朱俊生：从支付方到服务方 保险破解创新药支付难题

Core Insights - The increasing pressure on medical insurance funds is driven by an aging population and rising medical costs, while the demand for innovative drugs and personalized medicine continues to grow [1][2] - Commercial health insurance is seen as a crucial solution to address the payment challenges for innovative drugs and to enhance the multi-tiered medical security system [2][6] Summary by Sections Current State of Medical Insurance - China has established a comprehensive basic medical insurance system, covering a wide range of the population and providing reliable medical security [3] - As of the end of 2023, the fund payment ratio for employee medical insurance in hospitals is 84.6%, while for resident medical insurance, it is 68.1% [3] Personal Medical Expenses - Despite high coverage levels, personal medical expenses remain significant, with personal health expenditure accounting for 27.3% of total health spending in 2023 [4] - Direct medical expenses in 2023 reached approximately 57 trillion yuan, with personal out-of-pocket payments exceeding 25 trillion yuan, representing over 40% [4] Role of Commercial Health Insurance - Commercial health insurance is currently underutilized, covering only about 0.38 trillion yuan of medical expenses, which is less than 7% of total medical costs [4] - Policies have been introduced to emphasize the importance of commercial health insurance and to include innovative drugs in its coverage [5][4] Focus on Innovative Drug Coverage - There is a pressing need for commercial health insurance to focus on covering expenses for innovative drugs that are not included in the basic medical insurance directory [6][8] - The establishment of a commercial health insurance drug directory is crucial for improving access to innovative drugs and high-value medical services [9] Collaboration and Innovation - The construction of a commercial health insurance directory should complement the basic medical insurance directory to effectively support innovative drug coverage [9][10] - Collaboration among insurance companies, pharmaceutical firms, and hospitals is essential for enhancing the accessibility of innovative drugs and addressing payment challenges [10]