医保支付方式改革有关情况介绍

【编者按】党的二十大以来，党中央、国务院多次对深化医药卫生体制改革，促进医疗、医保、医药协同发展和治理作出决策部署。党的二十届三中、四中全会对深化医保支付方式改革提出明确要求，2026年《政府工作报告》提出要深化医保支付方式改革，完善结余资金使用政策。国家医保局坚决贯彻落实党中央、国务院决策部署，持续深化医保支付方式改革，蹄疾步稳推进按病种付费改革落地实施，赋能医疗机构高质量发展，不断增强人民群众医保获得感、幸福感和安全感。

[Editor’s Note] Since the 20th National Congress of the Communist Party of China, the Party Central Committee and the State Council have on many occasions issued decisions and plans for deepening reform of the medical and health-care system and promoting coordinated development and governance across medical services, medical insurance, and pharmaceuticals. The Third and Fourth Plenary Sessions of the 20th Central Committee set out clear requirements for deepening reform of medical insurance payment methods, and the 2026 Government Work Report called for deeper reform of such payment methods and for improving policies on the use of surplus funds. The National Healthcare Security Administration has resolutely implemented the decisions and plans of the Party Central Committee and the State Council, continued to deepen reform of medical insurance payment methods, advanced the implementation of disease-based payment reform at a brisk yet steady pace, empowered the high-quality development of medical institutions, and continually strengthened the people’s sense of gain, happiness, and security in medical insurance.

推进按病种付费为主的多元支付方式改革，是医保发挥战略性购买作用、赋能医疗创新的核心抓手。支付方式改革坚持尊重临床、包容创新、分类引导、动态适配，既守住基金可持续底线，又从资金保障、资源激励、方向引导、数据支持四方面，全方位支撑临床技术、诊疗模式、学科建设、医药协同创新发展，推动医疗服务从规模扩张转向质量效益驱动。

Advancing reform toward a diversified system of payment methods with disease-based payment as the mainstay is the core lever by which medical insurance can play its strategic purchasing role and empower medical innovation. Reform of payment methods adheres to the principles of respecting clinical practice, accommodating innovation, providing categorized guidance, and adapting dynamically. It both holds the bottom line of fund sustainability and, from four dimensions - funding guarantees, resource incentives, directional guidance, and data support - gives comprehensive support to the innovative development of clinical technologies, diagnosis-and-treatment models, discipline building, and medical-pharmaceutical coordination, driving medical services away from scale expansion and toward quality- and efficiency-led growth.

DRG/DIP uses big data as its foundation and resource consumption as its yardstick; its grouping design is dynamically adjusted and, together with supporting mechanisms such as case-by-case discussion for special exceptions, builds the institutional basis for accommodating new technologies, new therapies, new drugs and devices, and composite diagnosis and treatment. Cases such as organ transplantation, neonatal diseases, and multiple severe trauma are directly and prospectively placed into separate groups under DRG rather than entering conventional groups, so that cases with high degrees of innovation and heavy resource consumption are identified first. At the level of refined subgroups, stratification by MCC (major comorbidities or complications) and CC (comorbidities or complications) assigns complex cases to groups with higher weights, covering the incremental costs of innovative treatment. DIP separately generates core disease categories for newly added innovative procedures such as minimally invasive, targeted, and interventional operations, taking account of both grouping stability and innovation.

DRG/DIP是以大数据为基础、资源消耗为标尺，动态调整的分组设计，与特例单议等配套机制共同构建起包容新技术、新疗法、新药械、复合诊疗的制度基础。如器官移植、新生儿疾病、多发严重创伤等，在DRG中直接先期单独分组，不进入常规组，优先识别创新程度高、资源消耗大的病例。在细分组层面，通过 MCC（严重合并症或并发症）、CC（合并症或并发症）分层，复杂病例匹配更高病组权重，覆盖创新治疗增量成本。DIP对新增微创、靶向、介入等创新操作单独生成核心病种，兼顾分组稳定性与创新性。

Medical technology is advancing with each passing day. To ensure that grouping schemes better reflect clinical realities, the National Healthcare Security Administration issued the Interim Measures for the Management of Disease-Based Payment under Medical Security (Yibaofa [2025] No. 18), which clearly states that grouping schemes should, in principle, be adjusted once every two years. Beginning in August 2025, the Administration organized the adjustment of the version 3.0 grouping scheme for disease-based payment; a preliminary adjustment plan has now been formed and is being circulated for comment. Surgical robots, for example, as an innovative technology, have already been applied clinically across multiple disciplines because they cause less trauma to patients, involve milder pain, and allow faster recovery. In the DRG 3.0 grouping scheme, DRG groups are subdivided according to whether robot-assisted surgery is used, forming nine groups involving robot-assisted surgery; in the preliminary DIP 3.0 grouping scheme, corresponding groups have been established for disease categories including knee-joint disease, fractures of the lumbar spine and pelvis, and femoral neck fractures.

医疗技术进步日新月异，为使分组方案更加体现临床实际，国家医保局出台《医疗保障按病种付费管理暂行办法》（医保发〔2025〕18 号），明确提出分组方案原则上2年调整一次。2025年8月份开始，国家医保局组织按病种付费3.0版分组方案调整，目前已形成初步调整方案，正在征求意见。如手术机器人作为创新技术，由于对患者创伤小、疼痛轻、恢复快的特点，已有多学科应用于临床，在DRG3.0分组方案中，根据是否使用机器人辅助手术细分DRG组，共形成9个伴机器人辅助手术组；在DIP3.0版初步分组方案中，在膝关节病、腰椎和骨盆骨折以及股骨颈骨折等病种中设立相应分组。

No grouping scheme can cover every case. In clinical practice, a small number of cases involve complex conditions, multidisciplinary joint diagnosis and treatment, or the use of new drugs and new technologies. For this reason, the National Healthcare Security Administration has introduced a supporting policy of case-by-case discussion for special exceptions. Under the policy, the number of such cases must account for no more than 5 percent of total DRG discharge cases and no more than 0.5 percent of total DIP discharge cases. At present, half of the country’s pooled-fund regions use DRG payment and half use DIP payment, while the two municipalities of Tianjin and Shanghai use both DRG and DIP payment. Judging from nationwide applications for special exceptions in 2025, the average application ratio in DRG payment regions was 2 percent, while in DIP payment regions it was 0.4 percent. Nationwide, 2.674 million cases applied for special-exception discussion, 2.324 million were approved after review, and the approval rate was 86.9 percent; medical insurance fund expenditure was about 64.473 billion yuan, and the average medical insurance fund expenditure per approved special-exception case was 27,700 yuan. The full implementation of special-exception discussion has effectively dispelled medical institutions’ concerns about admitting critical and severe cases and using innovative drugs and consumables, making people feel more secure and better protected when seeking medical care.

分组方案不能覆盖所有病例，临床上会遇到病情复杂、多学科联合诊疗以及使用新药新技术等少数病例，为此，国家医保局配套出台特例单议政策。按政策要求，特例单议病例数占DRG出院总病例的5%以内，占DIP出院总病例的5‰以内。目前，全国一半统筹地区采用DRG付费，一半统筹地区采用DIP付费，天津、上海两个直辖市兼有DRG和DIP付费。从2025年全国面上特例单议申报情况看，DRG付费地区申报比例平均为2%，DIP付费地区申报比例平均为4‰。全国特例单议申请病例267.4万例，审核通过232.4万例，通过率为86.9%；医保基金支出约644.73亿元，通过特例单议审核的病例次均医保基金支出2.77万元。特例单议全面实施，有效打消医疗机构收治危急重症病例、使用创新药耗的顾虑，让群众看病就医更踏实、更有保障。

Disease-based payment reform guides hospitals to take the initiative in optimizing clinical pathways, improving service efficiency, and generating surpluses under disease-based payment. Surplus funds are retained by medical institutions and may be used as development funds and performance rewards, further encouraging institutions to reduce costs, increase efficiency, and innovate proactively, thereby forming a virtuous cycle of “technological innovation - higher CMI value (case mix index; the higher the index, the greater the technical difficulty of the cases treated by a hospital) - retained surplus - continued investment in innovation.” Since Lianyungang began reforming disease-based payment, for example, the CMI value of its tertiary hospitals has risen by about 24 percentage points, and the capacity and proportion of medical institutions treating difficult, severe, and complex cases have steadily increased. Xinjiang has promoted a shift among medical institutions from “scale expansion” to “quality and efficiency”: institutions have taken the initiative to strengthen cost control, optimize diagnosis-and-treatment processes, and raise their level of medical technology, making the allocation of medical resources more rational. In 2025, the CMI index of tertiary medical institutions across the region rose from 1.21 to 1.58; they became more oriented toward the diagnosis and treatment of acute, difficult, and severe diseases. In some tertiary medical institutions, surgical operations are now concentrated mainly in grade-three and grade-four procedures, while common and basic diseases are being diverted to secondary and primary medical institutions, powerfully promoting tiered diagnosis and treatment.

按病种付费改革引导医院主动优化临床路径，提升服务效率，形成按病种付费结余。结余资金由医疗机构留用，可作为医疗机构发展资金和绩效奖励，进一步鼓励医疗机构降本增效，主动创新，形成 “技术创新—CMI值（病例组合指数，指数值越高表明医院治疗病例的技术难度越高）升高—结余留用—持续投入创新”的良性循环。如连云港市病种付费改革以来三级医院CMI值上升约24个百分点，医疗机构收治疑难重症病例的能力和比例稳步提升。新疆推动医疗机构从“规模扩张型”向“质量效益型”转变，医疗机构主动加强成本管控、优化诊疗流程、提升医疗技术水平，医疗资源配置更加合理，2025年全区三级医疗机构CMI指数由1.21提升到1.58，更倾向于急难重症疾病的诊疗，部分三级医疗机构外科手术主要集中于三、四级手术，常见病、基础病向二级、一级医疗机构分流，有力促进了分级诊疗。

China’s medical insurance, guarding you for life! Safeguarding the security of the medical insurance fund is everyone’s responsibility. Reporting hotline for combating insurance fraud: 010-89061396, 010-89061397; email: jubao@nhsa.gov.cn.

中国医保，一生守护！维护医保基金安全，人人有责！打击欺诈骗保举报电话：010-89061396，010-89061397；邮箱：jubao@nhsa.gov.cn。