(People's Daily Health Client Reporter Tan Qixin Wang Aibing) On January 28, the entry "Reflux Medical Insurance Drugs Were Sold Whitewashed" appeared on multiple social platforms. According to CCTV News, recently, Yunnan seized a case involving an amount of up to 200 million yuan in reselling medical insurance drugs, in this case, the suspect instigated insured patients to prescribe drugs in many places and hospitals in a short period of time, and these patients are almost all patients suffering from uremia or other types of special diseases and chronic diseases.
In an interview with the People's Daily health client, a number of interviewed experts pointed out that the imperfect regulatory mechanism is one of the main reasons for this phenomenon; on the one hand, the outpatient reimbursement range for patients with chronic diseases and special diseases is large, and most of the commonly used drugs can be prescribed for a long period of time, and the maximum amount of drugs can be prescribed for 12 weeks, and the boundary between overdose and full dose is not clear; on the other hand, the current nationwide access to outpatient chronic diseases and special diseases, There is a lack of unified and clear laws and regulations for the audit, and the qualification review of outpatient chronic diseases and special diseases is "only in but not out".
According to data from the medical insurance agency in Pu'er City, Yunnan Province, the number of abnormal prescriptions reached 5,247. Screenshot of CCTV program
The reimbursement rate for chronic diseases can reach up to more than 90%, and there is no unified standard for patient qualification review and supervision
The People's Daily health client reporter inquired about the regulations on outpatient chronic diseases in various places and found that at present, the reimbursement treatment of outpatient chronic diseases across the country is higher than that of ordinary outpatient clinics, and the outpatient reimbursement rate of some retired patients with chronic diseases can reach more than 90%, and for some commonly used drugs, doctors can prescribe 4-12 weeks according to the patient's situation, but at this stage, there are great differences in the number of chronic diseases, chronic disease identification procedures and management in various places, and the degree of "tightness" of the audit is different.
According to the "Notice on Unifying the Management Services of Outpatient Special Diseases and Chronic Diseases of the Provincial Basic Medical Insurance" issued by Yunnan in 2020, there are currently 15 types of outpatient special diseases and 25 types of outpatient chronic diseases in Yunnan, and the proportion of outpatient reimbursement payment is higher than that of ordinary outpatient clinics, up to about 90%.
In the same year, Yunnan simplified the confirmation and filing and regular review of various certification materials such as hospitalization certificates and medication history by medical insurance agencies in the past to the filing of special diseases and chronic diseases diagnosed and issued by qualified physicians according to designated medical institutions, and handled them immediately at the medical insurance window, and cancelled all kinds of outpatient special diseases and chronic disease confirmation materials and stamped certificates in the past. At the same time, for the convenience of patients, the restrictions on the amount of drugs used for special and chronic diseases in outpatient clinics have been abolished, and the regulations on the selection of medical treatment and drug purchase for patients with special and chronic diseases in outpatient clinics have been gradually relaxed.
In Beijing, there are a total of 17 kinds of special diseases, and the insured must hold the special disease diagnosis certificate issued by the designated medical institution and the "Beijing Medical Insurance Special Disease Filing Declaration Form" to the insurance area agency for filing procedures, and select 1-2 designated medical institutions for medical treatment, retirees can be reimbursed up to 90%; In principle, the designated medical institutions for patients can be replaced once a year as needed.
It is difficult to supervise the use of outpatient chronic disease funds
One of the kidney disease treatment drugs resold in the case - Haikun Kidney Xi Capsule. Screenshot of CCTV program
"With the continuous expansion of chronic diseases, although the difficulty of diagnosis and treatment and the cost of a single medical treatment are significantly lower than that of hospitalization, in fact, many characteristics of outpatient chronic disease (such as disease characteristics/medication characteristics/disease population is mainly elderly, etc.) determine that its management difficulty is actually higher than that of inpatient diagnosis and treatment, and it also determines that it is difficult to supervise the use of outpatient chronic disease funds. On January 28, an expert who has been studying medical reform policies for a long time told the People's Daily health client reporter that the connotation of the outpatient chronic special system is more complex, compared with inpatient diagnosis and treatment, the diagnosis and treatment plan for outpatient patients with chronic disease is completed by medical personnel in medical institutions, but its implementation is highly dependent on the patients themselves, and the closed-loop management of the diagnosis and treatment process cannot be formed, which may bring a series of risks.
He further mentioned that because of the qualification for chronic disease and the related expenses are borne by the medical insurance fund, the insured will regularly prescribe sufficient or even excessive drugs in medical institutions regardless of whether they really need or use the drug.
Throughout the incident, lawyer Daniel Zhang, the founder of Medical Law Exchange, who has long been concerned about the supervision of medical insurance funds, also paid attention to the hidden dangers caused by the fragmentation of the outpatient chronic disease system in mainland China. "With the expansion of outpatient cross-provincial direct settlement coverage in the future, the number of medical insurance fund supervision involved will be larger, and there is a lack of relevant regulatory legal basis, and the insureds and medical workers have insufficient grasp of this medical insurance policy and a low degree of informatization, which has brought great difficulties to the work management of medical insurance agencies and designated medical institutions. ”
It is recommended to improve the regulatory mechanism at the national level
"If the whole country can unify the system and drug management, and supervise the variety and dosage of drugs for patients, especially for chronic diseases, some problems can be effectively avoided in advance. A medical insurance regulatory expert told the People's Daily health client reporter that a few years ago, Beijing has introduced relevant policies to monitor the dosage of patients, and once there is an overdose, it will be reminded and controlled, and it is recommended that relevant management measures should be introduced in various places;
Daniel Zhang also suggested that the national level should speed up the introduction of a unified policy and normative path for outpatient chronic disease access and drug supervision, and secondly, the case lasted for a long time before it was discovered, which to a certain extent reflects the urgent need to further promote the construction of regional medical insurance informatization and realize the information interconnection between medical insurance handling institutions and designated medical institutions. With the full launch of the national medical insurance information platform, all localities should further optimize the medical insurance information system, and on this basis, build a more convenient, efficient, safe and smooth upload and settlement network, realize the information processing of outpatient chronic disease settlement, and gradually improve the outpatient chronic disease diagnosis and treatment and drug catalog at the same time, and truly realize the information management of outpatient chronic disease medical insurance payment. ”
The above-mentioned experts also mentioned that the main body of the medical insurance drug reflux case is mainly patients with chronic diseases, and how to define whether there is an overdose and whether there is insurance fraud on the basis of respecting the clinical law of drug use is an unavoidable problem in the next step when formulating the relevant regulatory norms for chronic diseases.
"Judging from the past insurance fraud cases, although the amount of insurance fraud cases in which the insured participated is not large, the high proportion must be paid attention to. On the one hand, it is necessary to strengthen the publicity and education of the insured, increase the punishment for the insured who subjectively and intentionally abuse the fund to resell drugs, consider canceling the insurance qualification for life, and consider transferring the relevant case-handling agency to deal with the larger amount, and set up a model. Daniel Zhang suggested that in addition, the level of refined management of outpatient chronic diseases in hospitals should be gradually improved, and the annual drug specifications and maximum dosage should be determined for the outpatient chronic disease qualification treatment population, combined with the name of outpatient chronic disease, clinical diagnosis, and drug type, and maintain the functions of medication cycle, cumulative dosage, annual remaining drug amount, and repeated drug interception in the hospital's outpatient information system to ensure that their outpatient medication complies with medication principles and guidelines.