"暗战"——佛山医卫市场大变局之民营医院篇 消毒水的气味混合着焦虑，挂号窗口前的冷清与隔壁公立医院的人声鼎沸，构成鲜明的对比。佛山民营 医疗的生存正经历着"冰火两重天"：一边是中小机构的举步维艰，另一边是资本新贵的雄心勃勃。 "莆田系"阴霾未散，新的发展危机接踵而至。近几年，全国民营医院门诊量普遍下滑，部分机构萎缩高 达50%，有机构只能无奈宣布破产。佛山13家三甲医院中仅1家民营，占比不足8%，但在全市三级医院 中，民营机构数量占比却高达三成。除了几家头部，民营机构接诊量并不乐观，"数量多，难被认可"的 标签让民营机构成为市场的"影子军团"。 DRG付费改革挤压利润空间，公立医院特需服务扩张蚕食市场，民营机构面临着多重夹击，所有参与 者都试图重新定义"医疗价值"的边界。在信任危机与多重挤压下，佛山民营医疗的生机何在？答案或许 藏在几家头部机构的"非典型"突围样本中。 市场格局 信任构建与差异化发展的挑战 从市域角度来看，患者"用脚投票"的结果始终偏向公立医院。 某医疗媒体做的问卷调查显示，医生职业道德水平方面，民营医院"满意"一项为72%，优于公立医院的 61%；在排队时间方面，民营医院结果为55%，高于公 ...

在张小栋看来，当商保不再仅是"支付工具"，而是深度融入医 药创新生态时，便能成为打通供需的"价值引擎"，有助于真正 实现"患者可及、医保基金可持续、商业保险可作为、生物制 药可创新"的共赢局面。 作者：姜鑫 封图：受访者供图 编者按 中国医疗体制改革正驶入深水区。这场以"价值医疗"为核心的改革浪潮，正在重新定义"保 障"的边界，它不仅重塑了14亿人的健康服务版图，更将商业健康险推向了多层次医疗保障体 系的关键位置——既是医保的"补位者"，亦是医疗资源的"整合者"，更是创新支付与健康管 理的"探路人"。 《未来保障谈》栏目立足医改与健康险变革，通过对话商业健康险领域资深人士试图厘清一些 问题：保险如何借力特需医疗、创新药械支付打开差异化服务空间？当医保支付方式改革倒逼 医疗控费，保险能否通过数据共享与医院共建"风险共担"模式？在老龄化与慢病人数增多的 背景下，保险又如何从"风险补偿者"向"健康管理者"转型？保险与医疗如何实现深度融合， 以满足居民未来保障的新需求？ 2025年5月20日，三生制药宣布与辉瑞达成一项总额高达60.5亿美元的授权协议，创下了中国创新 药对外授权交易的新纪录。 三生制药及附属子公司将向 ...

在基本医保"保基本"的前提下，多元化的支付体系必不可少，其中，商业健康险被寄予厚望，且仍有很大的发展空间。《中国创新药械多元支付白皮书 （2025）》显示，2024年我国创新药销售市场规模达1620亿元，同比增长16%；其中，个人现金支付约786亿元，占比49%，商业健康险支出约124亿元，仅 占7.7%。 当下，商业健康险与医疗健康产业正走向进一步的深度融合，镁信健康正是其中的连接者。从首款产品肺癌创新药金融分期，到特药保险探索，再到推 出"一码直付"，镁信健康通过整合医疗、保险和药企资源，为用户提供多元支付解决方案。 编者按：中国医疗体制改革正驶入深水区。这场以 " 价值医疗 " 为核心的改革浪潮，正在重新定义 " 保障 " 的边界，它不仅重塑了 14 亿人的健康服务版图，更 将商业健康险推向了多层次医疗保障体系的关键位置 —— 既是医保的 " 补位者 " ，亦是医疗资源的 " 整合者 " ，更是创新支付与健康管理的 " 探路人 " 。 《未来保障谈》栏目立足医改与健康险变革，通过对话商业健康险领域资深人士试图厘清一些问题：保险如何借力特需医疗、创新药械支付打开差异化服务 空间？当医保支付方式改革倒逼医疗 ...

Financial Data and Key Metrics Changes - The company ended 2024 with approximately $440 million in cash, outperforming cash flow projections, and expects to burn about $110 million in 2025 [49] - The company aims to achieve cash flow breakeven by 2027, with several levers to pull, including contracting and cost control [50][52] Business Line Data and Key Metrics Changes - The company operates in two programs: Medicare Advantage (MA) and ACO REACH, with ACO REACH showing about $150 million in savings and a 13% gross savings rate [8] - Quality scores in the Medicare Advantage program are above 4 stars, with year two plus markets running at 4.25 or better, which is a key differentiator [6][7] Market Data and Key Metrics Changes - The company has seen a consistent cost trend of approximately 7% in 2023 and 2024, with a projected 5.3% for 2025 [30][31] - Utilization trends have remained consistent, with inpatient spend being a significant driver, particularly in oncology drugs [55] Company Strategy and Development Direction - The company is focused on transitioning from fee-for-service to value-based care, emphasizing the importance of the primary care physician-patient relationship [4][10] - The company is being measured in its growth strategy, with a reduction in new member classes for 2025 to 20,000, while planning for 30,000 to 45,000 in 2026 [15][70] Management's Comments on Operating Environment and Future Outlook - Management acknowledges a challenging macro environment but notes strong demand from physician groups and payers for the move to value-based care [14][19] - The company is focused on improving performance and reducing volatility, having exited two partnerships last year [41][46] Other Important Information - The company has reduced its Part D exposure from 70% to 30% of its membership for 2025, aiming to further decrease this by 2026 [44] - The company is implementing a new financial data pipeline to enhance revenue and claims information accuracy [34] Q&A Session Summary Question: What are the implications of the current risk adjustment process? - The company emphasizes the importance of the PCP-patient relationship and has a robust risk adjustment process in place, including a 100% chart review process [22][24] Question: How is the company managing utilization trends? - Utilization trends are consistent with expectations, with inpatient spend being a significant driver, particularly in oncology [55] Question: What is the company's strategy for physician partnerships? - The company maintains high net promoter scores from physicians, indicating strong engagement and satisfaction with the value-based care model [59][63]

Financial Data and Key Metrics Changes - The company reaffirmed its full-year guidance, indicating a strong start to 2025 with Q1 results ahead of plan [5][14] - Adjusted EPS guidance for the year is approximately $16.25, with an expected insurance segment benefit ratio of 90.1% to 90.5% [15][14] - G&A costs for the quarter were slightly better than expectations, attributed to the timing of costs expected in the second and third quarters [11][14] Business Line Data and Key Metrics Changes - The Medicare product and experience maintained membership guidance for 2025, with strong performance in the Open Enrollment Period (OEP) [8] - CenterWell and Medicaid businesses showed robust patient and membership growth, with 30 new centers added through acquisition and partnership [12][14] - The company reported a 30% to 50% reduction year over year in members with weight refills due to medication adherence campaigns [11] Market Data and Key Metrics Changes - The company is seeing strong year-to-date performance in markets with high concentrations of members, particularly in Florida, Illinois, and Texas [41] - Medicaid membership growth is on track, with approximately 100,000 growth year-to-date, aligning with the expected annual growth of 175,000 to 250,000 [74] Company Strategy and Development Direction - The company is focused on operational efficiencies, increasing flexibility, and operating leverage while making investments to improve member outcomes [14] - The integration between the insurance segment and CenterWell is aimed at delivering better health outcomes and improving STARS performance [58][60] - The company is committed to returning to a 3% pre-tax margin in Medicare Advantage (MA) by 2027, with ongoing focus on quality and operational excellence [48][90] Management's Comments on Operating Environment and Future Outlook - Management expressed confidence in the underlying progress of the business despite external challenges, emphasizing control over medical costs and operational efficiencies [50][52] - The company is monitoring changes in consumer behavior due to the Inflation Reduction Act (IRA) and is prepared for potential impacts on future performance [6][14] - Management highlighted the importance of navigating regulatory headwinds while focusing on controllable factors [51][52] Other Important Information - The company is actively working through STARS strategy and bids, with a focus on balancing membership and margins [32][33] - Recent fulfillment agreements with multiple companies are expected to contribute positively to growth [12][63] Q&A Session Summary Question: How much of your investments moved out of Q1? - Management indicated that most of the impact of incremental investments flowed through the MLR in Q1, with expectations for higher levels in the second through fourth quarters [20] Question: Update on the path to the 3% MA margin target? - Management reiterated focus on achieving the 3% margin, with timing tied to STARS outcomes, and no significant changes from previous communications [23] Question: Update on STARS initiatives and bids? - Management expressed confidence in progress made on STARS initiatives and ongoing work on bids, emphasizing a balanced approach to membership and margins [27][32] Question: Experience in Part D relative to expectations? - Trends in the business are consistent with expectations, with mid-single-digit growth on the medical side and low double-digit growth on the pharmacy side [36] Question: Visibility on risk adjustment and Group MA? - Management reported strong membership changes and visibility into risk adjustment, with no significant behavioral changes noted in Group MA [41][43] Question: Comments on Medicaid visibility and utilization? - Medicaid is performing in line with expectations, with strong growth and positive trends in member engagement and outcomes [75][76] Question: Clarification on GAAP EPS and valuation adjustments? - Management clarified that the adjustment in GAAP EPS guidance is unrelated to structural impairment and is part of a complex calculation [93]