我国商业口腔保险的发展研究
发布时间：2019-06-17 13:22
【摘要】：口腔疾病被世界卫生组织称为人类重点研究和重点防治的三大非传染性疾病之一。口腔疾病不仅本身会对人体健康和人们的生活品质造成重大影响,而且由其引起的全身系统病(如胃病、营养方面的疾病等),以及其可能引起的心理问题更是危害深远。 全国第三次口腔健康流行病学调查显示,我国口腔疾病患病率高达97.6%,几乎人人都或多或少地存在口腔问题,而就诊率却不到10%,即便前往就诊,也存在疼痛缓解就中断治疗和剧烈疼痛才选择医疗服务的现象。由于牙齿没有彻底处理,经过一定时间,损坏过大,无法修补,只能拔除。我国65岁以上老人平均失牙11颗,远远低于世界卫生组织制定的“8020”(80岁老人有20颗及以上健康恒牙)指标。 目前,口腔疾病的治疗成本非常高昂,在所有疾病中列于前三位。我国口腔疾病的治疗费用主要通过自费给付和社会医疗保险给付两种方式,且社会医疗保险保障的口腔疾病范围和种类很少,只有牙髓病、根尖周——根管治疗术(杀神经)、牙周炎——牙周基础治疗、埋伏阻生牙——拔除术(拔牙)四种可部分报销的治疗项目。而我国的商业口腔保险刚刚起步,尚处于试验阶段,目前仅有的两款口腔保险产品只突出了几种简单的常规牙科护理,却并没有补偿口腔疾病风险发生后的经济损失,从保险的定义上来看,不属于真正意义上的疾病保险。 研究发现,医疗费用支付方式是影响口腔疾病患者选择口腔医疗卫生服务的最重要的原因,享有较高医疗保障制度的人群,就诊概率较高。那么如何更好的减轻患者负担,建立起有效的口腔医疗费用保障机制呢?国外发达国家完善的商业口腔保险模式已经为本国患者提供了很好的患病费用补偿与保障机制。我们也可以提出这样的问题：可否用商业保险的方式来解决我国口腔疾病患者的医疗费用给付问题?商业口腔保险的形式是否必要,又能否可行?如必要且可行,那么在建立的初期会遇到哪些问题,又该如何发展?于是在这样的背景下,笔者开始了本文的思考与探索。 本文第一章对研究对象进行界定。将口腔保险及商业口腔保险的概念进行了梳理,针对国内为数不多的相关研究和使用较混乱的名词定义,给出了自己的理解和结论。 第二章,口腔医疗卫生服务及费用保障机制。从口腔科常见诊治项目及费用的角度,梳理口腔疾病种类及特点,分析我国口腔疾病患病率高,就诊率低的原因,得出费用支付方式是影响医疗卫生服务利用的重要因素的结论,进而论证用商业口腔保险的方式建立口腔医疗费用保障机制的必要性及可行性。 第三章,国外口腔保险发展现状及经验借鉴。首先梳理目前国际上比较常见的三种口腔保险模式,分别是以美国为代表的商业口腔保险模式、以荷兰为代表的公共牙科保健模式及日本为代表的齿科全民健保模式。重点介绍美国口腔保险模式,从发展历程到口腔保险管理式医疗HMO模式和PPO模式,美国主要的口腔保险提供商,得出对我国的启示：社会口腔(医疗)保险只能起到基础保障作用,商业口腔保险作为口腔基本医疗保险的有力补充,可以利用其灵活多样的保险项目、保险水平、以及投保的方式等,对社会口腔(医疗)保险没有覆盖到的诊疗项目、个人按比例自付的费用,甚至医疗事故的赔付等方面,根据投保者的意愿,因人而异,设计不同的保险合同,这填补目前社会口腔(医疗)保险的空白。 第四章,我国商业口腔保险现状及存在的问题。首先介绍处于起步试水阶段的口腔保险产品,市场上以主险形式存在的仅有两款牙科保健类商业保险产品,分别是人民保险公司的牙科管理式医疗保险产品—守护专家牙科医疗保险和平安保险公司的平安附加意外牙科及保健医疗保险,目前存在品种少,得不到政策支持,需要大但尚未转化成有效需求,只针对高端市场等弊端和不足的问题,而对于之后发展商业口腔保险要面临的不完善的相关政策法规环境、口腔卫生服务环境不规范、信用环境有待提高、供给及需求问题、口腔医疗市场问题也进行了分析。 第五章,发展我国商业口腔保险的具体战略。首先对我国发展口腔保险体系构建进行了构想。针对不同疾病按病种不同选择不同展业方式,将传统口腔疾病项目和预防保健日常检查类放入团险,将口腔创新类放入个险,利用管理式医疗手段,与口腔医疗机构(牙科诊所、口腔医院、综合医院口腔科)进行信息联网,分步搭建健康管理平台,构建有吸引力的医保合作框架。相关配套政策及可深入研究的问题。然后重点介绍国家相关部门及医疗机构的配套政策,在本章的最后对我国社会医疗保险目前针对口腔疾病和诊治项目的情况进行补充介绍。 总体而言,本文可能有以下几点特色和可能的创新。第一,首次将口腔保险及商业口腔保险的概念进行了梳理,针对国内为数不多的相关研究和使用较混乱的名词定义,给出了自己的理解和结论。第二,首次将口腔疾病付费保障机制进行了梳理,从商业口腔保险解决口腔疾病费用的可行性及必要性方面进行了分析及论证,提出在我国大力发展市场经济的背景下,在确定社会保险对于口腔疾病的保障范围及边界后,可以利用更加有效的市场机制——商业保险的手段来解决口腔疾病付费保障问题。第三,鲜明的将社会口腔保险与商业口腔保险区分开,对两者分别负责和保障的范畴和如何运营的思路,融合和镶嵌的预留空间等等进行了初步的构想。本文并未讨论社会口腔保险与商业口腔保险孰优孰劣的问题,强调融合,镶嵌和合理的边界制定,笔者认为,两种保障机制不是非此即彼的关系,而是应该相辅相成,优势互补,同步运作,共同发展。只是基于自身知识背景的考虑,切入角度的选择让笔者更多的从商业的角度对该问题进行了分析,并在本文最后表明了社会保险的作用及应有的边界。第四,对于商业口腔保险的未来发展战略,从政府政策制定、口腔医疗机构发展和商业保险公司运营三方面阐述了很多具体的构想和思路,希望能对后来研究人员、实务工作者及政策制定方有些许启发作用。
[Abstract]:Oral diseases are one of the three major non-communicable diseases called human focus research and focus prevention and control by the World Health Organization. Oral diseases are not only a major impact on the health of the human body and the quality of life of people, but also the systemic diseases (such as gastropathy, diseases, etc.) caused by the oral diseases, and the psychological problems that it may cause are far-reaching. The third oral health epidemiological survey of the country shows that the prevalence of oral diseases in our country is as high as 97.6%, and almost everyone has more or less oral problems, while the rate of treatment is less than 10%. Palpation, there is also pain relief to discontinue treatment and severe pain to select the current status of the medical service A. Due to the incomplete treatment of the teeth, the damage can not be repaired by a certain amount of time, and can only be pulled out. In addition, the average loss of 11 of the old people over the age of 65 in China is far lower than that of the "8020" developed by the World Health Organization (20 and more healthy permanent teeth of the 80-year-old man). The treatment cost of oral diseases is very high, and is listed in all the diseases. The treatment cost of oral diseases in China is mainly covered by the cost-of-pocket and social-medical insurance benefits, and the range and type of oral diseases guaranteed by social medical insurance are very few, only endodontic disease, periapical-root canal treatment (killing nerve), periodontitis _ periodontal basis Treatment of four parts, such as the treatment of tooth extraction (tooth extraction), and the treatment of four parts, which can be partially compensated The commercial oral insurance of our country has just started, and at the stage of the test, only two of the two oral insurance products have only highlighted several simple routine dental care, but have not compensated the economic loss after the risk of the oral disease, from the definition of the insurance On the other hand, it doesn't belong to the real meaning of the disease. The research shows that the medical expense payment method is the most important reason which affects the choice of the oral health care service in the patients with oral diseases, and the people with higher medical security system The probability of the diagnosis is high. So how to reduce the burden of the patient better and to set up effective oral medical expenses Where is the safeguard mechanism? The developed commercial oral insurance model developed by the developed countries has provided a good compensation for the patients in the country We can also put forward such a question: Can we use the way of commercial insurance to solve the medical expenses of patients with oral diseases in our country with benefits? Is the form of a commercial oral insurance necessary, Is it possible? If necessary and feasible, what problems will be encountered at the beginning of the establishment, and How to develop? So, in this context, the author has started this article. Thinking and exploration. The first chapter of this paper is the research The definition of the object is defined. The concept of the oral insurance and the commercial oral insurance is analyzed, and a few related research and the use of the more confused term definition are given. Self-understanding and conclusions. Chapter II, Oral and health care Service and expense guarantee mechanism. From the angle of common diagnosis and treatment project and cost of stomatology department, to sort out the types and characteristics of oral diseases, to analyze the causes of high prevalence of oral diseases and low treatment rate in our country, and to conclude that the cost payment method is the influence of medical and health service. The conclusion of the important factors used, and then the establishment of the oral cavity medical expense guarantee machine in the way of commercial oral insurance The necessity and feasibility of the system. Chapter 3, the foreign oral cavity The present situation and experience of the insurance development can be used for reference. First of all, the three kinds of oral insurance models which are common in the world are first combed, the commercial oral insurance mode represented by the United States, the public dental health mode represented by the Netherlands, and the Japan are the This paper mainly introduces the American oral insurance model, from the development course to the oral insurance management type medical HMO mode and the PPO pattern, the main oral insurance provider in the United States, and gives the enlightenment to our country: the social oral (medical) protection The insurance can only play a basic guarantee, and the commercial oral insurance can be used as a strong supplement to the basic medical insurance of the oral cavity, so that the medical insurance coverage of the social oral (medical) insurance is not covered by the flexible and diversified insurance items, the insurance level, the method of the insurance, and the like. According to the intention of the insured, the individual can design different insurance contracts according to the individual's will, even the payment of the medical accident, which fills the current society Blank for oral (medical) insurance. Chapter IV, Chinese The present situation and existing problems of oral insurance in the industry are introduced. First, the oral insurance products in the initial stage of water trial are introduced. The two dental health insurance products, the dental management medical insurance products of the people's insurance company, the dental medical insurance and the safe and additional accidental dental and health-care medical insurance of the safety insurance company, are currently few varieties and can not be supported by the policy, needs big but not yet converted into the effective demand, only aiming at the problems of the high-end market and the like, and the imperfect related policy and regulation environment, the environment of the oral hygiene service, the credit ring, The situation needs to be improved, the supply and demand problems, the mouth in chap 5, The development of the specific strategy of the commercial oral insurance in our country. First of all, to our country The development of the oral insurance system is conceived. The traditional oral diseases project and the preventive health-care daily inspection class are put into the group insurance for different diseases according to different disease types, and the oral innovation class is put into a risk, and the management type medical device and the mouth are used. The information networking is carried out in the cavity medical institution (the dental clinic, the oral hospital, the comprehensive hospital stomatology department), and the health management level is set up in step by step. Taiwan, to build an attractive health-care cooperation framework. The relevant supporting policies and the problems that can be in-depth study will be discussed. Then, the supporting policies of the relevant departments of the state and the medical institutions will be introduced. At the end of this chapter, the social medical insurance of our country is currently against the oral diseases. Supplementary information on the condition of the disease and the diagnosis and treatment of the project. Overall, This article may have the following features and possible innovations. First, the concept of oral insurance and commercial oral insurance is first combed, with a few related research and use in the country In the second part, the mechanism of the payment for oral diseases is analyzed, and the feasibility and necessity of the cost of the oral diseases are analyzed and demonstrated from the commercial oral insurance. In the background of developing a market economy in our country, it is suggested that more effective market mechanism _ commercial protection can be used to determine the scope and boundary of social insurance for oral diseases. The third, the distinction between the social and oral insurance and the commercial oral insurance, the scope of the responsibility and the guarantee and how to operate, the integration and the The paper does not discuss the problem of the superior and inferior of the social oral insurance and the commercial oral insurance, and emphasizes the integration, inlaying and reasonable boundary establishment. The author holds that the two safeguard mechanisms are not the same, but should be complementary. It is only based on the background of knowledge, and the choice of cut-in angle makes the author more and more analyze the problem from the perspective of business, and in this article the most important The fourth part, on the future development strategy of the commercial oral insurance, expounds a lot of concrete measures from the development of the government policy, the development of the oral medical institution and the operation of the commercial insurance company. The idea and the way of thinking, I hope to be able to study the later researchers, real
【学位授予单位】：西南财经大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：F842.684
本文编号：2501019
[Abstract]:Oral diseases are one of the three major non-communicable diseases called human focus research and focus prevention and control by the World Health Organization. Oral diseases are not only a major impact on the health of the human body and the quality of life of people, but also the systemic diseases (such as gastropathy, diseases, etc.) caused by the oral diseases, and the psychological problems that it may cause are far-reaching. The third oral health epidemiological survey of the country shows that the prevalence of oral diseases in our country is as high as 97.6%, and almost everyone has more or less oral problems, while the rate of treatment is less than 10%. Palpation, there is also pain relief to discontinue treatment and severe pain to select the current status of the medical service A. Due to the incomplete treatment of the teeth, the damage can not be repaired by a certain amount of time, and can only be pulled out. In addition, the average loss of 11 of the old people over the age of 65 in China is far lower than that of the "8020" developed by the World Health Organization (20 and more healthy permanent teeth of the 80-year-old man). The treatment cost of oral diseases is very high, and is listed in all the diseases. The treatment cost of oral diseases in China is mainly covered by the cost-of-pocket and social-medical insurance benefits, and the range and type of oral diseases guaranteed by social medical insurance are very few, only endodontic disease, periapical-root canal treatment (killing nerve), periodontitis _ periodontal basis Treatment of four parts, such as the treatment of tooth extraction (tooth extraction), and the treatment of four parts, which can be partially compensated The commercial oral insurance of our country has just started, and at the stage of the test, only two of the two oral insurance products have only highlighted several simple routine dental care, but have not compensated the economic loss after the risk of the oral disease, from the definition of the insurance On the other hand, it doesn't belong to the real meaning of the disease. The research shows that the medical expense payment method is the most important reason which affects the choice of the oral health care service in the patients with oral diseases, and the people with higher medical security system The probability of the diagnosis is high. So how to reduce the burden of the patient better and to set up effective oral medical expenses Where is the safeguard mechanism? The developed commercial oral insurance model developed by the developed countries has provided a good compensation for the patients in the country We can also put forward such a question: Can we use the way of commercial insurance to solve the medical expenses of patients with oral diseases in our country with benefits? Is the form of a commercial oral insurance necessary, Is it possible? If necessary and feasible, what problems will be encountered at the beginning of the establishment, and How to develop? So, in this context, the author has started this article. Thinking and exploration. The first chapter of this paper is the research The definition of the object is defined. The concept of the oral insurance and the commercial oral insurance is analyzed, and a few related research and the use of the more confused term definition are given. Self-understanding and conclusions. Chapter II, Oral and health care Service and expense guarantee mechanism. From the angle of common diagnosis and treatment project and cost of stomatology department, to sort out the types and characteristics of oral diseases, to analyze the causes of high prevalence of oral diseases and low treatment rate in our country, and to conclude that the cost payment method is the influence of medical and health service. The conclusion of the important factors used, and then the establishment of the oral cavity medical expense guarantee machine in the way of commercial oral insurance The necessity and feasibility of the system. Chapter 3, the foreign oral cavity The present situation and experience of the insurance development can be used for reference. First of all, the three kinds of oral insurance models which are common in the world are first combed, the commercial oral insurance mode represented by the United States, the public dental health mode represented by the Netherlands, and the Japan are the This paper mainly introduces the American oral insurance model, from the development course to the oral insurance management type medical HMO mode and the PPO pattern, the main oral insurance provider in the United States, and gives the enlightenment to our country: the social oral (medical) protection The insurance can only play a basic guarantee, and the commercial oral insurance can be used as a strong supplement to the basic medical insurance of the oral cavity, so that the medical insurance coverage of the social oral (medical) insurance is not covered by the flexible and diversified insurance items, the insurance level, the method of the insurance, and the like. According to the intention of the insured, the individual can design different insurance contracts according to the individual's will, even the payment of the medical accident, which fills the current society Blank for oral (medical) insurance. Chapter IV, Chinese The present situation and existing problems of oral insurance in the industry are introduced. First, the oral insurance products in the initial stage of water trial are introduced. The two dental health insurance products, the dental management medical insurance products of the people's insurance company, the dental medical insurance and the safe and additional accidental dental and health-care medical insurance of the safety insurance company, are currently few varieties and can not be supported by the policy, needs big but not yet converted into the effective demand, only aiming at the problems of the high-end market and the like, and the imperfect related policy and regulation environment, the environment of the oral hygiene service, the credit ring, The situation needs to be improved, the supply and demand problems, the mouth in chap 5, The development of the specific strategy of the commercial oral insurance in our country. First of all, to our country The development of the oral insurance system is conceived. The traditional oral diseases project and the preventive health-care daily inspection class are put into the group insurance for different diseases according to different disease types, and the oral innovation class is put into a risk, and the management type medical device and the mouth are used. The information networking is carried out in the cavity medical institution (the dental clinic, the oral hospital, the comprehensive hospital stomatology department), and the health management level is set up in step by step. Taiwan, to build an attractive health-care cooperation framework. The relevant supporting policies and the problems that can be in-depth study will be discussed. Then, the supporting policies of the relevant departments of the state and the medical institutions will be introduced. At the end of this chapter, the social medical insurance of our country is currently against the oral diseases. Supplementary information on the condition of the disease and the diagnosis and treatment of the project. Overall, This article may have the following features and possible innovations. First, the concept of oral insurance and commercial oral insurance is first combed, with a few related research and use in the country In the second part, the mechanism of the payment for oral diseases is analyzed, and the feasibility and necessity of the cost of the oral diseases are analyzed and demonstrated from the commercial oral insurance. In the background of developing a market economy in our country, it is suggested that more effective market mechanism _ commercial protection can be used to determine the scope and boundary of social insurance for oral diseases. The third, the distinction between the social and oral insurance and the commercial oral insurance, the scope of the responsibility and the guarantee and how to operate, the integration and the The paper does not discuss the problem of the superior and inferior of the social oral insurance and the commercial oral insurance, and emphasizes the integration, inlaying and reasonable boundary establishment. The author holds that the two safeguard mechanisms are not the same, but should be complementary. It is only based on the background of knowledge, and the choice of cut-in angle makes the author more and more analyze the problem from the perspective of business, and in this article the most important The fourth part, on the future development strategy of the commercial oral insurance, expounds a lot of concrete measures from the development of the government policy, the development of the oral medical institution and the operation of the commercial insurance company. The idea and the way of thinking, I hope to be able to study the later researchers, real
【学位授予单位】：西南财经大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：F842.684
【引证文献】
相关期刊论文 前3条
1 颜子琪;;目前我国口腔保险的不足与优化建议[J];现代商贸工业;2018年33期
2 南东旭;陶红兵;张汝柠;;基于我国社区口腔健康需求的公立口腔专科医院营销策略分析[J];医学与社会;2016年01期
3 陈稳;张艳艳;姜京徽;张静娴;单学鹏;瞿星;华成舸;;成都市儿童口腔医疗保险影响因素研究[J];华西口腔医学杂志;2015年06期
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