Recently, Founder Securities released an industry report on “Business Insurance Opens the Internet Medical Business Model Closed Loopâ€, which provides a constructive view from the perspective of medical reform and medical big data to break the current dilemma of the Internet medical business model.
History of the development of American commercial health insurance
Although China and the United States have significant differences in several important factors affecting the health insurance market, such as social system, economic development level, medical and health system, and household consumption habits. However, the US commercial health insurance market is so developed and well-functioning, and its development law will inevitably bring significant enlightenment to China's development of health insurance. In 2014, the US commercial health insurance market reached 2.2 trillion US dollars, a year-on-year increase of 6%. In terms of scale, the size of the US commercial health insurance market has reached more than 60 times that of China.
Looking at the development of American commercial health insurance, we believe that there are several important insights:
The full market-oriented medical supply system and the rise of managed care are prerequisites for the development of health insurance. The emergence of the US 1920s employer-led health maintenance organization, the Caesar medical model, and the emergence of the “Blue Cross Blue Shield†program led by medical institutions in the 1930s reflected that the supply and demand of the US medical market was completely guided by the market. At the same time, both organizations are health-maintained and are the primary stage of managed care. Their emergence opened the history of the development of American health insurance.
Group insurance should take precedence over individual risks. In the United States, group insurance is a very important market. In the 1840s and 1960s, under the promotion of policies, American commercial insurance institutions entered the group insurance market on a large scale and have always become the mainstream of the US health insurance market. The individual insurance market began to develop rapidly after the mandatory implementation of Obama's medical reform in 2010. However, due to the huge risk of moral hazard and adverse selection, the business newspapers are not motivated.
Insurance is the key to business closure, and the dominant power of managed care is ultimately attributed to insurance. From the employer-led Caesar medical model in the 1920s to the “double blue†medical model dominated by medical institutions in the 1930s, and the HMO model led by insurance institutions in the 1970s, the logic behind the medical market is from the structure of supply and demand. Business-closed-party evolution of the party-payer-demand side.
The payment method improves the driving force for releasing the healthy development of health insurance. In 1983, the United States began to introduce and use DRGs payment methods on a large scale, greatly improving the ability to control health insurance, and the US commercial health insurance has also developed rapidly.
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Figure 27: History of the US health insurance market
Major health insurance companies in the United States are profitable
From the international experience, the current US health insurance has replaced medical services as the core of the entire health industry chain. The top five commercial health insurance companies in the United States are United Health, Anson Insurance, Harmony, Antai Insurance and Cigna Insurance, all of which are Fortune 500 companies. In 2015, the premium income of five commercial health insurance companies was $127.2 billion, $73.4 billion, $52.4 billion, $51.6 billion and $29.6 billion.
From the operation of the top five commercial health insurance companies in the United States, the health insurance industry can maintain stable profits. (1) Unlike the “investment-driven†model of domestic health insurance companies, the insurance business of American commercial health insurance companies can achieve profitability. The income from investment business only accounts for a small proportion of operating income, and it shows a downward trend year by year. The top five businesses in the United States in 2015 Health insurance company's investment business income accounted for less than 3% of revenue. (2) Net profit is relatively stable and has remained between 2% and 6% in recent years. (3) The insurance insurance business loss ratio has also remained stable. Except for CIGNA Insurance, the other four companies are between 80-85%. CIGNA has a lower rate of compensation than other companies due to its high-end market.
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Figure 28: Scale of premium income for health insurance companies in 2006-2015
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Figure 29: 2006-2015 Health Insurance Company Investment Income / Revenue
Business model after the US commercial health insurance
In the early stage of the development of commercial health insurance in the United States, traditional expense reimbursement insurance products dominated, insurance and health services were in a relatively fragmented state, and the two sides lacked deep integration. Until the United States passed the Health Protection Law Organization Law in 1973, health management organizations rose, health management services gradually integrated into health insurance, and became an important means of health risk management risks. Therefore, health management is also called health risk management. The US healthcare industry has effectively curbed the excessive growth of medical expenses because of the joint participation of US commercial health insurance and health risk management.
After more than 30 years of development, the US health insurance business model completed the transformation from traditional expense reimbursement to managed care in the 1990s, and completed the business model of opening up health insurance in the true sense. From the aspect of customer consumption experience, managed medical care has more advantages than traditional reimbursement type, incorporating health management and health maintenance into health insurance services, enriching the service connotation of health insurance. From the perspective of cost control (medical control fees), managed medical care strengthens the cooperation between “medical†and “guaranteeâ€, strengthens the control over medical behavior, promotes the rational use of medical resources, and reduces the rapid increase in medical expenses caused by excessive medical treatment.
As the health industry chain matures, health insurance plays an important role as a bridge in the entire medical and health industry chain. For the upstream, integrating the health service resources, medical service resources, drugs and information in the industrial chain, downstream, Become a docking patient health demand, provide an integrated service model, and accordingly generate a new business model: health insurance + medical, health insurance + health management, health insurance + PBM, health insurance + Internet, PBM and so on.
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Exhibit 32: A variety of business models are formed after the US commercial health insurance hits
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