Pharmaceutical kickbacks refer to medical staff in medical institutions taking advantage of their position as prescribers to illegally receive property from sellers of pharmaceutical products, such as drugs, medical equipment, and medical hygiene materials, under various names, in exchange for pharmaceutical products. Illegal behavior by the seller to seek profit.
Since about the 1990s, some pharmaceutical companies have discovered that they can sell drugs to hospitals by buying off hospital directors. However, if doctors do not use them, the sales of the drugs will still be very limited. As a result, a group of people who specialized in medical work began to appear in the hospital, namely medical representatives. In order to encourage doctors to use more of the products they promote, a commission is given to every doctor who uses their own medicines. At the beginning, the amount of money was very small, only one or two yuan. Although it was small, the effect was very good. It costs less than advertising, but the effect is quite different. No matter what kind of medicine, as long as there is a rebate, the doctor can use it with a stroke of his pen, and there is no reason why it cannot be used. After the initial small talk was not effectively suppressed, the kickback trend intensified. From the initial 1 to the current maximum of 30 or even 50, pharmaceutical rebates have become an important part of the income of doctors in large hospitals, and they are generally blooming. trend. Pharmaceutical companies must have clinical salesmen, who are now medical representatives. If they do not do this, pharmaceutical companies will not survive at all. According to information provided by the Leading Group for Combating Commercial Bribery under the Ministry of Health in 2005, in the national pharmaceutical industry, drug rebates as commercial bribes embezzle national assets of approximately 772 million yuan every year, accounting for approximately 16% of the annual tax revenue of the national pharmaceutical industry. .
Unwritten rules for medical rebates
As for the unspoken rules for the operation of medical rebates, a medical representative said that there is a rule in the industry, which is called "If you don't find three kinds of doctors, you must know two kinds of doctors." ". The three types of doctors are: nurses, trainee doctors and training doctors; and the two types of doctors that must be known are: the clinical doctor in charge of the bed and the doctor in charge of the ward. Most of their positions in the hospital are attending physician, deputy chief physician, and chief physician.
Medical representatives need to investigate the departments and names of the two doctors, and even their personal hobbies. You can only come to your door after all the preparatory work is completed. First, we get to know each other in various ways, such as seeing a doctor, and then chatting until we are familiar with each other. Then there are meals, entertainment, travel, and reimbursement of book expenses. The so-called "book fee" is actually the "opening fee", which can range from a few hundred yuan to thousands of yuan. After the "opening fee" is delivered, the medical representative begins to negotiate with the doctor on the specific rebate ratio. "We all think the word 'kickback' is too ugly, so we call it 'prescription fee' and 'prescription fee,'" a pharmaceutical representative told China News Weekly.
After the drug enters the bidding catalog and starts to be used in the hospital, the medical representative will regularly conduct rebate settlement with the doctor. Doctors hand over their prescription records or the patient's bed number and medication records to the medical representative. Then the medical representative went to the pharmacy department for verification - the pharmacy department had naturally been opened up by the medical representative before.
The "prescription fee" is just the usual fee received by the doctor. Every year at the end of the year, drug dealers try their best to entertain them. Some large drug dealers hold various seminars and academic exchanges for free travel and shopping. Small drug dealers also need to reimburse doctors for some unexplained money. In return.
A medical representative said that kickbacks have become an important source of income for many doctors, and the root cause is that their normal income is low. The salary on the salary slip of a doctor (usually a university graduate) is only over 2,000, so it is difficult to resist the temptation of kickbacks.
An open secret
It has become an "open secret" in recent years that doctors can get kickbacks for prescribing medicines. In almost all major hospitals across the country, there are medical representatives. In order to promote their own medicines, they promise that for every box of medicines that doctors prescribe, they can receive a rebate based on a certain percentage of the drug price.
As the inside story of this industry continues to be exposed by the media, we have learned that medical rebates not only "enrich" a group of doctors, allowing them to live a life of driving famous cars and living in good houses, but also allow medical representatives themselves to earn a lot of money. The salary is full, and the average monthly income is about 10,000 yuan... Recently, a medical representative finally couldn't bear the condemnation of his conscience and stood up to express repentance for this behavior that extremely harmed the interests of consumers; and an Anhui doctor also had a sense of justice. Driven by this, he constantly reported the hospital’s various behaviors of accepting kickbacks, which attracted public attention. Our reporter recently listened to them tell their stories.
Medical representative starts "Charity Hall"
Zhao Zhongcheng was once a medical representative, but now he has started charity and opened a "Charity Hall" pharmacy in Changsha, Hunan Province with his own money. With a breakeven price and dozens of square meters of store space, it competes with powerful hospitals, pharmaceutical companies and even its former peers.
For nine years from 1994 to 2003, Zhao Zhongcheng had been working as a medical representative. He told reporters that after drugs leave the factory, they have to go through layers of agents from national, provincial and local pharmaceutical companies before they can reach the hospital. In these intermediate links, in addition to the money that agents at all levels "should take", everyone in the hospital, from the president, director of the pharmacy department, doctors to the finance and drug warehouse, all get corresponding "commissions" according to the size of their positions. In this way, the price of medicines has been raised step by step. A drug with an ex-factory price of 30 yuan has become 100 yuan in the hands of patients; and a drug with a 65 yuan price of 44 yuan has been used throughout the hospital. If the money is insufficient or not delivered in time, the hospital's "little shoes" will come immediately. To "save the situation", you have to double your "filial piety".
“Being a medical representative has improved my life, but it is also very hard.” Zhao Zhongcheng said that before 1996, he made five to six hundred kinds of medicines. If the hospital wanted goods, even just three to five The ten-yuan medicine had to be delivered dozens of miles away, and "the fare was not even enough." On a "big day" like the Spring Festival, he had to spend at least three days taking care of "all kinds of gods." One time, it was New Year's Eve, and he was still running out without even buying vegetables for the New Year's Eve dinner. In addition to the physical hardship, the human hardship also gave him a headache. Zhao Zhongcheng described it this way: If the leaders of the hospital need anything at home, they will come to you in the middle of the night. They went to have late-night snacks, dance, and sing. After they finished, they called directly: "Just come over and pay the bill." "As long as he has a little power in his hands, you have to bow your head and maintain the relationship. Even the porters don't dare to offend." Zhao Zhongcheng sighed.
Zhao Zhongcheng’s long career as a medical representative has not erased Zhao Zhongcheng’s conscience. He became increasingly intolerable to the practices of some hospitals: A cancer hospital in Changsha earned 300 million yuan a year and spent 6 million yuan on advertising, but even patients could not return boxes of medicine there. In the past nine years, he has seen too many patients being "eaten alive" by high drug prices for medical treatment, and they were kicked out as soon as the money ran out. All this made Zhao Zhongcheng's conscience tortured. Every time a relative or friend asked about it, he would advise them not to go to the hospital to buy medicine and buy it for him himself. Finally, when his uncle spent all the family savings on treating psoriasis and finally suffered a nervous breakdown and committed suicide by taking poison, he could no longer bear the torture. He went home and thought about it for two full months, and finally decided to use the experience and experience accumulated as a medical representative. With the money earned, he opened a charity pharmacy to help patients avoid the harm of inflated drug prices.
The "Charitable Hall" pharmacy was officially opened in January 2004. It mainly sells cancer drugs. The address was also specially chosen opposite the cancer hospital mentioned earlier. Because "among all patients, cancer patients are the most unfortunate. You can save a lot of money on the drug cost alone." The reporter saw on the drug price list provided by Zhao Zhongcheng: The hospital sells oral liquid for 175 yuan. Charity Hall only sells them for 35 yuan; a capsule sold by the hospital costs 369 yuan, while Charity Hall only sells it for 68 yuan... There are dozens of medicines, and the price difference ranges from a dozen yuan to more than 200 yuan. Such a price difference is absolutely unheard of by reporters. Where did they come from?
Zhao Zhongcheng told reporters that it is actually very simple, which is to eliminate the various "intermediate links" mentioned above and allow drugs to reach patients directly from pharmaceutical factories. The experience accumulated as a medical representative for 9 years came into play at this time.
When pharmacies purchase medicines or medicines for patients, Zhao Zhongcheng will go directly to the manufacturers and say that he wants to be a pharmaceutical agent, promising not to sell to pharmacies and to sell to patients immediately after getting them.
The "Charitable Hall"'s low, capital-guaranteed prices have attracted more and more patients, which has naturally aroused dissatisfaction among hospitals and colleagues. The hospital across the street often sends people to buy medicines and test the authenticity when they get them back, hoping to find "evidence of guilt"; the hospital also often carries out negative propaganda against patients and "demonizes" the charity hall, saying that there is something wrong with the medicines there; some medical representatives come directly After rummaging through boxes and cabinets, Zhao Zhongcheng scolded him. Not long ago, some colleagues threatened them with unfounded charges and forced them to raise prices. "Such things happen every day." The first way to crack down on charity halls is to investigate, and the second is to cut off supply. Zhao Zhongcheng overcame the latter through his "combat experience"; the former he could only work conscientiously to ensure that there were no loopholes in quality, certification, and management, without giving the other party a chance, and even promised to "compensate 10,000 yuan for any fake products." Zhao Zhongcheng said that every year, the drug regulatory department comes to the "Charity Hall" for random inspections 1-2 times, and they pass the test every time.
For more than two years, Charity Hall has also been undergoing tests from patients. Zhao Zhongcheng told reporters that most patients welcomed them, but a small number did not understand them and believed some malicious propaganda and thought they were liars. In this case, Zhao Zhongcheng said that he could make a computer order, indicate the production batch number, and compensate for any fakes. But even so, some people still don't believe it. "What else can I do?" Zhao Zhongcheng's tone was full of helplessness. However, during the interview, a patient came to buy anti-tumor drugs. The hospital sells this medicine for more than 440 yuan, while the "Charity Hall" only sells it for more than 200 yuan. Zhao Zhongcheng taught him how to return high-priced medicines in the hospital: "Just tell them to report it to the media and report it." The patient said that he was introduced to it by others and felt that it was really affordable. He did not expect it at the beginning. The medicine in the hospital is so expensive. "I hope there will be more pharmacies like this." "The support of these patients is enough." Zhao Zhongcheng told reporters that there are now many repeat customers, which gives him the confidence to make the "Charity Hall" bigger and "explore a new way to solve the problem of difficult and expensive medical treatment."
Anhui doctors have reported kickbacks for 8 years
Zhang Shu is the chief physician of the Department of Emergency Medicine at the Affiliated Hospital of Anhui Medical University (hereinafter referred to as "Anhui"). Since 1998, because he couldn't stand the growing trend of hospitals accepting kickbacks, he embarked on a difficult but continuous road of reporting. It has been eight years now. During these eight years, he reported to the Anhui Provincial Department of Health, the Supervision Department, and even the Ministry of Health using his real name, and submitted a letter to the People's Daily, reporting that the entire Anhui hospital was receiving kickbacks. Some people call him the modern "Don Quixote" because his report not only did not prevent the doctors of Anyi from receiving kickbacks, but the hospital was rated as a "model of spiritual civilization". However, he has repeatedly failed and fought hard to challenge the entire medical industry. The “black hole” of the system poses a challenge.
Zhang Shu told reporters that medical rebates quietly sneaked into Anyi as early as 1993. At that time, the hospital explicitly prohibited taking kickbacks and advocated learning from Bethune and promoting the spirit of dedication. Therefore, only a handful of doctors dare to take kickbacks. But by 1996, kickbacks began to increase. "At that time, there were few drugs with rebates, and the rebates were also low. They were 5% of the drug price, and the rebate for a box of medicines was 1 yuan. When prescribing drugs, doctors would not pay attention to which drugs had rebates and which did not. Inadvertently prescribing drugs with rebates. The rebate medicines were all sent by medical representatives at a cost of one to twenty yuan per month. "Zhang Shu didn't think there was anything wrong at the time.
But gradually, he discovered that a few doctors began to actively prescribe medicines with rebates, taking medicines that should not be used, and performing examinations that should not be done. Some doctors can get 1,000 yuan a month. rebate. Many doctors are disgusted with the few doctors who prescribe medicines indiscriminately and get kickbacks, but there are also envious imitators. During this period, Zhang Shu made a real-name report to the hospital and the Provincial Department of Health about two doctors who "intentionally took kickbacks." This was his first time reporting.
In 1998, drug rebates have increased to 10 yuan. The types of drugs with rebates have increased, and more and more doctors are receiving rebates. The maximum monthly rebate can be 2,000 yuan. But at the same time, the phenomenon of random prescribing of drugs is rampant. Some doctors abuse drugs to patients and often prescribe inappropriate drugs. This not only wastes medical resources, but may also produce toxic and side effects, making patients worse.
Zhang Shu realized more and more clearly that the hospital was changing from a public institution responsible for saving lives and healing the wounded to a profit-seeking enterprise. It was in this year that Zhang Shu, who had unintentionally received more than 300 yuan in kickbacks, officially withdrew from taking kickbacks and once again reported to the Anhui Provincial Department of Health and Supervision in his real name. The letter of complaint was like a drop in the ocean, but he was unwilling to give in. He then reported it to the Ministry of Health and submitted a letter to the People's Daily.
On January 23, 1999, "People's Daily" published Zhang Shu's letter - "Why Drug Rebates Are Repeatedly Prohibited". The article lists in detail the phenomenon and examples of kickbacks in medical insurance. This article caused a lot of trouble for Zhang Shu: the hospital held several special meetings, which turned into a "denunciation meeting" against Zhang Shu, accusing him of "ruining the hospital's affairs." But at the same time, this article also attracted the attention of superior leaders. Subsequently, the hospital's leadership team was changed, and the efforts to participate in the "National Top 100 Hospitals" were in vain. For more than a month after the article appeared in the newspaper, medical representatives did not dare to visit the hospital, and the number of patients visiting the hospital dropped sharply... But soon, as the matter was not handled, everything returned to "normal".
At the end of 1999, Zhang Shu went to a research institute in Beijing for one year of further study. While seeing the high personal quality and strong professionalism of doctors in Beijing, Zhang Shu was also surprised to find that "many hospitals here take kickbacks much more than Anyi." There are very few people who accept kickbacks from drug dealers and equipment dealers. Say "no". A heart stent used to treat coronary heart disease was sold for US$300 abroad at the time, but sold for 20,000 yuan in Beijing, an increase of eight times. Doctors can get a 2,000 yuan rebate for placing a stent on a patient. At a lecture, a doctor said that he could place 300 stents a year. As a result, everyone calculated that he could receive a rebate of 600,000 yuan, which made him sigh. What he saw and heard made Zhang Shu doubt his own behavior: The whole country is like this, is it fair to just report An Yi? He also fell into disappointment and confusion: These doctors were all good people, but why did they take kickbacks? Before he could figure it out, Zhang Shu set a "two no's principle" for himself: one would not collect medical kickbacks, and the other would not report them.
This principle did not last long. In 2002, Anhui Medical University was initially rated as an "Anhui Province Spiritual Civilization Model Unit" by the province, and it was announced to the public for opinions. Zhang Shu was angered: "The phenomenon of Anyi receiving kickbacks has not decreased, but has become more and more serious. How can it be worthy of being a model of spiritual civilization?" According to the public address, Zhang Shu reported again with his real name. His reporting materials were forwarded to the Provincial Department of Health. In June 2002, two department heads of the Department of Health came to talk to him and asked him to produce evidence. Zhang Shu took out several prescriptions signed by "Qi Deru" on the spot. Payment slip. It turns out that in the drug rebate network, counting doctors' prescriptions is an important link. The hospital computer center counts the names and quantities of each doctor's medicines and provides them to drug dealers, who then calculate and deliver rebates to doctors. In order to deal with "unreliable" doctors like Zhang Shu, the hospital specially made up the name "Qi Deru" and credited their prescriptions to this person's name. In this way, doctors who do not receive kickbacks will not find themselves "earning" kickbacks, and no one knows where the kickbacks from "Qi Deru" will end up.
But during the investigation, Anyi's computer charging system suddenly "broke down" and changed to manual charging. On the third day, the computer system was restored and "Qi Deru" no longer appeared. The hospital was eventually rated as the "Anhui Province Spiritual Civilization Model Unit" that year, and the phenomenon of receiving kickbacks did not end. Seeing that his repeated reports were ignored, Zhang Shu decided that instead of letting the "kickbacks" go unexplained, it would be better to use them in useful ways. Therefore, starting from April 2003, Zhang Shu also "collected" kickbacks. However, every month, he sends the kickbacks he collects to the "Chunlei Office" of the Women's Federation of Anhui Province to support out-of-school girls. As of 2006, the total amount has reached more than 40,000 yuan.
The Ministry of Health wants to crack down on drug rebates
Regarding Zhang Shu’s eight-year struggle against drug rebates, Yu Zonghe, former director of the Department of Medical Affairs of the Ministry of Health and a senior hospital management expert Zeng expressed his great admiration and pointed out that the phenomenon of collecting kickbacks and red envelopes in the pharmaceutical field has reached the point where "thousands of people are criticizing".
As for the formation of this phenomenon, he analyzed that on the one hand, the supervision of hospitals and doctors has not been in place for a long time, which has artificially allowed the formation of a situation of "supporting medicine with medicine"; on the other hand, it is due to the imperfect rules and fierce competition in the pharmaceutical industry. , leading to industry-wide chaos.
According to the reporter’s understanding, starting from July this year, the Ministry of Health will carry out in-depth self-examination and self-correction work in the national health system. The main content is to control the acceptance of kickbacks and commissions from pharmaceutical companies. Although the power of Zhao Zhongcheng and Zhang Shu is weak, we firmly believe that more and more people will wake up and eventually improve policies and systems so that the phenomenon of medical kickbacks will completely disappear.