医保指导建立商业健康保险创新药品目录（国家医保局牵头建立的丙类目录）是完善我国医疗保障药品目录体系的重要举措,有利于满足患者的多层次医疗保障需求。在梳理我国创新药品目录提出背景及内涵基础上,对其建构逻辑进行剖析,发现医保指导商业健康保险创新药品目录属于国家顶层设计,遵循“行动整合—体系优化—价值调适—治理转型”的价值建构逻辑,包括目录制定从分散的制度性集体行动走向整合的制度性集体行动,多层次医疗保障体系从模糊失序走向错位协同,推动我国公平医保体系建设更加均衡,助力医保治理从政府全能型倾向走向公私合作治理的新阶段。进一步分析发现,医保指导的商业健康保险创新药品目录的实施将面临政策协同挑战、数据治理障碍、商保参与约束、风险监管防控等潜在挑战。基于此,结合美国MA-PD计划和澳大利亚“假体清单”建设的引领性经验,提出医保指导商业健康保险创新药品目录的建构路径,包括强化顶层设计与统筹规划、完善目录制定与调整机制、优化支付与费用分担机制、促进医保与商保协同发展、提升监管与风险防控能力。

The establishment of the Innovative Drug Catalog for Commercial Health Insurance under the guidance of the National Healthcare Security Administration (Category C Catalog led by the NHSA) is an important measure to improve China's medical insurance drug catalog system, which is conducive to meeting the patients' needs for multi-level medical insurance. Based on the background and connotation of China's innovative drug catalog, we analyze its construction logic and find that the NHSA's guidance on innovative drug catalogs for commercial health insurance is a national top-level design, following the value construction logic of “action integration - system optimization - value adaptation - governance transformation”, including the development of the catalogs from decentralized institutional collective action to integrated institutional collective action, and the transformation of the multi-level medical insurance system from ambiguous disorder to mismatched synergy. The catalog promotes the construction of China's fair medical insurance system in a more balanced manner, and helps the governance of the medical insurance system move from the governmental omnipotence to the public-private cooperative governance. Further analysis reveals that the implementation of the innovative drug catalog of commercial health insurance guided by health insurance will face potential challenges such as policy synergy challenges, data governance barriers, constraints on the participation of commercial insurance, and risk supervision and control. Based on this, combining the leading experience of the MA-PD program in the United States and the construction of the Australian “Prosthesis List”, we propose a path for the construction of the innovative drug list of commercial health insurance under the NHSA, including strengthening the top-level design and overall planning, improving the mechanism of list development and adjustment, optimizing the mechanism of payment and cost sharing, promoting the synergistic development of basic medical insurance and commercial insurance, and enhancing the supervision and risk prevention and control capability.