Insurance Blog

2007 “reform of the State Council on the Development of the insurance industry views” and the September 1 “Health insurance management approach” for the insurance sector with the introduction of the medical community to provide a close co-operation policy and opportunities. Health insurance industry in the provision of medical insurance, disability income insurance, health care and insurance business as well as in other three carried out by life insurance companies with a major illness insurance, we all need to understand the health status of the insured determine the insurance and medical medical inseparable relationship.
1. In Western developed countries, health insurance and medical co-operation created organic top international health insurance companies.
1.1 The United States Aetna Group is the world’s leading health insurance companies, has more than 150 years of history, in 2005 premium income more than 22 billion U.S. dollars. Customer service groups and individuals to reach 28.3 million policyholders, medical network covers all 50 states, 74 million professional medical personnel. With the world’s major regions more than 7 million medical professionals have signed a long-term service contracts.
Aetna health insurance companies independent model, with the provision of medical services and insurance services, operational capacity of the organic integration of the two operations to effectively promote the value of the entire health care system and improve service. The health insurance industry’s fundamental mission is to continuously improve overall quality and efficiency of health care system, and to maximize the health of optimizing their health insurance policy holders can use their control of large amounts of data to play from the master multi-channel expertise, and drawing and medical systems at all levels (including hospitals, doctors, drugs and medical equipment manufacturers, consumers, employers and government agencies) to exert long-term partnership its unique influence. Insurance companies through the increasingly complex medical science into a series of tangible services to contribute to social harmony as a whole. Specific performance include enhancing the availability of medical resources, improve health care quality and reduce medical costs, and to maintain optimal health status of households. Accordingly, Aetna has developed a series of proprietary technology to improve medical management and expand the network of medical resources, the use of managed care industry in the United States has accumulated rich experience in medical and health optimizing the value of policyholders. Aetna is a walk from the insurance and medical insurance, mutual promotion of the road.
1.2BUPA (English visionary federation) is an international medical and health care, insurance organizations around the world more than 8 million customers and more than 40000 employees worldwide medical insurance and health care services, the Member over the more 190 countries. They are also to go from medical to insurance, health insurance can integrate.
BUPA’s largest and original business is to safeguard the health of individuals or groups of employees commercial medical insurance, BUPA Health Screening Center of the 42 pairs of clients through the whole body examinations, consulting a doctor data analysis to predict disease, the final outcome may be the same day to the customer Feedback disease prevention program of action.
Their health philosophy is to treat forward to prevention. Attaches great importance to physical examination that the examination is the first part of health management, through medical first-hand information, and then carry out health interventions, analyzing physical condition, family situation, work environment, finally arrive at a correct conclusion, and then based on expert opinions health interventions, exercise and dietary conditioning, thereby reducing the incidence of the possibility of the complete set of integrated management of this process is ultimately for the implementation of health management.
2. The insurance agencies and professional health examination institutions
In accordance with the successful experience of international health insurance, insurance, and health care is an integral whole, China due to historical reasons, insurance agencies and medical institutions as an independent operation of all departments, respectively, in two parallel track of development. Health insurance agencies and professional medical organizations say there are two co-general points:
⑴ data collection, health management.
In insurance, insurers need to insured (or insured) undergo a medical examination to confirm the standard body or a body of non-standard body or refused insurance coverage which require professional medical organizations to complete. Professional medical organizations to complete the following benefits. First of all, cost control. The use of direct cooperation with the deeds of their co-operation or outsourcing, not only can enjoy a high standard of medical services, while saving a substantial associated costs. Followed by professional and technical. Run by the existing medical insurance companies, due to costs and conditions when compared with professional medical organizations, there is a considerable gap. Again, risk diversification. Insurance companies and professional medical organizations to achieve bias due to medical underwriting risks caused by the dispersion and transfer. Finally, the position of neutrality. Medical institutions are independent legal entities, are standing on neutral position of the professional examinations for the customer to help customers build the trust and recognition of insurance companies. In the insured after the policy throughout the maintenance, insurance companies and medical institutions, through a medical and health insurance during follow-up by the medical institution issuing health warnings to customers and implementation of health management, insurance companies, to draw customers in time even if early treatment to reduce the medical expenses, and reduce insurance losses.
⑵ develop client resources, case management for clients.
Professional medical organizations large customer resources are an important target audience of insurance companies, but also a potential customer base, the insurance company’s customer base is also a medical institution to serve. More importantly, the examination of health records for the insurance company underwriting the policy to maintain the process to provide professional facilitation.
Physical examination, or the domestic industry, had just developed a new industry, if the achievement of the insurance sector, the implementation of the interests of both sides tied up and establish a resource-sharing partnerships with complementary advantages and will effectively assess the health examination and health management systems advantage, to avoid the huge customer resource and check the data lead to wastage.
3. Managed medical model of health
In August of this year, China Insurance Association and the Chinese Medical Association held in Shanghai, “health management health insurance” forum, the participating experts on how to develop the insurance company’s medical business conducted in-depth exploration of the issue. Tzu Chi Health Examination chain CEO Dr. Han Xiaohong proposed physical model of managed health concern by the delegates.
3.1 The model of managed health examination with reference to managed care model of abroad, from the physical examination of the co-operation with the insurance begins with the agreement reached by both sides, based on the insurance agency will fund and manage patterns of medical institutions, to take funds, shares, property rights the joint venture and cooperation, the interests of bundled together. Physical examination agencies in accordance with the needs of insurance, expanding health care benefits, enhance the medical services and health check service level, to make health insurance and health check these two different sectors in the development of two parallel lines converge together to inject new impetus to the development. Health insurance institutions, medical institutions and the insured to become interdependent whole, for the insured to provide efficient health management services and quality health insurance coverage to safeguard the common interests of three parties to achieve three win-win situation.
3.2 Managed physical examination focused on management, including medical service quality management and the insured group or individual health management.
In general, according to people’s physical and mental health status, social group, usually divided into the health groups, sub-health groups, and the sick (including the sick have been more) groups.
On the above three groups, health information collection, risk assessment and forecasting, health maintenance and health education, other health care institutions are unable to play the role of medical institutions is different from the major hospitals and community hospitals function is that it is in the prevention, treatment, the management of three stages of an objective position.
Such an orientation is adapted to people’s health needs and market demand, but also explained that in recent years, physical examination bodies to the rapid development of important reasons.
3.3 of managed health check based on its quality management system and medical services, control system, the biggest advantage is to effectively circumvent the moral hazard in health insurance and medical risks, can be multiplied by Tam and complete these tasks.
3.3.1 effective to avoid medical risks.
As medical technology, the early detection of cancer, cardiovascular and cerebrovascular disease, early prevention has played an important role, there was a medical authority said that there is no health screening for early diagnosis, much less early treatment. The use of advanced equipment and technology, the body can be hidden disease of early screening, done early detection and early treatment. Medical institutions to play a medical advantages to the scientific management, complete business processes and modern testing equipment to meet the insurance agency insurance the special needs of different levels to effectively hedge their risks.
3.3.2 effective to avoid moral hazard.
Medical institutions to implement a strict medical information management systems to hi-tech management to prevent changes to medical records, to ensure the original data security. Fundamentally put an end to the insurance salesman and medical personnel within the organization the possibility of attempts to change the medical report to ensure the reliability of medical data. Medical institutions to the status of neutrality and impartiality to provide a comprehensive assessment of the health of science, both to protect the interests of the insured, but also to make insurance more standardized management.
3.3.3 Prevention of screening prior to reduce the payment of expenditure.
In medical practice, a number of diseases, early detection, early treatment can cure disease and delay the occurrence and development of the disease. Medical costs can maximize savings, reduce medical costs at the branch. Early prevention is very important, some experts pointed out: 10 myocardial infarction, 9 may be forecast; 6 myocardial infarction, five could have been prevented. “Early prevention, early detection, early treatment” is to reduce the payment key.
3.3.4 three win-win situation. Managed health examination institutions and insurance institutions in close cooperation to create a higher level of people’s health insurance and health management. As the integration of insurance funds, so that physical examination of the equipment and technology can get timely updates, content of services and service quality will have a higher level, has enabled the masses to be more high-quality and effective health examination and health maintenance services. Insurance companies will also co-operation, there is a solid and stable medical institutions provide medical and health management technical support, design more suited to our people a new insurance health management, expanding the scope of insurance services to promote the health insurance industry.
3.4 of managed health check will collect system information, system health assessment and health management as the main service location is different from medical care. Relying on physical examination of professional bodies, to build a health insurance database, the establishment of medical data sharing mechanism. Health insurance data is a commercial health insurance and social health insurance pricing based on specialized commercial health insurance business foundation. In a sense, medical insurance, how much empirical data and data analysis capabilities will be to improve health insurance strength of the core competitiveness of the important content.
To sum up, as China’s health authorities about the promulgation and implementation of “Health care management approach”, health examination institutions to access management era. Insurance Capital of the integration of managed health check operations, will become a new model of cooperation by the market and people’s acceptance, health, medical and health industry consolidation in the insurance industry, showing a win-win situation.