政府购买医疗保障服务政策下商业健康保险的盈利模式

An Exploration on the Profit Model of Commercial Health Insurance under the System of Government Purchasing Medical Insurance Services

新医改提出政府向商业健康保险公司购买医疗保障管理服务的思路,为私营医疗保险市场的进一步发展提供了政策支持。但医改方案公布后,除人保健康进入这一市场外,其他公司仍举旗观望,提供该类服务的公司寥寥无几。这一困境出现的原因是保险机构对政府购买经办服务政策下,相关产品组合的盈利模式缺乏认识。对可得的有限数据进行分析,期望总结中美市场和提供相应服务保险人的盈利模式。研究发现,这些商业保险公司多以产品组合方式提供多种盈利水平的产品。经办医疗保障服务是产品组合中微利甚至亏损的一种,但这一服务却是扩大其他盈利水平较高的产品销售的基础,人保健康"湛江"和美国安泰两个案例反映提供基本医疗保障经办管理服务可以有效扩大其他产品的销售,提高组合的盈利能力。

The new medical system reform promoted the model of government purchasing medical insurance services from commercial health insurance companies, thus providing more policy support for the private medical insurance market. However,ever since the reform plan was announced,only PICC Health had entered this business,and almost all other insurers adopted a wait-and-see approach. This was mostly due to the insurer＇s dubiousness on the profit model of govemment＇s purchasing their medical insurance services. Therefore, the paper made an analysis of the limited data available, intending to summarize some findings on the profit model of this operation both in China and the United States. It was found out that most commercial insurance companies offered a number of portfolios with different profitability levels. Within their portfolios, medical insurance service was a product with lean profit or even a small loss, but it was often a door-opener for sales of other higher-margin products. The PICC Health Zhan- jiang Model and the case study of Aetna of the United States confirmed that medical insurance services offering could help expand sales of other products and enhance the profitability of the whole portfolio.