商业保险公司在承办大病保险中存在的问题与对策
发布时间：2018-09-04 07:25
【摘要】：随着社会生产力的进一步发展和人民生活水平的不断提高,社会保险在国民生活中发挥着愈来愈重要的作用。大病保险承担着极其重要的社会保障职能,通过对重大疾病的报销,重大疾病患者的经济负担得到了大大的减轻。近些年,城乡居民大病保险正在以市场机制逐步进入到社会保障制度,并取得到了相当满意的效果,同时在基本政策方面有了很大的进步,具有代表性的是:补偿比例方面、融资筹集方面、费用处理方面、结算管理方面等。但是在实践过程中,大病保险依然面临种种考验,商业保险公司承办的大病保险在政策法规、筹资水平、政商系统对接、合作模式、隐性价格竞争等方面存在诸多问题。此外,大病保险在公共财政支出与商业保险公司之间的有效衔接仍然存有一些问题,这一点表现在公共财政的支付与商业保险公司的对接环节尤为明显。本文希望通过从解决这些问题入手,将商业保险公司承办的大病保险业务的核心问题得以理顺。首先,本文以经营者地位的商业保险公司为视角,采取文献分析法、比较分析法等研究方法,通过了解典型的几个模式,更为清晰地分析商业保险公司在承办大病保险业务活动时的真实状况。并借此对目前我国商业保险公司在承办大病保险过程中存在的问题从三个方面进行分析:政策法规不健全,如相关法律法规不健全、政府监管错位越位现象时有发生、医疗保险政策缺乏整体性设计;大病保险基金浪费现象缺乏有效对策,如医院“过度医疗”,监督管理方式单一、医疗信息缺少共享,“智能审核”应用水平有待增强、医疗保险支出绩效评估不足,医疗保险效果定量分析不足;大病保险特点、机制、标准探究不足,导致大病医疗保障水平较低。最后,针对出现的问题提出一些对策和建议,不仅从政府的政策层面,配合多元利益需求,合理、科学建构整体法律框架;而且创新思路,加强对各参与主体的监管与考核,加强监管医院“过度医疗”,推广“智能审核”信息化手段运用,且引入第三方机构,对医疗保险效果进行评估;同时,随着大病保险的推广与深入研究,要综合施策,提高大病保险保障水平,加强对大病保险特点的分析研究,建立商业保险与社会保险联动工作机制,制定统一的大病保险保障标准。
[Abstract]:With the further development of social productivity and the continuous improvement of people's living standard, social insurance plays an increasingly important role in national life. The serious illness insurance plays an extremely important role in social security, and the financial burden of the patients with the major diseases is greatly reduced through the reimbursement of the major diseases. In recent years, urban and rural residents' serious illness insurance is gradually entering the social security system through the market mechanism, and has achieved quite satisfactory results. At the same time, great progress has been made in the basic policies. Financing aspects, cost handling, settlement management, etc. However, in the process of practice, the serious illness insurance still faces various tests. There are many problems in the policies and regulations, the level of financing, the docking of the government and business system, the cooperation mode, the hidden price competition and so on. In addition, there are still some problems in the effective connection between public expenditure and commercial insurance companies, which is especially obvious in the connection between public finance payment and commercial insurance companies. Through solving these problems, this paper hopes to straighten out the core problems of the serious illness insurance business undertaken by commercial insurance companies. First of all, from the angle of view of commercial insurance company with operator status, this paper adopts literature analysis, comparative analysis and other research methods to understand several typical models. A clearer analysis of the real situation of commercial insurance companies in undertaking major illness insurance business activities. In this way, the problems existing in the process of undertaking the insurance of serious illness in China's commercial insurance companies are analyzed from three aspects: the imperfect policies and regulations, such as the imperfect laws and regulations, the phenomenon of government supervision misplacing and offside, which occur from time to time. The medical insurance policy lacks the overall design, the serious illness insurance fund waste phenomenon lacks the effective countermeasure, such as the hospital "excessive medical treatment", the supervision and management way is single, the medical information is not shared, the application level of "intelligent audit" needs to be strengthened. The medical insurance expenditure performance evaluation is insufficient, the medical insurance effect quantitative analysis is insufficient, the serious illness insurance characteristic, the mechanism, the standard exploration insufficiency, causes the serious illness medical treatment safeguard level to be low. Finally, some countermeasures and suggestions are put forward to solve the problems, not only from the government policy level, to meet the needs of multiple interests, but also to construct the overall legal framework scientifically, and to create new ideas to strengthen the supervision and assessment of the participants. Strengthen supervision of hospital "excessive medical treatment", popularize the use of "intelligent audit" information means, and introduce third party organizations to evaluate the effect of medical insurance; at the same time, with the promotion and in-depth study of the insurance for serious illness, we should comprehensively implement countermeasures. To improve the level of insurance for serious illness, to strengthen the analysis and research on the characteristics of the insurance of serious illness, to establish the working mechanism of the linkage between commercial insurance and social insurance, and to formulate a unified standard of insurance for serious illness.
【学位授予单位】：山西大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：F842.6
本文编号：2221398
[Abstract]:With the further development of social productivity and the continuous improvement of people's living standard, social insurance plays an increasingly important role in national life. The serious illness insurance plays an extremely important role in social security, and the financial burden of the patients with the major diseases is greatly reduced through the reimbursement of the major diseases. In recent years, urban and rural residents' serious illness insurance is gradually entering the social security system through the market mechanism, and has achieved quite satisfactory results. At the same time, great progress has been made in the basic policies. Financing aspects, cost handling, settlement management, etc. However, in the process of practice, the serious illness insurance still faces various tests. There are many problems in the policies and regulations, the level of financing, the docking of the government and business system, the cooperation mode, the hidden price competition and so on. In addition, there are still some problems in the effective connection between public expenditure and commercial insurance companies, which is especially obvious in the connection between public finance payment and commercial insurance companies. Through solving these problems, this paper hopes to straighten out the core problems of the serious illness insurance business undertaken by commercial insurance companies. First of all, from the angle of view of commercial insurance company with operator status, this paper adopts literature analysis, comparative analysis and other research methods to understand several typical models. A clearer analysis of the real situation of commercial insurance companies in undertaking major illness insurance business activities. In this way, the problems existing in the process of undertaking the insurance of serious illness in China's commercial insurance companies are analyzed from three aspects: the imperfect policies and regulations, such as the imperfect laws and regulations, the phenomenon of government supervision misplacing and offside, which occur from time to time. The medical insurance policy lacks the overall design, the serious illness insurance fund waste phenomenon lacks the effective countermeasure, such as the hospital "excessive medical treatment", the supervision and management way is single, the medical information is not shared, the application level of "intelligent audit" needs to be strengthened. The medical insurance expenditure performance evaluation is insufficient, the medical insurance effect quantitative analysis is insufficient, the serious illness insurance characteristic, the mechanism, the standard exploration insufficiency, causes the serious illness medical treatment safeguard level to be low. Finally, some countermeasures and suggestions are put forward to solve the problems, not only from the government policy level, to meet the needs of multiple interests, but also to construct the overall legal framework scientifically, and to create new ideas to strengthen the supervision and assessment of the participants. Strengthen supervision of hospital "excessive medical treatment", popularize the use of "intelligent audit" information means, and introduce third party organizations to evaluate the effect of medical insurance; at the same time, with the promotion and in-depth study of the insurance for serious illness, we should comprehensively implement countermeasures. To improve the level of insurance for serious illness, to strengthen the analysis and research on the characteristics of the insurance of serious illness, to establish the working mechanism of the linkage between commercial insurance and social insurance, and to formulate a unified standard of insurance for serious illness.
【学位授予单位】：山西大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：F842.6
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