Based on the Real-World Evidence Framework published by the United Kingdom's National Institute for Health and Care Excellence (NICE), this paper explores its methodological innovations and discusses the instructive value for healthcare insurance reimbursement decision-making in China. Against the backdrop of a global shift toward value-driven healthcare governance, real-world evidence (RWE) has become a key tool for addressing the limitations of randomized controlled trials and supporting strategic purchasing decisions by payers. The scientific generation and standardized application of RWE are therefore of paramount importance. The NICE framework is built upon three pillars: transparency, data suitability, and methodological rigor. It systematically constructs an application system for RWE. It improves the validity of causal inference in observational studies by advocating the "target trial emulation" approach and incorporates qualitative evidence to comprehensively assess patient experience and clinical implementation pathways. Practice has demonstrated the significant effectiveness of this framework for evaluating technologies in domains such as oncology, digital therapeutics, and rare diseases. Considering this, China, in the exploratory phase of leveraging RWE for the comprehensive value assessment of health technologies within its healthcare insurance decision-making, can focus on three key dimensions: strengthening data governance foundations, standardizing methodological norms, and clarifying implementation pathways, to build a localized RWE application system suited to the national context.

Objective: To assess the in-hospital costs of transcatheter aortic valve replacement (TAVR) vs. surgical aortic valve replacement (SAVR) in the treatment of severe aortic stenosis. Methods: Patients treated with TAVR and SAVR in Shanghai Zhongshan Hospital from 2015 to 2019 were retrospectively collected, according to demography and baseline characteristics of the disease, propensity score matching (PSM) was used to control for baseline bias factors. The total hospitalization expenses, cost structure and per capita hospitalization days of the two groups were compared and analyzed. Results: A total of 285 cases (92 cases of TAVR and 193 cases of SAVR) were collected. After PSM, 30 cases of TAVR and 30 cases of SAVR were obtained. The results showed that the average total hospitalization cost of AS patients undergoing TAVR or SAVR for the first time was 284,476 yuan and 153,772 yuan, respectively, of which consumables cost accounted for 90.2% and 57.2%, respectively. The total hospitalization cost and consumables cost showed statistical differences between the two groups. In terms of hospitalization days, TAVR and SAVR were 9.3 and 15.0 days, respectively, with statistical differences. Conclusion: Compared with SAVR, TAVR can significantly reduce the length of hospital stay in the treatment of severe aortic stenosis. However, the total in-hospital costs of TAVR is significantly higher than SAVR, which leads to a heavy economic burden. Thus, we should pay attention to the clinical application and promotion of TAVR.

Objective: The report compares the differences in the impact of VBP generic drugs and original drugs on the main clinical outcome indicators in the treatment of major diseases, and promotes the rational use of VBP drugs in the clinical practice. Methods: The main focus is on the effectiveness and safety of the second and third batches of VBP drugs in clinical diagnosis and treatment. The paper investigates a total of 29 representative medical institutions in 16 provinces and municipalities in China, covering six major categories of cardiovascular, anti-tumor, neuropsychiatric, anti-infection, metabolic and endocrinic, and digestive systems. We extract baseline information and research indicators related to drug treatment and clinical outcomes from medical record data for efficacy, safety, and economic evaluation. Statistical analysis is conducted with inter-group baseline correction and analysis method of outcome indicators. Result: There is no statistically significant difference in the effectiveness and safety between the selected generic drugs in the national centralized procurement and the original drugs, providing evidence-based basis for rational clinical medication. Conclusion: This study provides an important reference for clinical doctors in decision-making of drug use, promotes the clinical rational use of selected drugs in centralized procurement, provides evidence-based data for the implementation of national centralized procurement policies, and also provides a model and method for the implementation and effectiveness evaluation of national centralized procurement policies.

Objective: Under the DIP payment schemes, all anti-tumor drugs are paid using the same payment standard, which is insufficient to reasonably reflect the value of various drugs. Using lung cancer drugs as an example, this study examined the cost differences of anti-tumor drugs based on drug mechanisms and innovation levels, and explored the methodology for adjusting the payment standards for DIP cancer diseases. Methods: Lung cancer patients admitted to two tertiary hospitals in Guangzhou from 2018 to 2020 were selected. The costs of different types of drugs were analyzed and the four treatment groups were compared pairwise. We divided the treatment groups with statistical differences in hospitalization expenses and a percentage difference greater than the given threshold into different disease groups for payment, and compared the impact of subdivision on the medical insurance fund budget. Results: The average hospitalization cost for the immunotherapy combined with chemotherapy group, the mono-immunotherapy group, the mono-targeted therapy group and the mono-chemotherapy group were 26379 yuan, 18832 yuan, 16345 yuan, 13753 yuan per case, respectively. There were statistical differences in the total hospitalization expenses among the four treatment groups, and the percentage difference was 20% higher than the base group. The budget impact analysis indicated further segmentation of disease groups could lead to overall decrease or stability of medical insurance funds due to reduction in expenses associated with a large amount of unnecessary chemotherapy. Conclusion: Dynamic adjustment of payment standard based on real world data could support refined management of medical insurance, increase hospital access of innovative negotiated drugs, and promote clinical rational drug use.

Objective: The paper draws on international experience to establish a localized real-world database classification system, and preliminarily explore the collection status and evidence levels of different types of real-world data (RWD), providing reference for the application of RWD in China's medical insurance access. Methods: Using 26 orphan drugs approved by the National Institute for Health and Care Excellence (NICE) through the Highly Specialised Technology (HST) evaluations before May 2025 as samples, this study systematically analyzed the use of RWD in the health insurance access assessment reports of NICE, the Canadian Agency for Drugs and Technologies in Health (CADTH), and the Institute for Clinical and Economic Review (ICER), and further developed a database classification framework. Case studies were conducted to examine data collection across different databases. Based on characteristic comparisons and the evaluators’ considerations, the study further explored the evidence grading framework for real-world evidence (RWE) in medical insurance access. Results: Among drugs assessed by NICE, CADTH, and ICER, 96%, 62%, and 19%, respectively, incorporated RWD. Guided by both domestic and international frameworks, this study constructed 9 categories of databases, including hospital information system data and health insurance claim data, and selected 9 representative drug cases to detail the key processes of data collection, curation, and organization. Feature analysis indicated substantial differences in data structure and quality across database types. The grading results showed that hospital information system data, health insurance claim data, and official health authority data exhibited high evidence levels; registry databases, general population cohort, and literature-derived data were rated as moderate; while patient-reported outcomes and expert survey data were associated with lower evidence levels. Although all database types were utilized by manufacturers or HTA agencies in drug assessments, the study identified that, for 13 drugs, 16 data sources spanning 5 database categories were questioned by HTA agencies due to limited applicability or low evidence quality. Conclusions: This study preliminarily established a China-specific real-world database classification system and its evidence grading framework, which can provide reference for the application of RWD in medical insurance access. Further standardization and multi-party validation are needed in the future to enhance the decision-making value of RWD.

Objective: To evaluate the implementation effect of hepatitis C medical insurance reimbursement policy in Chengdu, and to provide reference and basis for hepatitis C prevention and treatment and medical insurance policy. Methods: The electronic medical record data of a three tertiary hospital in Chengdu from January 2014 to December 2020 were extracted, and the interrupted time series model was used to analyze the changes of diagnosis and treatment behavior and disease burden of hepatitis C patients from the aspects of diagnosis and treatment, medical expenses, drug use and treatment effect. Results: In terms of diagnosis and treatment, the number of visits and treatments increased instantaneously after the implementation of the outpatient reimbursement policy in Chengdu, and there was no significant change after the implementation of the single line payment policy for oral direct antiviral (DAA) drugs. In terms of medical expenses, the total cost of treatment, out of pocket expenses and drug expenses of hepatitis C patients have been significantly reduced after the implementation of the single line payment policy. Conclusion: Chengdu hepatitis C medical insurance reimbursement policy can promote hepatitis C patients to actively seek medical treatment, promote the widespread use of DAA scheme, reduce the burden of patients, and improve the treatment efficiency of hepatitis C.

Objective: The paper evaluates the effect of centralized medical consumables procurement policy on expenses of patients undergoing knee arthroplasty and analyzes the law of cost change, providing evidence for reasonably controlling the cost of these surgeries. Methods: Based on the real-world data before and after the implementation of policy, RDD was applied to analyze the impact of centralized medical consumables procurement on the hospitalization costs of patients undergoing knee arthroplasty. Results: After the implementation of centralized medical consumables procurement policy, the hospitalization costs of patients undergoing knee arthroplasty have significantly decreased. The optimal bandwidth was approximately 57.48 days, and the average hospital expenses of patients decreased by 23311.29 yuan on April 30, 2022. The estimated results of 1/2 optimal bandwidth showed that the expenses decreased by 24923.05 yuan, and the estimated results of 2 times optimal bandwidth showed that the expenses decreased by 21547.30 yuan. The local average effect of different bandwidths is slightly different, but all shows a decreasing trend. Conclusion: The centralized medical consumables procurement policy has effectively reduced the hospital expenses of patients undergoing knee arthroplasty. Hospital managers should strictly implement the procurement policy, improve clinical pathways and standardize diagnosis and treatment behavior to reduce patients’ expenses. In addition, relevant departments should steadily expand the scope of procurement and strengthen supervision to ensure the effective implementation of policy and improve the accessibility and affordability of medical services.

Objective: Based on the real-world data (RWD) application case study of the National Institute for Health and Care Excellence (NICE) in the UK, this study analyzes the roles and challenges of RWD in medical insurance access of drugs, which can provide a reference for the policy making in China. Methods: A case study method was used to analyze the implementation details of the Managed Access Agreement (MAA) under the NICE system. Results: The UK healthcare system has facilitated the rapid entry of innovative medicines into the National Health Service (NHS) by utilizing RWD to assess the efficacy and cost-effectiveness of medicines through the MAA implemented by NICE. Conclusion: China can learn from the UK, improve RWD-related policies and standards, strengthen international cooperation, and promote the wide application and in-depth development of RWD in the medical insurance system, so as to provide a more solid support for the optimal allocation of healthcare resources and patients' healthcare security.

The process of innovative drug medical insurance admission in China is gradually accelerating, but the risk of admission decision-making is also increasing. Standardizing the application of real-world data can provide important evidence for medical insurance admission assessment, thereby reducing decision-making risks. This article analyzes the advantages and disadvantages of real-world data and application scenarios in medical insurance access, summarizes current policy frameworks and guidelines at home and abroad, and proposes research standards and application paths for real-world data in China's innovative drug medical insurance access, providing references for the application of real-world data research in medical insurance access.

Objective: Early outpatient medication is a critical means for the treatment and control of the progression of chronic diseases such as hypertension and diabetes. This study attempts to characterize the outpatient drug consumption of elderly patients with hypertension and diabetes under the outpatient security policy, and to analyze the effects of outpatient medication on inpatient service utilization and costs. Methods: Basic medical insurance participation and claim data of all insured residents in W city from 2019 to 2023 were collected. Elderly patients with hypertension and/or diabetes who are entitled to the outpatient chronic and special disease medical security policy and have visiting records at designated medical institutions were selected as study samples, dividing into three groups of people with different types and levels of medical insurance (residents level 1, residents level 2, and employees). The two-way fixed-effect model was constructed, with inpatient service utilization and cost indicators as the dependent variables, outpatient medication frequency and extent as the independent variables. Results: 140283 elderly patients with hypertension and diabetes were included, with an average age of 72.2±7.7 years old. Most patients had an average outpatient medication frequency of greater than or equal to 4 visits per year, the annual outpatient drug costs per capita decreased from 1848.6 yuan in 2019 to 888.3 yuan in 2023, and the annual outpatient medication frequency and outpatient medication costs show a trend of "residents level 1<residents level 2<employees", with total outpatient drug costs accounting for 96.1%. The probability, frequency, and length of hospitalization significantly decreased with the increase of outpatient medication frequency and extent (P<0.01), which is consistent among people with different levels of medical insurance. Inpatient medical costs and drug costs decreased significantly in the group with higher outpatient medication frequency (P<0.01), but showed an inverted U-shaped distribution with the increase of outpatient medication extent. Conclusion: The core outpatient demand of elderly patients with hypertension and diabetes is medication, and their medication utilization varies by medical insurance levels, comorbidities, and complications. Under the outpatient security mechanism of chronic disease, guiding adequate and rational outpatient medication is conducive to the “replacement effect” on inpatient medical services and the decrease of inpatient costs.

Objective: This study investigates the application of real-world evidence (RWE) in decision-making of drug medical insurance access in major countries, in order to provide evidence and support for the dynamic adjustment of the China’s national medical insurance drug catalog. Methods: A comprehensive literature review was conducted to systematically summarize the current experience of RWE in supporting drug access decision-making in major countries, including the United Kingdom, France, Germany, Italy, Australia, the United States, and Canada. Results: This study focuses on summarizing the application scenarios and specific practice of RWE in drug medical insurance access decision-making in major countries. Based on China’s practice, relevant suggestions are proposed for RWE to support the adjustment of national medical insurance drug catalog. Conclusions: RWE plays an increasingly important role in drug medical insurance access decision-making. By considering China’s national conditions and practical experience, and drawing upon the experience of major countries, a scientific pathway for RWE to support drug medical insurance access decision-making with Chinese characteristics should be explored.

Objective: The paper evaluates the difference in clinical efficacy between the bid-winning generic and original drugs in the centralized procurement of Bortezomib for the treatment of first-visit multiple myeloma based on multicenter real-world data. Methods: Data of patients treated with Bortezomib in the electronic medical record system of five hospitals in Shanghai from January 2017 to June 2024 were collected retrospectively. The first-visit patients were screened out and divided into the generic and original groups according to different medications. Patients’ baseline data of the two groups were corrected by the propensity score matching method. The direct and indirect indexes of therapeutic effect, adverse reactions and residents' affordability were compared between the two groups. Results: There were 215 patients in both the generic and original groups, screened by 1:1 matching of baseline data. There was no significant difference between the two groups after 4 courses of Bortezomib-containing therapy (P>0.05). There was no significant difference in the changes of M protein, plasma cell ratio of myeloma, β2-microglobulin, creatinine, calcium and sFLC-λ between the two groups. The original group had an advantage in protecting renal function (P<0.05), and the centralized procurement group had an advantage in controlling LDH increase (P<0.05). In terms of safety, there was no significant difference in the incidence of lethargy, pain, peripheral neuropathy, rash and allergy between the two groups (P>0.05). However, the incidence of fatigue was higher in the original group (P<0.05). The generic drugs were more affordable. Conclusion: The overall effectiveness and safety of selected drugs in the centralized procurement of Bortezomib are not inferior to the original drugs, and some indicators have their own advantages.

Objective: This study focuses on the quality issues of real-world medical insurance data, systematically constructs a data cleaning strategy for real-world medical insurance data, and evaluates the effectiveness of the data cleaning strategy using the statistics of the "cost of medicines included in the payment scope" of national negotiated drugs as an example. Methods: The study takes the original medical insurance settlement records database of anti-tumor drugs and immune regulators involved in the national medical insurance negotiation access in City A from January to September 2024 as the research object, and constructs a data cleaning strategy that includes establishing a verification dataset, text structuring, and handling of outliers. With the total cost of medicines and the cost of medicines included in the payment scope as effect indicators, the study compares and analyzes the changes in the observed indicators before and after data cleaning from multiple dimensions of different populations and medication scenarios. Results: After data cleaning, the total cost of medicines remained highly stable (deviation < 0.3%), while the cost of medicines included in the payment scope significantly decreased, with an absolute value reduction of approximately 2 million yuan, corresponding to a decrease of about 5%. Different deviations were observed across different populations (employees and urban and rural residents' medical insurance) and different medication scenarios (outpatient, inpatient, and retail pharmacies, as well as local and non-local medical treatment). Conclusion: The study verifies the effectiveness of the data cleaning strategy in improving the quality of medical insurance data and provides strong support for the scientific application of real-world medical insurance data. Meanwhile, the study reveals the heterogeneous distribution of medical insurance data quality issues, indicating that attention should be paid to data quality differences under different populations and medication scenarios in medical insurance data governance. In the future, it is necessary to further improve the medical insurance information system and strengthen cross-platform data governance to cope with the systemic challenges in medical insurance data governance.

This paper systematically reviews the institutional construction and practice of real-world data in charging item initiation and medical insurance admission of innovative medical technologies in China, providing inspiration for the item initiation, pricing, and payment of new price items in other regions. This article reviews the national-level policies on the item initiation, pricing and medical insurance access of innovative medical technology charges, summarizes the practice of typical regions in applying real-world data to the management of new price items, analyzes the logic of applying real-world data to the item initiation, pricing, medical insurance access and payment of innovative medical technology charges, and gains insights for optimizing the application, item initiation, pricing and medical insurance access management of new price items in other regions: promoting the conditional application model for new price items and conducting trials first for those who achieve clinical and economic effects as promised. The formation of real-world data during the regular implementation period can be used to provide a basis for the inclusion of innovative medical technologies in the medical insurance catalogue.

Objective: The paper compares the efficacy, safety and economics of centralized procurement and original tigecycline in the treatment of patients with bacterial infection to provide evidence for clinical drug selection. Methods: Data of 318 patients treated with centralized procurement (209 cases) and original (109 cases) tigacycline from 3 hospitals from July 2019 to July 2023 were retrospectively collected. The two groups of samples with balanced covariates were obtained by propensity score matching (PSM). The efficacy was evaluated by clinical effective rate, 28d mortality rate, bacteriological clearance rate and infection-related indicators, the safety was evaluated by the incidence of adverse reactions and abnormal rate of adverse events, and the economics was evaluated by the cost-minimization analysis. Results: After PSM, the centralized procurement group and the original group included 86 patients respectively. There was no significant difference in clinical effective rate, 28d mortality rate, bacteriological clearance rate, WBC, NEUT, NEUT%, hsCRP/CRP, IL-6 and PCT recovery between the two groups (P > 0.05). The proportion of patients whose body temperature returned to the normal range in the original group was higher than that in the centralized procurement group (P < 0.05). There was no statistically significant difference in the incidence of adverse reactions between the centralized procurement and original research groups (P>0.05). The incidence of PT extension in the centralized procurement group was higher than that in the original group (P<0.05), and there was no significant difference in the abnormal rate of other adverse event-related indicators between the groups (P>0.05). The cost-minimization analysis showed that the cost of tigacycline, total antibacterial drug cost, total drug cost and total hospitalization cost in the centralized procurement group were lower than those in the original group (P<0.01). Moreover, within the range of parameters for sensitivity analysis, the results were consistent with those of cost-minimization analysis. Conclusions: Centralized procurement and original tigecycline have similar efficacy and safety in the treatment of bacterial infection, and centralized procurement tigecycline has an economic advantage than original tigecycline.

Objective: The paper attempts to analyze the practical experience of the United Kingdom, Canada, and the United States in applying real-world data (RWD) to health insurance access (reimbursement) decision-making, and, in light of China's current policy context, propose a construction pathway for an RWD-driven comprehensive value assessment system for pharmaceuticals to inform the improvement of China's reimbursement policy. Methods: Twenty-six orphan drugs that had been included in the UK National Health Service (NHS) through the Highly Specialised Technologies (HST) evaluations conducted by the National Institute for Health and Care Excellence (NICE) before May 2025 were selected as the study samples. The reimbursement assessment reports issued by NICE, the Canadian Agency for Drugs and Technologies in Health (CADTH), and the US Institute for Clinical and Economic Review (ICER) were analyzed. Combining specific application cases, the study examined the use of RWD from two perspectives—companies (P1) and assessment agencies (P2)—to explore the specific purposes, data sources, and assessment agencies' considerations of RWD in addressing uncertainties related to effectiveness (D1), cost (D2), population and market share (D3). Results: RWD was used in the reimbursement assessments of 96%, 62%, and 19% of the drugs evaluated by NICE, CADTH, and ICER, respectively. Its primary applications were in evaluating four dimensions of pharmaceutical value: economic efficiency, effectiveness, safety, and accessibility. Specifically, RWD was employed to address three main categories of uncertainty: effectiveness uncertainty (D1), cost uncertainty (D2), and population and market share uncertainty (D3) . The main purposes included providing data on disease management costs, patient outcomes, and target populations. RWD was most widely applied in addressing cost (D2) and effectiveness (D1) uncertainties. All types of RWD were used by both companies (P1) and assessment agencies (P2), though some datasets were challenged by assessment agencies due to concerns about their applicability or low evidence level. Conclusion: The application of RWD in reimbursement decision-making has been increasingly adopted by assessment agencies. However, differences remain in the degree of acceptance across different purposes and RWD types. Overall, RWD plays a crucial role in the reimbursement process, yet its application still requires clarification of specific use scenarios, alignment of data-source grading with appropriate purposes, and the establishment of standardized guidelines to enhance scientific rigor and standardization of its application.

Objective: The study used interrupted time series analysis to evaluate the impact of medical insurance fund intelligent supervision with denial-of-payment policy on hospital consumables payment type verification error rates, and to explore the policy's effects on standardized utilization of medical insurance fund for consumables and mitigation of moral hazard in hospital consumables management control. Methods: This study selected inpatient cost data for staplers and specialized wound covering materials from a Class-A tertiary public hospital in Wenzhou City, covering the period from January 2023 to November 2024. We employed the DW test and BG test to examine autocorrelation in the consumables payment type verification error rate, conducted the ADF test to assess data stationarity, and utilized the implementation date of the consumables intelligent supervision and denial-of-payment policy as the interruption point. A segmented regression model was applied to analyze changes in the consumables payment type mis-verification rate. Results: Post-implementation of the consumables intelligent supervision and denial-of-payment policy, long-term analysis showed the self-payment mis-verification rate for staplers increased by 0.51 percentage points per month, while the self-payment mis-verification rate for specialized wound covering materials increased by 0.28 percentage points monthly. Conversely, the medical insurance mis-verification rate for staplers decreased by 0.08 percentage points per month, and the medical insurance mis-verification rate for specialized wound covering materials decreased significantly by 3.95 percentage points monthly. Conclusions: While the consumables intelligent supervision and denial-of-payment policy exerts a positive influence on hospitals' accurate verification of consumable payment types and compliant utilization of medical insurance funds, it simultaneously increases hospitals' burden in consumables cost review and the financial risk of bearing denied payment costs. Furthermore, it may lead hospitals to approve reimbursable medical consumables as self-paid items, thereby shifting the financial risk onto patients. To optimize the intelligent supervision and denial-of-payment policy, hospitals should transition their consumables audit model from a manual paradigm to an intelligent, machine-led one. This requires enhanced training for medical staff and the establishment of robust internal monitoring and incentive mechanisms to mitigate cost-shifting risks and reduce initial adaptation costs. Concurrently, collaboration with healthcare security authorities is essential to explore the development of a unified and standardized knowledge base for medical insurance payment rules.

Objective: Based on the real-world data of medical insurance in City C of Liaoning Province, this study analyzes the characteristics and reform practice of DIP special cases, conducts policy simulation verification, and explores policy optimization and adjustment measures. Methods: We selected 464369 DIP cases in City C, a representative city for DIP payment in Liaoning Province, in 2024. According to the proposed selection rules for high cost cases based on disease value segments, we calculated the number of special cases in each segment and provided distribution simulation results. These results were compared with the city's original special case negotiation policies. Results: The selection rules for high cost cases based on disease value segments demonstrated scientificity. The new rules improved the rationality of the coverage range of special case selection results, better met the requirements of the National Healthcare Security Administration for the proportion of special cases, and facilitated the management of these cases. The selection method in this study can also be implemented in the regions implementing DRG 2.0 version payment of Liaoning Province. Practical experience has proven the rationality and feasibility of this approach. During the transition from DIP 2.0 version to 3.0 version, the experience of segment-based selection of special cases in cities of Liaoning Province can provide useful references for other regions in China.

Objective: The paper analyzed, summarized the characteristics of medical insurance data quality by taking the statistical process of “drug costs included in the payment scope” of negotiated drugs as an example, providing references for medical insurance data cleaning, application. Methods: Through the medical insurance settlement system of a city, this study collected medical insurance settlement records of national negotiated products within the agreement periodfrom January2018to September2024as the target dataset, supplemented with several auxiliary datasets by Internet search. A data quality assessment framework covering completeness, standardization, consistency was constructed. Results: In the completeness dimension, the main data problems were missing disease diagnosis codes, names, involving29.6%, 29.7% of record items. In the standardization dimension, 66.2% of record items had non-standard one-to-many correspondence between drug codes, names. There were problems of abnormal medical institution coding content, irregularities in the correspondence between medical institution codes, names.60.3% of record items had disease diagnosis codes that did not conform to standards. There were48non-basic medical insurance participants, involving405record items. In the consistency dimension, 4.9% of record items had payment prices that exceeded the payment standard by ±10%;1.4% of pharmacy purchase data items corresponded to retail pharmacies outside the “dual-channel” recognition scope;78record items did not qualify for medical insurance coverage of patient age or prescription hospital conditions. Conclusion: There are quality issues in medical insurance data, such as missing data, irregular application of medical security information coding system, confusion of patient identity, logic error due to suspected improper payment of medical insurance. It is suggested to accelerate the exploration of appropriate uniform, operational statistical, cleaning rules which are suitable for medical insurance, promote the efficacy of medical insurance data for decision-making