What Are the Pros and Cons of Managed Care?

Managed medical insurance is a combination of the funds needed to provide medical services and provide medical services (insurance protection), and provide medical services to policyholders through agreements reached between insurance institutions and medical service providers. The core of the managed medical model is that insurance and medical service providers become a community of interests. This is also the fundamental reason why the managed medical insurance model can effectively control risks and reduce costs.

Managed medical insurance

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Managed

1. Organic integration of medical service financing and medical service provision, management of medical organizations signing contracts with clinics and hospitals or directly owning their own hospitals and clinics;

2. Adopt multiple payment methods to enable medical service providers to share benefits, share risks, and share costs with third parties;

3. Establish a third party association to supervise, measure and evaluate the medical quality of medical service providers. At the same time, in addition to providing medical services, managed medical insurance also includes prevention and health care, transforming disease insurance into

Managed health insurance originated in the United States in the 1960s, namely the Blue Shield and Blue Cross plans. It is a medical insurance model that integrates medical service provision and operation management. The key is that insurance companies directly participate in the management of the medical service system. In short, it can be summarized as follows: Under the traditional medical insurance model, the insurance company as the insurer is in a third-party position, but only assumes the responsibility to pay the corresponding medical expenses after the customer receives medical services, which will inevitably lead to uncontrollable medical expenses. . In managed medical insurance, when a medical provider agrees to cover all the medical services of a client with a fixed fee agreed in advance, he accepts and bears a considerable part

1. The current social medical insurance institutions directly control the hospital and establish a system in which the hospital does not charge patients a certain amount of fees. Enterprises and employees now pay social insurance,

1. Health insurance needs support from national legislation and taxation. National policies should clarify the legal status of commercial health and medical insurance, tax policies, and draw a line between social and commercial insurance. For example: German law requires supplementary medical insurance to be provided by a commercial insurance company, and social medical insurance organizations must not provide supplemental medical insurance. Therefore, although German social medical insurance covers 90% of the national population, commercial medical insurance is still very important. developed. Therefore, the support of national policies is a prerequisite for development.

2. Graft medical services and health insurance through health management organizations. Health management is a process of comprehensive management of personal health risk factors. In recent years, health management has developed rapidly in China, and high-income groups have gradually begun to recognize and accept it. Specifically, health management is mainly composed of three parts: first is to collect personal health information, including current physical conditions, lifestyle and habits, family history of disease, and physical examination. Then, based on the collected health information, a health evaluation is performed, also known as disease prediction. Finally, the health improvement process, that is, doctors provide targeted guidance to individuals on the basis of health assessment to improve their health. Through the implementation of health management, insurance companies can turn passive post-hoc claims into health management services throughout the process. In this way, by implementing risk control measures such as health education and preventive health care for the insured, the purpose of effectively reducing the incidence of the insured and reducing medical expenses can be achieved. From the perspective of the insured, health management is to control claims by reducing the incidence of the insured's disease and to block medical expenses from the source. This is a complete health protection system, similar to the risk management implemented by insurers in property insurance.

3. Insurance companies can participate in medical institutions. By establishing an insurance company's equity participation or investment in a medical institution, and forming an interest community between the insurance company and the medical institution, the insured can be avoided to the greatest extent from the moral hazard of hospitals, hospitals and the insured conspiracy. For example, because the medical examination results directly affect the insurance costs to be paid by the customer, if the customer has a physical health problem that affects the increase in insurance policy costs, the insurance salesperson or the customer himself will actively look for relationships to delete records to help customers reduce premiums. The salesperson does not Is willing to lose any opportunity to make a bill, the doctor's friends at the hospital provided them with such an opportunity, and the last damage will be the insurance company. However, if an insurance company has a stake in a medical institution and is bound by common interests, the hospital will actively participate in controlling the occurrence of moral hazard. At the same time, in this way, medical institutions can better help insurance companies collect insurance data, which will help insurance companies obtain complete health information files of the insured and stabilize the source of insurance customers. In addition, some value-added services of insurance companies can be realized, such as providing customers with a series of health services such as health education and preventive care.

4. Adopt the medical expense contract mode. Insurance companies do not need to invest in setting up medical institutions, but rather establish a relatively shallow level of cooperation with hospitals, which is also dominated by profit sharing. The specific method is to pay a certain percentage of the premiums paid by the insured to the insurance company to the medical institution in advance, and then the hospital fully bears the health risks of the insured. The purpose of controlling medical expenses. In addition, if the hospital can get paid in advance, it will be willing to adopt this cooperation method and establish a cooperative relationship with insurance companies more actively. However, the implementation of the cost-containment model requires scientific calculations of insurance premiums that insurance companies should allocate to medical institutions, as well as the choice and details of long-term cooperation of medical service institutions.