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Recently, AstraZeneca employees tampered with the genetic test results of tumor patients to defraud insurance funds, which caused widespread concern inside and outside the industry.
According to the public information of the National Medical Insurance Bureau, the cause of this incident was reported by the masses, and under the supervision of the National Medical Insurance Bureau, Shenzhen City set up a joint task force and a special case team of public security and other departments. After an in-depth investigation, the suspect has been arrested.
According to industry analysis, the product involved is AstraZeneca's ace product, the third generation of targeted drug oscitinib (trade name Teresa) for lung cancer treatment. In 2018, the product was included in the national medical insurance class B reimbursement directory through medical insurance negotiations, and the price dropped from 51,000 yuan to 15,300 yuan / box, and in the national negotiations in 2021, this price was further reduced to 5580 yuan.
This is undoubtedly a major benefit for patients, but behind it more stringent reimbursement conditions, many people can not enjoy the benefits of medical insurance reimbursement; at the same time, it is difficult for enterprises to put the amount. This also provides an incentive for medical representatives, patients and other parties to conspire to defraud insurance.
The National Medical Insurance Bureau reported the AstraZeneca insurance fraud case, which is also the first time that medical insurance has smashed the hammer of cracking down on insurance fraud to pharmaceutical companies and sales representatives. Medical insurance will also work together with the public security department to investigate and rectify the genetic testing of targeted drugs nationwide.
The National Medical Insurance Bureau and the Ministry of Public Security also interviewed the relevant responsible persons of AstraZeneca China involved, requiring them to strictly abide by laws and regulations, fully cooperate with the relevant departments to do a follow-up investigation, and order them to "immediately carry out internal investigation and rectification, plug loopholes in marketing supervision", and "expose the interview and rectification situation in a timely manner".
Next, the problem of tampering with genetic test results to deceive insurance will also become the focus of special rectification by the national medical insurance joint public security department, and will be investigated nationwide. If enterprises or individuals have similar behavior, they can voluntarily surrender themselves and may also strive for leniency.
This also means that the pressure of the oncology drug market and the upgrading of supervision will bring huge shocks to the entire clinical use of tumor drugs.
【Desperate under the pressure of performance? 】
AstraZeneca should be the multinational pharmaceutical company that is most familiar with the development of China's pharmaceutical market.
Since the national medical insurance negotiations in 2018, a large number of tumor-targeted drugs have been reduced into the medical insurance directory, which has brought good news to patients. However, behind it, the homogenization of the industry competition has intensified, and the medical insurance fee control, negotiated price reduction, and collection price reduction have all made the Chinese pharmaceutical market as a whole downturn.
AstraZeneca bucked the trend, with its annual operating income in China maintaining double-digit growth continuously. According to the company's annual report, AstraZeneca China's revenue in 2020 was US$5.3 billion, equivalent to a record high of RMB34 billion, holding the throne of the largest multinational pharmaceutical company in the Chinese market.
The star drug Teresa, the third-generation lung cancer targeted drug treatment drug, sold 500 million yuan in 2017 within 9 months of entering the Chinese market; in 2018, the price reduction of 63.5% entered the medical insurance market to maintain growth. According to the data of Aikunwei sample hospitals, the sales of the drug reached 2.135 billion yuan in 2019, which is also a "bellwether" in the field of lung cancer drugs in China.
Behind the halo, the high proportion of AstraZeneca's sales expenses has also attracted industry attention. Yaozhi ranked the proportion of sales expenses of 15 well-known multinational pharmaceutical companies in total revenue, and found that AstraZeneca was the highest, reaching 38.78%. At the same time, the cases of its staff being involved in bribery cases and fraudulent insurance reports have also been exposed.
In fact, although according to industry media such as Cyberblue, the market space for third-generation lung cancer targeted drugs is expected to reach 10 billion yuan, Teresa is also facing pressure from generic drugs. In its just-released 2021 annual report, the company revealed that it had "encountered some headwinds in China" and said that in addition to China, other major regions, including emerging markets, have maintained double-digit growth.
AstraZeneca's high requirements for grassroots sales representatives are also recognized in the industry.
From this point of view, the company's employees are desperate to tamper with patient genetic test reports, which is also suspected of promoting drug sales.
【Reshuffle of oncology drug market】
In the context of the prevalence of Sales in china's pharmaceutical market, the oncology drug market has always been a hard-hit area, and problems such as over-prescribed drugs, abusive drugs, and large prescriptions are often criticized.
After the establishment of the Medical Insurance Bureau in 2018, after the price reduction of more new and high-priced targeted drugs was included in medical insurance, the clinical supervision of the use of such drugs was also more stringent.
Taking targeted drugs based on genetic test results is a means of precise medication and preventing drug abuse. For example, one of the conditions that can be reimbursed by teresa (osimertinib) involved is that adult patients with locally advanced or metastatic non-small cell lung cancer with positive EGFR-T790M mutations have been confirmed.
Such a requirement also means that for patients to be supported by health insurance, they must have a genetic test report that proves the "positive mutation of the EGFR-T790M gene".
In clinical practice, or because of compliance with international authoritative medical guidelines, or because of kickbacks, or patient requirements, many doctors will give priority to recommending or prescribing osimertinib. If the patient can not get the above report, they can only take medicine at their own expense, according to the first national negotiation price of 15,300 yuan, 70% of the reimbursement ratio, the price of a single box can be higher than tens of thousands of yuan.
In order to reduce the burden on patients, medical representatives sell drugs, and alliances of interests are easily formed. Therefore, in practice, pharmaceutical companies collude with third-party institutions, doctors tamper with reports, and even medical representatives directly PS a fake genetic test report has occurred repeatedly, in addition to Shenzhen, Sichuan, Anhui and other places have appeared similar cases exposed. Some insiders said that liver cancer can be changed to lung cancer.
"It's only half a step away from getting rich and killing people." As early as a report in Caixin Weekly in 2019, there were sales staff of tumor drug genetic testing companies who commented on this industry.
As a new weapon in tumor therapy, targeted drugs can act at specific carcinogenic sites and kill cancer cells in a targeted manner. Compared with the traditional radiotherapy and chemotherapy model of "killing a thousand enemies and losing eight hundred" with obvious advantages, the birth of such drugs has also pulled tumor treatment into the era of precision treatment, and even changed the tumor from a terminal disease to a chronic disease.
However, targeted drugs are not a panacea, from the perspective of approved indications, they can only work on specific targets, and they are three points of poison, which can also be fatal if used improperly.
Next, according to the announcement of the medical insurance department mentioned above, medical insurance will work with the public security department to carry out a major rectification of this chaos. In other words, AstraZeneca is just the beginning, and any company that behaves like this will be investigated.
More importantly, some institutional researchers pointed out that the health insurance department is building a new regulatory system. In this kind of rule, the enterprise must build a compliance system, and it is clear that the internal reporting of the enterprise will be encouraged in the form of rewards.
This also puts an invisible shackle on the enterprise. Once the violation is not only the representative involved, the enterprise also faces a huge settlement fee, public statement, rectification and other penalties. For domestic pharmaceutical companies whose compliance systems have not yet been established, the situation is particularly grim.
In this way, the health insurance bureau further tightens the "money bag", and China's oncology drug market is more difficult to do.
According to Frost & Sullivan statistics, in 2018, the scale of only small molecule targeted drugs in China reached 11.4 billion yuan, and it is expected to reach 22.4 billion yuan by 2022, with a seven-year compound growth rate of 17.53%.
If these products are paid by the medical insurance fund, it is undoubtedly a huge pressure. In order to reduce the burden on patients and revitalize the pharmaceutical market, innovative drug companies need to participate in more payers to obtain reasonable profits.
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