A study on the current status of collaboration between China’s commercial health insurance and medical institutions and improvement strategies

BACKGROUND: Acting as a supplement to China's basic medical insurance, the overall development of commercial health insurance in China remains immature. Commercial health insurance institutions collaborate with medical institutions to provide healthcare services for their insured patients. This study aims to understand the current status of those two parties' collaboration, and evaluate the factors that influence their partnership, thereby providing empirical evidence and improvement strategies for fostering their healthier collaboration and achieving a win-win scenario, which will contribute to the high-quality medical services to the public. METHODS: A questionnaire survey was conducted among 616 medical institution personnel and commercial health insurance professionals from approximately ten regions across China. A measurement model was employed to examine the validity and reliability of the evaluation questionnaire, and then empirical analysis was used. RESULTS: Survey respondents from commercial health insurance institutions perceived that medical workers have limited understanding of commercial health insurance. Over 85% of respondents from both groups indicated that medical workers should enhance their knowledge in the coverage and claim rules of commercial health insurance. Regarding medical behaviors which will affect claim settlement or be identified as insurance fraud, "the medical record is not detailed" (80.14%) was identified as the primary concern for insurance institutions, while "the treatment plan is inconsistent with the diagnoses in the medical record" (67.48%) was the main concern for medical institutions. Regarding improving medical behaviors, insurance institutions hope that hospitals can avoid breaking down service times, prescribe reasonable examinations and charge fairly; Meanwhile, medical institutions hope that insurance institutions can "arrange a dedicated person to explain insurance-related questions". CONCLUSIONS: To improve their collaboration, commercial health insurance institutions can simplify claim process, design multi-level products to give full play to their supplementary role, and cooperate with medical institutions to strengthen publicity and education for medical workers and patients on insurance policies and rules. Government agencies should introduce more legislation to regulate patients' and medical workers' behaviors to curb insurance fraud. Medical institutions, in coordination with government agencies and insurance institutions, should explore mechanisms for medical data sharing to regulate medical workers' medical behaviors and help insurance institutions to innovate product designs. Based on survey findings from 616 respondents, this study identifies potential strategies that may improve collaboration between commercial health insurance and medical institutions. Further research is needed to evaluate whether these strategies effectively improve patient services.