(Source: "Chinese People's Political Consultative Conference" 2026-05-06)
The "Outline of the Fifteenth Five-Year Plan for National Economic and Social Development of the People's Republic of China" points out that "commercial insurance is encouraged to expand the scope of payment for innovative drugs." How to open up the "last mile" of innovative drugs and create a synergistic effect with the booming long-term care insurance (hereinafter referred to as "long-term care insurance") is a proposition that Sun Jie, a member of the National Committee of the Chinese People's Political Consultative Conference and deputy dean of the w88 casino of Insurance at the w88 casino, is thinking about.
The effectiveness and dilemma of commercial insurance empowering innovative drugs
“In recent years, under the positioning of basic medical insurance to ‘guarantee the basics’, commercial insurance has played an increasingly prominent role in the field of innovative payment, and is actively building an important pillar of the multi-level medical security system.” Sun Jie gave an example of inclusive commercial insurance represented by “Huimin Insurance”, which has quickly included a large number of high-value innovative drugs and rare disease drugs in the protection catalog. In 2025, the average number of drugs included in the "Huiminbao" special drug catalog in various regions will exceed 50, which greatly reduces the burden on patients. At the same time, some leading insurance companies have begun to try to establish a "risk sharing" mechanism with pharmaceutical companies, such as payment based on efficacy, fee capping and other payment plans, initially breaking the traditional "pay per project" model.
“What deserves more attention is that the design of commercial insurance is extending from simple ‘post-incident reimbursement’ to ‘full-cycle management’. Through front-end health management, funds are directed to invest in disease prevention and early screening, realizing the transformation from ‘treating existing diseases’ to ‘treating diseases before they occur’. "In Sun Jie's view, although the payment capacity and service level of commercial insurance are compared with the "China speed" of innovative drug research and development, there is still an obvious lag. These lags come from: first, data silos lead to "pricing difficulties." Insurance companies lack core data on diagnosis and treatment of medical institutions, and it is difficult to accurately measure the frequency of use and cost risks of innovative drugs, resulting in extremely high deductibles and extremely high costs in product design. The low reimbursement ratio makes the product less attractive to patients. Secondly, poor payment connection leads to "difficulty in entering the hospital". Due to the limitations of drug proportion assessment and other indicators, doctors are not motivated to prescribe innovative drugs covered by commercial insurance. The payment of commercial insurance and the hospital information system are not yet fully connected. Patients often need to "pay first and then make claims", which makes the process cumbersome and provides a poor experience. Third, the lack of a risk-sharing mechanism makes it difficult to sustain. At present, the payment of innovative drugs in commercial insurance mostly adopts a "fixed catalog, fixed compensation" model, which lacks a dynamic adjustment mechanism. Once the use of a certain high-priced drug increases, it is easy to cause the compensation rate to soar, forcing insurance companies to eliminate the drug or significantly increase the price. At the same time, as my country continues to The aging of the population is accelerating, and long-term care insurance, as the "sixth insurance" of the social security system, is moving from pilot to nationwide implementation. In March 2026, eight national departments jointly issued an implementation plan to clarify that all retirees will be included in the coverage. The implementation of long-term care insurance not only provides life care and medical care protection for disabled people, but also creates space for the coordinated development of commercial insurance and long-term care insurance.
Use the bridge of commercial insurance to open up the "last mile" of innovative drugs
Sun Jie believes that efforts should be made from multiple aspects such as system design, data sharing, and service integration to break through the "blocking points" of innovative drugs, promote the coordinated development of commercial insurance and long-term care insurance, and build a comprehensive health security network. For this it is recommended:
Break down data barriers and build a new cornerstone of "actuarial pricing". The government will take the lead to establish a "medical-medical insurance-commercial insurance" data sharing mechanism, relying on the National Big Data Bureau or the medical insurance information platform to open desensitized disease spectrum, diagnosis and treatment path, drug and consumable usage and other data to insurance companies to solve the problem of "missing data" of insurance companies and improve actuarial pricing capabilities. Support industry associations in establishing an "innovative drug and device risk database" to accumulate real-world data, help insurance companies develop more exclusive products that "dare to pay and can pay", and provide scientific basis for innovative drug payment.
Promote the deep integration of payment and medical services and open up the "landing channel". Promote direct payment settlement, encourage insurance companies to connect with hospital and pharmacy systems, realize "one-stop" direct payment settlement for innovative drugs, simplify the patient reimbursement process, and improve the medical experience. Optimize the assessment mechanism. When assessing hospitals, the health department will not include "reasonable use of commercially insured innovative drugs" in the assessment of drug proportions, or give them a separate expense, so as to stimulate the motivation of hospitals to equip and use innovative drugs covered by commercial insurance. Establish a dynamic adjustment mechanism. The commercial insurance innovative drug catalog should establish an annual dynamic adjustment mechanism to ensure that the latest approved life-saving drugs can be included in the guarantee in a timely manner and meet the clinical needs of patients.
Build a risk-sharing ecosystem and create a new paradigm of "value-based healthcare". Promote "payment based on efficacy" and encourage insurance companies and pharmaceutical companies to sign payment agreements based on clinical results. If the drug does not achieve the expected efficacy, the pharmaceutical company will bear part of the cost or refund, reducing the compensation risk of insurance companies and encouraging pharmaceutical companies to improve drug quality. Explore the "risk pool" mechanism, with government guidance and multi-party participation, establish an "Innovative Drug and Device Payment Risk Adjustment Fund" to underpin huge compensation payments caused by public health emergencies or ultra-high-value drugs, and enhance the resilience of the commercial insurance system. Front-end health management, in conjunction with the development of long-term care insurance, guides commercial insurance funds to invest in disease prevention and early screening, realizing the transformation from "treating existing diseases" to "treating diseases before they occur".
“By breaking down data barriers, promoting payment integration, building a risk-sharing ecosystem, and strengthening policy support, commercial insurance will surely become a solid bridge for innovative drugs to benefit the public.” Sun Jie said that the coordinated development of commercial insurance and long-term care insurance will further knit the health security network and contribute significantly to realizing the strategic goal of “Healthy China” and improving people’s well-being.
Attached original text link:
