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.

Objective: The paper proposes recommendations for continuously promoting the work of the National Medical Insurance Price Negotiation (NMIPN) and further harnessing the value and strategic purchasing strengths of medical insurance funds. Methods: Descriptive statistical method was applied to comprehensively review NMIPN drugs and their supply enterprises from 2016 to 2024. Additionally, the synergistic effects of NMIPN and National Volume-Based Procurement (NVBP) policies were analyzed. Results: Since 2019, the annual number, success rate and average price reductions remained at over 85, 58% and 55%, respectively. Drug categories expanded from 2 to 21, and the formulation increased from 1 to 23. 34 NMIPN drugs transferred to NVBP, experiencing a secondary price reduction ranging from 58.06% to 98.86%. 235 pharmaceutical companies participated in NMIPN, with an increasing trend. The percentage of Chinese companies has increased since 2019, and the proportion of new enterprises has slightly decreased. Conclusions: While expanding the scope of NMIPN, continuous optimization of drug selection and monitoring mechanism remains imperative, and substantial support for "true innovation" in NMIPN drugs is necessary. Under the functional positioning of "basic security", the NMIPN and NVBP policies operated synergistically to achieve the expansion of the list of medical insurance drugs and multiple significant price reductions and promote the market expansion and innovative transformation of pharmaceutical companies and high-quality development of the pharmaceutical industry, following the adjustment strategy of "making up for shortcomings" and the implementation principle of "meeting the clinical needs". It is suggested that a certain buffer period should be considered in the process of normalizing NMIPN and NVBP policies, to alleviate the impact of consecutive price reductions on the sustainable development capability and innovation drive of pharmaceutical enterprises. Meanwhile, efforts should be made to explore diverse value realization paths of innovative drugs.

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.

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: As a key supplement to a multi-tier healthcare security system, city-customized commercial health insurance has persistently low enrollment, revealing a supply-demand paradox of enthusiastic provision but lukewarm uptake. This study dissects heterogeneity in enrollment decisions across population groups and identifies micro-level causes of inadequate coverage and the loss of healthier enrollees from the risk pool, providing evidence to increase participation. Methods: Using the Andersen model and nudge theory as the analytic framework, we conducted a qualitative study with in-depth interviews of 21 residents from four prefecture-level cities in Shandong Province, representing never-enrolled, continuously-enrolled, and discontinued-enrollment profiles. We identified themes that captured differences in enrollment decisions. Results: The three groups exhibited markedly divergent decision rationales. Never-enrolled individuals refrained from enrolling because they underestimated risk and lacked product knowledge; continuously-enrolled individuals renewed coverage, driven by risk aversion, trust in the industry, and a sense of social responsibility; discontinued enrollees withdrew because of unsatisfactory claim experience and the spread of negative word-of-mouth. Conclusions: UCCMI should shift from generic mass publicity to precise nudges, deploying differentiated strategies that address group-specific information and trust gaps to balance expanded coverage with system sustainability.

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.

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.

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.

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.

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.

In 2023, the first centralized procurement for neurointerventional medical consumables by the Henan Province Public Medical Institution Alliance adopted an on-site, full-category negotiation mechanism. In 2024, the subsequent procurement chose a moderate policy of "price linkage from other provinces" as the main approach, integrating the results of centralized procurement from Beijing City,Tianjin City, Hebei Province, Jiangsu Province, and Anhui Province, effectively addressing the challenges of price troughs while ensuring clinical supply. This article conducts in-depth analysis from multiple dimensions such as background, rules, achievements, potential problems, and suggestions. In response to the high-risk and high-precision instrument demand of neurointerventional surgery, as well as the market situation dominated by imported brands, the Henan Province Alliance Procurement adopts policies such as setting differentiated pricing mechanisms and reasonable grouping to reduce consumables price and patient burden, while also taking into account clinical usage habits. Furthermore, the study offers optimization suggestions for future procurement policies for high-value medical consumables.

Long-term care insurance (hereinafter referred to as LTCI) is an important policy arrangement for actively addressing population aging and implementing the Healthy China strategy. Based on the framework of welfare pluralism, this study analyzes the dilemmas faced by China's LTCI policy from the perspectives of organizations, values, and relationships, and proposes a systematic optimization path. Specifically, by clarifying the roles and responsibilities of different parties, building consensus based on mutual benefit, coordinating interest relationships and improving the supervision and regulation system, multi-dimensional measures are taken to promote the formation of a collaborative governance pattern among the government, market, and social entities, and to promote the optimization and improvement of the LTCI system.

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.

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.

Objective: The paper analyzes the current status and influencing factors of the medical insurance settlement payment rate under the DIP payment system, providing a basis for improving the DIP payment policy, optimizing internal operations in medical institutions, and ensuring reasonable compensation. Methods: Based on the DIP settlement data from 158 medical institutions in G City from January to March 2024, multiple linear regression analysis was used to investigate the factors affecting the medical insurance settlement payment rate. Results: The empirical results show that lower hospitalization costs, shorter hospital stays were associated with higher medical insurance settlement payment rate (P<0.05). Medical insurance settlement payment rates were significantly lower for tertiary medical institutions and core diseases (P<0.05). The medical insurance settlement payment rate of employees' medical insurance is higher than that of residents' medical insurance, and non-conservative treatment is higher than that of conservative treatment (P<0.05). Conclusion: Healthcare security institutions should optimize payment policy design, dynamically adjust disease category values, improve the mechanism of special case negotiation, enhance the fairness and scientificity of payments, and improve the dynamic adjustment mechanism for the fundraising of the residents' medical insurance fund and benefit standards, ensuring the stable operation of the fund in the long term. Medical institutions should implement refined management, optimize cost accounting, strengthen internal supervision and management, and enhance their adaptability to the DIP payment system reform.

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.

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.

Objective: This article explores the price supervision and management mechanism of psychiatric hospitals, focusing on the development and application of intelligent price supervision systems, and uses information technology to solve traditional price management problems, in order to promote high-quality development of hospitals. Method: We develop a price intelligent supervision system and build an audit rule database that meets the requirements of clinical diagnosis and treatment, medication standards, and real-time updates of medical insurance policies. Relying on the HIS, we use an integrated platform to extract billing data, and conduct real-time online review of each medical expense. A full process management approach of "prior reminder, in-process supervision, and post audit" was adopted to cover supervision and statistical methods were used to analyze practical effectiveness. Result: Information technology has optimized the price management process, solved the problems of traditional price supervision and management, and provided scientific and efficient regulatory solutions. Conclusion: This model enables real-time online review of medical expenses, early detection and correction of suspected violations, and prevention of irregular medical behaviors, implement pricing policies to ensure compliance, improve work efficiency, reduce operating costs, and lay the foundation for the high-quality development of psychiatric hospitals.

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

This study takes international experience and local practice as the two supporting points, systematically sorting out the DRG performance evaluation practice of countries such as the United States, Germany, and Australia, as well as the practice of Diagnosis Related Groups (DRG) / Diagnosis-Intervention Packet (DIP) performance evaluation in three regions of China. Through multiple rounds of discussions and demonstrations participated by healthcare security authorities, medical institutions, experts and scholars, two regions were finally selected for trial evaluation, and a performance evaluation system for payment by DRG/DIP (hereinafter referred to as the performance evaluation system) was ultimately constructed. This performance evaluation system adopts a method combining quantitative and qualitative analysis. Starting from four dimensions, namely reform coverage, implementation quality, diagnosis and treatment services, and patient benefits, 15 indicators are set up, which can comprehensively and scientifically evaluate the progress and effectiveness of the payment method reform. This study not only provides an important reference for healthcare security authorities to evaluate the effectiveness of the reform and adjust reform policies, but also provides a decision-making basis for medical institutions to optimize internal management and improve service quality. It has important theoretical value and practical significance for promoting the high-quality development of payment method reform in China.

Objective: This study attempts to explore the impact of urban and rural residents’ medical insurance (URRMI) on rural labor supply and its underlying mechanisms. Methods: Using the four-period panel data of the China Family Panel Studies (CFPS), this study applies Logit model and multiple linear regression model, and adopts instrumental variable methods and entropy balance matching method to address endogeneity issues. Results: URRMI significantly promotes rural labor participation and supply time, through the pathway of improving employees’ health. Further analysis shows that URRMI exerts stronger positive impacts on labor supply in the western region and the youth group (16~44 years old). Meanwhile, it can improve the quality of labor supply and break the "low-skill lock-in" dilemma. Conclusion: It is suggested to strengthen publicity and guidance, as well as provide incentives for insurance participation, and continuously expand the coverage of URRMI, enhance the allocation of primary healthcare resources and service capabilities, and consolidate the foundation of health security, optimize the design of URRMI system, and increase the protection for key groups, improve the vocational skills training system and enhance the quality of rural labor supply.

Objective: By analyzing the implementation effect of the "Service Number Point Value Method" payment method reform in Zhangjiagang City of Jiangsu Province, the paper provides decision-making reference for improving the diversified and compound payment mechanism under the DRG payment framework. Method: Based on the summary of the underlying mechanism of the "service number point value method" and the theory of internal and external circle stakeholders, a three-dimensional assessment framework of "controlling costs, ensuring quality, and improving efficiency" was constructed. Using medical insurance final settlement data from 2021 to 2024, a quantitative assessment method was adopted to evaluate the implementation effect of the "service number point value method" payment method reform. Result: The average annual growth rate of total medical expenses of Zhangjiagang City was controlled at 6.08%. The operational efficiency of medical insurance funds has been improved. The average outpatient cost per visit decreased significantly. The hospitalization rate and the 31-day readmission rate have significantly decreased, and both the quality and efficiency of medical services have improved. Conclusion: The "service number point value method" payment method reform has achieved remarkable results in Zhangjiagang City in controlling the irrational growth of medical expenses, ensuring the quality of medical services, and improving the efficiency of medical insurance fund utilization. In the future, it is necessary to further explore the relevant indicators for the formation of point value and further refine the incentive mechanism of point value to enhance the scientific nature of point value.

The system of drug traceability codes is gradually implemented nationwide, and medical insurance departments will deal with cases involving the sale of "backflow drugs" and "fake drugs" by medical institutions, either proactively or passively. Whether it is a protocol processing or an administrative penalty, it is based on the medical insurance agreement, The Regulations on the Supervision and Administration of the Use of Healthcare Security Funds and local laws and regulations. The sale of "backflow drugs" and "fake drugs" also violates the Drug Administration Law of the People's Republic of China and other drug supervision laws and regulations. In the case of a conflict of illegal acts, how to properly handle cases, especially penalty decisions, under the framework of the "choose the heavier punishment" principle of The Administrative Punishment Law of the People's Republic of China. This article takes the handling of the selling of "backflow drugs" by medical insurance designated medical institutions as the target of analysis, tries to clarify the legal logic, put forward academic suggestions, and recommend the optimal model for the reference of the case handling organizations of medical insurance department.

With the deepening of the medical insurance payment method reform and the medical insurance digitalization construction, the value of medical insurance data in promoting high-quality development of medical institutions is increasingly prominent. Based on the theories of information asymmetry and collaborative governance, this study systematically explores the practical path and internal mechanism of medical insurance data empowerment through the analysis of policy and practice in Wuhan City and cases of two typical hospitals. Research has found that medical insurance data effectively promotes the refinement and high-quality development of medical institutions by driving management transformation, optimizing performance evaluation, and promoting clinical rationalization. However, issues such as data quality barriers, uneven application capabilities among institutions, and imperfect collaboration mechanisms have constrained the depth and breadth of empowerment effects. Therefore, this article proposes targeted suggestions such as building lifecycle management of data, deepening application of digital intelligence, and improving collaborative ecosystems.

Objective: In the DRG/DIP medical insurance payment system, traditional Chinese medicine (TCM) often faces relatively low payment standards and difficulties in reflecting its value. This study explores a way to realize “same payment” based on “same disease and same efficacy” between TCM and western medicine, using radial fracture treatment as an example to develop a case-based payment standard. Methods: Based on clinical practice in hospitals of Foshan City, Guangdong Province, an evaluation framework covering both safety and effectiveness was established. By integrating DRG payment big data with expert opinions, the equivalence of treatment outcomes between TCM and western medicine for radial fractures was verified. Based on these results, reasonable cost levels were estimated and a corresponding payment standard was formulated. Results: The evaluation showed comparable efficacy between TCM and western medicine in radial fracture treatment. The proposed price based on the study is higher than the average TCM cost but lower than the western medicine cost, ensuring hospital motivation while maintaining the price advantage of TCM. Conclusion: Based on the principle of “same disease and same efficacy”, this study explores implementation pathways of “same payment” for TCM and western medicine. The findings indicate that the proposed scheme balances patient affordability, hospital revenue, and medical insurance expenditure, which offers important reference for medical insurance payment reform and the coordinated development of TCM and western medicine.

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

This paper focuses on the issue of synchronous settlement of commercial insurance empowered by medical insurance under a multi-level healthcare security system, and conducts research based on the practice in some regions. Currently, basic medical insurance achieves efficient direct settlement through a unified national information platform, while commercial insurance still mainly relies on post-incident claim applications. The lagging settlement mechanism has become one of the constraints on the development of commercial insurance. The article systematically analyzes two major types of practical models: medical insurance agency and data transmission (including direct/indirect connection and different data granularity sub-models), and dissects the operation mechanisms, advantages and disadvantages, and applicable scenarios of each model. It points out that the empowerment of medical insurance to commercial insurance shows characteristics of unidirectionality, dominance, and limitation. Then, it proposes an optimized framework for synchronous settlement of commercial insurance empowered by medical insurance, namely "one network, two platforms, three channels, four functions, and five guarantees", aiming to break the coordination barriers between basic medical insurance and commercial insurance, effectively solve the settlement bottleneck of commercial insurance, and promote the high-quality development of commercial insurance.

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.

This article analyzes the medical expenses of patients undergoing percutaneous coronary intervention before and after centralized procurement of coronary stents at Z Hospital in Henan Province, reveals the implementation effect and problems of centralized procurement of coronary stents, and proposes feasible suggestions, providing reference for the development of centralized procurement of consumables and medical reform in the future. Method: A comprehensive analysis was conducted on the centralized procurement of coronary stents and the changes in costs before and after centralized procurement using methods such as literature analysis and descriptive analysis. Result: By comparing the impact of the implementation of the centralized procurement policy for consumables on drug costs, consumables costs, treatment costs and other fees, and total hospitalization costs, it was found that the centralized procurement policy for coronary stents had a significant effect on reducing patient costs. However, there are problems such as information asymmetry, increased use of some consumables, and weak motivation of doctors to treat patients during the implementation of centralized procurement results. Suggestions: It is recommended to advance centralized procurement and healthcare reform by reducing information asymmetry, properly compensating medical services, establishing a scientific performance evaluation system, and implementing a moderate, comprehensive centralized procurement model.

Objective: The paper explores how public hospitals can achieve cost reduction and efficiency enhancement through precise cost management and benefit analysis in the context of DIP payment. Methods: Using DIP settlement data from a Grade A hospital in Pingdingshan City from 2022 to 2024, and DIP cases from 2024 and January to June 2025 as research samples, comparative analysis and Mann-Whitney rank sum test were used to statistically analyze the cost and surplus of DIP cases. Results: The average cost per visit, disease score, and average length of hospital stay had a significant impact on the profit and loss of diseases (P<0.05). Cost management and benefit analysis can to some extent reduce average cost, improve disease surplus rate, and enhance medical service capabilities and efficiency. Conclusion: The operation mode of public hospitals needs to transform from "scale expansion" to "value-based healthcare", focusing on DIP diseases to improve quality and efficiency, integrating business and finance, and achieving high-quality development of public hospitals.

There is certain ambiguity in the hierarchical positioning of China's multi-level healthcare security system. This ambiguity, to a certain degree, hinders the enhancement of the system's guarantee efficiency. From a hierarchical perspective, this research constructs a theoretical framework of health "needs-demands- security". That is, the public's diverse health needs at different levels, when combined with their respective payment capabilities, are translated into differentiated health demands. These demands then drive multiple institutional forces to materialize health security. Drawing on international experience, this study delves into the adaptive arrangements of China's multi-level healthcare security system. Guided by the value orientation of "attaining efficiency while ensuring basic fairness", the triple-guarantee mechanism of the basic system is tailored to meet the basic medical needs. The aim is to fully safeguard the fundamentals and set a ceiling on personal out-of-pocket expenses. However, in the short term, it is imperative that programs such as city-customized commercial health insurance, employee mutual-aid security, and charitable medical assistance adapt to meet basic medical demands, thereby strengthening the support system for catastrophic diseases. Meanwhile, basic, mid-level, and high-end commercial medical insurances are respectively designed to address a wide range of health demands, including prevention and rehabilitation, comfortable medical services, and the self-actualization of health. Additionally, commercial disease insurance contributes to health security indirectly by fulfilling the financial security requirements, thereby working towards the goal of achieving more comprehensive "universal medical security". Based on these findings, this study puts forward several suggestions and considerations, including optimizing policies under the value orientation of hierarchical adaptation, establishing a 3 + N hierarchical collaborative governance mechanism, and refining hierarchical supply measures in line with health demands.

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

Objective: This study aims to analyze the impact of outpatient pooling reform on the development of designated retail pharmacies and explore optimization pathways for designated retail pharmacies to adapt to the outpatient pooling reform. Methods: Policy documents issued by relevant administrative authorities were retrieved through official websites. The SWOT analysis method was employed to discuss the strengths, weaknesses, opportunities, and challenges faced by designated retail pharmacies in Nanjing City under the backdrop of outpatient pooling. Results: The development of designated retail pharmacies in Nanjing City within the context of outpatient pooling possess several advantages and opportunities, including enhanced convenience for residents, expanded application scenarios, new settlement support mechanism, policy guidance, and optimization of service models. However, it also encounters disadvantages and threats such as increased costs, insufficient service capacity, poor prescription circulation efficiency, imperfect mechanisms, intensified competition, and mounting pressures on fund operations. Conclusion: A SWOT analysis matrix is established to propose optimization pathways for outpatient pooling reform in Nanjing City's designated retail pharmacies from three dimensions: supportive policies, pharmacy operation, and supervision by healthcare security departments.

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.

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.

Objective: The paper analyzes the changes and influencing factors of hospitalization expenses in patients with cerebrovascular disease undergoing interventional therapy under the background of DRG payment reform, and provides references for reasonable control of hospitalization expenses in patients with cerebrovascular disease undergoing interventional therapy. Methods: The basic medical records and the details of hospitalization expense of 865 patients with cerebrovascular disease undergoing interventional treatment in a Grade-III hospital from January 1, 2020 to December 31, 2024 in Shanxi Province were collected., The structural changes between the average hospitalization expenses and various expenses were analyzed by structural variation degree method. Interrupted time series analysis (ITSA) was used to analyze the trend of hospitalization costs of patients undergoing interventional therapy for cerebrovascular diseases from 2020 to 2024, and univariate analysis and generalized linear regression model were used to analyze the influencing factors of hospitalization costs of patients undergoing interventional therapy for cerebrovascular diseases after the actual operation of DRG. Results: The overall structural variation degree of each hospitalization cost was 12.05%, and the items with the largest structural contribution rate were health materials cost (43.09%) and medicine cost (29.77%), and the cumulative contribution rate was 72.86%. ITSA results showed that the overall hospitalization cost of patients with cerebrovascular disease undergoing interventional therapy decreased significantly, and the average monthly decrease was 154.82 yuan during the actual operation of DRG. The results of generalized linear regression showed that the treatment site, overall planning area, hospitalization days and admission status were the factors affecting the hospitalization cost of patients with cerebrovascular disease undergoing interventional therapy. Conclusion: The DRG payment reform can effectively control the average hospitalization cost of patients, but the cost structure still needs to be further optimized. Hospitals should consider the impact of treatment site, overall planning area and admission status on the cost, and reasonably control the number of days in hospital, so as to further reduce the cost of cerebrovascular disease interventional treatment and the economic burden of patients.

To advance the process of healthy aging and fulfill the objectives of the Healthy China initiative, health insurance has assumed an increasingly critical role in both institutional design and implementation pathways. This paper identifies three core models through which health insurance empowers healthy aging: health insurance plus health management, health plus insurance plus care, and health insurance plus insurance technology. Building on these models, it develops a “goal-mechanism-pathway” analytical framework that closely aligns healthy aging with the five strategic goals of the Healthy China initiative. This framework systematically explicates the operational logic of health insurance and identifies key mechanisms through which it contributes to enhancing health literacy, mitigating health risks, optimizing healthcare delivery, fostering innovation in the health industry, and strengthening institutional systems. In response to current challenges, the study further proposes three actionable pathways: establishing a system for improving health literacy among older adults; optimizing the distribution of health resources and workforce to reduce regional disparities; and dismantling data silos to facilitate coordination among multiple stakeholders. The study offers theoretical insights and policy recommendations to support the reform of China’s health insurance system and the advancement of healthy aging.

"Accelerating the completion of the shortcomings of rural elderly care services" is a major strategic deployment proposed by the third plenary session of the 20th Central Committee of the Communist Party of China. This article uses questionnaire surveys and case interviews, as well as the data of the fourth and fifth sampling surveys of the living conditions of elderly people in urban and rural areas in China, to analyze the problems and challenges faced by rural elderly care in China, based on the analysis of the changes in China's traditional rural elderly care system. The paper proposes to build a rural elderly care service system with township health centers as the main body. First, encourage qualified township health centers to provide long-term care services and make up for the shortcomings of rural elderly care services. Second, strengthen departmental linkage and financial subsidies to reduce the transformation cost of township health centers. Third, accelerate the coverage of long-term care insurance to all residents and improve the supply capacity of rural long-term care services. Fourth, rationally design long-term care insurance and medical insurance payment policies to improve the enthusiasm for service supply.

Objective: This research explores the method and application of intelligent extraction and calculation of daily average dosage for Chinese patent medicines in drug price monitoring, to provide key data support for improving the refinement and scientificity of drug price monitoring. Methods: In view of the difficulties of complex dosage forms of Chinese patent medicines, multi-scenario descriptions in package inserts, and the difficulty of traditional manual extraction of daily dosage, an intelligent system was developed on the DeepSeek open-source framework, taking the application of artificial intelligence (AI) technology to extract the daily average dosage of traditional Chinese patent medicines on the Shenzhen Drug Trading Platform as a practical case. This system synergistically employs natural language processing (NLP), rule engine, and dual anomaly detection algorithm. NLP is utilized for the precise extraction of dosage, frequency, and unit information from the package inserts. The rule engine enables multi-scenario segmentation and accurate daily dosage calculation. The dual anomaly detection algorithm provides a reverse validation mechanism to correct data inconsistencies. Results: Practice shows that the intelligent system attained an accuracy rate of 95.51% when processing 12000 Chinese patent medicine usage and dosage records. The F1 value of the dual anomaly detection algorithm reaches 0.9413, indicating that the system has good comprehensive capabilities such as language processing of traditional Chinese patent medicine usage and dosage, and self anomaly detection. Extraction efficiency is 12 times higher than traditional manual processing. The lightweight local deployment solution concurrently ensured data security. Conclusion: This study validates that AI technology provides practical technical solutions for calculating price differences of Chinese patent medicines, identifying covert price manipulation, supporting dynamic drug price monitoring, and compiling price indices of Chinese patent medicines. It represents initial exploratory efforts toward intelligent and standardized development in the pharmaceutical industry.

Objective: The paper analyzes the impact of dynamic adjustments in medical service prices on multiple parties and the implementation risks, and proposes preventive strategies. Method: Based on the practice in Ganzhou City of Jiangxi Province, the paper evaluates the impact of price adjustments on patients, medical institutions, and medical insurance funds, identifies risks in triggering mechanisms and total quantity regulation. Result: Price adjustment needs to balance the affordability of all parties and focus on enhancing the value of technology and labor services. There are risks such as increased patient burden and fund pressure. Conclusion: It is recommended to strengthen the awareness of fund security, take into account the affordability of special groups, guide medical institutions to participate in the process, and achieve a win-win situation for all parties.