Keywords: commercial health insurance rate, risk control, professional management
In the No.42 document issued by the China Insurance Regulatory Commission in 2000, the commercial health insurance was stated as follows: According to the insurance liability, health insurance is divided into sickness insurance, medical insurance and income protection insurance. Sickness insurance refers to insurance with the occurrence of diseases as the payment condition; Medical insurance refers to insurance with agreed medical expenses as the payment condition; Income security insurance refers to the insurance whose payment condition is the interruption or reduction of income due to accidental injury or illness.
With the rapid and healthy development of China's national economy and the continuous improvement of people's living standards, people pay more and more attention to health, and health insurance with "human health" as the insurance subject has great development space. According to experts' prediction, the market scale of health insurance in China from 2004 to 2008 is about 654.38+050 billion yuan to 300 billion yuan, while the premium income of health insurance in 2003 was less than 30 billion yuan, which is surprising. How to explore the development of commercial health insurance in China has become a hot issue for many insurance scholars.
Present situation and problems of domestic commercial health insurance
In the early 1980s, the former People's Insurance Company of China began to pilot commercial health insurance business in some areas of China. 1996 with the introduction of the basic medical insurance system for urban workers as an opportunity, the health insurance business is in full swing. On the basis of the original critical illness insurance and additional hospitalization insurance, companies have further developed a series of health insurance products such as hospitalization allowance insurance, hospitalization expense insurance and high medical expense insurance. According to the data released by the National Bureau of Statistics and the China Insurance Regulatory Commission, the premium income of health insurance increased from 1 0.36 billion yuan in 1997 to 1. 1 billion yuan in 2002 (see table1). Behind the attractive figures is a market whose benefits are not optimistic. At present, the average health insurance of each company in payout ratio is relatively high, and some companies even reach or exceed 100%.
Looking at the domestic health insurance market, the main problems are:
The product difference is very small. Although there are more than 300 kinds of commercial health insurance on the market at present, there is little difference in products as a whole, mainly including major illness fixed payment insurance, hospitalization medical expenses compensation insurance and hospitalization allowance, while high medical expenses insurance, income loss insurance, long-term care insurance, comprehensive medical insurance and special medical services are almost blank. Obviously, the poor operating efficiency of health insurance makes insurance companies flinch from developing new types of insurance, and companies fail to reflect their core competitiveness in product differences.
There is a great risk in the lack of rate determination for health insurance products. From the actuarial point of view, the pricing of health insurance products is based on the incidence of diseases, the recovery rate of diseases and the rate of medical expenses. In addition, the incidence of diseases and the level of medical expenses are different in different regions, and the empirical data in one region may not be suitable for another. The comprehensive development of health insurance in China is less than 10 years, and the accumulated experience data of insurance companies are insufficient. Actuarial pricing is usually modified by borrowing foreign data, so there will be great errors in the tested rates. Furthermore, at present, most foreign health insurance products are short-term products, and almost all long-term insurance products are designed without premium, while at present, similar products in China are basically guaranteed to renew their insurance and guarantee their premiums. With the development of society and medicine, the types and occurrence of diseases will also change. At present, insurance companies do not consider long-term risks in the design of health insurance products, and there are indeed great potential risks.
The risk control ability of insurance companies is weak. In the course of operation, the risk control of health insurance is very weak, especially the control of medical expenses. Health insurance is different from ordinary life insurance, which involves insurers, insured and medical institutions. At present, there is no economic mechanism between insurance companies, so they can't take risks and enjoy benefits. It is difficult for insurance companies to intervene in the process of medical service selection, to determine the rationality of medical service content and to control the expenditure of medical expenses. Because hospitals don't have to bear any risks, driven by their own interests, the phenomenon of arbitrarily increasing medical expenses, extending hospitalization time and falsely reporting medical expenses occurs from time to time, which leads to an increase in the amount of compensation paid by insurance companies. However, insurance companies have not established a special health insurance underwriting system, which makes adverse selection and moral hazard difficult to control.
The existence of these problems is ultimately caused by the low degree of specialization. Lack of professional talents, backward product development technology and weak risk control ability have led to the rise of payout ratio and the decline of profitability, which directly affects the enthusiasm and confidence of insurance companies in operating health insurance.
Countermeasures and suggestions for vigorously developing commercial health insurance
How to prescribe the right medicine to make commercial health insurance break through the bottleneck and flourish? The author believes that the following measures can be taken:
The state should further clarify the boundaries between social insurance and commercial insurance.
Generally speaking, social insurance is only responsible for basic medical insurance, while China is a developing country with very limited national financial resources. Supplementary medical insurance should be handed over to commercial insurance companies for operation; China's commercial insurance companies have always been the main institutions operating commercial supplementary medical insurance, with the most experience and talent technical advantages; According to the current laws and regulations, social insurance departments, insurance companies, industry insiders, etc. You can run health insurance. Many departments can run medical insurance at the same time, and each department only pays attention to its own interests. It is easy to become a bull, which is not conducive to management, data collection, actuarial pricing and product development.
The state should give more preferential policies to commercial health insurance.
According to the regulations and documents such as the Trial Measures for Annuity and the Notice of the Ministry of Finance on Financial Treatment of Enterprises Purchasing Insurance for Employees, there are some disbursement channels and corresponding preferential tax policies for enterprise annuity insurance and supplementary medical insurance, but they are still not enough to vigorously promote commercial health insurance, because the allowable disbursement ratio is too small for enterprises with good benefits and the ability to handle supplementary medical insurance; People not covered by social basic old-age insurance and basic medical insurance, such as family members of urban workers, floating population in cities and towns, freelancers, students, population, etc. There are no clear expenditure channels and corresponding preferential tax policies; Commercial health insurance insured by individuals of the public shall not be exempted from tax. If the state can give the above preferential policies, it will certainly promote and promote the rapid development of commercial health insurance.
It is necessary to establish a mechanism of "risk sharing and benefit sharing" between insurance companies and relevant departments and institutions.
Establishing this win-win mechanism between insurance companies and medical institutions will bring many benefits. First, it is conducive to collecting data from health departments, social security departments, insurance companies and other relevant departments, and establishing various databases, such as policyholder database, disease database, medical expense database, patient (or insured) database, drug database and so on. Adequate data and information are convenient for management and service, and more importantly, comprehensive information and data are convenient for product research and development, because the lack of empirical data is one of the important factors restricting the research and development of commercial health insurance products; Second, it can effectively prevent moral hazard and reduce the problems of false information and forged documents of hospitalization medical expenses when customers apply for insurance. , but also put an end to or reduce collusion between doctors and patients, separate fraud to "seek" the interests of insurance companies.
Intensify publicity and raise public awareness of insurance.
At present, the development of commercial health insurance in China is slow. In addition to the reasons for the management of insurance companies, there is also a problem that the public's awareness of insurance is insufficient. At present, the savings deposits of Chinese residents are as high as 1 1 trillion yuan, a considerable part of which is used for disease prevention and old-age care. The general public chooses to deposit in the bank instead of buying insurance, which is an obvious manifestation of the public's weak awareness of insurance, but in the final analysis, the reason is the problem that insurance companies do not publicize well. Therefore, it is an urgent task to strengthen publicity and raise public awareness of insurance.
Strengthen industry self-discipline and stop unfair competition.
In the exhibition of group health insurance, in the past, when some life insurance companies competed with other companies, they often used such means as giving high insurance policies to the leaders of the insured units, returning a high percentage of handling fees, giving away valuables such as cars, etc. In the competition of enterprise annuity insurance, the phenomenon of "zero management fee" underwriting occurs from time to time. These suicidal acts of unfair competition not only disrupt the market, but also harm the interests of insurance companies themselves. Only by strengthening industry self-discipline and standardizing market behavior can we maintain the sustained and healthy development of commercial health insurance business.
Actively explore the professional operation of commercial health insurance
Compared with general life insurance, health insurance has at least two differences: First, the management technology of health insurance is high and the management requirements are high. For example, the actuarial calculation of health insurance should not only consider the mortality rate, interest rate and expense rate, but also consider the incidence rate, disability rate, medical price and regional differences. For another example, the management of health insurance involves not only underwriting, compensation, financial and personnel management, but also medical management and health management. Second, health insurance covers a wide range of people. Therefore, the professional requirements of insurance companies in the field of health insurance are very high. Combined with the actual situation, we can discuss the following points:
At present, the company should adopt the business model of setting up a special health insurance division or establishing a professional subsidiary as soon as possible. Because of the professionalism, technicality and complexity of health insurance business, insurance companies should manage it professionally, that is, establish corresponding management methods and risk management methods in data collection and accumulation, product pricing, profit accounting, risk assessment methods, claims management, customer service content and methods, and cooperation with hospitals. In terms of management system, the Health Insurance Division or its subsidiaries should have an independent product development department, which is responsible for market research, insurance development and design, rate determination and clause drafting; Business management department, responsible for the formulation, implementation and inspection of business rules such as underwriting claims and preservation, as well as cooperation and management with hospitals; There is a marketing department, which is responsible for marketing, incentive, sales planning, personnel training and the development of auxiliary sales channels. This will not only benefit professional management, but also enjoy resources and improve the enthusiasm of operators.
With the continuous maturity of China's commercial health insurance market, we should actively explore the possibility of establishing professional health insurance companies. This model can make the company devote all its energy to the management of health insurance business, and make more professional research and attempts in business model, risk control method, actuarial system, cooperation between insurance companies and medical institutions, empirical data processing, product design and pricing, product marketing and so on. So as to promote the innovative development of health insurance business and further enhance the professional level of China's health insurance industry. In addition, the establishment of professional health insurance companies will effectively promote the competition in the health insurance market, stimulate the original insurance companies to accelerate the transformation of the health insurance system, and also help to integrate with the international insurance industry and improve the management level of China's health insurance industry. Therefore, when conditions are ripe, commercial insurance companies and foreign-funded companies should be encouraged to set up professional health insurance companies, which is one of the shortcuts to promote the rapid development of commercial health insurance.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.