20 May 2026, Volume 0 Issue 5

    

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Special Topic Analysis
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  Research on the Functional Orientation and Accounting Basis of the Medical Insurance Fund Accounting System: From the Perspective of Public Accountability

  China Health Insurance. 2026, 0(5): 5-14. https://doi.org/10.19546/j.issn.1674-3830.2026.5.001

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  With the expansion, structural complexity, and functional extension of China's medical insurance fund, the existing cash basis accounting system can no longer adequately respond to the governance demands of accountability. Drawing on public accountability theory, this paper constructs a three-dimensional framework comprising reporting responsibility, behavioral responsibility, and outcome responsibility. It defines the accounting functions of medical insurance funds as information disclosure, compliance control and risk warning, performance and sustainability assessment. By examining the accountability differences among employees’ medical insurance, residents’ medical insurance, long-term care insurance and maternity insurance, the paper analyzes their information needs and accounting basis choices. The study argues that while the cash basis retains advantages in budgetary control, it fails to reflect incurred but unsettled obligations, cross-period rights and duties, and long-term solvency pressures. The accrual basis not only objectively reflects the current revenue and expenditure situation, but also demonstrates long-term financial sustainability, yet its application should not mechanically replicate commercial insurance accounting models. This paper proposes a hybrid accounting system with cash basis and accrual basis, guided by the principles of function-orientation, category-specific application, and phased implementation, thereby providing theoretical foundations for deepening accounting system reform.
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  Reflections on Optimizing the Medical Insurance Fund Accounting System on the Accrual Basis

  China Health Insurance. 2026, 0(5): 15-25. https://doi.org/10.19546/j.issn.1674-3830.2026.5.002

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  Objective: The paper attempts to promote the orderly transformation of the accounting basis of medical insurance funds towards the accrual basis, and establish an accurate, management-oriented accounting system for medical insurance funds, so as to improve the efficiency of medical insurance management and the level of national financial supervision. Methods: The limitations of the cash basis accounting system were reviewed and analyzed, and in combination with the practice of medical insurance management system reform, the necessity and feasibility of introducing the accrual basis were systematically analyzed from a management perspective. Results: The current cash basis accounting system is difficult to truly reflect the financial status, revenue-expenditure balance, and potential risk of medical insurance funds, and it cannot comprehensively reveal the economic substance and management performance of medical insurance activities. The accrual basis can provide more equitable information on fund assets, liabilities, income, and expenses, offering effective decision-making support for regulating medical insurance management and improving fund utilization efficiency. Conclusion: It is recommended to introduce the accrual basis step by step and improve the supporting coordination mechanisms, build a fund accounting system that meets China's medical insurance management needs, improve supporting standards and coordination mechanisms, and provide a solid accounting foundation for refined medical insurance management and sustainable fund operation.
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  Practical Analysis of the Implementation of the Supplementary Provisions to the Social Insurance Fund Accounting System in Medical Insurance

  China Health Insurance. 2026, 0(5): 26-34. https://doi.org/10.19546/j.issn.1674-3830.2026.5.003

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  The Supplementary Provisions to the Social Insurance Fund Accounting System (hereinafter referred to as the Supplementary Provisions), issued by the Ministry of Finance, supplements and refines the original accounting system regarding businesses administered by healthcare security administrations, including long-term care insurance (uniformly administered by healthcare security administrations), premiums collected for future years of rural residents’ basic medical insurance, and advance payments for the centralized volume-based procurement of pharmaceuticals and consumables. Grounding its analysis in the financial management practices of healthcare security agencies, this paper systematically interprets the core content and key accounting points of the Supplementary Provisions, analyzes critical operational links and common difficulties in practice, and further proposes implementable suggestions for smooth implementation from three dimensions: organizational collaboration, business processes, and information systems, aiming to provide practical references for healthcare security administrations at all levels to ensure a stable transition to the new system.
Observation & Discussion
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  Synergy Between Close-Knit Medical Consortium Construction and Medical InsurancePayment Reform: Practice and Reflection——Taking Sanming City as a Typical Example

  China Health Insurance. 2026, 0(5): 35-40. https://doi.org/10.19546/j.issn.1674-3830.2026.5.004

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  This paper expounds, from theoretical and policy perspectives, the internal logic of the synergy between the construction of close-knit medical consortium and the reform of medical insurance payment models. The typical practice in Sanming City demonstrates that consolidating close-knit medical consortium, implementing global budget prepayment for medical insurance, establishing a diversified and composite payment model centered on capitation, coupled with incentive and constraint policies such as “surplus retained, overspending not compensated” and supporting these with a scientific incentive assessment system, are fundamental pathways and key measures to encourage medical institutions at all levels and of various types within the consortium to return to their functional positioning, standardize diagnosis and treatment behaviors, promote health management, build a system of “prevention, screening, diagnosis, treatment, rehabilitation, and management,” and ultimately achieve safer and more effective utilization of medical insurance funds, more stable and sustainable operation of the medical system, improved health levels of residents, and reduced financial burdens.
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  Research on the Compilation Characteristics and Price Level of Guidelines for Establishing Pricing Items for Nursing Medical Services

  China Health Insurance. 2026, 0(5): 41-47. https://doi.org/10.19546/j.issn.1674-3830.2026.5.005

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  Objective: The paper analyzes the implementation characteristics, price levels, and adjustments of the Guidelines for Establishing Pricing Items for Nursing Medical Services (Trial) across provincial-level regions in China, to provide empirical evidence for nursing pricing reform. Methods: Policy documents on nursing medical service pricing were collected from 31 provincial-level regions. Descriptive statistics and price change analysis were used to evaluate item setting, price distribution, and price changes of typical nursing items. Results: All provincial-level regions have completed the alignment and implementation of the Guidelines, with highly consistent item setting. Only Shanghai City and Zhejiang Province lacked a few items. Accompaniment-free care services underwent localized adaptations such as “one-on-one” “one-to-many” in 13 provincial-level regions. Price distribution showed that special care for children had the highest average price (196.3 yuan/day), while basic nursing items (e.g., oral care) averaged about 10 yuan per session. The coefficient of variation for most items ranged between 20% and 45%. Regarding price adjustments for typical items, Grade I nursing exhibited the highest average increase (71.3%), followed by special care (37.8%) and neonatal care (48.1%), with significant inter-provincial variation in adjustment magnitude. Conclusion: The integration logic of the Guidelines is reasonable, and provincial implementation is generally standardized, yet regional price differences exist. It is recommended to strengthen uniformity in provincial execution, improve price monitoring mechanisms, enhance publicity and training, and coordinate supporting reforms such as compensation systems.
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  Regulating Pharmaceutical Purchasing Order and Enhancing the Efficiency of Credit Evaluation Supervision——Construction and Optimization Strategies for the Credit Evaluation System of Pharmaceutical Pricing, Bidding and Procurement

  China Health Insurance. 2026, 0(5): 48-53. https://doi.org/10.19546/j.issn.1674-3830.2026.5.006

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  Objective: The paper analyzes the prominent problems in the order of pharmaceutical procurement, systematically evaluates the implementation effectiveness of the credit evaluation system of pharmaceutical pricing, bidding and procurement, and proposes optimization strategies. Methods: Based on policy text analysis, official statistical data, and typical cases, combined with the practical experience from the system’s establishment in 2020 to its revision and improvement in 2025, a systematic analysis was conducted using a problem-countermeasure-effectiveness logical framework. Results: The pharmaceutical procurement market faces transactional chaos, such as kickback sales, false invoicing, and bid-rigging. Price mechanism failures lead to inflated declared prices, vicious competition cycles, and low default costs. Traditional regulatory methods lag behind, and cross-departmental information sharing is inadequate. The credit evaluation system has effectively curbed violations through five mechanisms: standardizing the entire transaction process, strengthening data collaboration, tightening evaluation criteria, balancing punishment with guidance, and protecting enterprises’ legitimate rights and interests. As of January 2026, a total of 1236 enterprises have been assessed as enterprises with credit violations nationwide, more than 10 typical cases have been publicly notified, and most enterprises with credit violations have completed credit restoration by reducing prices or returning unreasonable profits. Conclusion: The credit evaluation system of pharmaceutical pricing, bidding and procurement is an effective policy tool for standardizing the procurement order and enhancing regulatory effectiveness. Future efforts should further refine evaluation criteria, deepen cross-departmental collaboration, and promote the application of credit evaluation results in more scenarios.
Topics in Focus
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  Quality Assurance Tool System for the Entire Process of Real-World Studies: Classification and Practical Guidelines

  China Health Insurance. 2026, 0(5): 54-64. https://doi.org/10.19546/j.issn.1674-3830.2026.5.007

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  Objective: In light of the current situation where the methodological standardization of real-world studies (RWS) needs improvement and the actual research implementation pathways in China are still in the exploratory stage, the paper constructs a standardized tool application framework centered on the entire research process. Methods: The RWS process was deconstructed into five stages—study design, data preparation, analysis implementation, report disclosure, and evidence appraisal, and the core quality risks at each stage were identified. Mainstream international standardized tools were systematically searched and screened, then grouped by function into four categories: risk-of-bias assessment, data suitability assessment, design and reporting standards, and evidence quality grading. A mapping between the tools and the risk nodes was established. Results: A full-lifecycle quality risk map of RWS was constructed, clarifying the risk manifestations at each stage and the appropriate timing for tool application. A three-dimensional tool selection logic based on “research objective-data source-evidence use” was derived, and specific tool combination schemes were provided for three typical scenarios in China. Conclusion: Integrating full-lifecycle risk awareness, stage-specific tool allocation, and scenario-based combination strategies helps improve the methodological rigor and evidence credibility of RWS in China, providing solid support for health technology assessment and healthcare security decision-making.
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  A Comparative Study on the Efficacy of Generic and Brand-Name Entecavir Based on Real-World Data

  China Health Insurance. 2026, 0(5): 65-72. https://doi.org/10.19546/j.issn.1674-3830.2026.5.008

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  Objective: This study utilized real-world medical insurance settlement data to conduct a comparative evaluation of the clinical efficacy of Entecavir (ETV) generic drugs and the original drugs in delaying disease progression in chronic hepatitis B (CHB). Methods: The study employed relational graph convolutional networks (RGCN) and heterogeneous graph attention (HGT) networks to standardize the identification of clinical behaviors and drug specifications, while employing the Kalman filtering algorithm to quantify patient prescription adherence. Propensity score matching (PSM) was used to balance baseline characteristics, and Cox proportional hazards regression models were applied to compare the risk differences between the two groups for severe liver events such as hepatocellular carcinoma (HCC), liver failure, and hepatic ascites. Results: After algorithmic bias control and correction, a total of 1481 patients were included (987 in the generic drug group and 494 in the original drug group). The Log-rank test revealed no statistically significant differences between the two groups in the incidence of HCC (P=0.097), liver failure (P=0.165), or hepatic ascites (P=0.661). Cox regression analysis demonstrated that the hazard ratio (HR) for HCC in the generic drug group was 1.21 (95% CI: 0.47-3.14), for liver failure HR was 0.58 (95% CI: 0.25-1.33), and for hepatic ascites HR was 1.13 (95% CI: 0.73-1.75), with all 95% CIs containing 1.0. Conclusion: After rigorous cleaning to exclude non-standard drug use and compliance-related confounders, there is no evidence of significant differences between ETV generic drugs and the original drugs in controlling hepatic hard-endpoint events, yielding robust and reliable conclusions. The findings provide real-world evidence of therapeutic equivalence to support the centralized drug procurement policy, as well as a reliable case study in the field of real-world research for coordinated development and regulation of medical insurance, medical services, and pharmaceuticals.
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  Management of New Medical Service Pricing Items Based on Real-World Comprehensive Value Evaluation

  China Health Insurance. 2026, 0(5): 73-79. https://doi.org/10.19546/j.issn.1674-3830.2026.5.009

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  To evaluate the comprehensive value of innovative medical service technologies, real-world data can be used to provide evidence-based support for the new project approval, outcome-based pricing, and medical insurance access of these innovations. On the basis of explaining the logic of real-world evidence (RWE) in supporting medical insurance decisions and reviewing the national-level requirements for real-world value assessment in new pricing project management, this study examines the practices of typical regions concerning real world study-based new project approval, outcome-based pricing, and medical insurance access. It then puts forward three recommendations for accelerating the clinical translation of innovative medical technologies through real-world comprehensive value assessment and promoting a shift from experience-based to evidence-driven pricing and access decisions. First, issuing systematic guidance documents for managing new medical service pricing projects to unify and standardize local practices; second, establishing operational comprehensive value assessment indicators to support approval and medical insurance access for innovative technologies; third, strengthening the application of assessment results by making RWE the basis for project outcome adjustments and medical insurance access.
Management Platform
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  Discussion on the Application and Coordination Mechanism of Administrative Handling and Contractual Handling in the Supervision of Medical Insurance Funds

  China Health Insurance. 2026, 0(5): 80-90. https://doi.org/10.19546/j.issn.1674-3830.2026.5.010

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  Administrative supervision and agreement management are the two major approaches to the supervision of medical insurance funds at present. In practice, for the behaviors of designated medical and pharmaceutical institutions that are both in breach of contract and in violation of the law, the boundaries between administrative handling and contractual handling remain ambiguous. The theoretical research on the coordination of liability for breach of administrative contracts and administrative handling is still insufficient, leading to difficulties in their application and connection. This article takes the medical insurance agreement and its implementation details of Beijing City in 2025 as the entry point, and conducts a multi-dimensional analysis of differences, connections, and applicable scenarios between the two. From a legal perspective, combined with practical cases in Beijing City, it analyzes the power source, procedural requirements, and content setting of liability for breach of administrative contracts, and discusses the application and connection mechanism of the two from aspects such as the degree of deterrence and error cost. Through three paths of "duty positioning plus basic principles plus connection mechanism", it clarifies the duty positioning of medical insurance administrative departments and handling institutions, grasps the basic principles from the aspects of handling methods and violation situations, and based on practice, refines the connection mechanism of administrative handling and contractual handling, and improves supporting measures.
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  Exploration of Improving Accounting for Medical Insurance Wallet Business Under the Framework of Fund Accounting System——Taking Ningxia Hui Autonomous Region as an Example

  China Health Insurance. 2026, 0(5): 91-95. https://doi.org/10.19546/j.issn.1674-3830.2026.5.011

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  As China’s healthcare security system reform deepens, the cross-provincial mutual aid policy for individual medical insurance accounts has become a bridge connecting the place of insurance enrollment and the place of medical treatment. The medical insurance wallet has emerged as a new vehicle for medical insurance fund settlement, representing a significant innovation in the digital transformation of medical insurance fund management. However, its capital attributes and circulation model differ markedly from those of traditional individual medical insurance accounts. Under the current fund accounting framework, the accounting treatment of medical insurance wallet transactions remains a new challenge for healthcare security administrations. This paper analyzes the operational characteristics of the medical insurance wallet and its impact on the accounting of medical insurance funds, and proposes accounting recommendations from both institutional development and operational practice perspectives. The aim is to improve the accounting system for medical insurance funds, accurately record the flow of medical insurance wallet funds, streamline the accounting treatment process, clarify the accounting treatment methods, facilitate the effective implementation of the mutual aid function of individual accounts, and provide theoretical support for the efficient and intelligent development of the healthcare security undertaking.
Medical Viewpoint
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  The Internal Mechanism and Implementation Paths of Smart Healthcare in Resolving the Challenges of Hierarchical Diagnosis and Treatment——A Grounded Theory Study Based on the Practice in Chengdu City

  China Health Insurance. 2026, 0(5): 96-104. https://doi.org/10.19546/j.issn.1674-3830.2026.5.012

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  Objective: The paper analyzes the deep-seated obstacles faced by hierarchical diagnosis and treatment, explores the internal mechanism by which smart healthcare addresses this challenge, and constructs an operable implementation path. Methods: Using Chengdu City as a sample and moving beyond the existing "technology tool theory" perspective, the grounded theory method was applied to conduct in-depth interviews with key managers of primary healthcare institutions to systematically diagnose the deep-seated obstacles in hierarchical diagnosis and treatment, and explore the internal logic through which smart healthcare solves these problems. Results: Hierarchical diagnosis and treatment in Chengdu City faces a systemic dilemma composed of macro-level institutional failure, micro-level motivational distortion, interrupted collaborative processes, and difficulties in technology application; the breakthrough path of smart healthcare lies in following four internal logics: resource integration, collaborative cooperation, risk control, and data empowerment, which correspond respectively to restructuring spatiotemporal efficiency, reshaping incentive trust, clarifying responsibility and traceability, and driving evidence-based decision-making. Conclusion: Considering the current situation in Chengdu City, efforts should be made in four dimensions—top-level design optimization, incentive mechanism reconstruction, collaborative process assurance, and data governance deepening—to construct a new hierarchical diagnosis and treatment ecosystem driven by both technology and institutional mechanisms, providing practical references for the high-quality implementation of hierarchical diagnosis and treatment driven by smart healthcare nationwide.
Medical Economy
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  Research on the Centralized Drug Procurement Policy and Financial Coordination Mechanism——From the Perspective of Modernized Medical Insurance Governance

  China Health Insurance. 2026, 0(5): 105-111. https://doi.org/10.19546/j.issn.1674-3830.2026.5.013

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  Objective: From the perspective of modernized medical insurance governance, this study explores the hierarchical governance pathways and collaborative mechanisms of financial support in national and inter-provincial alliance drug centralized procurement. Methods: Based on the theories of governance system modernization and collaborative governance, combined with transaction cost and institutional economics analytical approaches, the theoretical logic of centralized procurement and financial instrument synergy is elucidated, while differences in financial needs, risk attributes, and governance tools between the national and provincial levels are analyzed. Results: After centralized procurement enters the normalized stage, there is room for refinement in national financial infrastructure, regional risk-sharing mechanisms, and cross-departmental policy coordination. Traditional administrative measures struggle to meet the financing and supply guarantee needs of selected enterprises. Quantitative analysis reveals that the average financing demand of enterprises selected in national centralized procurement is approximately 6 to 7 times that of inter-provincial alliance enterprises, with significant financing cost disparities (200~300 basis points). Provincial risk compensation funds exhibit relatively limited coverage. Conclusion: The study establishes a dual-layer governance system integrating national credit information platforms with policy-based financial support, supplemented by provincial risk compensation funds and local financial collaboration, while designing phased implementation pathways for the near, medium, and long-term to provide theoretical support for the long-term operation of centralized drug procurement and the modernization of medical insurance governance.
Commercial Insurance
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  Market Translation Risks and Diversified Financial Solutions: An Analysis Based on the Technical Characteristics of Advanced Therapy Medicinal Products

  China Health Insurance. 2026, 0(5): 112-119. https://doi.org/10.19546/j.issn.1674-3830.2026.5.014

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  Objective: The paper systematically evaluates the patient accessibility risks posed by advanced therapy medicinal products (ATMPs) throughout their entire lifecycle due to their unique technological characteristics, and explores the key role of diversified financial solutions, centered on commercial health insurance, in mitigating these challenges. Methods: This study analyzes the entire lifecycle of ATMPs from basic research to commercialization, summarizing their core technological characteristics, such as high personalization, complex production supply chains, and potential long-term impacts. Based on this, identifying and evaluating pivotal risks such as R&D success probability, financial commitment, therapeutic performance, and long-term safety. Subsequently, this study systematically reviews the response strategies of government intervention, financial instruments, and commercial health insurance throughout the entire lifecycle, and conducts case studies on domestic and international practices. Results: Based on the technical characteristics of ATMPs, commercial health insurance designs pricing and multi-dimensional risk market transformation strategies. It shares the financial and efficacy uncertainty risks of ATMPs through early intervention in the R&D stage, innovative payment methods, and other strategies. Building a diversified payment system consisting of basic public medical insurance, private commercial health insurance, and innovative payment agreements is a feasible path to promote market transformation. Conclusion: By breaking down fragmented risk management, the paper constructs an integrated risk governance framework that involves collaboration among government, industry, finance, and healthcare institutions throughout the entire life cycle. This framework should be built by applying different levels of payment tools to create an efficient and diversified ATMPs healthcare payment system, thereby effectively translating the value of technological innovation into patient benefits.
International（ Region) Comparison
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  An International Comparative Study on Medical Insurance Payment Systems for Day Surgery and Its Implications——Based on the Practices of the UK, the US, Germany and Singapore

  China Health Insurance. 2026, 0(5): 120-128. https://doi.org/10.19546/j.issn.1674-3830.2026.5.015

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  As an efficient and cost-effective medical service model, day surgery has been widely adopted in developed countries, where it has evolved into a mature system. Although day surgery in China is gradually entering a phase of standardized development, its medical insurance payment system still needs further improvement in terms of payment standards, payment rules, the degree of correlation with actual clinical costs, and the quality evaluation system. From an international perspective, this study selects four developed countries with well-established day surgery systems—the United Kingdom, the United States, Germany, and Singapore—as case studies. It focuses on a comparative analysis of the institutional logic behind their day surgery medical insurance payment systems and systematically explores the top-level design and operational mechanisms in these countries, to provide targeted theoretical references and practical suggestions for building the institutional framework and optimizing the rules of China’s day surgery medical insurance payment system.