商业健康保险与医药产业高质量协同发展 ——团体补充医疗保险改革新视角 课题分报告（二） 新时代中国特色商业健康险的使命与定位 在中国特色社会主义新时代背景下，人民的需要已经从"物质文化需求"发展到"美好生活需 要"，步入新时代的商业健康保险应肩负什么使命、发挥什么作为、展现什么价值？本节力 图通过理论研究的方式，探索健康保险的本质和客观发展规律，分析新时代商业健康保险高 质量发展的内涵与外延，提出在中国特有国情下，企业团体补充医疗保险在多层次医疗保障 体系中的优势及挑战分析。 一、中国商业健康险所处的政治背景和新时代需要 （一）新时代中国特色社会主义建设的首要任务是促进高质量发展 党的十九大开启了新时代中国特色社会主义的新征程，明确了新时代我国社会主要矛盾是人 民日益增长的美好生活需要和不平衡不充分的发展之间的矛盾。不平衡不充分的发展就是发 展质量不高的直接表现，要更好满足人民日益增长的美好生活需要，不仅要重视量的发展， 但更要提升质的问题，为此，党的二十大报告明确提出，"高质量发展是全面建设社会主义 现代化国家的首要任务。推动高质量发展是当前和今后一个时期确定发展思路、制定经济政 策、实施宏观调控的根本要求 ...

Core Viewpoint - The commercial health insurance sector is becoming an essential part of China's multi-tiered medical security system, with the commercial insurance directory emerging as a key lever for high-quality development [1][2]. Group 1: Commercial Health Insurance Development - The commercial health insurance market is experiencing robust growth, with a continuous expansion of business scale and service capabilities, providing diversified health protection for the public [1]. - As of the end of 2024, the sales scale of China's innovative drug market is expected to reach 162 billion yuan, with commercial health insurance accounting for only 7.7% of the payment, highlighting the need for increased commercial insurance involvement [2][3]. - The total health payment market is projected to exceed 1 trillion yuan in 2024, with health insurance premiums reaching 977.3 billion yuan, emphasizing the urgency to develop commercial health insurance [2]. Group 2: Challenges and Opportunities - The high personal payment ratio and low commercial insurance payment ratio indicate that commercial health insurance is a viable path to reduce personal payment burdens [3]. - The development of innovative drugs is significantly dependent on the support of diversified payment from commercial insurance, as current payment structures limit the use of innovative drugs in hospitals [3][4]. - The establishment of a comprehensive commercial insurance directory is crucial for addressing the payment challenges of innovative drugs and ensuring that commercial insurance complements basic medical insurance [3][4]. Group 3: Directory Construction and Implementation - The proposed commercial insurance directory could be categorized into three classes: Class A (fully reimbursed by basic insurance), Class B (partially reimbursed), and Class C (not reimbursed) [4]. - The integration of commercial insurance and pharmaceutical companies is essential, as current discrepancies in the directory lead to resource misallocation [6]. - A unified platform for information sharing between basic medical insurance and commercial insurance is recommended to reduce patient out-of-pocket expenses and improve data accuracy [6][7]. Group 4: Regulatory and Regional Considerations - The rapid development of commercial insurance payment practices faces challenges such as data security and regional disparities in drug pricing and insurance product competitiveness [7]. - Regulatory bodies are adopting differentiated strategies to manage these issues, allowing for innovation in developed regions while maintaining caution in less developed areas [7].

来源：艾社康 2025年4月25日，"加强医保和商保的有效衔接，支持创新药械发展"会议在上海圆满举办。本场会议由中国医药教育协会、北京中康联公益基金会、北京 中健联健康服务促进中心联合主办，艾社康承办。 本届会议特邀多位中央和地方医保局领导、多层次医疗保障相关政策专家、保险行业代表，以及药械产业代表为核心嘉宾，分享完善多层次医疗保障制度 体系的思路与先进经验，探索基本医保与商业健康险更紧密地协同与衔接，共同支持创新药械发展。 会议首先由北京协和医学院讲课教授，中欧国际工商学院卫生健康研究中心顾问，国家医疗保障局医药服务管理司原司长熊先军带来题为《完善多层次医 疗保障制度体系政策的思考》的主题分享。熊先军教授系统阐释了我国多层次医疗保障体系的制度逻辑与功能定位，强调构建合理的多层次保障体系，首 要是厘清和完善基本医保制度。同时商业健康保险应聚焦基本医保之外的责任边界，承担提升医疗服务效率、优化就医体验等补充功能。在此基础上，熊 教授对医疗救助的定位、减轻患者个人负担、商保如何与医保互补协同提出了深度思考与政策建议。 上海医保部门分享了《完善多元支付机制，支持创新药械发展的上海实践》话题，介绍了上海在多元支付机制 ...

Summary of the Conference Call on Commercial Health Insurance in China Industry Overview - The conference call focused on the development of the commercial health insurance industry in China, detailing its growth trajectory and future prospects [3][5][6]. Key Points and Arguments 1. **Development Stages of Commercial Health Insurance**: - The industry has gone through four main stages from 1982 to the present, evolving from initial product offerings to specialized insurance products and a clearer role as supplementary coverage due to healthcare reforms [3][5]. 2. **Market Growth**: - The market size of commercial health insurance has grown from 3.6 billion yuan in 1995 to an expected 977 billion yuan by 2024, with a compound annual growth rate (CAGR) of approximately 6.7% from 2019 to 2024 [3][6]. 3. **Product Segmentation**: - Commercial health insurance is primarily divided into three categories: disease insurance, medical insurance, and long-term care insurance, with disease and medical insurance each accounting for 48% of premium income [7]. 4. **Emergence of Huiminbao**: - Huiminbao, a type of inclusive commercial health insurance, has gained traction with 298 products operational by the end of 2024, although there remains significant room for growth in coverage [8][9]. 5. **Claims and Support for Innovative Drugs**: - Huiminbao products have a high claims payout rate of around 90%, with over 90% covering special drug responsibilities, indicating strong support for innovative drugs [9][10]. 6. **Individual Medical Insurance Advantages**: - Individual medical insurance offers broader coverage and higher average claims compared to Huiminbao, with a 12% year-on-year increase in average claims amounting to 158,000 yuan in 2023 [12]. 7. **Policy Environment**: - The government is enhancing the policy framework for commercial health insurance, emphasizing its role as a crucial component of the multi-tiered medical security system [5][6]. 8. **Challenges and Future Prospects**: - The industry faces challenges such as product design limitations and the need for better data sharing. However, improvements in these areas are expected to unlock new growth opportunities for the pharmaceutical sector [15][16]. 9. **Direct Compensation Models**: - The development of direct compensation models in cities like Shanghai and Guangzhou is expected to enhance user experience and satisfaction, facilitating easier access to commercial health insurance [17]. 10. **Impact of Category C Drug Directory**: - The introduction of a Category C drug directory is anticipated to accelerate the inclusion of innovative drugs in commercial health insurance reimbursement, potentially driving market growth [18]. 11. **Emerging Industry Ecosystem**: - The expansion of commercial health insurance is likely to create a diverse industry ecosystem, with a focus on the development of innovative drug and high-end medical services [19]. Additional Important Insights - The disparity in coverage rates across different regions indicates significant potential for growth in the commercial health insurance market [8]. - The increasing awareness of health issues among residents is contributing to the growth of the commercial health insurance sector [6][14]. - The shift towards inclusive insurance products is aimed at attracting a broader demographic, thereby enhancing overall market penetration [14].