(A) the current situation of medical and health development in China
Since the founding of New China, China has spent a lot of manpower, material resources and financial resources to develop the urban social security system. After more than 50 years of development, China's urban social security system has been basically improved, but there are still many shortcomings, especially in medical and health care, and the people are still under great pressure. For example, in the calculation data of national total health expenditure, the proportion of national total health expenditure to GDP is only about 5%, and the proportion of personal health expenditure to national total health expenditure has also remained high.
The burden of national health expenditure is obvious. Because the Chinese government has put the urban medical and health undertakings in the top priority position, and the rural medical and health undertakings in China have just started in recent years, it is feasible to take the national total health expenditure and the proportion of the total health expenditure as the approximate proportion of the total urban health expenditure and the total health expenditure.
(B) China's urban medical insurance system defects
1. It is not in line with the basic principles of medical insurance system design to introduce the accumulated personal account into the medical insurance system. First, the basic principle of medical insurance is social economy, and the establishment of personal account obviously reduces the mutual aid function of medical insurance. Second, the demand for personal medical and health services is random, and it is impossible to accumulate first and then consume; The introduction of accumulation system does not conform to the law of medical demand. From the international experience, except Singapore, no country in the world has introduced personal accounts into the medical insurance (security) system. Moreover, the function of personal account in Singapore is far from the system design in China. The funds accumulated in Singapore's personal account are mainly used for personal conceit during hospitalization; In China, the need for personal accounts to pay the usual outpatient expenses essentially requires individuals to solve the basic medical service problems themselves. This system design of "serious illness as a whole, minor illness at one's own expense" violates the medical law of "prevention first"
2. The target population of the current urban medical insurance system only includes on-the-job and eligible retirees, excluding the vast majority of children, a considerable number of elderly people and other unemployed people. [1] This system design will lead to the following results: First, it is difficult to guarantee the medical needs of the above-mentioned people from the system, and it is difficult to resolve the medical risks faced by individuals and families, thus bringing negative economic and social consequences. Second, in the case that some people have medical insurance and some people don't, it is inevitable that people outside the system will eat into the medical resources within the system in various ways.
3. The current medical insurance system design and related supporting measures have not solved the problem of behavioral constraints on medical service providers, making the cost of medical services still out of control. [2] In this case, maintaining the balance of funds has become a difficult problem for medical insurance itself. In practice, the main approach is to emphasize that the benefits enjoyed by the insured are closely linked to the payment. If the payment cannot be made or even paid in time, the insured cannot enjoy the relevant security benefits. In the long run, medical insurance has actually evolved into a "rich club" that is voluntary and has the ability to pay. In the case that the behavior of service providers cannot be controlled, the relevant system shifts the focus of control to patients, and imposes comprehensive economic restrictions on patients through deductible lines, capping lines and various forms of individual payment regulations, so that the insured who can enter the system cannot get the due protection.
4. The current level of overall planning of medical insurance is too low to achieve a wide range of risk-taking. There are also differences in security standards among different types of people participating in medical insurance, which affects the fairness of the system.
The existence of the above problems has affected the sustainability and actual effect of the urban medical insurance system itself, and it is very difficult to continue to implement it. It is precisely because of the above defects of China's urban medical insurance system that it is more necessary to fully develop commercial medical insurance in the insurance market and make it a powerful pillar of the medical security level of ordinary people.
Two, China's commercial medical insurance development status and existing problems
(A) China's commercial medical insurance development status
Immature macro-environment, imperfect national insurance laws, insurance systems and policies, insufficient awareness of citizens' insurance, and the existing types of insurance can not meet the needs of multi-level medical security, and most of them exist in the form of additional insurance, which are the problems faced by the development of commercial medical insurance and the potential of its development.
Commercial medical insurance has a history of more than 200 years earlier than social medical insurance, and has formed a relatively perfect management mechanism and flexible and diverse management means. Self-financing, pursuing the stimulation of interests, with the inherent constraints of standardized operation, strict examination and approval system and supervision means, can meet all kinds of high-level medical security needs, and has strong anti-risk ability. Under the condition of market economy, commercial medical insurance can give full play to its advantages and is more mature and advanced than other supplementary medical insurance methods. [3] In the State Council's "Decision on Establishing the Basic Medical Insurance System for Urban Workers", it is also proposed that "medical expenses exceeding the maximum payment limit can be solved through commercial medical insurance." It can be seen that the basic medical insurance has left room for the development of commercial medical insurance.
With the continuous improvement of people's living standards and the deepening of social medical insurance system reform, the demand for commercial medical insurance is increasing. According to the survey, health insurance is one of the main life insurance products that people intend to buy. According to the statistics of China Insurance Regulatory Commission in 2006, the total premium income in 2006 was 56,465,438+44 million yuan, of which the health insurance premium income was 376.9 million yuan, accounting for 6.68% of the total premium income. According to the statistics of health insurance premium income in six major cities in 30 provinces, the top five are Beijing 4.357 billion yuan, Guangdong 3.287 billion yuan, Jiangsu 3.203 billion yuan, Shanghai 3.65438+09 billion yuan, Shandong 2.1.4/kloc-0.000 billion yuan, which shows that in Beijing, Shanghai and other places, society.
(B) Problems in the development of commercial medical insurance
Although China's commercial medical insurance has developed rapidly in recent years, there are still many problems restricting its development compared with the requirements of perfecting the urban social security system.
1. The development space of commercial medical insurance is limited. At present, social medical insurance enjoys many preferential policies and gets priority development, and its business expansion will squeeze the space of commercial medical insurance. Many local government departments rely on administrative power to implement supplementary medical insurance, which undermines the rules of market economy and dampens the confidence of commercial insurance investors and operators.
2. Uncontrollable payment of medical expenses. First, the current medical and health service system is single and lacks effective competition. At the same time, driven by the interests of medical institutions, the lack of effective supervision has contributed to the waste of medical resources and increased the burden on patients and insurance companies. Second, insurance companies cannot monitor medical expenses and cannot guarantee the rationality and necessity of medical services. Therefore, medical fraud and moral hazard are inevitable. Third, the insured has a greater risk of adverse selection, and it is not uncommon to insure against illness, conceal or exaggerate illness, and expand medical scope. Insurance companies are overwhelmed. [4]
3. Lack of high-quality compound talents. Because the business of commercial medical insurance involves the knowledge and skills of medical and insurance majors, it requires high professional skills. Therefore, in order to maintain the steady development of commercial medical insurance business, it is necessary to establish a management team that understands insurance, law and has certain clinical experience, and insurance companies are very short of such talents.
Therefore, in order to actively cooperate with the reform of China's medical and health system and strive to improve the professional management level of commercial medical insurance, the insurance industry must vigorously solve the above problems, provide more and better commercial medical insurance products and services, and effectively improve the medical security level of the people.
Three, improve the commercial medical insurance countermeasures and suggestions
(A) the combination of basic medical insurance and supplementary medical insurance
The combination of basic medical insurance and supplementary medical insurance is determined by China's national conditions and strength. China is a developing country with a large population, weak foundation, financial difficulties and low enterprise efficiency. Therefore, in order to ensure that medical insurance can not only play the role of ensuring life and stabilizing society, but also meet the specific needs under different economic conditions, it is appropriate to implement a variety of security models. The reform of medical insurance is a great impetus for medical insurance to fully play its role in China's social security system, and it also plays a vital role in improving the professional management level of health insurance, providing more and better health insurance products and services, and effectively improving the people's medical security level.
In recent years, the status of medical insurance in China's urban social security system has shown a good development trend. Through the implementation of medical and health system reform, China's urban social security system has been well developed, the coverage of medical insurance has expanded year by year, and the number of participants has increased year by year. At the end of each year, the accumulated balance of the national basic medical insurance fund increases year by year. Compared with 2000, the number of participants in 2005 increased by 945 1 10,000, which provided a solid foundation for the development of China's urban social security system.
Table 2 Statistics of the number of people participating in basic medical insurance in China from 2000 to 2005
Source: Statistical Bulletin on the Development of Labor and Social Security (2000-2005) by People's Republic of China (PRC) and the Ministry of Labor and Social Security.
(two) the development of low premium, high security commercial medical insurance products, that is, large commercial medical insurance products with high deductible.
In order to make up for the fact that social medical insurance does not bear the large medical expenses above the payment limit, some urban medical insurance departments entrust insurance companies to set up mutual funds for large medical expenses, and the insurance companies bear the expenses above the payment limit. For example, employees in Chongqing only need to pay 8 yuan every month, and the unit pays it at 1% of the average salary, that is, an employee only needs to pay the insurance premium of about 100 yuan every year, which can cover the medical expenses above the quota of about 30,000 yuan, and there is no upper limit for payment. Therefore, it is feasible for insurance companies to develop commercial medical insurance with high deductible and large amount in the insurance market. [5]
For a large number of insured people who have participated in social medical insurance, commercial medical insurance with high deductible and large amount is especially suitable for them. On the one hand, they don't have to apply for general commercial medical insurance, which brings economic uneconomical benefits. On the other hand, this insurance just makes up for the gap that social medical insurance does not bear the medical expenses above the payment limit, so that the serious illness and large medical expenses of those who participate in medical insurance are also guaranteed. This is also an effective way to give full play to the role of commercial medical insurance in the urban social security system.
(C) Commercial medical insurance as an important supplement to social medical insurance
Social medical insurance and commercial medical insurance belong to the category of social security system, but because of their different nature, they have different positions and functions in the social security system. Social medical insurance is the foundation, and commercial medical insurance is an important supplement. The advantages of the two are complementary and indispensable.
In China, due to the short time of social medical insurance and limited fund accumulation, individuals have to pay a lot of expenses, especially the medical expenses of some serious diseases far exceed the maximum payment limit of basic medical care, which makes individuals bear a heavy burden, and commercial medical insurance can bear most of their medical expenses. At present, the rapid growth of medical expenses has brought heavy pressure to society, units and individuals. During the period of 1982- 1996, the average annual growth rate of medical expenses in China exceeded 24%, and the total medical expenses of employees nationwide reached 77.37 billion yuan. The actual average medical and health care expenditure of each family was 7 18.3 yuan, excluding free medical care and labor insurance medical care.
For some groups with stable income and enjoying social medical security, the social medical security system can only provide the most basic medical security, and the degree of security is limited, which can not meet their needs, while commercial medical insurance can adapt to high-level and special medical needs. In addition, due to the deepening of China's economic system reform and enterprise employment system reform, there are still a large number of people in society who lack medical insurance, such as private enterprise employees, freelancers, students, farmers, etc., who are particularly eager to buy commercial medical insurance.
Basic medical insurance follows the principle of "low level and wide coverage" and mainly provides basic medical insurance, leaving a broad development space for commercial medical insurance. In order to meet the needs of establishing basic medical insurance system and multi-level medical insurance, and promote the development of medical insurance market and commercial medical insurance business, the development direction of commercial medical insurance should be as follows: first, the items and expenses that are not covered by basic medical insurance, such as drugs, medical treatment and service expenses, which are outside the "three catalogues" of basic medical insurance; Second, people who are not covered by the basic medical insurance, such as the unemployed in cities and towns, the elderly and children without medical insurance, and farmers who are not covered by the medical insurance system.
At present, commercial medical insurance in China contains huge business opportunities. If China's insurance industry strengthens the development and promotion of medical insurance products in time, it will promote the development and perfection of China's insurance industry, and eventually form a new medical security system combining personal accounts and public funds.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.