交叉内审：健全"常态化监督"内控闭环。建立"日常+专项"双轨内审机制，组织各业务股室交叉检查经 办资料完整性、业务办理时效性及签字审批规范性。8月20日开展的专项交叉检查中，高效发现并整改 问题13条立即整改13条，以"晒资料、互监督"倒逼内控要求落地见效。 制度筑基。构建"全流程规范"内控框架。今年以来，健全内控管理制度框架，细化参保登记、基金结 算、医疗救助、稽核管理、财务支付等业务流程经办规范，明确各岗位职责边界与风险点防控措施，实 现"事事有标准、步步有依据"，从源头防范经办漏洞，有效化解操作风险，切实保障医保基金安全与参 保人员合法权益。 今年以来，扶风县医保经办中心聚焦医保经办领域内控管理提质增效，以"防风险、提效能、优服务"为 核心目标，通过制度、科技、流程、队伍、监督、宣传六大维度协同发力，构建全链条、立体化内控体 系，既保障了医保基金安全，又显著提升了群众服务满意度。 科技赋能：打造"实时化预警"监管模式。搭建智能监控平台，对参保登记、医保关系转移接续、费用审 核、基金结算、智能审核、信息管理等所有医保经办业务环节等关键环节实时动态监测，通过智能预警 及时识别不合理经办行为，将风险隐患消灭在 ...

为推进以按病种付费为主的多元复合式医保支付方式改革，近日，国家医保局印发《医疗保障按病种付 费管理暂行办法》（以下简称《办法》）。根据《办法》，我国将为医保按病种付费建立病种分组方案 动态调整机制，原则上每两年调整一次。 我国传统的医保支付方式是按项目付费，药品、耗材、服务项目用多少结算多少，这种结算方式容易滋 生"大处方""大检查"等过度医疗行为。 为了规范医疗行为，自2019年起，国家医保局以按病种付费为抓手，开展支付方式改革试点。所谓按病 种付费，即通过历史数据测算，根据患者的病情分组，对同组患者确定相似的费用标准，由医保部 门"打包"支付给医疗机构。 经过六年时间，目前，病种付费实现了从试点到扩面，从地方探索到国家统一，基本实现病种付费覆盖 全部统筹地区，付费管理机制不断完善，在提升医保基金使用效率，促进医疗服务行为规范，减轻群众 就医负担等方面发挥了积极作用。 规范总额预算管理方面，要求合理编制支出预算，在此基础上确定按病种付费总额，强调总额预算的刚 性。 规范分组方案制定和调整方面，明确分组方案的制定主体、分组框架、数据和意见支撑、调整内容等， 原则上要求分组方案两年调整一次。 规范核心要素和配套 ...

Core Viewpoint - The article discusses the implementation of a new payment reform in China's healthcare system, focusing on a disease-based payment model to enhance efficiency and control costs in medical services [1][2]. Summary by Sections Payment Reform Overview - The National Healthcare Security Administration (NHSA) has introduced the "Interim Measures for the Management of Disease-Based Payment" to promote a multi-faceted payment reform primarily based on disease categories [1]. - The new measures will establish a dynamic adjustment mechanism for disease grouping schemes, with adjustments occurring approximately every two years [1][2]. Disease-Based Payment Mechanism - Disease-based payment involves grouping diseases or calculating values to implement a "bundled payment" system for medical institutions [2]. - The NHSA has been actively promoting disease-based payment for inpatient medical expenses, focusing on two pilot projects: Diagnosis-Related Groups (DRG) and Disease-Based Value Payment (DIP) [2]. - Adjustments to the DRG grouping scheme will maintain stability in major diagnostic categories while focusing on core and detailed subgroup adjustments [2]. Key Policies and Measures - The new measures clarify policies, key technologies, core elements, and supporting measures related to disease-based payment, emphasizing rigid total budget management [2]. - The NHSA will incorporate disease-based payment requirements into agreement management, enhance monitoring and evaluation of reform effectiveness, and strengthen fund supervision [2]. Special Case Mechanism - A "special case negotiation" mechanism has been established to support medical institutions in treating complex and severe patients, allowing for reasonable use of new drugs and technologies [3]. - Cases eligible for special negotiation include those with long hospital stays, high resource consumption, and complex conditions that do not fit standard payment models [3]. Impact on Medical Institutions - The shift from fee-for-service to disease-based payment encourages medical institutions to control costs while still generating revenue [5]. - Institutions can apply for special case negotiations for patients requiring extensive resources or new treatments, ensuring adequate care [5]. Impact on Patients - The reform does not alter the patient discharge settlement experience, and patients may see a reduction in out-of-pocket expenses due to fewer unnecessary medical services [6]. - The NHSA has not imposed restrictions on hospital stays, and any coercive practices by medical institutions regarding discharge will be strictly addressed [6].

Group 1: Healthcare Policy Focus - The core focus of healthcare policy in the second half of the year includes the development of medical institutions, innovation in the pharmaceutical industry, comprehensive implementation of long-term care insurance, and expansion of maternity insurance [1] - The meeting emphasized a shift in the healthcare system from "passive payment" to "active empowerment" and from "disease compensation" to "health investment" [1] - A series of new healthcare policies will be initiated or implemented, including the establishment of a commercial insurance innovative drug directory and the launch of the 3.0 version of the disease-based payment grouping scheme [1] Group 2: Drug Pricing and Innovation - The National Healthcare Security Administration announced a list of 534 drugs that passed the basic medical insurance directory review and 121 drugs that passed the commercial insurance innovative drug directory review [2] - The establishment of the commercial insurance innovative drug directory allows for the inclusion of high-innovation drugs that meet unmet needs and have confirmed clinical value, facilitating their entry into hospitals [2] - The policy aims to improve drug accessibility by not including these drugs in the basic medical insurance self-payment rate indicators and the monitoring scope of alternative drugs in centralized procurement [2] Group 3: Payment and Care Models - The meeting called for the initiation of the 3.0 version of the disease-based payment grouping scheme to enhance the quality and efficiency of medical institutions [3] - As of June, over 90% of coordinated areas in the country achieved instant settlement for medical insurance, with payment timelines reduced to within 20 working days after application [3] - The long-term care insurance, referred to as the "sixth insurance," will be fully implemented in the second half of the year, with a focus on planning and supporting long-term care service institutions [3] Group 4: Maternity Insurance Expansion - The maternity insurance system will undergo upgrades and expansions, encouraging the inclusion of flexible employment personnel, migrant workers, and new employment forms into the coverage [4] - As of now, the number of people covered by maternity insurance has reached 253 million, with maternity insurance benefit expenditures amounting to 67.832 billion yuan in the first half of the year [4] - Five provinces have achieved full coverage of hospitalization costs for childbirth within the policy scope, and 18 provinces have fully implemented direct payment of maternity allowances to insured individuals [4]

在以巴菲特旗下伯克希尔.哈撒韦(BRK.A.US)为首的多家机构在二季度持仓报告中披露买入联合健康 (UNH.US)后，美国银行发布了报告为投资者解答：是否应该跟着买入?美银指出，联合健康具有显著的 盈利能力，但存在重大不确定性，因此需要获取更多的清晰信息;目前维持"中性"评级，但上调目标价 至325美元。 伯克希尔.哈撒韦公司投资于联合健康是一个积极的信号，但这实际上只是再次证实了众多投资者普遍 持有的观点，即联合健康(以及大多数医疗保健公司的)盈利状况不佳，如果能以五年为视角来看待，那 么你很可能会获得良好收益。但很少有投资者有这种投资视野，而那些有这种视野的投资者，仍然希望 在这一期间每年都能获得正收益。所以问题不再是"是否有上涨空间?"，而是"何时才能实现?"。 美银总体上看好联合健康，并认为其在2027年有可能实现上涨，这可能会导致市盈率的上涨，但要实现 这一目标，需要回答三个问题，任何一个问题回答错误就意味着联合健康将表现不佳，这也使得美银将 维持"中性"评级，直至获得更清晰的信息，但将目标价从290美元提高到325美元，基于更优的同行市盈 率(17.1倍，之前为15.3倍)。 基于此，美银列出以 ...

Group 1: Medical Insurance Development - The National Medical Security Administration emphasizes empowering the pharmaceutical industry and implementing measures to support high-quality development of innovative drugs [1][2] - By mid-2025, significant progress is expected in medical security, including an increase in the number of people covered by maternity insurance to 253 million and maternity insurance benefit expenditures reaching 67.832 billion yuan in the first half of the year [1] - The meeting highlights the need for a comprehensive adjustment of the national medical insurance drug catalog and the establishment of a commercial health insurance innovative drug catalog [2] Group 2: Maternity Insurance and Long-term Care - The meeting encourages regions to include flexible employment workers, migrant workers, and new employment forms in maternity insurance coverage, while also exploring basic service packages for prenatal check-ups [3] - Long-term care insurance will be fully implemented, with a focus on planning and configuring designated long-term care service institutions and encouraging commercial insurance products that align with long-term care services [3] Group 3: Digital Transformation in Medical Insurance - The meeting calls for a shift in medical insurance from passive payment to active empowerment, focusing on health investment rather than disease compensation [3] - There is an emphasis on integrating medical insurance with technology to promote new medical services, AI health management, and smart elderly care [3]

Group 1: Medical Insurance Development - The National Medical Insurance Bureau emphasizes the need to empower the pharmaceutical industry and implement measures to support high-quality development of innovative drugs [1][2] - By mid-2025, significant progress is expected in medical insurance, including an increase in the number of insured individuals under maternity insurance to 253 million, with expenditures reaching 67.832 billion yuan in the first half of the year [1] - The meeting highlighted the importance of direct settlement of medical expenses for drug procurement enterprises, with an average settlement cycle reduced to within 30 days [1][2] Group 2: Maternity Insurance and Long-term Care - The meeting encourages regions to include flexible employment workers, migrant workers, and new employment forms in maternity insurance coverage, while also exploring basic service packages for prenatal check-ups [3] - Long-term care insurance will be comprehensively implemented, with a focus on planning and supporting community-based care services [3] Group 3: Healthcare System Reform - The meeting calls for the reform of medical service pricing and the expansion of immediate settlement of medical insurance funds to healthcare institutions [2] - There is a push for the integration of technology in medical insurance, transitioning from passive payment to proactive empowerment and health investment [3]

Group 1: Medical Insurance Development - The National Medical Insurance Administration emphasizes empowering the pharmaceutical industry and implementing measures to support high-quality development of innovative drugs [1][2] - By mid-2025, significant progress is expected in medical insurance, including an increase in the number of insured individuals under maternity insurance to 253 million and total maternity insurance benefits expenditure reaching 67.832 billion [1] - The meeting highlights the need for a comprehensive adjustment of the national medical insurance drug catalog and the establishment of a commercial health insurance innovative drug catalog [2] Group 2: Maternity Insurance and Long-term Care - The meeting encourages regions to include flexible employment workers, migrant workers, and new employment forms in maternity insurance coverage, while also exploring basic service packages for prenatal check-ups [3] - There is a push for the implementation of long-term care insurance, with a focus on planning and supporting long-term care services at the community level [3] - The meeting calls for the integration of long-term care services with commercial insurance products to enhance accessibility and suitability of care [3] Group 3: Digital Transformation in Medical Insurance - The meeting aims to transition the medical insurance system from passive payment to proactive empowerment, focusing on health investment rather than just disease compensation [3] - There is an emphasis on promoting research in disease prediction modeling, pharmacoeconomics, and disease attribution analysis in collaboration with medical institutions and research organizations [3] - The integration of technology in medical insurance is encouraged to foster new medical services, AI health management, and smart elderly care [3]

Core Insights - The National Medical Insurance Administration held a mid-year meeting on August 15 to summarize the work of medical insurance in the first half of 2025 and to outline key tasks moving forward [1] Group 1: Key Objectives - Empower the development of medical institutions [1] - Foster innovation in the pharmaceutical industry [1] - Ensure the health of the population [1] - Consolidate and expand the basic medical insurance coverage [1] - Improve the maternity insurance system [1] - Fully implement long-term care insurance [1] - Promote standardization in medical insurance [1] - Advance the digitalization of medical insurance [1] - Enhance the scientific approach to medical insurance [1]

Group 1 - The core viewpoint of the articles highlights significant investment activities by major institutional investors in Q2 2025, particularly focusing on sectors like healthcare, steel, real estate, and technology [1][2][6] - Berkshire Hathaway revealed its "mysterious holdings" by purchasing six new stocks, including UnitedHealth, Nucor Steel, and Lennar, with a total market value exceeding $3.6 billion at the end of the quarter [2][3] - Li Lu's Himalaya Capital re-entered Pinduoduo as its second-largest holding, indicating a stronger confidence in Chinese e-commerce, while also reducing its stake in Bank of America [4][5] Group 2 - Several prominent hedge funds, including Appaloosa and Scion, also invested in UnitedHealth, which has seen a significant stock price decline of over 45% since April 1, 2025 [3] - Major institutions like Hillhouse, Bridgewater, and JPMorgan increased their positions in technology stocks, capitalizing on the market downturn, with notable investments in Nvidia, Meta, and Google [6][7] - Vanguard, as one of the largest asset management firms, reported a total U.S. stock holding value of $6.18 trillion, with its top five holdings being Nvidia, Microsoft, Apple, Amazon, and Meta, reflecting a strong bullish sentiment towards the tech sector [7]