On August 15, the National Healthcare Security Administration released a notification regarding the issuance of the "Interim Measures for Medical Insurance Payment by Disease Type Management," clarifying policies, key technologies, core elements, and supporting measures related to disease-based payment. The measures highlight three key regulatory aspects: First, standardizing total budget management by requiring reasonable expenditure budget compilation, determining total amounts for disease-based payments, and emphasizing budget rigidity. Second, standardizing the formulation and adjustment of grouping schemes, clearly defining the entities responsible for scheme development, grouping frameworks, data and opinion support, and adjustment content, with grouping schemes generally required to be adjusted every two years. Third, standardizing core elements and supporting measures, clarifying the meanings of weights, rates, and payment standards, requiring medical insurance departments to fully consult with medical institutions to reach consensus on core element determination.
**Policy Background and Significance**
The Central Committee of the Communist Party of China and the State Council attach great importance to medical insurance payment method reform. The Third Plenary Session of the 20th Central Committee made renewed deployments and emphasis on deepening medical insurance payment method reform. The 2025 Government Work Report further requires "deepening medical insurance payment method reform and promoting tiered diagnosis and treatment."
The National Healthcare Security Administration has continuously promoted multi-element composite medical insurance payment method reform centered on disease-based payment. To continuously improve policy design and advance reform implementation, the administration recently issued the "Interim Measures for Medical Insurance Payment by Disease Type Management."
**Reform Progress and Challenges**
Promoting payment method reform centered on disease-based payment holds significant importance for encouraging medical institutions to standardize behavior, actively control costs, optimize medical resource allocation, improve medical insurance fund efficiency, and protect insured persons' health rights.
In recent years, the National Healthcare Security Administration has focused on promoting disease-based payment for inpatient services, conducting two pilot programs: Diagnosis Related Groups (DRG) payment and Diagnosis-Intervention Packet (DIP) payment. Over six years, disease-based payment has evolved from pilot to expansion, from local exploration to national unification, currently achieving basic coverage of all coordinated regions.
The payment management mechanism has continuously improved, playing a positive role in enhancing medical insurance fund efficiency, promoting standardized medical service behavior, and reducing patients' medical burden. However, during the reform process, local medical insurance departments and medical institutions have reflected some issues, including insufficient expectations for dynamic adjustment of disease groupings, unbalanced development of supporting measures across regions, and significant differences in refined management capabilities between areas.
**Main Content Framework**
The measures implement requirements from the "Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening Medical Security System Reform," comprehensively promoting medical insurance payment method reform with disease-based payment as the focus. The goal is to establish a nationally unified, vertically coordinated, internally and externally collaborative, standardized, and highly effective medical insurance payment mechanism to enable high-quality development of medical institutions.
The basic framework consists of eight chapters and thirty-nine articles, clarifying policies, key technologies, core elements, and supporting measures related to disease-based payment, highlighting three regulatory aspects:
**Disease Grouping Scheme Regulations**
Grouping schemes serve as important technical support for disease-based payment reform, relating to the scientific nature and rationality of medical insurance payments. The measures provide detailed explanations of procedures for formulating and adjusting disease grouping schemes:
The National Healthcare Security Administration is the main body for formulating and adjusting grouping schemes. Since launching disease-based payment reform pilots in 2019, the administration has developed nationally unified technical standards, issued national versions of DRG grouping schemes and DIP disease databases, requiring DRG payment regions to maintain consistency with national core groupings and DIP payment regions to align grouping rules with national standards.
The grouping framework includes DRG grouping with three levels: major diagnostic categories, core groups, and subgroups. DIP disease databases include core diseases and comprehensive diseases, with core diseases serving as main payment units and comprehensive diseases formed by converging cases below critical values as supplements to core disease payment units.
Adjustment procedures rely on objective historical cost data and medical institution feedback as important support. The administration collects data through the national unified medical insurance information platform, forming basic data for disease grouping while establishing opinion collection and feedback mechanisms.
**Benefits for Medical Institutions**
The measures clarify disease-based payment policies of general concern to medical institutions, helping guide collaborative progress between medical insurance and healthcare:
Total budget management becomes more transparent, following principles of "determining expenditure based on revenue, balancing income and expenditure with slight surplus," and establishing reasonable expenditure budgets for total disease-based payment management.
Technical standard optimization becomes clearer, particularly the two-year adjustment cycle that balances grouping scheme stability with improved matching between grouping updates and clinical technology development.
Payment standard calculation becomes more reasonable, requiring dynamic adjustment of core elements and scientific calculation of disease payment standards, considering three main approaches: fixed rates, floating rates, and flexible rates.
Supporting measure construction becomes more comprehensive, with clear requirements for special case negotiations, advance payments, opinion collection feedback, negotiation consultation, and medical insurance data working groups.
Fund settlement better reflects empowerment, fully utilizing the incentive role of disease surplus retention funds, clearly stating that medical institutions can treat disease surplus funds obtained through standardized services as business income.
**Implementation Requirements**
Local medical insurance departments must attach great importance to medical insurance payment method reform, maintain reform confidence, optimize reform paths, improve policies according to the measures, establish supporting mechanisms, and conduct reform effectiveness monitoring and evaluation.
Departments should promote medical insurance payment policy publicity and interpretation, strengthen training for medical insurance departments and medical institutions on disease-based payment knowledge, incorporate disease-based payment technical training into annual work as routine management, standardize training content, innovate training formats, and effectively improve relevant staff business capabilities.
The measures encourage designated medical institutions to follow new situations and requirements of payment method reform, strengthen medical insurance payment policy training for hospital managers and clinical medical staff, actively adapt to reform requirements, form reform synergy, and promote thorough reform implementation.
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