From June to September 2024, many cases related to AstraZeneca insurance fraud were sentenced one after another. An operation named "Star Project" by the prosecutor revealed the tip of the iceberg of pharmaceutical representatives tampering with genetic test reports and defrauding medical insurance funds. AstraZeneca, the fastest growing British multinational pharmaceutical company in China and the most watched "sales champion" in the pharmaceutical industry, was exposed to be involved in many "insurance fraud cases".

According to the criminal verdicts obtained by the reporter, in the past three years, there have been many AstraZeneca "insurance fraud cases" that have been tried or sentenced in Shenzhen and Fujian alone, and there are also cases waiting to be heard in Chongqing and Jiangxi. Some people in the pharmaceutical industry pointed out that the AstraZeneca insurance fraud case can be said to be the most shocking event caused by multinational pharmaceutical companies in China in recent years.

The importance of gene test reports is comparable to a "verdict" - it determines whether cancer patients can match the appropriate targeted drugs that may save their lives, and whether the drug has been included in medical insurance and meets the reimbursement conditions is an extremely important "pass" for patients and their families.
The relevant verdict shows that in order to include the lung cancer "magic drug" Tagrisso in the scope of medical insurance reimbursement, AstraZeneca's pharmaceutical representatives modified the gene test reports on their own, or colluded with genetic testing companies to modify the reports, or even issued reports without testing. According to statistics from reporters, the total amount involved in AstraZeneca insurance fraud cases in various places is about 30 million yuan. From grassroots pharmaceutical representatives to regional managers, the maximum sentence of employees who have been sentenced is as long as 13 and a half years.

Paradoxically, after the insurance fraud case continued to ferment, some grassroots pharmaceutical representatives said that the tampering of the test report was due to sympathy for the patient; some grassroots pharmaceutical representatives said that the tampering of the test report was known and agreed by the senior management. Sympathy, acquiescence or conspiracy?

It was AstraZeneca's star anti-cancer drug "Tagrisso" (osimertinib mesylate) that triggered the insurance fraud storm.
Osimertinib is a third-generation EGFR-TKI inhibitor. The emergence of this drug has effectively suppressed the problem of drug resistance in lung cancer and can be called a miracle drug in the field of lung cancer. On September 3, 2016, Osimertinib submitted a clinical application and was approved for marketing in March 2017, which took only six months. The following year, Osimertinib entered the national medical insurance. In 2020, the renewal of medical insurance negotiations reduced the price of the drug by more than 60%. This speed was unprecedented in the domestic medical environment at that time. At that time, it often took at least three years for a drug to go from application to listing.

The problem is that it is not suitable for all lung cancer patients. Starting from October 2018, patients with non-small cell lung cancer who tested positive for T790M can use "Tagrisso" for medical insurance reimbursement; starting from September 2019, although "Tagrisso" can be used for the first-line treatment of T790M-negative patients, medical insurance reimbursement no longer requires EGFR T790M mutation positive test results, but it will not be until the medical insurance catalog is updated in March 2021 that patients can use medical insurance reimbursement.

After "Tagrisso" entered the medical insurance, the price dropped from 51,000 yuan per box to 15,300 yuan per box, and then dropped to 5,580 yuan. The difference between self-paid and medical insurance reimbursement is huge. This also means that if non-T790M positive patients use "Tagrisso" and want to be reimbursed by medical insurance, there is a possibility of tampering with the genetic test report.

Against this background, in July 2021, the Shenzhen Medical Insurance Bureau found that AstraZeneca was suspected of tampering with the genetic test results of tumor patients to defraud medical insurance funds based on the clues of the report, and 17 employees were involved in the case. The way pharmaceutical representatives falsify is usually very simple: they will send test samples for patients, and after getting the report, they will directly modify the patient's EGFR T790M negative result P map to positive; there are also pharmaceutical representatives who privately charge patients 2,800 yuan for testing fees and directly issue reports without sending them for testing. People familiar with the matter said, "Pharmaceutical representatives want to improve sales performance, and patients want to 'blindly try' drugs to see if they happen to be effective."

How did AstraZeneca's insurance fraud case rise in many places in Fujian? One of the means-the "Star Project" has to be mentioned. Starting from January 2019, Huang Wei, who was the manager of AstraZeneca in Fuzhou and Quanzhou, asked Wang Chao, the middleman, whether there were resources for T790M single-target testing at a lower cost. Huang Wei proposed that he hoped the positive test rate would be higher, not as low as other companies. Wang Chao said that if you want a "positive report", just draw a five-pointed star on the test application form, so that Jianlu Company will issue a positive test report. Later, Jianlu Company did issue positive test reports for the star-marked test forms. According to the confession of the co-defendant, after 2020 alone, AstraZeneca's drug representatives sent 397 copies to this company for testing, of which more than 30 were marked with "stars".

In addition to the above three people, the "Star Project" also involved more than 20 drug representatives and regional managers and regional managers.
A pharmaceutical representative surnamed Huang confessed that in June 2020, he learned about the "Star Plan" and the commission for testing from Huang Wei: a commission of 200 yuan for a T790M single gene test and 4,000 yuan for a multi-gene test. Before the incident, he had made a total profit of about 50,000 yuan.

In addition to the "directly profitable" pharmaceutical representatives, some middle-level leaders were also implicated by the "performance theory". An industry insider commented that this company would create and convey performance anxiety. "First, they hold more meetings than other companies, emphasizing how tight the time is and how heavy the task is at the meeting; second, there are various and detailed assessment indicators, which are different for each team and are set to spur front-line employees." Another pharmaceutical representative working in a foreign company mentioned that obtaining patient information is a common means to help improve performance. Whether this unchecked method will be adopted depends mainly on the style of the small leaders of the sales team. "Some wolf-like teams even have KPI requirements for the number of patient information input every week." He said.

This method is not very efficient, but there are still people who try it one after another. The main reason is that some MNCs have been under severe pressure in China in the past two years, and AstraZeneca is a representative example. "The headquarters should not give clear pressure to China and emerging markets. After all, China's investment has been increasing. The main reason is that China has set high targets for itself, and the pressure is self-imposed." The above-mentioned resigned employee said.

From the market end to the sales end, AstraZeneca's strategy in China has always been known for its radical style. Relevant people took the company's former respiratory business line as an example: in order to promote a certain pediatric asthma product, the company established a large number of atomization centers in various places, and promoted the concept of disease management based on "lifelong use". "In fact, children may heal themselves after their immunity is improved, and the concept of taking hormone drugs for life is not correct. But it did achieve good market growth that year." When this radical tradition encounters a slowdown in growth, the KPI culture will become even crazier.

In 2023, from the perspective of regional revenue, AstraZeneca's revenue in China will be US$5.876 billion, a year-on-year increase of 7%, accounting for 13% of the global market share. In terms of the proportion of business in China, AstraZeneca ranks first among all MNCs; but in terms of growth rate, the company's business in China has undoubtedly sounded the alarm: Merck's revenue in China increased by 32% during the same period, and the growth of latecomers Novo Nordisk and Eli Lilly also exceeded double digits, reaching 11%.

Performance decline leads to layoffs. "After being optimized by AstraZeneca, employees often feel that it is difficult to find a job." Luo Lan said, "First of all, if you come from a business department that has had problems, people are not willing to hire you; secondly, AstraZeneca pays a relatively high salary, and now it belongs to the employer market. Even if you say you accept a pay cut, the employer will always think that you are coming here after a pay cut, and your stability is not good." At the same time, AstraZeneca's front-line representatives are now full of a large number of people born in the 1990s and even the 2000s, with short working years, and annual salary plus bonuses are not high, so they get less compensation and are more inclined to fight for their rights through reporting and breaking the news.

Chen Xiaoyu, a pharmaceutical representative who used to work at AstraZeneca, told the Southern Weekend reporter that large multinational pharmaceutical companies are not stupid enough to rely on defrauding medical insurance funds to survive. Once something goes wrong, the risk is too high. However, in order to boost performance, the leaders of the sales department may instruct the pharmaceutical representatives to do illegal things behind the company's back. "If something goes wrong, the pharmaceutical representative will take the blame, and if nothing goes wrong, the sales manager will be promoted." After Wang Lei was taken away for investigation, AstraZeneca China is currently temporarily taken over by the global headquarters, and some new compliance policies and requirements are also being issued. The company's business is generally stable and has not been affected too much. But the entire industry is "wait and see" to see how AstraZeneca will end up. According to the current official report, the people involved in the AstraZeneca insurance fraud case have not mentioned patients and doctors. But this long-lasting "insurance fraud" case has not yet come to a conclusion.

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