据了解，病种目录是医保基金清算实现"精准化、科学化"的关键基础。内蒙古在全面总结前期版本运行 经验、广泛征求各级医疗机构意见建议的基础上，经多轮专家论证与修订，形成的新版病种目录在分组 逻辑、编码规则、支付匹配等方面实现系统性优化，分组机制更清晰、支付导向更合理。 本报1月25日讯 （记者 梅刚）记者从自治区医疗保障局获悉，为深入推进按病种分值付费（DIP）改 革，夯实全区医保基金清算"三年提质增效"基础，连日来，自治区医疗保障局联合自治区卫健委组成宣 讲团，深入鄂尔多斯、兴安盟、呼和浩特、包头、巴彦淖尔、赤峰开展按病种分值付费宣讲培训。 （来源：内蒙古日报） 转自：内蒙古日报 宣讲团以"政策解读+实操指导+互动答疑"模式，重点阐释了目录成组规则、病种分类优化与分值赋值 机制，结合实际案例对病案首页填报规范、结算清单质量控制、清算流程衔接等关键环节进行专项辅 导，并对2025年度清算工作的整体安排、阶段任务与时间节点作了详细解读。同时，培训现场答疑环节 对医疗机构关注的病种入组、中医病种适用、特殊病例结算等问题进行了解答。 据悉，自治区医保与卫健部门将密切跟踪政策落地效果与基金清算进展，持续推动医保支付方式改 ...

聚焦于优化医保支付方式，将通过健全按病组付费（DRG）和病种分值付费（DIP）分组动态调整机 制，推动其3.0版方案高水平落地。同时，完善符合中藏医等民族医药服务特点的支付政策，支持其创 新发展，并引导医疗机构特别是基层医疗机构加强内部管理。此外，将严格执行医保目录与支付标准， 全面实施2026版国家医保药品目录，并持续监测谈判药品落地情况。医保基金运行数据将按"月告知、 季公布、年通报"原则定期公开，以稳定各方预期，促进规范运行。 药耗集中带量采购改革将持续深化与扩围。 在严格执行国家和省际联盟集采结果的基础上，将稳妥实 施中药饮片全国联采，并牵头推进民族药品联合采购，进一步扩大品种覆盖面。为确保群众切实受益， 将加强中选产品供应监测，引导医疗机构优先使用质优价宜的中选产品，并在结算上予以支持。同时， 巩固集采药品进药店、进村卫生室、进民营医院的"三进"活动成效，方便群众就近享受降价药品。 在医药价格管理方面， 将落实医疗服务价格动态调整机制，加快审核新增项目，更好体现医务人员技 术劳务价值。为促进优质医疗资源下沉，将对区域医疗中心在项目价格、医保准入等方面建立"绿色通 道"。此外，依托"医保药品云平台"， ...

Core Insights - The National Healthcare Security Administration has issued a notice to initiate pilot programs for real-world comprehensive value assessment of medical insurance in select regions including Haidian District of Beijing, Dalian City of Liaoning Province, and Shenzhen City of Guangdong Province [1] Group 1: Pilot Program Details - The pilot regions will focus on research directions such as comprehensive value assessment of drugs based on real-world data, unmet clinical needs research, and how healthcare data can support real-world studies [1] - The research outcomes will support healthcare decision-making and encourage pilot regions to prioritize the application of these findings for new or adjusted medical consumables charging directories and new medical service project approvals [1] Group 2: Future Goals - By the end of 2027, the pilot regions aim to establish a value-oriented, real-world research-based comprehensive value assessment system for medical insurance, which will be promoted nationwide [1]

Core Viewpoint - UnitedHealth Group has experienced a significant stock decline of over 50% since April 2024, primarily due to rising medical costs, leadership changes, and potential legal issues related to Medicare fraud [1][2][5]. Group 1: Financial Performance - The company initially forecasted adjusted earnings of $30 per share for 2025, but later revised its full-year earnings outlook down to a range of $24.65 to $25.15 per share [2][3]. - The Medical Benefits Ratio increased from 82% in 2022 to 85.5% in 2024, leading to a decrease in net profit margins from 6.2% to 3.6% during the same period [3]. Group 2: Leadership Changes - CEO Andrew Witty's unexpected departure unsettled investors, prompting the return of former CEO Stephen Hemsley, which was perceived as a sign of panic rather than a smooth transition [4]. Group 3: Legal and Regulatory Issues - Reports of a criminal investigation into Medicare fraud have emerged, which could significantly impact the company's revenue, as Medicare accounted for a quarter of total revenues last year [5].

Core Insights - The reform of medical insurance payment methods in China has achieved initial success, with a focus on sustainable funds, improved medical quality, and benefits for the public [2][3] - The current payment methods include Diagnosis-Related Group (DRG) and Diagnosis-Intervention Package (DIP), with 191 and 200 regions implementing these respectively, achieving 95% disease coverage and 80% fund coverage [2][3] Group 1: Reform Achievements - As of now, 24 provinces have implemented real-time settlement of medical insurance funds, covering 246,700 designated medical institutions and disbursing 165.7 billion yuan, alleviating hospital operational pressure [3][6] - The prepayment system for medical insurance funds has been effectively implemented, with a total prepayment scale of 72.3 billion yuan in the first quarter of 2025, helping public hospitals reduce financial burdens [3][6] Group 2: Challenges and Future Directions - The reform faces challenges such as the contradiction between rising medical costs and payment management, the need for quality improvement, and insufficient collaboration among stakeholders [2][3] - Future efforts will focus on building a diversified payment system and continuing to deepen the medical insurance payment reform [3][8] Group 3: Practical Insights from Experts - Experts suggest that hospitals should establish a refined operational management system centered on disease categories, integrating payment methods into daily operations to enhance management efficiency [5][6] - The Shanghai model emphasizes a flexible fee rate system and the establishment of a monitoring platform to support comprehensive management and ensure mutual benefits for medical institutions, insured patients, and the medical insurance fund [7][8]