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.

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.

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 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.

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.

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.

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 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: 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.

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: 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.

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.

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: 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: To enhance the accessibility of high-value innovative drugs for patients, to guarantee the sustainability of medical insurance funds, to support industrial innovation, this study aims to explore an innovative multi-payment system that supplements, refines the existing national negotiation framework. Specifically, it seeks to identify scientific, reasonable methodologies, implementation pathways for determiningthe patient payment price, the medical insurance payment, the muti-layer security. Methods: This study adopts a multi-disciplinary approach such as literature review, expert interviews, small-group workshops, integrating theories from health management, health economics to refine proposals for the innovative multi-payment system, its implementation strategies. Results: The Component A should be based on patients' affordability, actual costs of alternative therapies, international benchmarks. The Component B should follow the existing National Insurance Drug Listrules, the medical insurance price is calculated, negotiated by pharmacoeconomic methods. Medical insurance determines the levels of Component A, B by balancing the affordability of patients with medical insurance funds. Subtracting Component A, B from the drug price is Component C. For Component C, innovative pharmaceutical companies play a leading role by providing part of the funds, leveraging various social resources to build a collaborative, resource-sharing multi-stakeholder payment system. Simultaneously, the government ensures the effective functioning of Component A, B, C through organizational coordination, policy guidance, financial support, enhancing the overall security capacity, effectiveness of the payment system. Conclusion: This study explores a social diversified payment system that combines patient payment price, medical insurance payment price for expensive drugs with high clinical benefits. This approach provides a viable pathway for balancing patients' accessibility, the security of medical insurance funds, the sustainability of the pharmaceutical industry innovation. Future efforts will focus on local pilot programs, wherein the specific structures of Components A, B, C will be tailored to regional conditions. Lessons learned from these pilots will inform the refinement of the payment system, the development of scalable demonstration models for broader implementation

Objective: The application ofin clinical practice is in the stage of popularization, development. The purpose of this study was to explore the comparison of disease category score, medical insurance standard payment of medical insurance inpatients with FFR operation under the DIP policy of Guangzhou2018edition, 2022edition, explore the benefits of medical insurance payment for FFR operation-related diseases, put forward suggestions for disease grouping optimization. Methods: Comparative analysis method was used to analyze, compare the differences in enrollment, standard scores, medical insurance balance of hospitalization data with FFR operation in different versions of DIP disease catalogs. Independent sample T test was used to verify whether there were significant differences in the average medical insurance standard payment under different versions of DIP policies. Using the function statistics method, the total value, average value of the loss data of the diseases with FFR operation in recent three years were summarized, analyzed. Results: Compared with the DIP disease score database of2018edition, the number of diseases with FFR operation in the DIP disease score database of2022edition increased, the standard score payment increased, the payment was more adequate, the loss at the hospital side decreased significantly. Conclusion: DIP disease score database needs further optimization. The2022version of DIP disease database pays more adequate for diseases with FFR operation. The case mix of diseases with FFR operation can be adjusted by applying the operation code as an extended code or a new case mix of diseases to meet the actual clinical needs

Objective: According to the actual situation of the medical insurance payment method reform in Shandong Province, this paper discusses the current situation, difficulties, experience of the implementation of traditional Chinese medicineDRG payment method reform, analyzes the possibility of including TCM ambulatory ward in the TCM DRG settlement. Methods: In2023, the inpatient settlement cases of TCM ambulatory wards in four TCM medical institutions above the second level in the sample cities were collected, the four types of diseases of nucha disease, bone disease, back pain, frozen shoulderwere simulated for TCM DRG grouping. Results, Conclusion: TCM ambulatory ward diseases mainly treated by TCM could be included in the TCM DRG pilot for settlement

The modernization of the maternity medical service system, its service capability is an essential pathway to the high-quality development of maternity support policy, the enhancement of the welfare of women of childbearing age, families. This paper elucidates the connotations of the modernization of the maternity medical service system, its service capabilities. Based on social support theory, this study constructs a governance framework for this modernization from the perspective of the “subject-content-object”. Finally, the paper proposes implementation pathways for modernizing the maternity medical service system, its capability from a multi-stakeholder perspective, aiming to provide policy references for addressing China's social problems such as “aging”, “declining birthrates”, for achieving balanced development of population structure

Objective: The paper analyzed, summarized the characteristics of medical insurance data quality by taking the statistical process of “drug costs included in the payment scope” of negotiated drugs as an example, providing references for medical insurance data cleaning, application. Methods: Through the medical insurance settlement system of a city, this study collected medical insurance settlement records of national negotiated products within the agreement periodfrom January2018to September2024as the target dataset, supplemented with several auxiliary datasets by Internet search. A data quality assessment framework covering completeness, standardization, consistency was constructed. Results: In the completeness dimension, the main data problems were missing disease diagnosis codes, names, involving29.6%, 29.7% of record items. In the standardization dimension, 66.2% of record items had non-standard one-to-many correspondence between drug codes, names. There were problems of abnormal medical institution coding content, irregularities in the correspondence between medical institution codes, names.60.3% of record items had disease diagnosis codes that did not conform to standards. There were48non-basic medical insurance participants, involving405record items. In the consistency dimension, 4.9% of record items had payment prices that exceeded the payment standard by ±10%;1.4% of pharmacy purchase data items corresponded to retail pharmacies outside the “dual-channel” recognition scope;78record items did not qualify for medical insurance coverage of patient age or prescription hospital conditions. Conclusion: There are quality issues in medical insurance data, such as missing data, irregular application of medical security information coding system, confusion of patient identity, logic error due to suspected improper payment of medical insurance. It is suggested to accelerate the exploration of appropriate uniform, operational statistical, cleaning rules which are suitable for medical insurance, promote the efficacy of medical insurance data for decision-making

The medical assistance system for serious, critical diseases is an important measure to prevent returning to poverty due to illness, poverty caused by illness, to strengthen the bottom line of people's livelihood security in China. At present, medical assistance system for serious, critical diseases still faces many realistic problems, including unclear assistance boundaries that affect efficiency, fairness of the system, sustainable pressure, fairness in fund raising, use, difficulties, challenges in improving overall planning, inefficiency, barrier in collaborative governance among departments, lack of synergy, standardization in multi-party participation. Therefore, this article suggests the following five aspects for improvement: firstly, clarifying the institutional positioning, achieving moderate security; secondly, improving revenue, expenditure management, enhance institutional fairness; thirdly, enhancing the level of overall planning, empowering grassroots organizations; fourthly, clarifying departmental responsibilities, strengthening collaborative governance; fifth, guiding multiple forces to build a diversified assistance system

Obviously, the intensification of population aging brings challenges, but it also gives rise to new development opportunities in the silver economy. China encourages chain enterprises, listed companies to actively participate in the development of the pension industry, leveraging their resource advantages, leading roles, has achieved some accomplishments to date. This article takes Shanghai as an example to analyze the achievements, input-output differences, industrial cooperation effects of chain long-term care insurance designated service institutions in their investment in the pension industry. Also, with the thoughts on cultivating, developing the silver economy in China, it explores the role of chain long-term care insurance designated service institutions in resource integration, information sharing, industrial collaboration, providing ideas for chain enterprises, well-known brand companies in other key economic regions to participate in promoting the pension industry, offering guidance of direction for the development of the silver economy in central, western cities, thereby promoting the construction of multi-level, multi-subject development carriers for the silver economy

Objective: The paper analyzes the impact of outpatient security level on residents' willingness, continuity, payment grade of participation in basic medical insurance. Methods: Based on the CHARLS data from2011to2018, the paper uses outpatient reimbursement ratio to measure the level of outpatient security, uses Probit model to explore the impact of outpatient security level on residents' basic medical insurance participation behavior. Results: The improvement of outpatient security level of basic medical insurance can significantly increase the participation rate of residents, reduce the interruption of insurance coverage, raise the grade of insurance payment, improve the quality of participation. At the same time, improving the level of outpatient security can reduce residents' adverse selection behavior, the impact of outpatient reimbursement ratio on participation rate is more significant among young people, those with better health conditions. Conclusion: The level of outpatient security can enhance residents' willingness to participate in insurance, improve the quality of participation. It is recommended to improve the level of outpatient security steadily, adjust the deductible line for outpatient reimbursement, increase the proportion of outpatient medical expense reimbursement, expand the scope of reimbursement. Also, we should promote the linkage mechanism between the payment standards of medical insurance, the level of economic, social development, as well as the per capita disposable income of residents, formulate more refined, differentiated payment policies

Objective: The paper analyzes the practice of exploring the retention of medical insurance fund surplus in the centralized procurement of high-value medical consumables in E Autonomous Prefecture, Hubei Province, in order to provide a reference for the standardized, precise promotion of the retention of medical insurance fund surplus in the centralized procurement of high-value medical consumables. Methods: From the perspective of coordinated regions, the paper takes the centralized procurement of coronary stents as an example, uses descriptive statistical methods to review the practice of exploring the retention of medical insurance fund surplus for centralized procurement of coronary stents in E Autonomous Prefecture, summarizes measures to promote standardized, precise promotion of medical insurance fund surplus retention of high-value medical consumables centralized procurement. Results: The exploration of centralized procurement of high-value medical consumables in E Autonomous Prefecture to retain surplus medical insurance funds complies with national regulations, demonstrates strong operability, achieves good results, which is worth to be promoted

In recent years, the overall management of medical insurance funds in China has been improved, but there are still certain weak points in the supervision of grassroots medical insurance funds. Zhuji City of Zhejiang Province has fully exploited its advantage as the birthplace of the "Fengqiao Experience", integrated "Fengqiao Experience" in the new era with the supervision of grassroots medical insurance funds, explored, implemented a comprehensive governance model of "Fengqiao-style" medical insurance fund supervision, encompassing "one grid system, three Fengqiao teams, four working mechanisms, eight tasks", effectively enhancing the supervision efficiency of grassroots medical insurance funds. Based on the experience of Zhuji City, the logic of "Fengqiao Experience" contributes to the supervision of grassroots medical insurance funds in the new era can be summarized as follows: the leadership of the Communist Party of China is the core, the grassroots foundation is the support, digital empowerment is the knob, prevention, control from the source is the key, co-governance, sharing is the goal

In the context of a healthy aging strategy, establishing a health management service system for the elderly with community medical services at its core is crucial. Based on data from the China Longitudinal Aging Social Surveyin2020, this study thoroughly analyzed the impact of community medical services on health cognitive biases, medical treatment choices among the elderly. The results indicated that community-based health support, education services were effective in reducing health cognitive biases of the elderly, encouraging them to engage in positive health-seeking behaviors, such as visiting hospitals or community clinics. Furthermore, health cognitive bias plays a partial mediating role between the utilization of community medical services, the choice of medical treatment for the elderly. In this study, we propose recommendations to enhance the supply of community medical services, strengthen community health education for the elderly, improve their health literacy, reduce health cognitive biases based on the personalized, diversified, professional medical service needs of the elderly, in order to continuously improve the efficiency of medical service supply in grassroots communities, further optimize the utilization of medical services, health decision-making among the elderly

The release of the guide for project approval of medical service pricing is an important measure to promote the deepening of medical service pricing reform. It is also a major measure to standardize medical service price items at the national level for the first time since the establishment of the National Healthcare Security Administration in2018. This article briefly describes the background, significance of the release of guide for project approval of medical service pricing, takes the actual medical service pricing items as a case, compares, analyzes the content differences before, after the implementation of guide for project approval of medical service pricing, discusses the difficulties, countermeasures of the implementation, to provide patients, hospitals, pharmaceutical companies, medical industry authorities with a multi-angle understanding, thinking

Objective: The paper explored the impact of the iteration process of acid-suppressing drugs from oral proton pump inhibitorsto oral potassium ion competitive acid blockerson outpatient reimbursement, standardization of prescription in hospitals. Methods: This study used real-world sampling data from18hospitals of9cities, spanning from Q1of2021to Q3of2024. Descriptive statistical methods were used to analyze the compatibility between drug prescriptions of the PPI, P-CAB, their indications, in order to assess the standardization of prescription, the potential loss of medical insurance reimbursement due to non-standardized prescriptions. Results, Conclusion: During the observation period, the proportion of P-CAB drug usage increased from0.6% to18.9%, gradually replacing PPI drugs. Overall, the prescription compliance for oral acid suppressants in outpatient settings showed annual improvement. P-CAB drugs had a higher proportion of standardized prescriptions compared to PPI drugs, indicating that the iteration process of oral acid suppressants helps standardize prescribing behavior. Non-standardized prescriptions may lead to greater loss of medical insurance reimbursement opportunities for patients, increasing their economic burden

Objective: Health technology assessmentserves as a multidisciplinary evidence-based decision-making tool, which can provide scientific grounds for healthcare insurance decisions from multiple dimensions. This paper aims to draw on international advanced experience to explore the application pathways, improvement measures of HTA in healthcare security decision-making within China. Methods: This study employs a literature review method to outline the fundamental concepts of HTA, examine the experience of countries such as the United Kingdom, Canada in HTA process construction as well as management, operation systems. It summarizes the current status of HTA applications in China's healthcare security system, identifying, discussing the main challenges currently. Results: Despite continuous maturation in the application of HTA in China, there are still many challenges, room for improvement in the construction, optimization of its system. Issues include the absence of a specialized government-affiliated HTA institution, the need for process optimization in assessments, the lack of technical evaluation standards for diseases or drugs, the non-standardization of price adjustment increments, decrements. Conclusion: In the future, by continuously improving the HTA system, mechanisms, HTA will play a more significant role in optimizing resource allocation, enhancing the quality of medical services, ensuring public health

Globally, the regulatory system for long-term care services has become an important part for ensuring the quality of long-term care services. On the basis of literature research, the content analysis of policy texts, this study compares the long-term care service quality supervision systems in Germany, Japan, South Korea from three dimensions of structure, process, outcome by the SPO model. The study found that the long-term care service quality supervision in Germany, Japan, South Korea has a clear division of government responsibility, a standardized access system of institutions, the setting of hierarchical classification of service personnel qualifications, multi-dimensional needs assessment, strict rating of service institutions, transparent information disclosure, regular satisfaction surveys. Therefore, drawing on the experience of Germany, Japan, South Korea in the long-term care service quality supervision system, China needs to further improve the regulatory legislation, implement the rating of designated nursing institutions, optimize the disability assessment tools, establish information disclosure systems to ensure the improvement of long-term care service quality

Commercial health insurance is an important component in the construction of a multi-level healthcare security system. This study takes the social-commercial cooperation in critical illness insurance for urban and rural residents as the entry point, reveals the key issues of participation of commercial insurance in the critical illness insurance operation and analyzes the causes, through field research and a comprehensive analysis of the critical illness insurance operation and social-commercial cooperation models in sample regions. The study finds that while the critical illness insurance system has effectively alleviated the financial burden on patients with severe illnesses, it still faces numerous challenges, including unclear boundaries of stakeholder responsibilities, unequal distribution of profit and loss risks, inadequate incentive mechanisms, and unresolved information barriers. Based on these issues, this study proposes recommendations such as strengthening top-level design to clarify the functional positioning of stakeholders, improving cooperative mechanisms to fully leverage the advantages of commercial insurance, and optimizing supply-demand matching to reinforce the supplementary role of commercial insurance. These suggestions can provide practical insights and decision-making references for promoting the participation of commercial insurance in the construction of a multi-level healthcare security system.

Objective: The paper compares the differences between new-listed and sustained inclusive commercial medical insurance products to provide references for the sustainable operation of new-listed insurance products and the further development of inclusive commercial medical insurances. Methods: Information on inclusive commercial medical insurance in China from 2021 to 2023 was systematically collected. Based on their existence status, these insurances were classified into new-listed and sustained ones, and their number of participants, financing standards, requirements for enrollment and payment, and benefits were comparatively analyzed. Results: The financing standards for new-listed insurances were higher than sustained ones, yet the number of insured individuals was lower. In terms of participation and payment conditions, the new-listed insurances with higher premiums imposed stricter payment conditions for individuals with pre-existing conditions. In terms of benefits, the new-listed insurances reduced coverage for outpatient chronic and special diseases compared to sustained ones, and the insurances with higher premiums expanded their coverage to include other medical expenses not covered by basic medical insurance, and raised the overall cap. Conclusion: Inclusive commercial insurance should further optimize the design of security schemes, enhance outpatient chronic and special disease security, and expand coverage of the population to enhance its own anti-risk capacity.

With the prominent value of commercial health insurance in China's multi-level healthcare security system, the insurance industry is actively seeking ecological cooperation with industries such as medical equipment. To promote the transformation of commercial health insurance to be long-term, diversified, and sustainable, it is necessary to establish a systematic commercial health insurance catalog. This article analyzes the practice of establishing commercial insurance catalogs in the United States, Australia, Canada, and Germany, and summarizes their experience. It believes that commercial insurance catalog is a reflection of the high-quality development of commercial health insurance, and is positively correlated with the stability and maturity of basic medical insurance, also it can effectively meet the needs of customers and achieve multi-party balance. At the same time, suggestions were put forward for the establishment of China's commercial insurance catalog, including implementing a refined catalog management approach of graded payment, establishing third-party organizations, approving diversified security outside the catalog, and prioritizing the establishment of a Class C drug catalog in the city-customized commercial health insurance.

Objective: The paper attempts to analyze the “crowding-out” effect of long-term care insurance (LTCI) on intergenerational support from children to parents and its mechanisms. Methods: Based on four waves of panel data from the China Health and Retirement Longitudinal Study (CHARLS) from 2013 to 2020, a difference-in-differences (DID) model was employed to empirically examine the policy effects and mechanisms of LTCI on intergenerational support within families. Results: The implementation of LTCI significantly reduced both financial and caregiving support provided by children to their parents. Mechanism analysis revealed that LTCI decreased seniors' economic dependence on their families, thereby reducing the intergenerational support from their children. With the "exchange motivation", children were less inclined to offer financial assistance to parents. Heterogeneity analysis indicated that the impact of LTCI on intergenerational caregiving was more significant for female seniors, individuals with difficulties in daily activities, and those with poor mental health. Conclusion: LTCI can reduce the burden of intergenerational support and caregiving time within families, thereby releasing household labor. It is recommended to gradually expand the coverage of LTCI policies and diversify the payment items of LTCI policies to solve the problem of children supporting their parents.

Value-based healthcare driven by digital intelligence, as one of the cutting-edge concepts in the current international healthcare field, is expected to promote the coordination of medical services, medical insurance and pharmaceuticals and high-quality development to a new level by leveraging systematic mechanism optimization and whole-process model innovation. Starting from the problems and challenges faced by the current coordination of medical services, medical insurance and pharmaceuticals and high-quality development, this paper discussed the relationship between value-based healthcare driven by digital intelligence and the coordination of medical services, medical insurance and pharmaceuticals, as well as the paths and conditions for it to play a role. Combining specific scenarios and typical cases, it also looked forward to the application prospects of digital health technologies and the concept of value-based healthcare in promoting the coordination of medical services, medical insurance and pharmaceuticals and high-quality development, with a focus on the intelligent tools for the allocation of health resources that integrate multi-source heterogeneous data based on Geographic Information System (GIS), the determination of medical insurance disease costs and payment standards based on artificial intelligence actuarial simulation, the selection of new drugs empowered by digital intelligence and the post-marketing multi-dimensional value evaluation based on real-world data, and the deep coordination of medical services, medical insurance and pharmaceuticals oriented by value consensus and the innovative development of digital and intelligent integration.

This paper utilizes data from the 2010-2022 China Family Panel Studies (CFPS), adopts the method of moments to measure the indicators of rural household development resilience, establishes a fixed-effects model to systematically assess the impact of basic medical insurance on rural household development resilience, and explores the mechanism. The results show that basic medical insurance can significantly improve rural household development resilience. Specifically, for every unit increase in the basic medical insurance coefficient in rural areas, the rural household development resilience increases by 0.0866 unit on average, other things being equal. The mechanism test finds that family acts on household development resilience through the income effect and the knowledge effect of basic medical insurance, which is mainly manifested in the increase in the amount of medical insurance reimbursement and the improvement in the level of education. This study provides empirical evidence for the development of precise assistance policies to forestall any large-scale relapse into poverty and build a sustainable development system in the rural areas.

With the rapid development of medical insurance informatization, efficient processing of massive medical insurance data has become one focus of informatization construction. This article explores the application of KMP algorithm in the field of medical insurance, elaborating on the principles, workflow, and advantages of KMP algorithm in string matching, and analyzes its mathematical principles. Through case experiment data display and comparison with traditional algorithms, the implementation principles and advantages of KMP algorithm in core business processes such as medical insurance data matching, cost accounting, and fraud detection have been demonstrated, which provides strong technical support for the efficient operation of medical insurance information systems and precision medical services, and helps to carry out medical insurance informatization more accurately and efficiently.

Objective: This study aims to explore the way of monitoring drug prices and to leverage the role of price monitoring in improving the drug price formation system. This study constructs drug price indices to analyze trends in drug price changes and their underlying causes, as well as to provide references for drug price monitoring nationwide. Methods: Using health insurance claims data from Nanning City from January 2022 to September 2023, we construct monthly drug price indices based on the chained Fisher price index. We analyze trends and reasons of price changes across overall, categorized, and essential drug groups. Results: The average price of all drugs in Nanning City exhibits a general downward trend during the sample period, with an average decrease of approximately 12.7%. A categorized analysis revealed variations in price change trends across different categories (western and Chinese patent medicines, and drugs with varying reimbursement levels) and sales channels (pharmacies and hospitals, for-profit and not-for-profit hospitals, and hospitals with differing levels). The price changes of essential drugs (centralized procurement drugs and antipyretic analgesic drugs) were influenced by market supply-demand relationship and policies. Suggestions: We should establish and improve drug price monitoring mechanisms, promoting the institutionalization and normalization of drug price monitoring, implementing the monitoring on prices for categorized drugs and enhancing the monitoring of essential drugs.

Objective: The establishment of medical insurance admission rules for innovative high-value medical consumables and supporting medical service pricing projects is the key to promoting the clinical application of innovative technologies and realizing value purchases. This study proposes suggestions for improving the medical insurance admission management of innovative high-value medical consumables and supporting medical service price projects in China from the aspects of classification management, admission process, and evaluation indicators, providing a reference for relevant projects to be included in medical insurance reimbursement. Method: This study reviewed the management experience of medical insurance admission for innovative high-value medical consumables and supporting medical service price projects at home and abroad, formed preliminary suggestions, and further verified their applicability and operability through expert interviews. Results: The study found that Australia, Taiwan Province of China and other places effectively improved the evaluation efficiency of medical service price items and promoted the application of latest innovative medical technology through classified access, standardized window period and evaluation cycle, and set up differentiated evaluation processes and indicators. In terms of medical consumables medical insurance access, Australia, Japan, the Republic of Korea and other countries have formed mature experience and adopted classified management. The difference in evaluation content mainly lies in whether economic evaluation or complete health technology evaluation is needed. The interviewed experts further proposed applicable and feasible suggestions based on classification, admission process, and evaluation criteria. Conclusion: This study proposes management methods and path suggestions for optimizing the medical insurance admission of innovative high-value medical consumables and supporting medical services in China, providing policy references for regulating the medical insurance admission of related projects and promoting the timely and rational use of innovative technologies.

Objective: By analyzing the current situation of the medical insurance outpatient mutual aid system reform, and the inclusion and supervision of designated retail pharmacies in Baoding City, this paper explores how to strengthen the supervision of designated pharmacies for outpatient security while fully protecting the rights and interests of insured employees, ensuring the safe and stable operation of the medical insurance fund. Methods: The paper searches the outpatient mutual aid policies for employees of Baoding City and other cities in Hebei Province from January 1, 2022 to December 31, 2024, and compares the level of employee outpatient security benefits horizontally. Also, it analyzes the regulatory practice of Baoding City in incorporating designated retail pharmacies into outpatient security from 2022 to 2024, and summarizes the experience and problems. Results: After the reform of the employee outpatient mutual aid, the benefit level of employees' outpatient pooling in Baoding City is at medium to high level in Hebei Province. The number of outpatient patients has grown rapidly, and the insured people has begun to enjoy dividends of the reform. Baoding City includes the designated retail pharmacies to outpatient pooling in batches, which better serves the public and reduces regulatory pressure. However, it had some negative impacts on drug price management and medical insurance payments in pharmacies. The creative use of remote video surveillance systems has played a role in strengthening supervision, but we should continue to strengthen regulation by combining other regulatory measures. Conclusions: We should continue to strengthen and improve the drug price management of designated retail pharmacies, optimize medical insurance payment policies, improve the regulatory measures for outpatient security pharmacies, and ensure the safety of medical insurance funds while fully meeting the needs of the public for outpatient medication.

During the reform of DRG/DIP payment methods, the special case negotiation mechanism plays an important role in ensuring the scientific and fairness of the reform, and guiding value-based healthcare. The special case negotiation mechanism embodies the scientific idea of special treatment for special situations and specific analysis of specific problems based on facts, which is a necessary measure to ensure the smooth progress of DRG/DIP payment reform. The practice in Dongying City has proved that to make good use of the special case negotiation mechanism, its principles must be clarified, its necessity must be clarified, and the use of the special case negotiation mechanism should be regarded as a part of implementing DIP payment reform. In practice, it is necessary to attach great importance to the openness and transparency during the entire process, strictly follow the evaluation standards from a detailed perspective, promote closed-loop management with the use of data analysis, adhere to the essential principle of “ensuring basic medical insurance” as the direction, and continuously improve and make good use of the special case negotiation mechanism in the DIP payment reform.