How Pacific Healthcare Has Driven Industry Innovation Over the Past Three Years
In recent years, innovative technologies such as artificial intelligence (AI), big data, the Internet of Things (IoT), and blockchain have been widely implemented, with the digital wave impacting industries across the board. Influenced by digital technologies, the insurance industry has also ushered in significant innovation.
As a specialized subsidiary under China Pacific Insurance (CPIC) focusing on healthcare, Pacific Medical Health leverages the rich experience and data resources accumulated by CPIC over more than 20 years of serving medical insurance programs, its team of professionals with interdisciplinary expertise in medicine and data technology, and its experience in operating more than 260 government medical insurance service projects nationwide. It has pioneered multiple innovations in areas such as medical insurance fund management and the development of commercial health insurance, striving to explore the future.
What innovations has Pacific HealthCare made in various subfields over the past three years? VCBeat has conducted an in-depth review and compiled this article for our readers.
Key Insights:
1. Leverage big data to drive intelligent management throughout the entire lifecycle of medical insurance funds;
2. Technology drives the intelligent and intensive operation of long-term care insurance;
3. Advance intelligent and precise underwriting and claims processing, fraud monitoring, and innovative product design for commercial health insurance;
4. “Insurance + Health Management” Extends Insurance from Post-Claim Compensation to Pre-Event Prevention.
Pacific HealthCare believes: “Big data plays a significant role in the operation of medical insurance funds. Leveraging intelligent big data technologies can enhance the operational efficiency of medical insurance fund management, improve risk control capabilities, and increase return on investment.”
Based on this, the Pacific Health Insurance Plan replaces experience-driven approaches with data-driven ones, leverages diverse data sources, breaks down data silos, and unlocks data value to support the full lifecycle management of medical insurance funds.
Specifically, to address the issue of “leakage and waste” in medical insurance funds, Pacific Health Management, in collaboration with CPIC Life Insurance, has launched solutions with local medical insurance authorities across various regions.Intelligent Audit System for Medical Insurance Funds, real-time monitoring of medical insurance fraud and waste to address issues concerning the lawful, reasonable, and compliant use of medical insurance funds.
In August 2020, Pacific Health Care assisted medical insurance departments in multiple regions of Shandong Province with fund audits using its intelligent review system for medical insurance funds. Specifically, it provided 540,000 claims suspected of non-compliance from 2018 to June 2020 for a prefecture-level city, offering effective reference for the local medical insurance audit team to conduct targeted investigations, thereby significantly improving the efficiency and accuracy of the audit work.
Pacific Health Insurance Introduction: “The system has provided medical insurance fund supervision services for 15 regions across China, reaching hospitals, pharmacies, doctors, and insured individuals.”As of the end of December 2020, Pacific Health Insurance’s intelligent audit system for medical insurance funds had reviewed over RMB 700 billion in fund expenditures, covering more than 4,700 medical institutions.”
In terms of intelligent monitoring, Pacific Health Medical's self-developedBig Data Risk Control Platform for Medical Insurance Fund OperationsLaunched in Quzhou in April 2020, the platform visually presents the medical insurance fund’s status, ranging from overall macro-level trends to deeper micro-level real-time dynamics. It enables real-time monitoring of fund revenue, expenditures, and balances, facilitating drill-down analysis across multiple indicators and dimensions.
Through the big data risk control platform for medical insurance fund operations, Pacific Healthcare introduces data technology into risk management, achieving automated second-level analysis of risk control indicators. Additionally, the platform can display the development trends of medical insurance fund revenue, expenditures, and balances over the next five years, thereby supporting government decision-making.
Following its pilot implementation, the Big Data Risk Control Platform for Medical Insurance Fund Operations gained recognition from experts and medical insurance authorities. During the interim evaluation of national smart monitoring demonstration sites for medical insurance conducted in August 2020,Quzhou’s Intelligent Monitoring Demonstration Site, Centered on the Big Data Risk Control Platform for Medical Insurance Fund Operations, Ranks Among the Top. In December, the Big Data Risk Control Platform for Medical Insurance Fund Operations once again received recognition, being honored by China Banking and Insurance News asSecond Prize for Online Technology Application Cases in the Insurance Industry, 2020。
As of the end of 2020, Pacific Health Insurance had developed more than 50 digital analytics tools and obtained 40 national intellectual property certifications. It provided services such as precise fundraising calculations for medical insurance funds, risk identification in fund operations, intelligent settlement audits, and fraud monitoring to over 90 regions across 22 provinces in China. These services covered RMB 330.2 billion in medical insurance funds and 437 million insured individuals, with 135 data consulting projects implemented nationwide. In December 2020, Pacific Health Insurance was listed among the “Top 10 Innovative Services in Medical Insurance Big Data” due to its leading innovative achievements.
After three years of investigation, innovation, and application, Pacific Health Insurance has become more committed to its data-driven strategy. “We believe that dynamic policy adjustments will become the norm,”The supportive role of big data technology in decision-making will gradually strengthen."The standardized application of big data in healthcare will unlock significant value and substantially improve the operational efficiency of health insurance funds in the future."
China’s population aging is deepening, and the issue of long-term care for the elderly is becoming increasingly prominent.Long-Term Care InsuranceAccelerating the development of the elderly care service industry holds practical significance for meeting the continuously growing demand for elderly care services and properly and effectively addressing the caregiving needs of older adults.
However, compared with other types of insurance, long-term care insurance involves more complex processes, a wider range of stakeholders, and greater challenges in risk management. For instance, information silos arise among the numerous participants—including government agencies, insurers, nursing care providers, and elderly care institutions—due to inadequate information flow; it is difficult to monitor the authenticity of home-based nursing services and user experience; and the lengthy, intricate processes hinder effective auditing and inspections.
To address this challenge, Pacific Health has independently developed “Smart Long-Term Care Administration Platform”, integrating the entire workflow of long-term care insurance administration and all stakeholder roles into a single system to support integrated and centralized administration of long-term care insurance.
The Smart Long-Term Care Administration Platform consists of an information database, an information management system, and a mobile application. The unified foundational information database encompasses assessment standards, standardized nursing service packages, personnel information, basic configurations, and all administrative processes, thereby breaking down data silos, strengthening upstream and downstream data flow, and promoting the integration of long-term care insurance. The information management system supports five categories of business processes—including application, assessment, nursing, settlement, and audit—and connects multiple stakeholders such as insured individuals and their families, assessment agencies and experts, nursing institutions and caregivers, government bodies and insurance enterprises, and auditors, thus meeting the needs of all parties involved in long-term care insurance. The mobile application enables insured individuals, assessment experts, caregivers, and auditors to handle transactions online anytime and anywhere, facilitating the integration of online and offline services for long-term care insurance.
The Smart Long-Term Care Administration Platform leverages new technologies such as facial recognition, intelligent early warning systems, and big data analytics to achieve intelligent supervision across the entire administration process—pre-event, during-event, and post-event. This reduces labor costs and improves the administrative efficiency of long-term care insurance. Additionally, by implementing a three-tier assessment system comprising self-assessment by insured individuals, disability assessment, and nursing care assessment, the platform ensures more accurate assessment results and more targeted nursing care services.
Pacific Health Insurance disclosed: “As of the end of December 2020, leveraging our long-term care insurance administration projects, we had provided long-term care administration system services to 16 regions across China, covering 190 nursing institutions and reaching a population of approximately 19 million. We delivered nearly 40,000 assessment services and nearly 1.15 million nursing care services to 35,000 insured individuals.”
Through the smart long-term care insurance administration platform, long-term care insurance has achieved integrated and intelligent administration, addressing key pain points in practice. In the future, Pacific Health Medical will further promote the development of long-term care insurance.
In upgrading commercial health insurance, Pacific Health Insurance leverages self-developed tools—including a personal health risk scoring model, an intelligent claims anti-fraud system, and a chronic disease incidence risk assessment model—to achieve intelligent and precise underwriting and claims processing, fraud monitoring, and innovative product design.
By leveraging big data models, adverse selection of health risks can be effectively mitigated. For user groups that diligently adhere to health management protocols, underwriting as standard risks can be achieved when supported by health data. Meanwhile, certain chronic conditions previously deemed uninsurable are expected to be included in coverage with the support of big data models, thereby broadening the scope for innovation in insurance products.
The supplementary commercial insurance premium assessment model, developed by Pacific Health Insurance, can scientifically calculate the average per-capita premium for health insurance products and provide professional financing and pricing solutions. This supports rapid and precise pricing of insurance products, thereby facilitating the expansion and refined management of health insurance. This year, inclusive health insurance has seen rapid development; to date, this model has been used to conduct assessments and calculations for inclusive health insurance in 29 regions across China.
In fact, Pacific Health Care leverages its practical innovations in medical insurance and long-term care insurance to bolster commercial health insurance. By harnessing innovations and data technologies from these sectors, it designs more scientifically sound and reasonable insurance products, models, and systems.
It is foreseeable that Pacific Health Medical will ultimately drive the intelligent transformation of commercial health insurance in product development, enrollment, underwriting, and risk assessment through the integration of medical insurance technology applications with commercial health insurance.
In the past two years, health management has been more deeply integrated into the insurance sector. In November 2019, the China Banking and Insurance Regulatory Commission (CBIRC) issued the Measures for the Administration of Health Insurance, proposing that “insurance companies may combine health insurance products with health management services to provide health risk assessment and intervention... thereby reducing health risks and minimizing disease-related losses.” In 2020, the CBIRC further issued the Notice on Regulating Health Management Services Provided by Insurance Companies, to further standardize insurers’ conduct in delivering health management services and promote the integrated development of health management services and health insurance.
As a specialized subsidiary of China Pacific Insurance (CPIC) in the healthcare sector, Pacific HealthCare plays an active role in CPIC’s Grand Health Strategy, better meeting customers’ health management needs across their entire life cycle, contributing to the development of “CPIC Service,” and creating a multi-dimensional customer experience.
Pacific Health Insurance believes that “health management services enable insurers to extend their role from mere post-claim reimbursement to proactive pre-event and in-process interventions. Through health management, customers can better regulate their lifestyle behaviors and dietary habits, adopt healthier lifestyles, and improve their overall physical well-being; meanwhile, insurers’ risk control capabilities will be further strengthened, ultimately achieving a win-win outcome for both customers and insurance companies. Furthermore, insurance is a continuous service that spans the entire customer lifecycle, whereas traditional insurance products offer only low-frequency interactions. By incorporating health management, these low-frequency services can be transformed into high-frequency engagements, thereby enhancing customer stickiness.”
Based on these considerations, Pacific Health Insurance has launched a mobile health management platform and rigorously selected partners to provide customers with comprehensive “online + offline” services, including daily health consultations, health management, and medical coverage. This initiative delivers convenient, high-quality, and diverse health management services to insurance clients, including those of China Pacific Insurance (CPIC).
Specifically, Pacific Health Insurance launched a 24/7 video doctor consultation service. This online service transcends temporal and spatial barriers, enabling customers to access high-quality, cross-regional healthcare services anytime and anywhere. By the end of 2020, the “Video Doctor” consultation service had cumulatively covered 2 million household clients. Pacific Health Insurance also collaborated with China Pacific Life Insurance to launch the Employee Health Care Plan, a comprehensive “insurance + health management” solution tailored for corporate employees. Integrating multiple healthcare services—including Health E-Consultant, Medical Care Steward, Critical Illness Care, Premium Diagnosis and Treatment, and Pharmaceutical Benefits—the plan has initially been implemented in Shanghai, Changzhou, Suzhou, and Hebei Province, with further nationwide rollout planned. Additionally, Pacific Health Insurance partnered with Shanghai Cell Therapy Group to offer life bank cell cryopreservation services, providing cutting-edge biomedical technology solutions for high-net-worth individuals. By the end of 2020, more than 7,200 individuals had cryopreserved their cells, driving nearly RMB 2.5 billion in first-year premium income.
In the future, Pacific Health will expand from health management services to comprehensive healthcare services. First, it will promote the deep integration of health management into insurance product design, leverage the pivotal role of insurers as payers, guide customers toward healthy behaviors and appropriate medical care, improve adherence to medical advice, and thereby reduce disease incidence and claim rates. Second, it will provide full-cycle, network-wide medical and health services covering the entire process—including health management, physical examinations, medication, testing, chronic disease management, and rehabilitation—to further enrich insurance product offerings. Third, it will continue to broaden the scope of health management services, deepen their integration with insurance products, and utilize more robust and comprehensive big data support in medical and health sectors to facilitate the development of customized insurance plans...
An examination of the innovative measures implemented by Pacific Health Insurance over its first three years offers a microcosm of the insurance industry’s transformation and development, with “insurance + technology + services” having become a consensus for innovation and change within the sector.
In the long run, Pacific Health Healthcare has promoted the intelligent and refined management of medical insurance funds through innovative technologies such as artificial intelligence and big data, enhancing the management efficiency, risk control capabilities, and return on investment of these funds. The technology and experience accumulated in this process will further extend to commercial health insurance, with Pacific Health Healthcare setting a benchmark case for the industry.
On the other hand, Pacific Health Insurance’s “Insurance + Health Management” model has achieved a win-win outcome for multiple stakeholders, providing a practical example for the integration of the insurance and health management industries. This will significantly promote the deep convergence of the health management and insurance sectors, driving the development of the insurance industry through scenario innovation, business model innovation, and other approaches.
Looking to the Future Through Innovation: It is foreseeable that innovative technologies will deeply serve the entire lifecycle of medical insurance funds, promoting their intelligent operation; insurance companies will leverage innovative technologies to enhance underwriting and policy issuance capabilities, expand coverage, and deeply integrate with health management to provide comprehensive services to more users...
Innovative technologies such as artificial intelligence, big data, and the Internet of Things are being rapidly adopted in the insurance industry. We look forward to seeing what innovative applications Pacific Health will introduce in the future.