my country's medical insurance payment method reform has basically achieved full coverage of payment by disease type

  Medical insurance pays for treatment results to help win-win results

  "At present, the reform of payment methods has achieved positive results, and medical, insurance and patients have initially won the money." At the 2025 Medical Insurance Payment Method Reform Blue Book Release Conference and Trend Exchange Conference held recently, Xu Na, deputy director of the Medical Management Department of the National Medical Insurance Administration, introduced.

  The reporter learned that in the past, patients' diagnosis, examination and treatment were charged according to the item. The medical insurance fund first determines the project scope and reimbursement ratio, and then pays the expenses that should be reimbursed by the medical insurance to medical institutions. Although this medical insurance payment method is simple and convenient, it can easily induce excessive growth of medical expenses and "over-medicine", making it difficult to guarantee patient rights and medical insurance funds.

  In order to allocate medical resources more scientifically and standardize medical behavior, in recent years, the National Health Insurance Administration has continued to deepen the reform of medical insurance payment methods, and has reformed the past "pay by project" to pay by disease group (DRG) and disease type score (DIP), that is, it will pay for the treatment process and reform it to pay for the treatment result. Under these two payment methods, no matter how many drugs and consumables are used during the treatment process, there are payment standards set in advance.

  Xu Na introduced that at present, payment by disease type has basically achieved full coverage. Up to now, 191 payments by disease group (DRG) and 200 payments by disease type score (DIP) are implemented among the 393 coordinated regions across the country. Tianjin and Shanghai have both payment models, achieving full coverage of coordinated regions, full coverage of qualified medical institutions, a disease type coverage rate of 95%, and a medical insurance fund coverage rate of 80%.

  At the same time, the inclusion of hospitalization costs for medical treatment in other places in the management of paid by disease type has been steadily promoted. Long Xuewen, deputy director of the Medical Insurance Center of the National Medical Insurance Administration, introduced that as of the end of the first quarter, in addition to 6 provincial-level coordinated provinces and 11 coordinated areas that are not used as medical treatment places, 235 coordinated areas in 23 provinces have carried out inclusion of hospitalization costs for medical treatment in other places within the province in the province in the payment management according to the disease type, and 177 coordinated areas have actually paid.

  Talking about the win-win situation of the three parties brought about by the reform of medical insurance payment methods, Xu Na gave an example, such as the operation of medical insurance funds is balanced and the use efficiency is improved; medical institutions have obtained more medical insurance surpluses, and the internal income structure is improved; the economic burden of patients seeking medical treatment is reduced, and the cost of hospitalization is steadily reduced.

  At present, the results of the reform of medical insurance payment methods are gradually emerging, and various places have accumulated experience in implementing reforms. Lu Dawei, deputy director of the Medical Service Management Office of the Shanghai Medical Security Bureau, said that Shanghai has proposed a payment by disease grouping plan that integrates payment by disease group/pay by disease type score to meet the actual medical needs. At the same time, a "green channel" for intelligent review of special cases and individual cases has been established to eliminate the worries of treating difficult and critical cases.

  The introduction of medical insurance payment methods and a series of supporting policies has also brought significant changes to the medical service field.

  "Our hospital strengthens the digital transformation of the hospital through a series of measures such as establishing mechanisms, building platforms, strengthening management, and strictly controlling costs." Cao Ying, deputy director and associate researcher of the Medical Insurance Department of Jining First People's Hospital in Shandong Province, introduced that, especially by establishing a special team for drug consumption path management of disease types, standardizing diagnosis and treatment behaviors, reducing unnecessary use of drugs and consumables, in order to reduce costs and improve the efficiency of medical insurance fund use.

  Leng Jiahua, director of the Medical Insurance Department of Peking University Cancer Hospital, believes that under the macro-driven of medical reform, on the one hand, hospitals must actively embrace reform and obtain the development dividends brought by medical insurance payment through active and fruitful management; on the other hand, some medical institutions will be in a disadvantaged position in the competition if they are not adapted to the corresponding reform measures.

  Compared with the payment method reform goals, Xu Na admitted that there are still three major challenges in the reform of payment method reform that are currently in conflict with the growth of medical expenses and the management of payment method, and the overall quality of reform still has a lot of room for improvement.

  Ying Yazhen, executive director of the National Medical Insurance Research Institute of Capital Medical University, proposed that to deepen the reform of payment methods, we must continue to improve and explore from the perspectives of theory, policy, technology, and methods, and strive to improve the quality of payment based on disease types, fully implement diversified and compound payment methods, and promote the coordinated development and governance of "medical, medical insurance, and medicine".

  Wang Ronghua, director of the academic department of Hunan Medical Insurance Research Association and a special expert at the National Medical Insurance Research Institute of Capital Medical University, suggested that public hospitals establish a three-level refined operation and management system, take the disease type/disease group as the core in hospital-level coordination, supplement the functions and responsibilities of all administrative departments, integrate payment methods into daily life, and improve relevant systems and continuously improve the refined management level with disease type as the starting point.

  It is reported that in July 2024, the National Health Insurance Administration released the DRG/DIP paid version 2.0 grouping plan, which is currently being implemented smoothly in various places. Xu Na said that in the next step, we will coordinate the construction of a diversified payment system, accelerate the improvement of supporting management mechanisms, strengthen coordination of payment reform work, and steadily promote the implementation of the 2.0 version in groups. (Reporter Li Danqing)

[Editor in charge: Wang Xue]