本文選題：健康保險產(chǎn)業(yè)鏈 + 產(chǎn)業(yè)鏈延伸��； 參考：《西南財經(jīng)大學》2014年碩士論文

【摘要】：進入21世紀以來,我國商業(yè)健康保險業(yè)務經(jīng)歷了高速的發(fā)展。在本世紀前13年中,健康保險業(yè)務初年度保費已經(jīng)增長了18倍多；截至2013年,健康保險保費收入突破1000億元大關。同時,我國的保險密度不斷提高,每人健康保險的支出由2006年的29元人民幣增長至如今的83元人民幣,增長幅度為300%。從保險密度的提高可以看出我國民眾的健康保障意識正不斷增強。據(jù)有關部門在我國50個大中城市的統(tǒng)計結果顯示,民眾對健康保險有需求的比例高達77%。由此可見,經(jīng)濟高速增長、醫(yī)療費用居高不下以及健康知識的普及都直接或間接地提高了民眾對健康風險的關注。與此同時,為了促進健康保險業(yè)務的快速增長,相關監(jiān)管部門頒布了一系列法律條文。2003年保監(jiān)會頒布了《關于加強健康保險發(fā)展的指導意見》,以文件形式鼓勵成立專業(yè)化的健康保險公司,推進我國健康保險的專業(yè)化經(jīng)營。2006年國務院下發(fā)“國十條”,從總體上肯定了保險業(yè)對于國家經(jīng)濟建設的重要作用,并具體對健康保險在內(nèi)的各個險種今后的發(fā)展作了定位。2009年國務院再次頒布了《關于深化醫(yī)藥衛(wèi)生體制改革的意見》和《醫(yī)藥衛(wèi)生體制改革近期重點實施方案(2009年～2011年)》,不僅重申了商業(yè)健康保險對社會保險的補充作用,而且鼓勵政府以服務購買的方式向商業(yè)健康保險公司購買保險服務,實現(xiàn)政府保障計劃的外包。 當然,在看到我國商業(yè)健康保險高速發(fā)展的同時,也應注意到在其發(fā)展過程中存在的一些問題與障礙。從1990年到2009年,我國醫(yī)療費用支出的年均復合增長率達到了19%,同時城鎮(zhèn)醫(yī)療費用支出由25.7元增長至856.4元,增長了近34倍。在如此迅速的增長背后隱藏的是巨大的醫(yī)療費用風險。特別是在癌癥、心血管疾病等重疾高發(fā)的今天,因病致貧、因病返貧的事件屢見不鮮。同時,我國醫(yī)療資源也十分短缺,每萬人所擁有的醫(yī)生數(shù)量僅為14名,比率為0.14%；同時每萬人擁有床位22張,世界排名百位開外。緊缺的衛(wèi)生資源導致了醫(yī)療質(zhì)量不高、醫(yī)療費用居高不下以及醫(yī)療機構的尋租行為。對于商業(yè)健康保險公司來說,理賠效率低、理賠支出高和醫(yī)療費用風險管控難都是擺在其面前的難題。根源上,這些問題來源于健康保險公司粗放的經(jīng)營模式和委托代理關系中的弱勢地位。首先,當前我國健康保險的銷售普遍采用的是壽險附加的方式,也就是通過在壽險主險的保單中附加健康保險,憑借壽險的營銷渠道來銷售健康保險并將健康保險作為壽險銷售的噱頭。在這種模式下,直接造成了我國健康保險銷售模式單一,經(jīng)營專業(yè)化程度低以及對人身險的依賴性強等問題。除此之外,由于商業(yè)健康保險公司的市場影響力與客戶資源等方面的弱勢地位使得其在與醫(yī)療機構的合作中對醫(yī)療機構費用支出的控制力不強,而且醫(yī)保之間信息的不透明更是催生了醫(yī)療機構道德風險的發(fā)生。因此,構建健康保險產(chǎn)業(yè)鏈有助于實現(xiàn)商業(yè)健康保險公司的科學化、專業(yè)化運作,提升業(yè)務品質(zhì),推動健康保險市場的可持續(xù)發(fā)展。 本文先從我國商業(yè)健康保險的現(xiàn)狀著手,通過與美國管理式醫(yī)療的發(fā)展經(jīng)驗相對比,找出我國在發(fā)展健康保險產(chǎn)業(yè)中存在的不足,并提出符合我國國情的產(chǎn)業(yè)鏈延伸方法。接著,針對以上分析中所沒有涉及的主體間的利益分歧,本文采用博弈論的方式進行深入研究,最終綜合以上分析的結果提出有參考價值的發(fā)展策略。 導論章節(jié)主要對本文的研究背景和意義、研究目的和內(nèi)容、研究思路和方法以及文獻綜述做了詳細的闡述。在此之外,本文的論述結構主要分為五個部分： 第一部分主要概述我國健康保險產(chǎn)業(yè)的發(fā)展情況。在本部分的論述中,將會從健康保險的市場規(guī)模、健康保險業(yè)務的經(jīng)營模式、健康保險產(chǎn)業(yè)鏈的技術水平以及健康保險產(chǎn)業(yè)的政策環(huán)境這四方面做具體的介紹,同時借助相關產(chǎn)業(yè)數(shù)據(jù)來分析產(chǎn)生這些問題的根源。 第二部分是對美國商業(yè)健康保險產(chǎn)業(yè)成功經(jīng)驗的介紹和借鑒。在概述美國健康保險業(yè)務的基礎上,分析美國管理式醫(yī)療發(fā)展健康保險產(chǎn)業(yè)鏈的經(jīng)驗,最后通過與我國的現(xiàn)狀相對比得出符合我國國情的產(chǎn)業(yè)鏈延伸建議。 第三部分運用博弈理論分析我國健康保險產(chǎn)業(yè)鏈延伸過程中存在的問題與困境,主要分析了醫(yī)患的不誠實行為和保險公司對醫(yī)療機構進行監(jiān)管的過程中所遇到的難題。通過論述說明想要解決以上困境,必須采取適合的產(chǎn)業(yè)鏈延伸策略,以產(chǎn)業(yè)鏈帶動健康保險經(jīng)營模式的升級,增強保險公司的醫(yī)療支出控制能力。 第四部分基于博弈論的視角分別論述了保險公司與同業(yè)、醫(yī)療機構間的利益博弈,借助博弈模型的推導結果同時聯(lián)系我國健康保險市場的實際情況,提出具有建設價值的參考意見,從產(chǎn)業(yè)鏈主體層面對上文比較分析法得出的結果進行補充。 第五部分,我國健康保險產(chǎn)業(yè)鏈的延伸策略。本部分是論文的重點章節(jié),首先從保險公司與參保人、同業(yè)者、醫(yī)療機構、藥品供應商和政府部門這五方面主體入手,對我國健康保險產(chǎn)業(yè)鏈主體關系的協(xié)調(diào)提出有參考價值的建議；隨后針對我國健康保險產(chǎn)業(yè)的環(huán)境創(chuàng)建提出在人才培養(yǎng)、信息系統(tǒng)建設和政策環(huán)境三方面的改進方法；最后本人在產(chǎn)業(yè)鏈合同設計上提出了一些自已的觀點。 本文雖然針對美國管理式醫(yī)療進行了系統(tǒng)的分析與討論,但鑒于數(shù)據(jù)獲取方面的限制,個別地方說服力顯得略有不足。文章在前人的基礎上有如下的創(chuàng)新： 首先,本文創(chuàng)新性地采用了博弈論的方式來分析健康保險產(chǎn)業(yè)鏈中不同主體存在的利益分歧,為大家提供一種新的分析方式與視角。同時,本文較為系統(tǒng)地論述了美國管理式醫(yī)療的產(chǎn)業(yè)鏈延伸方式,為今后相關研究提供參考。
[Abstract]:Since entering the 21st century , our country ' s commercial health insurance business has experienced high - speed development . In the first 13 years of this century , the annual premium of health insurance has increased by more than 18 times ;
As of 2013 , the income of health insurance premiums exceeded 10 billion yuan . At the same time , our country ' s insurance density has improved continuously , the expenditure of health insurance is increased from 29 yuan in 2006 to 83 yuan , the increase is 300 % . In 2009 , the State Council issued a series of legal provisions . In 2009 , the State Council issued a series of legal provisions on strengthening health insurance . In 2009 , the State Council issued a series of legislative provisions on strengthening health insurance .

Of course , while seeing China ' s high - speed development of commercial health insurance , we should also pay attention to some problems and obstacles that exist in the course of its development . From 1990 to 2009 , the annual average composite growth rate of medical expense expenditure in our country reached 19 % , while the expenditure of medical expenses in town was increased by nearly 34 times . At the same time , the medical resources of our country were very short . At the same time , there was a shortage of medical resources in our country . At the same time , the number of doctors in our country was only 14 , the ratio was 0.14 % ;
At the same time , every ten thousand people have the bed position of 22 , the world ' s rank hundred open . The shortage of health resources leads to the problem that medical quality is not high , medical expense is high , and the medical expense risk control is difficult . At first , because of the weak position of the health insurance company ' s market influence and customer resources , it directly causes the health insurance and the health insurance to be used as the risk of life insurance . In this mode , the construction of health insurance industry chain can help to realize the scientific and professional operation of the commercial health insurance company , improve the service quality and promote the sustainable development of the healthy insurance market .

Based on the present situation of our country ' s commercial health insurance , this paper tries to find out the shortage of our country in the development of health insurance industry by comparing with the development experience of American administrative medical insurance , and put forward the extension method of industrial chain which accords with the national conditions of our country . Then , according to the differences of interests among the subjects not involved in the above analysis , this paper makes a thorough study on the way of game theory , and finally puts forward some valuable development strategies for the result of the above analysis .

The introduction chapter mainly describes the background and significance of the research , the purpose and content of the study , the research thoughts and methods , and the literature review .

The first part mainly summarizes the development of health insurance industry in China . In this part , it will introduce the market scale of health insurance , the operation mode of health insurance business , the technical level of health insurance industry chain and the policy environment of health insurance industry , and analyze the root causes of these problems by means of relevant industry data .

The second part is to introduce and draw lessons from the successful experiences of the American commercial health insurance industry . On the basis of summarizing the American health insurance business , the paper analyzes the experience of American management medical development health insurance industry chain , and finally obtains the industry chain extension proposal which accords with the national conditions of our country by comparing with the present situation of our country .

The third part uses the game theory to analyze the problems and difficulties existing in the extension process of health insurance industry chain in our country , mainly analyzes the problems that the dishonest behavior of the doctor and the insurance company encounters in the process of supervising the medical institution . Through the elaboration of the explanation that wants to solve the above predicament , it is necessary to adopt the appropriate extension strategy of the industry chain , to promote the upgrade of the health insurance business mode with the industrial chain , and to strengthen the medical expenditure control ability of the insurance company .

In the fourth part , based on the game theory , the benefit game between the insurance company and the same industry and the medical institution is discussed , and the result of the deduction of the game model is connected with the actual situation of the health insurance market in China , and the reference opinions with the construction value are put forward , and the result of the above comparative analysis method is supplemented from the main level of the industrial chain .

The fifth part is the extension strategy of health insurance industry chain in our country . This part is the key chapter of the thesis , first from the insurance company and the participant , the co - worker , the medical institution , the medicine supplier and the government department the five main body , this part puts forward some valuable suggestions for the coordination of the main body relation of health insurance industry chain in China ;
Then , aiming at the environment creation of health insurance industry in our country , this paper puts forward an improved method of training , information system construction and policy environment .
At last , I put forward some ideas on the design of industrial chain contract .

Although the systematic analysis and discussion are carried out for American managed medical treatment , in view of the limitation of data acquisition , individual local persuasion appears to be slightly inadequate . The article has the following innovations on the basis of predecessors :

First of all , this paper makes an innovative use of game theory to analyze the differences of interests existing in different subjects in health insurance industry chain and provide a new way of analysis and perspective . At the same time , this paper systematically discusses the extension way of American administrative medical industry chain , and provides a reference for future research .

【學位授予單位】：西南財經(jīng)大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：F842.684

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