“天价药”有救了！商保创新药目录呼之欲出 健康险风口来了？

Core Viewpoint - The introduction of the commercial health insurance innovative drug directory is seen as a significant opportunity for both innovative drug companies and insurance institutions, promoting collaborative development and mutual benefits in the industry [1][3]. Group 1: Policy and Market Dynamics - The National Healthcare Security Administration (NHSA) has released a plan for the adjustment of the commercial health insurance innovative drug directory, with 121 drugs passing the preliminary review [1]. - The innovative drug market in China is projected to reach approximately 162 billion yuan in 2024, with a year-on-year growth of 16% [2]. - Currently, commercial health insurance accounts for only about 7.7% of the payment structure for innovative drugs, indicating significant untapped potential compared to personal payments (49%) and medical insurance fund expenditures (44%) [2]. Group 2: Opportunities for Insurance Companies - The innovative drug directory negotiations provide a new opportunity for collaboration between insurance companies and pharmaceutical firms, allowing for a richer product structure and coverage of more high-value self-paid drugs [2]. - The expansion of the commercial health insurance innovative drug directory is expected to enhance the market recognition of commercial health insurance and increase its business scale [3]. - The introduction of the innovative drug directory marks the beginning of commercial health insurance's deeper involvement in strategic purchasing of innovative drugs, fostering integration between the insurance and pharmaceutical industries [3]. Group 3: Challenges and Risks - The implementation of the commercial health insurance innovative drug directory faces challenges such as pricing risks, adverse selection, and inadequate collaboration mechanisms [4][5]. - Insufficient data on innovative drugs leads to pricing difficulties, with reliance on overseas or preliminary medical data potentially causing discrepancies with actual compensation [4]. - The high costs associated with therapies like CAR-T pose challenges for insurance product pricing, as overly high prices may deter participation while too low prices could fail to cover compensation costs [4][6]. Group 4: Strategic Recommendations - Commercial health insurance should consider incorporating innovative drugs into their coverage through dynamic pricing mechanisms to address data insufficiencies and accumulate practical experience [6]. - Establishing a robust data security and pricing confidentiality mechanism is essential for sustainable collaboration between insurance companies and pharmaceutical firms [6].