打通高价创新药与患者之间“最后一公里”

Core Viewpoint - The release of the commercial health insurance innovative drug directory addresses the issue of "can it be used" at the hospital level, but the "last mile" between high-priced innovative drugs and patients remains unconnected. To achieve seamless transformation from "policy text" to "patient benefit," three key barriers must be crossed [1][3]. Group 1: Release of the Directory - On December 7, 2025, the National Healthcare Security Administration officially released the first version of the "Commercial Health Insurance Innovative Drug Directory," incorporating 19 high-clinical-value, high-cost innovative drugs into the commercial health insurance payment framework for the first time at the national level [2]. - The directory includes 14 anti-tumor drugs (including all 5 CAR-T therapies available in China), 2 rare disease drugs, and 2 Alzheimer's disease new drugs, aligning with the current claims data of commercial health insurance, where malignant tumors are the most prevalent and costly disease area [2]. Group 2: Policy Support and Challenges - The commercial health insurance innovative drug directory is supported by policies that exempt the listed drugs from self-payment rate assessments, collection of alternative monitored varieties, and DRG payment scope, addressing the challenges hospitals face in using innovative drugs under cost control pressures [3]. - Despite the directory solving the "can it be used" issue, the connection between high-priced innovative drugs and patients still needs to be established, requiring standardization and universalization of the directory [3][4]. Group 3: Standardization and Payment Collaboration - The current directory serves as a guiding list rather than a mandatory coverage requirement for commercial insurance products, necessitating the promotion of core drugs in the directory as standard configurations in commercial health insurance, especially in inclusive "benefit insurance" products [4]. - The basic medical insurance market can leverage its large insured population to negotiate lower drug prices, but the fragmented nature of the commercial health insurance market poses challenges in forming a cohesive payment force to negotiate with pharmaceutical companies [4]. Group 4: Service Integration and Patient Experience - An ideal multi-tiered payment system should achieve seamless integration and instant settlement among basic medical insurance, commercial insurance, and patient out-of-pocket expenses, which currently requires patients to prepay and navigate complex claims processes [5]. - Commercial insurance accounts for only 7.7% of the overall payment for innovative drugs, indicating significant growth potential. Bridging the "last mile" between the 19 innovative drugs in the directory and patients requires coordinated efforts from government and market forces [5].