团险赔付率逼近80％，如何为创新药械腾出空间？

Group 1 - The core viewpoint of the article is that after three years of slowdown, the Chinese commercial health insurance market is showing signs of recovery and is expected to surpass the trillion yuan mark this year, but structural transformation is urgently needed from "insuring healthy people" to "insuring people's health" [2][3] - The development of insurance for the "sick population" is crucial for building a multi-tiered medical security system and for the growth of innovative drugs [3] - Shanghai has taken the lead in promoting high-quality development of commercial health insurance with measures that encourage insurance institutions to include elderly individuals and those with pre-existing conditions in their coverage [3] Group 2 - In 2024, individual health insurance products like "Hui Min Bao" and "Million Medical Insurance" contributed nearly 40% of commercial insurance payments for innovative drugs, totaling approximately 4.5 billion yuan, while group insurance accounted for less than 10%, around 1 billion yuan [5][7] - The group insurance market, while larger in absolute scale, has been facing challenges such as a focus on common illnesses rather than major illness reimbursements, leading to a high claims ratio of 70%-80% [5][6] - The annual premium scale of group insurance has exceeded 100 billion yuan, accounting for nearly 30% of the commercial medical insurance market [6] Group 3 - The contribution of group insurance to innovative drug payments is limited, with a significant gap in coverage for special drugs, which are typically high-cost and effective treatments for severe diseases [7] - The group insurance market is characterized by a "20-80 rule," where 20% of large corporate clients pay 80% of the premiums, indicating a strong demand for high-value drugs among these clients [7][9] - The average claims ratio for group insurance is expected to remain high, around 80%, due to rising medical costs and increased health awareness among employees [9] Group 4 - Reform of group insurance is necessary to incorporate innovative drug coverage, as the current model leads to overuse of small medical claims and insufficient protection for major illnesses [10][11] - The commercial health insurance market is entering a phase where individual purchasing power is limited, making it more feasible to upgrade medical coverage based on group insurance rather than relying on individual payments [11]