A symposium on commercial medical insurance and innovative drug payment management was held in Beijing on July 31, 2026, hosted by the Central University of Finance and Economics' School of Insurance and co-organized by Sina Health Insurance Research Institute.
Experts from medical insurance policy research, commercial insurance, clinical medicine, legal practice, and academia gathered to discuss topics such as the implementation of commercial insurance innovative drug lists, optimizing payment structures for innovative drugs, multi-tiered rare disease coverage, and collaboration across medical, educational, research, and production sectors.
Basic medical insurance is the core infrastructure for commercial insurance payment management, and commercial insurance must adhere to market principles.
Experts pointed out that China's basic medical security system, as a public good, has natural positive externalities. The payment and settlement systems and regulatory functions established by basic insurance in medical care, pharmaceuticals, and health insurance provide a primary risk management foundation for commercial insurance. Commercial insurance must operate on top of public medical management and basic insurance to function effectively.
At the same time, commercial insurance must follow market laws. Differentiated product innovation related to innovative drugs can only be achieved by market entities through market mechanisms. The goal of the commercial insurance innovative drug list is not simply to lower drug prices, but to evaluate whether including a drug in the list can help insurers save costs, enhance operational value, and achieve sustainable operations.
Experts also called for maintaining stable and consistent basic medical insurance policies, accelerating the establishment of a robust data foundation, expanding funding sources, and exploring measures for cost sharing, risk sharing, and internalizing costs.
The commercial insurance innovative drug list is progressing steadily, but multiple bottlenecks remain in payment implementation.
Experts explained that the launch of the commercial insurance innovative drug list is based on two key factors: promoting innovative drug development and expanding commercial health insurance. By July 2024, over 90% of urban and rural residents' coordinated regions and 70% of employee medical insurance coordinated regions faced current-period deficits, making the development of commercial health insurance inevitable.
The 2025 commercial insurance innovative drug list includes 18 drugs across four categories: oncology drugs, CAR-T therapies, rare disease drugs, and Alzheimer's disease treatments. These drugs are characterized by their differentiation (filling gaps in basic medical insurance) and insurability (significant clinical benefits, clear indications, and low moral hazard).
Experts noted that drug insurability can be evaluated across four dimensions: customer acquisition ability, manageable patient numbers, controllable clinical management, and controllable disease risk, with varying constraints for different drug types.
In terms of implementation progress, as of the end of April 2026, 1,440 designated pharmacies and 724 designated medical institutions nationwide had been equipped with the listed drugs. Provincial and municipal supporting policies were issued promptly, with all 31 provinces, autonomous regions, and municipalities, as well as the Xinjiang Production and Construction Corps, having introduced relevant policies. Zhejiang Province had the most comprehensive regulations, explicitly stating that listed drugs are not included in the DRG/DIP payment scope and can be paid for on a fee-for-service basis.
However, several core bottlenecks remain in the payment implementation of the commercial insurance innovative drug list. After DRG/DIP reform, medical institutions are reluctant to use expensive innovative drugs due to cost control pressures, leaving patients unable to access them. Discounts are limited to out-of-hospital payment scenarios, and in-hospital channels are not yet available. Additionally, the 2025 list was released at the end of the year, while local Huiminbao (city-level supplemental insurance) and commercial health insurance coverage periods are typically adjusted annually, creating a significant policy time lag.
To address this, cross-departmental coordination should be promoted to form a unified effort, enabling data sharing, business efficiency, and consistent policy direction and implementation.
The innovative drug payment structure faces three unsustainable pressures, with the core issue being a lack of layering.
Data shows that in 2025, the total market size for innovative drugs in China was approximately 195 billion yuan, with basic medical insurance covering about 46.4%, personal out-of-pocket payments accounting for about 45.8%, and commercial health insurance contributing only about 7.8%.
Experts pointed out that the current payment structure is unsustainable, manifesting as three unsustainable pressures: the basic medical insurance fund cannot bear the burden, individuals cannot bear it, and drug companies cannot sustain price reductions. The core issue is not simply a lack of funds, but a lack of layering, with too much pressure from "covering major illnesses" and "supporting innovation" placed on the same basic medical insurance system. There is a lack of a market-based risk-sharing layer, and commercial health insurance has not yet effectively assumed the role of risk-sharing for innovative drug payments.
Given the constraints of strained medical insurance fund revenues and expenditures, limited commercial insurance funding pools, and concentrated risks from high-cost drugs, the innovative drug payment dilemma is becoming increasingly prominent. To enhance commercial health insurance's ability to pay for innovative drugs, simply asking insurers to "vigorously develop products covering innovative drugs" is insufficient. Instead, a restructuring of the system, division of labor, and risk mechanisms is required.
A more optimal path is to promote coordinated progress between social and commercial insurance on the basis of a reasonable division of labor, forming a development model with financial support and manageable risks, enabling innovative drugs to better serve the goals of a healthy China and social equity.
Regarding reform directions, experts proposed building a layered coordination mechanism between social and commercial insurance. Basic medical insurance should secure the baseline for people's livelihoods, focusing on clinically essential, high-cost-effective drugs for the general public, and gradually withdrawing from ultra-high-cost, niche drugs, guiding commercial insurance to take over. This should be accompanied by optimizing the dynamic management of drug lists, facilitating in-hospital distribution, and opening up standardized drug usage data.
At the same time, commercial insurance should leverage its market advantages to precisely fill gaps left by basic insurance. It should deepen reforms around mechanisms, products, and risk control, clarify coverage boundaries, and link cost sharing, risk prevention, scenario integration, and data sharing. This will enable innovative drug payments to accurately match needs, achieving a virtuous cycle with controllable risks and robust coverage.
Experts emphasized that the value of innovative drugs must ultimately translate into patient accessibility. In the future, basic medical insurance should secure the bottom line for people's livelihoods, commercial insurance should take on significant responsibilities, individuals should use drugs more rationally, and charitable and social assistance should support more vulnerable groups. Through institutional optimization, mechanism innovation, and coordinated collaboration, the goal of "new drugs can be promoted, patients can access them, payments can be sustained, and the industry can develop far" can be achieved.
The rare disease payment dilemma highlights the urgency of innovative drug accessibility.
Experts used the example of homozygous familial hypercholesterolemia (HoFH) to illustrate the challenges faced by rare disease patients. HoFH patients have significantly elevated LDL-C levels from birth and may experience myocardial infarction or even sudden death during childhood or adolescence, reaching the risk threshold for coronary heart disease nearly 50 years earlier than the general population. China has approximately 4,000 to 6,000 potential patients, but the diagnosis rate is less than 5%, and the average age at death is about 19 years.
Clinical application in developed countries has shown that lomitapide, an oral lipid-lowering drug that does not rely on the LDL receptor pathway, can reduce LDL-C by an additional 50% to 60% when combined with conventional therapy, lower the risk of major adverse cardiovascular events by more than 65%, and potentially extend life expectancy by over 11 years. Experts emphasized that early screening, timely diagnosis, sustained lipid-lowering to target levels, and improving access to innovative drugs are key to improving patient outcomes.
Roundtable discussion: Pathways and challenges for multi-party coordination in payment management.
During the roundtable discussion, experts engaged in lively debate on four major topics related to payment management. Regarding the practical path of commercial insurance payment for innovative drugs, some experts pointed out that Huiminbao has limited sustainability as a payment vehicle, and corporate group health insurance, particularly for state-owned enterprises, may become a new direction. Liability for innovative drugs should not be sold separately but bundled into group coverage through a combination of chronic disease drug payments, out-of-hospital drug services, and embedded innovative drug liability.
Data shows that from 2024 to 2025, payments for innovative drugs from million-medical insurance surged by 40%, from 28 billion yuan to over 40 billion yuan, while payments from Huiminbao and group medical insurance remained flat. Enterprise supplementary medical insurance should shift from the traditional "bill reimbursement" model to a "drug payment" and "health management" model.
On the supplementary value of commercial insurance in the early stages of innovative drug launch, experts noted that there is a time window between a drug's approval for market and its coverage by basic medical insurance. Commercial insurance can play a supplementary role from two dimensions: time accessibility and budget-level accessibility. By linking payments to efficacy, it can drive higher-value purchasing, forming a virtuous cycle of "commercial insurance supporting early-stage drug innovation, and basic insurance expanding coverage later."
Data was identified as a foundational support for coordinated payment management. Multiple experts emphasized that issues such as uncertainty in innovative drug payments, budget impact projections, and efficacy-based payment standards are largely related to insufficient data. They suggested exploring data-supported mechanisms like "conditional access" or "periodic evaluation," where insurers could grant temporary access after a drug's launch, dynamically adjusting payment rules based on real-world data.
Other experts pointed out that medical data has significant positive externalities, requiring the public sector to lead the development of data infrastructure. Currently, there are concerns among different entities about being "unwilling to give, unable to give, and afraid to give" data, necessitating the establishment of basic trust and rule foundations.
Regarding the boundaries and solutions for rare disease payment guarantees, some experts stated that relying solely on commercial insurance cannot achieve the goal of rare disease coverage; social insurance must play a pivotal role. This could be explored through the law of large numbers and specialized disease service packages. However, other experts warned that, using HoFH as an example, the annual treatment cost for lomitapide in the United States is about $300,000. Even if reduced to one-tenth of that, it would still be a heavy burden for local medical insurance systems. A few dozen patients could deplete the funding pool of Huiminbao, inevitably leading to a death spiral.
At the same time, some experts proposed that rare disease patients are martyrs in human evolutionary history. When effective drugs are available, their treatment costs should be shared by the entire population. Therefore, basic medical insurance, which covers the entire population, should assume the responsibility of guaranteeing and managing risks for rare disease patients. Commercial insurance should provide supplementary coverage from a multi-tiered perspective. In insurance products with a universal nature, the "one-size-fits-all" approach to rare diseases should be abandoned. Instead, risk-sharing mechanisms such as "pay-for-performance" and "annual payment caps" should be actively explored to reduce the treatment burden for rare disease patients.
A legal expert pointed out that current insurance clauses often broadly exclude "genetic diseases" and "congenital diseases" as general exceptions. Such vague wording can easily lead to differences in interpretation between policyholders and insurers, resulting in unreasonable claim denials in practice. It was suggested that rare diseases and congenital diseases be listed one by one using an enumeration method to avoid significant uncertainty in the validity of the clauses.
Additionally, some experts suggested that instead of bearing the high costs of treatment downstream, mandatory screening for high-risk groups should be conducted during the prenatal examination stage. Other experts recommended integrating the entire process of "prevention, screening, diagnosis, treatment, recovery, and management" into coverage to increase participation willingness and expand the funding pool.
Through this meeting, experts reached a consensus: innovative drug payment cannot simply pursue "full coverage and high reimbursement." The core lies in promoting layered coordination between social and commercial insurance, allowing basic insurance to secure people's livelihoods and commercial insurance to support innovation, each fulfilling its role and responsibilities. Commercial insurance's participation in innovative drug payment should neither copy the experiences of other countries nor take on responsibilities beyond its institutional capacity. Systematic progress is needed in areas such as product structure optimization, building risk-sharing mechanisms, and developing public data infrastructure. The symposium provided valuable insights and references for constructing a multi-tiered medical insurance payment structure and improving innovative drug accessibility.