Improving the multi-level medical security system provides a huge space for the development of commercial health insurance. The coordinated development of commercial health insurance and the pharmaceutical industry can not only promote the expansion of commercial health insurance to the sick population and achieve innovative development, but also give full play to the payment value and improve the accessibility of innovative drugs.
At present, the cooperation between commercial health insurance and the pharmaceutical industry is mainly concentrated in three important areas: chronic non-communicable diseases, tumors and rare diseases. From the perspective of the relationship between the market and the market, the cooperation model is mainly divided into two types: one is the integration of social business, the most representative is the urban customized commercial medical insurance (Huimin Insurance). The second is commercial insurance cooperation, including special drug and special disease insurance, drug benefit management (PBM) and managed care. The report mainly analyzes the current situation and challenges of the cooperation model between commercial health insurance and the pharmaceutical industry, and proposes to promote the collaborative innovation of commercial health insurance and pharmaceutical industry.
Special disease and special drug insurance has opened up the cooperation between the insurance industry and the pharmaceutical industry, and has developed three models in practice: special drug insurance for healthy people, special drug insurance for special diseases focusing on patient groups, and protection products for the whole population regardless of health status. The main challenges are limited scale and payment volumes, as well as limited integration with healthcare management. The development trend is to increase the volume of payment with policy support and strengthen the integration with medical management.
Pharmaceutical benefits (PBM) mainly refer to patient benefit plans supported by pharmaceutical companies, i.e., "innovative payments" carried out by the insurance and pharmaceutical industries. In practice, there are multiple drug channel models, designated innovative drug reimbursement models, and drug welfare programs that adopt service rights. The main challenge is to face certain compliance pressures. Regulatory governance documents have prompted the industry to explore more valuable business models, with innovative payments for disease-bearing individuals with specific diseases 2The 0 model accelerates the exploration, the insurance that endorses the efficacy of new drugs shows a trend of diversification and innovation, and the drug equity card model based on the ecology of the general drug chain is developing rapidly towards Internet outpatient insurance.
At present, China's insurance industry is actively exploring managed care. The main challenges are the lack of deep integration between the insurance industry and the pharmaceutical industry, the lack of substantial participation in health management services in the insurance industry, and the lack of connection between the medical insurance network. In the future, the insurance and pharmaceutical industry will choose different paths such as "from insurance to medicine", "from medical care to insurance" and "scientific and technological innovation" according to its own resources and endowments to explore managed care, so as to realize the deep integration of medicine, medicine and insurance. By exploring managed care, the role of commercial health insurance will gradually transform and upgrade from a medical expense reimbursement provider and medical insurance payer to a health service manager, promote the integration of health insurance and the pharmaceutical industry, and maintain the health of customers.
*: Tsinghua Wudaokou.
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