医疗保障按病种付费管理暂行办法印发，解读来了

Core Viewpoint - The article emphasizes the importance of reforming the medical insurance payment system in China, particularly focusing on the implementation of a disease-based payment system to enhance efficiency and transparency in healthcare funding [1][2]. Background of the Regulation - The introduction of the interim measures for disease-based payment management is aimed at promoting standardized behavior among medical institutions, controlling costs, optimizing resource allocation, and improving the efficiency of medical insurance fund usage [2]. - The National Healthcare Security Administration has been advancing the disease-based payment model over the past six years, achieving nationwide coverage and improving the management system [2]. Main Content of the Regulation - The interim measures consist of eight chapters and thirty-nine articles, focusing on establishing a unified, efficient medical insurance payment system that supports high-quality development of medical institutions [3]. - Key aspects include: - Standardizing total budget management to ensure a balanced budget and stable expectations for medical institutions [3]. - Defining the framework for grouping schemes and their adjustments, with a requirement for biennial updates [3][5]. - Clarifying core elements and supporting measures, including payment standards and negotiation processes [3]. Regulations on Grouping Schemes - The National Healthcare Security Administration is designated as the authority for developing and adjusting grouping schemes, ensuring consistency across regions [4]. - The grouping framework includes major diagnostic categories and core groups, with adjustments based on historical cost data and feedback from medical institutions [5]. Positive Effects on Medical Institutions - The regulation enhances transparency in total budget management, allowing for better financial planning by medical institutions [6]. - It provides clearer technical standards and a predictable adjustment cycle for grouping schemes, aligning them with clinical developments [6]. - Payment standards are to be dynamically adjusted, with a focus on collaboration between insurance departments and medical institutions [6]. - Supporting measures are detailed, including provisions for special cases and prepayment mechanisms, reinforcing the commitment to support medical institutions [6][7]. Requirements for Local Healthcare Departments - Local healthcare departments are urged to prioritize the implementation of the disease-based payment reform, optimize policies, and enhance monitoring and evaluation of reform outcomes [8]. - Training and capacity-building initiatives for healthcare staff regarding the new payment methods are emphasized to ensure effective adaptation to the reforms [8].