Chinese Studies
2013. Vol.2, No.3, 128-133
Published Online August 2013 in SciRes (
Copyright © 2013 SciRe s .
Financing Innovative Medicines in Mainland China: The Role of
Commercial Health Insurance
Hong Li1,2,3, Gordon G. Liu4, Christoph Glaetzer5
1Bristol-Myers Squibb Company, Wallingford, USA
2Cincinnati University, Cincinnati, USA
3Shanghai Jiao Tong University, Shanghai , China
4Peking University, Beijing, China
5Janssen Pharmaceutica l C ompanies of Johnson & Johnson, Singapore City, Singapo re
Email: b
Received June 1st, 2013; r evised July 8th, 2013; accepted July 16th, 2013
Copyright © 2013 Hong Li et al. This is an open access article distributed under the Creative Commons Attribu-
tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.
The National Reimbursement Drug List (NRDL) is a key component of the current government-led in-
surance policy to provide access to basic medicines in mainland China; yet NRDL coverage is limited due
to public budgetary constraints and new, innovative medicines are often excluded. This paper explores the
potential role of commercial health insurance as an optional approach to financing medicines excluded by
the NRDL. The current status of commercial health insurance (CHI) in Mainland China is reviewed and
we discuss proposed changes that may be needed to develop an effective and sustainable commercial in-
surance program to provide the Chinese population with better access to innovative medicines not cov-
ered by NRDL.
Keywords: Mainland China; NRDL; Innovative Medicines; Commercial Health Insurance;
Funding the increasing demands for access to health care is a
constant topic for health policy globally. In Mainland China
(hereafter referred to “China”), there are three primary gov-
ernment-run health insurance programs, including the Urban
Employee Basic Medical Insurance (UEBMI), the Urban Resi-
dent Basic Medical Insurance (URBMI), and the New Rural
Cooperative Medical Scheme (NRCMS) for the rural popula-
tion (Hougaard et al., 2008; Sussmuth-Dyckerhoff & Wang,
2010). With a strong commitment from the central government
including budget allocation, the China Healthcare Reform Blue-
print, published in April 2009 by the State Council, planned to
expand the basic medical security system to provide coverage
to all residents in both urban and rural areas (China healthcare
reform, 2012). Since this blueprint was published, nearly $18.5
billion USD has been allocated by the Chinese government at
all levels to boost the government health insurance programs
throughout the country. In November 2012, the China central
government announced the allocation of an additional $18.5
billion USD for fiscal year 2013 to continue expanding the
government health insurance program (China government an-
nouncement, 2012). As a result of these efforts, government
health insurance coverage in China reached 95% in 2012, cov-
ering 1.27 billion people out of a 1.34 billion national popula-
tion. The increased coverage by the government health insur-
ance programs has been a strong reason to stimulate the na-
tional healthcare spending in China. It is expected that health-
care spending in China would be $1 trillion USD in 2020, a
substantial increase from $357 billion USD in 2011 (Le Deu et
al., 2012).
Currently in China, drug costs are relatively high compared
to physician consultation fees, and hospital bed charges and
total healthcare costs. This difference is mainly due to the cost
structure in the current medical system in China. Published data
from a survey of 21,520 hospitals across China in 2011 shows
that drug costs were 50.6% and 41.8% of total medical costs in
the outpatient setting and discharged admission, respectively
(MOH China statistics, 2012). Recent reports on out-of-pocket
expenses for healthcare spending in China have been reported
to range as high as 60% in 2000 to 38.2% in 2009 (Table 1);
this is relatively high compared to other countries (Table 2)
(OECD, 2011; Bhattacharjye & Sapra, 2008). In 2011, there
were 6.3 billion outpatient visits and 153 million discharged
hospitalizations across all medical facilities in China (MOH
China Statistics, 2012). Assuming 30% and 20% coinsurance
for medicines incurred by patients for outpatient and inpatient
settings, respectively, thus the estimated out-of-pocket expenses
for medicines in 2011 alone would be $269.7 billion USD for
outpatients and $13.4 billion USD for inpatients in China.
Through the government-run health insurance systems, drugs
on the formulary list can be reimbursed at various levels. The
national formulary is updated every two years, starting with the
central government, after which local governments are free to
adapt and create their own local formularies. The most recent
officially updated version (2009) of the NRDL included 1140
Western medicines (by chemical names) and 987 Chinese m edi-
Table 1.
Components of the total h e a lt h e x p en d i tu re in China (%), from 1980 to 2010.
Component/year 1980 1990 1995 2000 2005 2006 2007 2008 2009 2010
From Government 36.2 25.1 18.0 15.5 17.9 18.1 22.3 24.7 27.2 28.7
Out of Pocket 21.2 35.7 46.4 59.0 52.2 49.3 44.1 40.4 38.2 35.3
All Others 42.6 39.2 35.6 25.6 29.9 32.6 33.6 34.9 34.6 36.0
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Table 2.
Out of pocket expenditure on healt h a s a percentage of total expendit ure
on health from sel e c t e d O ECD countries in 2010.
Country Percent
Australia 18.6*
Canada 14.2
France 7.3
Germany 13.2
Italy 17.8
Spain 20.1*
South Kore a 32.1
UK 8.9
US 11.8
Note: *Figure in 2009.
cines. However, the principles of government-run health insur-
ance are to provide “basic care” coverage, thus numerous medi-
cines are excluded for various reasons (NRDL in 2009).
The cost for medicines excluded by the NRDL or local gov-
ernment formulary is a key contributor to out-of-pocket medical
expenses. Various forms of charity, although still very limited
in China, have been a major resource to subsidize patients who
cannot afford expensive medications that are not listed for re-
imbursement by government programs.
Despite the ambitious goal set by the Chinese government
and the achievements by government-run healthcare insurance,
the financial burden of treating diseases, including drug utiliza-
tion for catastrophic conditions, remains significant for many
people. For example, the average direct medical cost for the
treatment of chronic myeloid leukemia (CML), can cost $5122
USD for patients without bone marrow transplantations and
$50,623 USD for patients with bone marrow transplantations
(Table 3); cost on medications is either 2% or 23% out of the
total medical cost, depending on if marrow transplantations are
involved or not (Wang et al., 2009). In contrast, the 2011 an-
nual disposable income per capita was $3000 USD in China
(China annual incomes, 2013). Therefore, without health in-
surance of any kind or patient assistance programs that often
charity organizations and pharmaceuticals would provide, ac-
cess to innovative medications to treat serious conditions like
CML would be challenging for many individual patients and
their families in China.
Relatively high expenses on healthcare from individual pa-
tients would be part of the potential factors to have significant
potential to adversely impact societal development (Whyte, 2010);
catastrophic cases on diseases without proper access to health-
care insurance or other reimbursement programs would cause
tremendous financial burden to individual patients and their
families in China. This issue would also have the potential to
generate significant political concern for the government if not
appropriately handled, especially when the national economy is
rapidly advancing. Therefore, the China government has strived
to further reduce the financial burden to both the government
system and individual patients by expanding its government run
health insurance programs. Among all possible approaches,
there is an urgent need to explore additional options to finance
the healthcare system, especially to provide affordable access to
innovative medications not listed by the national formulary in
Discussion on the role of private health insurance has been a
topic for health policy for a long time (Private health insurance,
2004; Private voluntary health insurance in development, 2007)
with successful examples in developing countries, such as Bra-
zil, where private health insurance has played a critical role in
assisting national health care system (Gordon et al., 2013). This
manuscript focuses on the concept of using commercial health
insurance (CHI) in China as a potential option to assist patients
to access medications not listed on the formulary by the gov-
ernment-funded healt h insurance programs.
Current State of Commercial Health
Insurance (CHI) in China
In China, CHI, under the general scope of the insurance in-
dustry, was formally recognized by Chinese government with
regulations and related policy in 1998. Currently, the insurance
industry in China is regulated under the supervision of China
Insurance Regulatory Commission (CIRC) which was also
established in late 1998. As supplement insurance coverage to
UEBMI, CHI has been focusing on urban areas to provide addi-
tional coverage to individuals with the necessary financial re-
sources. Rural areas with excellent economic development have
been brought into the focus only recently. However, the rural
population remains the minority covered by CHI in China. In
fact, individual disease insurance products were introduced to
China in 1995; but it wasn’t until 2005 that CHI began special-
ized operations in China (Chen & Ye, 2007). A total of 136
million enrollments (nearly 10% of the total national population)
were reported in China in 2002; in Beijing, enrollees of CHI
increased from 35,000 to 1 million, a 19% increase (China in-
surance regulatory commission, 2010). Although published in-
formation is very limited regarding the actual number of people
enrolled in CHI programs, the CHI market in China has greatly
expanded since 2002 based on the number of companies that
currently operate CHI programs and the reported annual pre-
mium revenue (Report on health insurance development in
China, 2010).
Based on published information by the China government, as
of November 2012, there are 61 insurance companies listed by
CIRC that are licensed t o provide life insurance including hea lth
insurance products. These 61 companies are either domestic
(36), or foreign-Sino joint ventures (25) depending on the s our ce s
of the company’s fina nce. From 1999 to 2012, income on hea lth
insurance has been increased by 24 times, from $596 million
USD in 1999 to $14 billion USD in 2012. The top companies,
Copyright © 2013 SciRe s . 129
Table 3.
Direct medical costs of treating CML in China (in USD).
With Transplantation Direct Medical Costs Percentage
Transplantation 33,664 66%
Medications 911 2%
Blood produc ts 11,621 23%
Antibiotics and hemopoietic growth factors 4427 9%
Total 50,623 100%
Without Transplantation Direct Medical Costs Percentage
Medications 1168 23%
Blood produc ts 2725 53%
Antibiotics and hemopoietic growth factors 1229 24%
Total 5122 100%
in terms of amount of annual premiums, include China Life
Insurance Company, e-Chinalife, China Pacific Insurance Com-
pany, and Ping-An Life Insurance; all are domestic companies.
Insurance companies operating in China with overseas funding
include Prudential, AIA, Tokyo Marine & Fire Insurance Com-
pany, and Royal Sun Alliance (China insurance regulatory com-
mission, 2013).
As a product line of the China insurance industry, CHI was
also created around 1998. In 1999, the premium volume from
CHI accounted for 2.6% out of the total insurance products, by
November 2012 this percentage increased to 5% (Figure 1),
reaching a total of $14 billion USD (China Insurance Regula-
tory Commission, 2013). The premium volume of all insurance
products (excluding health insurance) increased by 11.1% from
1999 to 2012 while the premium revenue from CHI increased
by 24% during the same period. This trend is an indicator of the
significant demands and growth of CHI in China in the last
In November 2011, CHI programs existed in 36 provinces or
large cities in China—a 71% increase from 2009. As of No-
vember 2011, Beijing is leading in terms of annual premium
revenue ($952 million USD), followed by Guangdong ($93.6
million USD), Jiangsu ($696 million USD), Shanghai ($677
million USD), and Shandong ($651 million USD). Provinces
with the least annual premium revenue are located in the west-
ern part of China (Tibet and Qinghai, $10 and $22 million USD,
respectively), and Hainan in the south ($33 million USD). In
2009, out of the total national health insurance premium, reve-
nue from medical care treatment products was about 62%; in-
comes from the other three major products included catastro-
phic disease (36%), nursing home (1%), and loss of insurance
due to unemployment (1%). However, CHI was less than 1%
out of the total national healthcare expenditure in China in 2007
(China Insurance Regulatory Commission, 2010).
CHI accounts for a $14 billion USD market in China ac-
cording to annual premiums up to November 2012; however, as
shown in Figure 1, this is a very small proportion (around 5%)
of the total insurance premium market in China. This percent-
age has remained constant over the past several years (Table 4).
It is reported that at present, CHI only covers 10% of the total
medical costs in China (National development and reform com-
mission, China, 2013). If the CHI expenditure is compared to
the total health care expenditure, the percentage would become
even much smaller, .3% in 2005, which is the lowest among
other Asian-Pacific countries, such as Indonesia, Malaysia, the
Figure 1.
Insurance Premi um Breakdown (%).
Philippines, Thailand, Vietnam, Papua New Guine a in East A s i a ;
and the Pacific (Drechsler & Jutting, 2007). A nu mber of fa ct ors
may contribute to this situation, including a negative perception
of having insurance in general, or no encouragement of buying
a commercial insurance after the coverage of UEBMI by the
government, structure of current CHI products, and government
Roles that Commercial Health Insurance
Could Play to Better Finance Innovative
Medicines in China
There are at least two major roles that CHI can play in China:
1) to provide medical services and medicines that are not cov-
ered by the government plans so CHI works as a supplement to
the government programs; 2) to serve as a contracted primary
insurer to directly manage the public insurance programs for
government agencies with Ministry of Human Resource and
Social Security (MHRSS). Both roles are in fact called for by
the State Council and explicitly stated in the State Council
Health Reform Plan issued on April 6, 2009 (National devel-
opment and reform commission, China, 2013).
This paper examines the feasibility of establishing a role in
China for CHI to provide access to medicines that are not cov-
ered by the government plans. In effect, CHI would function as
a supplement to government programs. The idea proposed by
the authors is that the NRDL would remain the primary target
Copyright © 2013 SciRe s .
Table 4.
Premium Revenue and Payment of Insurance in China from 19 9 9 to 2 0 11 (in 10,000 USD).
All Insurance including Health Insurance Health Insurance Only
Year Premium Income Paid Out Premiu m Income Paid Out
1999 2,272,786 832,371 59,606 17,949
2000 2,603,357 860,289 106,820 21,071
2001 3,441,035 975,933 100,410 54,680
2002 4,980,651 1,152,905 199,754 81,463
2003 6,330,173 1,371,964 394,656 114,032
2004 7,044,266 1,638,565 423,943 145,356
2005 8,038,067 1,842,854 509,465 176,046
2006 9,203,009 2,346,597 614,849 204,077
2007 11,477,585 3,695,293 626,698 190,644
2008 15,961,006 4,846,926 955,072 285,940
2009 18,168,514 5,098,667 936,342 354,052
2010 23,699,790 5,220,928 1,105,164 430,705
2011 23,391,927 6,410,070 1,128,420 586,729
2012 25,265,791 7,693,831 1,407,440 486,412
Note: The original data were in RMB and recalculated into USD w i t h the exchange rate of 1 USD = 6.13 RMB.
formulary for (basic) medicines to cover most of the population
in China. However, most of the innovative medicines that are
not listed by the NRDL would be covered by CHI programs.
Potential benefits of such an alternative would be multifold.
First, this would help relieve some of the pressure from the
government in the current process of efficiently maintaining
and updating the NRDL since the number of medicines, espe-
cially innovative medicines, is limited. If more people are cov-
ered by CHI as a supplementary health insurance to the gov-
ernment-run health insurance programs, some of the financial
can be transferred away from the government programs. There-
fore, the medications that eventually have to be covered by
NRDL would decrease as CHI increases its coverage of this
kind. In China, 95% of the medicines approved in China are
generic versions, while the majority of innovative medicines
come from outside China. Most of medications covered by the
government are generics; overall very few innovative medica-
tions are covered. Accordingly, since most of the innovative
medications approved by the China FDA are excluded by the
public health insurance programs, this has the potential to exert
tremendous pressure on the government for access to these
medications by the Chinese population.
Second, our proposal that the CHI function to provide access
to medical services and medicines that are not covered by the
government plans allows CHI to serve as a supplement to gov-
ernment program. This concept would provide an excellent op-
portunity for pharmaceutical companies, especially the multi-
national companies (MNCs), to achieve better strategic plan-
ning for market access of these products to patients in China. It
would support evaluating the trade-off of being listed by the
NRDL versus being covered by CHI. This would also incentiv-
ize the pharmaceutical industry, especially the MNCs, to ex-
plore a new market segment in China that would help further
patient access and generate needed return for further R&D de-
velopment in China. Third, the insurance industry (CHI) could
also take the advantage of covering more innovative medicines
to create a favorable business environment for the CHI industry
to grow in China.
Most importantly, introducing CHI programs that provide
expanded access to healthcare and innovative medicines could
actually decrease some of the financial pressure on patients and
improve overall affordability, simultaneously decreasing pres-
sure on the government to provide access. With this suggested
approach, more healthcare providers a nd patients in China co uld
be access new and innovative medicines to treat severe medical
problems. The recent partnership between Roche and Swiss Re
Health Insurance in China to market health insurance to indi-
viduals for cancer drugs underscores this point (Roche to boost
caner drug sales in China with Swiss Re health insurance part-
nership, 2012).
The proposed idea, if implemented properly, would require
long-term strategic involvement of myriad industries (e.g., phar-
maceutical manufacturers, health insurance, and the China h ea lt h-
care system) and various perspectives (e.g., business, law/regu-
lations, structure and capacity reconfiguration, etc). We believe
our proposal, if implemented effectively, could have significant
impacts on healthcare policy in China. Authors of this paper
propose five key changes that would need to take place in order
to make this proposed idea achieve reality.
Firstly, there is a critical need to recognize and appreciate the
value of CHI as a supplement to government run health insur-
ance programs. Having been operationalized in China for more
than 2 decades to supplement to the government programs, CHI
was not widely recognized. Senior government officials have
begun to recognize the need to better leverage CHI as part of
the current healthcare reform in China. In many countries,
where a comprehensive social health insurance is provided to
the population, a high percentage of the population still pur-
chase private health insurance programs (e.g., Canada [65%],
and France [85%]). In these countries, CHI (known as private
health insurance) provides access to services that are not cov-
ered by public health insurance. For example, private health
insurance programs that are specialized in providing prescrip-
tion drug benefits are common in Canada since the Canada
Health Act, which is the government-run health insurance pro-
gram, covers healthcare services (such as outpatient visits, hos-
pitalizations), but not prescriptions in outpatient settings. In
some markets (e.g., France) private insurance companies offer
programs that cover the out-of-pocket costs that are not covered
Copyright © 2013 SciRe s . 131
by the public insurance system (Wikipedia, 2010).
Promotion of CHI development in China offers a number of
benefits, including 1) having more medical treatment/medica-
tion options for individuals who are well-off financially and
may demand enhanced coverage compared with government
programs; 2) helping individuals and families to minimize the
risk of catastrophic medical expenses; 3) reducing the financial
burden and pressure on the government to provide health care
that may not be financially feasible at this point; and 4) when
more people, especially the relatively rich seek care using the
commercial programs, there would also more room for the rela-
tively poor to obtain care from public facilities through the
public programs (Wikipedia, 2010).
Let’s take a closer look at the structure of the current CHI
products. By examining products listed on their official web-
page, it is not too difficult to discover that most health insur-
ance products are run similarly to a term life insurance products.
For example, most of the CHI companies offer products called
“Insurance for Severe Diseases” that may include cancer treat-
ment. If a person unfortunately suffers from a disease covered
by one of these insurance products, a pre-agreed lump-sum
payment would be made to the beneficiary regardless of how
the payment would be used, and regardless whether this amount
would be sufficient enough to cover the expenses incurred to
treat the identified medical problem. The human body is so
complex and the odds of guessing which part of the body would
have a problem for an insurance product in advance is hard to
predict. Therefore, it is unlikely that many would have the in-
centive to purchase such a product, even for those who can
afford the premium of the insurance product. In addition, most
of the CHI products that are available to the public do not cover
medications, especially for outpatient visits. At present, CHI
products that do cover both outpatient and inpatient medication
expenses, follow the NRDL only. Therefore, the administration
cost of running this type of CHI in China would be relatively
low; however, these products would not have sufficient features
to attract customers who want to buy a CHI product “just in
As more and more insurance companies with foreign funding
resources are introduced into China, heavy competition is ex-
pected. Foreign companies, such as BCBL and Aetna, who
have already had very successful experience running health
maintenance organizations (HMOs) in various forms, would
introduce their experience and set up health insurance products
similar to those found overseas. This is to attract customers,
especially those in higher income brackets. A change would be
expected in this scenario, that an HMO type of formulary is to
reflect the relative higher share of drug expenses compared to
other health costs (formulary access, approval process etc.);
otherwise, the underlying risk model that in part of any insur-
ance based system would not be successful and would lead to
disproportional expenses, putting the entire business model at
risk. Insurance systems are all based on the “risk pooling” con-
cept and the assumption that many cover the unlikely event for
a few. This requires a balanced risk profile or different premi-
ums for different risk groups especially in the early stage of
new insurance scheme.
The second expected significant change would happen to the
relationship between these health insurance companies and the
healthcare system in China, (i.e., hospitals). Part of the reason
that China insurance companies do not have any formulary for
drug reimbursement outside NRDL is due to the fact that they
have little to no control over what drugs are prescribed for
which conditions. The current incentive system may lead to a
potential undesired prescribing behavior. Therefore, guidelines
to encourage physicians and hospitals to follow HMO formu-
lary recommendations would be an important task.
The third significant change is expected to happen to the
pharmaceutical industry, both domestic and foreign. All MNCs
in China and most of the top domestic pharmaceutical compa-
nies in China have departments submitting proposals to the
government agencies either for pricing considerations or for
listing in the NRDL considerations. Creating a successful part-
nership between MNCs and the CHI not only requires an un-
derstanding of how to work with HMO-type of CHI, but it is
also dependent upon applying good evidence-based data in
determining which medications are to be included in the CHI
formulary. Therefore, some fundamental new activities would
be needed, such as a new scope of agreements or contracts be-
tween a pharmaceutical company and a CHI company in China
(i.e., business capacity in terms of planning and pricing nego-
tiation) and medical team capacity providing necessary clinical
supports. Other considerations would include the process for
establishing a formulary; a consensus on the criteria used to
evaluate innovative medicines for inclusion in a CHI formulary;
who are the key stakeholders that should participate in the crea-
tion and maintenance of a formulary; and how to handle con-
flict among CHI, the pharmaceutical companies, and the health-
care system on inclusion or exclusions of treatment options.
Since all of these issues have been addressed previously in
other markets, it is possible to determine a comprehensive ap-
proach; but it would certainly take time and great efforts to
make it happen. There would be important items or areas that
would require close cooperation between the CHI industry, the
pharmaceutical industry, the academic researchers, and the gov-
The fourth change that needs to take place is to create a legal
framework that would provide good incentive to people to buy
CHI. Many examples can be gleaned from countries where
commercial health insurance has been well established while
the public health insurance is the dominate force in providing
finance to health care. For example, in Australia, all citizens are
covered by the government-run universal health insurance. Yet,
depending on age groups, the amount covered can be 30%, 35%,
and 40%, the Australian government subsidizes premiums of all
private health insurance coverage for both hospital admissions
and services at ancillary setting. On the other hand, if a person
does not join a private health insurance plan after reaching 31
years of age, an annual premium must include a loading of 2%
per year if the person goes without hospital coverage after this
critical date (Wikipedia, 2010); therefore, setting up proper law
or regulations to encourage participation in CHI is critical.
The fifth significant change would be to enhance the accu-
racy of the data, both clinical and accounting information at a
patient level, from hospitals in China. This data would be
shared with CHI companies. For a successful CHI, it is criti-
cally importa nt to perform a good act uary to estimat e an appro-
priate premium for providing medical insurance products to
patients for medical care including covering new innovative
drugs that are not included in the government reimbursement
list. This would also be the way to properly evaluate possible
risks in providing such coverage in this kind by CHI programs
in China.
Copyright © 2013 SciRe s .
Copyright © 2013 SciRe s . 133
Healthcare reform in China is in a very dynamic and exciting
phase, leading to great improvements in access to health care
for the people in China. Numerous changes are expected and
there is a great opportunity for all stakeholders to be involved,
including further growth in the CHI and pharmaceutical indus-
try as well. A critical issue is how to properly fund medicines
that are not covered by the NRDL. This paper explores CHI as
a viable option to finance innovative medicines that are not
listed by the NRDL. To make this proposal successful in reality,
more work and further research will be required. However,
once the concept/idea is well accepted among all stakeholders
and then implemented, optimal benefits will be significant for
patients, the Chinese government and the healthcare industry by
contributing to the economic development and further improve-
ment in health outcomes in China over the next few decades.
Authors of this manuscript are grateful to Julliana Newman,
ELS, for her professional editing on this manuscript.
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