目的: 系统分析沈阳市医保支付方式改革的政策演进、制度特征与实践经验,揭示其内在运行逻辑,以期为全国深化支付方式改革提供参考与借鉴。方法: 采用政策文本内容分析法与过程追踪法,对2016—2025年45份核心政策文件进行系统梳理,重点剖析以DRG付费为主线的住院及门诊支付的探索路径。结果: 研究发现,改革历经“试点探索”到“价值导向升级”五个阶段。住院支付方面,成功构建了以国家CHS-DRG标准为核心,集“双总量”控制风险、精细化分组与数据治理于一体的动态支付体系。门诊支付方面,则以门诊特殊病为切入点,呈现逐步探索、基础先行的特征。结论: 沈阳市的医保支付方式改革实践证明,DRG是一项系统性、动态化的政策实践,有效推动了医保基金从被动支付向主动的“价值购买”转型,并深刻引导了医疗服务行为。但仍面临医疗机构策略性行为、门诊与住院改革不协同等挑战。建议未来深化支付与质量的联动,加快构建“门诊—住院”一体化支付体系,完善多方共治机制。

Objective: This study aims to systematically analyze the policy evolution, institutional characteristics, and practical experience of medical insurance payment method reform in Shenyang City over the past decade, revealing its underlying operational logic and providing reference and insights for deepening payment reform nationwide. Methods: Using policy text content analysis and process tracking methods, this study systematically reviewed 45 core policy documents from 2016 to 2025, focusing on the analysis of inpatient payment method reforms centered on DRG payment and the exploratory pathways for outpatient payment. Results: The study found that the reform has undergone five stages, from “pilot exploration” to “value-oriented upgrading.” In terms of inpatient payment, a dynamic payment system has been successfully established, centered on the national CHS-DRG standard, integrating “dual total volume” risk control, refined grouping, and data governance. In terms of outpatient payment, the reform has taken outpatient special diseases as the entry point, exhibiting characteristics of gradual exploration and prioritizing foundational measures. Conclusion: Shenyang City's medical insurance payment method reform practice shows that, DRG is a systematic and dynamic policy practice that has effectively promoted the transformation of medical insurance funds from passive payment to active “value-based purchasing” and profoundly guided medical service behaviors. However, it still faces challenges such as strategic behaviors by medical institutions and a lack of coordination between outpatient and inpatient reforms. It is recommended that in the future, the linkage between payment and quality be deepened, an integrated outpatient-inpatient payment system be accelerated, and a multi-party governance mechanism be improved.