September has brought a dense wave of policy announcements in the medical insurance sector, with three pivotal developments shaking up the industry. On September 2nd, the National Healthcare Security Administration released version 3.0 of its Diagnosis-Related Group (DRG) and Diagnosis-Intervention Packet (DIP) payment plans. Two days later, a dedicated State Council Information Office briefing outlined strategic priorities for high-quality development of medical insurance during the "15th Five-Year Plan" period. Then, on September 5th, negotiations for the national drug reimbursement list and price consultations for the commercial insurance innovative drug catalog kicked off simultaneously for the first time. These three events, on the surface, address different areas, yet they represent three points of impact for a single policy trajectory: regulators are transforming the principle outlined in the August 28th Medical Insurance Law—encouraging the development of commercial health insurance—into concrete mechanisms for payment grouping, settlement systems, data infrastructure, and price negotiation frameworks. For commercial insurers advancing their "integrated health and wellness" strategies and exploring deeper integration of health insurance with innovative drug payments, this represents a policy window worth dissecting.

For the past eight years, national medical insurance drug negotiations followed a standard script: pharmaceutical companies making submissions, experts engaging in "soul-crushing price bargaining," and media reporting on the resulting reductions. This year marks a departure. On September 5th, at the Great Hall of the People, negotiations for the national reimbursement list and price consultations for the commercial insurance innovative drug catalog commenced simultaneously for the first time, expected to run for four to five days. The significance of this "synchronization" lies in the reversal of the payment logic it implies. Previously, negotiations were a matter of a "single payer squeezing prices"—the medical insurance fund naturally sought the lowest possible prices. While this reduced patient burden, it also meant that some innovative drugs with high R&D costs and strong clinical value struggled to recoup investments due to excessively low prices, dampening long-term innovation. The "dual catalog" simultaneous consultation upgrades the approach from "single-payer cost control" to "multi-tier synergistic support": basic insurance covers essential needs, while commercial insurance addresses high-value treatments. This also explains the positive shift in sentiment within the innovative drug sector this week—innovative drugs no longer have to rely solely on the medical insurance price reduction pathway; commercial insurance consultations offer a new outlet with comparatively better price protection. It is understood that several high-value innovative drugs that piloted market access through the commercial insurance catalog last year have now submitted centralized applications for basic medical insurance catalog admission. The applications span frontier areas including neurodegenerative diseases, rare diseases, pediatric oncology, cell therapy, and solid tumors—representing the first wave of beneficiaries from the establishment of a tiered high-value drug payment system. This year, the commercial insurance innovative drug catalog received 62 application submissions, with 58 products passing the review, a pass rate of 94%. Companies including 百利天恒, 科济药业, 百济神州, 三生国健, and 智翔金泰 all have products participating in these submissions.

However, with pricing power comes pricing responsibility. Industry experts point out that accurate pricing depends on detailed data—patient numbers, incidence rates, treatment cycles, and efficacy assessments. This data primarily resides with pharmaceutical companies and hospitals, and insurers face challenges in obtaining it while ensuring accuracy and standardization. After the first commercial insurance innovative drug catalog included an Alzheimer's drug, the claims payout ratio for a certain city's supplemental insurance program once exceeded 200%. Such high-value innovative drugs are prone to adverse selection risks, representing a "double-edged sword" hanging over insurers involved in these consultations.

While the dual catalog consultations address the "pricing" question, the version 3.0 DRG/DIP plan released on September 2nd tackles a more practical issue: once prices are negotiated, can these high-value innovative drugs actually enter hospitals and reach patients? Version 3.0 was developed over a year, incorporating approximately 35,000 pieces of feedback and analyzing around one billion historical settlement records. Huang Xinyu, Director of the Medical Services Management Department at the National Healthcare Security Administration, noted that DRG/DIP payment has now essentially achieved full coverage of eligible regions and medical institutions, with DRG/DIP cases accounting for 91.8% of all medical insurance discharge cases in 2025. Several details merit attention. The grouping has become more granular, with DRG fine groups expanding from 634 to 825. Robot-assisted surgery has been assigned its own group for the first time—Yan Bing, head of the DRG technical guidance group, explained this provides "clear, positive payment expectations for technological innovation and application." Specific groups have been created for the "elderly and children," with subgroups for patients under six and over seventy comprising approximately one-tenth of all DRG groups, aligning closely with the core demographics targeted by the "integrated health and wellness" strategy. Most crucially, there's the "special case review" mechanism. Li Tao, Deputy Director of the National Healthcare Security Administration, clarified at the State Council Information Office briefing: "For cases involving extended hospital stays, complex conditions, or new drugs, consumables, and technologies unsuitable for DRG/DIP payment, medical institutions can file applications according to procedure. After expert review, payment standards can be adjusted or shifted to fee-for-service payment, alleviating hospitals' concerns about admitting critically ill patients with complex conditions or using innovative therapies." This answers a long-standing question: if hospitals naturally have incentives to control costs, why would they adopt expensive commercial insurance innovative drugs? The answer is "special case review"—providing hospitals with a formal mechanism to remove complex cases using innovative drugs from the DRG framework and settle them separately. Huang Xinyu also stressed that DRG payment standards represent average costs and should not be simplistically linked to medical staff performance—a move to clear hidden implementation barriers for the special case review process. On the settlement front, as of the end of July, real-time settlement coverage had already reached 95.51%, well ahead of the year-end target of "80%+" set for 2026. This lays the technical groundwork for the next steps outlined at the State Council Information Office briefing: "promoting direct settlement with pharmaceutical companies and synchronized settlement with commercial insurance."

At the September 4th State Council Information Office briefing, four deputy directors of the National Healthcare Security Administration appeared together to outline the direction of medical insurance reform for the "15th Five-Year Plan" period. Several statements drew particular industry attention. First, the payment role of commercial insurance was specifically defined as "advance payment." Li Tao proposed: "For innovative drugs that exceed the scope of basic medical insurance but demonstrate high innovation, significant clinical value, and clear patient benefit, commercial health insurance is recommended to provide advance payment. Through the dual protection of 'basic medical insurance plus commercial health insurance,' we can reduce the economic burden on families of severely ill patients." This provides clear guidance for insurers designing specialty drug insurance and innovative drug liability products. Second, the "individual medical insurance cloud" could become critical infrastructure for addressing insurers' data challenges. Deputy Director Wang Wenjun introduced this initiative, which aims to aggregate complete lifecycle individual medical insurance data, noting that over 500 million imaging indices have already been collected. She explicitly stated that "relevant enterprises are welcome to participate with us in building the individual medical insurance cloud." This signals that regulators recognize the data shortcomings of commercial insurers and are opening the door for co-construction—if access is ultimately granted to commercial insurers, it could represent a fundamental breakthrough in actuarial pricing capabilities, with structural significance potentially exceeding that of individual price consultations. Third, for the first time, a specific timeline for expanding long-term care insurance was announced. Wang Wenjun revealed that 22 provinces have issued provincial plans, with 121 coordinated regions established, projected to expand to 247 by year-end and achieve near-comprehensive national coverage by the end of 2028. For insurers actively positioning in long-term care insurance administration, the next two years represent a critical window for capturing market share.

The Medical Insurance Law established the legal status of commercial health insurance, and the September reforms translate this framework into concrete technical mechanisms. The DRG/DIP version 3.0 plan, through "special case review" and refined grouping, clears payment obstacles for innovative drugs and devices in hospital settings. The State Council Information Office briefing articulated commercial insurance's specific roles—"advance payment," participation in the "individual medical insurance cloud," and alignment with the long-term care insurance expansion timeline. The "dual catalog" simultaneous consultation gives insurers formal negotiating power in drug pricing for the first time. This chain of developments shows regulators advancing commercial health insurance's integration into the broader medical insurance payment system across several technical dimensions simultaneously: payment grouping, settlement systems, data infrastructure, and price negotiation mechanisms. This also provides clearer direction for the market's previously voiced concern—"with pricing power secured, do insurers have sufficient data and actuarial capabilities to back it up?" The national government has acknowledged this gap and is attempting to address it fundamentally through the "individual medical insurance cloud," rather than expecting insurers to tackle it alone. For leading insurers, the differentiation effects of this change will be pronounced. Companies like 人保健康险, 平安健康险, and 太平洋健康险—which have established mature health management platforms and accumulated real claims data—will be better positioned to present credible pricing proposals in consultations and more likely to gain early access to infrastructure like the "individual medical insurance cloud." Conversely, smaller insurers lacking data accumulation and specialized actuarial teams may find themselves passively accepting consultation outcomes. The policy signals from this series of medical insurance reforms are clear: commercial health insurance is transitioning from a "standby supplement" in the multi-tier medical insurance system to a formal participant with substantive negotiating power and access to national medical insurance infrastructure. Yet, several hurdles remain between securing this position and translating it into sustainable products and profits. Will the commercial insurance innovative drug catalog evolve from "recommendatory" to a binding mechanism linking volume with pricing? How robust will actual hospital adoption of catalog drugs and implementation of "special case review" be? The specific scope and timeline for commercial insurance access to the "individual medical insurance cloud" remain undefined. How adverse selection risks will be managed in the absence of mature risk control tools is still unclear. These execution details will be the key storylines to track over the coming quarters—particularly the Q3 and annual results disclosures from leading insurers regarding health insurance claims ratios and innovative drug payment volumes, as well as whether they actually integrate with new infrastructure like the "individual medical insurance cloud." These will serve as the first concrete evidence of whether this policy "combination punch" translates into operational results.