China's multi-tiered healthcare security system is undergoing continuous refinement and deepening, coinciding with a critical phase where the pharmaceutical innovation industry is advancing towards high-quality development. During this period, the role of commercial health insurance within the industry is experiencing a fundamental transformation.
On April 14, the Chinese government's official website published the "Several Opinions on Improving the Drug Price Formation Mechanism" (State Council Document [2026] No. 9), formally issued by the General Office of the State Council. This national-level guiding document explicitly calls for "giving full play to the decisive role of the market in resource allocation and improving the market-oriented drug price formation mechanism."
Article 8 of the document specifically addresses "promoting diversified payment for innovative drugs and the rational formation of their prices." It proposes improving the multi-tiered healthcare security system, giving full play to the functions of commercial health insurance and public welfare charities, introducing multi-stakeholder participation in innovative drug price negotiations, and broadening payment channels for innovative drugs. Simultaneously, it emphasizes accelerating the implementation of the commercial health insurance innovative drug catalog and recommending its reference and use by the multi-tiered healthcare security system, including commercial health insurance and medical mutual aid. This marks the first time a State Council document has so clearly and systematically positioned commercial health insurance at the core of the innovative drug payment system, signaling the comprehensive formation of an institutional framework for commercial insurance participation in pharmaceutical innovation.
On the same day, the National Healthcare Security Administration (NHSA) released the "First Batch of Scenarios in the Healthcare Security Sector for 2026," proposing to deepen the application of healthcare security data and collaborate with the financial sector to empower the innovative development of China's pharmaceutical and health industries. The document points out that in serving enrollees, healthcare security departments have accumulated massive datasets covering basic information, disease diagnoses, and healthcare settlement records of 1.33 billion enrollees. This data can support collaborative efforts between healthcare security and finance to empower innovation in the pharmaceutical and health sectors, achieving multi-directional empowerment and positive interaction among healthcare security, finance, pharmaceuticals, and health.
For instance, leveraging healthcare security data can assist financial institutions in developing diversified commercial health insurance products, pharmaceutical supply chain credit, and other innovative offerings. It guides financial institutions to serve the needs of healthcare security reform, gain deep insights into the pharmaceutical industry's demands, support the research and development of innovative drugs and medical devices, aid the growth of high-quality enterprises, and promote the production of more high-quality and affordable pharmaceutical products.
This collaboration empowers commercial insurance companies in innovative product actuarial pricing and enables simultaneous settlement between basic medical insurance and commercial health insurance. It also improves medication security by pushing notifications to enrollees about the current National Reimbursement Drug List (NRDL) and the commercial health insurance innovative drug catalog, providing inquiry access and operational guidelines for healthcare institutions regarding the availability of negotiated drugs and commercial insurance innovative drugs. This facilitates the precise and timely matching of policy updates with public demand.
Capital Resilience Strengthens Innovation Foundation; Commercial Insurance Becomes Key Lever for Innovative Drug Development
Currently, China's pharmaceutical innovation industry is in a critical transition from catching up to running alongside global leaders. A research report titled "After Efficiency: The Value Ascent of China's Pharmaceutical Innovation," released by Boston Consulting Group on March 26, indicates that over the past decade, China's pharmaceutical innovation has completed an efficiency revolution centered on "more, faster, and cheaper." With regulatory rules accelerating their alignment with international standards, and deep integration of capital, talent, and industry-academia-research systems, China has become an emerging force that cannot be ignored in the global pharmaceutical innovation landscape.
From a funding structure perspective, China's innovative drug financing has formed a multi-tiered layout involving policy funds, market-based investments, and enterprise self-raised capital, with a basically sound foundational support framework. However, a significant gap remains compared to global leading levels. In 2025, R&D investment in innovative drugs in the United States exceeded $260 billion, while China's total innovative drug R&D funding was only about $39 billion. Furthermore, Chinese innovative drug companies lack sufficient self-sustaining capability; in 2025, self-funded R&D expenditure accounted for only about 40% of the total, indicating that funding sources still heavily rely on government support and external capital investment.
A consensus within the industry is that the core supporting the next decade of high-quality development for China's pharmaceutical innovation lies in the comprehensive evolution of capital resilience, talent sustainability, and the industry-academia-research translation system. Against the dual backdrop of pressure on the healthcare security fund and fluctuations in external capital, commercial health insurance, with its market-based payment capability and risk dispersion function, is entrusted with the great expectation of boosting the capital resilience of pharmaceutical innovation and improving the payment ecosystem. It has become a key lever for overcoming the funding bottleneck in innovative drug R&D and promoting sustainable industrial development.
The outline of the 15th Five-Year Plan explicitly proposes to focus on key areas guiding future development, build a full-chain cultivation system for future industries, and promote quantum technology, bio-manufacturing, hydrogen and nuclear fusion energy, brain-computer interfaces, embodied AI, and sixth-generation mobile communication (6G) as new economic growth points. The biomedical industry, as an important component of future industries, cannot develop without the comprehensive support of a payment system.
Simultaneously, the 15th Five-Year Plan outline emphasizes the need to improve mechanisms for healthcare security to support the high-quality development of innovative drugs and medical devices, refine the innovative drug catalog, and encourage commercial insurance to expand the payment scope for innovative drugs, charting a clear path for commercial health insurance to empower pharmaceutical innovation.
The 2026 Government Work Report further outlined requirements to accelerate the development of commercial health insurance, promote the high-quality development of innovative drugs and medical devices, and better meet the people's diverse needs for medical treatment and medication. This series of top-level policies intensively signals the nation's firm determination to promote the deep integration of commercial insurance and the pharmaceutical industry, also laying a solid policy foundation for the role upgrade of commercial health insurance.
Payment Proportion Continues to Rise; Implementation of Commercial Insurance Innovative Drug Catalog Accelerates
On April 8, the China Insurance Institute successfully held the "Cloud Share 2026, Session 3." Professor Xu Xian, Vice Dean of the School of Economics at Fudan University, Director of the Department of Risk Management and Insurance, and Lead Principal Investigator of a Major National Social Science Fund Project, delivered a thematic presentation titled "Linkage, Implementation of the Commercial Health Insurance Drug Catalog and High-Quality Development of the Multi-tiered Security System," sparking widespread discussion.
In July 2025, the application process for the National Commercial Health Insurance Innovative Drug Catalog was initiated, with 141 drug generic names participating. Among them, 121 passed the formal review, and 79 drugs were simultaneously applying for inclusion in both the basic medical insurance catalog and the commercial health insurance innovative drug catalog. On January 1, 2026, the National Commercial Health Insurance Innovative Drug Catalog was officially implemented, initially covering 18 drugs (with Tazemetostat hydrobromide tablets delisted due to market withdrawal), marking a new stage of standardized and institutionalized development for commercial insurance payments for innovative drugs.
Professor Xu Xian pointed out that compared to the establishment of the catalog, the subsequent implementation and effectiveness of supporting mechanisms are more critical. Inclusive Commercial Health Insurance (commonly known as "Hui Min Bao"), leveraging its普惠性 and wide coverage, has become the primary vehicle for implementing the commercial insurance innovative drug catalog. Relevant data analysis shows that among 169 basic version traditional Hui Min Bao products, 16 drugs within the catalog have already achieved coverage. However, there are significant differences in implementation effectiveness across regions and products. For example, Ipilimumab injection and Naxitamab injection have been incorporated into Hui Min Bao products in 22 provinces and cities nationwide. The progress of including CAR-T therapy drugs in Hui Min Bao coverage is also among the forefront. City-customized commercial medical insurance has become an important breakthrough point for improving the accessibility of innovative drugs.
Concurrently, Professor Xu Xian innovatively proposed the "Drug-Insurance Dilemma" theoretical framework: pharmaceutical companies pursue widespread drug use and returns on innovative R&D, while insurance companies focus on controlling claim costs and ensuring fund sustainability. These two entities, revolving around the same patient population, form a natural structural payment paradox.
The key to resolving this dilemma lies in constructing refined institutional arrangements, finding a dynamic balance among drug access, price setting, payment methods, risk sharing, and efficacy evaluation. This aims to transform the commercial insurance innovative drug catalog from a mere "policy list" into an efficiently operating, multi-party win-win "effective payment mechanism."
Resolving Implementation Bottlenecks: Multi-party Collaboration to Build a Win-Win Ecosystem for Commercial Insurance and Pharmaceuticals
The journey of the commercial insurance innovative drug catalog from policy blueprint to practical implementation still faces numerous real-world bottlenecks. The three main stakeholders—hospitals, insurance companies, and pharmaceutical companies—each have their own pain points, creating a complex industry game dynamic. During this year's National People's Congress (NPC) and Chinese People's Political Consultative Conference (CPPCC) sessions, CPPCC National Committee member Professor Wu Fan, Vice President of Shanghai Medical College of Fudan University, precisely focused on the "last mile" challenges of catalog implementation, proposing three practical suggestions to address industry difficulties and facilitate policy落地.
The core original intention of establishing the commercial insurance innovative drug catalog is to allow innovative drugs with significant clinical value but high prices, such as CAR-T cell therapies and expensive orphan drugs, to benefit more patients through commercial insurance payment channels. This aims to bridge the gap between basic medical insurance and commercial insurance, thereby strengthening the multi-tiered healthcare security system. However, during implementation, the pain points of the three stakeholders have become major obstacles to policy advancement.
Firstly, hospitals face assessment constraints leading to "difficulty in drug procurement." Although the "Three Exemptions" policy exempts drugs in the commercial insurance innovative drug catalog from three assessments—basic medical insurance out-of-pocket ratio monitoring, monitoring of substitutable varieties selected in centralized procurement, and Diagnosis-Related Group (DRG)/Diagnosis-Intervention Packet (DIP) payment assessments—public hospitals still confront multiple assessment pressures. These include the proportion of essential drugs, completion rates for centralized procurement drugs, allocation rates for nationally negotiated drugs, and average drug costs per outpatient visit and hospitalization. Coupled with the zero markup policy for drugs, hospitals incur additional operational costs for storing, maintaining cold chain requirements, and providing specialized pharmacists for high-value innovative drugs, further reducing their incentive to procure these medications.
Secondly, insurance companies fear the failure of risk control defenses, facing potential losses. Historically, risk control in commercial health insurance heavily relied on strong supervision of hospitals by healthcare security and health authorities. This supervisory line effectively reduced the actual claim probability for high-value innovative drugs. After the implementation of the "Three Exemptions" policy, this original risk control "firewall" is weakened, significantly increasing the赔付 risk for insurance companies.
Thirdly, pharmaceutical companies are caught in a dilemma where commitments made during price negotiations are difficult to fulfill, and profits are squeezed. Commitments made by pharmaceutical companies during drug price negotiations are challenging to implement on the ground. There is a lack of efficient information exchange channels between insurance companies and hospitals, making it difficult to accurately grasp drug usage data and conduct scientific actuarial calculations and reasonable pricing.
Addressing the above pain points, CPPCC member Wu Fan proposed a "three-dimensional" solution:
Improve regulatory mechanisms to resolve hospitals' "difficulty in drug procurement." Leveraging mature local healthcare security intelligent supervision systems, establish dedicated intelligent prescription supervision subsystems for drugs listed in the commercial insurance innovative drug catalog. These systems would automatically identify patients enrolled in commercial insurance plans and trigger the "Three Exemptions" mechanism for eligible treatment plans, ensuring unimpeded drug supply and prescription issuance. Simultaneously, utilize the system for intelligent prescription review, providing warnings, intercepting, and enabling full traceability for actions like off-label use or excessive dosage. This shifts insurance companies' risk control from post-event outcome management to pre-event and real-time intelligent review, balancing medical safety with claim control.
Promote one-stop settlement to resolve patients' "difficulty in settlement." Encourage collaborative efforts between financial regulatory authorities and healthcare security departments, drawing on pilot experiences from Shanghai, Zhejiang, and other regions, to establish a nationally unified one-stop settlement mechanism linking basic medical insurance and commercial health insurance. This involves setting up a nationwide通用 service hotline and online platform for basic medical insurance and commercial health insurance, providing patients with full-process services including consultation, complaints, and settlement. The goal is to achieve one-click settlement upon patient discharge, allowing real-time query of reimbursement limits through the healthcare security information platform and supporting convenient online settlement, significantly enhancing the patient experience and closing the loop on commercial insurance payment services.
Respect market laws and maintain the operational autonomy of commercial insurance. Grant commercial insurance products sufficient market autonomy and innovation autonomy. Encourage insurance companies to innovate in products, models, and channels, enrich the security system, expand funding pools, and enhance product attractiveness to enrollees. Achieve the sustainable development of commercial health insurance through market-oriented operations, thereby better meeting the payment demands for innovative drugs.
Policy innovations at the local level provide strong support for the implementation of the commercial insurance innovative drug catalog. In August 2025, Shanghai introduced the "Several Measures on Promoting the High-Quality Development of Commercial Health Insurance to Support Bio-pharmaceutical Industry Innovation" (referred to as Shanghai's "18 Measures"). As the first policy document in China to systematically establish a "two-way empowerment" mechanism between commercial health insurance and the bio-pharmaceutical industry, it crucially shifted the lead department from the Healthcare Security Bureau to the Financial Regulatory Bureau, achieving a key institutional breakthrough.
On April 7, ten departments in Beijing jointly issued the "Several Measures of Beijing Municipality to Support the High-Quality Development of Innovative Pharmaceuticals (2026)." The document proposes to "accelerate the construction of Beijing's trusted data space for healthcare and health, promote the sharing and application of data among medical institutions, healthcare security, and commercial health insurance. Explore the development of specific disease insurance or specific drug insurance targeting disease prediction and intervention. Promote the inclusion of more innovative drugs and devices, orphan drugs, and innovative technologies into the coverage of commercial health insurance like Beijing's Inclusive Health Insurance. Advance 'one-stop' settlement between commercial health insurance and basic medical insurance, and optimize fast claim services," providing comprehensive policy support for the implementation of the commercial insurance innovative drug catalog.
According to incomplete statistics, since 2024, besides Beijing and Shanghai, multiple regions including Anhui, Hubei, Hunan, Sichuan, Hainan, Shenzhen, Chongqing, Liaoning, Zhejiang, Jiangxi, and Jiangsu have successively issued policy documents supporting the high-quality development of innovative drugs. These documents explicitly support the implementation and application of the commercial health insurance innovative drug catalog, guide the multi-tiered healthcare security system including commercial health insurance and medical mutual aid to reference and use it; support insurance companies in optimizing the supply of city-customized commercial medical insurance products and incorporating new medical technologies, drugs, and devices into the coverage scope; and guide commercial insurance to strengthen cooperation with medical institutions and pharmacies to promote direct settlement covering more innovative drugs and devices.
From the perspectives of both market supply and demand, the potential for commercial health insurance to empower innovative drug payment is enormous. Analysis by Professor Xu Xian's team of all health insurance product clauses from life insurance companies over the past 15 years shows that China's commercial health insurance market exhibits a long-term trend of continuously expanding coverage responsibilities, enriching value-added services, and rapidly growing coverage for treatment methods. The product supply system is increasingly refined. Calculation data from the demand side releases even more positive signals: the proportion of innovative drug payments covered by commercial health insurance is expected to surge from 8.5% in 2025 to 29.9% by 2035, representing a qualitative leap in the weight of commercial insurance within the innovative drug payment system.