Study On The Problems And Suggestions In The Process Of Insurance Companies Undertaking The Major Illness Medical Insurance For Residents Both In Rural And Urban Areas In China

On August30,2012, the National Development and Reform Commission, the Ministry of Health, Ministry of Finance, Human Resources and Social Security programs Ministry, the Ministry of Civil Affairs and the China insurance Regulatory Commission issued<the Guidance on the Work of Implementing the major illness medical insurance for Urban and Rural Residents>(here referred to as the "Guidelines" below), to determine the basic framework of the urban and rural residents’serious illness insurance (here referred to as "serious illness insurance" below), namely the department designated by the government around will buy the major illness medical insurance from insurance companies for the participants of the Urban Employee Basic Medical Insurance (here referred to as the UEBMI) and the New Rural Co-operative Medical System (here below referred to as the "NCMS") in the case of high medical expenses. Therefore the insurance companies will provide further security programs for personal burden of the medical costs after the insured get the basic compensation from the UEBMI and the NCMS.Under the basic framework determined by the "guidance", many governments made implementation scheme of the major illness medical insurance combining with local actual situation, and developed the major illness medical insurance pilot work. Several power-strong insurance companies actively undertook the major illness medical insurance. The insurance companies have achieved initial success since the major illness medical insurance pilot work was carried out. To a certain extent, it eased the burden of high medical expenses on the insured; at the same time, the pilot area government and the insurance companies also has accumulated experience on carrying out the work of the major illness medical insurance. However, in the process of "touch stone across the river", a series of problems were exposed gradually.Based on such background, this paper will try to dissect the main problem existing in the process of insurance companies undertaking the major illness medical insurance through literature analysis, typical analysis, comparative method and investigation method, based on the perspective of insurance companies who are the operators of the major illness medical insurance, and try to put forward the corresponding countermeasures. Starting from domestic and international experience, this paper will provide empirical support for the main problem existing in the process of insurance companies undertaking the major illness medical insurance and then analyze the problems of three aspects, namely Security programs design, premium set and Medical risk control, and offer some suggestions for reference accordingly.Based on the research object of the topic, this paper is divided into five chapters.The first chapter is introduction. This part introduces the general situation of the major illness medical insurance system of urban and rural residents, the present situation of the insurance companies undertaking urban and rural residents’ serious illness insurance in our country and the research significance and purpose of this paper; introduces the research content and the adopted methods in this paper; and overviews the related research status at present stage through literature review.Chapter ii introduces the experience and enlightenment of foreign insurance companies participating in. This part analyzes the actual situation of insurance companies involved in in the United States and the Netherlands and gets enlightenment in three aspects that the way of insurance companies participating in catastrophic medical insurance system construction, medical management methods and the insurance clause design.The third chapter introduces the exploration and experience summary of domestic insurance companies undertaking the urban and rural residents’major illness medical insurance. This part has chosen the PICC health "Taicang model" and "Zhanjiang model" and Ping An endowment "Xiamen model" to analyze the practical experience of our insurance companies undertaking urban and rural residents’ major illness medical insurance. It is concluded that the insurance companies need to improve the medical risk control ability and pay attention to the cooperation with the health care institutions if they want to undertake the major illness medical insurance sustainably.The fourth chapter introduces and analyzes the main issues existing in the operation of insurance companies undertaking urban and rural residents’ serious illness insurance. This part analyzes the following main problems:the problems of security programs design are mainly concentrated in the dispute of the insurance coverage and the set of deduction and the payment limit; the difficulty point of premium rates set lies in the considerable lack of the actuarial data, some local governments do not accept the reasonable costs incurred in insurance companies and the policy of the major illness medical insurance have high standards; the problem in the aspect of medical risk control is that the companies only pay attention to the verification for the payment after the illness, and lack deep cooperation with medical health care institutions and government departments.Chapter v describes the sustainable advice on the insurance companies undertaking urban and rural residents’major illness medical insurance. This part puts forward the corresponding suggestions on the problems given in the fourth chapter:the scope of the major illness medical insurance responsibility should be prescribed for the medical costs paid by the insured inside the basic medical directory, urban residents’per capita disposable income or per capita net income of farmers; the insurance companies undertaking the major illness medical insurance should set up a payment limitation of the major illness medical insurance, but the companies can explore and adopt the method that combine the provisions of individual medical treatment charge payment limit with the payment limit in total; and the major illness medical insurance can cope with the difficulties existing in premium rate set through the methods such as broadening the channels gaining the data, using scientific data analysis tools, strengthening the cooperation with government departments, the insurance companies should establish a co-working mechanism, implement health management before disease, strengthen the diagnosis and treatment monitoring during the disease and strengthen the verification for the payment after the illness to strengthen medical risk control ability.The possible innovative ideas in the research made by the author:Considering from the angle of the insurance companies, this paper provides methods and suggestions for them to solve the practical problems.This paper has tracked the implementation plan in27national pilot provinces of the urban and rural residents’major illness medical insurance, so it is empirical to some extent.This paper analyzes the key problems existing in the process of insurance companies undertaking urban and rural residents’major illness medical insurance in China and puts forward the corresponding suggestions.This paper’s shortcomings:It failed to get a large number of data of the individual medical treatment cost, so it can’t analyze payment limit set standards further.It failed to get empirical data of the insurance companies, and the suggestions on solving the problem of the lack of the data only stay at the method level, which is unable to verify the validity of the method.This paper analyzes problems mainly on the insurance companies’ perspective and less to consider problem and analyze the risk from the perspective of the government.