What trade association represents three of the four largest healthcare companies in the country? It’s not a group that represents pharmaceutical manufacturers, hospitals or chain drug stores.

The correct answer is an association that connects all three: Healthcare Distribution Management Association (HDMA). Aware of its obscurity, the medical wholesale and distribution industry is hoping to raise its profile this year by letting more people on Capitol Hill and across the healthcare system know about its members and their role in the movement of 13 million drugs each year.

All three of the largest distributors are Fortune 50 companies: In 2007, McKesson ranked 18th with $88 billion in revenue, Cardinal Health was 19th with $81.9 billion; and AmerisourceBergen came in 29th with $61.2 billion.

That makes McKesson and Cardinal Health bigger than the largest health insurance company in America, UnitedHealth Group (21st, $71.5 billion), and all three bigger than the largest pharmaceutical companies (Johnson & Johnson: 36th, $53.3 billion; and Pfizer: 39th, $52.4 billion) and the largest pharmacy chain (Walgreens, 44th, $47.4 billion).

And yet, HDMA President and CEO John Gray said, “No one really knows and understands how does the product go from the manufacturer to the pharmacy,” and ultimately to the patient. “It’s a process and a business model that’s not well understood, and it needs to be,” he added.

As 2008 progresses and the specter of a major national debate about the future of the healthcare system looms on the horizon for 2009, these healthcare wholesalers and distributors, like their business partners in the pharmaceutical and pharmacy industries, want to make sure they are positioned to be part of that discussion.

As part of this effort, the HDMA hired the consulting firm Booz Allen Hamilton to produce an analysis of the distributors’ role in the healthcare system. The report concluded that distributors are responsible for more than $33 billion in annual savings to the healthcare system, something the HDMA wants Congress to hear. Booz Allen based this finding, in part, on the fact that distributors provide specialized services, such as storage and trucking, more efficiently than the manufacturers could.

Indeed, the distributors’ customers were the primary audience for the report, which was completed in December and is a follow-up to a 2004 Booz Allen analysis.

But Gray also hopes that having a dollar figure to illustrate what distributors do will help him and the HDMA’s lobbyist make their case in Congress. “We saw an even bigger opportunity to use the report as a way to explain” what his members do, he said.

They will be doing so with a relatively modest budget, compared to other healthcare industry trade associations, though the HDMA has significantly increased its spending on lobbying and campaign contributions in recent years.

Gray believes that the HDMA’s lobbying budget has reached the right level. “Right now, I think we’re appropriately sized” in the association’s in-house government affairs operation, he said. The HDMA also does not have plans to hire additional outside lobbyists, he said: “I think we’re comfortably situated.”

In the first half of last year, the HDMA spent $300,000 on lobbying, and it spent $700,000 in 2006. As recently as 2003, the group’s lobbying budget was just $140,000, according to CQMoneyLine.com. During the first half of last year, by contrast, the Pharmaceutical Research and Manufacturers of America spent $10.7 million on lobbying.

Likewise, the HDMA has gotten more aggressive in generating contributions to its PAC and has been spreading the money around to more lawmakers and, notably, more Democrats since Congress changed hands. “When you look at the issues that we deal with … you will find support across the parties,” Gray said.

So far during this election cycle, the  HDMA has given $31,000 to congressional candidates, CQMoneyLine.com reports. That compares to the $838,000 given to candidates by GlaxoSmithKline, the drug maker. During the previous two-year cycle, the HDMA contributed $38,500, and in the 2003-2004 cycle, the group channeled only $8,500 to campaigns. The association will “continue … to hopefully see those numbers trend up” through this cycle and in the coming years, Gray said.

Although the HDMA has short-term interests in Congress, especially legislation that would advance “track and trace” technologies that could help strengthen the integrity of the supply chain by keeping closer tabs on shipments of drugs from the manufacturer onward, Gray said the association is also looking ahead to next year. “[There’s] going to be a big debate in the next 12 to 14 months,” he said.

Although the three major presidential candidates — Sens. John McCain (R-Ariz), Barack Obama (D-Ill.) and Hillary Rodham Clinton (D-N.Y.) — have issued health reform proposals, Gray sees no indication of how his members would be affected by them — yet. “I don’t think any of the candidates are there on these topics,” he said.