The Real-World Value Assessment for Lifelong Universal Healthcare Security (hereinafter referred to as “R-VALUES”) is a key institutional innovation that enables China’s healthcare security system to move toward “value-oriented strategic purchasing”. This paper systematically elaborates on the practical background and strategic significance of R-VALUES, analyzing the historic achievements China’s healthcare security has made in terms of coverage scale, fund operation, and innovative drug coverage, as well as the emerging challenges posed by accelerated population aging, rapid iteration of medical technologies, and growing uncertainties in the clinical value of pharmaceutical products. On this basis, the paper defines the core evaluation framework of R-VALUES from three dimensions—relative value, long-term value, and systemic value—and systematically introduces its implementation pathways from four aspects: data infrastructure development, standard and specification formulation, organizational mechanism building, and application translation of assessment outcomes. On the basis of respecting internationally accepted norms, R-VALUES has established an evaluation system based on China's real-world data, and enriched the methodological toolbox for global pharmaceutical value assessment, offering a replicable practical approach for developing countries to implement strategic purchasing in healthcare security.

Currently, real-world evidence-based comprehensive value evaluation of medicines in medical insurance (hereafter referred to as “R-VALUES”) is gradually becoming an important tool for medicine value assessment and medical insurance decision-making support. However, compared with randomized controlled trials, real-world studies are more susceptible to factors such as selection bias, confounding factors, information bias, and missing data. Therefore, scientific and appropriate research questions and study designs are essential to ensure the reliability of research findings. At present, there are still deficiencies in the study design phase of R-VALUES, which may affect the scientific validity of the generated evidence and its value in decision-making applications. By reviewing research protocols for R-VALUES, this study identifies and summarises the key issues in current evaluation practices. The findings indicate that the central challenge in current research design lies in a disconnect between the design of these studies and the core objectives of R-VALUES. On this basis, this study proposes targeted approaches for optimisation to promote the standardised conduct of R-VALUES and provide higher-quality evidence to support evidence-informed medical insurance decision-making.

Objective: The paper attempts to explore the value of Real-World Data (RWD) in the assessment of medical insurance access for new indications of multi-indication drugs, and to provide guidance for improving China’s medical insurance pricing mechanism for such medicines. Methods: A systematic review was conducted of the mechanisms and approaches used in Germany, France, Italy and Japan for applying RWD in the assessment of medical insurance access for new indications of multi-indication drugs, and an analysis was carried out of China’s current policies and the current status of RWD application. Results: The four countries adopted distinct approaches to the application of RWD: Germany utilises RWD to supplement clinical evidence, supporting the re-evaluation of additional therapeutic benefits and adjustments to reimbursement amounts; France uses RWD to calibrate projected usage volumes, enabling dynamic adjustments to payment standards; Italy employs RWD to validate treatment responses as defined in outcome-based agreements, underpinning differentiated net payments at the indication level; and Japan utilises real-world sales data to drive periodic price adjustments through a volume-price linkage mechanism. China’s current “one generic name, one reimbursement standard” model struggles to reflect differences in clinical value across different indications, whilst the application of RWD remains primarily focused on cost monitoring, facing the dual challenges of “a lack of value assessment dimensions” and “insufficient RWD evidence”. Conclusion: It is recommended to establish a mechanism for indication-specific value assessment and categorised management, to refine the mechanism for adjusting differentiated reimbursement standards based on value assessment outcomes, to strengthen institutional support for the use of RWD in pricing new indications, and to advance the development of infrastructure for refined medical insurance management at the indication level.

The Medical Insurance Image Cloud (MIIC) is a cloud-based medical imaging management system led by the National Healthcare Security Administration, aiming to achieve the business objectives of "accessible to patients, retrievable by healthcare providers, and verifiable by medical insurance" and address the persistent problem of repeated imaging examinations across healthcare institutions. Drawing on systems theory, this paper analyzes the construction logic of the MIIC business system along three dimensions: system architecture, operation mechanisms, and optimization mechanisms. The study deconstructs the business system into four core business domains—data collection, quality control, caching, and retrieval—and elucidates the operational logic of the full-pipeline closed loop of "collection-quality control-caching-retrieval". It further reveals a synergistic architecture comprising the "1+32" hierarchical structure as the organizational backbone, "centralized indexing with distributed data" as the technical foundation, the MIIC index as the data circulation hub, the "5-yuan service fee" as the operational fulcrum, diversified settlement mechanisms as the operational safeguard, and data-driven medical insurance governance as the value engine. The study identifies four structural challenges confronting the system: dilemmas in data quality governance, inadequate incentives for healthcare institutions, the trade-off between privacy protection and data utilization, and structural risks to operational sustainability. Accordingly, it proposes optimization pathways across four dimensions—full-pipeline data quality governance, incentive-compatible participation mechanisms, a legal framework for privacy protection, and sustainable operational ecosystems with technology evolution paths—so as to provide theoretical support and policy references for the high-quality development of the MIIC.

Credit management has been established as a foundational institution for the supervision of the basic medical insurance fund. The effectiveness of credit evaluation depends heavily on the sufficiency of information sources. The current model, which relies primarily on information concerning administrative penalties, has limitations in terms of coverage, timeliness, and the dimensions of information. Determinations of violation facts made by procuratorial organs in handling public interest litigation cases and confirmed through statutory procedures are reliable, relevant, and accessible. The factual information underlying these determinations constitutes an information resource for credit evaluation that has not yet been institutionally utilized. To incorporate procuratorial supervision information into the credit evaluation system for the basic medical insurance fund, it is necessary to clarify the scope of information linkage and the criteria for acceptance, establish a closed-loop process encompassing receipt, verification, adoption, and feedback, and improve procedures for handling objections raised by evaluated entities and safeguards for credit repair. This approach aligns with the normative space reserved by existing policies for diversified information supply.

Objective: The paper attempts to systematically analyze the internal logic, economic effects, and operational patterns of the evolution of China's universal medical insurance system from 1998 to 2025 from the perspective of health economics, providing economic evidence for high-quality development of medical insurance. Methods: Based on 15 macro indicators from 1998 to 2025, elasticity analysis, long-run equilibrium analysis, and identification of the transmission mechanisms were applied to construct an analysis framework of "coverage-financing-funds-resources-output", revealing the economic mechanisms underlying the evolution of the medical insurance system. Results: Over 28 years, medical insurance enrollment climbed from 1.5% to 94.7%, achieving universal coverage. Total health expenditure rose from 4.28% to 6.74% of GDP, while out-of-pocket spending dropped from 60.1% to about 26.8%, representing a fundamental shift in financing structure. The elasticity of health consumption fluctuated markedly, significantly affected by policy adjustments and external shocks. The transmission mechanisms between coverage expansion and fund growth differed across phases. After 2012, reform priorities shifted from coverage expansion to financing level improvement. The active-contributor-to-retiree ratio fell from 4.09 to 2.60, heightening intergenerational balance pressure. Tertiary hospital beds approached half of the total, and the inverted-pyramid allocation of resources caused efficiency losses. Average life expectancy rose by 8.42 years, reflecting substantial returns on health human capital investment. Conclusion: China's universal medical insurance system has completed a structural shift from individual to social financing, with notable achievements. However, it faces profound economic challenges, including intergenerational balance, cost containment, and resource allocation efficiency. Going forward, reforms should focus on optimizing financing mechanisms, deepening payment reform, correcting resource imbalances, and strengthening health investment, thereby shifting the system from scale expansion toward quality-and-efficiency improvement.

DRG/DIP faces multiple challenges in both grouping and admission management, including large-scale datasets, variable medical record quality, reliance on manual expertise for rule setting, and high technical demands for data processing. Admission management further involves complex tasks such as detecting enrollment errors and abnormal behaviors, which directly impact the fairness and efficiency of medical insurance payments. Artificial intelligence (AI) offers promising solutions and technologies to these challenges. By efficiently processing large volumes of medical data, AI enhances data utilization, while modeling and learning from historical records allows it to capture complex patterns of medical behavior. This capability supports more accurate development of grouping schemes, admission management, and dynamic adjustment, thereby improving the scientific rigor and intelligence of the payment system. Focusing on DRG as a representative example, this paper examines the core difficulties of traditional, manual-driven medical insurance management, highlights the advantages and characteristics of AI in this domain, and reviews domestic and international research on its applications in medical behavior feature extraction, grouping optimization, and admission supervision. The approaches discussed are also applicable to DIP and other payment models, providing insights for the intelligent transformation of China’s medical insurance payment system.

Objective: The paper attempts to analyze the impact of institutional problem perception on the willingness of flexible employment workers to enroll in basic medical insurance, and to examine the explanatory role of medical insurance cognition. Methods: Based on questionnaire data from 1876 flexible employment workers, an institutional problem perception index and a medical insurance cognition variable were constructed. A Logit model was used for empirical analysis, and robustness tests were conducted by switching to a Probit model and adjusting the measurement of the core explanatory variable. Results: Institutional problem perception had a significant positive impact on flexible employment workers’ willingness to enroll in basic medical insurance, with an average marginal effect of 11.26 percentage points. Institutional problem perception also had a significant positive impact on medical insurance cognition. Dimension-specific results showed that perceptions of contribution burden, expected benefits, portability of social insurance relations, and information access all significantly affected enrollment willingness. Conclusion: The willingness of flexible employment workers to enroll in basic medical insurance is affected by institutional problem perception, and medical insurance cognition also plays a certain explanatory role. Enrollment willingness is closely related to various institutional links. It is recommended to optimize institutional arrangements in terms of contribution mechanisms, benefit expectations, transfer and continuation, and information services, so as to improve the adaptability of the basic medical insurance system to flexible employment workers.

In 2021, General Office of the State Council issued the 14th Five-Year Plan for Universal Healthcare Security, and in 2026, the National Healthcare Security Administration released the 15th Five-Year Plan for Universal Healthcare Security—marking the two systematic strategic blueprints in the history of China's healthcare security system to be formulated as dedicated five-year sectoral plans. Drawing on institutional change theory, this paper conducts a systematic comparative analysis of the two five-year planning documents to reveal the underlying logic of China's healthcare security system as it evolves from "scale coverage" to "institutional maturity" and from "institutional construction" to "governance modernization". The study identifies three major transition trends across the two plans: the goal system evolves from the establishment of the "Five Healthcare Security Priorities" framework to the systematic deepening of the "Six Healthcare Security Priorities"; the governance logic shifts from "healthcare-security-department-led" unidirectional control to "coordinated development and regulation of medical insurance, medical services, and pharmaceuticals" with systemic integration; and the policy focus moves from "basic coverage" under the system to "quality and sustainability" with enhanced effectiveness. Underlying these transitions is a deeper logic: China's healthcare security system is undergoing a fundamental governance paradigm shift—from "having or not having" to "good or not good", from "whether the system exists" to "whether the system works"—with its core proposition being a paradigm shift from "universal healthcare security" to "universal health". The Healthy China strategy provides the fundamental rationale and institutional environment for the triple transitions above; five-year plans represent concrete practices to advance the modernization of healthcare security governance within the framework of the Healthy China strategy. Looking ahead, China's healthcare security system should continue to intensify efforts along three dimensions—further optimized and more sustainable institutions, collaborative governance, and performance enhancement—to advance healthcare security from "institutional full coverage" to "governance with high quality".

Objective: The paper analyzes the revenue and expenditure performance of China’s basic medical insurance fund for employees, forecasts its trends and risk status from 2026 to 2030, and provides evidence for improving dynamic fund monitoring and risk early-warning mechanisms. Methods: Annual revenue and expenditure data for China’s basic medical insurance fund for employees from 2015 to 2025 were analyzed. After harmonizing the statistical scope to account for the integration of maternity insurance, GM(1,1) models were constructed to forecast trends in fund revenue and expenditure. A Markov chain was then introduced to correct the residuals of the grey forecasting models according to their states. On this basis, the current-period balance, expenditure-to-revenue ratio, and balance rate were calculated to classify the risk level of the fund’s revenue-expenditure balance. Results: The GM(1,1) models achieved a good fit for both the revenue and expenditure series, and the Markov state-based residual correction further improved the fitting accuracy. During the forecast period, both fund revenue and expenditure are projected to continue increasing, while the current-period balance is expected to remain positive. The expenditure-to-revenue ratio is projected to range from 76.6% to 80.5%, and the balance rate from 19.5% to 23.4%. In 2027, the balance rate is projected to decline to 19.5%, placing the fund in the “caution” category and the fund is projected to remain in the “security” category in all other forecast years. Conclusion: During China’s 15th Five-Year Plan period, the basic medical insurance fund for employees is not expected to face an overt deficit risk in the short term. Although short-term revenue-expenditure risks are generally manageable, the fund’s safety margin is projected to narrow temporarily in 2027. Accordingly, 2027 should be treated as a key monitoring point within the forecast period. Actual changes in the expenditure-to-revenue ratio and balance rate should be continuously tracked, and the forecasting model and risk classification should be updated on a rolling basis as new annual data become available. These measures would help strengthen the fund’s operational risk early-warning mechanism and enhance the sustainability of the basic medical insurance system for employees.

Objective: The paper analyzes the effectiveness and governance transformation characteristics of medical insurance fund supervision during the 14th Five-Year Plan period, to provide references for improving the supervision system during the 15th Five-Year Plan period. Methods: Based on data from the National Healthcare Security Administration's Statistical Communiqués on the Development of Healthcare Security Undertakings (2021-2025), descriptive statistics and trend analysis were employed to examine five dimensions: recovery scale, recovery structure, intelligent supervision, criminal enforcement, and institutional innovation. Results: During the 14th Five-Year Plan period, the scale of recovered medical insurance funds expanded year by year, with an annual trajectory characterized by "low in the early years and high in the later years". Agreement management served as the primary channel for fund recovery, accounting for nearly 80%. Intelligent supervision extended the regulatory frontier to pre-event and in-event stages, with the effectiveness of pre-event reminders and in-event payment refusals gradually becoming evident. In 2025, the medical insurance payment qualification management system was fully implemented, extending supervision from institutions to individuals. Conclusion: During the 14th Five-Year Plan period, medical insurance fund supervision exhibited a transformation trend from post-investigation to whole-chain prevention and control, from institutional supervision to the dual constraint of "institutions plus individuals", and from manual inspection to a combination of intelligent screening and targeted enforcement. A multi-level supervision system has largely taken shape. Nevertheless, problems persist—insufficient clinical-dimension coverage of intelligent supervision rules, difficulties in identifying emerging violations under payment method reform, and inadequate grassroots supervision capacity. During the 15th Five-Year Plan period, further efforts are needed to refine the rule system, strengthen coordination between payment and supervision, and enhance capacity building.

Objective: The paper analyzes the structural imbalance in medical assistance expenditure between inpatient and outpatient services for disadvantaged groups in Guangxi, and explores assistance differences across identity groups, providing a reference for optimizing fund allocation. Methods: Data on outpatient chronic and special disease and inpatient assistance for subsistence allowance recipients and extremely poor individuals across 14 prefecture-level cities in Guangxi (2022-2024) were collected. Descriptive statistics, t-tests, ANOVA, multiple linear regression, and linear mixed models were employed. Results: (1) Per capita inpatient assistance (1585.67±196.63 yuan) was significantly higher than outpatient assistance (185.54±71.53 yuan), approximately 8.5 times as high (P<0.001). (2) No significant difference was found in overall assistance between the two groups (P>0.05), but the interaction between care type and identity group was significant (β=0.754, P<0.001): extremely poor individuals received higher inpatient assistance while subsistence allowance recipients received higher outpatient assistance. (3) No significant annual differences were observed across 2022-2024 (P>0.05), with robust mixed model results. Conclusion: Medical assistance in Guangxi is relatively balanced, yet prioritizes inpatient care to the disadvantage of the extremely poor in outpatient services. Assistance levels have remained stable over three years, though intercity disparities are widening. Recommendations include raising assistance standards of outpatient chronic and special disease, exploring a graded scheme linked to care types, establishing a dynamic adjustment mechanism for assistance standards, and gradually narrowing the gaps in security levels within the assistance groups and across regions.

Against the backdrop of the nationwide advancement of standardized, normalized, and convenient administrative services, coupled with the deepening of the "streamlining administration, delegating power, and optimizing services" reforms in the healthcare security sector, county-level medical insurance service windows serve as the core public service platforms through which the public receives medical insurance benefits, interprets medical insurance policies, and addresses livelihood-related appeals. Consequently, the efficiency of their human resources largely determines the quality of public service delivery and the credibility of government departments. As the core production factor for enhancing the quality and efficiency of these windows, human resources—encompassing the overall competence of the workforce, the degree of person-post alignment, and the supporting management mechanisms—jointly constitute the key variables that constrain the release of service efficiency at the windows. Taking the medical insurance service windows of multiple counties and districts in Huai'an City as the subjects of investigation, this study conducts empirical research. At the current stage, grassroots medical insurance windows generally face practical constraints such as an imbalanced personnel identity structure, rigidified assessment mechanisms, monotonous incentive approaches, insufficiently targeted training systems, imperfect talent retention mechanisms, and weak management mechanisms, leaving the value of human capital insufficiently activated. Within the analytical framework of human capital theory, equity theory, and management by objectives theory, this study systematically reviews the operational status of human resource management in county-level medical insurance windows, precisely identifies the multidimensional shortcomings in their efficiency-building efforts, and conducts an in-depth analysis of the underlying causes at the levels of institutional design, management philosophy, and resource guarantees. On this basis, the study constructs a closed-loop efficiency enhancement strategy system encompassing "dynamic person-post adaptation, tiered and categorized assessment, multidimensional and multi-faceted incentives, laddered training and development, full-cycle talent retention, and digital management empowerment". The findings are intended to provide localized theoretical references and practical solutions for optimizing the human resource allocation model of county-level medical insurance windows, alleviating the occupational burnout of frontline service personnel, and activating the intrinsic motivation of practitioners, thereby reinforcing the talent foundation for the high-quality development of grassroots healthcare security public services.

Objective: The paper attempts to explore the reform process, practical characteristics, and implementation outcomes of capitation payment models for chronic disease management under an integrated service orientation, and to provide references for policy improvement. Methods: Policy text analysis, case study, and comparative analysis were conducted. Based on policy documents, published literature, and research team survey data, four cases were selected for comparison: Suixi County (Anhui Province, China), Tianjin City (China), Singapore’s Healthier SG, and the US Medicare APCM. Results: Chronic disease capitation payment in China has expanded from outpatient chronic disease coverage to outpatient special/chronic diseases, general outpatient pooling, total budget for county-level medical alliances, and family doctor contracting, showing a trend from a single payment tool toward a collaborative governance mechanism. More effective models generally feature payment refinement, service integration, health outcome orientation, and digital intelligence empowerment. Through mechanisms such as accountability binding, risk calibration, and performance feedback loops, they drive chronic disease management from passive treatment to proactive health management, achieving multiple goals of cost management, quality improvement, and health enhancement. Conclusion: Capitation payment is not only an important tool for medical insurance method payment reform but also a key institutional lever for promoting chronic disease management and integrated service system development. Future efforts should strengthen collaboration between healthcare security administrations and health commissions, improve risk adjustment, performance assessment, and benefit distribution mechanisms, and enhance digital intelligence technology support.