Model essay on medical insurance: On the combination of social medical insurance and commercial medical insurance Abstract In order to meet the objective requirements of the socialist market economic system, the reform of social medical insurance in China has been carried out in most cities. Although the medical insurance system provides an important guarantee for the basic medical care of urban workers, China is still in the primary stage of socialism, with a low level of productivity development, unlike developed welfare countries. The implementation of comprehensive medical security, the rigid increase of medical expenses caused by various reasons, and the increasing burden of individual medical expenses of residents have become more and more prominent problems at present.
Keyword discussion; The combination of social medical insurance and commercial medical insurance
First, the status quo and problems of social medical insurance system
Social medical insurance refers to a social security system established by the state to solve the problem that workers temporarily lose their ability to work due to medical treatment, work-related injuries, maternity and other reasons, and then give them financial help in treatment and life. For example, since the founding of the People's Republic of China, the system of free medical care (employees of administrative organs, institutions and college students) and labor insurance medical care (employees of enterprises) has been established and implemented for a long time. However, due to its own shortcomings, the State Council began to reform the medical security system every month from 65438 to 0994. Speeding up the reform of the basic medical insurance system and ensuring the basic medical care for employees is an objective requirement and an important guarantee for establishing a socialist market economic system, and it is also an important decision made by the CPC Central Committee and the State Council to realize China's cross-century strategic goal. The establishment of the basic medical insurance system means that the medical security of our workers has changed from the unit security system to the social insurance medical insurance system, which means that the welfare has been guaranteed. Free medical care? And then what? Labor insurance medical care? Change to the basic medical insurance mechanism of mutual assistance and effective restraint. The establishment and implementation of the basic medical insurance system in China has not only freed enterprises and institutions under the socialist market economy system from the heavy burden of medical expenses, but also brought vital benefits to urban employees of enterprises and institutions who have been unable to reimburse medical expenses for a long time due to financial difficulties. Therefore, China's current basic medical insurance system has played an important role in safeguarding workers' health, promoting economic development and maintaining social stability. The new medical insurance system has been extended to most cities in China. As of March this year, the number of participants has reached1.1.200 million, of which 73% are employees and 27% are retirees. More than 80% former employees of state-owned enterprises, especially 50% employees of difficult state-owned enterprises, have participated in medical insurance.
However, because China is still in the primary stage of socialism and the level of productivity development is limited, it is impossible to implement comprehensive medical security like developed welfare countries. Not only does it stipulate the scope of use of drugs, diagnosis and treatment facilities and medical services, but individuals also need to bear a certain proportion of medical expenses. At present, due to the continuous development and improvement of medical technology, the price of medical technology and drugs has increased too fast, and the interests of some hospitals and drug production and circulation fields have driven the rigid growth of medical expenses year by year, resulting in personal medical expenses.
In August, 2000, Beijing Municipal Bureau of Statistics conducted a public opinion survey on the draft reform plan of Beijing's basic medical insurance system (the public opinion survey used questionnaire survey * * * to select 507 enterprises, institutions and administrative units in the whole city, and distributed 40 questionnaires1kloc-0/40, all of which were recovered within the specified time, accounting for1.7 of urban workers enjoying medical insurance. ), 89.8% of the respondents believe that medical expenses have increased too fast; 94.8% people think that drug prices are rising too fast; 74.6% people think that the degree of social security is low; 83% of the respondents believe that in addition to the basic medical insurance, it is necessary to establish supplementary medical insurance such as supplementary medical insurance for large medical mutual aid enterprises and institutions and Medicaid for civil servants.
Second, the status quo and problems of commercial medical insurance
At present, in China's insurance market, various life insurance companies have set foot in the field of medical insurance and started various types of medical insurance. Commercial medical insurance can be roughly divided into three categories: income subsidy, fixed payment and expense reimbursement. However, the insurance and business development of various types of insurance are not satisfactory, and even some types of insurance are artificially cancelled because insurance companies are afraid of going out of danger. According to the statistics of relevant departments, there are 1 1 insurance companies engaged in commercial medical insurance business in China, and 13 1 medical insurance business has been launched, but the business volume is not large. By 2000, the premium income of commercial medical insurance in China accounted for about 13.4% of life insurance premium income in the same period, which was far from the total health expenditure of more than 400 billion yuan in China, accounting for only about 2.5%. So far, this situation has not changed by leaps and bounds, which shows that the role of commercial medical insurance in China's medical insurance industry is very small and its development is still very insufficient. In my opinion, commercial medical insurance has been neglected for the following reasons: First, the scope of claims is relatively limited, such as expense reimbursement, which only stipulates the medical expenses of a few specific diseases and cannot meet the needs of the insured for treating various diseases; Second, the amount of compensation is relatively fixed; Third, the claim settlement procedures are cumbersome and the waiting period is long, which makes some people who want to participate in the insurance discouraged; Fourth, integrity needs to be improved, and fifth, publicity needs to be strengthened.
Third, the necessity of combining social medical insurance with commercial medical insurance.
Social medical insurance is enforced by the state through legislation, while commercial medical insurance belongs to the category of health insurance, which is the commercial behavior of insurers to pay insurance premiums. Social medical insurance embodiment? Low level, wide coverage? However, in people's medical needs, social medical insurance still does not pay medical expenses, and projects and individuals have to bear a certain proportion of expenses, which can become the development space of commercial medical insurance. It is necessary to solve the outstanding problem of overweight personal medical expenses and give full play to the supplementary role of commercial medical insurance to social medical insurance. The CPC Central Committee and the State Council also demand and advocate the combination of social medical insurance and commercial medical insurance to build a complete medical security system in China. There are significant differences between commercial medical insurance and social medical insurance, and there are also many similarities. If the two complement each other, it is possible for the insured to achieve the goal of less or zero burden of medical consumption.
Four, the operability of the combination of social and commercial medical insurance
The combination of commercial medical insurance and social medical insurance can be roughly divided into the following steps: (1) The insured person is treated in the designated hospital of basic medical insurance due to illness.
At the time of settlement, the insured patient swipes the social security card at the treatment hospital to go through the settlement formalities at the social medical insurance handling outlets, prints the basic medical insurance settlement form, and pays the personal burden. (2) Insured patients hold social security cards, discharge records and basic medical insurance statements to the medical insurance business department of a commercial insurance company to make claims. (3) The business department of a commercial insurance company shall verify the settlement with the social medical insurance agency on the Internet according to the submitted materials, and make claims according to the agreement after the materials are verified to meet the requirements. Because the settlement of patients participating in basic medical insurance has been strictly reviewed, the re-examination of commercial insurance companies is relatively simple.
Verb (abbreviation of verb) Suggestions on the combination of social medical insurance and commercial medical insurance
All kinds of facts show that China's medical security system has now entered the substantive operation stage, which will lead to the prosperity of commercial medical insurance. Although China Life Insurance Company, Ping An Insurance Company and Taikang Insurance Company are all trying to provide some types of medical insurance, on the whole, the commercial medical insurance market has not been well developed, and the basic social medical insurance has not been fundamentally filled, which has led to the emergence of social medical insurance system. Vacuum zone? . So, it's increasing? Medical reform? While strengthening and perfecting the basic medical insurance system, it is particularly urgent to vigorously develop commercial supplementary medical insurance. (1) The government should make clear its policies and give commercial medical insurance a social space for full development; (2) The government should actively cooperate with commercial insurance companies to guide and help them develop commercial medical insurance from the overall situation of stabilizing society and ensuring people's health; (3) Commercial insurance companies should
Strengthen market research activities, accurately grasp market demand, enhance risk awareness, and actively develop and design marketable medical insurance types based on actuarial talents and medical professionals; (4) Strengthen the gap between social medical insurance and commercial medical insurance.
Pass, find a reasonable connection between the two, and finally promote the coordinated development of the two; (5) The government and businesses should unite to publicize the supplementary role of commercial medical insurance, and eliminate many people's concerns about the integrity of commercial medical insurance and the feeling that it is difficult to accept its full payment; (6) pilot projects can be set up in some parts of the country, and after gaining some experience, they can be gradually popularized. You can also set up insurance from the cost that can be easily and effectively controlled to ensure the balance of premiums. In short, in our country, basic medical services have not been popularized to all people, the share of commercial medical insurance is still very low, and the population covered is not wide. Therefore, it is very important to develop commercial medical insurance while actively promoting the reform of social medical insurance system for urban workers. The development of commercial medical insurance can reasonably share the medical expenses by establishing different insurance forms, which is helpful to solve the problems of excessive medical consumption in the current employee medical insurance, so that the medical expenses paid by social medical insurance can provide basic medical services for more people. At the same time, it is also conducive to raising people's awareness of healthy investment, guiding people to consume healthily, and providing certain long-term available funds for national economic development. In the process of establishing the socialist market economic system in China, commercial medical insurance, as an indispensable form of social insurance, is still in its infancy. With the development of China's economy, the change of population structure and disease structure, people's demand for different levels of health service guarantee will certainly become more and more urgent. Therefore, it is necessary to develop commercial medical insurance in China, especially in economically developed areas.
Medical insurance Fan Wener: On the medical liability insurance system Abstract With the prominent contradiction between doctors and patients, the disputes between doctors and patients have been escalating, which has seriously affected the establishment of a harmonious society. Facing the increasing frequency and amount of claims, how to protect the legitimate rights and interests of hospitals, doctors and patients has become an urgent social problem. Although the academic circles have discussed many effective ways to solve the doctor-patient disputes, the author believes that vigorously promoting the medical liability insurance system is one of the effective ways to fundamentally solve the doctor-patient disputes. This paper puts forward the idea of reconstructing the medical liability insurance system from the perspective of insurance law, aiming at providing theoretical basis for the implementation of the medical liability insurance system.
Keywords: liability insurance, medical dispute insurance system
China Library Classification Number: F840.69 Document Identification Number: A
The increasingly tense relationship between doctors and patients in China has affected the normal operation and orderly development of medical institutions. Seeking a good strategy to disperse medical occupational risks and ease the tension between doctors and patients has become a hot issue of concern to experts and scholars. Medical liability insurance has the function of transferring medical occupational risks and compensating patients for economic losses, which is one of the effective ways to solve disputes between doctors and patients.
1 Feasibility analysis of implementing medical liability insurance system
Medical liability insurance refers to an insurance system in which the insurer (insurance company) and the insured (medical party) agree that when a medical insurance accident occurs and the insured bears the liability for damages to a third party (patient) according to legal requirements, the insurer will perform the liability for compensation on his behalf. Due to the particularity and complexity of modern medicine and the individual differences of patients, it is difficult to avoid disputes between doctors and patients. According to "Regulations on Handling Medical Accidents" and "Tort Liability Law", patients pay more and more compensation for medical liability, which makes it difficult for hospitals to bear huge compensation pressure and operational risks, and the psychological pressure of medical practitioners is also increasing, which seriously affects their service quality and service attitude. Carrying out medical liability insurance system can effectively transfer medical risks.
First of all, medical liability insurance can transfer the accident risks concentrated in a single hospital to insurance companies, reduce the financial burden of doctors and get rid of medical disputes. When applying for medical liability insurance, after the disputes between doctors and patients occur, the insurance institutions, as a third party, participate in mediation through medical dispute mediation institutions, and their handling opinions are more easily accepted by patients, and many disputes can be solved smoothly. Only hospitals and doctors can have enough energy to serve patients, and ultimately promote the virtuous circle development of the medical industry. In addition, the implementation of medical liability insurance can also improve the risk prevention and control level of doctors. Insurance companies educate medical staff on laws and regulations, insurance knowledge and medical risk prevention before and during insurance, which plays a very good role in preventing medical risks.
Secondly, medical liability insurance is also of great benefit to patients. On the one hand, after the dispute occurs, patients can get economic compensation fairly and reasonably through a third party. On the other hand, because insurance companies will strictly examine and approve medical applications, hospitals with too high risks and poor staff quality may be refused insurance. Therefore, this indirect supervision has virtually become one of the criteria for patients to measure the advantages and disadvantages of hospitals and choose the best medical care. In addition, in order to reduce risks and claims, insurance institutions not only participate in claims, but also invite experts to analyze the causes of medical accidents and put forward improvement suggestions for the problems existing in hospitals, which is undoubtedly of great benefit to the improvement of hospital management level and medical quality.
Of course, the implementation of medical liability insurance can not only protect the legitimate rights and interests of both doctors and patients, but also broaden the business scope for insurance companies. As long as it is operated properly, it will increase economic benefits. The system will take into account the interests of all parties and is conducive to the establishment of a harmonious society.
2 Analysis of the current situation of China's medical liability insurance system
Compared with other property liability insurance, China's medical liability insurance started late and developed very slowly. At present, there is no unified medical liability insurance system in China, and only some provinces and cities have carried out the practice of medical liability insurance. However, in China's practice, the recognition of medical liability insurance by medical institutions is low and the participation rate is not high. This shows that there is an unfavorable situation in the implementation of the medical liability insurance system. This situation also exposes the problems in the design of medical liability insurance system in China.
2. 1 The content design of medical liability insurance is not mature.
The market development of medical liability insurance in China started late, and insurance companies lack detailed historical data. In addition, medical liability insurance has certain medical particularity. Insurance companies need the help of experts in legal and medical fields to develop and study it. For insurance companies, it is very expensive to formulate mature medical liability insurance rules. Therefore, in practice, the determination of insurance rate is still in the stage of empirical rate. At present, the insurance premium is only charged according to the number of hospital beds and medical staff, and it is impossible to determine the rate according to the management level, technical level and risk coefficient of posts and titles of different medical institutions, which has dampened the enthusiasm of hospitals for insurance and caused a downward trend year by year. High-grade and large-scale hospitals are unwilling to participate in insurance, while poor-grade and high-risk medical institutions are relatively safe. Some insurance institutions choose high-risk departments such as obstetrics and gynecology and cardiothoracic department, which undoubtedly increases the underwriting risk of insurance companies. Therefore, the enthusiasm of insurance companies to develop medical liability insurance is not high, which makes the underwriting and claim settlement design of this kind of insurance immature, thus directly affecting the promotion of medical liability insurance system.
Besides, the coverage of this kind of insurance is too narrow. At present, most insurance companies that underwrite medical liability insurance limit the scope of insurance liability to medical accidents, and insurance companies only compensate medical claims that constitute medical accidents. Therefore, in many disputes between doctors and patients, patients often go to the hospital to consult with doctors, and doctors still have to spend a lot of energy to negotiate and communicate with patients. Medical institutions feel that the benefits of insurance are less than the costs and have not achieved the original purpose, so their enthusiasm for medical liability insurance is not high.
2.2 Medical liability insurance processing procedures are not perfect
After a medical dispute, how to determine the amount of damages in time so that the victim can get compensation from the insurer in time directly determines the operation effect of medical liability insurance. It is the premise of medical liability insurance to determine the amount of compensation recognized by doctors, patients and insurance through a certain mechanism. At present, the Regulations on Handling Medical Accidents stipulates three dispute settlement methods: negotiation, administrative mediation and litigation. Although the litigation solution has the characteristics of fairness, authority and compulsion, it has high cost and long cycle, and although it is easily recognized by the insurer, it is by no means the first choice for both doctors and patients. As for administrative mediation, due to various reasons, it is the least used solution at present; As for the negotiation and settlement between the two sides, it is the most important way at present, but it is difficult for insurance companies to recognize the settlement reached by doctors and patients in private. For medical damage cases defined as the scope of medical liability insurance, patients have no right to claim compensation directly from insurance companies. When medical institutions demand compensation from insurance companies, there are still shortcomings such as complicated procedures and long compensation time.
2.3 Unrealized transfer of doctor-patient disputes
Medical liability insurance is not practical for medical institutions. The implementation of medical liability insurance has not completely freed medical institutions from medical disputes. For the insured medical institutions, it is hoped that the insurance company will transfer the economic compensation responsibility and coordinate the routine work of handling medical disputes. In this way, the participating hospitals and doctors can avoid direct contact with each other, and only need to submit professional materials to the third party, so they can concentrate on their business work without worries. This is also conducive to avoiding the intensification of contradictions and properly handling the interests of both sides. Although the medical liability insurance clauses in all regions of China almost stipulate the insurer's right to participate in claims settlement, that is, when necessary, the insurance company can defend the lawsuit or participate in handling related claims in the name of the insured, the fact is that few insurance companies can play their due role in medical liability insurance litigation or disputes, and hospitals have to spend a lot of energy to deal with patients' claims settlement. 3 Reconstruction of China's medical liability insurance system
The medical liability insurance system is an effective means to solve medical disputes, but there are still various problems in the current medical liability insurance system in China, which limits the role of the medical liability insurance system. Therefore, we must learn from the mature experience of developed countries, proceed from the realistic social foundation, balance the interests of doctors and patients, rebuild its internal system and improve the medical liability insurance system.
3. 1 Establish a compulsory medical liability insurance system
At present, the coverage of medical liability insurance in China is low. Due to various reasons, medical institutions are not enthusiastic about medical liability insurance. In developed countries in Europe and America, compulsory medical liability insurance is actually a normal state of liability insurance, and it is very common to participate in compulsory medical liability insurance. Taking out medical liability insurance has become a common practice for doctors to transfer their practice risks and deal with disputes between doctors and patients. In the tense doctor-patient relationship, in order to give full play to the role of medical liability insurance, it is necessary for our government to distinguish the medical liability insurance system established by it from other commercial insurance, and give it a certain coercive force, making it the main method to alleviate the contradiction between doctors and patients and solve medical disputes. Our government should establish compulsory medical liability insurance as the key system in the medical and health system, and stipulate that all hospitals in China must participate in the insurance, so as to ensure the participation rate of doctors, stimulate the service enthusiasm of insurers and truly realize the purpose of implementing medical liability insurance.
3.2 The establishment of the third party's direct claim
In China's current medical liability insurance, the injured third party does not enjoy the right of direct claim. Therefore, after the occurrence of medical disputes, the insured medical institutions have to spend time and manpower to participate in the complicated claims settlement process, but the original intention of insurance has not been realized. Therefore, our country should establish the system of the third party's direct claim and give the injured third party the direct claim. After the occurrence of medical disputes, patients can directly negotiate with insurance companies to handle claims procedures, so that medical institutions and medical staff can really get rid of medical disputes and put more energy into clinical work.
3.3 Give full play to the positive role of the government in promoting medical liability insurance.
Medical liability insurance system is one of the effective means to improve the current situation of medical disputes, and relevant government departments should take measures to promote the development of medical liability insurance system. First of all, the government should organize relevant professionals to study and improve the terms of medical liability insurance, and attach importance to the introduction of medical liability insurance professionals, so as to enhance the professionalism of medical liability insurance in China and ensure the quality of insurance. Secondly, due to the professionalism and meager profit of medical liability insurance, insurance companies often invest more and earn less, and their participation enthusiasm is not high. The government should give corresponding subsidies or preferential tax policies to insurance companies that carry out medical liability insurance, so as to mobilize the enthusiasm of insurance companies and promote the operation of compulsory medical liability insurance in China.
In short, the medical liability insurance system is conducive to establishing a buffer zone between patients and doctors, transforming the suspicion between doctors and patients into a doctor-patient relationship of equality and mutual trust, and is conducive to transferring medical risks, thus building a harmonious and mutual trust doctor-patient relationship.
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