打通高价创新药与患者之间“最后一公里”

Core Insights - The National Healthcare Security Administration (NHSA) has officially released the first version of the "Commercial Health Insurance Innovative Drug Directory," incorporating 19 high-value, expensive innovative drugs into the commercial health insurance payment framework for the first time [1][2] - The introduction of this directory marks a significant step in improving China's multi-tiered medical security system and transforming the role of commercial insurance [1] Group 1: Directory Overview - The directory includes 19 drugs, of which 14 are anti-tumor drugs (including all 5 CAR-T therapies available in China), 2 are rare disease medications, and 2 are new drugs for Alzheimer's disease [1] - The structure of the directory aligns closely with current claims data from commercial health insurance, as malignant tumors are the most prevalent and costly disease area in China [1] Group 2: Policy Support - The drugs listed in the commercial health insurance innovative drug directory are exempt from self-payment rate assessments, do not fall under centralized procurement monitoring, and are not included in the Diagnosis-Related Group (DRG) payment scope, referred to as the "three exclusions" policy [2] - This policy alleviates the challenges hospitals face in using innovative drugs amid pressures from centralized procurement and DRG payment reforms [2] Group 3: Implementation Challenges - The transition from policy text to patient benefits requires overcoming three key barriers: standardization and inclusivity of the directory, payment coordination and bargaining power, and service fluidity and one-stop experience [2][3][4] - The current directory serves as a guiding list rather than a mandatory coverage requirement for commercial insurance products, necessitating efforts to make core drugs standard features in commercial health insurance, especially in inclusive "benefit insurance" products [3] Group 4: Payment and Service Integration - The commercial health insurance market is fragmented, with varying funding levels and coverage across different regions, which raises uncertainties about its ability to negotiate effectively with pharmaceutical companies [3] - Establishing a regional or national commercial insurance procurement coordination mechanism is essential for negotiating better drug prices and conditions, ensuring financial sustainability of coverage plans [3][4] - The ideal multi-tiered payment system should enable seamless integration and immediate settlement among basic medical insurance, commercial insurance, and out-of-pocket expenses, which currently requires patients to prepay and navigate complex claims processes [4]