商业医保合作模式创新与风险管控机制优化浅探

Research on the Co-operation Mode and Risk Control of Commercial Health Insurance

商业医疗保险作为基本医疗保险的补充,在我国新型医疗体制的建构乃至国家完善社会保障体系、改善民生的总体战略中占据重要地位,但由于商业医疗保险的风险控制难度大、专业技术要求高等特点,缺乏有效的风险管控机制一直是制约其发展的重要障碍。本文从医保合作关系这一关键制度环节入手,分析了商业保险公司与医疗机构传统合作模式的弊端,在深入借鉴美国商业医疗保险风险管控经验的基础上,就商业医疗保险合作模式创新,以及优化风险管控机制优化策略进行了探讨。

Commercial health insurance,as a necessary complement to the basic health insurance,is playing an important role in the construction of new health care system and the realization of overall strategy of improving people＇s livelihood.However,for the characteristic of high difficulty in risk control and barriers in professional skills,the lack of effective risk control mechanism is a major constraint to its development.This paper focusing on the cooperation relationship between medical organization and insurance company,analyzes the drawbacks of the traditional mode of cooperation,in depth investigates the experience of risk management in U.S.commercial health insurance,brings forward the innovative cooperation mode between medical and insurance organizations,and the mechanisms and strategies of optimizing the risk control.