创新药保障背景下普惠型商业健康保险可持续性的演化博弈研究

Evolutionary Game Study of the Sustainability of Inclusive Commercial Health Insurance for Innovative Drug Coverage

摘要: 随着我国多层次医疗保障体系的逐步完善，普惠型商业健康保险逐渐成为基本医疗保险的重要补充，尤其在创新药保障中发挥着越来越重要的作用。创新药价格高昂、保障强度不足及医保风险池不稳定等问题影响了制度的可持续发展。针对这些问题，本文聚焦于惠民保创新药保障体系，通过演化博弈模型分析药企、保险公司和参保人三方主体的行为交互及其对制度运行稳定性的影响。研究发现，在药企高让利、保险公司高保障、参保人积极参保的理想状态下，系统能够稳定收敛至“高保障–高参保–高让利”的协同均衡，增强了保障体系的可持续性。本研究为政策制定者提供理论依据，以优化制度设计、提高保障可及性及其可持续性。

Abstract: With the gradual improvement of China’s multi-level healthcare security system, inclusive commercial health insurance has become an important supplement to basic medical insurance, especially in the coverage of innovative drugs. However, the high cost of innovative drugs, insufficient coverage strength, and the instability of insurance risk pools affect the sustainability of the system. Focusing on the inclusive health insurance model for innovative drugs, this study constructs an evolutionary game model to analyze the interaction between pharmaceutical firms, insurers, and enrollees and its impact on the stability of the system. The findings reveal that under ideal conditions where pharmaceutical firms offer high discounts, insurers provide strong coverage, and enrollees actively participate, the system can converge to a stable equilibrium of “high coverage - high participation - high discount”, which enhances the sustainability of the insurance system. This study provides theoretical support for policymakers to optimize system design and improve the accessibility and sustainability of health insurance.