Based on United Health, integrating the medical service ecosystem and realizing the synergy between medical care and insurance is the only way to transform the health insurance industry.

Editor’s note: This article is from WeChat public account “ Light Source Capital ” (ID : Lighthousecap), author light source capital, reproduced with permission.

Two years ago in the winter, an article entitled “Beijing Middle Age under the Flu” blew up the circle of friends. When the disease hits, a series of problems that may be caused by the lack of professional knowledge about diseases, hospitals, doctors, medicines, and medical resources have caused heated discussions, and the concept of managed care has attracted wider attention.

Managed medical care is the cooperation between medical payers and medical service providers to participate in the balance of medical services through health risk management, service utilization management, and medical quality management, so as to optimize the cost and effectiveness of medical services. a method. Taking the developed American market for commercial health insurance as an example, from the perspective of proportion, managed medical insurance products occupy almost all of commercial health insurance.

The health insurance industry in China is still in its infancy. The Outline of the “Thirteenth Five-Year Plan” for the Development of China’s Insurance Industry proposes that until 2020, the role of China’s commercial insurance in the social security system needs to be continuously improved. Medical treatment, measures to realize the sharing of commercial insurance information and public health, medical services, basic medical insurance, medical assistance and other information. The industry development space for managed medical services, and the limitless future value of medical care may have begun to appear.

01 Upgrade of managed medical needs behind the development of commercial health insurance

From 2013 to 2018, the scale of China’s health insurance has grown rapidly, and premium income has increased from 112.4 billion yuan to 544.8 billion yuan, an increase of 385%, but there is still a large gap in density and depth compared with developed countries such as Germany and Germany. Moreover, with the acceleration of urbanization and the growth of middle-income groups, the needs of basic medical insurance and the general population have gradually shown a mismatch. A series of problems such as lack of professional medical guidance, difficulty in finding suitable hospitals and doctors, poor experience in seeing and treating patients, and lack of full-course health management are common. The problems are particularly prominent in cases of serious illness and serious illness. It is foreseeable that in the next ten years, the basic medical insurance and basic medical insurance will share the larger medical expenses. It has become the consensus of the medical industry and the insurance industry. In the development of commercial health insurance, how to effectively implement managed medical care is a key link.

Based on observations and studies of mature insurance markets, some paths may be found. The United States is one of the countries with the most developed commercial health insurance in the world. Since 1840, it has experienced nearly 80 years of exploration and development of primary health insurance. In this process, the health insurance market has experienced the development of fragmented health insurance and work injury insurance funds.Recession and so on, until 1966, the rise of managed care, commercial health insurance officially entered a period of rapid development.

In addition to the management of expense claims, managed medical organizations need to conduct professional operations on the content, form, time, doctors and service places of medical services. This puts high demands on professional capabilities, medical resources, system construction, and specialized services for medicines. To form an integrated medical service platform requires long-term accumulation and precipitation of the medical industry. Taking United Health in the United States as an example, United Health Group is the largest commercial health insurance company in the United States. Its health management industry chain effectively solves the core of the insured people behind health insurance for getting good medical guidance and intervention and obtaining appropriate medical resources. Demand can not only enhance the insurance company’s service capabilities and become an insurance company’s business booster; it can also help insurance companies analyze and optimize medical output and become an insurance cost control system; at the same time, it provides the most reasonable and effective insurance participants Medical resources and market-based compensation. The industry generally believes that, based on United Health, opening up medical resource channels, integrating the medical service ecosystem, and realizing the synergy between medical care and insurance are the only paths for the reform of the health insurance industry.

Of the more than 200 commercial insurance companies in China, only no more than 10 are building medical networks, and their professional service capabilities are seriously lacking. In the case of continuous growth in demand, broad market space, and extremely high barriers to entry, who can take the lead in opening up the industry chain, integrating medical resources, and forming a comprehensive medical service ecosystem, who can occupy the market and win the first opportunity.

02 “China’s Joint Health Model”: Spie Group, Winning First!

The essence of health insurance is the service resources after the insurance is released, but the laying of any infrastructure is not a overnight project. To build a complete medical service ecological platform, it must be based on long-term medical industry’s accumulated industry understanding and medical treatment. Resources and data information. Established in 2014 and having received investment from a number of well-known industries and institutions, Sipai Group is at the forefront of managed medical services.

The founding team of Sipai Group, from major foreign pharmaceutical companies such as Bayer, Roche, Pfizer, etc., are senior management who have worked in the medical field for many years and have a deep understanding of the medical industry. Sipai Group initially focused on the field of oncology and established a solid oncology medical service supply chain system. Beginning with serving oncologists, Spiegel has further improved the full service line for pharmaceutical companies, insurance, doctors and oncology patients based on the needs of doctors’ scientific research and patient management. It has successively built the only ecological integration system in China that provides clinical oncology specialty medical services and professional medical services, including three business sectors: Bisun Medical, Sipai Pharmacy, and Sipai Health.

In this closed-loop ecological network, Spie Group has a national expert PPO network, oncology clinical trial network, nationwide special pharmacy network, and health management and drug welfare management operation network, successfully building the first integrated health in China Management system. At present, various schools of thoughtThe service line covers 3,000+ oncologists, 300+ cooperative oncology specialist hospitals and important third-class hospitals in the field of oncology, and solves the problem of the availability of scarce medical resources from the source. As the only fully-controlled professional pharmacy service special drug pharmacy network, 70+ special pharmacies have penetrated all key tumor treatment cities in 29 provinces and autonomous regions, and 200+ professional pharmacist teams provide pharmacy and follow-up services. To solve the problem of access to oncology drugs from the channels. Relying on all the above medical service networks and drug service networks, Sipa Health provides patients and doctors as the center, providing suspect judgment, triage, referral to appropriate doctors, accompanying medical records throughout the process, diagnosis and treatment services, concomitant judgment, medicines Provide complete services such as follow-up, etc .; and use this complete medical network and drug network to serve various types of payers such as insurance companies, enterprises, and non-corporate customers.

Based on the medical gene of the company’s management team, in most medical service platforms are still at the stage of Internet medical and pharmacy services, Spiegel has clearly established the goal of managing the entire information flow of medical services, and in medical management, drug management The payment square has become the data barrier of the whole chain. For more than five years, the medical industry has accumulated a first-mover advantage that enables it to settle and understand the data generated in the entire medical service process, further empowering all parties, and providing a network of experts throughout the disease and patient flow. , Prescription flow and payment flow to achieve integrated operation of the whole chain.

With the integration of the moat built by the key resource nodes of tumors, and the downstream customer acquisition channels in cooperation with insurance companies and self-built channels, based on the effective management of the entire information flow of medical services, Spiegel has become an insurance company. The clinical oncology full-chain medical ecological comprehensive service provider on the client, expert, patient, and drug sides, and possesses the resource endowment to build the largest insurance support network and drug management service business, and will become the “joint health” medical management model in China in the future.

03 Industry future: integrated operation, value healthcare

Sipai Group’s insight into the future trends of the medical industry determines that it is not only satisfied with the current positioning of the only integrated tumor management platform in China. Under the reform trend of “value medical”, Spiegel is committed to becoming a helper of payment and medical behavior in the future, and creating a value medical platform trusted by doctors and patients.

In 2016, the Chinese government, in conjunction with the World Bank and the World Health Organization, released a report entitled “Deepening China’s Medical and Health System Reform-Building a Value-Based Quality Service Delivery System”, marking the “birth” of value medicine in China. Value medical care is the trend of future medical industry reform. Compared with the traditional medical service model centered on medical institutions, value medical care emphasizes patient-centeredness, starting from the three aspects of cost control, treatment effect and patient demand, and aims to reduce patients. The total cost of treatment, meeting the patient’s expected treatment effect, and taking care of the patient’s life and health, to obtain the maximum medical value at the least cost. This includes both money, energy,The comprehensive management and control of time cost also includes comprehensive analysis and optimization of the diagnosis and treatment process, medical behavior and treatment results. The value management platform with full chain management is a necessary demand and an inevitable product under the value medical requirements.

There are many and complicated parties involved in medical services. Sipai Group has now served core expert / doctor networks, pharmaceutical companies, and insurance companies in oncology treatment, providing patient-centered integrated services, and gradually establishing commercial health insurance. Integrated operational capabilities required for services. Under the general trend of value medical in the future, Spie hopes to serve commercial insurance companies while widely entering C-side scenarios such as medical insurance supplements and corporate benefits, to serve more healthy people and potential patients. Through more diversified channels, provide full-chain medical management services to realize the future of value medical care.

The medical field is a key area of ​​focus for Light Source Capital. People are the most decisive factor in social production. Light Source Capital has long been concerned about health and people-oriented. We are optimistic that technological change empowers the medical industry, which can accelerate the transformation and upgrading of the medical industry, and ultimately achieve the overall improvement of the quality of life and social welfare of the entire people.