部分项目收费低于成本、超适应证不报销，多委员建言打破“三医”壁垒

Core Viewpoint - The article discusses the challenges in the collaboration of the medical, medical insurance, and pharmaceutical sectors in China, emphasizing the need for reform in pricing mechanisms and payment systems to align incentives and improve healthcare delivery [3][5][13]. Group 1: Barriers in "Three Medical" Collaboration - The fundamental issue lies in the misalignment of incentives among the medical, insurance, and pharmaceutical sectors, where healthcare focuses on public welfare, insurance on sustainability, and pharmaceuticals on profit [3]. - There are significant barriers in the pricing mechanism of medical services, with some procedures priced below actual costs, such as the breast cancer surgery priced at only 497 yuan, which does not cover the associated costs [6][7]. - The current payment system does not adequately reflect clinical needs, particularly in rehabilitation services where standardized billing does not accommodate complex patient requirements [6][7]. Group 2: Payment Mechanism Challenges - The bundled payment system for diseases does not accurately cover complex cases, leading to inefficiencies in resource allocation within public hospitals [7][8]. - The Case Mix Index (CMI) used for payment adjustments lacks precision, affecting the treatment of cancer patients differently based on their stage, which can lead to hospitals being reluctant to treat certain cases [8]. - The strict adherence to insurance regulations can hinder the use of necessary treatments that fall outside the standard indications, creating a dilemma for clinicians [9][10]. Group 3: Recommendations for Reform - To enhance the collaboration among the three sectors, it is suggested to conduct annual evaluations of medical service pricing and simplify adjustment procedures to ensure fair compensation for medical services [13][16]. - The optimization of payment methods is crucial, with proposals to refine the special case payment system and better categorize complex cases to improve hospital willingness to treat high-risk patients [16][17]. - The health authorities should focus on improving the pricing mechanisms and clinical pathways for complex cases, ensuring that the economic realities of healthcare are addressed while maintaining public welfare [17][18].