Core Insights - The article discusses the ongoing reform of the "Diagnosis-Related Group (DRG)" payment system in China's healthcare, which aims to improve the efficiency of medical insurance fund usage and enhance patient experience [1][4][13] Payment Reform Overview - The traditional payment method was based on "fee-for-service," which incentivized excessive medical practices. The DRG system groups similar cases and sets a unified payment standard based on historical data, promoting rational use of medical insurance funds [1][2] - The DRG payment reform has been implemented since 2019 and is set to evolve with the release of version 3.0 in 2026, aiming for better fund utilization, hospital sustainability, and improved patient satisfaction [1][13] Challenges and Solutions - Issues have arisen during the implementation, such as hospitals limiting patient stays to under 15 days and pushing patients out prematurely to control costs. This has led to concerns about the quality of care for complex cases [2][3] - Experts suggest that hospitals should collaborate with medical insurance departments to avoid cost-cutting measures that compromise patient care. A mechanism for special cases has been established in some regions to address these challenges [3][5] Case Study: Anyang City - Anyang City has implemented a unique approach where cases exceeding 60 days or requiring special treatment are settled separately, allowing hospitals to manage costs without compromising care [4][6] - In 2024, Anyang reported over 13,000 special cases with a total expenditure of 266 million yuan, demonstrating the effectiveness of this model in preventing premature discharges [6][7] Financial Outcomes - The reform has led to a surplus in the medical insurance fund, with Anyang's fund showing a balance after years of deficits. The total expenditure for hospitals has increased, and the average hospitalization cost has decreased significantly [7][9] - The average hospitalization cost in Anyang dropped from over 11,100 yuan in 2020 to 9,780 yuan in 2024, a reduction of 11.99% [9][10] Day Surgery Implementation - The introduction of "day surgery" has accelerated bed turnover and reduced costs, with nearly 60% of tertiary hospitals adopting this practice. Patients can now complete procedures within 24 hours, leading to lower expenses and resource optimization [10][12] - The average hospitalization duration has decreased, and personal out-of-pocket expenses have also declined, indicating a positive trend in patient care and cost management [12][13] Future Directions - The upcoming version 3.0 of the DRG payment system will focus on more refined classifications and regular updates to payment standards, ensuring that the system adapts to changes in medical practices and technologies [13][14] - Enhancing the service capacity of primary healthcare institutions and facilitating cross-province reimbursement for patients are essential steps for future improvements in the healthcare system [14]

Core Insights - The National Healthcare Security Administration (NHSA) has been implementing the "Diagnosis-Related Group (DRG)" payment reform since 2019, which has now covered all medical insurance coordination areas in China [1] - The DRG payment model aims to standardize the use of medical insurance funds by grouping similar inpatient cases and establishing a unified payment standard based on historical data, transitioning from a fee-for-service model to a value-based payment model [1][22] - The upcoming release of the DRG 3.0 version in 2026 is expected to further refine payment groupings and enhance the efficiency of medical insurance fund usage, hospital sustainability, and patient satisfaction [1][22] Payment Reform and Its Implications - The traditional fee-for-service model incentivized excessive medical practices, leading to issues like "over-prescription" and "over-testing" [1] - The DRG model shifts the focus from paying for services rendered to paying for patient outcomes, encouraging hospitals to control costs and reduce unnecessary procedures [1] - Some hospitals have imposed arbitrary limits on hospital stays, such as "no more than 15 days," which can negatively impact patient care [1][3] Collaboration Between Insurance and Healthcare Providers - Effective collaboration between medical insurance and healthcare institutions is crucial for the success of the DRG model, ensuring that funds are used efficiently while hospitals receive appropriate compensation [1][22] - In Anyang, a city implementing DRG, a "special cases, negotiated settlement" mechanism allows for separate billing for complex cases, ensuring that hospitals are not financially penalized for treating severe patients [8][10] Financial Outcomes and Efficiency - The Anyang region has seen a turnaround in its medical insurance fund, achieving a surplus after implementing the DRG model, with total fund expenditures reaching 2.66 billion yuan for special cases in 2024 [8][11] - The average hospitalization cost in Anyang decreased from over 11,100 yuan in 2020 to 9,780 yuan in 2024, a reduction of 11.99% [15] - The overall efficiency of the medical insurance fund has improved, maintaining a balance between income and expenditure, with a surplus of 5.78 billion yuan in 2024 [15] Day Surgery and Cost Reduction - The introduction of "day surgery" has allowed patients to complete procedures within 24 hours, significantly reducing hospitalization time and costs [19][21] - Nearly 60% of tertiary public hospitals in China have adopted day surgery, contributing to faster patient turnover and lower medical expenses [19] Future Directions for DRG Reform - The DRG 3.0 version is expected to introduce more detailed classifications for payment groups, addressing variations in disease severity and treatment methods [22] - Future efforts should focus on enhancing the service capabilities of primary care hospitals and facilitating patient referrals from community settings to hospitals for better resource allocation [22]