Core Viewpoint - The collaboration between basic medical insurance and commercial health insurance in China is advancing significantly, with new measures and systems being implemented to enhance efficiency and accessibility for patients [1][2][3][4]. Group 1: Policy Developments - The first national "medical insurance + commercial insurance" clearing settlement center has begun operations in Beijing, reducing the time lag in claims settlement between the two systems [1]. - A joint initiative by the Shanghai Financial Regulatory Bureau and seven other departments has been launched to promote the high-quality development of commercial health insurance, focusing on payment mechanisms and data sharing [1][2]. - The preliminary review of the innovative drug directory for commercial insurance, which includes several high-priced cancer drugs, has been completed, providing new payment avenues for innovative drugs [1][2]. Group 2: Market Insights - As of 2024, the basic medical insurance system covers 1.326 billion people, maintaining a coverage rate of 95%, with total fund expenditures reaching 2.97 trillion yuan [2]. - The commercial health insurance market is experiencing rapid growth, with original insurance premium income reaching 977.3 billion yuan in 2024, a year-on-year increase of 8.2% [2]. - Despite the growth, there remains significant room for improvement in the coverage and effectiveness of commercial health insurance compared to the over 95% utilization rate of basic medical insurance funds [2]. Group 3: Operational Enhancements - The new clearing settlement center allows patients to complete basic insurance reimbursement and directly use commercial insurance for remaining costs, streamlining the payment process [2][3]. - The National Medical Insurance Administration is exploring synchronized settlement between basic and commercial health insurance, aiming to reduce patient burden through data sharing [3]. - Future developments will include collaborative efforts to expand the coverage of commercial health insurance and enhance the integration of data and regulatory frameworks between the two systems [4].

Core Viewpoint - The era of collaborative development between medical insurance and commercial insurance has arrived, as evidenced by recent policy changes and initiatives aimed at enhancing the synergy between commercial health insurance and the biopharmaceutical industry [1][2]. Group 1: Policy Initiatives - In July 2023, Shanghai introduced 28 measures to support the development of innovative drugs and medical devices, which has sparked industry discussions and set a precedent for nationwide implementation [1]. - Recently, seven departments in Shanghai released 18 specific measures to promote the high-quality development of commercial health insurance, focusing on payment mechanisms, data sharing, service models, and regulatory innovation [1][4]. - The 18 measures represent a systematic approach to creating a dual empowerment mechanism between commercial health insurance and biopharmaceutical innovation, emphasizing the need for diverse payment mechanisms beyond basic medical insurance [1][4]. Group 2: Highlights of Commercial Health Insurance Innovation - One highlight is the support for "pre-existing condition" insurance, allowing the trial development of insurance products for patients with chronic diseases under a regulatory sandbox mechanism [3]. - The measures also aim to activate individual medical account funds, permitting eligible group health insurance to use accumulated personal account balances for payments [3]. - There is encouragement for "insurance + service" models, promoting the development of long-term care insurance and collaboration between insurance companies and health service providers [3]. Group 3: Focus on Group Health Insurance - The 18 measures will prioritize the development of group health insurance, which has proven to be a mature sector, particularly in providing customized corporate supplementary medical insurance [3][4]. - Group health insurance can effectively cover pre-existing conditions and chronic diseases, addressing adverse selection issues while expanding funding and improving management efficiency [3]. - The measures will also focus on innovative drugs and medical devices, encouraging the insurance industry to develop exemplary clauses for group health insurance that include new medical technologies and products [4]. Group 4: Future Outlook for Consumers - The future of insurance products is expected to be more diverse, with broader coverage and more efficient services, reducing the economic burden of using innovative drugs and medical devices for consumers [5]. - Shanghai plans to optimize existing insurance products and develop specialized offerings for specific demographics, such as the elderly and those with pre-existing conditions [5]. - The implementation of policies will continue to signal positive developments in the market, with efforts to eliminate payment bottlenecks for innovative drug applications and support the growth of the biopharmaceutical industry [5].

Core Viewpoint - Shanghai has introduced a new set of measures aimed at enhancing the development of commercial health insurance and supporting innovation in the biopharmaceutical industry, focusing on improving the multi-payment mechanism and data sharing among medical institutions, pharmaceutical companies, and insurance providers [1][2]. Group 1: Policy Measures - The new measures, referred to as "New 18 Measures," aim to strengthen the collaboration between basic medical insurance and commercial health insurance, addressing core issues related to the application of innovative medical devices and patient payment [1][3]. - The document emphasizes the importance of data sharing among medical institutions, pharmaceutical companies, and commercial insurance companies to facilitate product development and pricing [2][3]. - The measures encourage the development of innovative commercial health insurance products that can expand basic coverage and provide reasonable pricing [3][4]. Group 2: Data Sharing and Collaboration - The new policies establish a framework for a data-sharing mechanism among medical, insurance, and pharmaceutical sectors, ensuring data security and privacy while expanding the scope of data available for product design and risk assessment [2][3]. - Insurance companies are encouraged to access historical health data in a secure environment to support the development of targeted insurance products [3][4]. - The measures aim to enhance the interaction between insurance institutions and the biopharmaceutical industry, promoting collective procurement and payment mechanisms to improve the accessibility and affordability of innovative medical devices [7]. Group 3: Targeted Insurance Products - The new measures support the development of various health insurance products, including group insurance, special disease insurance, and high-end medical services, tailored to specific populations such as the elderly and those with pre-existing conditions [2][5]. - The policies also propose using personal account balances for purchasing insurance products, thereby facilitating access to health insurance for a broader audience [5][6]. - The measures highlight the importance of group insurance products, which do not differentiate based on pre-existing conditions, as a key growth area for the health insurance industry [6]. Group 4: Financial and Operational Support - Shanghai aims to address fundamental issues affecting the commercial health insurance sector, such as funding challenges and customer acquisition difficulties, through multi-departmental collaboration [4][6]. - The new measures propose financial incentives for employers to purchase group health insurance for employees, allowing for shared premium payments and tax deductions [6][7]. - The integration of commercial health insurance with basic medical insurance is emphasized, with a focus on optimizing claims processes and expanding the coverage of innovative medical devices [6][7].

Core Viewpoint - The National Healthcare Security Administration has issued guidelines for the adjustment of the basic medical insurance directory and the commercial health insurance innovative drug directory, marking a significant shift in the role of commercial health insurance in the multi-tiered medical security system [1][2]. Group 1: Policy Changes - The new guidelines include the first incorporation of the commercial health insurance innovative drug directory into the adjustment scheme, indicating a major adjustment in the design logic and industry positioning of the directory [1][2]. - The commercial insurance companies will exit the price negotiation process, with the directory's nature shifting to a "recommended list," while the healthcare department will lead drug access and price confidentiality negotiations [1][2]. Group 2: Industry Participation - Pharmaceutical companies now have two pathways for submitting information for national negotiations and competitive drug pricing, akin to "filling out college applications," allowing them to choose between the medical insurance directory or the commercial insurance directory [2]. - There is a general expectation within the industry regarding the new directory, particularly as it allows companies to bypass restrictions from DRG/DIP reforms, making participation more attractive [2][4]. Group 3: Market Dynamics - The commercial health insurance market is experiencing a stabilization in growth, with 298 local health insurance products launched across various provinces as of October 31, 2024 [4]. - The participation level of commercial insurance companies may significantly influence the actual implementation of the directory, as it currently resembles a "recommended directory" without strict volume relationships [4][5]. Group 4: Support for Innovative Drugs - There is a consensus in the industry that the payment responsibility for innovative drugs is shifting from medical insurance to commercial insurance, which is seen as an inevitable trend [6]. - The 2023 measures from Shanghai aim to enhance the multi-payment mechanism to support the development of innovative drugs, indicating a broader push for integrating innovative drugs into both basic medical insurance and commercial health insurance [7]. Group 5: Future Outlook - The 2025 government work report emphasizes the need to deepen medical insurance payment reforms and support the development of innovative drugs, highlighting the potential for commercial insurance to play a larger role in this area [8]. - The commercial health insurance sector currently contributes only 7.7% to the payment for innovative drugs, indicating significant room for growth as demand for specialized medical services increases [8].