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市场调查报告书
商品编码
1725066
2032 年医疗保健报销市场预测:按索赔、付款人、服务供应商和地区分類的全球分析Healthcare Reimbursement Market Forecasts to 2032 - Global Analysis By Claim (Underpaid, Fully Paid, Overpaid Claims and Denied Claims), Payer (Private Payers and Public Payers), Service Provider and By Geography |
根据 Stratistics MRC 的数据,全球医疗保健报销市场规模预计在 2025 年达到 315.9 亿美元,到 2032 年将达到 1,151.9 亿美元。
医疗保健提供者(例如诊所、医院和医生)从保险公司、医疗保险和医疗补助等政府倡议或直接从患者处获得服务费用的过程称为医疗保健报销。该系统确保医疗保健专业人员所提供的服务(从标准测试到复杂的外科手术)都能获得报酬。不同的报销模式,如人头税、基于价值的照护、捆绑支付和按服务收费,对提供者的奖励、成本控制和照护品质有不同的影响。
根据美国医学会(AMA)预测,2023年美国医疗保健支出将成长7.5%,达到4.9兆美元,即人均14,570美元。这一成长率明显高于2022年的4.6%的增幅,也是自2003年以来的最高成长率(不包括2020年因新冠疫情而产生的10.4%的增幅)。
慢性病盛行率不断上升
在全球范围内,糖尿病、癌症和心臟病等慢性疾病是导致死亡和残疾的主要原因。根据世界卫生组织(WHO)的数据,非传染性疾病约占全球整体死亡人数的74%。此外,这些疾病通常需要持续照护、定期就医、处方药,有时还需要住院治疗。人们越来越需要全面、持续的报销制度来帮助病患和医疗保健系统控制长期医疗成本。
复杂且分散的医疗收费框架
不同国家之间,甚至同一国家内部,医疗保健报销政策存在很大差异,取决于付款人(私人或公共)、服务类型和人口统计资料。在美国,医疗保险、医疗补助和私人保险公司的监管方式各不相同。此外,由于缺乏一致性,还会导致行政效率低下、计费错误以及患者和提供者之间的误解。复杂的文件要求、编码规格和核准流程会导致付款延迟,并阻碍供应商参与某些报销计画。
数位健康和远端医疗服务的发展
医疗报销成长潜力巨大,尤其是在新冠疫情期间和之后远端医疗医疗迅速普及的情况下。政府和保险公司越来越多地将行动健康应用程式、远端监控和虚拟咨询纳入报销计划。此外,根据美国医院协会的数据,远端医疗的使用率已稳定在疫情前的 38 倍。扩大这些服务的保险覆盖范围可以减少医疗保健差距、增加农村地区的医疗服务覆盖率并减轻机构负担,有助于长期扩大医疗报销市场。
网路安全与资料外洩风险
数位平台对于医疗保健系统处理计费工作流程、储存患者个人资讯和处理医疗索赔至关重要。这些依赖性使得该行业特别容易受到网路攻击。一次资料外洩就可能导致业务中断,并使数千份患者记录面临风险。此外,根据美国卫生与公众服务部 (HHS) 的数据,报告的医疗保健资料外洩数量一直在稳步增加,仅在 2023 年就有超过 700 起洩漏事件影响了超过 1.33 亿人。此类事件会破坏公众信任并增加安全和合规成本。
COVID-19 疫情极大地改变了全球报销模式,促进了监管灵活性,并加速了向数位医疗服务的转变,所有这些都对医疗报销市场产生了影响。远端保健、远端监控和居家照护以前是报销不足或被排除在外的服务,随着医疗系统负担过重,这些服务正迅速被政府和保险公司覆盖。对于虚拟访问,临时政策变更(例如美国医疗保险和医疗补助服务中心 (CMS) 实施的政策变更)允许支付均衡和扩展计费代码。此外,儘管这些变化最初是紧急措施,但数位化和基于价值的报销现已根植于医疗保健生态系统中。
预计全额付费部分将在预测期内占据最大份额
预计在预测期内,全额付费部分将占据最大的市场占有率。全额付款索赔是指保险公司或医疗保健提供者根据医疗保健计划的条款处理并全额支付的索赔。由于医疗费用可以获得有效付款且患者无需承担未偿余额,该领域已占据了相当大的市场份额。此外,全额计费可确保病患和医疗服务提供者拥有支付医疗服务所需的资金,尤其是在医疗成本不断上涨且医疗计画日益复杂的情况下。
预计在预测期内,医疗诊所部门的复合年增长率最高。
预计医疗诊所部门在预测期内将以最高速度成长。人口老化、慢性病盛行率上升以及门诊护理需求增加是推动这一增长的一些因素。医生办公室在医疗保健系统中的作用日益增强,这是因为它能够提供负担得起的医疗服务,并在管理慢性病方面发挥关键作用。此外,远端医疗的发展和向基于价值的护理模式的转变正在增加对医生办公室提供的服务的需求。在医疗保健报销方面,预计该细分市场将以最快的速度成长。
预计北美地区将在预测期内占据最大的市场占有率。美国占全球市场的约38.7%,是罪魁祸首。这一领先地位很大程度上归功于该地区强大的医疗保健体系、广泛的保险覆盖范围和完善的报销结构。此外,《平价医疗法案》等立法加强了报销制度并确保了更多人获得医疗服务。
预计亚太地区在预测期内的复合年增长率最高。医疗成本的上涨、慢性病的增多以及新兴国家保险覆盖范围的扩大是推动这一快速成长的一些因素。中国和印度等国家正在大力投资医疗保健基础设施,这增加了对可报销服务的需求。此外,由于公共和私人保险系统的扩展以及数位健康技术的采用,该地区的市场正在扩大。
According to Stratistics MRC, the Global Healthcare Reimbursement Market is accounted for $31.59 billion in 2025 and is expected to reach $115.19 billion by 2032 growing at a CAGR of 20.3% during the forecast period. The process through which healthcare providers-such as clinics, hospitals, or doctors-are paid for their services by insurance companies, government initiatives like Medicare and Medicaid, or directly from patients is known as healthcare reimbursement. This system guarantees that healthcare professionals receive payment for the services they provide, ranging from standard examinations to intricate surgical operations. Different reimbursement models, such as capitation, value-based care, bundled payments, and fee-for-service, have varying effects on provider incentives, cost control, and care quality.
According to the American Medical Association (AMA), U.S. health spending indeed increased by 7.5% in 2023, reaching $4.9 trillion or $14,570 per capita. This growth rate is notably higher than the 4.6% rise in 2022 and is the highest observed since 2003, apart from the 10.4% rise in 2020 due to the COVID-19 pandemic
Increasing chronic illness prevalence
Globally, chronic diseases like diabetes, cancer, and heart disease rank among the top causes of death and disability. Non-communicable diseases are responsible for about 74% of all deaths globally, according to the World Health Organization (WHO). Additionally, these illnesses frequently necessitate continuous care, regular checkups with the doctor, prescription drugs, and occasionally hospitalization. In order to assist patients and healthcare systems in controlling the long-term costs of care, there is a growing need for comprehensive and ongoing reimbursement frameworks.
Complicated and disjointed reimbursement frameworks
Depending on the payer (private vs. public), the service type, and the demographic, healthcare reimbursement policies differ significantly between nations and even within them. Medicare, Medicaid, and private insurers are subject to different regulations in the United States. Furthermore, administrative inefficiencies, billing errors, and misunderstandings between patients and providers are caused by this lack of consistency. Complicated documentation requirements, coding specifications, and authorization processes can cause payment delays and deter providers from taking part in specific reimbursement programs.
Development of digital health and telehealth services
There is a significant chance for reimbursement growth due to the quick uptake of telemedicine, particularly during and after the COVID-19 pandemic. More and more, governments and insurance companies are incorporating mobile health apps, remote monitoring, and virtual consultations into their reimbursement schemes. Moreover, telehealth utilization has stabilized at 38 times higher levels than it was prior to the pandemic, according to the American Hospital Association. By increasing coverage for these services, the reimbursement market can grow in the long run by lowering healthcare disparities, enhancing access in rural areas, and relieving systemic burdens.
Risks to cyber security and data breach
Digital platforms are essential for handling billing workflows, storing private patient information, and processing reimbursement claims in healthcare systems. The industry is particularly vulnerable to cyber attacks because of this dependence. A single data breach has the potential to stop operations and jeopardize thousands of patient records. Additionally, the number of reported healthcare data breaches has been increasing steadily, with over 700 breaches impacting over 133 million people in 2023 alone, according to the U.S. Department of Health and Human Services (HHS). These occurrences damage public confidence and raise the expense of security and compliance.
The COVID-19 pandemic significantly altered global reimbursement models, prompted regulatory flexibility, and accelerated the transition to digital health services, all of which had an effect on the healthcare reimbursement market. Telehealth, remote monitoring, and home-based care-services that were previously under-reimbursed or excluded-were quickly covered by governments and insurers as healthcare systems became overburdened. For virtual consultations, temporary policy changes, like those implemented by the U.S. Centers for Medicare & Medicaid Services (CMS), allowed for payment parity and wider billing codes. Furthermore, digital and value-based reimbursement is now more ingrained in the healthcare ecosystem, despite the fact that these changes were initially emergency measures.
The fully paid segment is expected to be the largest during the forecast period
The fully paid segment is expected to account for the largest market share during the forecast period. Fully paid claims are medical reimbursements that have been processed and paid in full by insurance companies or medical providers in accordance with the terms of the health plan. Given that it shows the effective settlement of healthcare costs without leaving the patient with any outstanding balance, this segment accounts for a sizeable portion of the market. Moreover, fully paid claims guarantee that patients and providers have the money needed to pay for medical services, especially in light of rising healthcare costs and the complexity of healthcare plans.
The physician offices segment is expected to have the highest CAGR during the forecast period
Over the forecast period, the physician offices segment is predicted to witness the highest growth rate. The aging of the population, the growing incidence of chronic illnesses, and the increased need for outpatient care are some of the factors driving this growth. Physician offices' growing role in the healthcare system is a result of their ability to provide affordable care and play a key role in managing chronic conditions. Furthermore, telemedicine developments and the move to value-based care models have increased demand for services rendered by doctors' offices. In the context of healthcare reimbursement, this market segment is therefore expected to grow at the fastest rate.
During the forecast period, the North America region is expected to hold the largest market share. The United States, which alone accounts for roughly 38.7% of the global market, is principally responsible for this dominance. This top ranking is largely due to the region's strong healthcare system, extensive insurance coverage, and sophisticated reimbursement schemes. Additionally, the reimbursement systems have been reinforced by the implementation of laws such as the Affordable Care Act, guaranteeing greater access to medical care.
Over the forecast period, the Asia Pacific region is anticipated to exhibit the highest CAGR. Growing healthcare costs, the occurrence of more chronic illnesses, and the expansion of insurance coverage in emerging economies are some of the factors driving this quick growth. Because of their significant investments in healthcare infrastructure, nations like China and India are seeing an increase in demand for reimbursement services. Furthermore, the region's market is expanding due to the expansion of both public and private insurance programs as well as the adoption of digital health technologies.
Key players in the market
Some of the key players in Healthcare Reimbursement Market include Anthem, Inc, Cigna Corporation, Nippon Life Insurance Company Limited, Aetna Inc., Humana Inc., CVS Health Corporation, Allianz Care (Allianz Group), Molina Healthcare, Inc., Centene Corporation, Agile Health Insurance, WellCare Health Plans, Inc., UnitedHealth Group Incorporated, Health Care Service Corporation (HCSC), Aviva plc and MetLife, Inc.
In April 2025, Cigna Healthcare and Mercy Health have reached a multi-year agreement, ensuring that Cigna's commercially insured patients will remain in-network at Mercy Health facilities in Ohio. The agreement, effective, averts a potential disruption in healthcare access that had been looming as contract negotiations between the two entities stretched past multiple deadlines.
In December 2024, Nippon Life Insurance Company has agreed to consolidate its ownership interest in Resolution Life by acquiring the remaining shares from the firm's investment limited partnership for $8.2 billion. The transaction values Resolution Life at $10.6 billion, with shareholders also retaining final dividends before completion.
In July 2024, Humana Inc. announced a new multi-year agreement with Google Cloud to further modernize Humana's cloud infrastructure and leverage cutting-edge AI capabilities to accelerate innovation in healthcare. This agreement builds on an ongoing collaboration between Google Health and Humana to co-develop solutions focused on population health and bringing the best of Google's AI technologies and products to Humana members and patients.