As an important supplement to China’s basic medical insurance, how should commercial insurance participate? How to price?
“At this stage, we have just completed the catalogue of drugs, diagnosis and treatment items and medical consumables of commercial health insurance (hereinafter referred to as the catalogue of commercial health insurance) Phased research work, including experience summary of developed countries, directory function positioning, trend research and judgment, etc. In the next step, we need to gather consensus among various commercial insurance institutions and get greater support in communication with local health committees, medical insurance bureaus and other departments. Since the final use and payment of drugs are in the hospital, a set of professional evaluation and landing process is essential. ” Dr. Shao Xiaojun, a participant in the formulation of the commercial insurance catalogue and an expert in the commercial health insurance industry, said in an interview with China first finance and economics.
China’s national medical security plan for the 14th five year plan clearly defines the goal of “improving the multi-level medical insurance system”. During the two sessions last year, Zheng Bingwen, member of the CPPCC National Committee and director of the world social security research center of the Chinese Academy of Social Sciences, submitted a proposal on the commercial insurance catalogue. He said that building a multi-level medical insurance system objectively requires the deep integration of social security and commercial insurance. We should not only respect the “consumer sovereignty” of patients, but also mobilize the enthusiasm of medical staff for scientific and on-demand diagnosis and treatment.
Zheng Bingwen said in an interview with China first finance that the commercial insurance catalogue plays an important connecting role in China’s multi-level medical insurance system. It connects basic medical insurance and commercial medical insurance with a list. At the same time, it also solves the problem that a batch of innovative drugs and medical devices cannot be successfully put on the shelves in the hospital after volume procurement to some extent.
give priority to innovative drugs
The reporter learned that after Zheng Bingwen submitted the above proposal, the China Insurance Industry Association took the lead to launch the topic of standard formulation and long-term development of commercial health insurance catalogue on May 17, 2021, including China health information and health care big data society, China Meheco Group Co.Ltd(600056) Health Culture Association, The Pacific Securities Co.Ltd(601099) health China Life Insurance Company Limited(601628) and other 18 insurance institutions and a number of pharmaceutical machinery and science and technology consulting enterprises participated in the research group.
Zheng Bingwen stressed that as a breakthrough in the integrated development of multi-level medical insurance system, the commercial insurance catalogue should mainly focus on innovative drugs, innovative medical consumables and treatment methods, so as to meet the medical needs and preferences of consumers outside the basic medical insurance system.
In fact, most of the inclusive insurance (i.e. Huimin insurance) widely implemented in various places cover special drugs outside the basic medical insurance catalogue. According to incomplete statistics, among the 126 Pratt & Whitney insurance products that have been launched, 99 provide special drug protection, accounting for nearly 80%. Among them, the number of special drugs covered by Pratt & Whitney insurance is mostly in 15~25 species. The indications for specific drugs are concentrated in liver cancer, lung cancer, breast cancer, and myeloma.
Yu Baorong, deputy director of the health insurance and health economics research center of the University of international business and economics, told reporters that most of the special drugs guaranteed by inclusive insurance are anti-tumor drugs, and a few are drugs for rare diseases.
“Special drugs mainly have the characteristics of high price, being used to treat major diseases and having definite curative effect. The insured of Pratt Whitney insurance limits the scope of responsibility of special drugs in the form of special drug catalogue, so as to manage the risk exposure.” Yu Baorong said that the disadvantage is that the commercial insurance institutions are more conservative in the inclusion of high-value special drugs and the setting of compensation rate. They often set the provision that “previous diseases cannot be compensated”, and the policyholders have a weak sense of gain.
“The formulation of the commercial insurance catalogue is to include innovative drugs and therapies, not just special drugs that people need.” Shao Xiaojun said that at present, many commercial health insurance types are still not clear about the definition of drug selection, claim scope and payment conditions in the claim settlement process. For example, tax excellent health insurance has set up “insurance with illness”. The larger the claim range and the more value-added services, the higher the premium price. Therefore, how much its extension is still to be discussed.
“In terms of innovative drugs, take car-t drugs as an example, which is an option for cancer patients when the first-line drug use effect is obviously poor. Although car-t drugs have certain clinical guidelines, they may not be included in the above commercial health insurance types. This requires the commercial insurance catalogue to include such innovative drugs.” Shao Xiaojun said.
Shao Xiaojun also said that insurance should be a kind of “commitment” at present. There should be a clear difference between the health insurance purchased by the policyholder and the basic medical insurance. What can be done and what can not be done should be very clear.
In principle, should the commercial insurance catalogue, as a supplement to medical insurance, include all innovative drugs and therapies other than basic medical insurance?
Shao Xiaojun explained that in general, innovative drugs and therapies should be included in the commercial insurance catalogue, except for some that have poor clinical effects, are particularly expensive and will have a significant impact on the pricing of health insurance products. “The premium of health insurance products depends on the clinical use rate of this drug (that is, how many patients will use it) Therefore, at the drug level, we are considering to include some PD-1 drugs, second-generation and third-generation monoclonal antibody drugs and cellular immune drugs; At the level of instruments and services, we are also considering including dental implants, orthopedic joints, Da Vinci surgery Siasun Robot&Automation Co.Ltd(300024) and a number of therapies other than basic medical insurance but with large clinical needs. “
How to price the commercial health insurance under the commercial insurance catalogue, Shao Xiaojun said: “with the commercial insurance catalogue, all kinds of commercial health insurance products can be priced according to specific innovative drugs and therapies. In the next stage, the reason why we need to make in-depth communication with the hospital is that in the past, commercial insurance institutions priced according to the incidence of diseases, but later they need to price according to the utilization rate of drugs and therapies, which will be more accurate.”
how to effectively connect basic medical insurance and commercial medical insurance
According to the scheme first proposed by Zheng Bingwen, after determining the scope of the commercial insurance catalogue, a dynamic adjustment mechanism, enterprise declaration and exit mechanism will be established based on the commercial insurance catalogue; Then, gradually make sure that the products included in the commercial insurance catalogue can be purchased by hanging the net and carrying the quantity according to the basic medical insurance, and the hospital should be equipped and used according to the same treatment in the basic medical insurance catalogue; Finally, gradually implement the information sharing between social security and commercial insurance, and promote the realization of one-stop settlement.
To this end, Shao Xiaojun said that the catalogue of commercial insurance should be dynamically adjusted as the catalogue of basic medical insurance. For example, after the state releases the latest catalogue of basic medical insurance every year, it should update the innovative drugs and therapies in the catalogue of commercial insurance, “We hope that this commercial insurance catalogue can play a greater role in the second health market (the first health market is the part of basic medical insurance), such as prevention, physical examination and subsequent medical and health management.”
Zheng Bingwen told reporters that from the perspective of commercial insurance, on the one hand, the commercial insurance catalogue should reflect the diversified and economically capable needs of policyholders. On the other hand, the formulation of the commercial insurance catalogue can provide a unified reference basis for commercial health insurance types such as million medical insurance and people-friendly insurance. In this way, special drugs, innovative drugs and therapies can be popularized to a wider range of people, which opens a way for more universal coverage of Huimin insurance.
Some medical insurance experts believe that the commercial insurance catalogue may provide assistance for the “accessibility” of innovative drugs and devices on the patient side, and further open the market for these enterprises.
“Hospitals need to purchase drugs and medical devices on the basis of using the belt quantity to put innovative drugs and devices on the shelves; after better connecting basic medical insurance and commercial medical insurance, patients have a wide range of choices in the future, meeting the needs of multi-level medical security.” Zheng Bingwen said that this also ensures the enthusiasm of innovative drug and device enterprises for continuous research and development.
“Under the national strategy of improving the multi-level medical security system, the interaction between basic medical insurance and commercial medical insurance is a higher level of connection.” The importance of is to bring the innovative, cutting-edge drugs, devices or biological agents that may be included in the catalogue of basic medical insurance into the scope of commercial medical insurance in advance, and provide a price discovery mechanism through commercial insurance institutions to provide data reference for the access of basic medical insurance in the future. ” Liang Jialin, Secretary General of the value medical advisory expert committee, told reporters.
