我国商保创新药目录在药品配备、商保承接和支付结算等方面已取得阶段性进展,但距离充分落地仍有较大差距。基于过程性视角分析发现,公立医院管理体制约束与电子处方流转不畅共同导致目录药品临床可及性偏低;“适保性”评估标准缺失及跨部门协同不足,致使百万医疗险等主流产品承接滞后;药品折扣返点的合规路径与财务处理规则尚不明确,制约了支付结算模式的实质性落地。据此提出,2026年商保创新药目录调整应优化准入机制,强化真实世界证据支撑与“适保性”评估,并在落地实施中围绕“进院—承保—结算”三大环节协同发力。优化医药机构药品配备,细化考核豁免并探索药事服务补偿机制;强化跨部门协同,以惠民保为基础推动商保产品分层承接;打通支付结算梗阻,探索将折扣比例转化为药企与保司风险共担比例。
Abstract
China's commercial insurance innovative drug catalog has achieved certain progress in terms of drug availability, insurance coverage, and payment settlement. However, its full implementation still confronts a series of challenges. From a process-oriented perspective analysis reveals that constraints within the public hospital management system and inefficient electronic prescription circulation have resulted in low clinical accessibility of drugs in the catalog. Additionally, the absence of standards for “insurance suitability” assessments and inadequate coordination among relevant departments have delayed the adoption of mainstream products such as million-yuan medical insurance. Furthermore, unclear compliance pathways for drug discounts and rebates, as well as ambiguous financial processing rules, impede the implementation of payment settlement models. It is recommended that the 2026 revision of the commercial insurance innovative drug catalog should optimize the entry mechanism, strengthen real-world evidence support, and enhance “insurance suitability” assessments. During the implementation process, coordinated efforts should focus on the three core stages of drug access—"hospital admission - insurance coverage - claims settlement". First, improving drug supply at medical institutions by refining evaluation exemptions and exploring mechanisms to compensate for pharmaceutical services; second, strengthening interdepartmental collaboration to promote tiered product coverage based on city-customized commercial health insurance; and third, removing bottlenecks in drug payment and settlement by exploring the conversion of discount rates into shared risk ratios between pharmaceutical companies and insurers.
关键词
创新药 /
商保创新药目录 /
折扣返点
Key words
innovative drugs /
commercial insurance innovation drug catalog /
discounts and rebates
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基金
北京市社会科学基金重点项目“失能失智老人家庭照护社会支持体系优化研究”（24SRA006）
