Industry insiders said that the abnormally low drug prices on the Internet are derived from "reflux drugs", which greatly disrupts the price system of industry and chains...
Finishing | Uncle Mo
In recent years, there have been a series of incidents of insurance fraud in the pharmaceutical retail industry, which have attracted great attention from the regulatory side. For example, the Guangzhou Huadu Supervision Bureau investigated and dealt with a serious illegal case involving the online sales of "reflux drugs" by a large pharmacy, a "reflux drug" case in Shenzhen involving an amount of up to 200 million yuan, the Shanghai police seized more than 20 tons of "reflux drugs" since the beginning of the year, and someone in Yulin, Shaanxi Province bought enough therapeutic drugs for 15 years in just three months...
These insurance frauds not only cause losses to the medical insurance fund, but also use "abnormally low prices" to disrupt the order of the drug market, and even have a serious impact on public health and safety.
01
3 months to buy 15 years of medication
CCTV announced on June 30 that in Yulin City, the daily inspection of the Medical Insurance Bureau accidentally found an insured named Chang Mou's abnormal drug purchase behavior, who bought enough treatment drugs for 15 years in just three months. After an in-depth investigation by the police, a chain of fraud and insurance fraud by the insured and drug dealers was uncovered.
The investigation by the Yulin police found that Chang (the insured person of the case) suffered from chronic renal failure and other diseases, and according to the chronic disease medical insurance reimbursement policy, Chang's usual medical insurance reimbursement reached 85%. Chang saw an opportunity to resell some of the extra drugs to drug dealers at low prices, and the drug dealers then flowed the drugs to the market.
What's more serious is that cases like this are not unique, CCTV News has previously exposed the reflux drug industry chain with an amount of up to 200 million yuan, which is shocking.
When communicating with the front-line operators of retail pharmacies, I learned that the abnormally low drug prices on the current considerable part of the network come from the above-mentioned channels, which greatly disrupts the price system of industrial and chain pharmacies, and is also one of the reasons why the industry is in trouble.
02
Shanghai seized more than 20 tons of "reflux drugs".
It is worth noting that since the beginning of this year, there have been many major cases about "reflux drugs".
Since 2024, the Shanghai police have destroyed 9 medical insurance fraud gangs, arrested more than 200 criminal suspects, and seized more than 20 tons of drugs involved in the case.
The scene of the press conference
The Shanghai police introduced three typical cases:
First, it is to attract unspecified retirees to over-dispense; The criminal gang used WeChat groups to recruit some retirees with unspecified household registration in the city to become downline, or borrowed social security cards for a fee to dispense drugs on their behalf, or induced downline "insureds" to use social security cards to go to the hospital to dispense drugs, and then resell them for cash. After the old man prepared the medicine, Wang and Chen went offline to collect the medicine from the old man at 60% of the price of the drug, and stored it in a centralized manner. After accumulating a certain amount, Wang and Chen packaged the recalled drugs in a centralized manner, and shipped them to pharmaceutical merchants in other provinces and cities through logistics at a price of 20% of the drug recovery price per box, so as to make a profit.
Second, it is a "mobile" contact with different patients to develop "downline"; The criminal gang had "mobile" contact with different patients in the city's major hospitals, and once it was discovered that the other party was willing to be greedy, it would develop it into a "downline", and Lu Mou, who had a channel for illegal drug sales, would sell it. After a certain amount of hoarding, it was transported to other provinces and sold by Lu to private clinics and small pharmacies in remote areas, and the modus operandi was relatively hidden.
Third, it is to use "part-time money" and "free physical examination" as bait to induce the elderly to lend social security cards; With "part-time money" and "free physical examination" as bait, criminal gangs set up stalls to induce the elderly to lend social security cards or borrow social security cards for a fee on the grounds of "assisting in dispensing medicines". Since 2022, the gang has sent more than 700 drugs out, weighing nearly 30 tons
More public details show that the reimbursement ratio of many special drugs and chronic disease drugs is around 90%, and the price after the price increase is still far below the market price. According to previous reports, this kind of "ultra-low-cost drugs" have a large sales volume in retail pharmacies, the Internet, micro-businesses and other channels.
03
Establish a "traceability code" payment supervision system
The birth of this gray industry chain is mainly due to the inability to connect the drug and medical insurance settlement information between different hospitals, different medical institutions, and different cities, resulting in these criminals having an opportunity.
Therefore, the National Health Insurance Administration is actively exploring the development of a big data supervision model of "reselling medical insurance drugs", improving the intelligent reminder function of the medical insurance intelligent monitoring system, and putting an end to the phenomenon of repeated prescription of drugs between different hospitals and reselling of drugs for profit.
At present, the National Health Insurance Administration has carried out a big data supervision pilot, and Yulin, Shaanxi Province, as a pilot city, has promoted the application of the "traceability code" of medical insurance drugs in outpatient co-ordination and designated pharmacies, realizing the integration of the traceability code and the commodity code, and forcing the scanning code in the drug settlement and medical insurance payment links. Fully grasp the information of the prescribing institution, the number of drugs purchased, and the purchase cycle. If the insured purchases drugs in advance or in excess of any pharmacy in Yulin City, the system will automatically remind them.
As of June 10, in 81 chronic disease pharmacies in Yulin City, the "traceability code" control system compared a total of 2.03 million pieces of data, intercepted the same drug and paid again 14,057 times, involving a cost of 1.2629 million yuan.
In an interview with the media, the Fund Supervision Department of the National Medical Security Administration said that at present, nearly half of the provinces in the country have started the work of reminding abnormal drug prescriptions, of which Beijing, Tianjin, and Ningxia have basically achieved full coverage; Zhejiang, Hainan, Xinjiang, Inner Mongolia and other countries are also advancing, and will also be deployed at the national level in the future.
Source: CCTV News, Shanghai Municipal Public Security Bureau, etc
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