Topic: Insurance-Health Insurance
Report type: Research Report on Commercial Health Insurance Participation in Innovative Drug Payment and Healthcare Collaboration (商业健康险参与创新药支付与医疗协同机制研究报告)

Amid rising prices of innovative drugs, increasingly complex boundaries between public and commercial insurance coverage, and the acceleration of value-based care, U.S. commercial health insurers play an increasingly critical role in improving access to innovative therapies while controlling healthcare costs. However, they face a structural paradox: the need to enhance drug accessibility while simultaneously containing cost growth. How can leading institutions strike a balance between these objectives?

Focusing on the theme of "How U.S. Commercial Health Insurance Supports Access to Innovative Drugs and Value-Based Care," and drawing on the practices of major insurers such as UnitedHealth Group, Elevance Health, and Cigna, please prepare a structured in-depth research report addressing the following issues:

1. The dilemma of PBM vertical integration:
UnitedHealth (Optum), CVS/Aetna, and Cigna (Express Scripts) have all vertically integrated pharmacy benefit management (PBM) capabilities. Does this model genuinely improve drug affordability and access, or does it primarily function as a profit extraction mechanism? What key evidence supports each perspective?

2. Value-based contracts: where is the evidence?
Insurers have entered into numerous value-based contracts for innovative drugs. Identify specific therapeutic areas (e.g., oncology, gene therapy) and analyze whether outcome-based payment models have effectively improved access in these areas, and where meaningful progress remains limited.

3. Service gaps beyond coverage:
For patients with rare diseases or high-cost biologics, obtaining insurance coverage is only the first hurdle. What roles should (and can) commercial insurers play in care navigation, medication adherence, and clinical support? Which current business models are most feasible and sustainable in addressing these gaps?

## Evaluation Criteria for *How U.S. Commercial Health Insurers Support Innovative Drug Access and Value-Based Care*

This framework evaluates deep research reports on commercial health insurance, innovative drug access, and value-based care. The focus is whether the report explains how insurers balance access and cost control, assesses the real effects of PBM vertical integration and value-based contracts, and identifies service gaps beyond coverage together with sustainable business models. Total: 100 points.

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### 1. Core Mechanisms of Commercial Insurance Support for Drug Access (25 points)

#### (1) Problem framing and core tension (10 points)
- **9–10**: Clearly defines the structural tension between improving access and controlling costs, and accurately explains the role of commercial insurance in drug payment.
- **6–8**: Identifies the main tension, but the framework is incomplete.
- **0–5**: Weak definition and limited system-level perspective.

#### (2) Industry structure and leading-company practices (8 points)
- **7–8**: Effectively analyzes UnitedHealth, Elevance, Cigna, and peers, highlighting model differences and sector relevance.
- **4–6**: Covers major firms, but with limited comparison.
- **0–3**: Lacks company-practice analysis.

#### (3) Data and evidence support (7 points)
- **6–7**: Uses key data on pricing, claims, coverage, and utilization effectively.
- **3–5**: Includes data, but weakly connected to conclusions.
- **0–2**: Insufficient evidence.

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### 2. PBM Vertical Integration and Value-Based Contract Assessment (35 points)

#### (1) Pros and cons of PBM vertical integration (12 points)
- **10–12**: Systematically evaluates models such as Optum, CVS/Aetna, and Express Scripts, including their impact on pricing, access, cost control, and profit allocation.
- **7–9**: Explains key pros and cons, but lacks depth.
- **0–6**: Surface-level description only.

#### (2) Evidence and controversy analysis (10 points)
- **9–10**: Identifies the main evidence supporting both “better affordability/access” and “profit extraction,” and gives a balanced judgment.
- **6–8**: Discusses evidence, but controversy analysis is incomplete.
- **0–5**: Limited evidence or one-sided judgment.

#### (3) Real-world effect of value-based contracts (13 points)
- **11–13**: Uses cases in oncology, gene therapy, and other areas to assess the real effect of outcomes-based payment on access, cost control, and execution feasibility, while distinguishing areas of progress from those still constrained.
- **8–10**: Covers major fields, but lacks implementation analysis.
- **0–7**: Describes the model without validating outcomes.

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### 3. Service Capability Beyond Coverage and Business Models (25 points)

#### (1) Identification of service gaps (8 points)
- **7–8**: Accurately identifies gaps in care navigation, adherence support, and clinical assistance.
- **4–6**: Identifies some gaps, but not systematically.
- **0–3**: Lacks service-layer analysis.

#### (2) Role of insurers and capability boundaries (9 points)
- **8–9**: Clearly explains what insurers should do and what they can realistically do in patient support.
- **5–7**: Provides role analysis, but boundary judgment is incomplete.
- **0–4**: Role definition is unclear.

#### (3) Feasibility and sustainability of business models (8 points)
- **7–8**: Compares different support models in terms of feasibility, economics, and sustainability.
- **4–6**: Includes comparison, but not deeply.
- **0–3**: Lacks business-model assessment.

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### 4. Report Quality and Conclusions (15 points)

#### (1) Structure and professionalism (5 points)
- **5**: Clear structure, strong logic, and solid healthcare-payment research quality.
- **3–4**: Basically complete, but average in organization.
- **0–2**: Weak structure.

#### (2) Actionability of conclusions (6 points)
- **5–6**: Provides clear and actionable implications for insurer strategy, payment models, or service models.
- **3–4**: Clear conclusions, but only moderately actionable.
- **0–2**: Vague conclusions.

#### (3) Risks and boundary conditions (4 points)
- **4**: Covers key risks such as regulation, drug pricing, execution complexity, data availability, and incentive mismatch.
- **2–3**: Lists major risks, but without depth.
- **0–1**: Missing risk disclosure.