Summary of Key Points
Just one year after the launch of the commercial insurance innovative drug catalog, its popularity has cooled down significantly: The number of applications submitted in 2026 dropped from 141 last year to 61, far falling short of expectations. Behind this are various complex issues stemming from conflicts among different stakeholders:
- Medical insurance companies wish to expand coverage through the catalog to provide better protection, but they are hesitant due to their risk aversion.
- There are compliance risks associated with the hidden discounts on drugs.
- The premium scale of consumer-friendly insurance programs is too small to meet the demand for high-value medications.
- Hospitals are reluctant to introduce innovative drugs due to performance evaluation pressures.
- Pharmaceutical companies have realized that the catalog is not a magic solution to increase sales.
At its core, this conflict reflects the fundamental difference in approaches between medical insurance (which focuses on public protection) and commercial insurance (which prioritizes financial risks), making it difficult for the catalog to be successfully implemented.
Detailed Analysis
1. A Halving in Application Numbers: The Difficulties Stemming from Multiple Stalemates
Why are pharmaceutical companies less enthusiastic about applying this year? The first version of the catalog had little impact on actual sales after half a year of implementation.
- What do insurance companies fear?
- Compliance risks related to drug discounts (which will be discussed in detail later).
- High-risk drugs are often not covered by insurance: Rare disease medications inherently carry high risks, and early-stage Alzheimer's drugs have long-term, costly treatment options. Pharmaceutical companies may also encourage patients to purchase insurance, leading to a phenomenon known as "adverse selection," which can result in significant losses for insurers.
- Why are hospitals uninterested?
- Hospitals are evaluated based on average costs per patient and the increase in hospitalization drug expenses. Innovative drugs are expensive and can raise these metrics, so hospitals prefer not to use them.
- What do pharmaceutical companies think?
- Initially, they hoped the catalog would help insurance companies purchase more drugs, but now they realize that even with the catalog, sales remain low. As a result, applying has become a way for sales departments to avoid responsibility.
In short, every link in the process is encountering obstacles, making the final step an insurmountable hurdle.
2. Consumer-Friendly Insurance: Too Weak to Support High Demands
Consumer-friendly insurance programs are designed to complement the commercial insurance catalog, but their premium scale is insufficient:
- Nationwide, the annual revenue for these programs is only 20 billion yuan, of which only 10% (2 billion yuan) is allocated to innovative drugs, far from what pharmaceutical companies need.
- No increase in coverage for high-value drugs: For example, after CAR-T and Alzheimer's drugs were included in the catalog, the number of users did not increase, disappointing pharmaceutical companies.
- Adverse selection hurts insurance companies: One consumer-friendly insurance program set a reimbursement limit of 1 million yuan for rare disease drugs, leading to a surge in claims, which forced insurers to lower the limit to 300,000 yuan.
- Insurance companies are selective: They often remove high-risk drugs from the catalog (for instance, the Shanghai HuHuiBao program removed CAR-T drug Yikaida) due to financial constraints.
In conclusion, consumer-friendly insurance programs are not a viable solution for covering the costs of innovative drugs; they merely provide a partial remedy.
3. Drug Discounts: Hidden Compliance Challenges
During negotiations for the commercial insurance catalog, pharmaceutical companies propose a negotiated price lower than the public price, which becomes an untransparent "hidden discount." Insurers pay the public price and seek reimbursement for the difference, but there is no clear mechanism for transferring this money.
- Direct transfer? Not feasible as there is no legal basis for such financial transactions between insurers and pharmaceutical companies.
- TPA intermediaries? Difficult to implement: TPA companies (third-party service providers) might try to cover the full cost first, with insurers paying the negotiated price and pharmaceutical companies making up the difference under the guise of "service fees," but this is risky due to regulatory scrutiny.
- Direct payment models? Risky: If insurers pay hospitals directly, they could face bad debt risks if patients stop taking the drugs or pass away. Previous direct payments were limited to 20,000 yuan.
- Government collection? Difficult to replicate: In Ningbo, the government collected discounts for consumer-friendly insurance programs, but this requires significant local government involvement and is not easily replicable elsewhere.
In summary, the lack of transparency in these hidden discounts and the absence of compliant payment channels are major barriers to the implementation of the catalog.
4. The Conflict Between Medical Insurance and Commercial Insurance: Two Different Logics
The fundamental issue with the commercial insurance catalog lies in the clash between medical insurance (public protection) and commercial insurance (financial profit):
- Medical insurance aims to expand coverage: By shifting the burden of high-risk drugs to commercial insurers, it hopes to reduce patient costs and support pharmaceutical company development, following the approach of national price negotiations.
- Commercial insurance focuses on risk management: Insurance is a business that seeks profits, and they are unwilling to cover high-risk drugs (such as those for rare diseases and Alzheimer's).
- Dramatic differences in approaches: Medical insurance tends to be more aggressive (quickly implementing new policies), while commercial insurance is more cautious (only moving forward when risks are manageable). For example, insurance associations require pharmaceutical companies to bear excess costs, which encourages their participation.
This tension between the two approaches has stalled the implementation of the catalog.
5. Directions for Improvement: Moving from Idealism to Reality
This year's catalog applications may be more pragmatic:
- Prioritize suitable drugs: Reduce the inclusion of high-risk drugs like those for rare diseases and Alzheimer's, focusing on those with manageable risks and clear clinical benefits.
- Shared risk models: Insurers and pharmaceutical companies could share the costs (for example, covering excess expenses), which would reduce pressure on insurers and address compliance issues.
- Emphasize the catalog's additional value: Pharmaceutical companies should recognize that the catalog can boost drug awareness and promote sales outside of insurance coverage. For instance, one catalog increased the self-paid sales of certain drugs by 80%.
Perhaps only by balancing support for innovation with risk management can the commercial insurance catalog truly be successful.
In Conclusion
The difficulties faced by the commercial insurance innovative drug catalog reflect the gap between the idealism of public protection and the reality of commercial insurance. To make it a viable solution, medical and commercial insurance parties need to find common ground and clearly define their responsibilities and benefits. Otherwise, the catalog will remain just an empty promise on paper.