2025年医疗保障领域10大热词，点击查看→

Core Viewpoint - The year 2025 marks significant advancements in China's medical insurance system, showcasing resilience and a focus on people's health through various reforms and initiatives [1][20]. Group 1: "1+3+N" Multi-layered Medical Security System - The National Healthcare Security Administration emphasizes the establishment of a "1+3+N" multi-layered medical security system, which includes a unified national medical insurance information platform, three levels of basic medical insurance, and support for commercial health insurance and other forms of assistance [2][21]. - The reimbursement rates for inpatient expenses under employee and resident medical insurance have reached approximately 80% and 70%, respectively, while the level of serious illness insurance has increased by 10 to 15 percentage points [2][21]. Group 2: Dual Directory System - The introduction of the "dual directory" system, which includes the National Basic Medical Insurance and Commercial Health Insurance Innovation Drug Directories, represents a significant step in defining the boundaries of basic and commercial insurance [3][23]. - In 2025, the basic medical insurance directory added 114 new drugs, with 50 being innovative drugs of significant clinical value, achieving a historic high [3][23]. Group 3: Provincial Coordination - The push for provincial coordination of basic medical insurance aims to enhance fairness and sustainability within the system, with 20 provinces already advancing this initiative [5][24]. - The National Healthcare Security Administration has mandated the optimization of fund management and the establishment of provincial adjustment funds to support this coordination [5][24]. Group 4: Anti-Overcompetition - The eleventh round of centralized drug procurement has shifted towards a focus on quality and sustainability, with the concept of "anti-overcompetition" introduced to prevent irrational price competition [6][24]. - Mechanisms have been implemented to ensure rational pricing and to enhance clinical choice, allowing medical institutions to report quantities based on specific brands [6][26]. Group 5: Real-World Research - Real-world research (RWS) has been established as a key tool for evaluating the comprehensive value of drugs and medical technologies, aiming to support sustainable fund management and high-quality industry development [7][25]. - The National Healthcare Security Administration is planning to integrate real-world evaluation results into the entire chain of medical insurance payment and management [7][27]. Group 6: Long-term Care Workers - Long-term care workers have been introduced as a new profession to support long-term care services, with over 3,500 candidates participating in skill assessments across 28 provinces [10][29]. - The long-term care insurance system has covered nearly 300 million people, benefiting over 3.3 million individuals with disabilities [10][30]. Group 7: Maternity Insurance System - The maternity insurance system aims to achieve "no out-of-pocket" expenses for childbirth within policy coverage, with 2.55 billion people enrolled in maternity insurance during the 14th Five-Year Plan [11][30]. - The plan includes expanding coverage to flexible workers and improving prenatal care expense coverage [11][12]. Group 8: Drug Traceability Codes - The implementation of drug traceability codes has led to the collection of 39.885 billion codes, enhancing consumer protection and combating drug return issues [14][32]. - By July 2025, all medical institutions will be required to implement full traceability code collection [14][32]. Group 9: Three Settlement Reforms - The "three settlements" reform (instant, direct, and synchronized settlements) aims to reshape the payment ecosystem in the healthcare sector, with significant progress made in instant settlements covering 593,600 medical institutions [15][33]. - Direct settlements are designed to expedite payments to enterprises, reducing the average payment cycle from 180 days to under 30 days [15][33]. Group 10: Medical Service Pricing Guidelines - The National Healthcare Security Administration is working on standardizing medical service pricing across provinces to enhance transparency and service quality [18][35]. - By 2026, the administration aims to complete the compilation of 40 pricing guidelines to unify medical service pricing projects nationwide [18][35].