Qui tacet, consentire videtur!
Silence implies consent!Dear Colleagues; As we leave 2018 behind, with the “Health Services Pricing Commission Decisions” published on December 28, 2018, for the Magistral Tariff priceswe received the news of a 14.47% increase. To be honest, we cannot say we are pleased with this news. The increases in foreign exchange rates are unfortunately far above the increase in the magistral tariff. Whereas, how important the compounding of magistral products in pharmacies is for our country and profession, I can say that we are tired of expressing at every opportunity.Of course, the only obstacle in front of our Art of Compounding is not the low pricing policies set by the SGK for the reimbursement of magistral products. The lack of standard rules during the inspections of magistral prescriptions by institution pharmacists, leaving them instead to the discretion of auditing pharmacists, and the deficiencies in the SGK’s Medula provision system are known as obstacles to the development of this art.
The following question immediately comes to our minds: can the problems or deficiencies we listed above not be resolved? Of course yes, these problems can be resolved in a short time. In this sense, our professional organization has a responsibility. This way, pharmacists will know which rule violations lead to deductions when preparing magistral prescriptions and will prepare the formula by adhering to these rules while preparing their prescriptions. In short, we pharmacists, the masters of the healing art, now expect the SUT rules for magistrals to be implemented as soon as possible.
Dear Colleagues, in recent months I received a message on my Medula screen. In the message;‘…that the prescriptions under batch list number 19712880 were examined using the sampling method, that I caused a loss of 0.38 TL to the institution because the 80 cc of 70% alcohol in a compounding formula on a prescription was not converted to grams and entered into the system in that manner, that the sampling error rate calculated as a result of examining this figure with the sampling method was: 0.0636, that the deduction amount after proportioning would be deducted as 6.23 TL, and that an application must be made to the S.G.K. Health Social Security Center within 5 business days for a re-examination of the deduction or an examination of all prescriptions…’was stated.
I presume that many of my colleagues receive such deduction notices and, unfortunately, remain silent. As I stated in the title of my article, “Remaining silent is giving consent”.
Believing that staying silent means consent, I filed my objection to this notification within the designated timeframe. In my justification;I exercised my right of objection specified in the protocol by stating that the formula prescribed by the physician to the patient was calculated and prepared exactly as written on the prescription, that there was no calculation error or preparation mistake, that the absence of an ML button in the Medula system should not be evaluated as a pharmacist error, and that this deficiency is an institutional Medula system error and should not be a reason for deduction.As is known, in the section (4.) PAYMENT TERMS AND TIME of the PROTOCOL ON THE PROVISION OF MEDICINALS FROM PHARMACIES MEMBERS OF THE TURKISH PHARMACISTS’ ASSOCIATION FOR PERSONS COVERED BY THE SOCIAL SECURITY INSTITUTION, Article 4.3.5; “The Pharmacy objection review commission consists of a total of 4 (four) persons, chaired by the director of the health social security center or personnel designated by them, comprising 1 (one) healthcare services class personnel serving in the health social security center, the pharmacist whose prescription is being examined, and a pharmacist from the regional chamber of pharmacists. Decisions are made by majority vote. In case of a tie, it is referred to the objection review higher commission established at the general directorate.”is regulated as follows.
In accordance with this article; the issue causing the deduction was discussed in the OBJECTION REVIEW COMMISSION, and regarding the calculation by weight (GRAM) on the grounds that there is no volume (ML) button upon entry into SGK’s provision system MEDULA, despite the alcohol quantity being written by volume (ML) by the physician in the prescription that formed the basis of the objection to the deduction, while the two pharmacists serving at the SGK institution within the four-person objection commission found the deduction justified, my pharmacist colleague participating from the Chamber of Pharmacists as a commission member and Istated that actions were taken in accordance with the Contract and the Health Implementation Communiqué (SUT) rules, that there is no provision in the SUT indicating that prescriptions written in volume (ML) by physicians would be converted to weight (GRAM), that the formulation was prepared correctly as requested by the prescribing physician, that it was incomprehensible why such a conversion was not requested for the other liquid in the same formula in the prescription, that this was a contradiction and showed a lack of standard rule on this matter, that the deduction was entirely at the discretion of the pharmacist performing the prescription check, whereas if a volume (ML) button were added to the MEDULA system, such problems would not occur; and we objected to the deduction and requested its removal.Upon the failure to achieve a majority vote in the objection review commission;to the General Directorate Objection Review Higher Commission’s office, the file was referred. As is also known; the examination of prescriptions and accompanying documents, for which a decision could not be reached by a majority vote in the pharmacy objection review higher commission, is conducted. In connection with the rule that decisions in the pharmacy objection commission are made by a majority vote, when referred to the higher objection commission in the event of a tie, according to the contract, the “higher objection review commission” and “decision-making method of the higher commission” is constituted as follows: “The General Directorate superior objection review commission consists of a total of 3 (three) persons: 2 (two) persons representing the Institution and 1 (one) person representing the TEB (Turkish Pharmacists’ Association). Decisions are taken by majority vote.” As can be seen, state representatives have a 2-to-1 majority in the composition of the commission. In this case, it is evident that there is a situation in favor of the defendant institution.
The General Directorate superior objection review commission, on the other hand, reviewed our file and notified us of the following decision;
On the date of …., ’’The deduction concerning your pharmacy was discussed at the Pharmacy Objection Evaluation Superior Commission Meeting; despite the statement of the Commission member representing TEB that “Since there is no field in the SSI Medula application that can be calculated in ml, the pharmacy had to enter it into the system as grams even though it had prepared the medication in ml. Furthermore, there is no provision in the HIB (Health Implementation Communiqué) regarding the conversion of prescriptions written in ml into grams in this manner. The deduction is unfair.” a consensus could not be reached. Upon examining the procedure performed, it was decided by a majority vote to maintain the deduction.’’In the notification letter in question, it is seen that although the pharmacist representing the TURKISH PHARMACISTS’ ASSOCIATION in the Pharmacy Objection Evaluation Higher Commission defended the same view as ours, the two pharmacist representatives representing the public sector in the commission held an opposing view.
If the protocol in force between SGK (Social Security Institution) and TEB does not belong solely to SGK, but is a unilateral administrative act agreed upon by both SGK and TEB—both considered public institutions—then the decisions rendered by the objection commissions should not be solely SGK’s decisions either. As can be seen, the distribution of commission members is not fair and favors the institution. I hope that this unfair protocol provision will be evaluated by our professional organization during the upcoming protocol process and the necessary adjustments will be made.
Essentially, all members of these commissions must act objectively and lawfully. Furthermore, based on professional knowledge and understanding, legal perspective, the lack of prior and complete notification of deduction reasons, and the absence of any provision regarding deductions in the SUT (Health Implementation Communiqué), I objected to the deduction made in the final days of the year, applied to the court, and ensured that a lawsuit was filed regarding the matter.
In my petition, I outlined my objections as follows:
- The failure to allow the doses of substances in magistral formulations to be entered into the system by volume is the responsibility of the Institution. The Institution should create and publish a separate Health Implementation Communiqué for magistral formulations. Penalizing pharmacists when no such specification has been made or announced, and when the legislation has not been regulated accordingly, is contrary to the Constitution, the law, and human rights.
- In the Health Implementation Communiqué (SUT), published by the Defendant Institution and specifying the reimbursement conditions of medicines, there is also no information indicating that extemporaneous formulations must be prepared and entered into the system by calculating the density by weight, regardless of what the physician prescribes for the ingredients in the formulations or in the compounds to be prepared with this ingredient.
- Pursuant to Article 25 of Law No. 6197; “It is legitimate and required that prescriptions left at the pharmacy for compounding be prepared without modification or alteration, and the dispensing of medicines and prescriptions to the recipient (with their prices indicated on them) shall be carried out according to the principles determined and announced by the Ministry of Health and Social Welfare. The managing director of the pharmacy is directly responsible for any errors or other issues seen in the medications of prescriptions prepared in pharmacies. Pharmacists cannot compound prescriptions whose contents they suspect to be erroneous, or prescriptions containing pharmaceuticals exceeding the amounts stated in the pharmacopoeia (codex) that are not underlined twice and additionally signed, without contacting the attending physician. However, in cases where it is not possible to contact the attending physician, they shall compound the prescription according to the maximum amounts specified in the pharmacopoeia, while reporting the situation to the highest local health authority.” Therefore, the pharmacist is obliged to prepare the prescription true to the original, and this obligation has been fulfilled by us. This matter will also be confirmed by the expert examination to be conducted within the scope of the case file.
While announcing here that in the coming days I will share with my colleagues the report from the pharmacist expert witness and the ruling of the Supreme Court that will evaluate this report and render a decision, I experience the peace of taking the matter to court rather than remaining silent, whatever the Supreme Court’s decision may be. 30/12/2018
Wishing you a happy and healthy new year…
Spec. Pharm. Ahmet Nezihi Pekcan
Pekcan Pharmacy – Konya
[email protected]
Tel: (332) 3520657http://www.majistralformul.com/
