The development of commercial insurance needs to grasp the "3 degrees"

Basic medical insurance and commercial health insurance are important components of a multi-level medical security system
.

After more than 20 years of development, China's basic medical insurance has achieved full coverage, the level of protection has been continuously improved, the management and service capabilities have been continuously improved, and world-renowned achievements have been achieved

At present, the active development of commercial health insurance has become the consensus of all walks of life
.

However, there are still some disagreements and misunderstandings in how to deal with the relationship between commercial health insurance and basic medical insurance, and how to treat commercial insurance products such as universal insurance.

Respective degree of protection

Respective degree of protection

The current and long-term structural relationship between basic medical insurance and commercial health insurance, that is, what degree of protection should be provided, and what degree can be achieved, involves major people's livelihood and industrial institutional arrangements
.

The degree of protection involves not only the weight comparison of market share, but also the scope and content of the protection

Basic relationship

Basic relationship

Academia usually distinguishes the medical insurance system models of various countries based on the relationship between social medical insurance and commercial medical insurance coverage and the content of coverage
.

From the perspective of the degree of protection, it is generally believed that the system with a relatively large proportion of commercial medical insurance is the commercial medical insurance system model, such as the United States; the system with a high proportion of social medical insurance is the social medical insurance system model, such as Germany and Japan

The current situation

The current situation

At present, China's medical security system is based on social insurance (that is, basic medical insurance), and commercial insurance is a supplementary system model
.

Mainly manifested in four aspects

First, from the perspective of payment scale, basic medical insurance currently occupies an absolute dominant position
.

In 2020, the income of the basic medical insurance fund will be 2,484.

Second, from the perspective of development space, the total national health expenditure in 2020 will reach 7.
23 trillion yuan, of which personal hygiene expenditure is 2.
00 trillion yuan, and personal hygiene expenditure accounts for 27.
66%.
According to the international standard of about 10% (according to WHO research) , The proportion of personal expenditure in total health expenditure should be controlled below 15%-20%, in order to avoid poverty due to illness and return to poverty due to illness), the future development space for commercial health insurance is close to 20%, and the new market scale of commercial health insurance It is expected to exceed 1.
2 trillion yuan
.

Thirdly, from the perspective of the development of the medical insurance system, the government has led the way throughout the development of the medical insurance system in China.
Great achievements have been made in the construction of the medical insurance system, and it has also been widely trusted and supported by the insured people
.

With the reform of medical insurance, China's commercial health insurance has developed rapidly.

Fourth, from the perspective of China’s political system and basic national conditions, the social medical insurance system insists on covering the whole people, equal rights and responsibilities, universal benefits for public welfare, and high social acceptance; commercial health insurance has voluntary insurance, conditional participation, and profit as the goal.
Commercial attributes, the acceptance of the masses and society still needs to be improved
.

In comparison, basic medical insurance follows the principles of full coverage, basic insurance, multiple levels, and sustainability, and is compatible with the level of economic development and financial affordability

development trend

development trend

From the perspective of future development, is it necessary to leave more room for commercial health insurance, or will commercial health insurance in the future exceed basic medical insurance in scale and become the main body of China's medical insurance system? It is estimated that China’s total GDP in 2035 Will grow to 209 trillion yuan
.
If according to the standard estimate that health expenditure accounts for 10% of GDP, the total medical and health expenditure will exceed 20 trillion yuan
.
As China's economy enters a new normal, the basic medical insurance benefit list system has been formally implemented, and basic medical insurance has left ample market space for commercial health insurance
.
On the basis of providing basic medical insurance services, how to better encourage and support the development of commercial health insurance is a major issue for the Healthy China strategy and the construction of China's multi-level medical security system
.

Degree of mutual participation

Degree of mutual participation

The degree of mutual participation directly reflects the synergy and competition between social medical insurance and commercial health insurance
.
The coordinated development of China's social medical insurance and commercial health insurance can be roughly divided into three stages
.
In the first stage, before 2012, pilot commercial insurance institutions to participate in critical illness insurance management in Taicang, Jiangsu and Zhanjiang, Guangdong, and commercial insurance institutions to participate in the new rural cooperative medical insurance system and urban residents’ basic medical insurance management in Luoyang, Xinxiang, Henan, etc.
Project
.
In the second stage, from 2012 to 2020, commercial insurance will fully participate in the basic medical insurance stage, which is marked by the implementation of the major illness insurance system for urban and rural residents in 2012
.
At the same time, basic medical insurance has innovatively supported and promoted the development of commercial insurance in some cities, such as Shenzhen and Jinhua
.
The third stage, since 2020, the release of the "Opinions" has put forward clear requirements for the construction of a multi-level medical security system, and the development of social and business integration has entered a new stage
.
Studying the reasonable degree of mutual participation between basic medical insurance and commercial insurance is essential to the healthy development of commercial insurance
.

Competitive

Competitive

According to different levels of competition, there are three forms
.

One is all-round competition
.
That is to say, in terms of coverage, treatment level, treatment provision, service network, risk prevention and control, etc.
, basic medical insurance and commercial insurance are not as supplementary to the other party’s existing protection status and protection advantages, but as a leader or strive to become a leader.
The dominant posture is to enter the opponent's dominant field or traditional business field, and the development direction is to completely replace or suppress the opponent
.
This relationship has only triggered controversy at the theoretical level within a certain period of time.
It mainly emphasizes and promotes the advantages of commercial insurance in actuarial, management, risk control, service, network, personnel, and market flexibility.
Service provision and risk management replace basic medical insurance
.

The second is the competition of some guarantee items and content
.
In some coordinating regions and some commercial insurance institutions, out of market demand or business strategy requirements, strong intervention is a new field relative to oneself, but compared to the other party, it is a traditional business field or an area that needs to be expanded in the next step
.
For example, in terms of major disease protection, chronic disease protection and management, and rare disease drugs and treatment, the two are in a state of intertwining that they have had or are experiencing in some regions
.

The third is to manage and service competition
.
Service provision is an important part of a complete guarantee system
.
In the field of medical security, the competition between commercial insurance and basic medical insurance began to focus on the field of management services
.
For example, the Xinxiang, Luoyang, Jiangyin, Zhanjiang models that have been hotly discussed, some of which are basic medical insurance with a part of the funds and part of the protection content, and entrust commercial insurance institutions to operate independently and be responsible for their own profits and losses (or part of the profits and losses); some are to handle basic medical insurance.
Services or risk management and control are gradually transferred to commercial insurance, and service fees are paid according to a certain percentage or amount
.
The original intention of this transfer is not as a temporary and fragmented consideration, but as a directional system reform design
.

Supplementary

Supplementary

The relationship between basic medical insurance and commercial health insurance is relatively mild, and there is more room for complementary development.
Due to the early development of basic medical insurance and strong institutional rigidity, this supplement is mainly manifested as one-way commercial insurance supplementing basic medical insurance, which is mainly reflected in Two aspects
.

One is to fill in the gaps
.
The medical needs of the masses can be roughly divided into four aspects: treatment, improvement, convenience and comfort
.
The current basic medical insurance coverage is mainly for therapeutic needs
.
The requirements for improvement (such as beauty), convenience (such as a green channel for famous doctors), and comfort (such as high-end wards) are not covered by basic medical insurance.
This is also an international practice
.
In terms of therapeutic needs, basic medical insurance only guarantees the basics.
Some extremely expensive innovative drugs and treatment methods have not yet been included in the basic medical insurance coverage
.
From the perspective of the protection needs of the whole cycle, the whole process, and the whole link of the construction of a healthy China, the masses' massive preventive and rehabilitation needs have not yet been included in the basic medical insurance coverage
.
These can be regarded as important areas for the supplementary development of commercial health insurance
.

The second is to supplement the deficiency
.
Policy decision-making requires a process, the demand of the people is rising rapidly, and service improvement is endless.
Medical insurance risk management is a world problem.
Many factors have caused basic medical insurance to have shortcomings and shortcomings in terms of coverage, benefit levels, service provision, fund supervision, and performance evaluation.
The board is objective and inevitable
.
Commercial health insurance supplements basic medical insurance and has developed rapidly in recent years
.
For example, critical illness insurance, as an institutional arrangement, supplements basic medical insurance and is undertaken by commercial insurance institutions; some local general insurance projects provide supplementary protection for expenses within the scope of the basic medical insurance policy while expanding the scope of the basic medical insurance policy.
Part of the protection of medical items and medical supplies; commercial health insurance is widely involved in basic medical insurance handling services and risk management.
In some areas, basic medical insurance and commercial health insurance have formed a good situation in which basic medical insurance and commercial health insurance complement each other and develop soundly
.

Functional positioning

Functional positioning

Medical security departments and commercial insurance institutions, as two entities with different natures, have different understandings of their own functions and the relationship between them and their different grasp of development prospects, which may lead to different treatment methods
.
From the perspective of the medical security department, there may be four states of leadership, guidance, active participation, and general participation in the development of commercial insurance
.
Government-led is generally enforced and organized by government departments with the help of economic, administrative and legal means to directly expand the coverage of commercial health insurance
.
For example, government departments set up working groups, issue implementation plans, carry out work deployment, and perform government functions in system design, policy planning, publicity and promotion, premium collection, and supervision and management
.
Government guidance, especially participation, is mainly directional guidance, but it is mostly involved in the specific operation of commercial insurance
.
For example, through policy guidance, legal norms, public opinion propaganda, support and supervision and other measures to improve and promote the development of commercial health insurance
.
From the perspective of commercial insurance institutions, there may be three states of assistance, participation, and substitution, from the shallower to the deeper
.

Publicity reference level

Publicity reference level

At present, our country has established a basic medical insurance system covering all people
.
In the process of commercial health insurance market expansion, some commercial insurance institutions use basic medical insurance as the reference object, and use exaggerated publicity, false promises, and misleading consumers as marketing methods.
This will not only damage the objectivity and recognition of publicity, but also The authority and public welfare of the basic medical insurance system have a certain impact, damaging the environment for the coordinated development of basic medical insurance and commercial insurance
.
Therefore, commercial health insurance, especially inclusive insurance and other products, should deal with the following key points in publicity
.

Basic positioning

Basic positioning

Regarding the basic positioning and basic relationship between basic medical insurance and commercial insurance, as large as the overall development direction of the two, as small as the development and development of a single specific commercial insurance product, it should fully reflect the multi-level medical insurance system and basic medical insurance and commercial insurance.
The basic positioning
.
The core of China's basic medical insurance is to "guarantee basic", and we insist on doing our best and doing what we can; commercial health insurance is an effective link and supplement of basic medical insurance, critical illness insurance and medical assistance, and it is in a complementary relationship with basic medical care, and it is a multi-level medical insurance.
An important part of the system
.
The publicity of commercial health insurance should more reflect the positive role of the product in protecting the people's multi-level medical service needs.
By enriching the supply of commercial health insurance products, improving health protection service capabilities, and meeting the objective requirements of the people's diversified and personalized protection needs , Is a major measure to further improve the multi-level medical security system
.

Treatment policy

Treatment policy

At present, when commercial health insurance products are sold, there is a tendency to exaggerate the promotion of treatment policies.
In particular, most inclusive insurance is promoted through the Internet, leaflets, slogans, banners, etc.
If the insured understands medical insurance Inadequate understanding may lead to misunderstandings, and may cause policyholders to think that everything outside the scope of basic medical insurance can be reimbursed through universal insurance, which is far from the actual compensation standard, and there is a huge difference in treatment
.
Therefore, commercial health insurance needs to standardize the propaganda caliber and conduct propaganda activities rationally, so that consumers can accurately grasp the characteristics of commercial insurance products, policies, and conditions and levels of treatment
.
In particular, it is important to explain to the public clearly the service methods, service channels, and non-reimbursement circumstances of commercial health insurance products
.

Power and responsibility

Power and responsibility

Unlike basic medical insurance’s public product attributes, government responsibility, and financial support, commercial health insurance is a non-public product.
Both the insurance institution and the policyholder voluntarily conclude a commercial insurance contract.
The policyholder pays the insurance premium to the insurance institution according to the contract.
According to the contract, the government is not liable for compensation for losses
.
In the publicity of some inclusive insurance products, excessive emphasis on the participation of government departments can easily confuse the market attributes of commercial insurance and the public product attributes of basic medical insurance.
The behavioral logic of medical insurance asks the medical insurance department for fairness
.

Personal responsibility

Personal responsibility

An insurance contract is an agreement between the applicant and the insurer to agree on the relationship of insurance rights and obligations, and has legal effect
.
Even if the consumption threshold is low and the purchase channel is simple, it will not reduce the seriousness of the insurance contract
.
The significant difference between commercial insurance and social insurance is that people participating in basic medical insurance do not need to carefully understand the basic medical insurance system regulations.
Basic medical insurance also simplifies policy interpretation text as much as possible for the convenience of the masses
.
However, the general terms of commercial insurance are complex, and the terms are numerous and difficult to understand
.
It is difficult for non-professionals to fully understand .
Therefore, when government departments participate in the promotion of inclusive insurance, they should focus on helping consumers understand the difference between basic medical insurance and commercial insurance policies and handling, and guide consumers to carefully understand the commercial health insurance’s effects on past illnesses, deductibles, and scope of claims.
Various requirements, so as to avoid disputes caused by failure to meet expectations during the application stage of commercial insurance compensation
.
Commercial insurance institutions should also truthfully explain to the insured the product liability and the difference between basic medical insurance, etc.
, and must not intentionally confuse commercial insurance with basic medical insurance, leaving hidden dangers for subsequent protection
.

Based on the analysis and grasp of the above three degrees, the next step should be to promote the coordinated and sustainable development of basic medical insurance and commercial health insurance as an important direction of medical insurance reform, and accelerate the construction of a multi-level medical security system with Chinese characteristics
.
Commercial health insurance plays an active role in the national medical security system, which is a clear requirement of the "Opinions" and the "Opinions on Accelerating the Development of Commercial Health Insurance" of the General Office of the State Council
.
In the process of advancing the realization of the goal of universal coverage of basic medical insurance, it is advisable to follow the requirements of the central government to improve the top-level design of the medical security system with Chinese characteristics, and to simultaneously consider promoting the development of commercial health insurance and strengthening the complementary connection with basic medical insurance to better meet the diverse needs of the insured.
To improve the demand for medical security, and effectively enhance the sense of gain and satisfaction of the people
.
At the same time, strengthen supervision and management in accordance with laws and regulations, prevent and defuse risks, and effectively protect the legitimate rights and interests of consumers
.
(ZGYB2021-10)