健康中国战略下我国商业健康保险定位价值、发展趋势及问题建议  

The Positioning,Value,Development Trend,Problems and Suggestions of Commercial Health Insurance in China Under the Healthy China Initiative

作　　者：马振涛 文晓初[2] 

机构地区：[1]安阳师范学院马克思主义学院,安阳455000 [2]首都医科大学附属北京同仁医院护理部,北京100005 [3]北京师范大学政府管理研究院,北京100875

出　　处：《中国医疗保险》2025年第3期92-106,共15页China Health Insurance

基　　金：国家社科基金一般项目“数字技术赋能城市群协同治理问题研究”(22BGL269)。

摘　　要：商业健康保险作为多层次医疗保障体系的重要组成部分,能够有效降低个人支付比例,合理分担医疗费用,进而促进医疗卫生服务总体水平的提升。近年来,我国商业健康保险在经历快速发展后,已迈入社商融合的新发展阶段。然而,商业健康保险的发展亦面临一系列挑战,包括产品创新不足、标准化体系缺失、政策支持力度有限、产业融合不深、数据共享困难以及理赔情况不理想等。鉴于此,本研究提出以下优化发展的建议:进一步明确商业健康保险定位范围,完善商业健康保险药品目录等标准体系;推动商业健康保险扩面提质,同时需更好地适应DRG/DIP支付方式改革要求;探索管理式医疗保险模式,推动保险行业与其他医疗健康领域的深度协作与融合发展。此外,还需强化政策激励与扶持力度,推进数据共享机制建设、优化服务流程,以助力健康中国战略的实施。As an important component of the multi-level healthcare security system in China,commercial health insurance can effectively reduce individual payment ratios,reasonably share medical expenses,and promote the overall improvement of medical and health services.In recent years,China's commercial health insurance has entered a new stage of social insurance-commercial insurance integration after rapid development.However,the development of commercial health insurance also faces a series of challenges,including insufficient product innovation,lack of standardization system,limited policy support,insufficient industry integration,difficulties in data sharing,and unsatisfactory claims.In view of this,this study proposes the following optimization and development suggestions.The positioning and scope of commercial health insurance should be further clarified,the standard system of commercial health insurance drug catalog should be improved,and the expansion and improvement of commercial health insurance should be promoted,better adapting to the requirements of DRG/DIP payment reform.The managed healthcare insurance model can be explored and deep collaboration and integrated development between the insurance industry and other healthcare sectors should be promoted.In addition,it is necessary to strengthen policy incentives and support,promote the construction of data sharing mechanisms,and optimize service processes to assist in the implementation of the Healthy China Initiative.

关 键 词：多层次医疗保障体系 基本医保 商业健康保险 健康中国 普惠保险 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]