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 - The group insurance market is larger in absolute terms but has different characteristics compared to individual insurance products, focusing on common illnesses rather than critical illness reimbursement [2] - The group insurance market faces challenges such as rising claims ratios (70%-80%) and slowing growth due to increased operational pressures on companies [2][4] - The total annual premium scale of group insurance in China has exceeded 100 billion yuan, accounting for nearly 30% of the commercial medical insurance market [3] Group 2: Innovation and Coverage - Group insurance has the potential to cover a significant portion of the "sick population," which is crucial for the sales of innovative drugs and medical devices [4] - There is a notable gap in coverage for outpatient medications under individual insurance products, prompting innovative drug companies to explore group insurance as a viable market [4] - The group insurance market is characterized by a "Pareto principle," where 20% of large corporate clients contribute to 80% of the premiums, indicating a concentration of health-conscious employees who are more likely to accept high-value medical treatments [4] Group 3: Challenges and Reforms - The rising medical costs and the need for reform in group insurance products are pressing issues, as current models may not adequately cover innovative drug responsibilities [6] - The average claims ratio for group insurance is expected to remain high, potentially reaching 80%, which poses sustainability challenges for insurers [5][6] - There is a call for a shift towards a "secondary reimbursement" model in group insurance to address the increasing frequency of claims for minor ailments, which could lead to overuse of benefits [6][7]