How does commercial insurance connect with basic medical insurance?Former officials of the National Medical Insurance Administration suggested four major directions

The 21st Century Business Herald reporter Zhu Ping reported that "discuss the connection between medical insurance and commercial insurance, and do not discuss the problem of benefits. In addition to the connection with basic medical insurance on commercial insurance, commercial insurance must be The service information and medical insurance management four aspects are connected. "Recently, at the Fifth International Health Financial Summit Forum at the Fifth International Health Financial Summit, the former director of the Medical Insurance Service Management Department of the National Medical Insurance Bureau, Xiong Xianjun, pointed out Essence

In Xiong Xianjun's view, making money is a basic characteristic of commercial insurance, which is one of the main differences from medical insurance. At the same time, although many commercial insurance and commercial insurance companies are nationwide, due to the existence of multiple companies existing , Can only cover some areas and some people, and Commercial Insurance is competing with each other. In the status of the Chinese medical insurance system, commercial insurance is always supplementary in China. The main responsibility.

Making money is the basic feature of commercial security

Xiong Xianjun pointed out that the classification of commercial insurance is based on the relationship between basic medical insurance.

Among them, one is independent insurance, which has nothing to do with basic medical insurance. These products are quite a lot, including some fixed payment insurance insurance. As long as it meets the scope of commercial insurance protection, no matter if you enjoy the medical insurance compensation, how much money is paid at one time, this is also this is also Most commercial insurance companies launched a method of major illness insurance.

Secondly, the cost of medical expenses is in line with the costs incurred by the patients of a commercial insurance company, and commercial insurance will be paid in accordance with the full or according to the proportion. These patients do not enjoy basic medical insurance. For example, these specific high -end people's commercial insurance; the other category, the commercial insurance connected to the basic medical insurance is divided into tight and non -tight types.

The close -up commercial insurance is a medical expenses incurred in patients within the scope of basic medical insurance. After the personal burden of personal affords and major illness insurance is paid, commercial medical insurance is paid in proportion. Its scope and basic medical insurance are exactly the same. Foreign capital Most of the supplementary commercial medical insurance purchased by enterprises belongs to this type.

Another kind of non -tight type, which is also a type of commercial insurance at present. After the patients with medical expenses occur with basic medical insurance and medical insurance payment of medical expenses, the patient pays for its own payment part, including the personal payment part of the basic medical insurance, or or not. It belongs to the basic medical insurance, but it is a project that is identified by commercial insurance. Its personal payment part can be paid by commercial insurance in proportion. This is currently an inclusive commercial insurance that is pushed by various places. Most of them belong to this non -close commercial insurance.

Xiong Xianjun pointed out that it emphasizes the positioning of commercial insurance companies in the medical security system, but its status is already clear, which is part of the Chinese medical security system system.

At the same time, Xiong Xianjun pointed out that as a commercial insurance company, the following characteristics must be possessed:

First, it must be profitable. This is a basic feature of commercial insurance. This is also the most important difference from basic medical insurance.

Second, although many commercial insurance and commercial insurance companies are all nationwide, due to the existence of multiple companies, commercial insurance can only cover some areas and people in part, covering less than 99%. It can cover a city and can only cover cities A and B, but it cannot be nationwide.

Third, commercial insurance companies are competing with each other, unlike social insurance without any competition. Competition will bring price competition, guarantee scope competition, product quality competition, etc. The results of competition fail, with withdrawal, and winning can survive. This is also its characteristic.

In addition, its status in the Chinese medical insurance system has always been supplemented in China, and it cannot bear the main responsibility of solving the burden of medical expenses of the Chinese people's medical expenses.

"When there are many studies, many experts talk about commercial insurance data, it is often used to compare with the development of American commercial insurance companies. This is wrong. We cannot be like the United States, because the United States is a solution for commercial insurance as the main body. For most American people's medical expenses, 90%of our medical expenses are resolved by its social insurance. It can bear the main responsibility of solving the medical expenses of Chinese people. It can only be basic medical insurance. Insurance, many scholars compare Chinese data with some of the United States when writing articles. This is inappropriate. "Xiong Xianjun pointed out.

Commercial security must make a good choice

At present, the National Medical Insurance Bureau not only must establish a Chinese medical security system, but also incorporates the price management function of pharmaceutical service price management. Because the price is the prerequisite for the expense of medical expenses, if the price is not good, the price is not controlled, and it cannot provide the masses with better medical protection.

To this end, Xiong Xianjun believes that the connection with the price of pharmaceutical services is very important. "Including basic medical insurance, medical insurance, and commercial insurance are all medical expenses, and they are also buyers. Therefore, we should form a relationship with medical services in the medical service market. The motivation to reduce the price of medical services. "

Because commercial security companies are decentralized, the right to speak for pharmaceutical prices in the pharmaceutical market is not great. For example, the current benefit of the people in various places, basically how much price of pharmaceutical companies sell, how much price is to accept. Therefore In this case, insurance is difficult to obtain more reasonable medical prices, so commercial insurance must rely on basic medical insurance to talk about the price of prices, talk about the price with medical service providers, to obtain reasonable medical prices; in terms of price issues, commercial insurance, commercial insurance The company is a purchaser as a pharmaceutical service. Xiong Xianjun believes that the important characteristics of products incorporated into the field of basic medical insurance include, clinically necessary, and long -term (lifelong) use and expensive price, such as enzyme substitution preparations for rare diseases, immune regulation preparations for long -term chronic diseases. The price of these products must be united through basic medical insurance and commercial insurance, and conduct price negotiations with medical service providers in order to obtain reasonable prices, and commercial insurance can be included in it.

"Otherwise, these companies always think that commercial insurance companies have incorporated their products into commercial insurance protection, and they will no longer be included in basic medical insurance. In this way, the price cannot be reduced. It belongs to the basic medical insurance, because it is expensive and cannot be reduced, but the commercial insurance company does not have a good mechanism to negotiate with the enterprise. Only basic medical insurance has. When the price is reduced, the cost of medical care is relatively low. "Xiong Xianjun said.

At the same time, Xiong Xianjun used a pharmaceutical company for the treatment of SMA as an example. It was said that the drug was 700,000 yuan before the medical insurance, and the price was 2.1 million yuan a year. The price was very high. They saw that the 700,000 yuan of commercial insurance companies could be included in, and they would not talk to basic medical insurance at all. At that time, many commercial insurance companies were not included. Last year, 33,000 yuan was set up after the basic medical insurance negotiations, only 100,000 yuan a year. "Therefore, when commercial insurance companies are connected with medical prices, it must be very different from whether this variety should be basic medical insurance. It is indeed because the price is expensive. The medicine is included in the commercial insurance at will. "

In the management of pharmaceutical service projects, Xiong Xianjun believes that the close commercial insurance should be consistent. For non -tight medical insurance, it is highly cautious when choosing a project that is not in the scope of basic medical insurance security; Insurance, it is necessary to be cautious in the management of medical service projects. Commercial insurance needs to be profitable for a long time. Not only must they control the risk of disease, but also the risk of the occurrence can be eliminated in the short term. It is those long -term high cost risks.

Xiong Xianjun said, "If you treat rare diseases, you need to take medication for life. I don't think it can be included in commercial insurance. If you include these things into commercial insurance, reimburse according to proportion, but it is not basic medical insurance. The price is more expensive and the price is relatively expensive. The annual cost of millions, the patient's personal burden is still very heavy, and these risks will be accumulated for a long time. It cannot eliminate these risks in the short term, so this also makes commercial insurance unable to continue to carry out these projects. Assure."

However, Xiong Xianjun believes that for some short-term use prices, such as CAR-T the treatment of cancer, tumor risk is 3 to 5 years, and the risk can be eliminated in the short term.

For the high cost, and the long -term use of varieties, especially Huimin insurance, the risk accumulation will increase every year, but it is impossible to ensure that Huimin Insurance has a healthy person to come in every year. Insurance, people who have risky risks are up every year, and they especially emphasize a special emphasis when they are promoting the government insurance: they are also guaranteed by these risks. In response, Xiong Xianjun reminded that for the past costs Can it be eliminated in the short term? If it cannot be eliminated in the short term, these projects cannot be guaranteed if they exist for a long time.

Personal data needs desensitivity

Xiong Xianjun believes that Commercial Security also needs to connect with medical service information. But in fact, it is difficult to comprehensively grasp the medical service information.

At present, the information of medical service patients is basically scattered in various medical institutions, and the health department is engaged in integration and unity. Xiong Xianjun said that there is no big data available now. Basic medical insurance unifies the national medical insurance information system, and he can get the medical service items, costs, and price information enjoyed by the patient in the medical institution, but there is still a lot of information in the national medical insurance system, including Patient's condition, diagnosis and treatment process, examination and examination results, etc. However, the national unified medical insurance information system can get some information about patients enjoying services in medical institutions.

Although commercial insurance companies also have a lot of information, because they are developed by themselves, the standards are different, and they must also face the privacy protection of patients. Big data.

For basic medical insurance, it belongs to the privacy protection of patients. This data must be shared with commercial insurance. It must be disclosed after the patient's personal information and the desensitization of the medical service information that occurred. This is given by the patient's privacy protection rights. right. Therefore, based on these desensitization information, it is impossible for commercial insurance companies to provide personal health management product services for personal risk screening. "Commercial Insurance Company hopes that we can develop some personal health management products. Some technologies for personal risk screening can pass the information of basic medical insurance. But this contradiction will never be solved, because basic medical insurance cannot be desertensive. Just give this information. "Xiong Xianjun pointed out.

In the above forum, Xiong Xianjun repeatedly emphasized that the sharing of basic medical insurance and commercial insurance information must be the data of the patient's personal information and medical service information. Insurance company.

"Can the Medical Insurance Bureau and the China Banking Regulatory Commission establish a platform for medical insurance data sharing, so that various commercial insurance companies and research institutions can apply these desensitized medical service information as much as possible. Although it is desensitized, I think that information is very very available for commercial insurance companies. For value, we must establish a desensitization platform so that both commercial security companies and research institutions can use this information, "Xiong Xianjun pointed out.

When it comes to the connection with the service of the medical insurance agency, Xiong Xianjun believes that it depends on whether the medical insurance service service can be uniform management and uniformly provide the service service, which can enable patients and pharmaceutical institutions to serve one -stop services.

"When we used to do serious illness insurance, we explored office with commercial medical institutions, but the Hui Minzi insurance pushed by commercial insurance companies was connected with basic medical insurance. The cost of settlement is very good, so I think whether the basic medical insurance and commercial insurance personnel can work together. In the government public platform, there is a comprehensive window. The business is handled in the background, allowing ordinary people to run once and complete all the expenses. Target the compliance and rationality of medical services to avoid a medical expenses, and the audit of multiple institutions will be reviewed to reduce the interference in the work of pharmaceutical institutions. Insurers cannot participate in the audit of basic medical insurance for medical institutions, and reduce unnecessary expenditures of commercial insurance. Promote the settlement of DRG and DIPs of medical institutions, and strengthen commercial insurance as a payment party's positioning of medical service providers in terms of cost control.

Xiong Xianjun emphasized that it is necessary to do a good job of designing the background business process. Through the information system of basic medical insurance, one -time settlement of basic medical insurance, major illness insurance, medical assistance, and commercial insurance should be paid and the cost of personal burden. Since the commercial insurance is part of the Chinese medical security system, the current commercial insurance cannot be politics. First of all, the commercial insurance company should be united in some basic ideas. Medical insurance has a good connection on medical service project management, information management, especially price management and service management.

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