团险赔付率逼近80％，如何为创新药械腾出空间丨“病有所保”大调研

Core Insights - The Chinese commercial health insurance market is showing signs of recovery after three years of slowdown, with expectations to surpass the trillion yuan mark this year [1] - A structural transformation is necessary, shifting from "insuring healthy people" to "insuring people's health," particularly focusing on the large population with pre-existing conditions or chronic diseases [1] - Shanghai has introduced measures to promote high-quality development of commercial health insurance, encouraging the inclusion of elderly and chronic disease patients in coverage [1] Group 1: Market Dynamics - In the past year, innovative drug companies have expressed interest in expanding their market through group insurance channels, despite the group insurance market being larger but facing challenges such as low reimbursement for common diseases [3][4] - The group insurance market has a significant potential for covering innovative drug costs, with the annual premium scale exceeding 100 billion yuan, accounting for nearly 30% of the commercial medical insurance market [4][5] - The contribution of group insurance to the payment for innovative drugs is currently low, at around 10 billion yuan, indicating a gap in coverage for specialized drugs [5] Group 2: Challenges and Opportunities - The group insurance market is experiencing pressure from rising claims and a slowdown in premium growth, with a compound annual growth rate of about 11% from 2018 to 2023, significantly lower than that of individual insurance products [6][7] - The average claims ratio for group insurance is expected to remain high, around 80%, due to increased healthcare utilization and employee health awareness [8] - There is a pressing need for reform in group insurance products to accommodate innovative drug coverage, as current structures may lead to overuse of benefits for minor ailments [9][10]