Starting from the second half of April 2026, Wu Hao has been soliciting improvement suggestions for a new commercial health insurance product from the company's risk control and compliance department at irregular intervals.

As the head of the product department of a health insurance company, one of the major selling points of the new commercial health insurance product he participated in designing is to include multiple innovative drugs in the claims category based on the "Catalogue of Innovative Drugs for Commercial Health Insurance".

The risk control and compliance department has raised many questions: can innovative drug usage data be shared with pharmaceutical companies and hospital management information systems to achieve standardized alignment of drug flow, fund flow, and information flow; Can we establish a one-stop claims direct payment system with a third-party service provider (PTA); Whether the incidence rate, course of medication and clinical efficacy of specific diseases can be collected to provide insurance companies with refined pricing basis.

But what troubled Wu Hao the most was the issue of drug discounts.

The so-called drug discount refers to a certain percentage of drug discounts offered by insurance companies to pharmaceutical companies when setting claim prices for newly developed drugs in the catalog, in order to alleviate their own compensation pressure. In order to be included in the insurance claims mechanism, many pharmaceutical companies have agreed to this demand from insurance companies. In the eyes of insurance companies and pharmaceutical companies, drug discounts are a risk sharing mechanism that compensates for potential compensation losses, allowing insurance companies to "dare to underwrite and afford" expensive innovative drugs listed in the catalog, thereby reducing the financial pressure of residents' huge self funded treatment.

However, the insurance industry still has not found a proper solution on how to give drug discounts a compliant identity.

As the Director of Health Insurance Business Operations at a large insurance company, Zhao Quanlong found that there are significant differences in the understanding of this among different government departments. Some government departments believe that the negotiation of drug discounts between insurance companies and pharmaceutical companies is a commercial activity aimed at enabling insurance companies and pharmaceutical companies to share risks; Some government departments are also concerned that some pharmaceutical companies may use "drug discounts" to "stuff" their innovative drugs into the scope of health insurance claims, which can easily breed illegal behaviors such as commercial bribery and off the books concealment (not recorded in financial accounts, transferred to other financial accounts). Therefore, strict supervision and management should be implemented.

We are quite confused now, "Wu Hao admitted. Due to the lack of a compliant identity for drug discounts, the company's risk control and compliance department has repeatedly stated that insurance companies must not accept such discounts, resulting in the risk actuarial and claims clauses of this new commercial health insurance product being overturned twice, and there is still a long way to go before it is launched.

Zhao Quanlong frankly stated that after the release of the "Catalogue of Innovative Drugs for Commercial Health Insurance", many insurance companies are exploring the inclusion of new drugs in the claims category as a major selling point of health insurance products. But so far, no health insurance product has been registered and filed in the National Medical Insurance Bureau's big data center.

Behind this is the unresolved compliance status of drug discounts, and related health insurance products have always faced risks such as commercial bribery and off balance sheet secrecy, "said Zhao Quanlong.

Controversy over Drug Discount Compliance

At the end of April this year, during an internal company meeting, Wu Hao engaged in a debate with relevant leaders from the risk control and compliance departments, as well as the finance department, regarding the nature of drug discounts.

The relevant person in charge of the company's risk control and compliance department emphasized that once an insurance company "collects" drug discounts, it is easy to face risks such as commercial bribery, off balance sheet secrecy, and illegal rate adjustments, which can easily lead to penalties from financial regulatory authorities.

The relevant person in charge of the finance department also echoed that there is still a compliance vacuum in drug discounts, for example, in the financial subject, the nature of drug discounts is not yet clear - whether it is a handling fee, a health management fee, or a deduction compensation, there is still no clear statement. But until the nature of the funding for drug discounts is clear, the company cannot collect drug discounts.

Wu Hao felt quite aggrieved about this - the reason why the company's product department proposed drug discounts to pharmaceutical companies was to establish a risk sharing mechanism.

Wu Hao said that the actuarial department of the product has found through big data analysis that when new drugs listed in the catalog are included in the scope of health insurance claims, the payout ratio of many high priced specialty drugs fluctuates greatly, which can easily lead to insurance companies experiencing significantly higher than expected claims expenses, thereby causing losses in the coverage of health insurance products. Therefore, they came up with the idea of introducing drug discounts, which can not only alleviate their own compensation pressure, but also through this risk sharing mechanism, allow more innovative drugs in the catalog to be included in the claims scope, thereby expanding the selling points of health insurance and benefiting residents.

Zhao Quanlong also encountered similar difficulties. Since the end of last year, he has had multiple disputes with the company's risk control department regarding the compliance handling of drug discounts.

Initially, he suggested to the company's risk control department to include drug discounts as risk compensation in the insurance company's claims expenditure fund pool, directly offsetting the insurance company's claims expenses, rather than treating it as a financial income. However, the risk control department refused to adopt the relevant suggestions on the grounds that they have not yet been recognized by regulatory authorities.

In the past two months, Zhao Quanlong has started studying the relevant provisions of the Memorandum of Cooperation between the National Healthcare Security Administration and insurance companies (hereinafter referred to as the "Memorandum of Cooperation"), hoping to find a proper solution from it.

The "Memorandum of Cooperation" obtained by the reporter shows that in terms of negotiating discount prices, the National Healthcare Security Administration will promptly inform insurance companies of the dynamic adjustment of the "Catalogue of Innovative Drugs for Commercial Health Insurance". For "commercial insurance products" registered by insurance companies with the National Healthcare Security Administration, the National Healthcare Security Administration supports relevant pharmaceutical companies to provide drugs to "commercial insurance products" at negotiated discount prices and promptly informs insurance companies of the adjustment of drug price discounts in the catalogue of innovative drugs for commercial insurance.

Wang Pingyang, Vice President of the Zhejiang Medical Security Research Association, said that this shows that the National Healthcare Security Administration regards drug discounts as a commercial activity, and insurance companies and pharmaceutical companies can negotiate and set the proportion of drug discounts, how to pay drug discounts, and how to pay drug discounts.

Zhao Quanlong admitted that he has not yet found a solution to the compliance status of drug discounts from the Memorandum of Cooperation. Recently, he also found that some pharmaceutical companies are rapidly raising concerns about the compliance of drug discounts.

Due to the unclear compliance status of drug discounts, the compliance departments of these pharmaceutical companies have also issued corresponding risk warnings - regulatory authorities have not yet recognized the inclusion of drug discounts as "claims support offsets" or "risk management benefits" in accounting standards. If pharmaceutical companies refund drug discounts or provide drug discounts, they may face the risk of "commercial bribery". Therefore, until the relevant policies are clear, the sales departments of pharmaceutical companies cannot agree to the drug discount requirements of insurance companies.

Taking a different path also hits a wall

Faced with the issue of compliant identity for drug discounts, some insurance companies have chosen to take a different approach.

Since February this year, Wu Hao has visited three cooperating hospitals multiple times, trying his best to persuade these hospitals to purchase newly created drugs from the catalog at discounted prices proposed by insurance companies and pharmaceutical companies. After the launch of new health insurance products, if insured patients experience medication problems, the insurance company will pay relevant claims to the hospital at a discounted price.

For example, a new innovative drug listed in the catalog has a market price of 500000 yuan and a discount rate of 20%. The hospital first purchases this innovative drug for 400000 yuan, and when the hospital uses this innovative drug for the treatment of insured patients, the insurance company pays the relevant compensation of 400000 yuan, "he said.

Wu Hao once had high expectations for this direct and efficient solution.

However, he soon became disappointed. Because the feedback from the three cooperating hospitals is that this operating mode can only be applied to situations with small amounts and short cycles. For high priced innovative therapies such as CAR-T, hospitals often need several weeks from patient hospitalization to completion of treatment, and then to issuing a complete invoice, which puts pressure on their cash flow. In addition, the hospital's procurement platform has nationwide linkage of drug prices, and specific drug discounts must be kept confidential and cannot be shared with insurance companies.

Seeing that the hospital's direct compensation model was not working, Wu Hao tried the pharmacy model again.

In March of this year, he approached multiple large chain pharmacies, hoping that the latter could purchase newly created drugs from the catalog at discounted prices agreed upon by insurance companies and pharmaceutical companies. After the launch of the new health insurance product, insured patients only need to bring the outpatient prescription issued by the doctor, go to the designated pharmacy of the commercial insurance to purchase drugs and show the commercial insurance code. The insurance company will directly pay the pharmacy according to the discount price of the relevant innovative drug agreement.

Wu Hao found that this approach may seem quite flexible, but there are many obstacles in practical operation, such as the detachment of off hospital drug purchases from the hospital's pharmaceutical supervision, and the uncertainty of whether doctors are willing to prescribe off hospital drugs; For example, there is also uncertainty about whether certain specialty drugs in the catalog can be purchased outside the hospital. Moreover, insurance companies and pharmacies have different system standards, making it difficult to establish a direct payment system for drug expenses.

Since April this year, he has been frequently in contact with third-party service platforms, attempting to find new solutions through the PTA advance payment model.

The so-called PTA advance payment model mainly refers to PTA relying on insurance company authorization to advance the cost of new drugs in the insured patient's catalog to the hospital, and the hospital issuing a full invoice. The insurance company pays compensation to PTA based on the discounted amount. At the same time, PTA provides technical services such as patient medication management and clinical efficacy data analysis to pharmaceutical companies, allowing them to pay the discounted amount to PTA in the name of patient health management service fees.

This operating mode is not complicated, "Wu Hao said. Assuming that the insured patient uses a new drug in the catalog worth 500000 yuan during the treatment period, PTA will fully advance the payment. After receiving the full invoice issued by the hospital, the insurance company will pay a claim of 400000 yuan to PTA based on the proposed 80% drug discount; In addition, the pharmaceutical company will pay a 20% discount on drugs (100000 yuan) to PTA in the name of patient health management service fees.

The advantage of this move is that both insurance companies and pharmaceutical companies have breathed a sigh of relief - there is no longer the annoyance of "pharmaceutical companies dare not give drug discounts, and insurance companies dare not accept drug discounts".

However, third-party service platforms have raised two thorny practical issues: first, whether there are compliance issues when offsetting patient health management service fees with drug discount fees - how to solve related tax compliance issues; Secondly, such cooperation between pharmaceutical companies and PTA still requires compliance definitions at the policy level to avoid the fees paid by pharmaceutical companies being classified as "drug sales kickbacks" and falling into new suspicion of "commercial bribery".

At present, Wu Hao is in communication with relevant departments to clarify whether PTA's intermediary position in risk sharing fund management can be recognized, in order to build a compliant safe haven and enable pharmaceutical companies to convert their discounts into insurance company compensation hedging funds in compliance.

Local Government Exploration

The lack of compliance status for drug discounts also affects the claims and operation of customized commercial medical insurance (commonly known as "Huimin Insurance") in cities.

As the Business Operations Director of Huiminbao, a third-party health management platform, Li Wei has participated in the design of Huiminbao products in multiple locations.

He found that as a commercial medical insurance supported by local governments, Huimin Insurance would also propose a certain percentage of drug discounts to pharmaceutical companies based on reducing its own claims pressure when including multiple innovative drugs in the list of claims. However, due to the inability to find a compliant identity for drug discounts, some Huimin Insurance can only fully claim high priced specialty drugs, which invisibly increases their own claims burden; Either certain high priced specialty drugs were not included in the scope of claims, resulting in a narrower coverage of medical claims and failing to alleviate the burden of self funded medical expenses for some local residents.

Since the beginning of this year, Li Wei has traveled to multiple cities multiple times to discuss with local departments, insurance companies responsible for welfare insurance operations and claims, how to address the compliance status of drug discounts.

He found that some local governments have provided some practices worth learning from.

In some cities, local medical insurance departments first sign discount agreements for newly developed drugs in the catalog with pharmaceutical companies, and then register with the National Medical Insurance Bureau to obtain relevant discount ratios. Finally, the local finance department directly collects drug discount payments from pharmaceutical companies and includes the relevant discount funds in the Huimin Insurance fund pool to subsidize Huimin Insurance's claims expenses.

In addition, some local governments have converted drug discounts into a shared proportion by constructing a risk sharing approach. They have agreed with pharmaceutical companies that the local Hui Min Bao will set a limit on the amount or number of claims for certain innovative drugs in the catalog, and the excess amount will be borne by the pharmaceutical companies.

At present, Li Wei is in negotiations with multiple local government departments and insurance companies to determine whether local Huimin Insurance products can set separate reimbursement ratios and deductibles for certain innovative drugs in the catalog. Through this risk sharing mechanism, the compliant status of drug discounts can be resolved.

Many local government departments are quite interested in this, but whether this approach can be implemented depends on whether pharmaceutical companies agree, "said Li Wei. In addition to the compliance assessment of related operations, pharmaceutical companies also have other concerns - once the reimbursement ratio is low or the deductible is high, pharmaceutical companies may feel that the risk they bear is relatively high, which is "not cost-effective" in terms of economic benefits.

Li Wei also found that although local governments have given drug discounts a compliant identity through different practices, many officials from local government departments admitted that in order to address this issue fundamentally, cross departmental collaboration is still needed to clarify the compliant identity of drug discounts as "risk compensation". One effective approach is for multiple departments to issue joint accounting/regulatory standards, clarifying the risk sharing and cost compensation nature of drug discounts, and agreeing to include them in the accounting standards as "claims expense deduction" or "risk management benefits".

(At the request of the interviewee, Wu Hao is using a pseudonym)