2 1 Shi Ji Jing Ji Bao Dao·2025-06-23 12:18Core Insights - The core viewpoint of the articles is that commercial health insurance is increasingly incorporating high-value innovative drugs into their coverage, responding to the gaps in basic medical insurance and the evolving healthcare needs of consumers [1][2][3]. Group 1: Market Trends - Insurance companies are launching new products and upgrading existing ones to include innovative drugs, driven by the demand for advanced medical resources [1][3]. - The recent upgrades in health insurance products are a response to the national healthcare reform aimed at providing basic coverage while addressing the diverse medical needs of residents [3][4]. Group 2: Payment Structure - The current payment structure for innovative drugs is imbalanced, with basic medical insurance covering only a fraction of the costs, leading to a significant burden on patients [3][4]. - In 2024, the innovative drug market is expected to reach 162 billion yuan, with basic medical insurance covering approximately 710 billion yuan (44%), while personal cash payments account for about 786 billion yuan (49%), and commercial health insurance only contributes around 124 billion yuan (7.7%) [3]. Group 3: Challenges and Solutions - The commercial health insurance sector faces challenges in balancing the risk of claims with the need for high coverage of innovative therapies [6][7]. - To mitigate risks, insurance companies are employing big data modeling and dynamic risk assessment, setting parameters like deductibles and reimbursement ratios, and establishing reinsurance mechanisms [6][7]. Group 4: Accessibility Issues - Despite the increased coverage of innovative drugs, patients may still encounter barriers to access, such as hospitals prioritizing drugs listed in the basic medical insurance directory [8][9]. - Solutions proposed include creating a direct payment network with pharmacies, real-time monitoring of drug availability, and simplifying the claims process for patients needing urgent access to innovative therapies [9].