医保谈不动的高价药终于有出路了

Core Viewpoint - The introduction of a dual-track payment system for innovative drugs in China, combining basic medical insurance and commercial health insurance, marks a significant shift in the industry, providing a structured approach to address the payment challenges faced by high-priced innovative drugs [2][5][34]. Summary by Sections Introduction - The release of the new medical insurance directory and the first commercial health insurance directory for innovative drugs signifies the establishment of a dual-track payment system in China [2]. Innovative Drug Payment Mechanism - The reliance on a single payment channel through medical insurance has become unsustainable due to rising costs and the increasing number of high-priced innovative drugs [5]. - The latest medical insurance directory adds 114 new drugs, with 50 being class 1 innovative drugs, achieving a negotiation success rate of 88%, the highest ever [5]. Commercial Health Insurance Directory - The first commercial health insurance directory includes 19 high-value innovative drugs, providing a structured payment pathway for drugs previously excluded from medical insurance [8][20]. - This directory signals a shift in the payment structure, where both basic medical insurance and commercial insurance will share the payment responsibilities for innovative drugs [8][21]. Challenges in Medical Insurance - Despite the expansion of the medical insurance directory, high-priced innovative drugs still face significant barriers to entry due to strict cost-effectiveness evaluations and negotiation mechanisms [10][11]. - The trend indicates that medical insurance is moving towards risk control rather than merely expanding coverage [10][16]. Filling the Payment Gap - The introduction of the commercial health insurance directory is a necessary response to the limitations of the medical insurance system, providing a payment avenue for high-value drugs that have been excluded [18][21]. - The directory includes drugs with high clinical value and costs, addressing the long-standing payment vacuum in the market [18][20]. Growth Opportunities for Innovative Drugs - The commercial health insurance directory opens new growth avenues for high-priced innovative drugs, allowing for a broader patient reach and a more structured payment approach [23][24]. - The directory is expected to enhance the commercial health insurance market, with high-value innovative drugs becoming a core differentiator in product offerings [24]. Structural Bottlenecks for Commercial Health Insurance - There are significant barriers to the short-term adoption of the commercial health insurance directory, including data insufficiency, product risk acceptance, and user payment behavior [28][29][30]. - The lack of real-world data on innovative drug usage complicates pricing and risk assessment for insurance companies [29]. Conclusion - The dual-track payment system represents a structural change in the payment landscape for innovative drugs, but challenges remain in achieving widespread accessibility and effective implementation [34][35]. - The commercial health insurance system is expected to play an increasingly important role in providing payment solutions for innovative drugs, although it will take time to fully realize its potential [36].