Research On Expenses Restriction Mechanism Of Commercial Health Insurance Of China

Commercial health insurance is an indispensable ingredient of a country medical security system, blends with society medical insurance mutual replacement, mutual influence, and mutual integration; each one has his own good points. Not only commercial health insurance has made up the deficiency of society medical insurance supplies, but also has enriched the medical treatment and perfected the entire country ensures system. China is one of the countries that the commercial health insurance has not well developed and the coverage rates are low, the various indexes are far away from the ones of developed countries'. From the view of premium income scale, China's health insurance premium income accounts for 9.12% of life insurance premium income in 2006, 7.6% in 2007, and 5.98% in 2008, but this proportion in Britain, the United States and other developed countries is generally above 20%. From the view of penetration rates, China's commercial health insurance provides protection for population accounted for about 30% of the total population only, while the proportion in United States is 85.96%, and in Taiwan is 96%.One of the important factors to restrict the development of China's commercial health insurance is the defect of Medical cost control mechanisms of the existent insurance management pattern, can not effectively control the cost of moral hazard and unreasonable medical expenses, thereby increasing the operating costs and the operating risks of insurance companies, constraining the development of commercial health insurance. Therefore, the study of China's commercial health insurance cost-control mechanisms has become an important issue that the development of China's commercial health insurance needs to be resolved.In this paper, on the base of expound the connotation and the risk characteristics of commercial health insurance, comprehensively analysis the moral hazard of China's commercial health insurance and cost control problems and their causes, review the successful practices and experiences of the health care costs control system of commercial health insurance in U.S. insurance industry. And finally, drawing on its successful experience, bring forward the recommendation to perfect the health insurance in China's commercial risk-control system. This paper is divided into three chapters; the basic contents are as follows:The first chapter is the basic theory of commercial health insurance.Section I expounds the connotation of the commercial health insurance. First of all, explain the concept of commercial health insurance: To the insured person's health for the subject, the insurance for medical expenses that occurred because of disease or accidental injury or loss of income due to sickness or accident disability, At the same time, the commercial health insurance also includes financial compensation insurance because of old age, illness or disability who needs to be given long-term care. Secondly, the analysis of the difference between the commercial health insurance and the social medical insurance, Including the nature, modalities for participation, the protection of objects, the degree of responsibility and the level of protection etc. And then expounds the features of commercial health insurance.Section II describes the origin and development of commercial health insurance. First of all, introduces the origin of commercial health insurance, as well as the development process in foreign countries; Secondly, the status quo of China's commercial health insurance. Pointed out that although in recent years, China's health insurance industry has been considerable developed, the various indexes are far away from the developed countries'.Section III analyzes the importance of cost control in commercial health insurance industry. The significance to control the cost of commercial health insurance mainly focuses on three aspects: Conducive to control the risk of moral hazard; Conducive to the promotion of optimal allocation of social medical resources; Conducive to improving the protective ability of health insurance. Pointed out that the focus of health care cost control is that how to deal with the moral hazard problem in medical insurance.The second chapter is the analysis of how to control moral hazard and medical cost problems in China's commercial health insurance. First of all, explains on China's commercial health insurance market, the performance of moral hazard is mainly reflected two aspects of moral hazard: the insured risk and medical supplies; and then analyzed the risk of moral hazard, mainly includes the excessive consumption of induced medical services, will hinder the efficient allocation of resources and reduce several aspects of social integrity. Section II analyzes the cost control mechanisms on "pay-style" management model of China's health insurance. First of all, Expounded China's current operating mode of the medical insurance business model is pay-style. The second section describes the cost control of our health care problems: 1. the management style of monitoring after is missing the best time to control costs; 2.Can not fundamentally solve the problem of excessive demand of the insured medical services; 3. can not co-ordinate the interests between Insurance companies and medical service organizations; 4.It is difficult to achieve optimal control of the"After the payment system "of medical expenses; 5.Insurance companies can not effectively monitor the treatment process.The third chapter is to draw on the experience of the developedCountries and to improve our countries'health insurance cost control mechanisms.Section I analyzes the advanced practice of cost control of the developed countries, managed care system in U.S., General Practitioner in Britain, As well as the reference price system in Germany。Section II draws on the basis of the advanced experience of developed countries,bring forward the countermeasures and suggestions on improving China's commercial health insurance, medical cost control mechanisms. Respectively describes the cost control measures of medical services supply-side and demand-side, the strategies adopted to control the health care cost of the demand side include: Set starting pay line, co-insurance provisions and the implementation of the policy limits; the cost control measures taken for supply-side include: from managed care system - the establishment of integrated"Hospital-insurance company"health care model, a wide range of medical costs the way combining for regulating and promoting competition between medical institutions and to enhance the supervision and management, the establishment of evaluation mechanisms, a combination of a wide range ways of medical costs payment, regulating and promoting competition among supply-side, as well as strengthen supervision and management of medical institutions, the establishment of evaluation mechanisms.