Tudy On Status Of Suzhou Commercial Medical Insurance Participating In Social Medical Insurance And Their Payment And Countermeasure

ObjectiveThrough to the Suzhou some large Business insurance company in recent years the medical insurance products business development data were analyzed, and through to the social medical insurance in Suzhou city in recent years the development status and existing problems are reviewed, analysis of commercial medical insurance in social medical insurance and the prospect of advantage, for the commercial medical insurance in the developing process of the problem for analysis, the study of the commercial medical insurance in the future development of space and how to set up the multi-level medical security system to the greatest degree of complementary role, for the development of commercial medical insurance and improving the medical insurance management efficiency and security level to offer countermeasure proposal.MethodsThis article uses the literature material and special field survey combined with qualitative analysis and other methods, research, combined with the insurance, finance, economics, political science and other disciplines of knowledge, independent thinking and consult with all possible means the combination. Selection of survey market share is29.3%of a large insurance company, the insurance company from January to20112000were collected in December all insured persons hospitalized expense and major diseases claim data to quantitative data, by single factor analysis and multiple factor analysis, related to the benefit side of the interview data according to the theme summarized and analysis.Results1、Suzhou the commercial medical insurance in social medical insurance status. China life, Ping An Life Insurance, Pacific Life for the residents of Suzhou insurance market acceptance before the insurance companies, the market accounted for30.4%,29.3%,14.5%. Commercial medical insurance in the insurance business in the proportion of low. By the end of09, the commercial medical insurance depth of1.9%, insurance density is2342yuan,65786yuan per capita main insurance coverage,45049yuan per capita re-disease risk insurance, medical insurance premium rate of only44.8%, compared with the national average level and Taiwan and other industrialized nations worldwide average is still low.Commercial medical insurance medical expenses increased year by year, the Social Medicare supplement function appears day by day. But the amount is small, narrow range of supplementary. At the same time, medical insurance breed is little, narrow coverge, for infants, children, women and the elderly care health insurance products lack, can not meet people’s multi-level demand for insurance. Residents of the insurance company service satisfaction is not high, especially for medical insurance claims, some insurance companies have pity for, excessive compensation phenomenon2、Payment status: the insured population accident rate increased year by year, but both claim the smaller increase. Accident rate from05years rose from4.3%in2011to5.7%in2010, which claims the number of5189, all the payment amount is846.4yuan only, as a result of the commercial medical insurance follow the " compensation ", the social security as a whole benefit and expense part not pay, so for the social medical insurance role of complement is not outstanding. Social medical insurance for the fixed standard setting "threshold " is slightly higher than the top, above the high medical expense burden the risk is big, the insured person’s medical cost ratio is still high.2000-2011, critical illness insurance are paid no significant growth, just below40000, major disease high risk age45～60years, treatment of high cost, poor prognosis, growth speed, younger patients, residents to participate in critical illness insurance awareness is not strong. At the same time, insurance fraud, moral hazard, adverse selection exists, in2010urban medical insurance light disease hospitalization accounted for more than11.02%,2011young hospitalized accounted for more than27.40%of the hospitals, insurance company risk management strength is low, the insured people s moral risk and converse choice without effective preventive and control measures, the compensation rate year after year rose.3、Sentinel medical services in2010:the insured population hospitalized expense drugs accounted for13.32%,2011self-medication accounted for more than11.30%, the light disease accounted for more than high, in201127.3%, partial area up to46.25%. Medical service market charges, drug abuse, excessive examination and the medicine production and circulation link high price administrative monopoly has been broken, the commercial medical insurance the complementary role of government of new medical reform policy support.Conclusion1、Commercial medical insurance in social medical insurance degree low, face bigger risk in insurance business, design, scope, compensation standards and the need to further optimize.2、Social medical insurance coverage required further extension in deep, benefit standards needs to be further improved, the commercial medical insurance in the involvement of complement in social medical insurance level needed to be further expanded. Should emphasize governmental dominant and market guide pay equal attention to, the building of commercial medical insurance and social medical insurance complement each other, mutual cooperation, common development of the medical insurance model.3、Commercial medical insurance is not associated with hospital, social medical insurance institutions to establish in-depth cooperation mechanism, can effectively control the insurance fraud, lack of medical service supply of the effective restriction mechanism.4、Commercial medical insurance is required in the internal risk control, the insured population health management, the quality of insurance employees, the level of service to further improve.