创新药保障“最后一公里”待解：买得到、赔得快、保得起

Core Insights - The release of the 2025 National Medical Insurance Directory and the first Commercial Health Insurance Innovative Drug Directory marks a significant milestone in China's healthcare payment system, transitioning to a dual-driven model of "basic medical insurance + commercial health insurance" [1][3][10] Group 1: Policy Changes - The new policies clarify the payment boundaries between government and market, with the Commercial Health Insurance Innovative Drug Directory focusing on high-value innovative drugs that exceed the basic medical insurance coverage [3][4] - The 2025 Medical Insurance Directory adds 114 new drugs, achieving a negotiation success rate of 88.19%, the highest in seven years, with a total of 3,253 drugs now covered [3][4] Group 2: Drug Inclusion - The first Commercial Health Insurance Innovative Drug Directory includes 19 drugs, such as CAR-T therapies and new Alzheimer's medications, which are typically expensive and risky, thus not included in basic medical insurance [4][5] - Five CAR-T therapies have been included in the directory, representing over half of the currently available products in China, with prices exceeding 1 million yuan for most [5][6] Group 3: Market Dynamics - The dual-track system addresses the affordability of high-value drugs for patients while providing a sustainable return mechanism for pharmaceutical companies, thus driving high-quality development in China's innovative drug industry [4][6] - The introduction of these directories is expected to enhance clinical medication levels and overall R&D returns, particularly benefiting leading innovative pharmaceutical companies with extensive pipelines [6][7] Group 4: Consumer Impact - The integration of the two directories allows for a complementary relationship, where commercial insurance can cover innovative drugs first before they are potentially included in basic medical insurance [7][8] - The "gradient payment" mechanism enables patients to access the latest therapies without facing the dilemma of full out-of-pocket expenses, as commercial insurance will provide payment support [8][10] Group 5: Implementation Challenges - There are practical challenges in ensuring that hospitals stock the newly included high-priced drugs, as they may face financial disincentives to do so [10][11] - The claims process for commercial insurance may still require patients to pay upfront, which can be a significant burden for high-cost innovative drugs [10][11] - The potential for increased claims rates due to the inclusion of high-risk drugs may lead to higher insurance premiums or stricter underwriting standards in the future [12]