導語(yu)：商業健(jian)康保險的逆選擇風險防(fang)控一文來(lai)源(yuan)于網友上(shang)傳，不代表本站觀點，若(ruo)需要(yao)原創文章可(ke)咨詢(xun)客服老師，歡迎參考。

[摘要]當前，我國商業健康保險發展勢頭強勁，但風險防控問題愈發嚴峻，逆選擇成為其發展的絆腳石。本文分析逆選擇風險對我國商業健康保險發展的影響，在借鑒國際相關經驗的基礎上，基于保險科技賦能，從商業健康保險經營公司和政府部門兩個層面提出逆選擇風險防控的政(zheng)策建議，以期助推商業健康(kang)保險高質量發展。

[關鍵詞]商業健康保(bao)險；逆選擇；風險防控；保(bao)險科(ke)技

國(guo)家衛生(sheng)健(jian)(jian)康(kang)(kang)(kang)委2019年(nian)(nian)發(fa)(fa)布的(de)(de)(de)(de)《健(jian)(jian)康(kang)(kang)(kang)中國(guo)行（2019—2030年(nian)(nian)）》提(ti)出，要(yao)(yao)促進基本醫(yi)療(liao)保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)、大病(bing)保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)、醫(yi)療(liao)救助(zhu)(zhu)、應急救助(zhu)(zhu)、商(shang)業(ye)健(jian)(jian)康(kang)(kang)(kang)保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)及(ji)慈善救助(zhu)(zhu)等制度的(de)(de)(de)(de)互(hu)補(bu)聯動(dong)和有(you)效銜接，形成(cheng)保(bao)(bao)(bao)障合力，切實降低患者(zhe)就(jiu)醫(yi)負擔。商(shang)業(ye)健(jian)(jian)康(kang)(kang)(kang)保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)（以下簡稱健(jian)(jian)康(kang)(kang)(kang)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)）是以人(ren)的(de)(de)(de)(de)身體為(wei)保(bao)(bao)(bao)障對象，保(bao)(bao)(bao)證(zheng)被保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)人(ren)在(zai)疾(ji)病(bing)或(huo)(huo)發(fa)(fa)生(sheng)意外事故所致傷害時的(de)(de)(de)(de)費(fei)用或(huo)(huo)損(sun)失能(neng)(neng)獲得補(bu)償的(de)(de)(de)(de)一類商(shang)業(ye)保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)，包括醫(yi)療(liao)保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)、疾(ji)病(bing)保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)、失能(neng)(neng)收入(ru)保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)以及(ji)長期(qi)護理保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)。當前，我國(guo)經濟社(she)會發(fa)(fa)展(zhan)進入(ru)新階段，健(jian)(jian)康(kang)(kang)(kang)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)發(fa)(fa)展(zhan)勢頭強勁。其中，醫(yi)療(liao)保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)與疾(ji)病(bing)保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)發(fa)(fa)展(zhan)最快(kuai)，例如(ru)當前快(kuai)速發(fa)(fa)展(zhan)的(de)(de)(de)(de)城(cheng)市(shi)普惠險(xian)(xian)(xian)(xian)(xian)(xian)(xian)，作為(wei)醫(yi)療(liao)保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)的(de)(de)(de)(de)分支遍布各大城(cheng)市(shi)；又如(ru)重疾(ji)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)作為(wei)疾(ji)病(bing)保(bao)(bao)(bao)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)的(de)(de)(de)(de)分支，也占有(you)重要(yao)(yao)席位。2016—2021年(nian)(nian)，健(jian)(jian)康(kang)(kang)(kang)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)的(de)(de)(de)(de)保(bao)(bao)(bao)費(fei)收入(ru)從4042.5億元增長至8447億元，五年(nian)(nian)翻(fan)一番（見(jian)圖1）。與此同時，健(jian)(jian)康(kang)(kang)(kang)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)的(de)(de)(de)(de)風險(xian)(xian)(xian)(xian)(xian)(xian)(xian)防(fang)控(kong)問題愈發(fa)(fa)嚴峻，逆選擇成(cheng)為(wei)健(jian)(jian)康(kang)(kang)(kang)險(xian)(xian)(xian)(xian)(xian)(xian)(xian)發(fa)(fa)展(zhan)面臨的(de)(de)(de)(de)主要(yao)(yao)風險(xian)(xian)(xian)(xian)(xian)(xian)(xian)之(zhi)一[1]，亟待研究解(jie)決。

1逆選擇成為健康險發展的絆腳石

逆選擇行(xing)(xing)為是指投(tou)保(bao)(bao)人(ren)或被保(bao)(bao)險(xian)人(ren)在(zai)已知風險(xian)會發生的情況下仍購(gou)買(mai)保(bao)(bao)險(xian)，通過獲(huo)得(de)保(bao)(bao)險(xian)賠償，實現風險(xian)轉移。健康險(xian)的逆選擇行(xing)(xing)為主(zhu)要表現為帶病(bing)投(tou)保(bao)(bao)，即投(tou)保(bao)(bao)人(ren)已知自己患(huan)病(bing)或可(ke)能(neng)患(huan)病(bing)，卻刻意(yi)隱(yin)瞞，利(li)用信息不對稱獲(huo)得(de)理(li)賠；而(er)健康人(ren)群購(gou)買(mai)意(yi)愿(yuan)較低(di)。本質就是高風險(xian)投(tou)保(bao)(bao)人(ren)以低(di)于精(jing)算(suan)費率(lv)的價格(ge)購(gou)買(mai)健康險(xian)，導致理(li)賠概率(lv)提升(sheng)，運營成本增加，經營效率(lv)與利(li)潤下降，成為健康險(xian)可(ke)持續(xu)發展(zhan)的絆(ban)腳石。

（1）逆(ni)選擇(ze)會導(dao)致(zhi)(zhi)健康險(xian)(xian)產(chan)品供需(xu)失衡(heng)。均衡(heng)保(bao)(bao)費(fei)的(de)定價方式易吸引高風(feng)(feng)險(xian)(xian)人群(qun)投保(bao)(bao)，而健康人群(qun)的(de)購買(mai)意愿較(jiao)低，風(feng)(feng)險(xian)(xian)池中聚集大量次標準體(ti)甚至拒保(bao)(bao)體(ti)投保(bao)(bao)人，偏(pian)離了保(bao)(bao)險(xian)(xian)群(qun)體(ti)消化個(ge)體(ti)風(feng)(feng)險(xian)(xian)的(de)本質。健康險(xian)(xian)經(jing)營(ying)公司(si)為控制(zhi)經(jing)營(ying)風(feng)(feng)險(xian)(xian)，尋求(qiu)續(xu)保(bao)(bao)和盈利(li)之間的(de)平衡(heng)，只能采取停(ting)售措(cuo)施。在健康保(bao)(bao)障需(xu)求(qiu)日益(yi)攀升的(de)時(shi)代，健康險(xian)(xian)產(chan)品的(de)供給不足，會導(dao)致(zhi)(zhi)供需(xu)失衡(heng)及保(bao)(bao)險(xian)(xian)資源浪費(fei)，保(bao)(bao)障功能受(shou)阻。

（2）健(jian)康險經(jing)(jing)營(ying)(ying)(ying)成(cheng)本升(sheng)高，陷(xian)入(ru)(ru)經(jing)(jing)營(ying)(ying)(ying)逆境(jing)。逆選擇行為(wei)增加了(le)(le)健(jian)康險經(jing)(jing)營(ying)(ying)(ying)公(gong)司的核保(bao)(bao)(bao)運營(ying)(ying)(ying)成(cheng)本。全(quan)球衛(wei)生保(bao)(bao)(bao)健(jian)欺(qi)詐(zha)網絡(GHCAN)統(tong)計，全(quan)球每年因(yin)健(jian)康險欺(qi)詐(zha)造成(cheng)的損失達2600億美(mei)元[2]。健(jian)康險經(jing)(jing)營(ying)(ying)(ying)公(gong)司為(wei)應對逆選擇風險制定(ding)了(le)(le)嚴格(ge)的核保(bao)(bao)(bao)流程(cheng)，人力(li)、物(wu)力(li)、財力(li)成(cheng)本攀升(sheng)，智能(neng)核保(bao)(bao)(bao)系統(tong)的引入(ru)(ru)也提(ti)升(sheng)了(le)(le)研(yan)發(fa)費用和核保(bao)(bao)(bao)成(cheng)本。同時(shi)，逆選擇行為(wei)致使產品賠付率加速惡(e)化(hua)，健(jian)康險經(jing)(jing)營(ying)(ying)(ying)公(gong)司為(wei)了(le)(le)維(wei)持產品盈利，只(zhi)能(neng)提(ti)高保(bao)(bao)(bao)費，導(dao)致更多(duo)投保(bao)(bao)(bao)人脫落(luo)而(er)形成(cheng)惡(e)性循環，最終陷(xian)入(ru)(ru)經(jing)(jing)營(ying)(ying)(ying)困境(jing)[3]。

（3）保險(xian)(xian)人(ren)與投保人(ren)關系惡化，健康險(xian)(xian)經營(ying)虧名損實(shi)。一是(shi)在健康險(xian)(xian)市場(chang)上劣幣驅逐良幣情況頻發，高(gao)性價比產品少(shao)，消費(fei)者(zhe)對健康險(xian)(xian)產品的(de)(de)印象不佳(jia)而失(shi)去信(xin)心。二是(shi)保險(xian)(xian)銷(xiao)售的(de)(de)誤(wu)導加劇了保險(xian)(xian)雙方關系惡化，個別銷(xiao)售人(ren)員誤(wu)導投保人(ren)，不如實(shi)告知，在出險(xian)(xian)時理(li)賠糾紛不斷。同(tong)(tong)時，消費(fei)者(zhe)對健康保險(xian)(xian)合同(tong)(tong)的(de)(de)眾(zhong)多專業(ye)術語(yu)較難理(li)解，易產生誤(wu)解和糾紛。

2逆選擇應對過程中可能產生的問題

2.1市場競爭(zheng)激(ji)烈，忽視(shi)逆選擇(ze)風險

市場(chang)競爭是提(ti)高(gao)市場(chang)運行效率(lv)的(de)有力手段，也是市場(chang)經(jing)(jing)濟發展的(de)根本特征。當前健(jian)康險(xian)(xian)市場(chang)競爭激烈，經(jing)(jing)營(ying)公司(si)為了(le)搶占市場(chang)，被迫采取降低(di)保費、降低(di)核保標(biao)準、減(jian)少等待期等手段，極(ji)大增加了(le)逆選擇隱匿風險(xian)(xian)。在戰(zhan)略發展方(fang)向上(shang)，健(jian)康險(xian)(xian)經(jing)(jing)營(ying)公司(si)重(zhong)渠道深(shen)度、輕(qing)渠道廣度，忽視保單質量與(yu)風險(xian)(xian)管理，“重(zhong)規模、輕(qing)利潤”，忽視逆選擇風險(xian)(xian)漏洞[4]。

2.2健康告知存在漏洞，銷(xiao)售誤導時(shi)有(you)發生

一是(shi)(shi)(shi)部分健(jian)康險經(jing)營公(gong)司(si)的健(jian)康告知形(xing)同虛設，僅將投(tou)保(bao)(bao)人健(jian)康告知列(lie)為(wei)主要(yao)篩(shai)選條(tiao)件。在(zai)出現保(bao)(bao)額高(gao)、財務狀(zhuang)況與(yu)(yu)保(bao)(bao)額不匹配(pei)、健(jian)康告知或體檢異常時才(cai)觸發(fa)實質核(he)保(bao)(bao)工作(zuo)。其(qi)他有關投(tou)保(bao)(bao)人的詳盡調查，在(zai)發(fa)生(sheng)理賠申(shen)請時才(cai)進行，是(shi)(shi)(shi)理賠糾(jiu)紛(fen)頻發(fa)的重要(yao)原(yuan)因(yin)。二是(shi)(shi)(shi)健(jian)康告知規(gui)則制定(ding)固定(ding)化、機械化、模糊化。健(jian)康險經(jing)營公(gong)司(si)為(wei)提高(gao)銷售業績(ji)，在(zai)健(jian)康告知時設置“模糊”問題或概括(kuo)性問題，客觀上導(dao)致(zhi)投(tou)保(bao)(bao)人無法作(zuo)出準確回答(da)，弱化了健(jian)康告知篩(shai)選功能。三是(shi)(shi)(shi)醫(yi)學界(jie)與(yu)(yu)保(bao)(bao)險界(jie)對健(jian)康的定(ding)義存在(zai)差(cha)異，醫(yi)學關注疾病當下的狀(zhuang)況，而(er)核(he)保(bao)(bao)醫(yi)學關注疾病未來發(fa)生(sheng)的概率(lv)。由于(yu)缺(que)少既懂保(bao)(bao)險又懂醫(yi)學的專業人士為(wei)投(tou)保(bao)(bao)人進行講解，銷售誤(wu)導(dao)時有發(fa)生(sheng)，容易產生(sheng)糾(jiu)紛(fen)。

2.3核保(bao)環(huan)節形式主義嚴重，智能(neng)核保(bao)經驗不足

健康(kang)險(xian)(xian)(xian)核(he)保(bao)(bao)工(gong)作是風(feng)險(xian)(xian)(xian)管(guan)控的重要一(yi)環，多數健康(kang)險(xian)(xian)(xian)經營(ying)公司受(shou)運營(ying)成本(ben)限制，對(dui)核(he)保(bao)(bao)工(gong)作投入力度小，前(qian)端風(feng)控效果差。保(bao)(bao)險(xian)(xian)(xian)科技時(shi)代(dai)的到來(lai)為(wei)健康(kang)險(xian)(xian)(xian)核(he)保(bao)(bao)工(gong)作帶來(lai)了機(ji)遇(yu)，智(zhi)能(neng)(neng)(neng)核(he)保(bao)(bao)系(xi)統(tong)可有效防(fang)控逆選擇行為(wei)，但目前(qian)尚處于初級階段，受(shou)科技手段及數據(ju)來(lai)源所限，未能(neng)(neng)(neng)實(shi)現真正“智(zhi)能(neng)(neng)(neng)”，誤判(pan)(pan)情況時(shi)有發(fa)生。在經營(ying)實(shi)務中，智(zhi)能(neng)(neng)(neng)核(he)保(bao)(bao)系(xi)統(tong)依(yi)(yi)據(ju)保(bao)(bao)險(xian)(xian)(xian)科技將健康(kang)告知分層細化(hua)(hua)，以(yi)客戶選擇為(wei)判(pan)(pan)斷依(yi)(yi)據(ju)，存在應用(yong)機(ji)械(xie)化(hua)(hua)、覆蓋(gai)范圍(wei)小、動力不(bu)足(zu)、缺(que)乏(fa)靈活性(xing)等問(wen)題(ti)。同時(shi)，智(zhi)能(neng)(neng)(neng)核(he)保(bao)(bao)系(xi)統(tong)在實(shi)際(ji)應用(yong)中只能(neng)(neng)(neng)處理簡單問(wen)題(ti)，存在智(zhi)能(neng)(neng)(neng)核(he)保(bao)(bao)快捷性(xing)與前(qian)端核(he)保(bao)(bao)精準性(xing)之間的矛盾(dun)。另外，部分健康(kang)險(xian)(xian)(xian)經營(ying)公司由于實(shi)力不(bu)足(zu)及資金缺(que)乏(fa)，仍采取以(yi)調查問(wen)卷(juan)和健康(kang)體檢為(wei)主的傳(chuan)統(tong)核(he)保(bao)(bao)手段，在核(he)保(bao)(bao)系(xi)統(tong)創新上相對(dui)滯后(hou)。

2.4數據收集系統及風控模型尚不完備

一是保(bao)(bao)(bao)險公(gong)司(si)缺(que)乏(fa)(fa)數(shu)據共(gong)(gong)享渠道(dao)。當前(qian)我國(guo)保(bao)(bao)(bao)險行業與醫(yi)療機構(gou)信息共(gong)(gong)享頻率低(di)、內容少，保(bao)(bao)(bao)險公(gong)司(si)缺(que)乏(fa)(fa)對疾(ji)病的(de)(de)(de)深(shen)入分析(xi)以及對治療費用、人力(li)(li)成(cheng)本的(de)(de)(de)科學評(ping)估，對醫(yi)療服務的(de)(de)(de)臨床合(he)理(li)性缺(que)乏(fa)(fa)判斷力(li)(li)，無法高效(xiao)敏(min)銳檢測(ce)出(chu)欺詐行為，成(cheng)本控制效(xiao)率低(di)下。二是信息收(shou)集與需求管(guan)理(li)不(bu)匹配。在保(bao)(bao)(bao)險公(gong)司(si)經營(ying)實務中(zhong)由(you)于科技應(ying)用能(neng)力(li)(li)不(bu)強，數(shu)據收(shou)集定位存(cun)在偏差，導致系統數(shu)據不(bu)足以支(zhi)撐(cheng)風(feng)控算法。三是風(feng)控模(mo)型(xing)的(de)(de)(de)構(gou)建缺(que)乏(fa)(fa)客(ke)戶(hu)粘性。當前(qian)我國(guo)健康險覆(fu)蓋客(ke)戶(hu)群體(ti)狹(xia)窄(zhai)，缺(que)乏(fa)(fa)連續且(qie)可追(zhui)蹤的(de)(de)(de)用戶(hu)健康數(shu)據，基于大數(shu)據的(de)(de)(de)風(feng)控模(mo)型(xing)應(ying)用效(xiao)果(guo)較差。

2.5一刀切式的核保(bao)流程問題嚴重

一(yi)是健(jian)康險(xian)仍以(yi)體(ti)(ti)(ti)檢(jian)指標(biao)作為(wei)主要核(he)(he)保(bao)(bao)(bao)標(biao)準(zhun)，將投保(bao)(bao)(bao)人(ren)分為(wei)標(biao)準(zhun)體(ti)(ti)(ti)承(cheng)保(bao)(bao)(bao)和(he)非標(biao)準(zhun)體(ti)(ti)(ti)拒(ju)保(bao)(bao)(bao)，大量(liang)非標(biao)準(zhun)體(ti)(ti)(ti)投保(bao)(bao)(bao)人(ren)被拒(ju)之門外。同時針(zhen)對高齡群體(ti)(ti)(ti)的(de)投保(bao)(bao)(bao)排外嚴(yan)重，損(sun)失了大量(liang)客源(yuan)。二是健(jian)康險(xian)產品同質化(hua)現象，核(he)(he)保(bao)(bao)(bao)、承(cheng)保(bao)(bao)(bao)、理(li)賠流(liu)程固(gu)化(hua)，經營公司為(wei)避免出現標(biao)準(zhun)流(liu)程之外的(de)情況，設置一(yi)刀(dao)切(qie)式核(he)(he)保(bao)(bao)(bao)規(gui)則，統一(yi)將患有慢性病等投保(bao)(bao)(bao)群體(ti)(ti)(ti)列為(wei)非承(cheng)保(bao)(bao)(bao)體(ti)(ti)(ti)。另外，部分互聯網健(jian)康險(xian)僅提供(gong)線(xian)上核(he)(he)保(bao)(bao)(bao)，無人(ren)工審核(he)(he)。當前一(yi)刀(dao)切(qie)式的(de)核(he)(he)保(bao)(bao)(bao)流(liu)程有違健(jian)康險(xian)初衷，使真(zhen)正需要健(jian)康保(bao)(bao)(bao)障的(de)客戶(hu)暴露于風險(xian)之下(xia)，亟需科(ke)技助力構建個性化(hua)核(he)(he)保(bao)(bao)(bao)系統，規(gui)避逆選(xuan)擇(ze)行為(wei)發生。

3各國應對健康險逆選擇的經驗

3.1美國

（1）Cloverhealth。美國Cloverhealth公司(si)成立(li)于2014年，主營(ying)(ying)業務(wu)是為(wei)65歲以(yi)上(shang)老(lao)年人(ren)提供健(jian)康(kang)險(xian)。Cloverhealth通(tong)過(guo)兩個價值(zhi)循環實(shi)現健(jian)康(kang)險(xian)管理(li)服務(wu)（見圖(tu)2）。一(yi)(yi)是商業價值(zhi)循環。利(li)用(yong)數(shu)(shu)據(ju)技(ji)術分析、組織、使用(yong)數(shu)(shu)據(ju)，彌(mi)補醫療護理(li)漏洞(dong)，通(tong)過(guo)數(shu)(shu)據(ju)閉(bi)環減(jian)少醫療支出、降低保費(fei)。同(tong)時(shi)，利(li)用(yong)數(shu)(shu)據(ju)技(ji)術及網絡手段(duan)，優化(hua)、評估(gu)、迭(die)代對會員的健(jian)康(kang)干預(yu)(yu)(yu)手段(duan)。二(er)是社(she)會價值(zhi)循環。與(yu)被保險(xian)人(ren)建立(li)一(yi)(yi)對一(yi)(yi)關系，基于信任，合理(li)獲取數(shu)(shu)據(ju)，通(tong)過(guo)數(shu)(shu)據(ju)挖掘提高患者和醫生(sheng)體驗，提供更精準的治療。Cloverhealth公司(si)擁(yong)有(you)(you)兩大優勢。一(yi)(yi)是全方(fang)位(wei)掌握患者數(shu)(shu)據(ju)，將電子病(bing)歷、藥物(wu)處方(fang)、病(bing)理(li)檢驗數(shu)(shu)據(ju)、影像數(shu)(shu)據(ju)納(na)入數(shu)(shu)據(ju)庫，通(tong)過(guo)機(ji)器學(xue)習方(fang)法，預(yu)(yu)(yu)測患者疾病(bing)發生(sheng)率，評估(gu)風險(xian)，將數(shu)(shu)據(ju)置于運營(ying)(ying)核心。二(er)是擁(yong)有(you)(you)專業軟件平臺。通(tong)過(guo)整合用(yong)戶(hu)數(shu)(shu)據(ju)，建立(li)估(gu)測模(mo)型(xing)，區分不(bu)同(tong)人(ren)群(qun)患病(bing)風險(xian)，優化(hua)、創(chuang)新干預(yu)(yu)(yu)手段(duan)，以(yi)整合大數(shu)(shu)據(ju)為(wei)基礎，實(shi)時(shi)掌握人(ren)群(qun)健(jian)康(kang)狀況，進行風險(xian)預(yu)(yu)(yu)測，減(jian)少逆選擇的存(cun)在(zai)空間。

（2）OscarHealth。美(mei)國OscarHealth公(gong)司(si)(si)成立于2013年，主(zhu)(zhu)營業(ye)務是提(ti)供健(jian)(jian)(jian)康險(xian)產(chan)品(pin)，包括個人業(ye)務、團體(ti)業(ye)務、MA市場(chang)(chang)（MedicareAdvantage）,其中MA針對的(de)是65歲(sui)以上人群(qun)。在核(he)保(bao)流程上，OscarHealth公(gong)司(si)(si)的(de)客(ke)(ke)戶只(zhi)需提(ti)供年齡、收(shou)入(ru)等基礎個人信息，即可實(shi)現快(kuai)速核(he)保(bao)，得到個性(xing)化產(chan)品(pin)報價。同(tong)時，OscarHealth公(gong)司(si)(si)致力于改(gai)變(bian)客(ke)(ke)戶健(jian)(jian)(jian)康觀念，鼓勵(li)客(ke)(ke)戶養(yang)成健(jian)(jian)(jian)康生活習慣，從(cong)被動健(jian)(jian)(jian)康管理(li)轉向主(zhu)(zhu)動健(jian)(jian)(jian)康管理(li)。但OscarHealth公(gong)司(si)(si)發(fa)展至(zhi)后期，未從(cong)技術(shu)角度(du)考慮(lv)解決市場(chang)(chang)逆(ni)(ni)選(xuan)擇問(wen)題，僅依賴(lai)傳統(tong)風控手段(duan)，導(dao)致賠付率(lv)攀(pan)升(sheng)。可見，健(jian)(jian)(jian)康險(xian)的(de)發(fa)展要重視產(chan)品(pin)定價、風控手段(duan)的(de)選(xuan)擇，同(tong)時正(zheng)確利用科技手段(duan)構建風控系統(tong)，減少逆(ni)(ni)選(xuan)擇，才(cai)能降低賠付率(lv)，提(ti)升(sheng)經營效益。

3.2英國

Bupa（保(bao)(bao)(bao)柏）公司(si)成(cheng)立(li)于(yu)1947年，是一家互(hu)助保(bao)(bao)(bao)險機(ji)構，70%的(de)業(ye)(ye)務來自(zi)健(jian)康險，并以(yi)預防、緩解、治(zhi)療疾病(bing)和健(jian)康不(bu)佳狀況為發展原則。Bupa公司(si)的(de)業(ye)(ye)務范圍遍布全(quan)球，擁有(you)(you)1550萬客戶(hu)(hu)、120萬家醫療機(ji)構。同時，Bupa公司(si)成(cheng)立(li)自(zi)己的(de)醫院(yuan)、口腔護理(li)門診機(ji)構、護理(li)院(yuan)、養老(lao)院(yuan)等(deng)，并提(ti)供(gong)(gong)居家醫療護理(li)、職場健(jian)康、慢性(xing)病(bing)管理(li)及健(jian)康評估等(deng)服務。Bupa公司(si)的(de)健(jian)康險產(chan)品涵蓋既有(you)(you)病(bing)癥，始終公平(ping)對待所有(you)(you)客戶(hu)(hu)，提(ti)供(gong)(gong)多款保(bao)(bao)(bao)險產(chan)品為不(bu)同年齡客戶(hu)(hu)提(ti)供(gong)(gong)適合的(de)健(jian)康保(bao)(bao)(bao)障，并配有(you)(you)專(zhuan)屬健(jian)康助理(li)。Bupa公司(si)的(de)經(jing)驗顯示，應加(jia)強健(jian)康管理(li)，直接(jie)對接(jie)疾病(bing)，消除逆(ni)選擇(ze)行(xing)為。

3.3南非

Discovery公(gong)司成立于1992年，是(shi)南非最大的健(jian)(jian)(jian)康(kang)險(xian)經營公(gong)司。其核心業(ye)務是(shi)通過電子健(jian)(jian)(jian)康(kang)記錄、在線(xian)醫療咨詢、價值共享保險(xian)模型，收集索(suo)賠和病(bing)(bing)理學(xue)實驗臨床(chuang)信息，評估個人(ren)風險(xian)因素，鼓勵人(ren)們參與健(jian)(jian)(jian)康(kang)促進和預防(fang)活動，為(wei)市(shi)場提供統(tong)一(yi)的系(xi)統(tong)框架(jia)。Discovery公(gong)司注重健(jian)(jian)(jian)康(kang)管理，關注慢性病(bing)(bing)患者，從源頭(tou)改善人(ren)們身體健(jian)(jian)(jian)康(kang)狀(zhuang)況，積極(ji)規避逆選擇行(xing)為(wei)。

4啟示及建議

4.1對健康險經營(ying)公司的建(jian)議

（1）提(ti)高數(shu)(shu)據(ju)(ju)收集(ji)能(neng)力(li)，推(tui)進大數(shu)(shu)據(ju)(ju)應(ying)用發展(zhan)。大型保險(xian)公(gong)司財力(li)、物力(li)、人(ren)力(li)資本雄厚，加(jia)之政策扶持(chi)，可自(zi)建(jian)信(xin)息(xi)收集(ji)系統(tong)，形(xing)成(cheng)數(shu)(shu)據(ju)(ju)信(xin)息(xi)庫(ku)。以(yi)5G、大數(shu)(shu)據(ju)(ju)、物聯網、人(ren)工智(zhi)能(neng)等(deng)現(xian)代技術(shu)為核(he)心，助推(tui)核(he)保系統(tong)數(shu)(shu)字化(hua)轉型；以(yi)數(shu)(shu)字中(zhong)臺為紐帶，一(yi)(yi)端(duan)連(lian)接保險(xian)公(gong)司，一(yi)(yi)端(duan)連(lian)接用戶(hu)生(sheng)活場(chang)景，加(jia)快數(shu)(shu)據(ju)(ju)收集(ji)整合；基(ji)于人(ren)工智(zhi)能(neng)技術(shu)，實(shi)現(xian)信(xin)息(xi)分析學(xue)習，為客(ke)戶(hu)身份驗證、信(xin)息(xi)抽取、逆選(xuan)擇行為分析提(ti)供智(zhi)能(neng)識別結果。規模較小的(de)健康(kang)險(xian)經營(ying)公(gong)司，可外包數(shu)(shu)據(ju)(ju)收集(ji)等(deng)任(ren)務模塊，利用第三方機構的(de)專業性與(yu)高效性，實(shi)現(xian)個性化(hua)信(xin)息(xi)收集(ji)。

（2）加強與(yu)醫療(liao)(liao)(liao)機(ji)構(gou)的(de)數(shu)(shu)據(ju)(ju)(ju)(ju)共享。醫療(liao)(liao)(liao)數(shu)(shu)據(ju)(ju)(ju)(ju)對(dui)健(jian)康(kang)險(xian)(xian)風險(xian)(xian)控(kong)制至關重要，是(shi)實(shi)現健(jian)康(kang)險(xian)(xian)產(chan)品創新和個性化承(cheng)保的(de)關鍵。因此，健(jian)康(kang)險(xian)(xian)經營(ying)公(gong)司應加強與(yu)醫療(liao)(liao)(liao)機(ji)構(gou)信息系統的(de)聯網，融合科技手段(duan)，利用醫療(liao)(liao)(liao)機(ji)構(gou)收集到的(de)病歷數(shu)(shu)據(ju)(ju)(ju)(ju)、體檢信息、醫保卡使用記錄等，實(shi)現前期診(zhen)斷、中期治(zhi)療(liao)(liao)(liao)的(de)全過(guo)程(cheng)核保，強化高精準風險(xian)(xian)控(kong)制。未來(lai)也要加快(kuai)推進醫療(liao)(liao)(liao)數(shu)(shu)據(ju)(ju)(ju)(ju)信息化，消除數(shu)(shu)據(ju)(ju)(ju)(ju)共享壁壘，實(shi)現數(shu)(shu)據(ju)(ju)(ju)(ju)與(yu)業務協同(tong)發展。

（3）科技賦能健康(kang)(kang)保(bao)險風(feng)控系統(tong)(tong)建設。健康(kang)(kang)險經(jing)營公(gong)司應充分(fen)發揮(hui)科技優勢，構(gou)建智能風(feng)控系統(tong)(tong)。依(yi)據前期收集到(dao)的(de)數據，形(xing)成風(feng)險因子，包括健康(kang)(kang)數據、就醫行為(wei)、既(ji)往理賠(pei)、征信數據、互(hu)聯網行為(wei)、其他(ta)數據（見表1），全面系統(tong)(tong)地洞察投(tou)保(bao)人的(de)實際身體狀況、潛在風(feng)險、消費能力以及是否存在帶(dai)病投(tou)保(bao)傾向等，以此(ci)為(wei)基礎，劃分(fen)風(feng)險等級。

（4）構建(jian)智(zhi)能(neng)+人(ren)工(gong)雙效(xiao)核(he)(he)保體(ti)系(xi)。智(zhi)能(neng)核(he)(he)保體(ti)系(xi)能(neng)有效(xiao)提升(sheng)核(he)(he)保效(xiao)率，降低逆(ni)選擇行為發生(sheng)概(gai)率，但當前的智(zhi)能(neng)核(he)(he)保技術無法解決特定復(fu)(fu)雜情(qing)況(kuang)，仍需(xu)人(ren)工(gong)核(he)(he)保系(xi)統(tong)的輔助(zhu)。首(shou)先通過智(zhi)能(neng)核(he)(he)保系(xi)統(tong)初步(bu)篩查(cha)(cha)判斷，對低風險群(qun)體(ti)可直接通過核(he)(he)保，對中高風險群(qun)體(ti)可轉入人(ren)工(gong)核(he)(he)保系(xi)統(tong)進行復(fu)(fu)核(he)(he)（見圖3）。同(tong)時(shi)，如(ru)果情(qing)況(kuang)復(fu)(fu)雜，智(zhi)能(neng)核(he)(he)保系(xi)統(tong)無法全面評析(xi)投保人(ren)實(shi)際健(jian)康(kang)狀(zhuang)況(kuang)，也需(xu)人(ren)工(gong)核(he)(he)保輔助(zhu)。后(hou)期(qi)跟進收集人(ren)工(gong)核(he)(he)保審查(cha)(cha)經驗，同(tong)步(bu)上傳到智(zhi)能(neng)核(he)(he)保系(xi)統(tong)，實(shi)現(xian)系(xi)統(tong)的更(geng)新迭代。

（5）搭(da)建(jian)分(fen)(fen)級健(jian)(jian)康保(bao)(bao)(bao)(bao)(bao)(bao)障(zhang)體(ti)(ti)(ti)(ti)系(xi)，掃除逆(ni)選擇存在(zai)(zai)空間。健(jian)(jian)康險(xian)(xian)(xian)(xian)經營(ying)公(gong)司(si)為應(ying)對(dui)(dui)逆(ni)選擇風(feng)(feng)(feng)(feng)險(xian)(xian)(xian)(xian)，一(yi)般將(jiang)慢性病患者(zhe)、高風(feng)(feng)(feng)(feng)險(xian)(xian)(xian)(xian)群(qun)(qun)體(ti)(ti)(ti)(ti)、高齡人(ren)群(qun)(qun)排除在(zai)(zai)外(wai)，或以高額保(bao)(bao)(bao)(bao)(bao)(bao)費(fei)、除外(wai)責(ze)任、嚴苛條款限制(zhi)投(tou)保(bao)(bao)(bao)(bao)(bao)(bao)人(ren)，在(zai)(zai)一(yi)定(ding)(ding)程(cheng)度上違反了健(jian)(jian)康險(xian)(xian)(xian)(xian)的(de)(de)(de)保(bao)(bao)(bao)(bao)(bao)(bao)障(zhang)本(ben)(ben)質。為了從源頭規(gui)(gui)避逆(ni)選擇風(feng)(feng)(feng)(feng)險(xian)(xian)(xian)(xian)，應(ying)搭(da)建(jian)分(fen)(fen)級健(jian)(jian)康保(bao)(bao)(bao)(bao)(bao)(bao)障(zhang)體(ti)(ti)(ti)(ti)系(xi)（見表2），實(shi)現(xian)全(quan)量(liang)承保(bao)(bao)(bao)(bao)(bao)(bao)，探索對(dui)(dui)特(te)定(ding)(ding)患病體(ti)(ti)(ti)(ti)專(zhuan)項投(tou)保(bao)(bao)(bao)(bao)(bao)(bao)，加(jia)強對(dui)(dui)有投(tou)保(bao)(bao)(bao)(bao)(bao)(bao)意愿人(ren)群(qun)(qun)的(de)(de)(de)全(quan)覆蓋承保(bao)(bao)(bao)(bao)(bao)(bao)，發(fa)揮(hui)健(jian)(jian)康險(xian)(xian)(xian)(xian)的(de)(de)(de)保(bao)(bao)(bao)(bao)(bao)(bao)障(zhang)功能。一(yi)是標準(zhun)(zhun)體(ti)(ti)(ti)(ti)，其(qi)身體(ti)(ti)(ti)(ti)健(jian)(jian)康，保(bao)(bao)(bao)(bao)(bao)(bao)費(fei)低，可(ke)(ke)直接(jie)通(tong)過智能核保(bao)(bao)(bao)(bao)(bao)(bao)系(xi)統(tong)分(fen)(fen)析其(qi)個人(ren)數據，提(ti)供投(tou)保(bao)(bao)(bao)(bao)(bao)(bao)建(jian)議及產(chan)品(pin)(pin)推薦(jian)。二(er)是非(fei)標準(zhun)(zhun)體(ti)(ti)(ti)(ti)，在(zai)(zai)保(bao)(bao)(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)科(ke)技(ji)時代(dai)，可(ke)(ke)融(rong)入健(jian)(jian)康保(bao)(bao)(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)管(guan)(guan)理(li)(li)服(fu)務(wu)[5]。2019年(nian)中國(guo)銀(yin)保(bao)(bao)(bao)(bao)(bao)(bao)監會發(fa)布的(de)(de)(de)《健(jian)(jian)康保(bao)(bao)(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)管(guan)(guan)理(li)(li)辦法》提(ti)出(chu)(chu)，健(jian)(jian)康管(guan)(guan)理(li)(li)服(fu)務(wu)成(cheng)(cheng)本(ben)(ben)占比可(ke)(ke)提(ti)升至20%。在(zai)(zai)全(quan)量(liang)承保(bao)(bao)(bao)(bao)(bao)(bao)理(li)(li)念下，健(jian)(jian)康險(xian)(xian)(xian)(xian)經營(ying)公(gong)司(si)要切(qie)實(shi)發(fa)揮(hui)健(jian)(jian)康管(guan)(guan)理(li)(li)服(fu)務(wu)功能，從促(cu)進非(fei)標準(zhun)(zhun)體(ti)(ti)(ti)(ti)人(ren)群(qun)(qun)身體(ti)(ti)(ti)(ti)健(jian)(jian)康出(chu)(chu)發(fa)，滿(man)足(zu)投(tou)保(bao)(bao)(bao)(bao)(bao)(bao)人(ren)真實(shi)訴求，提(ti)升保(bao)(bao)(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)產(chan)品(pin)(pin)匹配(pei)(pei)精(jing)度，實(shi)現(xian)雙贏。三是常規(gui)(gui)產(chan)品(pin)(pin)拒(ju)保(bao)(bao)(bao)(bao)(bao)(bao)體(ti)(ti)(ti)(ti)，在(zai)(zai)保(bao)(bao)(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)科(ke)技(ji)加(jia)持(chi)下，可(ke)(ke)探索對(dui)(dui)特(te)定(ding)(ding)患病體(ti)(ti)(ti)(ti)的(de)(de)(de)專(zhuan)項投(tou)保(bao)(bao)(bao)(bao)(bao)(bao)，并融(rong)合(he)(he)健(jian)(jian)康管(guan)(guan)理(li)(li)服(fu)務(wu)，從源頭上降(jiang)低逆(ni)選擇風(feng)(feng)(feng)(feng)險(xian)(xian)(xian)(xian)。前期通(tong)過人(ren)工(gong)(gong)智能風(feng)(feng)(feng)(feng)險(xian)(xian)(xian)(xian)診斷(duan)算(suan)法，識別(bie)風(feng)(feng)(feng)(feng)險(xian)(xian)(xian)(xian)類(lei)別(bie)，描繪(hui)個性風(feng)(feng)(feng)(feng)險(xian)(xian)(xian)(xian)畫像(xiang)；中期利用人(ren)工(gong)(gong)智能風(feng)(feng)(feng)(feng)險(xian)(xian)(xian)(xian)處方算(suan)法，提(ti)出(chu)(chu)健(jian)(jian)康管(guan)(guan)理(li)(li)方案，并與(yu)特(te)定(ding)(ding)醫院、健(jian)(jian)康管(guan)(guan)理(li)(li)機(ji)構合(he)(he)作，實(shi)施健(jian)(jian)康管(guan)(guan)理(li)(li)和(he)健(jian)(jian)康干預；后期基于人(ren)工(gong)(gong)智能風(feng)(feng)(feng)(feng)控(kong)管(guan)(guan)理(li)(li)算(suan)法，結(jie)合(he)(he)機(ji)器自動更(geng)新學習技(ji)術，將(jiang)前期檢查、中期干預結(jie)果與(yu)醫學結(jie)果和(he)邏輯關系(xi)進行(xing)對(dui)(dui)比，形(xing)成(cheng)(cheng)自動加(jia)減保(bao)(bao)(bao)(bao)(bao)(bao)費(fei)和(he)定(ding)(ding)價(jia)適(shi)配(pei)(pei)的(de)(de)(de)量(liang)化指(zhi)引。最終，滿(man)足(zu)所有投(tou)保(bao)(bao)(bao)(bao)(bao)(bao)人(ren)的(de)(de)(de)保(bao)(bao)(bao)(bao)(bao)(bao)障(zhang)意愿，減少(shao)拒(ju)保(bao)(bao)(bao)(bao)(bao)(bao)比例，縮(suo)小逆(ni)選擇存在(zai)(zai)空間。

（6）加(jia)強銷(xiao)(xiao)售(shou)端管(guan)理力(li)(li)度(du)(du)，提高(gao)銷(xiao)(xiao)售(shou)人員素質[6]。一是銷(xiao)(xiao)售(shou)人員如果專(zhuan)業能力(li)(li)不足(zu)、敏銳度(du)(du)不高(gao)，容(rong)易造成銷(xiao)(xiao)售(shou)誤導(dao)，對(dui)此(ci)要強化(hua)技能培訓(xun)，包括職業操守(shou)、法律法規、專(zhuan)業知識等方面的(de)培訓(xun)。二(er)是對(dui)故意進行(xing)銷(xiao)(xiao)售(shou)誤導(dao)的(de)銷(xiao)(xiao)售(shou)人員，應加(jia)強懲(cheng)罰(fa)力(li)(li)度(du)(du)，完善責任(ren)追(zhui)究機制，同時，借助(zhu)中國銀(yin)保監會(hui)、行(xing)業協會(hui)網站以(yi)及自媒體平臺，公(gong)開(kai)通(tong)報(bao)批評，提升(sheng)威懾效果。

4.2對政(zheng)府部門的政(zheng)策建(jian)議

（1）完善(shan)社會(hui)信(xin)(xin)(xin)用(yong)機(ji)制(zhi)體(ti)(ti)系，強(qiang)化逆(ni)(ni)選擇(ze)(ze)行(xing)(xing)(xing)為(wei)處(chu)理機(ji)制(zhi)。在(zai)健康(kang)(kang)險(xian)市場(chang)中(zhong)(zhong)，治理逆(ni)(ni)選擇(ze)(ze)行(xing)(xing)(xing)為(wei)需要社會(hui)信(xin)(xin)(xin)用(yong)體(ti)(ti)系發(fa)揮作(zuo)用(yong)，營(ying)(ying)造良好(hao)的(de)(de)市場(chang)環境。一是完善(shan)個(ge)(ge)人(ren)(ren)(ren)信(xin)(xin)(xin)用(yong)評級機(ji)制(zhi)。政(zheng)府應從(cong)宏觀(guan)角度完善(shan)個(ge)(ge)人(ren)(ren)(ren)信(xin)(xin)(xin)用(yong)評級體(ti)(ti)系，將(jiang)投(tou)保(bao)(bao)人(ren)(ren)(ren)逆(ni)(ni)選擇(ze)(ze)行(xing)(xing)(xing)為(wei)納入個(ge)(ge)人(ren)(ren)(ren)征信(xin)(xin)(xin)系統(tong)。同(tong)時(shi)，完善(shan)個(ge)(ge)人(ren)(ren)(ren)信(xin)(xin)(xin)用(yong)檔(dang)案庫，在(zai)信(xin)(xin)(xin)息共(gong)享(xiang)基(ji)礎上收集(ji)投(tou)保(bao)(bao)人(ren)(ren)(ren)信(xin)(xin)(xin)用(yong)信(xin)(xin)(xin)息。投(tou)保(bao)(bao)人(ren)(ren)(ren)的(de)(de)失信(xin)(xin)(xin)行(xing)(xing)(xing)為(wei)會(hui)記(ji)錄(lu)到(dao)(dao)個(ge)(ge)人(ren)(ren)(ren)誠信(xin)(xin)(xin)數據庫中(zhong)(zhong)，影響未來購買(mai)其他保(bao)(bao)險(xian)產品(pin)(pin)，甚至可與(yu)銀(yin)行(xing)(xing)(xing)貸款(kuan)申請(qing)掛(gua)鉤，起到(dao)(dao)有(you)效(xiao)(xiao)的(de)(de)威懾作(zuo)用(yong)。二是普及征信(xin)(xin)(xin)和(he)保(bao)(bao)險(xian)知識。在(zai)保(bao)(bao)險(xian)經營(ying)(ying)實務中(zhong)(zhong)，部(bu)分(fen)投(tou)保(bao)(bao)人(ren)(ren)(ren)不理解最(zui)大誠信(xin)(xin)(xin)原則的(de)(de)含(han)義，或(huo)不理解個(ge)(ge)人(ren)(ren)(ren)征信(xin)(xin)(xin)系統(tong)的(de)(de)作(zuo)用(yong)，由此被(bei)動發(fa)生逆(ni)(ni)選擇(ze)(ze)行(xing)(xing)(xing)為(wei)。政(zheng)府部(bu)門應發(fa)揮其公(gong)信(xin)(xin)(xin)力，普及相關知識，利用(yong)自媒體(ti)(ti)加大宣傳普及力度，營(ying)(ying)造良好(hao)的(de)(de)道德(de)法制(zhi)氛圍(wei)。同(tong)時(shi)，提升(sheng)公(gong)眾對保(bao)(bao)險(xian)行(xing)(xing)(xing)業的(de)(de)良好(hao)印象，增強(qiang)其風(feng)險(xian)意識，吸引更多(duo)健康(kang)(kang)標準體(ti)(ti)投(tou)保(bao)(bao)健康(kang)(kang)險(xian)產品(pin)(pin)，從(cong)源頭(tou)上有(you)效(xiao)(xiao)規(gui)避逆(ni)(ni)選擇(ze)(ze)行(xing)(xing)(xing)為(wei)，實現投(tou)保(bao)(bao)人(ren)(ren)(ren)與(yu)保(bao)(bao)險(xian)公(gong)司的(de)(de)互利共(gong)贏。

（2）協(xie)助(zhu)中(zhong)小公(gong)司搭(da)建(jian)(jian)信(xin)息收(shou)(shou)集(ji)(ji)(ji)系(xi)(xi)統，監督大(da)型保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)公(gong)司規范信(xin)息運(yun)用(yong)。數(shu)(shu)(shu)字經濟時代，數(shu)(shu)(shu)據(ju)是(shi)(shi)健(jian)康保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)市(shi)場發展(zhan)的(de)重要(yao)資源；對數(shu)(shu)(shu)據(ju)的(de)獲取與(yu)運(yun)用(yong)，有關部門需監管(guan)到位。一(yi)是(shi)(shi)中(zhong)小保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)公(gong)司要(yao)實(shi)現數(shu)(shu)(shu)字化變革，搭(da)建(jian)(jian)智(zhi)能(neng)核(he)(he)保(bao)(bao)(bao)(bao)系(xi)(xi)統存在困(kun)難(nan)，亟(ji)待政府(fu)助(zhu)力協(xie)助(zhu)。人(ren)(ren)才是(shi)(shi)科技(ji)實(shi)力，是(shi)(shi)構(gou)建(jian)(jian)智(zhi)能(neng)系(xi)(xi)統的(de)核(he)(he)心要(yao)素(su)。針對中(zhong)小保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)公(gong)司人(ren)(ren)才流失(shi)嚴重，核(he)(he)保(bao)(bao)(bao)(bao)人(ren)(ren)員(yuan)、保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)科技(ji)人(ren)(ren)員(yuan)等(deng)復合人(ren)(ren)才缺乏的(de)問題(ti)，政府(fu)應制(zhi)定人(ren)(ren)才引(yin)進發展(zhan)計劃，通過引(yin)薦人(ren)(ren)才、輔(fu)助(zhu)培(pei)訓等(deng)，協(xie)助(zhu)其(qi)搭(da)建(jian)(jian)人(ren)(ren)才庫；同(tong)時，給予(yu)財政支持，減輕其(qi)運(yun)行(xing)壓力，幫(bang)助(zhu)構(gou)建(jian)(jian)智(zhi)能(neng)核(he)(he)保(bao)(bao)(bao)(bao)系(xi)(xi)統。二(er)是(shi)(shi)大(da)型保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)公(gong)司人(ren)(ren)才及資本(ben)雄(xiong)厚，在科技(ji)引(yin)用(yong)與(yu)智(zhi)能(neng)核(he)(he)保(bao)(bao)(bao)(bao)系(xi)(xi)統搭(da)建(jian)(jian)上(shang)存在優勢，政府(fu)應加(jia)強對其(qi)前端數(shu)(shu)(shu)據(ju)收(shou)(shou)集(ji)(ji)(ji)與(yu)利用(yong)的(de)監督。當前，我國法(fa)規在界定健(jian)康數(shu)(shu)(shu)據(ju)權屬(shu)問題(ti)上(shang)比較模糊，對此(ci)要(yao)完(wan)善數(shu)(shu)(shu)據(ju)收(shou)(shou)集(ji)(ji)(ji)與(yu)歸(gui)屬(shu)領域的(de)法(fa)規建(jian)(jian)設，推動保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)行(xing)業數(shu)(shu)(shu)據(ju)共享系(xi)(xi)統構(gou)建(jian)(jian)，從國家層面(mian)布局建(jian)(jian)設，規避(bi)盜用(yong)、濫用(yong)數(shu)(shu)(shu)據(ju)，形成健(jian)康共享大(da)數(shu)(shu)(shu)據(ju)的(de)局面(mian)。

（3）助推(tui)保險行業(ye)構(gou)(gou)(gou)建(jian)統一的(de)(de)(de)風(feng)(feng)(feng)控模型。保險公(gong)司(si)大多擁(yong)有(you)獨立的(de)(de)(de)風(feng)(feng)(feng)控系(xi)統，投保人在不同(tong)(tong)公(gong)司(si)核(he)保會出現不同(tong)(tong)的(de)(de)(de)結果，在一定程度留下逆選(xuan)擇風(feng)(feng)(feng)險漏洞，政(zheng)府部門(men)應協助構(gou)(gou)(gou)建(jian)統一的(de)(de)(de)核(he)保系(xi)統。前期(qi)(qi)，可制(zhi)定基礎核(he)保系(xi)統的(de)(de)(de)構(gou)(gou)(gou)建(jian)要素(su)和核(he)保規則，同(tong)(tong)時設(she)置調整空(kong)間，供各保險公(gong)司(si)自行調整。后期(qi)(qi)，隨著專業(ye)健(jian)康(kang)險公(gong)司(si)增多，逐步建(jian)立統一的(de)(de)(de)核(he)保系(xi)統，減少各公(gong)司(si)體(ti)系(xi)建(jian)設(she)的(de)(de)(de)成本，進而弱(ruo)化(hua)逆選(xuan)擇風(feng)(feng)(feng)險。

參考文獻

[1]王(wang)向楠，潘力.我國商業健康(kang)險逆(ni)選擇風險的防(fang)治分析[J].時(shi)代金(jin)融，2008（8）：48-50.

[2]姚(yao)奕(yi)，孫祁祥(xiang)，林山君，等.健康保險道德風險防范研究(jiu)———以商業健康保險欺詐為例[J].經(jing)濟研究(jiu)，2020，55（6）：189-206.

 [3]唐金成(cheng)，薛珂.互聯網時代我國反(fan)保險欺詐工作研究[J].浙江金融，2018（1）：55-61.

[4]劉月星，宗文紅，姚(yao)有華.我國(guo)商(shang)業(ye)健康保險風險控制問題分(fen)析及對策[J].衛(wei)生(sheng)經(jing)濟研(yan)究，2012，29（7）：29-31.

[5]馬(ma)杰(jie).商業健康險高質量發展(zhan)及挑戰(zhan)[J].中國金(jin)融(rong)，2020（18）：79-80.

作者:魏倩 唐金成
[6]黃薇，張嵐(lan)，鄭小華,等(deng).新形(xing)勢下商業(ye)健康保險產品開發思路與策(ce)略[J].衛(wei)生經濟研究(jiu)，2021，38（2）：26-29.