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.

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.

Special case review is a crucial supplementary mechanism in DRG/DIP payment reforms, designed to provide flexible payment pathways for exceptional cases that cannot be accommodated within standard payment groups due to complex conditions, application of new technologies, or significant individual variations. In practice, special case review process generally faces challenges such as low efficiency, inconsistent standards, and heavy manual review burdens in various regions. As a national pilot city, Shanghai City has innovatively established a "fast-track" mechanism for special case review. By defining eligibility criteria based on historical review experience and big data analysis, it has achieved automatic screening and rapid approval, while retaining a "regular channel" for cases not covered by the fast track. This mechanism has significantly improved review efficiency, standardized payment criteria, and promoted the application of innovative technologies. It is recommended to dynamically adjust the classification criteria for special case review in the future, expand coverage for new technologies and critical illnesses, and establish a "short term-medium term-long term" linkage mechanism to ensure alignment between medical insurance payments and clinical needs.

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.

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.

In the context of rapid population aging, the surge in care demands from disabled groups has made long-term care insurance (LTCI) a key measure to address family caregiving challenges and improve the social security system. The standardized management of designated LTCI service institutions is a core link to ensure the sustainable operation of the LTCI system. Based on China’s LTCI pilot practices, this study systematically reviews the current status, characteristics, and difficulties in the management of designated institutions. By constructing a government management framework, it analyzes institutional design, governance structures, and operational mechanisms. It also selects two mature LTCI systems—Germany and Japan—for international comparison, examining their experience in resource allocation, access management, quality control and evaluation, and exit mechanisms. The study finds that China’s management of designated LTCI institutions has formed a “national-provincial-municipal” three-tier policy system and a full-cycle closed-loop management mechanism. However, challenges remain, including difficulties in standardizing management norms, insufficient coordination among multiple regulators, inconsistency in quality evaluation systems, difficulties in supervising community-based and home-care institutions, weak incentive and restraint mechanisms, and poor transition in service exit procedures. Based on China’s national conditions and a critical appraisal of German and Japanese experiences, this study proposes optimization recommendations: establishing a tiered and categorized differentiated policy system; strengthening cross-departmental coordination to create a consistent governance synergy; optimizing the full-cycle management to improve the closed loop of access, evaluation, and exit; and enhancing technology empowerment and incentive support to improve governance efficiency.

Medical assistance serves as a fundamental institutional arrangement safeguarding the basic healthcare rights of disadvantaged populations. Technologies such as big data and artificial intelligence are driving the digital and intelligent transformation of medical assistance. Drawing on case studies, this paper constructs a theoretical analytical framework centered on core elements—needs identification, service provision, and outcome feedback—to systematically elucidate the logic of how digital and intelligent technologies empower medical assistance governance. Research findings reveal that digital and intelligent empowerment has yielded significant outcomes in medical assistance governance: the policy framework has been continuously refined, digital and intelligent infrastructure development has progressed steadily, and administration services have been consistently optimized. However, challenges persist, including the digital divide and equity gaps, insufficient information sharing and institutional coordination, incomplete rules for technology integration, and underdeveloped digital governance mechanisms. Based on this analysis, the paper proposes pathways for digital and intelligent empowerment in medical assistance governance: bridging the digital divide and promoting service equity at the value level, deepening governance coordination and information sharing among stakeholders at the governance entity level, advancing the deep integration of technology and services at the governance process level, and strengthening safeguards for digital and intelligent governance mechanisms at the governance mechanism level.

The national centralized drug procurement policy, as a key initiative in deepening China's healthcare reform, is reshaping the competitive landscape and corporate behavior of the pharmaceutical market. Using a sample of 317 listed pharmaceutical companies in China from 2015 to 2025, this study employs a multi-period difference-in-differences (DID) model to empirically examine the impact of the centralized drug procurement policy on the innovation investment of listed pharmaceutical companies and its underlying mechanisms. The results show that the policy significantly promotes increased innovation investment, a finding that remains robust after a series of robustness tests including parallel trend test, placebo test, variable substitution, intensity DID, and PSM-DID. Examining the mechanisms through which the policy affects innovation investment, it reallocates firm resources from sales to research by weakening marketing channels, compressing the space for non-productive expenditures, intensifying survival pressures and compelling a strategic transformation. The heterogeneity analysis indicates that the stimulating effect is more salient in larger, non-state-owned, and more mature pharmaceutical firms.

As one of the first long-term care insurance (LTCI) pilot cities in China, Ningbo City has gradually shaped its operation mode and established “five systems” of fund-raising, disability assessment, service supply, benefit payment and claim management. Through field investigation and data statistics, this paper analyzes the implementation plan and effects of LTCI of Ningbo City in detail, and summarizes the problems of financing mechanism, disability assessment, nursing service and operation by third-party agencies. After evaluating the risks by analytic hierarchy process (AHP), it is found that the LTCI needs to pay attention to the long-term care demand risk, operational risk, service supply risk and moral hazard. This article proposes a specific path for the sustainable development of long-term care insurance in the future, which is to improve policy design and establish an independent dynamic financing system, strengthen the uniformity and transparency of disability assessment, expand the scope of guarantee and improve nursing benefits, improve the quality and regulatory level of nursing services, clarify the procedures and systems for third-party agencies, and incentivize active participation by the third-party agencies.

Objective: Focusing on the stage of volume reporting for centralized procurement of medical consumables, the paper analyzes the practical difficulties and management bottlenecks in the process, providing empirical evidence for improving the accuracy, timeliness, and standardization of volume reporting work. Method: Using semi-structured in-depth interviews, five representative public hospitals in a city were selected to conduct research and analysis around core contents such as volume reporting process, data review, exception handling, and policy implementation. Result: The study found that there are three major problems in the volume reporting work, including underreporting, untimely reporting, and insufficient accuracy. The root causes involve multiple factors such as deficiencies in hospital system and process, insufficient prioritization, and the lack of incentive mechanisms. Conclusion: It is recommended to optimize the in-hospital volume reporting system and process framework, solidify the main responsibility for management, customize a reasonable incentive and restraint mechanism, and enhance the informatization management level of medical consumables in the hospital.

Objective:Against the backdrop of constructing a multi-tiered healthcare security system, this study focuses on the synergy mechanism between city-customized commercial health insurance and basic medical insurance. Methods:Based on the basic version data of 34 representative city-customized commercial health insurance products across China in 2025, this study quantitatively analyzes their synergy mechanism with basic medical insurance from six dimensions: operating entities, enrollment conditions, thresholds and deductibles, reimbursement ratios, coverage scopes, and payment and settlement methods. Results:City-customized commercial health insurance and basic medical insurance demonstrate good synergy in terms of operating entities, enrollment conditions, payment methods, and supplementary coverage for high-cost drugs outside the basic insurance catalog. However, significant obstacles remain, including coverage gaps caused by high deductibles, inadequate actual compensation for policyholders with pre-existing conditions, and insufficient data sharing that restricts precise product design. Conclusion:It is essential to clarify the tiered division of responsibilities between basic medical insurance and city-customized commercial health insurance, strengthen their coverage synergy, and establish a data-sharing mechanism between basic medical insurance and commercial insurance. These measures aim to enhance coverage precision and institutional sustainability, thereby building a systematic, efficient, and sustainable multi-tiered healthcare security system.

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.

Objective:This study examines Zhejiang Province's DRG exclusion payment policy for innovative technologies, analyzing its design logic, selection pathways, and outcomes, with the aim of providing insights for nationwide healthcare payment reforms to support medical innovation. Methods:Combining literature review and policy practice analysis, the study first provides a theoretical analysis of the DRG exclusion payment policy. It then focuses on Zhejiang Province's incentive catalog management system for innovative medical technologies under medical insurance payment and its first incentive catalog, exploring the three core mechanisms of application, evaluation, and payment. Finally, it summarizes the characteristics of catalog selection and the implementation effects of the system, identifying key challenges in policy operation. Results:Zhejiang Province has established a payment incentive mechanism centered on healthcare institutions as the applicants, multi-dimensional evaluation indicators, and a three-year degressive point-based supplementary compensation system. The first incentive catalog includes 25 drugs, 3 medical service items, and 2 medical consumables. Conclusion:Zhejiang Province’s DRG exclusion payment practice offers a referential model for promoting the clinical application of innovative medical technologies under the DRG payment. Meanwhile, addressing challenges in policy optimization and implementation supervision, the study proposes recommendations such as establishing a dynamic evaluation mechanism and enhancing digital-intelligent supervision to further improve policy sustainability and precision.

Against the backdrop of deepening the reform of medical service prices in China, since 2021, the National Healthcare Security Administration has issued a series of medical service price project approval guidelines to guide the unified and standardized medical service price project in various regions, enhance comparability and fairness of medical service, further improve the quality of medical services, and promote the high-quality and sustainable development of China’s healthcare system. This study adopts a combined approach of policy document analysis and case studies to examine the guidelines’ impacts on the operation and management of public hospitals, focusing on project integration, standardized pricing, emphasis on service outputs, recognition of technical complexity, and support for innovation. Based on these findings, the paper proposes countermeasures such as refined cost accounting, strengthened staff training, improved information management, and promotion of technological innovation. The study’s novelty lies in analyzing the guidelines from the perspective of hospital operations and offering actionable strategies. However, the lack of large-scale quantitative data and reliance on limited cases may affect the generalizability of its conclusions.

Monopoly agreements for active pharmaceutical ingredients (API) occur from time to time. In the first half of 2025, The Supreme People's Court of the People’s Republic of China and Administration for Market Regulation have disclosed two cases of horizontal monopoly agreements in the API sector. Among them, the CP camphor case resulted in penalties and multiple remedial measures, offering valuable insights. The API market has become a hotbed for monopoly agreements due to the low cost and ease of maintaining such agreements among API operators, coupled with the broad profit margins available to the parties involved. The essential elements of an API monopoly agreement encompass subject element, form element, and effect element. The subject element should be defined primarily through demand substitution analysis. The form element should be assessed by examining the operators' collusive intent and shifts in competitive advantage. The effect element analysis should emphasize the operators' market share and API market price. With the deepening of anti-monopoly enforcement in the field of API, it is necessary to improve the anti-monopoly regulatory system of API by increasing the enforcement efforts, enhancing the precision of law enforcement and promoting the whole-chain supervision, optimize the regulatory system of the API industry in terms of streamlining the overall approval process and strengthening the bargaining power of downstream preparation enterprises, and implement a fair competition review system in this area, with a view to effectively enhancing the quality and effectiveness of the regulation of monopoly agreements on API.

In recent years, China's healthcare security authorities have continuously promoted the construction and optimization of a dynamic adjustment mechanism for the medical insurance drug catalog. By including newly approved drugs, adjusting drug coverage, payment standards, and renewing expired agreements for drugs, while simultaneously removing drugs with low clinical value, replaceable alternatives, market withdrawals, or insufficient supply from the catalog, the structure of the drug catalog has gradually been optimized. However, issues such as insufficient standardization and normalization persist in the current drug re-evaluation and dynamic adjustment mechanisms, leading to some drugs with uncertain clinical value or significant discrepancies between real-world efficacy and clinical trial results still benefiting from policy incentives. The re-evaluation process also requires further standardization. This study focuses on optimizing the drug re-evaluation and dynamic adjustment mechanisms in China's medical insurance catalog, systematically analyzing the policy framework and existing challenges for drug re-evaluation among the three departments—medical products administration, health commission, and healthcare security—under the current governance system of coordinated development and regulation of medical insurance, medical services, and pharmaceuticals. By reviewing policy experiences from typical countries such as the UK, Canada, Germany, Japan, and South Korea in medical insurance drug re-evaluation and adjustment mechanisms, the study extracts practical insights for reference. Building on this, the study proposes optimization suggestions for China's medical insurance drug re-evaluation and dynamic adjustment mechanisms based on the national conditions, covering trigger conditions, evaluation processes, assessment criteria, adjustment rules and pathways, as well as appeal and review mechanisms. Additionally, the study integrates China's "Real-World Comprehensive Value Assessment for Medical Insurance" series of initiatives to provide theoretical and practical references for further policy adjustments.

Objective: The paper attempts to evaluate the mid-to-long-term sustainability of China's long-term care insurance (LTCI) fund under different financing models and provide empirical evidence for the nationwide establishment of the LTCI system. Methods: Four representative pilot cities — Qingdao, Shanghai, Nantong, and Chengdu — were selected as research subjects. Their financing models were classified into two categories: the medical-insurance-dominated model and the multi-source co-financing model. Based on national LTCI fund operation data from 2020 to 2024, a dynamic revenue-expenditure balance model was constructed. Fund sustainability was simulated under three scenarios (conservative, moderate, and aggressive) for the period 2024-2035, followed by univariate sensitivity analyses on three core parameters. Results: Under the conservative scenario, the revenue-expenditure ratio will decline gradually from 1.86 to 1.17, maintaining balance throughout the projection period. Under the moderate scenario, the ratio will fall below 1 around 2029 and further decline to 0.59 by 2035. Under the aggressive scenario, the fund deficit will emerge in 2028, with the ratio dropping to 0.39 by 2035. Sensitivity analysis revealed that the target benefit coverage rate had the greatest impact on fund sustainability, with the magnitude of impact approximately twice that of the financing growth rate and benefit growth rate. Conclusion: Given that expenditure growth driven by the expansion of coverage consistently outpaces financing growth, the sustainable operation of the LTCI fund requires coordinated efforts across three dimensions: controlling the scope of coverage, enhancing financing capacity, and managing cost growth.

Objective: This study investigates the implementation status of intelligent whole-process management system for cross-regional malignant tumor patients with outpatient special diseases. Methods: The study takes a tumor hospital in Guangzhou City as an example. On the physician side, electronic application forms integrated with AI agents were adopted to facilitate semi-automatic generation of application forms. For patient verification, a WeChat mini-program employing facial recognition and basic medical insurance data validation was deployed. The introduction of AI-assisted decision support has improved the efficiency and accuracy of the approval process. Furthermore, automated and precise claim processing was achieved by embedding the settlement logic into the backend system, alongside the implementation of a dynamic eligibility exit mechanism. Results: The one-stop eligibility certification of outpatient special disease is available at the hospital for patients throughout Guangdong Province at present, yielding a multiplicative rise in certified cases and a cumulative certification count of approximately 100000. By 2025, non-local patient services represented 72.6%. The introduction of AI-assisted review led to 80.1% of cases being processed within one hour, alongside a reduction of the minimal approval time to less than five minutes. Conclusion: The fully intelligent management system of outpatient special disease markedly improves approval efficiency while ensuring the proper use of medical insurance funds. These outcomes position it as a promising candidate for implementation across diverse healthcare institutions and outpatient special or chronic disease programs.

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.

As the long-term care insurance (LTCI) system transitions from pilot programs to nationwide implementation, frequent violations such as “fake services, fake assessments, and fake disabilities” in care services have become prominent. Traditional supervision models face challenges including insufficient coverage, low efficiency, and poor interpretability, threatening the security of LTCI funds and the sustainable operation of the system. In response to national LTCI regulatory policy requirements, this study develops an end-cloud collaborative, real-time interpretable supervision agent for LTCI care behaviors. Through deep coupling of device-side intelligence and cloud-side large models, the agent enables a transformation in LTCI supervision from a service “ black box” to a state of “knowing both what and why”. To objectively evaluate the system’s operational capabilities, this study further constructs a benchmark for LTCI care behavior supervision, which includes a video-based benchmark test dataset, a five-dimensional system evaluation index system, and an agent-based comparison baseline, providing a basis for horizontal comparison and iterative optimization of system capabilities. The results indicate that this approach effectively addresses the issues in LTCI supervision and offers an effective technical solution and efficacy testing for intelligent LTCI supervision.

Medical insurance data possesses dual attributes of public resource and sensitive personal information, with its value realization following a “core-intermediate-external” transmission mechanism. The core layer defines the data management responsibilities of healthcare security authorities, the intermediate layer serves as a bridge through cross-departmental collaboration and data sharing, while the external layer empowers diverse stakeholders including insured individuals, medical institutions, pharmaceutical entities, and commercial insurance companies. However, the current system suffers from issues such as unclear internal responsibilities, ambiguous intermediate processes, and imbalanced external rights, revealing a structural contradiction between internal governance capacity and external empowerment demands. To address this, the core layer achieves statutory clarification of responsibilities through a dual mechanism of “power constraints” and “liability limitations”, the intermediate layer resolves sharing challenges via a dual-track model of “approval flow plus data flow” and a tripartite rights-responsibilities framework, and the external layer balances the interests of diverse stakeholders through rights protection and collaborative governance. Medical insurance data governance must seek a dynamic equilibrium among security, fairness, and efficiency, establishing a comprehensive regulatory framework that integrates the entire internal and external chain.

Objective:Using real-world data, the paper examines the impact of diagnosis-related groups (DRG) payment reform on the utilization and costs of typical coronary interventional consumables (coronary stents and drug-coated balloons (DCB)), providing evidence for improving payment reform and consumables governance. Methods:Medical insurance settlement data of 179867 inpatient cases with coronary heart disease were collected from 27 DRG pilot hospitals (first and second batches) in City S from 2020 to 2022. Descriptive analysis and interrupted time series (ITS) analysis with a control group were applied to evaluate the effects of DRG reform on average quantity and cost per case, and utilization rate of the typical consumables. Further analyses of changes in average quantity and cost per case were conducted for different categories of stents. Results:After DRG reform, among all inpatients, average quantity and cost of stents per case decreased significantly, whereas the average quantity and cost of DCB per case increased significantly. ITS analysis indicated that, following DRG reform, stent quantity and utilization rate shifted from a post-volume-based procurement (VBP) high plateau to gradual decline, with sustained cost reduction. The rapid post-VBP growth of DCB quantity and utilization rate was curbed, achieving long-term stabilization. In the subgroup of patients undergoing stent implantation, selected products maintained high utilization at low cost, Non-selected products stabilized at persistently low utilization and cost levels following VBP implementation. Utilization and costs of out-of-scope stents exhibited a sustained convergent decline. Conclusion:DRG reform effectively constrained the expansion of stent utilization and costs, and complemented the VBP policy to form a coordinated pattern: VBP reduces prices, while DRG controls total volume and contains costs. It also reversed excessive DCB growth toward a pattern of stable volume with reduced costs. Overall, DRG reform promotes a shift from scale-driven to rational and value-oriented use of consumables, aligns with the clinical trend of “leave-nothing-behind”, and advances rational medical behavior and efficient resource allocation.

Objective:The paper explores the differentiated design logic of centralized procurement rules for special categories of pharmaceuticals using blood products as an example, providing empirical references for improving China’s centralized volume-based procurement system. Methods:The study employed a combination of desk research, field visits, data analysis, and expert interviews. Results:Blood products are characterized by scarce raw materials, inflexible cost structures, and long production cycles. Centralized procurement faces challenges such as mismatches between rigid volume commitments and dynamic clinical demand, conflicts between price reduction pressure and high cost structures, and limitations on clinical payment affecting accessibility. In response to these challenges, various regions have adopted differentiated approaches in the design of centralized procurement rules, forming distinct policy approaches. Among them, the differentiated centralized procurement rules implemented by the Guangdong Alliance have achieved moderate price reductions, effectively ensuring market stability and supply resilience. Conclusion:Centralized procurement of blood products should adhere to a clinical value-oriented approach and establish a refined governance system that balances cost management goals with supply resilience. This includes developing a flexible volume commitment mechanism, optimizing price formation mechanisms, improving a risk prevention and control system centered on “quality assurance and stable supply”, and simultaneously enhancing the coordination between medical insurance payment and clinical use, thereby systematically improving the supply security and accessibility of blood products.

Objective:The paper attempts to explore refined management pathways for the disease group structure of public hospitals under DIP payment, develop a regional classification management tool for disease groups, and provide an evidence-based reference for decision-making. Methods:Based on two consecutive years of DIP settlement and medical charge data in S City, a four-quadrant disease matrix was constructed using DIP-CMI and average balance per case as core indicators. Disease groups were categorized into strategic, advantageous, problematic, and special groups. Their distribution characteristics, resource consumption, and annual evolution trends were comparatively analyzed. Results:During the study period, the overall distribution of surplus and deficit diseases in S City was relatively balanced, with the number of overspending diseases slightly exceeding that of profitable ones. Matrix analysis shows that the current disease structure is dominated by advantageous and problematic diseases, while strategic and special diseases have relatively small admission volumes. Longitudinal tracking indicates that the city’s disease structure is continuously optimizing towards a more rational and balanced direction: the proportion of cases in the profitable range is steadily increasing, the concentration of inefficient problematic diseases has been effectively reduced, and the overspending loss magnitude of high-difficulty special diseases has been substantially narrowed. Conclusion:Public hospitals in S City are in a critical transition period from scale expansion to intensive development. Hospital administrators are advised to adopt matrix thinking and implement differentiated strategies—specifically to "strengthen strategic groups, stabilize advantageous groups, remediate problematic groups, and mitigate special groups"—to drive high-quality hospital development.

Based on the "Typical Cases of Individuals Defrauding Medical Insurance Funds (Second Issue)" released by the National Healthcare Security Administration, this paper conducts an in-depth analysis of the phenomenon of seeking medical treatment and purchasing medications under false identities, which poses a serious threat to the security of medical insurance funds. The study finds that among the disclosed typical cases, instances of seeking medical treatment and purchasing medications under false identities account for a relatively high proportion of individual fraud cases, exhibiting trends of diversified methods, industrialized chains, and targeted objectives. The paper thoroughly examines the primary causes of such fraudulent behaviors, further revealing that the real-name policy for medical treatment and medication purchases is inadequately implemented in practice due to underlying issues such as outdated technical verification methods and lax enforcement by medical institutions. To address these challenges, it is recommended to establish a multi-dimensional and systematic regulatory framework, and comprehensively promote precise verification technologies such as facial recognition, which can provide academic references and practical pathways for strengthening the security of medical insurance funds and improving the real-name policy.

Objective: The paper analyzes the impact of the implementation of approval guidelines for traditional Chinese medicine (TCM) medical service price on inpatient diagnosis and treatment behavior in TCM hospitals, providing a reference for better adapting to these guidelines and optimizing hospital resource allocation. Methods: Based on medical insurance settlement data from March to June, 2025 at a tertiary TCM hospital in Guangzhou City, with the guideline implementation in April 2025 as the intervention point, Stata was used to draw box plots for comparative analysis of the number of cases, actual settlement scores, length of hospital stay, number of surgical procedures, and total expenses. Results: After implementing the guidelines, repetitive procedures for mild cases decreased, inpatient diagnosis and treatment services became more standardized, and resource input for severe and chronic consumptive cases increased significantly. The structure of medical expenses showed a differentiated pattern of "fewer mild cases, more severe cases". Conclusion: The implementation of approval guidelines for TCM medical service price effectively curbed over-treatment of mild cases, guided hospitals to allocate more resources to severe and complex cases, and promoted the standardization of inpatient diagnosis and treatment services in TCM hospitals. It had a positive effect on optimizing the cost structure and improving the efficiency of medical insurance fund utilization. Future studies should incorporate long-term observational data to compare clinical outcome indicators and further assess the systemic impact after guideline implementation.

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.

With an ageing population and increasing burden of chronic diseases, demand for rehabilitation services has surged. However, the current Diagnosis-Related Groups (DRG) /Big Data Diagnosis-Intervention Packet (DIP) payment system is not fully compatible with the characteristics of rehabilitation care. Meanwhile, per-diem payment systems have given rise to issues such as over-treatment. Against this backdrop, Nanjing City has drawn upon international and domestic experience to introduce the Value-based Rehabilitation Groups (VRG) payment model. The article first analyses existing rehabilitation payment practices globally and domestically, summarising approaches to establishing value-oriented rehabilitation payment systems. It then details Nanjing City's VRG design philosophy and operational mechanisms, and the value-based payment framework is introduced, alongside a preliminary effectiveness analysis using data from Nanjing City. Finally, it summarises the reform's achievements and shortcomings while proposing refinement strategies, aiming to provide valuable insights for China's rehabilitation medical insurance payment reforms.

Objective:The paper evaluates the economic burden of implantable cardioverter-defibrillator (ICD) implantation in patients with heart failure (HF) in Xinjiang under DRG reform and centralized procurement of medical consumables, and to analyze disparities between health insurance schemes. Methods:We retrospectively analyzed 975 patients undergoing first-time ICD implantation at a tertiary hospital in Xinjiang, China, from 2021 to 2025. Regression models were used to assess determinants of inpatient costs, out-of-pocket (OOP) proportion, and high medical burden (OOP > 50000 yuan). Results:The median total inpatient cost was 130200 yuan, with medical consumables accounting for 72.5%. The median OOP proportion was higher in the Urban and Rural Resident Basic Medical Insurance (URRBMI) than in the Employees’ Basic Medical Insurance (EBMI) (0.30 vs 0.20, P<0.001). In multivariable logistic regression, URRBMI was associated with a higher risk of high medical burden compared with UEBMI (OR=2.34, 95% CI: 1.45-3.78), and subcutaneous ICD (S-ICD) further increased the risk (OR=3.50, 95% CI: 1.42-8.60). During follow-up, the all-cause readmission rate was 43.9%, and the median readmission cost was 10100 yuan. Conclusions:The cost of ICD implantation for HF patients in Xinjiang is primarily composed of consumable expenses, and marked disparities in OOP burden exist across insurance schemes in Xinjiang, and high-cost cardiac devices/consumables such as S-ICD may further amplify the economic burden among URRBMI beneficiaries. It is recommended to continue promoting regional centralized procurement of high-cost consumables and refining DRG payment standards, while exploring refined payment mechanisms such as payment exclusion for consumables or case-by-case special review. Meanwhile, efforts should be accelerated to establish post-implantation programming and remote monitoring of ICD as medical service items, with clear charging and regulatory standards, and to promote their inclusion into the scope of medical insurance coverage in accordance with regulations, so as to facilitate full-cycle standardized management and reduce the risk of readmission.

To assess the impact and mechanism of provincial-level pooling of the urban and rural residents’ basic medical insurance (hereafter referred to as “residents’ medical insurance”) on medical expenses, and to provide policy references for the goal of basically achieving provincial-level pooling of basic medical insurance as outlined in the 15th Five-Year Plan Outline, this paper employs a five-wave unbalanced panel microdata from the China Family Panel Studies (CFPS) covering the period 2014-2022. Using the multi-period propensity score matching difference-in-differences (PSM-DID) methods, we systematically evaluate the impact and mechanism of provincial-level pooling of the resident’ medical insurance on medical expenses. The empirical results show that provincial-level pooling of resident’ medical insurance has significantly promoted the growth of total medical expenses per capita, with an average annual increase of 4087.654 yuan after policy implementation. Regarding the mechanism, the policy exerts its effects by influencing behaviors of both the demand and supply sides. On the demand side, patients show a higher tendency to seek medical care in higher-level hospitals, and healthcare accessibility has been improved. On the supply side, inpatient services have notably substituted outpatient services; meanwhile, the reimbursement ratio has decreased while the out-of-pocket ratio has increased. Heterogeneity analysis reveals significant regional and group disparities in policy effects. Regionally, the growth of medical expenses has been effectively mitigated in areas where provincial-level pooling of the employees’ basic medical insurance (hereafter referred to as “employees’ medical insurance”) was implemented earlier, whereas the rise in medical expenses is more pronounced in regions piloting direct settlement of outpatient expenses. By group, provincial-level pooling of residents’ medical insurance has suppressed the growth of medical expenses among migrant populations, but boosted medical expenditure among low-income groups, people aged 60 and above, and those with chronic diseases. Therefore, in the process of advancing the provincial-level pooling of residents’ medical insurance, it is necessary not only to manage the unreasonable growth of medical expenses but also to improve the supporting policy system with targeted measures. This will help resolve the adaptability issues in medical insurance governance that emerge with the elevation of pooling levels, ensuring the effective and sustainable implementation of the provincial-level pooling policy.

Objective:The paper attempts to evaluate the impact of the DRG payment reform on the expenditure of the employees’ medical insurance fund, and to provide empirical evidence for alleviating the pressure on the balance of the fund. Methods:Based on the panel data of 282 prefecture-level cities in China from 2015 to 2023, a multi-period difference-in-differences (DID) method was adopted, combined with parallel trend tests, placebo tests, PSM-DID, Bacon decomposition, CSDID and other multi-dimensional robustness tests to systematically analyze the impact of DRG reform on the expenditure of the medical insurance fund. Results:DRG reform significantly affected the expenditure levels of the employees’ medical insurance fund—a finding contrary to the intuition of cost containment —suggesting the release of medical demand and institutional adaptation costs during the early phase of the reform. The number of health technicians per thousand people had a significant positive impact on the fund's expenditure, while the number of hospital beds per thousand people had no significant effect, indicating that human resources are more policy-sensitive than material resources. The reform effect was more prominent in eastern regions and central cities, while the effect in central and western regions and non-central cities was not obvious. Conclusion:DRG reform has improved the operational performance of the medical insurance fund, but the short-term expenditure expansion effect of this reform needs to be taken seriously. A linkage mechanism for fund income and expenditure should be established, regional differentiated strategies should be implemented, and a reform orientation prioritizing human resources should be established to ensure the sustainability of the medical insurance fund.

Focusing on the infringement of public health interests caused by excessive medical treatment and the limitations of traditional relief mechanisms, this paper takes civil public interest litigation as the institutional entry point to analyze the current situation of regulation of excessive medical treatment cases in China. It is found that there are difficulties such as limited administrative supervision and punishment, heavy burden of proof for patients, and insufficient existing practical cases. The study systematically proves the legitimacy and necessity of civil public interest litigation in the field of excessive medical care from the dimensions of institutional advantages, legal basis, and normative basis, and proposes a comprehensive path that combines theoretical logic and practical operability. It is necessary to clarify the connection logic between administrative supervision and civil public interest litigation at the legal level, as well as to construct a more implementable rule system at the institutional level, including refined definition of excessive medical care, specialized collection of relevant evidence, and compensation distribution that balances public and private interests. This paper provides theoretical reference and practical guidance for the handling of similar cases of excessive medical care, and helps to improve and develop prosecutorial public interest litigation in emerging medical consumption fields.

Objective:The urban and rural residents' basic medical insurance system is a key livelihood security mechanism for alleviating residents' medical burden and preventing return to poverty due to illness. The paper attempts to analyze the constraining factors and explore boosting strategies for the continuous enrollment of urban and rural residents in basic medical insurance in economically underdeveloped rural areas of western China, so as to provide references for improving the long-term participation mechanisms of basic medical insurance. Method:This study was based on field research in three administrative villages of Baise City, Guangxi Zhuang Autonomous Region, which employed in-depth interviews with rural residents, village cadres, and grassroots healthcare security staff. A four-dimensional analytical framework was constructed from the perspectives of policy, institutional, individual, and environmental levels. Results:The main factors constraining residents' continuous enrollment in basic medical insurance include the inadequate departmental collaboration and policy transmission at the institutional level, the lack of resources and weak grassroots medical service capacity at the service level, and the individuals' short-term rationality and the spending priorities under the pressure of financial survival. Conclusion:Recommendations include strengthening risk awareness education, improving the targeted financing mechanism, enhancing the supply of grassroots medical services, and optimizing the incentives for continuous participation in medical insurance, so as to systematically enhance residents' willingness to remain continuously enrolled and contribute to the sustainable development of the urban and rural residents' medical insurance system.

Objective: The paper attempts to analyze the current status of price governance tools, local practice differences, implementation dilemmas, and underlying causes for non-selected brand-name drugs under centralized volume-based procurement, and to provide a reference basis for improving the coordinated mechanism of online listing prices, medical insurance payments, procurement and utilization, risk warning, and evidence feedback. Methods: Policy document analysis, comparative case study, framework analysis, and thematic analysis were applied. National and local policies were systematically reviewed. Field investigation materials from Shanghai, Heilongjiang, Hebei, Fujian, and Jiangsu, together with expert consultation findings, were used to conduct a structured comparison and synthesis of governance tools and implementation issues. Results: A policy tool system has taken shape for the price governance of non-selected brand-name drugs, with listing price management as the foundation, reimbursement standards as the core lever, hospital procurement and use management as the key implementation mechanism, and price risk warning as a supplementary tool. The five regions have developed differentiated governance approaches in reimbursement coordination, competitive listing, transparent procurement platform management, red/yellow risk labeling, price comparison rules, and filing-based procurement. Thematic analysis identified several key problems, including overreliance on a single price benchmark, unclear boundaries for clinical substitution, insufficient linkage between reimbursement and listing procurement policies, and difficulties in balancing special clinical needs with the prevention of generalized use of high-cost drugs. These problems are mainly attributable to unclear price gradient rules, overlapping pressures from reimbursement and hospital performance assessment, insufficient evidence on clinical substitution, and inadequate interdepartmental coordination and data feedback mechanisms. Conclusion: Price governance for non-selected brand-name drugs should be stratified, coordinated, and evidence-informed. Policy priorities include improving reasonable price gradient rules, clarifying the boundaries of clinically appropriate use, strengthening coordination between reimbursement and procurement policies, optimizing dynamic price risk warning mechanisms, and establishing feedback systems based on quality, supply stability, and real-world evidence.

Objective: The paper attempts to investigate the current situation regarding the utilization and payment of traditional Chinese medicine (TCM) and ethnic minority medicine (EMM) in Xinjiang Uygur Autonomous Region, analyze the influencing factors for implementing medical insurance payment method reform in TCM and EMM medical institutions, and provide a reference for establishing a medical insurance payment mechanism that aligns with the characteristics of TCM and EMM. Methods: Semi-structured interviews were conducted with responsible personnel from 10 relevant institutions. Descriptive analysis was applied to the interview content, and thematic coding and influencing factor analysis were performed based on the thematic framework analysis method. Results: The current influencing factors for implementing medical insurance payment method reform in TCM and EMM medical institutions in Xinjiang Uygur Autonomous Region involve five aspects: clinical application, payment management, standardization issues, discipline development, and policy coordination. Conclusion: Promoting the successful implementation of medical insurance payment method reform in TCM and EMM medical institutions is of significant importance for the application, development, protection, and inheritance of TCM and EMM. Targeting the main influencing factors, it is recommended to systematically construct a standardized system for EMM to consolidate the foundation of the payment method reform, build a medical insurance payment mechanism more aligned with the characteristics of TCM and EMM based on the existing DRG/DIP framework, and strengthen policy coordination to explore a multi-level healthcare security support system.

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.

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.

Under the voluntary enrollment policy for basic medical insurance for urban and rural residents, motivating sustained proactive participation is crucial for the system’s sustainability. This study introduces the behavioral economics concept of “policy experience utility”, defining it as a four-dimensional comprehensive perception encompassing process, service, outcome, and emotional trust throughout the enrollment cycle. Based on field research and semi-structured interviews in regions such as Guizhou Province and Yunnan Province, and integrating the principles of “loss aversion” and “mental accounting” from prospect theory, this paper constructs an integrative analytical framework. This framework elucidates the internal logic of how policy design drives proactive enrollment behavior by systematically shaping residents’ positive experience utility, thereby influencing their risk perception and value judgment. On this basis, the study identifies multiple pathways—policy incentives, organizational coordination, stakeholder interaction, and norm shaping—to systematically optimize the policy experience of residents, ultimately aiming to establish a long-term driving mechanism characterized by precise targeting, multi-party collaboration, value perception reshaping, and health demand orientation.

The reform of medical insurance payment is a core measure to promote the high-quality development of healthcare, and comprehensive value evaluation is a key tool to test the effectiveness of the reform. Based on the paradigm of real-world research, this paper takes the Diagnosis-Intervention Packet (DIP) payment model as the starting point, employs a combination of bibliometric initial screening and two-round Delphi expert consultation to select 23 indicators from a candidate indicator pool, and systematically constructs a four-dimensional comprehensive value evaluation system for medical insurance, including efficiency, quality, equity and sustainability. The weights of the indicators were determined by the Analytic Hierarchy Process (AHP), with all consistency ratios (CR) below 0.1. Combined with more than 100000 real case data in the field of maternal and child health care in Shenzhen City, this paper comprehensively employs Propensity Score Matching (PSM) and Interrupted Time Series (ITS) analysis to quantify the net effect of the DIP policy, and adopts the Entropy Weight-TOPSIS method to conduct a dynamic ranking evaluation of the comprehensive medical insurance value across various institutions. Empirical results indicate that after DIP payment, average inpatient costs fell by 15.6%, success rate of critical maternal care reached 97.1%, the fund surplus rate increased from 2.3% to 5.8%, and overall value scores rose by 25.9%. Yet, the evaluation accuracy is still constrained by insufficient adaptability to specialty disease groups, delayed equity improvement, and barriers to cross-institutional data exchange. Accordingly, this paper recommends enhancing the specialty group weighting system, introducing a dynamic indicator adjustment mechanism, establishing a “data sandbox” for secure sharing, and reinforcing a closed-loop feedback process for the four-dimensional value assessment.

The cross-regional benefit mechanism of long-term care insurance (LTCI) is a critical institutional arrangement for safeguarding the continuity of care rights and the equity of care benefits for disabled individuals. Drawing on policy documents from pilot regions across China, this study systematically reviews the implementation of cross-regional LTCI benefits. The paper found that although initial progress has been made in mutual recognition of cross-regional disability assessments, delivery of benefits and real-time expense settlement, challenges remain, including limited policy coverage, inadequate disability assessment, disparities in benefit access, unrealized cross-regional settlement, and insufficient oversight. Based on the analysis, this study proposes optimization pathways for the cross-regional benefit mechanism of LTCI: improving benefit portability and insurance transfer arrangements, standardizing assessments and promoting mutual recognition, coordinating cross-regional benefits and ensuring equitable payment, facilitating information sharing and direct settlement across pooling areas, and strengthening collaborative oversight and follow-up mechanisms.