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.
Key words
dual catalogues /
commercial health insurance /
innovative drugs /
diversified payment system /
multi-tiered healthcare security
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