Can’t Always Get Watcha’ Want

“Oh, you can't always get what you want, aaaahhwaw
But if you try sometimes, you just might find
You get what you need.”

Rolling Stones, You Can't Always Get What You Want

“Positive anything is better than negative nothing.”

Elbert Hubbard

A long decade ago an important pharmacy-practice-related windmill presented itself… just ripe for the tilting.  Some years previous to this, several large Pharmacy Benefits Managers, (PBM s), had implemented a new policy of mandatory pharmacy mail-order participation for prescription insurance enrollees.  The threat to pharmacy practice, and the potential negative impact upon patient access to important pharmacy services, loomed large and clear.

A telephone query to a dean at the University of Michigan Law School put a potential response into play.  The dean decried the monopolistic implications of the practice of forcing patients to utilize any given prescription dispensary against their own personal choice.  He recommended that organized pharmacy respond quickly and decisively by soliciting a federal antitrust lawsuit against the offending insurers; and he opined that the legal effort would likely succeed.  The actions by the insurers walked like a duck, and quacked like a duck.  They still do… even to this very day.

Organized pharmacy, (then, as is the case now), proved to be less-than-organized.  A clarion call to action fell on mostly deaf ears.  State and professional pharmacy associations played their part by raising rallying cries… but the organization member pharmacists were having little of it.  The pharmacy associations spun and spun the issue… but could gain little traction with pharmacists at large.  Ironically, pharmacy associations are currently blamed by revisionist historian-pharmacists for snoozing at this particular switch.  Nothing could be farther from the truth.

The pharmacy association in Michigan chose to raise awareness of the problem by supporting a petition drive that proposed creation of new state law that would allow but regulate mandatory mail-order practices.  The law would define ways that patients could opt out of mandatory dispensing requirements that might create barriers to patient access to pharmacy care, or that might unreasonably inflate the cost of providing pharmacy services to insurance enrollees.  The strategy was not to malign the insurers, but was rather to ensure sensible cost effective patient access to pharmacy care.

A modest number of pharmacists responded well to the petition effort; but overall response was under-whelming.  The biggest barriers to participation were disinterest and apathy.  The national pharmacy associations were terrific boosters of the Michigan cause, but the drum roll of their support banged equally unheard.

A surprising number of pharmacists actually opposed the effort:  some pharmacists hoped to form their own little PBM to seize a business advantage from a monopolistic mandatory dispenser benefit, the big-box chains had recently embarked upon a PBM buying spree and also coveted the mandatory dispenser benefit, and some pharmacists refused support because the effort to legislate did not lean far enough toward punishing the evil prescription insurers and seemed toothless.

Petition efforts require millions of dollars in financial support in order to succeed.  That’s just a fact.  This effort had only tens-of- thousands of dollars to spend, and it got soundly and predictably trounced by richer opponents.  The project died a pauper’s death, and the funeral was sparsely attended.

The main goal of galvanizing pharmacists to rally behind an organized effort to regulate mandatory mail-order prescription benefits, and to pursue federal litigation against the monopolistic tactics of prescription insurers went unrealized.

“But I tried didn’t I?  Goddammit, at least I did that,” barked Randall McMurphy in the book, One Flew Over the Cuckoo’s Nest.  Easy to relate.

The current effort to gain support for federal legislation to create Medicare provider status for pharmacists has reeled this cautionary pharmacy tale gasping and struggling back to the surface.  The parallels are strong and worrisome.

The pharmacy associations are once again leading the charge into battle, all the while struggling to rally troops behind them.  Apathy and indifference are again playing a familiar role, while some pharmacists even devise reasons to oppose the fight.  Déjà vu.  The needs of the many are at risk of being outweighed; by the inaction of the most, and by the wants of the few.  That’s the cautionary twist in this fable, the moral of the story.

You can’t always get what you want.  If laws are indeed made like sausages… then their casings are the slippery stuff of compromise.  Sweet surrender holds everything tautly in place.  Compromise dictates that everybody gets something, and that nobody gets everything.  Everybody wins by graciously losing.  Pharmacists would be wise to learn how to embrace grace and loss.

A frank refusal to yield guarantees that nobody gets anything.  Apathy, inactivity, contrariness, and obstinacy are venalities… that cashier the same wages as do all other sins.  Willingness to settle for what you can have is the only reliable way to demonstrate that… positive anything is better than negative nothing.

The current push to gain limited Medicare provider status for pharmacists might not offer all-pharmacists-all-things-all-of-the-time… but this grounded approach is certainly worth the try.  And if you’ll try sometimes, you just might find… you’ll get what you need.

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