Exploring Innovative Payment Pathways for CAR-T Therapy Under the Guidance of the Commercial Insurance Innovative Drug Catalog

doi:10.19546/j.issn.1674-3830.2026.8.012

China Health Insurance ›› 2026, Vol. 0 ›› Issue (8) : 97-103. DOI: 10.19546/j.issn.1674-3830.2026.8.012

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Abstract

The guidance for establishing a commercial innovative drug catalog is a crucial step toward improving China's multi-tiered healthcare security system and addressing the payment challenges associated with high-cost innovative medicines. Taking CAR-T therapy as an example, this paper explores pathways for innovative payment models by integrating the access process of commercial insurance catalog for innovative drugs. The study develops a dual regulatory model combining value-based payment according to therapeutic outcomes with total budget control, designing a phased payment mechanism linked to "treatment initiation—short-term remission—long-term survival", supplemented by budget threshold-triggered stop-loss mechanisms and cost-sharing discounts for overspending. Simulation results show that compared to traditional one-time payment models, the innovative payment approach can effectively reduce annual fund expenditures, improve financial efficiency, and enhance patient access. Based on these findings, we recommend refining hospital accessibility and monitoring designs under the "three exclusions" framework, establishing a segmented independent settlement mechanism tied to treatment efficacy, optimizing real-world data verification systems, and enhancing a tiered governance structure where government sets standards and the market manages operations, thus building a sustainable, time-value-oriented, risk-sharing, and long-term payment mechanism for innovative drugs.

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commercial health insurance drug catalog / CAR-T therapy / innovative payment / practical pathway

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Exploring Innovative Payment Pathways for CAR-T Therapy Under the Guidance of the Commercial Insurance Innovative Drug Catalog[J]. China Health Insurance. 2026, 0(8): 97-103 https://doi.org/10.19546/j.issn.1674-3830.2026.8.012

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