明年健康险创新三大看点：自费药“进院”、团险创新成焦点

Core Viewpoint - The commercial health insurance sector is currently in a phase of "selecting from a menu," with significant potential for innovation as the market approaches a trillion yuan scale. The year 2025 is anticipated to be a pivotal year for commercial health insurance, marked by the release of an innovative drug directory and regulatory encouragement for the development of insurance products for individuals with pre-existing conditions [1] Group 1: Commercial Health Insurance Development - The 2025 National Medical Security Work Conference emphasized the support for the development of commercial health insurance, placing it as a priority in establishing a multi-tiered medical security system [1] - The conference called for the integration of commercial health insurance with basic medical insurance, encouraging the inclusion of reasonable medical expenses outside the basic insurance directory and promoting investment in innovative drugs [1][3] - The market is expected to shift from a focus on rapid growth to a more structured approach that addresses the diverse needs of the elderly and individuals with pre-existing conditions [1] Group 2: Innovative Drug Directory - The first version of the commercial health insurance innovative drug directory includes only 19 types of drugs, primarily for specific clinical uses with clear reimbursement rules [4] - Concerns remain regarding the implementation of this directory, particularly whether the listed drugs can be easily accessed in hospitals and whether negotiated discount prices can translate into higher reimbursement rates [5][6] - The directory aims to facilitate the entry of high-value innovative drugs into public hospitals, enhancing the synergy between commercial health insurance and basic medical insurance [3][5] Group 3: Role of Commercial Health Insurance in Clinical Pathways - There is an expectation for commercial health insurance to play a more active role in optimizing clinical pathways for patients, moving from a passive reimbursement model to influencing treatment decisions [7] - The integration of innovative drugs into the insurance payment framework is seen as a way to enhance the insurance sector's influence on healthcare practices [7][10] - The need for collaboration with healthcare providers and access to clinical data is crucial for commercial insurers to effectively manage costs and improve patient outcomes [10][11] Group 4: Market Innovations and Trends - The aging population is driving demand for innovative health insurance products, with a focus on integrating group and individual health insurance models [12][13] - The concept of "personal account-based long-term medical insurance" is emerging, which combines long-term medical coverage with savings features, potentially addressing the challenges posed by an aging society [13][15] - Employers can benefit from this innovative model by attracting and retaining employees while facilitating their long-term health savings [14][15]