On October 16, the National Medical Insurance Administration issued the "Notice of the Office of the National Medical Insurance Administration on Standardizing the Management of Prescriptions for Medical Insurance Drugs Outside the Hospital", proposing to carry out special governance on the use of prescriptions outside the hospital.

Before the end of December 2024, special inspections will be carried out on prescription drugs for outpatient chronic diseases and special diseases, urban and rural residents' outpatient "two diseases" medication mechanism, and other prescription drugs with high amounts, high costs, and high risks of fraud and insurance fraud.

The National Medical Insurance Administration requires that, relying on big data analysis, paper prescriptions with large usage must be checked, single prescriptions with large dosages must be checked, repeated prescriptions of the same insured person must be checked, single designated medical institutions with large paper prescriptions must be checked, and key departments with large prescriptions of medical insurance doctors must be checked.

At the same time, designated retail pharmacies should apply drug traceability codes in accordance with the relevant provisions of the medical insurance department on drug traceability codes to ensure that the prescription drugs for external prescriptions can be traced; designated medical institutions with large external prescription volumes, large amounts or abnormal data fluctuations should focus on strengthening policy guidance and supervision and inspection; from January 1, 2025, designated retail pharmacies equipped with "dual-channel" drugs must circulate "dual-channel" drug prescriptions through the electronic prescription center, no longer accept paper prescriptions, and realize the effective connection between the medical insurance electronic prescription center and the intelligent supervision subsystem. It is worth noting that because the prescription of medical insurance drugs for external prescriptions involves many high-value drugs, the use of medical insurance funds is large, and there are blind spots in supervision, many provinces have previously expressed their intention to strengthen supervision.

On January 16, 2024, the Sichuan Health Commission issued the "Notice on Further Strengthening the Management of Prescriptions for External Dispensing in Public Medical Institutions", which clearly stated: Regular dynamic monitoring and abnormal warning of clinical departments and physicians who prescribe external prescriptions, as well as the specifications, quantities, and amounts of drugs prescribed, are carried out, and it is strictly forbidden to use external prescriptions to seek improper benefits.

In addition, Sichuan requires that, except for original research drugs and medical insurance "dual channel" drugs, the types and specifications of drugs that have been equipped in this medical institution should not be prescribed for external prescriptions. According to incomplete statistics, Zhejiang, Qinghai, Shanxi, Guangdong, Heilongjiang, Chongqing, Fujian, etc. have issued regulatory documents on purchased drugs.

In addition, Cyber Blue learned that in Ningbo City, Zhejiang Province, the Municipal Health Commission, Municipal Medical Insurance Bureau, and Municipal Market Supervision Bureau had jointly carried out standardized rectification of external prescriptions. The Ningbo Municipal Health Commission and the Municipal Market Supervision Bureau jointly conducted special random inspections of external prescriptions in retail pharmacies around municipal hospitals.

After the National Medical Insurance Bureau included designated retail pharmacies in the national medical insurance fund flight inspection for the first time in 2023, the supervision of medical insurance funds for designated pharmacies has increased.

Various provinces have also successively launched special rectifications on the illegal use of medical insurance funds by designated medical insurance pharmacies, installed monitoring on pharmacies, and regularly conducted real-time inspections of designated pharmacies. In addition to all-round real-time video surveillance, the medical insurance department can also discover violations in designated pharmacies through big data analysis, financial inspections, inventory verification and other means.

While the relationship between pharmacies and the pooling fund has become "closer", it has also entered an era of strong medical insurance supervision. After the reform of personal accounts of urban employee medical insurance, by the end of 2023, more than 20 provinces and cities in China have included designated retail pharmacies in the scope of outpatient pooling.

In addition, some have expanded the payment scope of local urban and rural residents' medical insurance outpatient chronic disease funds to designated pharmacies, and the use of pooling funds by designated pharmacies has increased.

However, some pharmacies have proposed to reduce their dependence on medical insurance through transformation. For example, Jianzhijia stated in its annual report that it would take the initiative to transform from "relying on medical insurance" sales and drug price competition models to long-term adherence to strengthening professional pharmaceutical services, health management services, and differentiated product category management capabilities. Strengthen the planning, introduction and sales of prescription drugs, OTCs that are less affected by medical insurance, and non-drugs that are not affected by medical insurance.

As of the end of August 2023, the number of designated pharmacies in China has reached 484,000, and the number of pharmacies covered by medical insurance is still increasing. How to find an advantageous development path under the background of strict medical insurance supervision and low gross profit of categories will be the next problem that nearly 500,000 designated pharmacies must face.

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