通讯作者: 吴方, xiaoyll@126.com

DOI：10.12201/bmr.202610.00060

Challenges and Optimization of Dual-Catalogue Governance for Basic Medical and Commercial Health Insurance:An SFIC-Based Analysisn

• 摘要：目的：分析医保-商保“双目录”协同治理的现实困境，探索促进创新药多元支付与多层次医疗保障体系建设的优化路径。方法：收集相关政策文件、行业报告、学术文献及地方实践资料，采用文献研究与政策文本分析方法，以修正SFIC模型为理论框架展开研究。结果：当前“双目录”协同治理已取得一定进展，但仍面临外部环境限制、起始条件薄弱、催化领导缺位、制度设计不明和协同过程不畅等问题，具体表现为商保市场支撑不足、数据信息配置失衡、常态化统筹协调机制不健全、目录衔接规则不完善，以及“准入-使用-支付-报销”链条衔接不畅。结论：应以“医药险融合”为目标，从数据安全共享、分类落地、价格传导和目录转换责任四方面完善相关机制，推动“双目录”从形式衔接走向实质协同。

  关键词： 商业健康保险；基本医疗保险；SFIC模型；协同治理; ; ; 

   

  Abstract: Objective: To identify challenges in collaborative governance of the dual drug catalogues for basic medical and commercial health insurance and explore strategies for diversified financing of innovative drugs and a multi-tiered medical security system. Methods: Relevant policy documents, official publications, industry reports, academic literature, and local practice materials were collected. Literature review and policy text analysis were conducted using the modified SFIC model as the theoretical framework. Results: Although some progress has been made in the collaborative governance of the dual catalogues, challenges remain in five dimensions: external environment, starting conditions, facilitative leadership, institutional design, and collaborative process. These challenges are reflected in insufficient commercial health insurance market support, imbalanced data and information allocation, inadequate institutionalized coordination mechanisms, incomplete catalogue linkage rules, and poor coordination across the drug access, use, payment, and reimbursement processes. Conclusions: Guided by healthcare–pharmaceutical–insurance integration, mechanisms for secure data sharing, differentiated implementation, price transmission, and catalogue conversion responsibility should be strengthened to advance the dual catalogues from formal linkage to substantive coordination.

  Key words: Commercial health insurance; Basic medical insurance; SFIC model; Collaborative governance

  提交时间：2026-10-27

  版权声明：作者本人独立拥有该论文的版权，预印本系统仅拥有论文的永久保存权利。任何人未经允许不得重复使用。
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• 序号	提交日期	编号	操作
  1	2026-08-20	10.12201/bmr.202610.00060V1	下载

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