"Missing" innovative drug protection, can Huimin Insurance still be called "Huimin"?
Today, I saw the news on the hot search, an 8-year-old boy was diagnosed with the dangerous rare disease "atypical hemolytic uremic syndrome", and his life was in danger, fortunately, the life-saving drug for the treatment of the disease - "eculizumab" was included in the new version of the medical insurance catalog, and it will be officially implemented on January 1, 2024.
The price of each drug is about 1,000 yuan after the medical insurance reimbursement in the past, and the price of each drug is about 1,000 yuan, which has helped his family save 400,000 yuan.
Seeing this news, I sighed, you know, the incidence of "atypical hemolytic uremic syndrome" is only 7 per 1 million, but no matter which family it happens in, it is 100% for them, and the high medical costs are likely to crush a family.
The core of insurance is the word "insurance", which will not make you rich, but can ensure that your family's financial situation will not fall off a cliff.
However, the history of domestic insurance development is too short, and the popularization of insurance in economically underdeveloped areas is far from enough.
Some people either don't buy any insurance, or spend a lot of money to buy the so-called "financial insurance" with very weak protection function, and when they really need to pay a large amount of medical expenses in the event of a serious illness, they find that it is useless.
Okay, good, the big guy doesn't have a strong sense of insurance, so can the government push it?
As a result, the urban Huimin Insurance project, as a health insurance model with government participation and commercial operation, has developed rapidly in the past few years.
Today, more than 200 urban Huimin Insurance projects have been implemented, with 298 million insured people and 32 billion yuan of annualized premiums.
You may not have bought Huimin Insurance in your city, but most people should have heard the name. With a premium of one or two hundred, or even dozens of yuan per year, you can have millions of protection, which feels quite cost-effective.
However, do you really understand such a "hot" Huimin Insurance? With Huimin Insurance, can you reimburse everything? Is there anything that can't be reported?
1. The current situation of the operation of Huimin Insurance
Huimin Insurance has only started trial operation in 2015, and most of them have only been in operation for 1-2 years.
Shenzhen, as the earliest pilot city, has been in operation for the longest time, reaching 9 years. This was followed by Zhuhai with 5 years of operation and Guangzhou, Foshan and Suzhou for 4 years.
There are also a few cities that have been suspended, accounting for about 14%, but after the shutdown, they have also provided people with provincial Huimin Insurance products.
The operation of Huimin Insurance
1. From the perspective of the insurance participation rate, the development of various regions is quite different, and the overall insurance participation rate is low, only 19.8%. Most of the urban Huimin Insurance projects with high participation rates are concentrated in coastal areas.
2. From the perspective of premium level, the average premium level is about 100 yuan, but it also shows an upward trend, and the price of a few products exceeds 200 yuan. The vast majority of Huimin Insurance products are priced at a uniform price, but more and more products are starting to adopt tiered pricing.
The distribution of premiums of Huimin Insurance products
Uniform pricing is more age-friendly because the loss ratio is higher than that of younger people, but they can enjoy the same premiums as younger people. Therefore, in the case of uniform pricing, it is highly recommended for the elderly to be insured.
Tiered pricing sets higher premiums for older participants. But in fact, this pricing method is more reasonable for the long-term operation of the product. And in comparison, the premiums of the middle-aged and elderly people of Huimin Insurance are still much lower than those of commercial insurance.
3. From the perspective of loss ratio, most Huimin Insurance products have not announced the loss ratio. Since the government's requirement for Huimin Insurance products is to "guarantee capital and small profits", it is reasonable for the loss ratio to be above 90%. But if it exceeds 100%, it means that there is a loss, which is not conducive to the long-term operation of the product. If the payout ratio is less than 70%, there is a lot of room for improvement.
Some of the Huimin Insurance products that disclose the loss ratio
Second, you may "ignore" the innovative drug guarantee
The product structure of Huimin Insurance is very similar to the million-dollar medical insurance that began to appear in 2015, and as long as the cost of hospitalization exceeds the deductible, it can be claimed, regardless of social insurance. However, the product compensation ratio and compensation limit are lower.
It can be said that the birth of millions of medical insurance and the experience of successful operation gave birth to the birth of Huimin Insurance products.
The biggest feature of Huimin Insurance is that it can cover patients with pre-existing conditions. Although pre-existing conditions have a lower payout ratio and limit of benefits, Huimin Insurance has the advantage of "benefiting the people" compared to commercial health insurance, which is almost difficult to underwrite.
These situations are probably already known to most people who are enrolled. What many people overlook may be the inconspicuous innovative drug guarantee, but this is actually important to us.
If you don't know about the innovative drug coverage of your city's Huimin Insurance products, you can't say that you know about the Huimin Insurance you are insured.
The guarantee of innovative drugs is reflected in the "Special Drug List" of Huimin Insurance. Drugs on the "Special Medicines List" are not restricted for use in or out of hospitals.
Innovative drugs are an urgent treatment for patients with many diseases, which are essential to reduce mortality and improve the quality of life of patients, and can significantly improve the overall survival rate of cancer patients, such as targeted therapy, live cell extraction drugs, immunotherapy, CAR-T cell therapy, and CRISPR gene editing.
特药vs化疗的五年生存率对比（数据来源：Health at a Glance 2019）
Since the start of the normalization adjustment of the National Medical Insurance Catalog, more than 100 innovative drugs have successfully entered the National Medical Insurance Catalog. However, there is still a large gap in health insurance protection. Of the 270 patented drugs approved for marketing in mainland China, only 146 are covered by medical insurance. Among them, only 57% of the 82 innovative oncology drugs were included in the medical insurance, and only 46% of the 28 innovative drugs for rare diseases were included in the medical insurance.
Therefore, in order to afford the medical costs of advanced treatment methods and improve the quality of life expectancy, medical insurance alone is far from enough, and commercial insurance is needed to escort it.
However, as mentioned earlier, the level of domestic insurance science popularization is insufficient, the insurance concept is low, and the coverage rate of commercial health insurance is low, so the government will think that they will lead the insurance company to launch the urban Huimin Insurance, so as to make up for the gap in residents' protection.
However, at present, Huimin Insurance's coverage of innovative drugs is limited. Through the analysis of the "special drug list" of 138 Huimin Insurance products, on average, a single Huimin Insurance can only cover 19 diseases and 20 varieties of drugs.
138 Huimin Insurance products cover diseases and the distribution of the number of varieties
Of the 121 high-burden diseases defined by WHO, about 90 are still not covered by any of the city's Huimin Insurance, and only 19 of the 121 rare diseases listed in the National Rare Disease Catalogue are covered by Huimin Insurance.
19 rare diseases covered by Huimin Insurance
In addition, the reimbursement ratio of most Huimin Insurance for people with pre-existing conditions is significantly lower than that for people with non-pre-existing conditions, and the vast majority can only report 20%-40%, and only a small number of urban Huimin Insurance can report more than 80% of pre-existing conditions.
Therefore, it is almost impossible to reduce the cost of personal burden to less than 25%.
Finally, to sum up, the matters to be paid attention to when choosing whether to participate in the city Huimin Insurance:
1. See if the deductible does not exceed 10,000;
2. It is better for patients with non-pre-existing conditions to pay more than 80%, and for patients with pre-existing conditions to pay more than 60%;
3. Let's take a look at which innovative drugs can be covered by the "special drug list", at least not lower than the median of 19 high-burden diseases and 20 varieties of drugs, and the higher the better;
4. See if you can reimburse CAR-T cell therapy that costs tens of millions of dollars for one injection, and whether high-cost drugs such as PD/L-1 are included.
If most of the above conditions cannot be met, then Huimin Insurance in your city is not a good product.
In this case, regardless of whether you choose to participate in the insurance or not, it is still recommended to purchase a comprehensive medical insurance policy (preferably guaranteed renewal), otherwise the protection gap is still large.
The list of 121 high-burden diseases defined by WHO and the coverage of Huimin Insurance is attached for cross-reference.
List of 121 high-burden diseases and their coverage as defined by WHO