Abstract:Improving the multi-level medical security system, solving the problem of payment for innovative drugs, and giving full play to the supplementary role of commercial insurance are being paid attention to.
Text|Mu Jing. Edit|ZHANG Jing.
The sustainable and innovative development of health insurance has once again attracted attention. Recently, a notice issued by the Beijing Supervision Bureau of the State Administration of Financial Supervision to the industry on the provision of relevant products has made health insurance the focus of the market again.
The products required to be submitted this time include not only special drug health insurance products, but also dental health insurance products, among which due to the cooperation products involving several leading third-party health management institutions, in the eyes of industry insiders, or related to health insurance innovation business norms, under the closed loop of medicine, medicine and insurance, innovation around health insurance products is also emerging, and health management companies are also participating in it and becoming an important role.
Chen Hao, director of the Drug Policy and Management Research Center of Tongji Medical College of Huazhong University of Science and Technology, believes that "the routine of this supervision is to standardize the existing insurance products, ensure that the basic functions and attributes of insurance risk protection are not missing, and stop non-compliant 'edge ball' behaviors in a timely manner."The second is to further open up the policy space of this type of supplementary insurance, and give more space for new and innovative payments to explore and develop more models. ”
How can the scope of innovation in health insurance be more reasonable?How can health insurance be healthy?
Looking back, after 2018, more and more domestic innovative pharmaceutical companies have new drugs on the market and have entered the commercialization stage, and they need to seek payers other than national medical insurance, and "innovative payment" has become a hot word in the industry.
With the introduction of two major policies to promote the development of commercial health insurance, the penetration rate of commercial insurance is expected to further increase, and the innovative payment environment other than basic medical insurance will continue to improve.
The advent of innovation** has brought hope to patients who were originally facing existential threats, but at the same time, it is often expensive to pay**, and this economic pressure has cast a shadow on patients and their families. For enterprises, how to recover costs as soon as possible and how to solve the payment problem of patients from the perspective of marketing have become the top priorities in the commercialization layout of high-value innovation**.
According to the statistics of the China Health Development Bulletin, China's total health expenditure has increased year by year in recent years, and the total national health expenditure in 2022 is preliminarily estimated to be 84,846700 million yuan, of which: ** health expenditure 23,916400 million yuan, accounting for 282%；Social health expenditure 38015800 million yuan, accounting for 448%；Personal health expenditure 22914500 million yuan, accounting for 270%。The total per capita health expenditure is 60100 yuan, the proportion of total health expenditure to GDP is 70%。Although basic medical insurance has included more than 96% of the Chinese population, its connotation of "guaranteeing the basics" is destined to fail to achieve good coverage of high-value innovations**. Therefore, for high-value innovations that are not included in medical insurance**, in such a payment context, the proportion of individual payments is still relatively high.
In this context,The basic medical insurance focusing on "breadth" cannot cover the "depth" required for high-value innovative payment, and commercial insurance, as the role of innovative payment, explores the way to balance "breadth" and "depth" and provides solutions.
Zhang Lufa, executive dean of the Yangtze River Delta Institute of Health of Shanghai Jiao Tong University, said that in the context of healthy China, how to make medical insurance, medical treatment, and medicine truly achieve benign and substantial synergy and linkage, and strive to let the people enjoy affordable, high-quality, and high-quality medical services is the ultimate goal. Innovation is the first driving force, and the development of the biomedical industry, especially the development of the innovative pharmaceutical industry, is inseparable from the support of the whole chain of innovation chain, industrial chain, talent chain and capital chain. In recent years, Shanghai has carried out a series of explorations to build an innovation highland for the biomedical industry with global influence, and to empower the innovation and development of the front-end of the industry by improving the payment mechanism and application mechanism of the back-end of the pharmaceutical industry.
According to Zhang Songqi, vice president of WeDoctor, recently said that with the advancement of medical technology, the service format of chronic diseases, including tumors, has developed rapidly, and the market scale is growing day by day. Chronic diseases account for 70% of total health spending in China, yet the market for commercial chronic disease services has not been effectively developed in the past few years. With the rapid progress of digital and intelligent capabilities, combined with the reform of medical insurance payment methods and the acceleration of innovative payment of commercial insurance, the digital chronic disease management industry has ushered in a real market explosion period.
He believes that for many years, China's commercial insurance compensation accounts for a small proportion of the total medical and health expenses, and we should focus on the largest payer in the entire chronic disease management system: medical insurance. In fact, in the future of chronic disease management, the combination of chronic disease management and commercial insurance is an inevitable trend of development.
According to Wu Guoliang, deputy secretary-general of the Shanghai Insurance Association, Shanghai's commercial health insurance has developed rapidly in the past two years, and the process of innovative medical device products entering the medical insurance has also been significantly accelerated. Up to now, there are nearly 10 commercial health insurance products in Shanghai that can be purchased with the balance of the medical insurance account. At the same time, he believes that as an innovative inclusive health care service and security platform, the emergence of "Shanghai Huibao" is a breakthrough way to improve the accessibility and affordability of innovative drugs and accelerate the landing and use of innovative drugs and devices. At present, the cumulative number of insured people in Shanghai Huibao is nearly 20.22 million, and a total of 510,000 claims have been paid, with more than 1.3 billion yuan in compensation, of which 1700 million yuan. "If we want to support the development of innovative drugs and promote the supply-side reform of insurance products, this requires the top-level design of medical insurance, supervision and other departments, and the insurance industry continues to innovate and explore, and work together to contribute to the construction of a multi-level medical security system in China. ”
Industry experts suggest that the insurance innovation of short-term health insurance such as special drug health insurance and even dental health insurance requires all parties, including insurance companies, to make corresponding efforts to grasp the scale and prevent risks, and commercial health insurance is at the forefront of innovation in the combination of medical, pharmaceutical and insurance models.
There are professionals who predict thatThe market size of special drug insurance will reach about 10% of one million medical insurance, which means that the future market size of special drug insurance will be about 3.5 billion yuan.
According to the "Opinions on Promoting the Development of Commercial Insurance in the Field of Social Services" jointly issued by 13 ministries and commissions including the China Banking and Insurance Regulatory Commission, the health insurance market will strive to exceed 2 trillion yuan by 2025By 2025, we will strive to accumulate 6 trillion yuan of pension insurance liability reserves for the insured.
For many cancer patients, the high cost of anti-cancer drugs is an unavoidable problem in their process. In response to this pain point, "special drug insurance" covering the cost of targeted drugs outside of medical insurance has become the expectation of patients.
Regarding the development trend of special drug insurance in recent years, Zhou Jin, PwC China Financial Industry Management Consulting Partner, said that special drug insurance is an innovation in the field of health insurance in recent yearsOn the other hand, this innovation integrates the ecology of intermediaries, direct insurance companies, reinsurance companies, and TPA companies for health management, trying to find a win-win model for all parties.
According to the evaluation of the insurance industry, "special drug insurance" optimizes the combination of commercial medical insurance, oncology medical services and special drug services, and solves the problem of out-of-hospital drug purchase demand that cannot be covered by general consumer commercial health insurance. The emergence of "special drug insurance" is not only an innovation in the form of health insurance products, but also an innovation in the insurance industry to "sneak" into the medical security system to discover people's needs and solve health pain points.
However, compared with the relatively mature critical illness insurance, the development of "special drug insurance" is still immature, and most insurance companies are not yet able to develop such insurance due to the current situation of "no pricing data, no risk control measures, and no service network". In addition, changes in drug approval and medical insurance policies, as well as adjustments to the medical insurance drug list and clinical specifications, have also made the development of "special drug insurance" face variables.
However, in recent years, relevant departments have successively implemented or brewed a series of policies to strengthen the prevention and treatment of major diseases such as cancer and rare diseases, including speeding up the registration and approval of new anti-cancer drugs at home and abroad, and including more anti-cancer drugs in medical insurance. This also means that the protection of the basic medical insurance system and the help of "special drug insurance" are expected to alleviate the difficulty of cancer patients who "cannot afford to use" targeted drugs.
Under the diversified payment pattern, how can commercial health insurance innovate and develop within a reasonable boundary?
Due to the functional orientation of China's basic medical insurance and the limited nature of basic medical insurance resources, it is unrealistic to incorporate all medical technology innovations into basic medical insurance and reimburse all innovative drugs and technologies by medical insurance, so it is necessary to establish a multi-level medical security system and form an innovative payment system to solve the problem. For example, commercial supplementary medical insurance, charitable donations, various forms of medical mutual assistance, etc., protect the interests of the masses at multiple levels and through multiple channels.
Looking at the health insurance market in developed countries and regions around the world, commercial insurance companies cover innovative medical technologies and provide innovative medical services to meet the diversified needs of the masses through a multi-level and diversified innovative product system.
Improving the multi-payment mechanism is actually to encourage innovation in biopharmaceutical enterprises. Ding Sheng, founding dean of the School of Pharmacy of Tsinghua University and director of the Global Health Drug R&D Center (GHDDI), said that under the premise of reasonable pricing, multiple payment mechanisms such as medical insurance and commercial insurance can support pricing, which can not only allow enterprises to operate normally, but also allow patients to use good drugs and devices. Patients can be reimbursed through medical insurance or commercial insurance, and companies can also sell drugs and make profits, so that companies have enough funds and motivation to take the initiative to innovate.
On July 31 this year, the Shanghai Municipal Medical Security Bureau, together with the Municipal Commission of Economy and Information Technology, the Municipal Science and Technology Commission, the Municipal Health Commission, the Municipal Local Financial Supervision and Administration Bureau, the Shanghai Supervision Bureau of the State Financial Supervision and Administration Administration, and the Shanghai Big Data Center, issued the "Several Measures for Further Improving the Diversified Payment Mechanism in Shanghai to Support the Development of Innovative Drugs and Devices", which pointed out that the establishment of a regulatory cooperation mechanism between the basic medical insurance and commercial health insurance industries, the improvement of the formation mechanism of innovative drugs and devices, and the acceleration of the clinical application of innovative drugs and devices. Increase payment support for innovative drugs and medical devices, etc., and encourage biomedical enterprises to innovate.
The industry consensus believes that the above measures can enable enterprises to focus more on R&D and innovation, and realize a virtuous circle of industrial innovation and development from R&D investment to output returns. How to sustain the sustainable development of commercial insurance and play the role of health service guarantee is a common problem faced by the industry. In the future, commercial insurance companies should think about and improve the efficiency of urban insurance, such as effectively improving claims services through modern technology, improving the overall sense of gain and overall efficiency, etc., increasing publicity, exploring a new path for the sustainable development of commercial insurance, and effectively helping to solve the problem of accessibility and affordability of innovative drugs, meeting the people's needs for high-quality medical treatment and medication, and further helping inclusive insurance to truly realize inclusive sinking and benefit the people.
According to Zhu Junsheng, a member of the Expert Committee of the China Insurance and Social Security Research Center of Peking University, and the former deputy director, professor and doctoral supervisor of the Insurance Research Office of the Institute of Finance of the ** Development Research Center, analyzedAt present, the combination of commercial health insurance and medicine, the largest piece in the short term is Huimin Insurance, but there is a big difference between Huimin Insurance in various places. Even if 80% of them contain special drug liability, the practices in various places are not exactly the same, but everyone still takes optimizing the catalog and including more special drugs as the direction of exploration.
He also pointed out that according to the current research, in the combination of insurance and medicine, in fact, group medical insurance can do more combination. In addition, at present, the personal insurance of domestic health insurance is mainly millions of medical insurance, which is also expanding to non-healthy individuals, and in this direction it can actually be combined with medicine to do some expansion. Because of the large user base of China's million-dollar medical insurance, only a large user base, which extends to chronic diseases and diseased individuals, can have the foundation for integration with the pharmaceutical industry.
According to Zhang Chu, head of the product development department and industry and finance innovation division of China Re Life Insurance, the health insurance industry, especially in the field of critical illness insurance, has stalled, and due to the environment, the industry has reached the stage of transformation and redefinitionInternally, health insurance companies need to continuously improve their capabilities, build new capabilities, and build new consumption scenarios in the new environment.
Actually,In the eyes of industry insiders, as an important participant in the multi-level security system, insurance products have become a carrier and a bridge between customers and hospitals, customers and pharmaceutical companies.
Some research institutions suggest that insurance companies should focus on key regions and groups to achieve key breakthroughs, refine and innovate products, and make differentiated characteristics of short-term health insurance products. For example, insurance companies can develop different products for children who have posture correction and vision and dental management needs, women who have protection needs for special female diseases such as breast cancer and cervical cancer, and elderly people who have chronic disease protection needs.