大数据背景下整合健康保险&健康维护的理论方法体系

在理论和实践上,健康保险与健康维护应为统一体,但目前结合不紧密。为此,提出了“整合健康保险&健康维护”新范式,并创建了其大数据共享平台。进而,遵循“大数据驱动、跨系统(健康保险、健康维护)整合、全程式(生命历程、疾病进程)干预、多学科交叉”思路,创建了“整合健康保险&健康维护”的理论方法体系。该体系包括大数据驱动的健康管理学理论方法、健康保险精算理论方法、I-M-P-G新三角四方范式及其管理决策和政策体系。在大数据驱动下,它将健康管理和管理式医疗应用到健康维护中,在减少健康保险机构I方赔付、增加预防/医疗服务提供M方收入及效率、维护享受保障人群P方健康、确保政府G方目标之间形成良性互动,达到四方共赢;旨在充分发挥轴心G方宏观调控作用推进社保-商保共赢发展,引导资金投向健康管理和管理式医疗,实现关口前移,达到节约经费和维护健康双赢目标,为“健康中国”战略的“大卫生”管理体制和“互联网+健康保险+健康维护”新业态提供理论方法支持。

Theoretical method system for integrating health insurance and health maintenance in the context of big data

Health insurance are supposed to be united with health maintenance in both theory and practice, while their current combination is not close enough in China. For this reason, this study proposed a novel paradigm that integrates health insurance and health maintenance, and established its big data sharing platform. Then, the theoretical and methodological system for integration of health insurance and health maintenance was established following the design ideas, including big data-driven, cross-system(health insurance and health maintenance)integration, whole-course(life course and disease process)intervention and multidisciplinary intersection. This system includes the theory and method of health management driven by big data, the actuarial theory and method of health insurance, the novel triangular quadrilateral paradigm of I-M-P-G and its management decision-making and policy system. Driven by big data, health management and managed care could be applied in health maintenance, by which decreasing the compensation of health insurance organizations(I), increasing the income and efficiency of preventive/medical service providers(M), maintaining the health of insured population(P)and ensuring the objectives of government(G)were well interacted, and achieved an all-win situation. Meanwhile, this paradigm could give full play to the role of government for macro-regulation to promote the win-win development between social insurance and business insurance, as well as guide the funds to health management and managed care to implement earlier prevention and realize the goals of both reduction of expenditures and maintaining health. This article provided a theoretical method support for the health management system in “Health China” strategy and the new type of operation of “Internet + Health insurance + Health maintenance”.