商业健康险与医药协同创新模式研究报告-清华五道口-RDPAC-PhRMA

商业健康险与医药协同创新模式研究报告清华大学五道口金融学院中国保险与养老金研究中心中国外商投资企业协会药品研制和开发工作委员会（RDPAC）美国药品研究与制造企业协会（PhRMA）年月商业健康险与医药协同创新模式研究报告清华大学五道口金融学院中国保险与养老金研究中心中国外商投资企业协会药品研制和开发工作委员会（RDPAC）美国药品研究与制造企业协会（PhRMA）2024 年 2 月 PhRMA：夏文杰（John Sullivan）、高山、詹怡和 ( Irene Chan)项目组成员： 清华大学五道口金融学院中国保险与养老金研究中心：魏晨阳、朱俊生、刘晓 RDPAC：嘉雷诺（Renaud Gabay）、李京帅、卢欣 专家组：蔡卓、陈佳、冯鹏程、何剑钢、严霄摘 要 ···························································································1第一章 商业健康险与医药产业协同创新背景 ··········································3一、深化医改为商业健康险提供巨大发展空间······································· 3二、与医药协同已成为商业健康保险重要创新方向· ·································· 7三、商业健康保险发挥支付价值可以提高创新药品可及性· ····························· 7四、商业健康险与医药产业协同创新主要研究内容· ·································· 8第二章 我国商业健康险与医药产业结合的主要领域与实践 ························9一、特病特药保险与医药协同创新模式研究· ······································· 9( 一 ) 我国传统医疗险发展遇困境，无法充分回应市场期待 ·························· 9( 二 ) 特病特药保险以人群特征划分的三大创新发展模式 ··························· 10( 三 ) 特病特药保险发展主要面临规模有限、赔付价值不高、创新支付与保险监管 逻辑冲突的困境 ····················································· 12( 四 ) 特病特药保险的风险管理逻辑：杠杆来自汇聚与管理 ························· 13( 五 ) 促进特病特药保险发展应从税优、管办分开和医疗管理三方面着手 ·············· 14二、药品福利（PBM）与医药协同创新模式研究···································· 17( 一 ) 我国药品福利机制的特殊性与发展背景 ··································· 17( 二 ) 我国药品福利已发展出多药品通道、制定创新药报销和采用服务权益三种模式 ····· 18( 三 ) 监管推动药品 + 保险创新支付探索 2.0 模式 ································ 19( 四 ) 我国药品福利与医药产业协同发展面临体制机制制约、专业化水平有限以及 寻找可持续商业模式的挑战 ············································ 20( 五 ) 我国药品福利与医药产业协同发展模式将走向基本医保为主、商业健康险市场 多元化发展的格局 ···················································· 21三、管理式医疗与医药协同创新模式研究········································· 22( 一 ) 我国管理式医疗发展需考虑本土化特点 ··································· 22( 二 ) 我国管理式医疗实践及关键路径 ········································· 23( 三 ) 我国管理式医疗实践所面临的挑战 ······································· 23( 四 ) 我国管理式医疗与医药产业协同创新未来发展趋势 ··························· 23目 录第三章 肿瘤领域商业健康险与医药协同创新模式研究 ···························· 25一、我国肿瘤疾病定义及肿瘤创新药发展概况······································ 25二、国内肿瘤保险发展现状· ·················································· 26( 一 ) 重疾险 ···························································· 26( 二 ) 面向健康人群的医疗险 ················································ 27( 三 ) 面向带病人群的医疗险 ················································ 29三、肿瘤创新药与商业医疗险协同发展方向与趋势· ································· 32( 一 ) 通过服务聚合更广人群：全病种、全人群是前提 ···························· 33( 二 ) 更长链条的融合：筛查是机会，管理是必须 ································ 33( 三 ) 更长期限的保障：终身保证续保是方向 ··································· 34四、促进肿瘤创新药与商业医疗险协同发展的建议· ································· 35( 一 ) 以癌症早筛入手 ····················································· 35( 二 ) “防、治、保”结合 ·················································· 35( 三 ) 探索肿瘤保险新模式设计：以早筛为起点，促进“防治保”一体化 ·············· 36第四章 慢性病领域商业健康险与医药协同创新模式研究 ························· 38一、研究背景· ···························································· 38二、慢性病领域商业健康险与医药协同创新模式梳理······················