基于博弈视角的我国健康保险产业链延伸研究

发布时间：2018-04-18 12:05

本文选题：健康保险产业链 + 产业链延伸　；参考：《西南财经大学》2014年硕士论文

【摘要】：进入21世纪以来,我国商业健康保险业务经历了高速的发展。在本世纪前13年中,健康保险业务初年度保费已经增长了18倍多；截至2013年,健康保险保费收入突破1000亿元大关。同时,我国的保险密度不断提高,每人健康保险的支出由2006年的29元人民币增长至如今的83元人民币,增长幅度为300%。从保险密度的提高可以看出我国民众的健康保障意识正不断增强。据有关部门在我国50个大中城市的统计结果显示,民众对健康保险有需求的比例高达77%。由此可见,经济高速增长、医疗费用居高不下以及健康知识的普及都直接或间接地提高了民众对健康风险的关注。与此同时,为了促进健康保险业务的快速增长,相关监管部门颁布了一系列法律条文。2003年保监会颁布了《关于加强健康保险发展的指导意见》,以文件形式鼓励成立专业化的健康保险公司,推进我国健康保险的专业化经营。2006年国务院下发“国十条”,从总体上肯定了保险业对于国家经济建设的重要作用,并具体对健康保险在内的各个险种今后的发展作了定位。2009年国务院再次颁布了《关于深化医药卫生体制改革的意见》和《医药卫生体制改革近期重点实施方案(2009年～2011年)》,不仅重申了商业健康保险对社会保险的补充作用,而且鼓励政府以服务购买的方式向商业健康保险公司购买保险服务,实现政府保障计划的外包。当然,在看到我国商业健康保险高速发展的同时,也应注意到在其发展过程中存在的一些问题与障碍。从1990年到2009年,我国医疗费用支出的年均复合增长率达到了19%,同时城镇医疗费用支出由25.7元增长至856.4元,增长了近34倍。在如此迅速的增长背后隐藏的是巨大的医疗费用风险。特别是在癌症、心血管疾病等重疾高发的今天,因病致贫、因病返贫的事件屡见不鲜。同时,我国医疗资源也十分短缺,每万人所拥有的医生数量仅为14名,比率为0.14%；同时每万人拥有床位22张,世界排名百位开外。紧缺的卫生资源导致了医疗质量不高、医疗费用居高不下以及医疗机构的寻租行为。对于商业健康保险公司来说,理赔效率低、理赔支出高和医疗费用风险管控难都是摆在其面前的难题。根源上,这些问题来源于健康保险公司粗放的经营模式和委托代理关系中的弱势地位。首先,当前我国健康保险的销售普遍采用的是寿险附加的方式,也就是通过在寿险主险的保单中附加健康保险,凭借寿险的营销渠道来销售健康保险并将健康保险作为寿险销售的噱头。在这种模式下,直接造成了我国健康保险销售模式单一,经营专业化程度低以及对人身险的依赖性强等问题。除此之外,由于商业健康保险公司的市场影响力与客户资源等方面的弱势地位使得其在与医疗机构的合作中对医疗机构费用支出的控制力不强,而且医保之间信息的不透明更是催生了医疗机构道德风险的发生。因此,构建健康保险产业链有助于实现商业健康保险公司的科学化、专业化运作,提升业务品质,推动健康保险市场的可持续发展。本文先从我国商业健康保险的现状着手,通过与美国管理式医疗的发展经验相对比,找出我国在发展健康保险产业中存在的不足,并提出符合我国国情的产业链延伸方法。接着,针对以上分析中所没有涉及的主体间的利益分歧,本文采用博弈论的方式进行深入研究,最终综合以上分析的结果提出有参考价值的发展策略。导论章节主要对本文的研究背景和意义、研究目的和内容、研究思路和方法以及文献综述做了详细的阐述。在此之外,本文的论述结构主要分为五个部分：第一部分主要概述我国健康保险产业的发展情况。在本部分的论述中,将会从健康保险的市场规模、健康保险业务的经营模式、健康保险产业链的技术水平以及健康保险产业的政策环境这四方面做具体的介绍,同时借助相关产业数据来分析产生这些问题的根源。第二部分是对美国商业健康保险产业成功经验的介绍和借鉴。在概述美国健康保险业务的基础上,分析美国管理式医疗发展健康保险产业链的经验,最后通过与我国的现状相对比得出符合我国国情的产业链延伸建议。第三部分运用博弈理论分析我国健康保险产业链延伸过程中存在的问题与困境,主要分析了医患的不诚实行为和保险公司对医疗机构进行监管的过程中所遇到的难题。通过论述说明想要解决以上困境,必须采取适合的产业链延伸策略,以产业链带动健康保险经营模式的升级,增强保险公司的医疗支出控制能力。第四部分基于博弈论的视角分别论述了保险公司与同业、医疗机构间的利益博弈,借助博弈模型的推导结果同时联系我国健康保险市场的实际情况,提出具有建设价值的参考意见,从产业链主体层面对上文比较分析法得出的结果进行补充。第五部分,我国健康保险产业链的延伸策略。本部分是论文的重点章节,首先从保险公司与参保人、同业者、医疗机构、药品供应商和政府部门这五方面主体入手,对我国健康保险产业链主体关系的协调提出有参考价值的建议；随后针对我国健康保险产业的环境创建提出在人才培养、信息系统建设和政策环境三方面的改进方法；最后本人在产业链合同设计上提出了一些自已的观点。本文虽然针对美国管理式医疗进行了系统的分析与讨论,但鉴于数据获取方面的限制,个别地方说服力显得略有不足。文章在前人的基础上有如下的创新：首先,本文创新性地采用了博弈论的方式来分析健康保险产业链中不同主体存在的利益分歧,为大家提供一种新的分析方式与视角。同时,本文较为系统地论述了美国管理式医疗的产业链延伸方式,为今后相关研究提供参考。
[Abstract]:Since entering the 21st century , our country ' s commercial health insurance business has experienced high - speed development . In the first 13 years of this century , the annual premium of health insurance has increased by more than 18 times ;
As of 2013 , the income of health insurance premiums exceeded 10 billion yuan . At the same time , our country ' s insurance density has improved continuously , the expenditure of health insurance is increased from 29 yuan in 2006 to 83 yuan , the increase is 300 % . In 2009 , the State Council issued a series of legal provisions . In 2009 , the State Council issued a series of legal provisions on strengthening health insurance . In 2009 , the State Council issued a series of legislative provisions on strengthening health insurance .

Of course , while seeing China ' s high - speed development of commercial health insurance , we should also pay attention to some problems and obstacles that exist in the course of its development . From 1990 to 2009 , the annual average composite growth rate of medical expense expenditure in our country reached 19 % , while the expenditure of medical expenses in town was increased by nearly 34 times . At the same time , the medical resources of our country were very short . At the same time , there was a shortage of medical resources in our country . At the same time , the number of doctors in our country was only 14 , the ratio was 0.14 % ;
At the same time , every ten thousand people have the bed position of 22 , the world ' s rank hundred open . The shortage of health resources leads to the problem that medical quality is not high , medical expense is high , and the medical expense risk control is difficult . At first , because of the weak position of the health insurance company ' s market influence and customer resources , it directly causes the health insurance and the health insurance to be used as the risk of life insurance . In this mode , the construction of health insurance industry chain can help to realize the scientific and professional operation of the commercial health insurance company , improve the service quality and promote the sustainable development of the healthy insurance market .

Based on the present situation of our country ' s commercial health insurance , this paper tries to find out the shortage of our country in the development of health insurance industry by comparing with the development experience of American administrative medical insurance , and put forward the extension method of industrial chain which accords with the national conditions of our country . Then , according to the differences of interests among the subjects not involved in the above analysis , this paper makes a thorough study on the way of game theory , and finally puts forward some valuable development strategies for the result of the above analysis .

The introduction chapter mainly describes the background and significance of the research , the purpose and content of the study , the research thoughts and methods , and the literature review .

The first part mainly summarizes the development of health insurance industry in China . In this part , it will introduce the market scale of health insurance , the operation mode of health insurance business , the technical level of health insurance industry chain and the policy environment of health insurance industry , and analyze the root causes of these problems by means of relevant industry data .

The second part is to introduce and draw lessons from the successful experiences of the American commercial health insurance industry . On the basis of summarizing the American health insurance business , the paper analyzes the experience of American management medical development health insurance industry chain , and finally obtains the industry chain extension proposal which accords with the national conditions of our country by comparing with the present situation of our country .

The third part uses the game theory to analyze the problems and difficulties existing in the extension process of health insurance industry chain in our country , mainly analyzes the problems that the dishonest behavior of the doctor and the insurance company encounters in the process of supervising the medical institution . Through the elaboration of the explanation that wants to solve the above predicament , it is necessary to adopt the appropriate extension strategy of the industry chain , to promote the upgrade of the health insurance business mode with the industrial chain , and to strengthen the medical expenditure control ability of the insurance company .

In the fourth part , based on the game theory , the benefit game between the insurance company and the same industry and the medical institution is discussed , and the result of the deduction of the game model is connected with the actual situation of the health insurance market in China , and the reference opinions with the construction value are put forward , and the result of the above comparative analysis method is supplemented from the main level of the industrial chain .

The fifth part is the extension strategy of health insurance industry chain in our country . This part is the key chapter of the thesis , first from the insurance company and the participant , the co - worker , the medical institution , the medicine supplier and the government department the five main body , this part puts forward some valuable suggestions for the coordination of the main body relation of health insurance industry chain in China ;
Then , aiming at the environment creation of health insurance industry in our country , this paper puts forward an improved method of training , information system construction and policy environment .
At last , I put forward some ideas on the design of industrial chain contract .

Although the systematic analysis and discussion are carried out for American managed medical treatment , in view of the limitation of data acquisition , individual local persuasion appears to be slightly inadequate . The article has the following innovations on the basis of predecessors :

First of all , this paper makes an innovative use of game theory to analyze the differences of interests existing in different subjects in health insurance industry chain and provide a new way of analysis and perspective . At the same time , this paper systematically discusses the extension way of American administrative medical industry chain , and provides a reference for future research .

【学位授予单位】：西南财经大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：F842.684

【参考文献】