保險公司政策型健康險轉型實踐研究 —以CL保險公司為例

Abstract

商業保險作為國家醫療保障體系的第三支柱，在中國以國家醫保為主體的保障體系下，一直難以有效地支撐目前的醫療保障體系。但是，隨著中國加入WTO和經濟的高速發展，國人對於商業保險的需求和認知得到了大幅提升。雖然目前的保險深度和廣度還不及發達國家，但是每年的保費增長率還是體現了背後巨大的市場潛力。在2012年召開的黨的第十八次全國代表大會後，國家首次提出商業保險是國家醫療保障的組成部分，而政策型健康保險是政府積極推動商業保險公司參與民生保障體系的一種探索路徑，部分的社會轉移支付和協助醫保基金管理是目前政策型健康保險的主要功能。但是，隨著國家醫保基金的改革，商業保險公司將更加深度地參與到國家社會保障體系的建立之中去，政策型健康保險將成為商業保險和國家醫保基金融合的主要橋樑。 就此背景而言，政策型健康保險的轉型方向和商業保險公司如何借助政策型健康保險自我轉型將是本文的主要研究方向。CL保險公司作為為國內大型綜合金融保險集團，在中國現代保險業發展的前30年就憑藉市場潛力和國資優勢迅速成為中國保險行業的頭部企業，但是依然面臨了商業保險社會口碑欠佳、三醫融合度低、未能有效支撐社會保障制度健全等問題。因此，CL公司被選作為研究的案例來支撐起理論上的探討。2015年國家開始推動政策型商業保險的發展，CL保險公司需要繼續探索新的融合發展模式。由此，本文將主要介紹CL保險公司目前運行政策型商業保險的模式和經營經驗，以及已經出現的一些商業保險模式的創新點。同時結合目前的中國醫療保障現狀和保險市場背景，本文將提出一些關於未來商業保險公司結合政策型商業保險改革和創新的探索路徑。作者還將對未來政策型商業健康保險的轉型發展提出研究觀點，為商業保險公司佈局健康管理領域以及政策型商業健康保險的可持續經營提供一個參考和借鑒。

Commercial insurance, as the third pillar of the national medical insurance system, has been difficult to effectively support the current medical insurance system in China under the national medical insurance-based protection system. However, with China's accession to the WTO and rapid economic development, the country's demand for and awareness of commercial insurance has been dramatically increased. Although the current depth and breadth of insurance is not as deep as that of developed countries, the annual premium growth rate still reflects the huge market potential behind it. After the 18th National Congress of the Party held in 2012, the country proposed for the first time that commercial insurance is an integral part of national medical insurance, and policy-based health insurance is a path for the government to actively promote the participation of commercial insurance companies in the livelihood protection system, with partial social transfer payments and assistance in the management of medical insurance funds being the main functions of policy-based health insurance at present. However, with the reform of the national health insurance fund, commercial insurance companies will be more deeply involved in the establishment of the national social security system, and policy-based health insurance will become the main bridge for the integration of commercial insurance and the national health insurance fund. In this context, the main research direction of this paper is the transformation direction of policy-based health insurance and how commercial insurance companies can transform themselves with the help of policy-based health insurance.CL Insurance Company, as a large domestic integrated financial insurance group, has rapidly become the head of China's insurance industry in the first 30 years of the development of China's modern insurance industry by virtue of its market potential and state-owned capital advantage, but still faces the problems of commercial insurance problems such as poor social reputation, low integration of the three medical services, and failure to effectively support a sound social security system. Therefore, CL was chosen as a case study to support the theoretical discussion. 2015 saw the state start to promote the development of policy-based commercial insurance, and CL insurance companies need to continue to explore new integration development models. As a result, this paper will focus on the current model and operating experience of CL insurers running policy-based commercial insurance, as well as some innovative points of commercial insurance models that have emerged. At the same time, the paper will propose some exploration paths about the future reform and innovation of commercial insurance companies combined with policy-based commercial insurance, taking into account the current situation of China's health care coverage and insurance market background. The authors will also put forward research perspectives on the transformation and development of policy-based commercial health insurance in the future, which will provide a reference and reference for commercial insurance companies to layout the health management field and the sustainable operation of policy-based commercial health insurance.