团险赔付率逼近80％，如何为创新药械腾出空间？

Core Viewpoint - The Chinese commercial health insurance market is showing signs of recovery after three years of slowdown, with expectations to surpass a trillion yuan in scale this year. However, a structural transformation is necessary, shifting from "insuring healthy people" to "insuring people's health" [3]. Group 1: Market Dynamics - The development of insurance for individuals with pre-existing conditions or chronic diseases, referred to as "sick population," is crucial for building a multi-tiered medical security system and promoting innovative drug development [3]. - In 2024, individual 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 contributed less than 10%, around 1 billion yuan [5][8]. - The group insurance market, despite its larger absolute scale, is primarily focused on common illnesses rather than major illnesses, with a payout ratio typically between 70% and 80% [5][6]. Group 2: Policy Support and Innovation - Shanghai's "New 18 Measures" encourages insurance institutions to include elderly individuals and those with pre-existing conditions in their coverage, aiming to foster high-quality development of commercial health insurance [3][6]. - The group insurance market is facing challenges such as slowing growth rates and rising payout ratios, necessitating innovative product development to support the payment for innovative drugs [6][9]. Group 3: Challenges in Group Insurance - The group insurance market is experiencing a "two-eight rule," where 20% of large corporate clients account for 80% of the premiums, indicating a concentration of health-conscious and financially capable clients [9]. - Due to economic pressures, many small and medium-sized enterprises are reducing their group insurance budgets, impacting the overall market dynamics [9][10]. - The average payout ratio for group insurance is expected to remain high, around 80%, due to increased medical expenses and a rise in the number of employees with chronic conditions [11][12]. Group 4: Future Directions - Reform of group insurance is essential to accommodate the coverage of innovative drugs, as the current model may lead to overuse of small medical expenses and insufficient coverage for major illnesses [13][14]. - The shift towards upgrading medical insurance based on group insurance fundamentals is seen as a more feasible approach compared to direct individual payments, especially in a challenging economic environment [14].