China's Commercial Health Insurance Formulary Development: Current State and Future Directions
Executive Summary
The commercial health insurance sector in China presents substantial opportunities for growth, with the development of commercial insurance formularies acting as a major catalyst. These formularies are vital for managing medical insurance, fostering collaboration between commercial insurers and life sciences manufacturers, and supporting medical innovation in China.
However, the progress of commercial insurance formularies in China encounters several challenges. The relatively low payment volume from commercial health insurance has restricted most formularies to basic drug lists, focusing primarily on drug price assessments for cost management and limited literature reviews. Advanced techniques like pharmacoeconomic evaluations are seldom used. Additionally, both the direct insurance and reinsurance sectors lack the capacity for in-depth evaluations, often resorting to third-party partnerships.
Despite the hurdles, the ongoing development of Huiminbao paints a promising picture for the advancement of commercial health insurance formularies in China. Notably, some regions have made significant strides by introducing city-level commercial insurance formularies. These formularies, with their clear inclusion and exclusion criteria, close alignment with basic medical insurance (BMI) catalogs, and reliance on expert assessments for listings, could serve as a model for other regions.
Moreover, the Insurance Association of China, a key industry self-regulating body, has recently issued a series of reports to set standards for the long-term development of commercial health insurance formularies in China. These reports provide a clear roadmap for future progress in this area, outlining key tasks in advancing formulary development, evaluation, and management.
This article provides an in-depth analysis of the formulary design for five major types of commercial health insurance products in China. It also examines three crucial tasks and the expected pilot projects that are vital for progressing to the next stage of development for commercial health insurance formularies to support medical innovation in China.
