城乡居民大病保险“社商合作”模式研究  

Research on the Social-Commercial Cooperation Model of Critical Illness Insurance for Urban and Rural Residents

作　　者：张心洁[1] 谭琪 陈妮婧 付银裕 

机构地区：[1]江苏大学管理学院,镇江212013 [2]镇江市医疗保险基金管理中心,镇江212013 [3]烟台市医疗保障局办公室,烟台264003

出　　处：《中国医疗保险》2025年第2期5-12,共8页China Health Insurance

基　　金：国家自然科学基金面上项目“基于激励相容的城乡居民门诊大病保障支付模式研究”(72174078);国家医疗保障局2024年度课题“大病保险筹资模型研究”(202412);江苏高校“青蓝工程”资助(2022)。

摘　　要：商业健康保险是多层次医疗保障体系建设的重要内容。本文以城乡居民大病保险的社会保险与商业保险合作(以下简称社商合作)模式为切入点,通过实地调研,结合对样本地区大病保险运行情况、社商合作模式等的综合分析,揭示商保参与大病保险运行的关键问题并分析成因。研究发现,尽管大病保险制度有效减轻了大病患者的费用负担,但仍存在主体责任边界不清、盈亏风险不对等、激励机制不健全及信息壁垒难破除等诸多挑战。基于此,提出通过加强顶层设计,明确主体功能定位;健全合作机制,全面发挥商保优势;优化供给匹配,夯实商保补充功能等建议,以期为推动商保参与多层次医保体系建设提供实践思考和决策依据。Commercial health insurance is an important component in the construction of a multi-level healthcare security system.This study takes the social-commercial cooperation in critical illness insurance for urban and rural residents as the entry point,reveals the key issues of participation of commercial insurance in the critical illness insurance operation and analyzes the causes,through field research and a comprehensive analysis of the critical illness insurance operation and social-commercial cooperation models in sample regions.The study finds that while the critical illness insurance system has effectively alleviated the financial burden on patients with severe illnesses,it still faces numerous challenges,including unclear boundaries of stakeholder responsibilities,unequal distribution of profit and loss risks,inadequate incentive mechanisms,and unresolved information barriers.Based on these issues,this study proposes recommendations such as strengthening top-level design to clarify the functional positioning of stakeholders,improving cooperative mechanisms to fully leverage the advantages of commercial insurance,and optimizing supply-demand matching to reinforce the supplementary role of commercial insurance.These suggestions can provide practical insights and decision-making references for promoting the participation of commercial insurance in the construction of a multi-level healthcare security system.

关 键 词：居民医保 大病保险 多层次医疗保障体系 商业健康保险 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]