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20 February 2026, Volume 0 Issue 2
    

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  • China Health Insurance. 2026, 0(2): 5-15. https://doi.org/10.19546/j.issn.1674-3830.2026.2.001
    Abstract ( )   Knowledge map   Save
    The traditional chronic disease management system is confronted with challenges such as the growing pressure on medical insurance fund expenditures, inefficient allocation of medical resources, and inadequate regulatory methods. Taking the practice of Tai'an City, Shandong Province as a case study, this research discusses a full-chain management system for medical insurance funds of outpatient chronic and special diseases based on big data and artificial intelligence (AI) technologies. In terms of architecture, this model constructs a functional framework of "1 platform plus 4 subsystems", with the AI-based risk management analysis platform as the core, integrating four functional modules: eligibility admission and withdrawal, standardized diagnosis and treatment pathways, intelligent medical insurance supervision, and health management. At the institutional level, the model is supported by a governance framework featuring government-society resource collaboration, an efficient and unified pharmaceutical supply chain management, and an incentive-compatible medical insurance payment method. Statistics and empirical analysis based on the actual operation data of the system show that this system has significantly alleviated the expenditure pressure on medical insurance funds and improved the health status of patients.
  • China Health Insurance. 2026, 0(2): 16-23. https://doi.org/10.19546/j.issn.1674-3830.2026.2.002
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    Under the prevailing intellectual property logic of “patent protection-market pricing”, outputs from public hospitals—such as clinical guidelines, diagnostic and therapeutic protocols, and management tools—cannot secure patent rights due to the lack of a suitable valuation framework. This situation traps these outputs in a dilemma of high social value but low economic return. These “non-patentable, difficult-to-price” clinical knowledge products not only undermine hospitals' incentives for innovation but also, more critically, due to the absence of payer-recognizable evidentiary forms and standardized vehicles, struggle to enter the healthcare payment and regulatory systems. Consequently, clinical knowledge that could enhance efficacy, standardize practices, and optimize costs fails to translate into fund utilization efficiency, thereby hindering the realization of “value-based healthcare”. To address this, this paper, grounded in public goods and public value theory, introduces the concept of “clinical public goods” and constructs a hierarchical classification system for clinical knowledge outputs. Patentable outputs like pharmaceuticals continue to follow the traditional intellectual property asset logic, while items such as clinical guidelines, pathways, management models, and quantitative tools fall under the category of clinical public goods. Building on this, the paper proposes a dual-track governance framework of “intellectual property assets-clinical public goods”. Clinical public goods are further classified into evidence-based, standard-setting, management, and tool-oriented types, with their value realized through institutional adoption and scaled implementation leading to health gains. To promote value translation, the paper designs a three-pronged pathway: “policy access-data assetization-rights licensing”. Policy access opens institutional entry points, compliant data governance provides a sound evidence base, and rights licensing coupled with service delivery facilitates standardized dissemination and sustainable supply. This pathway provides a clear and actionable operational solution for identifying, governing, and incentivizing non-patent clinical outputs in research-oriented hospitals.
  • Special Topic Analysis
  • China Health Insurance. 2026, 0(2): 24-33. https://doi.org/10.19546/j.issn.1674-3830.2026.2.003
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    Objective: The paper analyzes the application practices and standards for real-world data (RWD) generated from expert surveys in international health insurance access processes, providing reference for the rational and standardized use of expert survey data in China's health insurance access procedures. Methods: At the application level, we selected 26 rare disease drugs approved for inclusion in the UK National Health Service (NHS) through the National Institute for Health and Care Excellence (NICE)'s Highly Specialised Technology (HST) assessment as case studies. We analyzed the application practices of expert survey data and the considerations of assessment bodies in drug reimbursement review reports from NICE, the Canadian Agency for Drugs and Technologies in Health (CADTH), and the Institute for Clinical and Economic Review (ICER). At the application standard level, we analyzed the application and reporting standards of expert survey data published by the Pharmaceutical Benefits Advisory Committee (PBAC) of Australia and the Zorginstituut Nederland,(ZIN) of the Netherlands in the context of health insurance access. Results: At the application level, based on the proportion of drugs using expert survey data in RWD across NICE, CADTH, and ICER: NICE used expert survey data for 6 drugs (24%), CADTH used it for 6 drugs (38%); and the study found no application of expert survey data in ICER assessments. Expert survey data can be utilized for three core purposes: addressing uncertainties related to efficacy (D1), cost (D2), and population and market share (D3). Most such data is generally accepted by evaluation agencies (P2). However, certain expert survey data has been contested by evaluation agencies due to inherent limitations and methodological flaws. At the application standard level, PBAC and ZIN regulate the use of expert survey data across three stages: proposal design and preliminary preparation, survey implementation, and analysis and interpretation of results. Conclusion: RWD generated from expert surveys holds certain application value and necessity in the medical insurance access process and can be adopted by evaluation agencies. However, its implementation still faces a series of challenges, and its application and reporting standards require further clarification. Future efforts should explore and define the role, application scenarios, and application standards of expert survey data in China's medical insurance access process.
  • China Health Insurance. 2026, 0(2): 34-41. https://doi.org/10.19546/j.issn.1674-3830.2026.2.004
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    The rapid emergence of high-value innovative medicines and the dynamic evolution of their value characteristics pose real challenges to the balance between “basic coverage” and “innovation promotion” within medical insurance funds. This study systematically examines the practical dilemmas faced by medical insurance in terms of decision-making risk, fund affordability, risk sharing, and value identification, and constructs a comprehensive evaluation framework encompassing clinical, economic, social, and innovation value. On this basis, it proposes the establishment of a value-oriented long-term purchasing mechanism supported by real-world data, including value-based risk-sharing agreements, innovative and diversified payment models, and dynamic drug price adjustment mechanisms. The aim is to promote a transformation of medical insurance strategic purchasing from static access decisions to dynamic value management, thereby ensuring fund sustainability while effectively incentivizing pharmaceutical innovation.
  • China Health Insurance. 2026, 0(2): 42-46. https://doi.org/10.19546/j.issn.1674-3830.2026.2.005
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    The innovative drug market in China is experiencing robust growth, accompanied by increasing public demand for medications and higher expectations for coverage under the national healthcare security system. However, innovative drugs often face challenges such as insufficient clinical evidence and uncertainty regarding long-term efficacy. Achieving a balance between ensuring patient access and maintaining the financial sustainability of the healthcare security fund has therefore become a pivotal issue in healthcare reform. The United Kingdom establishes the Cancer Drugs Fund and the Innovative Medicines Fund, systematically integrates real-world evidence into reimbursement decision-making, establishing a dynamic mechanism for access and exit of high-value innovative drugs. This paper provides an in-depth analysis of the evolution, operational framework, and key design of these UK funds. It aims to offer insights for China to explore innovative drug payment models leveraging domestic healthcare data and to promote the application of real-world studies within its healthcare security framework.
  • Observation & Discussion
  • China Health Insurance. 2026, 0(2): 47-59. https://doi.org/10.19546/j.issn.1674-3830.2026.2.006
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    The long-term care insurance (LTCI) system has become a key policy tool for alleviating the care pressure on disabled elderly people in China and promoting the high-quality development of the health and elderly care industry. This study takes 154 elderly care listed companies in China's capital market as the research sample, and uses the difference-in-differences method to construct a quasi-natural experiment framework to systematically evaluate the impact of the LTCI policy on the financial performance of various elderly care industries, and verify the differentiated performance of the policy in different regions and sub-sectors. The research shows that the LTCI pilot policy has significantly improved the profitability of elderly care enterprises in the pilot areas, increasing the average ROA by 2.27 percentage points and ROE by 6.33 percentage points. The heterogeneity analysis indicates that the industrial driving effect, service innovation level, and financial improvement amplitude in economically developed regions are significantly higher than those in the central and western pilot areas. Among the sub-sectors, medical care services stand out, with ROA increasing by 4.17 percentage points. The research indicates that the LTCI policy mainly exerts its influence through the dual effects of demand pull and cost optimization. Technology-intensive elderly care enterprises and economically developed regions benefit more due to their inherent advantages. To some extent, this study enriches the quantitative research results on the impact of the LTCI system on the health and elderly care industry and provides practical references for policy optimization, industry development guidance, and enterprise operation decisions.
  • China Health Insurance. 2026, 0(2): 60-67. https://doi.org/10.19546/j.issn.1674-3830.2026.2.007
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    Currently, the aggregation standards for medical charge items in China are not fully unified, and various regions have developed multiple versions of aggregation standards during policy implementation, affecting the comparability of expense categories across regions. This study reviews relevant policies on item aggregation standards and regional differences in practice, and analyzes the main issues and their causes in the process of docking multiple versions of aggregation systems with current item initiation guidelines. Based on this, this study proposes suggestions for accelerating the development of standardized and normalized item initiation guidelines for medical charge item aggregation standards, which includes compiling item initiation guidelines for various disciplines released in batches, uniformly adding relevant information derived from item aggregation standards; classifying and accepting new price item applications based on the degree of technological innovation, and clarifying the aggregation standards for newly established items.
  • China Health Insurance. 2026, 0(2): 68-79. https://doi.org/10.19546/j.issn.1674-3830.2026.2.008
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    Objective: The paper attempts to evaluate the policy effect of the long-term care insurance (LTCI) system on the health level of disabled older adults and its underlying mechanisms. Methods: Using four-period panel data (2013, 2015, 2018, and 2020) from the China Health and Retirement Longitudinal Study (CHARLS), we selected self-rated health, number of chronic diseases, cognitive ability (MMSE), and depression level (CES-D) as health indicators and employed a Difference-in-Differences (DID) model for empirical analysis. Results: The LTCI significantly improved the overall health level of disabled older adults in pilot regions, with notable group heterogeneity. Improvements in self-rated health, chronic disease management, and cognitive ability were more pronounced among male and highly educated older adults, while female and less educated older adults benefited more from alleviation of psychological depression. Mechanism analysis indicates that the policy operates through enhancing life satisfaction and reducing medical financial burden. Conclusion: The LTCI system has a positive health-promoting effect. Future policies should develop more precise and differentiated service provision and matching mechanisms to promote national coordination of the system and improve the quality of safeguards.
  • Management Platform
  • China Health Insurance. 2026, 0(2): 80-89. https://doi.org/10.19546/j.issn.1674-3830.2026.2.009
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    Objective: The paper evaluates the impact of linking DRG points with performance evaluation results on healthcare provider behavior. Methods: An interrupted time series analysis (ITSA) was conducted using monthly settlement data from January 2018 to December 2024 for all medical institutions in Panzhihua City participating in the DRG payment reform pilot, focusing on DT10 disease group (otitis media and upper respiratory infection, patients aged under 17). Results: The policy significantly reduced the proportion of medical consumables expenses among all hospitals for penalty-related indicators. Analysis by hospital level indicated that, the proportion of drug and medical consumables expenses declined in tertiary hospitals, while the downward trend in average length of stay was maintained. In secondary and primary hospitals, the proportion of medical consumables expenses declined significantly. Monitoring and constraint indicators were associated only with an increase in the proportion of medical service expenditures in primary hospitals. Conclusions: The policy linking DRG points with performance evaluation results contributed to managing medical consumables expenditures, whereas monitoring and constraint indicators demonstrated limited incentive effects and failed to induce substantial behavioral changes among medical institutions. DRG payment method reforms should prioritize incentive-compatible mechanisms, strengthen coordination with national volume-based procurement (VBP) and medical service pricing policies, and adopt differentiated performance assessmentand motivation mechanisms aligned with hospital functional roles. In the longer term, payment systems may consider a transition toward a value-based model that assessment and payment are linked to health outcomes.
  • China Health Insurance. 2026, 0(2): 90-96. https://doi.org/10.19546/j.issn.1674-3830.2026.2.010
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    Objective: The paper evaluates the practical effect of the single-disease global budget payment model for outpatient hemodialysis in uremia, to provide empirical evidence for deepening the reform of medical insurance payment methods, controlling the unreasonable growth of medical expenses, and ensuring the medical quality of dialysis patients. Methods: Based on pre- and post-implementation data of the global budget payment model for outpatient hemodialysis in Chuxiong Yi Autonomous Prefecture, Yunnan Province from 2015 to 2024, we analyzed changes in medical expenses, medical insurance fund expenditure and medical institution service behaviors. Results: Following the implementation of the global budget payment model for outpatient hemodialysis, the average monthly medical expenses of outpatient hemodialysis patients and the growth rate of annual medical insurance fund expenditure slowed down significantly, while the average monthly out-of-pocket expenses of patients decreased remarkably. Meanwhile, the medical quality of medical institutions was guaranteed, and the service quality and efficiency were improved steadily. Conclusion: The global budget payment model for outpatient hemodialysis in uremia can effectively manage the medical expenses, guide medical institutions to proactively standardize their clinical practices, achieve a balance between "managing expenses" and "ensuring quality", with significant promotion value.
  • Medical Viewpoint
  • China Health Insurance. 2026, 0(2): 97-103. https://doi.org/10.19546/j.issn.1674-3830.2026.2.011
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    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.
  • Medical Economy
  • China Health Insurance. 2026, 0(2): 104-111. https://doi.org/10.19546/j.issn.1674-3830.2026.2.012
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    Objective: This study aims to evaluate the degree of deviation of Guangdong Province's drug online listing prices from the winning bid prices in the alliance centralized procurement, providing a reference for drug price regulation and hospital procurement. Methods: A price deviation index was constructed, and empirical research was conducted using IBM SPSS Statistics 27 software, employing the Mann-Whitney U test and Pearson correlation analysis methods. Results: 58.89% of the drug prices had a deviation degree not exceeding 0.5. Significant differences in deviation degrees were observed among different dosage forms, with suppositories showing a significantly higher deviation than injections, and a weak correlation between online listing duration and deviation degree. However, factors such as the qualification of active pharmaceutical ingredients, the nature of enterprise property rights, the status of market listing, and whether the drug was included in the medical insurance directory did not have a statistically significant impact. Conclusion: It is recommended to incorporate the price deviation index into regular price monitoring, implement refined governance based on key factors such as dosage form, and enforce price control responsibilities for both drug buyers and sellers.
  • Commercial Insurance
  • China Health Insurance. 2026, 0(2): 112-119. https://doi.org/10.19546/j.issn.1674-3830.2026.2.013
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    This paper systematically reviews domestic research since the launch of the new healthcare reform in 2009 on the multitiered healthcare security system and the development of commercial health insurance, providing a comprehensive analysis of its theoretical construction, policy evolution, market positioning, and developmental challenges. Currently, academic consensus has been reached on the necessity of a multitiered system, the structural imbalances within it, and the pivotal supplementary role of commercial health insurance. At the same time, significant disagreements persist regarding pathway choices such as the relationship between social and commercial insurance and the boundaries between government and market roles. Commercial health insurance faces multiple constraints, including product homogeneity, data barriers, and ecological sustainability. Its development urgently requires macrolevel institutional consolidation, mesolevel mechanism coordination, and microlevel product innovation. This paper argues that future research should strengthen empirical evaluation of policy effects, design protection mechanisms for key population groups, and construct localized theoretical frameworks, so as to promote the systematic optimization and coordinated development of the multitiered healthcare security system.
  • International( Region) Comparison
  • China Health Insurance. 2026, 0(2): 120-125. https://doi.org/10.19546/j.issn.1674-3830.2026.2.014
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    Purpose: The paper introduces the structure of Germany's pediatric healthcare system and proposes recommendations for enhancing China's multi-tiered pediatric healthcare system. Methods: A literature study was conducted to investigate the institutional bases, coverage, and linkage mechanisms within Germany's multi-tiered pediatric healthcare system, and assessed its effectiveness. Results: Germany has established a pediatric health security system based on the collaboration between statutory and private health insurance. The government offers supplementary protection through specialized agencies and medical institutions, while social charitable organizations further expand the scope of services, forming a comprehensive and well-coordinated multi-tiered framework. This system has achieved significant outcomes in terms of expanding insurance coverage and alleviating the financial burden of pediatric medical expenses. Conclusion: It is recommended that China's healthcare insurance policies are prioritized towards children, promote innovation in commercial health insurance products, and further strengthen the government's leading role in system coordination and foundational security.