目的: 基于政策演进视角,分析中医优势病种按病种付费地方实践的模式创新路径与内在逻辑,为国家层面的政策整合与标准化提供参考。方法: 运用政策文本分析法,对东、中、西部代表性统筹地区的19份政策文件进行分析;借助公共政策间断均衡理论,阐释不同付费模式产生的政策背景与演进动因。结果: 地方实践历经“按病种定额付费”与“按DRG/DIP付费”两种主导模式,二者在政策复杂性、技术精细度和价值导向上呈现明显的演进关系。定额付费模式操作简便,但激励作用有限;DRG/DIP模式则衍生出固定比率倾斜、按病种倾斜、同病同价三类支付标准,并积极探索与疗效价值挂钩。两种模式的并存,反映了改革在“支付标准化”与“中医特色化”“管理精细化”与“操作简易性”之间的现实张力。结论: 中医优势病种付费改革呈现从简单定额向复杂整合的演进路径。国家层面应实施分类推进策略,强化中医临床路径与疗效评价标准的数据化、标准化建设,构建“自上而下”规范与“自下而上”创新相结合的政策学习机制,引导地方实践向更科学、更具价值导向的付费模式演进。

Objective: From a policy evolution perspective, this study analyzes the innovative pathways and internal logic of local practices in case-based payment for dominant diseases of Traditional Chinese Medicine (TCM), aiming to provide references for policy integration and standardization at the national level. Methods: Policy text analysis was employed to review 19 policy documents from representative pilot regions in eastern, central, and western China. The Punctuated Equilibrium Theory of public policy was utilized to explain the policy context and evolutionary drivers behind different payment models. Results: Local practices have differentiated into two dominant models: the "Fixed-Quota Payment" and the "DRG/DIP Payment". These two models exhibit a clear evolutionary relationship in terms of policy complexity, technical sophistication, and value orientation. The fixed-quota model is simple to operate but offers limited incentives, while the DRG/DIP model has given rise to three types of payment standards—fixed-ratio premium, disease-specific premium, and equal payment for equal disease—and actively explored linking payment to therapeutic value. The coexistence of the two models reflects the practical tension in the reform between "payment standardization" and "TCM characteristics", as well as between "management refinement" and "operational simplicity". Conclusion: The payment reform for dominant TCM diseases presents an evolutionary spectrum from simple fixed-quota to complex integration. At the national level, a classified promotion strategy should be implemented. Efforts should be strengthened in digitizing and standardizing TCM clinical pathways and efficacy evaluation criteria. A policy learning mechanism that combines "top-down" standardization with "bottom-up" innovation should be established to guide local practices toward more scientific and value-oriented payment models.