摘要
2025年末,国家医保局发布首版商保创新药目录,医保与商保“双目录”协同成为破解高值创新药支付难题、健全多层次医疗保障的关键制度安排。本文以多层次医疗保障与风险分散理论为基础,运用文献分析、数据分析和国际比较方法,构建涵盖基本医保、商业健康险、患者自付及企业社会慈善的“ABCD”四元支付框架,系统考察“双目录”下创新药多元支付体系的建设困境。数据显示,当前创新药支付结构明显失衡: 医保基金承担46.4%、患者个人自付占45.8%,而商业健康保险仅占7.8%;2026年初商保目录药品在三级医院的覆盖率仅为12.3%,商保补充保障作用严重不足。研究从支付主体、支付方式、支付标准和风险分担四个维度梳理主要堵点: 医院绩效考核阻碍创新药入院、创新支付模式推广缓慢、药险数据割裂影响精算定价、全流程风险共担机制缺位。借鉴美国按疗效付费、英国过渡支付及德国附条件准入等国际经验,本文提出优化公立医院考核机制、建立药事服务费补偿机制、搭建全国医保—商保数据交换平台、推行疗效挂钩的风险共担模式、完善跨部门智能监管体系等对策,以期疏通政策落地梗阻、优化费用分担结构、提升高值创新药可及性,推动多层次医疗保障体系可持续运转。
Abstract
At the end of 2025, the National Healthcare Security Administration (NHSA) released China's first Commercial Health Insurance Innovative Drug Catalog. The coordinated dual-catalogue system of basic medical insurance and commercial health insurance serves as a core institutional arrangement to resolve payment dilemmas of high-cost innovative drugs and improve the multi-tiered healthcare security system. Supported by multi-tiered healthcare security theory and risk diversification theory, this paper adopts literature analysis, data analysis and international comparative methods, and constructs an ABCD quadripartite payment framework covering basic medical insurance, commercial health insurance, patient out-of-pocket expenses, and corporate and social charity. It investigates the bottlenecks in establishing a diversified payment system for innovative drugs under the dual-catalog mechanism. Empirical data reveals an unbalanced payment structure for innovative drugs: basic medical insurance bears 46.4% of costs, patient out-of-pocket payments account for 45.8%, while commercial health insurance only covers 7.8%. By early 2026, merely 12.3% of tertiary hospitals stocked drugs on the commercial insurance catalog, demonstrating the insufficient function of commercial health insurance. This study sorts out four major obstacles from payer coordination, payment modes, payment standards and risk-sharing mechanisms: hospital performance appraisal hinders drug admission, innovative payment models see slow promotion, fragmented drug-insurance data undermines actuarial pricing, and full-process risk-sharing mechanisms are absent. Drawing on overseas practices including outcome-based payment in the US, transitional payment in the UK and conditional market access in Germany, this paper proposes countermeasures: optimizing public hospital performance assessment, establishing pharmaceutical service fee compensation mechanisms, building a national drug-insurance data sharing platform, rolling out outcome-linked risk-sharing models, and improving cross-departmental intelligent supervision. These proposals aim to eliminate barriers to policy implementation, rationalize cost-sharing structures, boost accessibility of high-cost innovative drugs, and facilitate sustainable operation of the multi-tiered healthcare security system.
关键词
双目录 /
商业健康保险 /
创新药 /
多元支付体系 /
多层次医疗保障
Key words
dual catalogues /
commercial health insurance /
innovative drugs /
diversified payment system /
multi-tiered healthcare security
李飞飞, 杨诗婷.
“双目录”协同机制下创新药多元支付体系构建[J]. 中国医疗保险. 2026, 0(8): 104-111 https://doi.org/10.19546/j.issn.1674-3830.2026.8.013
Construction of a Multi-Payer Payment System for Innovative Drugs Under the "Dual-Catalog" Collaborative Mechanism[J]. China Health Insurance. 2026, 0(8): 104-111 https://doi.org/10.19546/j.issn.1674-3830.2026.8.013
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