高值创新药的快速涌现及其价值的动态演变特征,对医保基金“保基本”与“促创新”的平衡构成了现实挑战。本研究系统剖析医保在决策风险、基金承受力、风险分担及价值识别等方面的现实困境,构建涵盖临床、经济、社会与创新价值的综合评估框架,并以此为基础,提出依托真实世界数据建立以价值为导向的长效购买机制。该机制包括建立基于价值评估的风险分担合同、创新多元支付方式以及药品价格动态调整,旨在推动医保战略购买从静态准入决策向动态价值管理的转型,在保障基金可持续的同时,有效激励医药创新。
Abstract
The rapid emergence of high-value innovative medicines and the dynamic evolution of their value characteristics pose real challenges to the balance between “basic coverage” and “innovation promotion” within medical insurance funds. This study systematically examines the practical dilemmas faced by medical insurance in terms of decision-making risk, fund affordability, risk sharing, and value identification, and constructs a comprehensive evaluation framework encompassing clinical, economic, social, and innovation value. On this basis, it proposes the establishment of a value-oriented long-term purchasing mechanism supported by real-world data, including value-based risk-sharing agreements, innovative and diversified payment models, and dynamic drug price adjustment mechanisms. The aim is to promote a transformation of medical insurance strategic purchasing from static access decisions to dynamic value management, thereby ensuring fund sustainability while effectively incentivizing pharmaceutical innovation.
关键词
创新药 /
真实世界数据 /
价值评估 /
医保战略购买 /
长效机制
Key words
innovative drugs /
real-world data /
value assessment /
strategic purchasing in medical insurance /
long-term mechanism
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基金
国家社会科学基金青年项目“医保支持创新药发展的成效评估与长效机制研究”（25 CGL122）; 国家自然科学基金项目“临终前医疗支出水平及其经济效率的实证评价”（72273094）
