2025商业健康险医药行业与医疗机构协同创新案例研究报告.pdfVIP

商业健康险、

医药行业与医疗机构

协同创新案例研究

����年�月

目录

摘要····························································································1

一、研究背景·················································································2

（一）商业健康险对创新药的支付贡献不断提升···············································2

（二）协同创新可提升商保对创新药的支付价值···············································3

（三）协同创新可促进创新药物应配尽配····················································4

二、三方协同创新案例的主要探索方向·················································5

（一）建立医疗机构与商保的合作机制——中山医院与人保合作···································5

（二）深度促进医疗与保险机构协同——阳光人寿“直通30”服务································6

（三）整合资源形成协同网络——复星医药险闭环模式··········································6

（四）提升惠民保特药保障落地可及性——某跨国创新药企助力打通惠民保落地最后一公里·············6

（五）推动单病种创新支付和多方共付模式——某跨国创新药企血友病医药险合作模式·················7

（六）缓解商保理赔滞后导致客户住院期间资金压力——商涌科技即时垫付服务······················7

（七）从“医保补充型”向“医保替代型”——柏盛健康推动健康险市场转型························8

（八）海外市场可参考经验·······························································8

三、三方协同创新的关键堵点、痛点·················································10

（一）医保费用管理影响高价值药品处方可及性··············································10

（二）医院绩效考核影响药品按需使用·····················································11

（三）信息系统难以互联互通，数据难以共建共享············································11

（四）商保产品创新药保障有待提升·······················································12

四、促进三方协同创新的政策建议····················································13

（一）优化医保费用管理政策，发挥商保在支付改革下的作用···································13

（二）优化医院绩效考核，发挥商保支付功能················································15

（三）加快数据共享，实现一站式结算·····················································15

（四）促进保险机构提升创新药保障水平···················································16

（五）医疗机构可加强临床用药精细化管理，促使药品合理使用··································16

商业健康险、医药行业与医疗机构协同创新案例研究I1

摘要

近年来，商业健康险与医药行业不断融合，商保对创新药的支付贡献不断提升。在医保费用管