In June 2021, Yescarta, China’s first CAR-T (Chimeric Antigen Receptor T-cell) cell therapy product, received market approval, marking the start of the commercialization era for CAR-T therapies in the country. Five years later, this cancer treatment, priced at around one million yuan, has delivered a notable performance report. According to the recently released "White Paper on Multi-Payer Payment Models for Innovative Drugs and Devices in China (2026)", by the third quarter of 2025, Yescarta had benefited over 1,000 patients, with more than 50% of the costs covered by insurance payouts. This indicates that commercial health insurance has evolved from a supplementary role to a core payer supporting access to high-value innovative drugs.
The white paper reveals that the sales scale of China's innovative drug market is projected to reach 195 billion yuan in 2025. Basic medical insurance, serving as the foundational payer, accounts for approximately 90.5 billion yuan in expenditures. Meanwhile, commercial health insurance has demonstrated strong growth momentum, with its annual payment scale for innovative drugs and devices climbing to 15.2 billion yuan, a year-on-year increase of 23%.
As China's innovative drug industry transitions from "following" to "running alongside" global leaders, the critical challenge has become making "sky-high priced drugs" affordable. Data from the white paper shows that from 2018 to 2025, China accounted for nearly 40% of new innovative drugs entering the clinical stage globally, with this proportion rising further to 47.4% in 2025. Against this backdrop, building a multi-payer payment system has become an industry consensus.
Wu Jinglei, President of the Shanghai Medical Association, noted that individual out-of-pocket payments currently constitute about 28% of China's total health expenditure, underscoring an urgent need to ensure the public shares in the benefits of innovative drug and device development. From a clinical perspective, Wu emphasized that the core value of innovative drugs and devices lies in three areas: extending lifespan, improving quality of life, and reducing long-term medical burdens on society and families. He advocates for a multi-tiered payment system that combines basic medical insurance as a safety net, appropriate societal participation, and the involvement of commercial insurance.
Data from the National Financial Regulatory Administration shows that in 2025, the premium scale of China's commercial health insurance reached 997.3 billion yuan, with a compound annual growth rate of 15.3% over the past decade, establishing it as a major medical payer second only to basic medical insurance. Faced with the increasingly pressing need to fund innovative treatments, commercial health insurance has demonstrated its core value within the multi-payer system through substantial financial contributions.
The white paper details that in 2025, commercial health insurance payments for innovative drugs and devices in China amounted to 15.2 billion yuan, a 23% increase year-on-year. In terms of payment structure, medical insurance accounted for 8.2 billion yuan (53.9%), while critical illness insurance contributed 7 billion yuan (46.1%). Insurance products like "Hui Min Bao" (Inclusive Commercial Health Insurance) have been significant forces in paying for innovative treatments. However, the latest report data indicates that personal medical insurance products, such as million-yuan medical insurance, have become the primary growth driver, with payments reaching 5.3 billion yuan in 2025, an increase of approximately 40%.
The white paper attributes the growth in payments to the rising proportion of insured individuals with pre-existing conditions within commercial health insurance pools. As healthy policyholders age and their health conditions evolve, they gradually become users of innovative drugs and devices.
Despite commercial health insurance forming a payment scale in the tens of billions for innovative drugs, shortcomings in the industry's refined operations are becoming apparent. The white paper notes that commercial insurance still faces significant gaps in key areas such as formulary management, actuarial pricing, prescription circulation, and data interoperability. These limitations in sophisticated development hinder the efficiency of industry collaboration.
On the product side, some commercial insurance products for innovative drugs fall into the trap of "covering drugs immediately upon market launch," lacking scientific access evaluations based on clinical value, with pricing and coverage designs detached from real-world usage scenarios. On the supply side, practical challenges such as barriers to hospital adoption of innovative drugs and inefficient out-of-hospital prescription flows further increase patient access hurdles and weaken the effectiveness of coverage.
Frontline claims personnel from insurance companies point out that the industry's core pain points are concentrated in prescription flow blockages and breaks in the service chain. Due to insufficient support from real-world data, actuarial pricing lacks a scientific basis. Coupled with obstacles patients face in obtaining medications, many innovative drug insurance products end up in an "idle" state, making it difficult to realize their intended coverage value.
A consensus has now formed within the industry: the multi-payer system for innovative drugs has moved past the initial stage of "whether to cover" and the core challenge has shifted to capacity building for "how to cover effectively and sustainably."
"To achieve the goal of deep collaboration between commercial insurance and the pharmaceutical industry, market entities urgently need to establish a neutral, regulatory-compliant information and operations platform for commercial insurance and innovative drugs," the white paper suggests. This platform should adopt a three-tier architecture—data layer, functional layer, and business layer—and undertake four core functions: First, information sharing to enable the exchange of drug clinical data, market usage data, and insurance claims data. Second, risk assessment and pricing support to provide actuarial pricing references for new drugs and devices. Third, unified payment settlement to address the pain points of fragmented reconciliation and cumbersome settlement processes between pharmaceutical companies and multiple insurers. Fourth, comprehensive risk management to dynamically monitor behaviors such as inappropriate medication use and fraudulent claims.
Notably, AI technology is becoming a core driver for activating the integration of pharmaceuticals and insurance. The white paper indicates that privacy computing and federated learning can break down barriers of data trust and compliance, achieving a state where "data is usable but not visible." Utilizing multimodal analysis and knowledge graphs can optimize claims review efficiency. AI-assisted case management for insured individuals' medication use can address capacity bottlenecks in Third-Party Administrator (TPA) services. Furthermore, insights from real-world data mining can feed back into optimizing pharmaceutical companies' R&D and market strategies.
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