I felt a little sore throat, so I thought about experiencing the outpatient coordination of the pharmacy. The store was crowded, and I only heard the salesman asking an old man: "You are an employee medical insurance, think about it, are you uncomfortable?"Your outpatient pooled credit expires in the year. "That's not a big deal.
Coincidentally, at this moment, my ** sounded, and a leader of the medical insurance department said to me worriedly: "It's really unacceptable, I saw the outpatient co-ordination pharmacy packaging some edible Chinese medicine sachets such as angelica and gastrodia, and selling them to the outpatient co-ordination patients with almost the same prescription." "Coincidentally, two friends were asking me for confirmation in the evening: the old man heard that the pharmacy said that he should buy medicine quickly, and if he didn't buy it, he would waste this year's reimbursement, so he was eager to try it.
I don't want to do specific statistics, I believe that "surprise consumption" before the end of the year is already an indisputable fact, which is led by a small number of bad pharmacies, causing many patients, especially elderly patients, to be out of proportion.
The inclusion of designated retail pharmacies in the overall planning of employee outpatient clinics is an important supporting measure for the reform of employee outpatient mutual aid. To put it simply, the employee medical insurance is divided into two parts: overall planning and personal account, and the past policy design is that the personal account is mainly used to protect daily minor illnesses and pains, that is, mainly outpatient clinics and drug purchases;Co-ordination** is mainly for inpatient reimbursement, but also includes reimbursement for outpatient chronic diseases, dual-channel drug purchases, etc. The biggest disadvantage of this is that many healthy young people do not use their personal accounts at all, and a large amount of funds are deposited. The medical insurance itself is not a savings, but a mutual aid role, so that those who need it can use it a little more and can solve people's difficulties more. Therefore, after careful research, the reform of employee outpatient mutual aid was launched, the amount of personal accounts was reduced, and the overall reimbursement of employee outpatient medical care was increased, so as to revitalize the deposited large amount of funds and better realize the mutual aid function of medical insurance. At the same time, in order to better facilitate patients to seek medical treatment and purchase drugs, it is clarified that patients can purchase drugs at designated retail pharmacies with compliant prescriptions, which will also be included in the reimbursement.
Taking Hunan Province as an example, the maximum annual payment limit for in-service employees is set at 1,500 yuan, and the annual payment limit for retired employees is 2,000 yuanThere is no minimum payment line for employee medical insurance in primary medical institutions, and 70% of the reimbursement is within the policy scope, and there is a certain minimum payment standard above the second level. Pharmacies included in the outpatient co-ordination have the same policy as primary medical institutions, and the annual maximum payment limit is calculated together with the medical institutions. And the current problem of "surprise consumption" is caused by the annual maximum payment limit. It doesn't seem to be a problem, the annual payment limit, which has not been paid this year and will not accumulate until next year, "if you have money, you don't need it, and it will be invalid when it expires". However, is this really the case?
Let's start with the insured patients, the core question is: are the drugs you buy really worth it?It is indeed unwell, even if it is a sore waist and legs, it is understandable to ask the doctor to take a look at it and buy some medicine to go back. However, what I am most afraid of is that the pharmacy will instigate and buy a bunch of messy medicines, which seems to take a big advantage, and if you think about it carefully, you will find that you will suffer more.
One is that you have to pay for these medicines, and you have to pay at least 30% of themThis means that buying 1,000 yuan of medicine is at least 300 yuan, and you have to think about whether the 300 yuan is worth it, and many of them are probably shelved when they buy it.
The second is that drugs have an expiration dateThis thing can't be eaten as a meal, nor can it be used as a snack, and once it expires, there is a high probability that their destination will be a trash can. It is undoubtedly a huge waste of resources and individuals.
The third is that medicine has character, and without professional guidance, it is probably easy to eat something wrong with taking medicine. For example, even the simplest cold is divided into wind-heat cold and wind-cold cold, and the wrong medication may be the opposite, which is the author's personal experience;Anti-inflammatory drugs may not be used indiscriminately, and penicillin is not something that everyone can eat, let alone other diseases**. There are probably not a few cases of taking the wrong medicine and aggravating the disease, and it seems that there is no need to be greedy for this cheap to make your own claims. Even if it is angelica and codonopsis, I am afraid that not everyone is suitable for stewed and eaten, traditional Chinese medicine pays more attention to individual conditions, and there are 9 kinds of constitutions from the identification of physique.
Fourth, the safeguard mechanism is unimpededThe outpatient co-ordination of insured employees has a quota of 1500 or 2000 every year, and it is certainly enough to protect the general cold and fever, and there are special protection channels for two diseases and outpatient chronic diseases, and in addition to these larger diseases, it is impossible to buy medicines by themselves, or they will be hospitalized, and there is no need to stock up on medicines.
On the pharmacy side, the core question is: can your drug purchase reimbursement really stand up to inspection?Guiding the formation of the psychological effect of "not buying drugs for reimbursement will be a loss", and advocating the bad remarks that "the quota will be invalid before the end of the year" may bring a certain increase in turnover. However, there are many paradoxes here.
One is, is the prescription issued compliant?Internet prescriptions have strict norms, and the National Health Commission has specially issued measures for the management of Internet diagnosis and treatment and measures for Internet hospitals, and Internet diagnosis and treatment activities shall comply with the requirements of medical management, and Internet diagnosis and treatment activities shall not be carried out for first-time patients. Word after word, our pharmacy prescriptions, especially those that are purchased before the end of the year, do not comply with the above regulations. It is important to know that pharmacies are the main body responsible for medical insurance reimbursement, so it is a basic obligation to ensure that they are sold and included in the reimbursement according to the compliant prescription.
The second is, is the diagnosis and treatment reasonable?In the era of big data, all drug purchase behaviors are transparent, and the time interval between drug purchases, the main symptoms of each drug purchase, and the details of each drug purchase can form a complete logical chain. That is, only a few rules need to be written in the rule library of medical insurance supervision, and the suspicious data will surface one by one, and the rest is to be verified. Will the law not be held accountable to the public, how is it possible, just look at the strength of medical insurance supervision.
The third is, is the cost of fraud and insurance fraud great?If the above inducements and adaptations are just marginal balls and violations, then I am afraid that some retail pharmacies are stepping on the red line and crossing the bottom line. If it involves the exchange of drugs and involves false transactions (i.e., cashback), it is a very clear violation, and once it is verified, it will not only usher in the punishment of breach of contract, but also the criminal liability that must be borne may bring imprisonment. The main body of responsibility for this kind of fraud and insurance fraud is very clear, and whoever instructs and operates will benefit, and the law is unforgiving, and I am afraid that some people will regret it. In addition, it was reported that a listed company was deceived by insurance fraud in individual stores, resulting in hundreds of millions of yuan in financing plans being shelved, which is a very profound lesson. If large chain companies cannot strictly manage their own direct or franchised stores, the consequences may also be disastrous.
I really hope that the designated retail pharmacies can uphold long-termism, strengthen self-awareness and self-discipline, earn legal and compliant profits, jointly protect the safety of medical insurance, and jointly protect the rights and interests of the insured people. It is foreseeable that the medical insurance departments, especially the city and county medical insurance departments, will definitely increase the intensity of verification, inspection and inspection, and the gains and losses of violations of laws and regulations will outweigh the losses and pay the price.
* |The medical road is forward, and the medicine is shared by you.
Edit |Zhang Chenxuan, Liu Xinyu.
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