商业健康险与医药协同创新模式研究报告

����年�月 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） 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） 项目组成员： PhRMA：夏文杰（John Sullivan）、高山、詹怡和 ( Irene Chan)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 目 录 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 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 )慢病版百万医疗 + 药品责任············································39( 二 )单病种医疗险 + 药品责任··············································40( 三 )惠民保类普惠型健康险 + 药品责任·······································41( 四 )本土化药品福利计划（PBM）模式·······································42 三、慢性病领域商业健康险与医药协同创新模式发展趋势展望··························43 ( 一 )慢病版百万医疗保险将成为最重要的慢病险产品····························43( 二 )单病种医疗险仍有较大发展空间·········································44( 三 )惠民保类普惠型健康险将提升慢病人群的特药与普药保障·····················44( 四 )本土化药品福利计划（PBM）将主要与团体医疗险结合·······················45 四、慢性病领域商业健康险与医药协同创新发展建议·································45 ( 一 )加强产品模式与销售场景融合式创新，推动慢病险场景化销售··················45( 二 )产业融合满足多元需求，共促产品创新···································47( 三 )场景融合实现精准营销················································47 第五章 罕见病领域商业健康险与医药协同创新模式研究·························48 ( 一 )国家层面···························································49( 二 )地方层面···························································49 ( 三 )公益慈善···························································50( 四 ) 惠民保·····························································51( 五 )其他商业保险·······················································51 ( 一 )重大疾病保险·······················································52( 二 )医疗保险···························································55( 三 )保险产品增值服务····················································58 四、罕见病领域商业健康险与医药协同创新面临的挑战·······························59 ( 一 )重疾产品对于罕见病的保障相当有限，与医药缺乏协同·······················59( 二 )医疗保险产品对于罕见病的保障尚在探索中································59( 三 )罕见病增值服务经济效益有限···········································60 五、罕见病领域商业健康险与医药协同创新趋势展望·································61 ( 一 )将罕见病责任纳入传统产品中，扩大罕见病责任的销售和覆盖面················61( 二 )惠民保是推广罕见病的快速渠道和双刃剑··································62( 三 )特药责任是罕见病保险广覆盖的重要抓手··································62 六、罕见病领域商业健康险与医药协同创新建议····································62 ( 一 )商业保险在罕见病保障需要清晰的顶层定位································62( 二 )商业健康险可以更多承保罕见病早期筛查··································63( 三 )责任保障和罕见病服务两手抓···········································63( 四 )完善以患者为中心的罕见病多层次保障方案································64 第六章 促进商业健康险与医药产业融合发展