind of service to all comers on its Web site, not just District residents.
The concept is the same as that used by the Catholic Charities program, but without the same level of intensive personal attention.
Christian Clymer, director of Internet services for the pharmaceutical manufacturers, said that in June more than 2,300 searches were conducted for Rx4DC, and 1,118 matches were made with at least one free drug program.
"We can tell just from the number of people who have responded to what we put out there that there is a need for this," he said. "There are people who didn't know about these programs before."
Doctors say the city is better off with assistance programs than without them, but they complain of the inefficiency and unreliability of any service that deals with 48 different drug companies operating 225 individual assistance programs to provide free or cut-rate supplies of 1,300 prescription drugs.
"It's hit and miss," said Janelle Goetcheus, medical director of Unity Health Care, which runs a string of charity clinics. "You never know what drugs you're going to get and what you're not. It's not the resource center's fault. They never know what's going to come. And by the time the medications have come back, sometimes the dosage for patients has changed. There are lots of headaches, and it's not a good way to practice medicine, but it's better than nothing."
Despite all the misgivings, Rx4DC has been endorsed by more than 25 health care, patient advocacy and business groups, including the D.C. Healthcare Alliance, a city-run, privatized care program for the indigent. The Mental Health Association of D.C., the Asthma and Allergy Foundation local chapter, the National Medical Association and many other agencies also agreed to promote Rx4DC.
Princess Wilson, 39, of Northeast D.C., a full-time housekeeping worker at Howard University Hospital who has no health insurance, recently signed up for Rx4DC. She figures she will save $77 a month on drugs to control her cholesterol and a chronic skin condition.
LaMar Lucas, a 59-year-old disabled man in Northwest D.C., said he was amazed that Rx4DC counselors said he could save $91 in monthly drug costs. The drugs won't arrive for a while, and he'll believe it when he sees it, but he's nonetheless pleased.
"I never thought the pharmaceutical companies would do anything," he said. "I thought they were like the tobacco companies."
The campaign is using direct mail, door-to-door solicitation and bus and subway advertisements, and has recruited churches and health centers to promote the program, said Larry Lucas, the pharmaceutical manufacturer group's associate vice president for state government relations.
The District clearinghouse follows those that the group recently launched in Rhode Island, Ohio and West Virginia. More may follow, he said. Ohio's is the largest, and in the past year it received 1.1 million inquiries, he said.
"It's going very well," Lucas said. "A lot of the people that need the services and the free and discount drugs are getting them."