發(fā)布時(shí)間：2018-04-18 12:05

  本文選題：健康保險(xiǎn)產(chǎn)業(yè)鏈 + 產(chǎn)業(yè)鏈延伸��； 參考：《西南財(cái)經(jīng)大學(xué)》2014年碩士論文

【摘要】：進(jìn)入21世紀(jì)以來(lái),我國(guó)商業(yè)健康保險(xiǎn)業(yè)務(wù)經(jīng)歷了高速的發(fā)展。在本世紀(jì)前13年中,健康保險(xiǎn)業(yè)務(wù)初年度保費(fèi)已經(jīng)增長(zhǎng)了18倍多；截至2013年,健康保險(xiǎn)保費(fèi)收入突破1000億元大關(guān)。同時(shí),我國(guó)的保險(xiǎn)密度不斷提高,每人健康保險(xiǎn)的支出由2006年的29元人民幣增長(zhǎng)至如今的83元人民幣,增長(zhǎng)幅度為300%。從保險(xiǎn)密度的提高可以看出我國(guó)民眾的健康保障意識(shí)正不斷增強(qiáng)。據(jù)有關(guān)部門(mén)在我國(guó)50個(gè)大中城市的統(tǒng)計(jì)結(jié)果顯示,民眾對(duì)健康保險(xiǎn)有需求的比例高達(dá)77%。由此可見(jiàn),經(jīng)濟(jì)高速增長(zhǎng)、醫(yī)療費(fèi)用居高不下以及健康知識(shí)的普及都直接或間接地提高了民眾對(duì)健康風(fēng)險(xiǎn)的關(guān)注。與此同時(shí),為了促進(jìn)健康保險(xiǎn)業(yè)務(wù)的快速增長(zhǎng),相關(guān)監(jiān)管部門(mén)頒布了一系列法律條文。2003年保監(jiān)會(huì)頒布了《關(guān)于加強(qiáng)健康保險(xiǎn)發(fā)展的指導(dǎo)意見(jiàn)》,以文件形式鼓勵(lì)成立專(zhuān)業(yè)化的健康保險(xiǎn)公司,推進(jìn)我國(guó)健康保險(xiǎn)的專(zhuān)業(yè)化經(jīng)營(yíng)。2006年國(guó)務(wù)院下發(fā)“國(guó)十條”,從總體上肯定了保險(xiǎn)業(yè)對(duì)于國(guó)家經(jīng)濟(jì)建設(shè)的重要作用,并具體對(duì)健康保險(xiǎn)在內(nèi)的各個(gè)險(xiǎn)種今后的發(fā)展作了定位。2009年國(guó)務(wù)院再次頒布了《關(guān)于深化醫(yī)藥衛(wèi)生體制改革的意見(jiàn)》和《醫(yī)藥衛(wèi)生體制改革近期重點(diǎn)實(shí)施方案(2009年～2011年)》,不僅重申了商業(yè)健康保險(xiǎn)對(duì)社會(huì)保險(xiǎn)的補(bǔ)充作用,而且鼓勵(lì)政府以服務(wù)購(gòu)買(mǎi)的方式向商業(yè)健康保險(xiǎn)公司購(gòu)買(mǎi)保險(xiǎn)服務(wù),實(shí)現(xiàn)政府保障計(jì)劃的外包。 當(dāng)然,在看到我國(guó)商業(yè)健康保險(xiǎn)高速發(fā)展的同時(shí),也應(yīng)注意到在其發(fā)展過(guò)程中存在的一些問(wèn)題與障礙。從1990年到2009年,我國(guó)醫(yī)療費(fèi)用支出的年均復(fù)合增長(zhǎng)率達(dá)到了19%,同時(shí)城鎮(zhèn)醫(yī)療費(fèi)用支出由25.7元增長(zhǎng)至856.4元,增長(zhǎng)了近34倍。在如此迅速的增長(zhǎng)背后隱藏的是巨大的醫(yī)療費(fèi)用風(fēng)險(xiǎn)。特別是在癌癥、心血管疾病等重疾高發(fā)的今天,因病致貧、因病返貧的事件屢見(jiàn)不鮮。同時(shí),我國(guó)醫(yī)療資源也十分短缺,每萬(wàn)人所擁有的醫(yī)生數(shù)量?jī)H為14名,比率為0.14%；同時(shí)每萬(wàn)人擁有床位22張,世界排名百位開(kāi)外。緊缺的衛(wèi)生資源導(dǎo)致了醫(yī)療質(zhì)量不高、醫(yī)療費(fèi)用居高不下以及醫(yī)療機(jī)構(gòu)的尋租行為。對(duì)于商業(yè)健康保險(xiǎn)公司來(lái)說(shuō),理賠效率低、理賠支出高和醫(yī)療費(fèi)用風(fēng)險(xiǎn)管控難都是擺在其面前的難題。根源上,這些問(wèn)題來(lái)源于健康保險(xiǎn)公司粗放的經(jīng)營(yíng)模式和委托代理關(guān)系中的弱勢(shì)地位。首先,當(dāng)前我國(guó)健康保險(xiǎn)的銷(xiāo)售普遍采用的是壽險(xiǎn)附加的方式,也就是通過(guò)在壽險(xiǎn)主險(xiǎn)的保單中附加健康保險(xiǎn),憑借壽險(xiǎn)的營(yíng)銷(xiāo)渠道來(lái)銷(xiāo)售健康保險(xiǎn)并將健康保險(xiǎn)作為壽險(xiǎn)銷(xiāo)售的噱頭。在這種模式下,直接造成了我國(guó)健康保險(xiǎn)銷(xiāo)售模式單一,經(jīng)營(yíng)專(zhuān)業(yè)化程度低以及對(duì)人身險(xiǎn)的依賴(lài)性強(qiáng)等問(wèn)題。除此之外,由于商業(yè)健康保險(xiǎn)公司的市場(chǎng)影響力與客戶(hù)資源等方面的弱勢(shì)地位使得其在與醫(yī)療機(jī)構(gòu)的合作中對(duì)醫(yī)療機(jī)構(gòu)費(fèi)用支出的控制力不強(qiáng),而且醫(yī)保之間信息的不透明更是催生了醫(yī)療機(jī)構(gòu)道德風(fēng)險(xiǎn)的發(fā)生。因此,構(gòu)建健康保險(xiǎn)產(chǎn)業(yè)鏈有助于實(shí)現(xiàn)商業(yè)健康保險(xiǎn)公司的科學(xué)化、專(zhuān)業(yè)化運(yùn)作,提升業(yè)務(wù)品質(zhì),推動(dòng)健康保險(xiǎn)市場(chǎng)的可持續(xù)發(fā)展。 本文先從我國(guó)商業(yè)健康保險(xiǎn)的現(xiàn)狀著手,通過(guò)與美國(guó)管理式醫(yī)療的發(fā)展經(jīng)驗(yàn)相對(duì)比,找出我國(guó)在發(fā)展健康保險(xiǎn)產(chǎn)業(yè)中存在的不足,并提出符合我國(guó)國(guó)情的產(chǎn)業(yè)鏈延伸方法。接著,針對(duì)以上分析中所沒(méi)有涉及的主體間的利益分歧,本文采用博弈論的方式進(jìn)行深入研究,最終綜合以上分析的結(jié)果提出有參考價(jià)值的發(fā)展策略。 導(dǎo)論章節(jié)主要對(duì)本文的研究背景和意義、研究目的和內(nèi)容、研究思路和方法以及文獻(xiàn)綜述做了詳細(xì)的闡述。在此之外,本文的論述結(jié)構(gòu)主要分為五個(gè)部分： 第一部分主要概述我國(guó)健康保險(xiǎn)產(chǎn)業(yè)的發(fā)展情況。在本部分的論述中,將會(huì)從健康保險(xiǎn)的市場(chǎng)規(guī)模、健康保險(xiǎn)業(yè)務(wù)的經(jīng)營(yíng)模式、健康保險(xiǎn)產(chǎn)業(yè)鏈的技術(shù)水平以及健康保險(xiǎn)產(chǎn)業(yè)的政策環(huán)境這四方面做具體的介紹,同時(shí)借助相關(guān)產(chǎn)業(yè)數(shù)據(jù)來(lái)分析產(chǎn)生這些問(wèn)題的根源。 第二部分是對(duì)美國(guó)商業(yè)健康保險(xiǎn)產(chǎn)業(yè)成功經(jīng)驗(yàn)的介紹和借鑒。在概述美國(guó)健康保險(xiǎn)業(yè)務(wù)的基礎(chǔ)上,分析美國(guó)管理式醫(yī)療發(fā)展健康保險(xiǎn)產(chǎn)業(yè)鏈的經(jīng)驗(yàn),最后通過(guò)與我國(guó)的現(xiàn)狀相對(duì)比得出符合我國(guó)國(guó)情的產(chǎn)業(yè)鏈延伸建議。 第三部分運(yùn)用博弈理論分析我國(guó)健康保險(xiǎn)產(chǎn)業(yè)鏈延伸過(guò)程中存在的問(wèn)題與困境,主要分析了醫(yī)患的不誠(chéng)實(shí)行為和保險(xiǎn)公司對(duì)醫(yī)療機(jī)構(gòu)進(jìn)行監(jiān)管的過(guò)程中所遇到的難題。通過(guò)論述說(shuō)明想要解決以上困境,必須采取適合的產(chǎn)業(yè)鏈延伸策略,以產(chǎn)業(yè)鏈帶動(dòng)健康保險(xiǎn)經(jīng)營(yíng)模式的升級(jí),增強(qiáng)保險(xiǎn)公司的醫(yī)療支出控制能力。 第四部分基于博弈論的視角分別論述了保險(xiǎn)公司與同業(yè)、醫(yī)療機(jī)構(gòu)間的利益博弈,借助博弈模型的推導(dǎo)結(jié)果同時(shí)聯(lián)系我國(guó)健康保險(xiǎn)市場(chǎng)的實(shí)際情況,提出具有建設(shè)價(jià)值的參考意見(jiàn),從產(chǎn)業(yè)鏈主體層面對(duì)上文比較分析法得出的結(jié)果進(jìn)行補(bǔ)充。 第五部分,我國(guó)健康保險(xiǎn)產(chǎn)業(yè)鏈的延伸策略。本部分是論文的重點(diǎn)章節(jié),首先從保險(xiǎn)公司與參保人、同業(yè)者、醫(yī)療機(jī)構(gòu)、藥品供應(yīng)商和政府部門(mén)這五方面主體入手,對(duì)我國(guó)健康保險(xiǎn)產(chǎn)業(yè)鏈主體關(guān)系的協(xié)調(diào)提出有參考價(jià)值的建議；隨后針對(duì)我國(guó)健康保險(xiǎn)產(chǎn)業(yè)的環(huán)境創(chuàng)建提出在人才培養(yǎng)、信息系統(tǒng)建設(shè)和政策環(huán)境三方面的改進(jìn)方法；最后本人在產(chǎn)業(yè)鏈合同設(shè)計(jì)上提出了一些自已的觀點(diǎn)。 本文雖然針對(duì)美國(guó)管理式醫(yī)療進(jìn)行了系統(tǒng)的分析與討論,但鑒于數(shù)據(jù)獲取方面的限制,個(gè)別地方說(shuō)服力顯得略有不足。文章在前人的基礎(chǔ)上有如下的創(chuàng)新： 首先,本文創(chuàng)新性地采用了博弈論的方式來(lái)分析健康保險(xiǎn)產(chǎn)業(yè)鏈中不同主體存在的利益分歧,為大家提供一種新的分析方式與視角。同時(shí),本文較為系統(tǒng)地論述了美國(guó)管理式醫(yī)療的產(chǎn)業(yè)鏈延伸方式,為今后相關(guān)研究提供參考。
[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 .

【學(xué)位授予單位】：西南財(cái)經(jīng)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：F842.684

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