October 16th, 2009 
youhan Abroad, the theory and practice of professional experience in health insurance, when introduced into China, there are many concepts (such as managed care, HMO, etc.) that contains the contents of its broader, which filled our understanding of health insurance and health management has been a combination of modes deviation, and even think that health care network management are also part of health management. In fact, the foreign professional health insurance companies in the medical expenses of the control, is two-pronged approach: the first medical provider network or health care management (eg, treatment services and medication review, specific treatment services, pre-authorization system, medical institutions, performance appraisal, etc.), audit unreasonable expenses, through benefit-sharing mechanisms to manage the health care provider behavior; second is the adoption of the above mentioned health management to improve the health status of insured groups, thereby reducing the medical expenses. The so-called health insurance and health management combination, refers to the latter. Of course, with the cooperation of health care providers, you can introduce a certain incentives to demand its insured to provide health management services (such as vaccination, health counseling, etc.). This is evident from expressions of view, is a medical network management and health management into one, but logically, the right health care network management and introduction of health management services to health insurance companies try to control medical costs of two kinds of means, each with of different expertise. From China’s current situation of health insurance companies and medical institutions (in particular, there is a strength, has been widely trusted by people in large medical institutions) of the game process, still vulnerable position, hard to form a community of interests, health insurance companies hoping to Build your own managed health care network is difficult and still very great. In addition, mainstream medical institutions are still concerns treatment of disease, the short-term fear is also too busy to help the company to provide further health management services. Thus, the domestic health insurance companies are mainly through independent third-party health management companies, to outsource services-based, self-built service, supplemented by way of providing health management services to clients. Services have a health consultation, health check, health assessment, appointment register and lifestyle management. However, on the one hand because the domestic health management services industry is still in its infancy, effective health management services, supply capacity is not enough; the other hand, the health insurance industry is still in its infancy, how to integrate health management services to the insurance risk control process has not yet matured into the model. Therefore, health insurance and health management of the combined form still rudimentary, health management services, primarily for the exhibition industry, the marketing tool of risk control for the role of medical expenses is not yet obvious, and difficult to account for health benefits management services.
Principles Health insurance companies in recent years on how to integrate the field of health management services, has done a lot of exploration and practice, many of whom are successful experiences, but also into the off errors in the development review process, it seems a few basic principles can be summarized, as health insurance companies the choice to carry out health management services guidelines. (A) based on the principle of insurance, the main industry. Health management technology and services to a variety of ways, but as a health insurance company in the selection of external services, integration of resources, or build their own service project, the insurance must be based on the primary industry itself, that is carried out by health management services must contribute to the development insurance business, controlling expenses paid and avoid vague position, in order to make health management and health management to do, so that the health management and health insurance, made of two separate business areas, there is no point of integration has become a "Liangzhang Pi." (B) the costs and benefits of matching principle. The field of professional health insurance companies is limited because of operational and business risk management and control is difficult, and generally in the "survival" of the early days, the financial pressure significantly. In the cost of extremely tense situation, carrying out health management services to more costs and benefits should adhere to the principle of matching. Some health management services appears to be simple, but if large-scale implementation, the actual cost of the necessary human and material resources are not small. In order to build customer health record, for example, due to various hospitals, medical institutions of medical reporting formats vary, it is difficult to achieve a direct exchange of data that, if carried out in all insurance customers this service, only the medical reports and review input links artificial workload is high, but the services can bring benefits (for example, to enhance customer satisfaction, lower paid, etc.) is difficult and cost-match. (C) service differentiation principle. Health Management Services supply and the supply of any product, should be aimed at different target customer base while differentiation. Health insurance companies to provide health management services, have to combine the characteristics of insurance business further subdivided. For example, chronic disease management is to maintain health and control health care expenses in an effective way, but for insurance companies is precisely the population suffering from chronic diseases is a high-risk customers. In underwriting a risk the autonomy of the higher channels, should be part of the underwriting risk to be screened (eg, fees, exemptions or exclusions, etc.), rather than underwriting and then passively through the implementation of chronic disease management to risk control. However, in the field of social security supplementary services, insurance groups can not be selected at this time according to past payment history of chronic disease groups chosen to carry out targeted chronic disease management, you can play a lower paid role.
Model proposed According to these principles, combined with the current health insurance, internal and external environment, or from several fields to promote health insurance and health management model of a combination of practice: (A) the social security supplementary services for customers in specific diseases of chronic disease management services. As noted above, such operations can not be selected underwriting group, so through effective health education, health tips, behavioral interventions, such as a set of chronic disease management services, on the one hand can help to control medical expenses, and to show the professional health insurance companies, risk control capability, on the other, can improve patient satisfaction, and thus promote the social security sector partnerships will be of such business relationships based maintenance mode gradually evolved as a professional health management technology-based maintenance model, further enhance the stability of such operations to achieve the patient’s health was improving, the social security sector must enhance the reputation, business insurance profits may have to raise the win-win situation. In addition, because the cost of carrying out the service and availability of the direct benefits (ie, the amount paid reduced rate) are measurable, so we can clearly calculate the input-output ratio of this service. (B) For a small minority of customers throughout health records management services. The health of the file mentioned here is not simply input the medical report, but around the customer life cycle, through his physical examination, Chuxian claims, health consultation, the health of the whole process of information gathering, and thus the formation of health records, and thus produce targeted Report of health assessment and health recommendations for improvement. Clients can be purchased to ensure renewal of the high medical expenses-type, high pay period of heavy disease type, or a high period of the investment products paid customers. The company may take an annual medical examination services, presented the way, year after year to collect information on the health status of clients, and through health assessment and health promotion programs and other value-added services to increase customer satisfaction, thereby enhancing customer stickiness. In the meantime, the former two types of customers, the company has real-time control over their health status changes in the trend of enhanced ability to control the risk of payment. In addition, countries are promoting the building of universal health records work, ahead of companies such operations carried out for the relevant government departments can also provide good advice and suggestions. (C) for the public health consulting services. Channels such as through the company’s Web site to the public transmitted diseases, medication, health management, and treatment recommendation of such knowledge and information, both play a role in education, consulting, but also can improve the company’s professional brand image. Health management services for more than three, respectively, from the medical cost control, customer experience improvement, upgrading the company’s brand with the three health insurance to do the binding, and without the need to mobilize a lot of medical resources, from the current industry, internal and external environment is concerned, should be more feasible to attempt the direction.
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