社会医疗保险与商业保险合作的模式选择与机制设计

A Study on Mode Selection and Mechanism Design for Cooperation between Social Medical Insurance and Commercial Insurance

本文基于国内典型地区商业保险公司参与社会医疗保险管理的实践探索,对社会医疗保险与商业保险不同合作模式的适应性及特点进行了归纳和比较研究,认为二者合作必须准确定位,不能界限不清、权责不明。提出基本保障之上的大病医疗补充保险应引入市场竞争机制、采取保险合同型运作模式,基本医疗(工伤、生育)保险业务采取服务外包、政府购买服务的运作模式。并以成都市为例,对商业保险公司参与大病医疗互助补充保险管理的运行机制、政府购买基本医疗(工伤、生育)保险服务的运行方案及机制进行了具体设计和探讨。

Based on the practices and experimentation of commercial insurance companies to participate in the so- cial medical insurance administration in typical areas of China, the paper summarized and analyzed the adaptability and characteristics of different cooperation modes between social medical insurance and commercial insurance. The paper held that the cooperation must be based on accurate role positioning and clear defining of responsibilities and obligations. For the supplementary major medical insurance for topping up the basic social medical plan, a market competition mechanism should be introduced and an insurance contract mode of operation should be used;and for the basic social medical insurance （work injury and maternity）, an operation mode of service outsourcing and gov- ernment procurement of services should be applied. Taking Chengdu as an example, the paper discussed the specific design of operating mechanism for commercial insurance companies to participate in supplementary major medical insurance and the government to purchase services for basic social medical insurance （work injury and maternity）.