我國商業(yè)口腔保險的發(fā)展研究
發(fā)布時間：2019-06-17 13:22
【摘要】：口腔疾病被世界衛(wèi)生組織稱為人類重點研究和重點防治的三大非傳染性疾病之一�？谇患膊〔粌H本身會對人體健康和人們的生活品質(zhì)造成重大影響,而且由其引起的全身系統(tǒng)病(如胃病、營養(yǎng)方面的疾病等),以及其可能引起的心理問題更是危害深遠。 全國第三次口腔健康流行病學(xué)調(diào)查顯示,我國口腔疾病患病率高達97.6%,幾乎人人都或多或少地存在口腔問題,而就診率卻不到10%,即便前往就診,也存在疼痛緩解就中斷治療和劇烈疼痛才選擇醫(yī)療服務(wù)的現(xiàn)象。由于牙齒沒有徹底處理,經(jīng)過一定時間,損壞過大,無法修補,只能拔除。我國65歲以上老人平均失牙11顆,遠遠低于世界衛(wèi)生組織制定的“8020”(80歲老人有20顆及以上健康恒牙)指標。 目前,口腔疾病的治療成本非常高昂,在所有疾病中列于前三位。我國口腔疾病的治療費用主要通過自費給付和社會醫(yī)療保險給付兩種方式,且社會醫(yī)療保險保障的口腔疾病范圍和種類很少,只有牙髓病、根尖周——根管治療術(shù)(殺神經(jīng))、牙周炎——牙周基礎(chǔ)治療、埋伏阻生牙——拔除術(shù)(拔牙)四種可部分報銷的治療項目。而我國的商業(yè)口腔保險剛剛起步,尚處于試驗階段,目前僅有的兩款口腔保險產(chǎn)品只突出了幾種簡單的常規(guī)牙科護理,卻并沒有補償口腔疾病風(fēng)險發(fā)生后的經(jīng)濟損失,從保險的定義上來看,不屬于真正意義上的疾病保險。 研究發(fā)現(xiàn),醫(yī)療費用支付方式是影響口腔疾病患者選擇口腔醫(yī)療衛(wèi)生服務(wù)的最重要的原因,享有較高醫(yī)療保障制度的人群,就診概率較高。那么如何更好的減輕患者負擔(dān),建立起有效的口腔醫(yī)療費用保障機制呢?國外發(fā)達國家完善的商業(yè)口腔保險模式已經(jīng)為本國患者提供了很好的患病費用補償與保障機制。我們也可以提出這樣的問題：可否用商業(yè)保險的方式來解決我國口腔疾病患者的醫(yī)療費用給付問題?商業(yè)口腔保險的形式是否必要,又能否可行?如必要且可行,那么在建立的初期會遇到哪些問題,又該如何發(fā)展?于是在這樣的背景下,筆者開始了本文的思考與探索。 本文第一章對研究對象進行界定。將口腔保險及商業(yè)口腔保險的概念進行了梳理,針對國內(nèi)為數(shù)不多的相關(guān)研究和使用較混亂的名詞定義,給出了自己的理解和結(jié)論。 第二章,口腔醫(yī)療衛(wèi)生服務(wù)及費用保障機制。從口腔科常見診治項目及費用的角度,梳理口腔疾病種類及特點,分析我國口腔疾病患病率高,就診率低的原因,得出費用支付方式是影響醫(yī)療衛(wèi)生服務(wù)利用的重要因素的結(jié)論,進而論證用商業(yè)口腔保險的方式建立口腔醫(yī)療費用保障機制的必要性及可行性。 第三章,國外口腔保險發(fā)展現(xiàn)狀及經(jīng)驗借鑒。首先梳理目前國際上比較常見的三種口腔保險模式,分別是以美國為代表的商業(yè)口腔保險模式、以荷蘭為代表的公共牙科保健模式及日本為代表的齒科全民健保模式。重點介紹美國口腔保險模式,從發(fā)展歷程到口腔保險管理式醫(yī)療HMO模式和PPO模式,美國主要的口腔保險提供商,得出對我國的啟示：社會口腔(醫(yī)療)保險只能起到基礎(chǔ)保障作用,商業(yè)口腔保險作為口腔基本醫(yī)療保險的有力補充,可以利用其靈活多樣的保險項目、保險水平、以及投保的方式等,對社會口腔(醫(yī)療)保險沒有覆蓋到的診療項目、個人按比例自付的費用,甚至醫(yī)療事故的賠付等方面,根據(jù)投保者的意愿,因人而異,設(shè)計不同的保險合同,這填補目前社會口腔(醫(yī)療)保險的空白。 第四章,我國商業(yè)口腔保險現(xiàn)狀及存在的問題。首先介紹處于起步試水階段的口腔保險產(chǎn)品,市場上以主險形式存在的僅有兩款牙科保健類商業(yè)保險產(chǎn)品,分別是人民保險公司的牙科管理式醫(yī)療保險產(chǎn)品—守護專家牙科醫(yī)療保險和平安保險公司的平安附加意外牙科及保健醫(yī)療保險,目前存在品種少,得不到政策支持,需要大但尚未轉(zhuǎn)化成有效需求,只針對高端市場等弊端和不足的問題,而對于之后發(fā)展商業(yè)口腔保險要面臨的不完善的相關(guān)政策法規(guī)環(huán)境、口腔衛(wèi)生服務(wù)環(huán)境不規(guī)范、信用環(huán)境有待提高、供給及需求問題、口腔醫(yī)療市場問題也進行了分析。 第五章,發(fā)展我國商業(yè)口腔保險的具體戰(zhàn)略。首先對我國發(fā)展口腔保險體系構(gòu)建進行了構(gòu)想。針對不同疾病按病種不同選擇不同展業(yè)方式,將傳統(tǒng)口腔疾病項目和預(yù)防保健日常檢查類放入團險,將口腔創(chuàng)新類放入個險,利用管理式醫(yī)療手段,與口腔醫(yī)療機構(gòu)(牙科診所、口腔醫(yī)院、綜合醫(yī)院口腔科)進行信息聯(lián)網(wǎng),分步搭建健康管理平臺,構(gòu)建有吸引力的醫(yī)保合作框架。相關(guān)配套政策及可深入研究的問題。然后重點介紹國家相關(guān)部門及醫(yī)療機構(gòu)的配套政策,在本章的最后對我國社會醫(yī)療保險目前針對口腔疾病和診治項目的情況進行補充介紹。 總體而言,本文可能有以下幾點特色和可能的創(chuàng)新。第一,首次將口腔保險及商業(yè)口腔保險的概念進行了梳理,針對國內(nèi)為數(shù)不多的相關(guān)研究和使用較混亂的名詞定義,給出了自己的理解和結(jié)論。第二,首次將口腔疾病付費保障機制進行了梳理,從商業(yè)口腔保險解決口腔疾病費用的可行性及必要性方面進行了分析及論證,提出在我國大力發(fā)展市場經(jīng)濟的背景下,在確定社會保險對于口腔疾病的保障范圍及邊界后,可以利用更加有效的市場機制——商業(yè)保險的手段來解決口腔疾病付費保障問題。第三,鮮明的將社會口腔保險與商業(yè)口腔保險區(qū)分開,對兩者分別負責(zé)和保障的范疇和如何運營的思路,融合和鑲嵌的預(yù)留空間等等進行了初步的構(gòu)想。本文并未討論社會口腔保險與商業(yè)口腔保險孰優(yōu)孰劣的問題,強調(diào)融合,鑲嵌和合理的邊界制定,筆者認為,兩種保障機制不是非此即彼的關(guān)系,而是應(yīng)該相輔相成,優(yōu)勢互補,同步運作,共同發(fā)展。只是基于自身知識背景的考慮,切入角度的選擇讓筆者更多的從商業(yè)的角度對該問題進行了分析,并在本文最后表明了社會保險的作用及應(yīng)有的邊界。第四,對于商業(yè)口腔保險的未來發(fā)展戰(zhàn)略,從政府政策制定、口腔醫(yī)療機構(gòu)發(fā)展和商業(yè)保險公司運營三方面闡述了很多具體的構(gòu)想和思路,希望能對后來研究人員、實務(wù)工作者及政策制定方有些許啟發(fā)作用。
[Abstract]:Oral diseases are one of the three major non-communicable diseases called human focus research and focus prevention and control by the World Health Organization. Oral diseases are not only a major impact on the health of the human body and the quality of life of people, but also the systemic diseases (such as gastropathy, diseases, etc.) caused by the oral diseases, and the psychological problems that it may cause are far-reaching. The third oral health epidemiological survey of the country shows that the prevalence of oral diseases in our country is as high as 97.6%, and almost everyone has more or less oral problems, while the rate of treatment is less than 10%. Palpation, there is also pain relief to discontinue treatment and severe pain to select the current status of the medical service A. Due to the incomplete treatment of the teeth, the damage can not be repaired by a certain amount of time, and can only be pulled out. In addition, the average loss of 11 of the old people over the age of 65 in China is far lower than that of the "8020" developed by the World Health Organization (20 and more healthy permanent teeth of the 80-year-old man). The treatment cost of oral diseases is very high, and is listed in all the diseases. The treatment cost of oral diseases in China is mainly covered by the cost-of-pocket and social-medical insurance benefits, and the range and type of oral diseases guaranteed by social medical insurance are very few, only endodontic disease, periapical-root canal treatment (killing nerve), periodontitis _ periodontal basis Treatment of four parts, such as the treatment of tooth extraction (tooth extraction), and the treatment of four parts, which can be partially compensated The commercial oral insurance of our country has just started, and at the stage of the test, only two of the two oral insurance products have only highlighted several simple routine dental care, but have not compensated the economic loss after the risk of the oral disease, from the definition of the insurance On the other hand, it doesn't belong to the real meaning of the disease. The research shows that the medical expense payment method is the most important reason which affects the choice of the oral health care service in the patients with oral diseases, and the people with higher medical security system The probability of the diagnosis is high. So how to reduce the burden of the patient better and to set up effective oral medical expenses Where is the safeguard mechanism? The developed commercial oral insurance model developed by the developed countries has provided a good compensation for the patients in the country We can also put forward such a question: Can we use the way of commercial insurance to solve the medical expenses of patients with oral diseases in our country with benefits? Is the form of a commercial oral insurance necessary, Is it possible? If necessary and feasible, what problems will be encountered at the beginning of the establishment, and How to develop? So, in this context, the author has started this article. Thinking and exploration. The first chapter of this paper is the research The definition of the object is defined. The concept of the oral insurance and the commercial oral insurance is analyzed, and a few related research and the use of the more confused term definition are given. Self-understanding and conclusions. Chapter II, Oral and health care Service and expense guarantee mechanism. From the angle of common diagnosis and treatment project and cost of stomatology department, to sort out the types and characteristics of oral diseases, to analyze the causes of high prevalence of oral diseases and low treatment rate in our country, and to conclude that the cost payment method is the influence of medical and health service. The conclusion of the important factors used, and then the establishment of the oral cavity medical expense guarantee machine in the way of commercial oral insurance The necessity and feasibility of the system. Chapter 3, the foreign oral cavity The present situation and experience of the insurance development can be used for reference. First of all, the three kinds of oral insurance models which are common in the world are first combed, the commercial oral insurance mode represented by the United States, the public dental health mode represented by the Netherlands, and the Japan are the This paper mainly introduces the American oral insurance model, from the development course to the oral insurance management type medical HMO mode and the PPO pattern, the main oral insurance provider in the United States, and gives the enlightenment to our country: the social oral (medical) protection The insurance can only play a basic guarantee, and the commercial oral insurance can be used as a strong supplement to the basic medical insurance of the oral cavity, so that the medical insurance coverage of the social oral (medical) insurance is not covered by the flexible and diversified insurance items, the insurance level, the method of the insurance, and the like. According to the intention of the insured, the individual can design different insurance contracts according to the individual's will, even the payment of the medical accident, which fills the current society Blank for oral (medical) insurance. Chapter IV, Chinese The present situation and existing problems of oral insurance in the industry are introduced. First, the oral insurance products in the initial stage of water trial are introduced. The two dental health insurance products, the dental management medical insurance products of the people's insurance company, the dental medical insurance and the safe and additional accidental dental and health-care medical insurance of the safety insurance company, are currently few varieties and can not be supported by the policy, needs big but not yet converted into the effective demand, only aiming at the problems of the high-end market and the like, and the imperfect related policy and regulation environment, the environment of the oral hygiene service, the credit ring, The situation needs to be improved, the supply and demand problems, the mouth in chap 5, The development of the specific strategy of the commercial oral insurance in our country. First of all, to our country The development of the oral insurance system is conceived. The traditional oral diseases project and the preventive health-care daily inspection class are put into the group insurance for different diseases according to different disease types, and the oral innovation class is put into a risk, and the management type medical device and the mouth are used. The information networking is carried out in the cavity medical institution (the dental clinic, the oral hospital, the comprehensive hospital stomatology department), and the health management level is set up in step by step. Taiwan, to build an attractive health-care cooperation framework. The relevant supporting policies and the problems that can be in-depth study will be discussed. Then, the supporting policies of the relevant departments of the state and the medical institutions will be introduced. At the end of this chapter, the social medical insurance of our country is currently against the oral diseases. Supplementary information on the condition of the disease and the diagnosis and treatment of the project. Overall, This article may have the following features and possible innovations. First, the concept of oral insurance and commercial oral insurance is first combed, with a few related research and use in the country In the second part, the mechanism of the payment for oral diseases is analyzed, and the feasibility and necessity of the cost of the oral diseases are analyzed and demonstrated from the commercial oral insurance. In the background of developing a market economy in our country, it is suggested that more effective market mechanism _ commercial protection can be used to determine the scope and boundary of social insurance for oral diseases. The third, the distinction between the social and oral insurance and the commercial oral insurance, the scope of the responsibility and the guarantee and how to operate, the integration and the The paper does not discuss the problem of the superior and inferior of the social oral insurance and the commercial oral insurance, and emphasizes the integration, inlaying and reasonable boundary establishment. The author holds that the two safeguard mechanisms are not the same, but should be complementary. It is only based on the background of knowledge, and the choice of cut-in angle makes the author more and more analyze the problem from the perspective of business, and in this article the most important The fourth part, on the future development strategy of the commercial oral insurance, expounds a lot of concrete measures from the development of the government policy, the development of the oral medical institution and the operation of the commercial insurance company. The idea and the way of thinking, I hope to be able to study the later researchers, real
【學(xué)位授予單位】：西南財經(jīng)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2013
【分類號】：F842.684
本文編號：2501019
[Abstract]:Oral diseases are one of the three major non-communicable diseases called human focus research and focus prevention and control by the World Health Organization. Oral diseases are not only a major impact on the health of the human body and the quality of life of people, but also the systemic diseases (such as gastropathy, diseases, etc.) caused by the oral diseases, and the psychological problems that it may cause are far-reaching. The third oral health epidemiological survey of the country shows that the prevalence of oral diseases in our country is as high as 97.6%, and almost everyone has more or less oral problems, while the rate of treatment is less than 10%. Palpation, there is also pain relief to discontinue treatment and severe pain to select the current status of the medical service A. Due to the incomplete treatment of the teeth, the damage can not be repaired by a certain amount of time, and can only be pulled out. In addition, the average loss of 11 of the old people over the age of 65 in China is far lower than that of the "8020" developed by the World Health Organization (20 and more healthy permanent teeth of the 80-year-old man). The treatment cost of oral diseases is very high, and is listed in all the diseases. The treatment cost of oral diseases in China is mainly covered by the cost-of-pocket and social-medical insurance benefits, and the range and type of oral diseases guaranteed by social medical insurance are very few, only endodontic disease, periapical-root canal treatment (killing nerve), periodontitis _ periodontal basis Treatment of four parts, such as the treatment of tooth extraction (tooth extraction), and the treatment of four parts, which can be partially compensated The commercial oral insurance of our country has just started, and at the stage of the test, only two of the two oral insurance products have only highlighted several simple routine dental care, but have not compensated the economic loss after the risk of the oral disease, from the definition of the insurance On the other hand, it doesn't belong to the real meaning of the disease. The research shows that the medical expense payment method is the most important reason which affects the choice of the oral health care service in the patients with oral diseases, and the people with higher medical security system The probability of the diagnosis is high. So how to reduce the burden of the patient better and to set up effective oral medical expenses Where is the safeguard mechanism? The developed commercial oral insurance model developed by the developed countries has provided a good compensation for the patients in the country We can also put forward such a question: Can we use the way of commercial insurance to solve the medical expenses of patients with oral diseases in our country with benefits? Is the form of a commercial oral insurance necessary, Is it possible? If necessary and feasible, what problems will be encountered at the beginning of the establishment, and How to develop? So, in this context, the author has started this article. Thinking and exploration. The first chapter of this paper is the research The definition of the object is defined. The concept of the oral insurance and the commercial oral insurance is analyzed, and a few related research and the use of the more confused term definition are given. Self-understanding and conclusions. Chapter II, Oral and health care Service and expense guarantee mechanism. From the angle of common diagnosis and treatment project and cost of stomatology department, to sort out the types and characteristics of oral diseases, to analyze the causes of high prevalence of oral diseases and low treatment rate in our country, and to conclude that the cost payment method is the influence of medical and health service. The conclusion of the important factors used, and then the establishment of the oral cavity medical expense guarantee machine in the way of commercial oral insurance The necessity and feasibility of the system. Chapter 3, the foreign oral cavity The present situation and experience of the insurance development can be used for reference. First of all, the three kinds of oral insurance models which are common in the world are first combed, the commercial oral insurance mode represented by the United States, the public dental health mode represented by the Netherlands, and the Japan are the This paper mainly introduces the American oral insurance model, from the development course to the oral insurance management type medical HMO mode and the PPO pattern, the main oral insurance provider in the United States, and gives the enlightenment to our country: the social oral (medical) protection The insurance can only play a basic guarantee, and the commercial oral insurance can be used as a strong supplement to the basic medical insurance of the oral cavity, so that the medical insurance coverage of the social oral (medical) insurance is not covered by the flexible and diversified insurance items, the insurance level, the method of the insurance, and the like. According to the intention of the insured, the individual can design different insurance contracts according to the individual's will, even the payment of the medical accident, which fills the current society Blank for oral (medical) insurance. Chapter IV, Chinese The present situation and existing problems of oral insurance in the industry are introduced. First, the oral insurance products in the initial stage of water trial are introduced. The two dental health insurance products, the dental management medical insurance products of the people's insurance company, the dental medical insurance and the safe and additional accidental dental and health-care medical insurance of the safety insurance company, are currently few varieties and can not be supported by the policy, needs big but not yet converted into the effective demand, only aiming at the problems of the high-end market and the like, and the imperfect related policy and regulation environment, the environment of the oral hygiene service, the credit ring, The situation needs to be improved, the supply and demand problems, the mouth in chap 5, The development of the specific strategy of the commercial oral insurance in our country. First of all, to our country The development of the oral insurance system is conceived. The traditional oral diseases project and the preventive health-care daily inspection class are put into the group insurance for different diseases according to different disease types, and the oral innovation class is put into a risk, and the management type medical device and the mouth are used. The information networking is carried out in the cavity medical institution (the dental clinic, the oral hospital, the comprehensive hospital stomatology department), and the health management level is set up in step by step. Taiwan, to build an attractive health-care cooperation framework. The relevant supporting policies and the problems that can be in-depth study will be discussed. Then, the supporting policies of the relevant departments of the state and the medical institutions will be introduced. At the end of this chapter, the social medical insurance of our country is currently against the oral diseases. Supplementary information on the condition of the disease and the diagnosis and treatment of the project. Overall, This article may have the following features and possible innovations. First, the concept of oral insurance and commercial oral insurance is first combed, with a few related research and use in the country In the second part, the mechanism of the payment for oral diseases is analyzed, and the feasibility and necessity of the cost of the oral diseases are analyzed and demonstrated from the commercial oral insurance. In the background of developing a market economy in our country, it is suggested that more effective market mechanism _ commercial protection can be used to determine the scope and boundary of social insurance for oral diseases. The third, the distinction between the social and oral insurance and the commercial oral insurance, the scope of the responsibility and the guarantee and how to operate, the integration and the The paper does not discuss the problem of the superior and inferior of the social oral insurance and the commercial oral insurance, and emphasizes the integration, inlaying and reasonable boundary establishment. The author holds that the two safeguard mechanisms are not the same, but should be complementary. It is only based on the background of knowledge, and the choice of cut-in angle makes the author more and more analyze the problem from the perspective of business, and in this article the most important The fourth part, on the future development strategy of the commercial oral insurance, expounds a lot of concrete measures from the development of the government policy, the development of the oral medical institution and the operation of the commercial insurance company. The idea and the way of thinking, I hope to be able to study the later researchers, real
【學(xué)位授予單位】：西南財經(jīng)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2013
【分類號】：F842.684
【引證文獻】
相關(guān)期刊論文 前3條
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2 南東旭;陶紅兵;張汝檸;;基于我國社區(qū)口腔健康需求的公立口腔專科醫(yī)院營銷策略分析[J];醫(yī)學(xué)與社會;2016年01期
3 陳穩(wěn);張艷艷;姜京徽;張靜嫻;單學(xué)鵬;瞿星;華成舸;;成都市兒童口腔醫(yī)療保險影響因素研究[J];華西口腔醫(yī)學(xué)雜志;2015年06期
，本文編號：2501019
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