Core Viewpoint - The article discusses the current status, challenges, and potential breakthroughs of commercial health insurance in China, emphasizing its significant social management function in addressing the medical expense payment gap and improving healthcare accessibility [2][10]. Current Status - On a macro level, self-paid medical expenses account for a high proportion of total healthcare costs in China, with personal out-of-pocket expenses reaching 2.5 trillion yuan, representing 27% of total healthcare expenditure in 2023 [12]. - The commercial health insurance payout in 2023 was only 0.4 trillion yuan, accounting for 4% of total healthcare costs, indicating a significant gap in coverage [12]. - The basic medical insurance system covers over 1.3 billion people, achieving a participation rate of around 95%, but it is constrained in its ability to further increase payment proportions due to rising healthcare costs and demographic changes [15][21]. Challenges - The effective supply of commercial health insurance is insufficient, primarily due to a lack of industry infrastructure and product development capabilities [5][25]. - The perception of adequate coverage from basic medical insurance leads to a "sufficient protection illusion," which hinders the demand for commercial health insurance [36]. - The insurance industry has historically focused on rapid expansion through high-premium critical illness insurance, which has limited the development of more integrated health insurance products [43][44]. Potential Breakthroughs - Key variables for breaking the current deadlock include reforms in medical insurance payment systems and support from regulatory bodies to enhance industry infrastructure [5][51]. - The promotion of personal account-based medical insurance and long-term care insurance could provide comprehensive health solutions and open new avenues for industry growth [64][65]. - The increasing income levels and the growing middle-income population in China are expected to drive demand for commercial health insurance, creating a favorable environment for its development [62]. Investment Opportunities - The article identifies four main investment themes: leading internet platforms and large insurance groups building commercial health insurance systems, efficient corporate group insurance channels, reinsurers benefiting from health insurance market growth, and pharmaceutical companies gaining from increased commercial insurance payments [6][66].

2025.11. 23 本文字数：2389，阅读时长大约4分钟 作者 | 第一财经 吴斯旻 在老龄化加速、基本医保基金持续承压的背景下，商业健康险发展始终伴随争议。争议背后是，商业 健康险被公众质疑为赔付总额低、与保费规模的增长节奏不匹配。 国家金融监管总局数据显示，2024年，中国商业健康险保费收入合计达到9774亿元，同比增长 8.2％，增速较去年同期提升3.8个百分点。2025年前8个月，商业健康险保费收入突破7599亿元， 有业内人士预测今年全年商业健康险保费规模有望突破万亿元大关。 而从赔付情况来看，2024年，商业健康险赔付支出约4037.77亿元。如果使用简单赔付率(当年赔付 支出与当年保费收入之比)单一指标进行评估，不难得出中国商业健康险赔付率在40％左右的结论， 而这显著低于发达国家水平(70%～85%)。 但在商保业界人士看来，这样的测算有失偏颇，甚至与实际情况相去甚远，无法真实反映中国商业健 康险的保障效能与盈利状况。 这是因为疾病保险(以重疾险为主)与医疗保险作为商业健康险的主要险种，贡献了超过95％的保费规 模，但其中占据约50％保费规模的重疾险，并非实报实销类保险，它的保障期长，存 ...

根据研究，长期医疗险的赔付率稳定在55%～80%，短期健康险中个人业务实际综合赔付率达50%～ 70%，团体业务赔付率位于100%～120%区间。 在老龄化加速、基本医保基金持续承压的背景下，商业健康险发展始终伴随争议。争议背后是，商业健 康险被公众质疑为赔付总额低、与保费规模的增长节奏不匹配。 国家金融监管总局数据显示，2024年，中国商业健康险保费收入合计达到9774亿元，同比增长8.2％， 增速较去年同期提升3.8个百分点。2025年前8个月，商业健康险保费收入突破7599亿元，有业内人士预 测今年全年商业健康险保费规模有望突破万亿元大关。 而从赔付情况来看，2024年，商业健康险赔付支出约4037.77亿元。如果使用简单赔付率(当年赔付支出 与当年保费收入之比)单一指标进行评估，不难得出中国商业健康险赔付率在40％左右的结论，而这显 著低于发达国家水平(70%～85%)。 但在商保业界人士看来，这样的测算有失偏颇，甚至与实际情况相去甚远，无法真实反映中国商业健康 险的保障效能与盈利状况。 这是因为疾病保险(以重疾险为主)与医疗保险作为商业健康险的主要险种，贡献了超过95％的保费规 模，但其中占据约50 ...

Core Insights - The insurance industry has provided significant support to the national economy during the "14th Five-Year Plan" period, with total compensation reaching 9 trillion yuan and agricultural insurance covering 800 million farming households, laying a solid foundation for the upcoming "15th Five-Year Plan" [1][9] - The "15th Five-Year Plan" emphasizes the role of the insurance industry in enhancing financial strength, supporting rural revitalization, and improving social welfare through various insurance products [1][2] Group 1: Financial Strength and Economic Support - The "15th Five-Year Plan" suggests accelerating the construction of a financial powerhouse, focusing on technology finance, green finance, inclusive finance, pension finance, and digital finance to strengthen the real economy [2][3] - The insurance sector has effectively gathered resources towards new productive forces, with technology insurance providing over 10 trillion yuan in risk coverage and green insurance projected to exceed 330 trillion yuan in 2024 [2][3] Group 2: Risk Management and Social Stability - The insurance industry is expected to enhance its risk management capabilities, developing a comprehensive risk management system that includes pre-warning, response, and post-event support [3][4] - The focus on social governance through insurance products such as inclusive insurance, pension insurance, and health insurance aims to ensure that all residents have access to suitable and affordable insurance coverage [3][6] Group 3: Enhancing Welfare and Healthcare Systems - The "15th Five-Year Plan" highlights the need for a multi-tiered pension and healthcare system, with commercial insurance playing a crucial role in providing supplementary coverage [6][7] - The commercial health insurance sector has paid out 1.8 trillion yuan in economic compensation, supporting a multi-tiered healthcare system and covering 1.22 billion urban and rural residents through major illness insurance [7][8] Group 4: Agricultural Insurance and Rural Development - Agricultural insurance has provided coverage for 800 million farming households, with significant compensation for natural disasters, indicating a robust safety net for rural areas [9][10] - The insurance industry is encouraged to develop tailored products for rural infrastructure projects and provide inclusive pension and health insurance for farmers, addressing their specific needs [10]

Investment Rating - The industry investment rating is "Outperform the Market," indicating an expected industry index increase of over 5% in the next six months [39]. Core Insights - From January to September 2025, the national medical insurance fund accumulated revenue of 21,086 billion yuan, a year-on-year increase of 5%, while expenditures totaled 17,280 billion yuan, a decrease of 2% [2][5]. - The commercial health insurance sector reported a cumulative premium income of 8,427 billion yuan during the same period, reflecting a year-on-year growth of 2% [32]. Summary by Sections National Medical Insurance Fund Tracking - Cumulative revenue for the national medical insurance fund from January to September 2025 was 21,086 billion yuan, with a year-on-year growth of 5%. Monthly revenue in September was 2,276 billion yuan, down 11% year-on-year [2][5]. - Cumulative expenditures for the same period were 17,280 billion yuan, showing a decrease of 2% year-on-year, with September expenditures at 1,847 billion yuan, down 1% year-on-year [5]. Provincial Medical Insurance Fund Tracking - In Hunan Province, the employee medical insurance fund accumulated revenue of 340.04 billion yuan (up 4% year-on-year) and expenditures of 221.49 billion yuan (down 6% year-on-year) from January to September 2025 [15][18]. - Guizhou Province reported a cumulative revenue of 573.99 billion yuan (up 12% year-on-year) and expenditures of 474.71 billion yuan (down 1% year-on-year) during the same period [23][26]. - Guangdong Province's employee medical insurance fund had a cumulative revenue of 1,368.41 billion yuan (up 5% year-on-year) and expenditures of 1,072.85 billion yuan (up 4% year-on-year) [27][30]. Commercial Health Insurance Tracking - The national commercial health insurance sector's cumulative premium income reached 8,427 billion yuan from January to September 2025, marking a year-on-year increase of 2% [32].

Core Viewpoint - The article discusses the recent establishment of a commercial health insurance (CHI) innovative drug directory in China, marking a significant shift towards a dual-track payment system for innovative drugs, alongside the traditional national medical insurance system [4][6][12]. Group 1: Introduction of Commercial Health Insurance Innovative Drug Directory - The CHI innovative drug directory focuses on high-innovation, clinically valuable drugs that cannot be included in the basic medical insurance directory due to their high costs [4][6]. - This directory aims to address the multi-layered payment challenges for innovative drugs, with the implementation of supportive measures still pending [4][6]. Group 2: Transition to Dual-Track Payment System - The introduction of the CHI innovative drug directory represents a historic transition from a single-track medical insurance system to a dual-track system combining both national medical insurance and commercial health insurance [6][12]. - The new policy is expected to alleviate the financial pressure on the basic medical insurance fund while enhancing access to innovative drugs [6][12]. Group 3: Current Challenges in Commercial Health Insurance - There are significant disparities in coverage provided by commercial health insurance for innovative drugs, with only 7.7% of the market being covered by CHI [7]. - The current commercial health insurance market is small, and expanding its scale is a pressing issue, with group insurance being a potential avenue for growth [12][13]. Group 4: Implementation and Operational Challenges - The successful implementation of the CHI innovative drug directory requires collaboration among the National Medical Insurance Administration, pharmaceutical companies, and insurance providers [10]. - There are concerns regarding the ability of existing commercial health insurance products, such as "Hui Min Bao," to adequately cover innovative drugs due to low reimbursement rates [11][12]. Group 5: Need for Improved Payment Mechanisms - The article emphasizes the need for improved payment mechanisms, such as direct settlement systems, to facilitate the integration of innovative drugs into hospitals [16]. - Establishing a collaborative mechanism between medical insurance and commercial health insurance is crucial for effective implementation and data sharing [16].

Core Insights - The introduction of a dual-track payment system for innovative drugs, combining public health insurance and commercial health insurance, marks a significant shift in China's healthcare financing landscape [3][4][12] - The commercial health insurance directory for innovative drugs aims to address the high costs of innovative treatments that cannot be included in the basic health insurance directory due to their pricing [3][4] Group 1: Policy Changes - The establishment of the commercial health insurance innovative drug directory is a historic turning point, officially integrating it into the annual health insurance adjustment framework [3][4] - The new policy allows for a more structured approach to including innovative drugs in the commercial insurance system, enhancing the efficiency of the approval process [5][12] Group 2: Market Dynamics - The innovative drug market is projected to reach 162 billion yuan in sales by 2024, with public health insurance covering approximately 71 billion yuan, representing 44% of the market [4] - Commercial health insurance currently contributes only 7.7% to the payment for innovative drugs, indicating a significant gap in coverage [4] Group 3: Implementation Challenges - The successful implementation of the commercial health insurance directory requires collaboration among health insurance authorities, pharmaceutical companies, and insurance providers [7][8] - There are concerns regarding the low reimbursement rates of existing commercial health insurance products, particularly for innovative drugs, which may hinder their adoption [8][12] Group 4: Future Considerations - The need for innovative commercial insurance products is emphasized to ensure that the multi-tiered payment system can effectively support the coverage of innovative drugs [8][12] - Establishing a direct compensation mechanism and improving data sharing between health insurance and healthcare providers are critical for the successful integration of innovative drugs into the healthcare system [10][12]

Core Insights - Shenzhen Beiyi Rehabilitation Hospital, a flagship rehabilitation institution under Ping An's Peking University Health Group, officially opened on November 1, 2025, marking a significant addition to the healthcare landscape in Shenzhen and the Greater Bay Area [1][3][5] Industry Overview - The rehabilitation medicine sector is experiencing rapid growth, transitioning from a "hundred billion blue ocean" to a "two hundred billion urgent demand market," with an expected annual compound growth rate of approximately 20%, potentially exceeding 200 billion yuan by 2025 [4][13] - There is a significant supply-demand gap in rehabilitation services in Shenzhen, with a calculated demand for around 6,000 rehabilitation beds, while the actual supply is less than 2,000, highlighting a substantial shortfall of over 4,000 beds [4][5] Company Strategy - The establishment of Shenzhen Beiyi Rehabilitation Hospital is a strategic move in Ping An's "comprehensive finance + medical care and elderly care" strategy, aimed at addressing the increasing demand for high-quality rehabilitation services in the Greater Bay Area [3][5] - The hospital features a total construction area of nearly 30,000 square meters, with 301 approved beds and an expected annual patient volume of 100,000, covering a wide range of rehabilitation needs from acute to chronic care [5][10] Innovative Approach - The hospital adopts a "family-style rehabilitation living hall" concept, emphasizing a warm and supportive environment for long-term patients, which includes art therapy spaces and interactive areas for family engagement [7][8] - An "AI brain" integrated into the hospital's operations allows for personalized rehabilitation plans through precise assessments and AI analysis, enhancing the effectiveness of treatment [8][9] Integration with Insurance - The hospital represents a shift in Ping An's business model from being merely a claims payer to becoming a proactive "health partner," aligning its interests with the health outcomes of its clients [10][11] - The integration of health management, top-tier medical services, and rehabilitation care creates a seamless continuum of care, enhancing patient outcomes and reducing insurance claim rates [11][13] Financial Performance - The North University Medical Group, which operates the hospital, reported a revenue of nearly 4.1 billion yuan in the first three quarters of 2025, indicating robust financial health and operational stability [14] - The collaboration between Shenzhen Beiyi Rehabilitation Hospital and Ping An's elderly care services aims to create a comprehensive care model that spans from hospital to home, enhancing the quality of life for patients [14]

Core Insights - The insurance industry in China is expected to continue its growth trajectory during the "15th Five-Year Plan" period, with a focus on enhancing the social security system and emphasizing the role of commercial insurance as a supplementary protection mechanism [1][2][3] Group 1: Development Focus - The "15th Five-Year Plan" highlights the importance of commercial insurance in supporting the multi-tiered pension and healthcare systems, indicating that these areas will be key growth points for the industry [2][3] - The insurance sector is seen as a "second support belt" that can help manage longevity and health risks through diversified insurance products [2][3] - The potential for the insurance industry to address unmet insurance needs remains significant, particularly in the context of disaster risk management and the growing new citizen demographic [6][7] Group 2: Market Opportunities - The commercial health insurance market is projected to grow significantly, with estimates suggesting a potential premium scale of 1.6 trillion yuan by 2035 under normal growth conditions, and up to 2.6 trillion yuan if latent demand is fully realized [5] - The integration of health management services with health insurance products is becoming increasingly common, creating a win-win situation for both consumers and insurance companies [3][4] - The insurance industry is expected to maintain a stable growth rate in premium income, with property insurance premiums projected to grow around 5% and health insurance likely to recover from previous declines [7][8] Group 3: Regulatory and Structural Changes - The regulatory framework for the insurance industry is evolving, with goals set for 2029 to enhance coverage, service quality, and financial stability [7][8] - The industry faces challenges such as product homogeneity and intense competition, which necessitate a focus on risk management and differentiation strategies [8][9] - There is a call for improved data standards and regulatory infrastructure to facilitate better risk management and service delivery in the insurance sector [8][9]

Core Insights - The application of artificial intelligence (AI) in the insurance industry is driving the intelligent upgrade of traditional business processes, enhancing efficiency and service quality while addressing issues in pricing and risk management [1][3][5] Group 1: AI Applications in Insurance - AI has been implemented in six key areas: intelligent underwriting, intelligent claims processing, rapid product generation, customer service optimization, personalized services, and enhancing inclusivity [1][2] - Intelligent underwriting utilizes computer vision and natural language processing to analyze medical reports, significantly reducing the underwriting cycle for commercial health insurance [2] - Intelligent claims processing leverages image recognition technology to improve efficiency, such as instant damage assessment in auto insurance scenarios [2] Group 2: Risk Management Transformation - AI is transforming risk management from reactive claims handling to proactive, full-process risk management, enabling precise risk assessment and fraud detection [3][5] - The shift from group pricing to individual customization is facilitated by integrating dynamic data, allowing for more accurate premium adjustments [4] Group 3: Data Governance and Talent Development - Strengthening data governance and talent development is crucial for the integration of AI in insurance, focusing on data standardization and quality improvement [6] - Collaboration between insurance institutions and academic research organizations is essential for cultivating talent with expertise in both insurance and AI technologies [6]