Basically achieved payment by disease type for over 95% of short-term hospitalization cases. With Grouping Scheme 3.0 coming, what will be the next reform focus?

Major Daily Reporter | Zhang Hong Major Daily Editor | Liao Dan

More than 95% of short-term hospitalization cases are now paid by diagnosis-related groups! Version 3.0 of the grouping scheme is coming soon. What is the next focus of reform?

On March 16, the National Healthcare Security Administration released the 2025 Statistical Bulletin on the Development of Medical Security.

The bulletin shows that by the end of 2025, the version 2.0 diagnosis-related groups payment scheme has been implemented in all pooled regions. Nationwide, over 95% of short-term hospitalization cases are paid by diagnosis, and over 80% of inpatient pooled funds are covered by diagnosis-based payments.

Since 2019, the National Healthcare Security Administration has been promoting the reform of “diagnosis-related groups” payment methods. In December last year, the National Medical Security Work Conference was held in Beijing, where it was clarified that the version 3.0 diagnosis-related groups payment scheme will be released in 2026.

Senior healthcare security expert Tian Haoling told the Daily Economic News in a written interview on March 16 that after achieving near-complete coverage with diagnosis-related groups, the reform has moved from “building the framework” into the “deep water zone” of “full-scale construction.”

Tian Haoling: Further narrowing regional payment standard differences is necessary

After nearly full coverage of diagnosis-related groups, what is the next focus of reform?

Tian Haoling told the Daily Economic News: “I believe the next stage will focus entirely on ‘improving quality and efficiency,’ with emphasis on four dimensions.”

First, deepen coordination and break regional barriers. Building on the implementation of version 2.0, the next step is to promote regional coordination and refinement of payment policies. Especially for cross-region medical treatment, further narrowing the differences in payment standards across regions to achieve “same-city” treatment, facilitating personnel mobility and tiered diagnosis and treatment. The more detailed version 3.0 grouping scheme is also under scientific calculation and validation.

Second, extend scenarios and address outpatient shortcomings. Currently, the reform mainly covers short-term hospitalization. Future efforts will accelerate extension to outpatient and long-term care, exploring combining per capita payments with chronic disease management, and linking long-term care insurance with service quality to build a comprehensive disease course and cycle protection system.

Third, empower with digital intelligence and upgrade supervision models. Using big data and AI technology, shift from experience-based estimates relying on historical data to real-time, forward-looking intelligent monitoring. Establish dynamic adjustment mechanisms to quickly respond to new drugs and technologies, ensuring payment standards keep pace with clinical developments.

Fourth, guide value and achieve win-win outcomes for healthcare, insurance, and pharmaceuticals. The reform will shift from merely controlling costs to guiding “value-based healthcare.” By improving mechanisms like special case negotiations and exclusion payments, motivate medical institutions to proactively improve quality and control costs, creating a win-win situation for insurance, healthcare providers, and patients.

In 2024, recovered 2.74 billion yuan of medical insurance funds through reporting channels

In terms of insured population, by the end of 2025, the basic medical insurance coverage reached 1,330,681,400 people, an increase of 4.06 million from the previous year, with an insured rate of 95%. Employee medical insurance covered 385.607 million people, and resident medical insurance covered 942.1208 million people.

In terms of revenue and expenditure, in 2025, the total income and total expenditure of the basic medical insurance fund (including maternity insurance) were 3,587.311 billion yuan and 3,000.938 billion yuan, respectively, an increase of 106.316 billion yuan and 3.3346 billion yuan over the previous year.

The income of the employee basic medical insurance fund (including maternity insurance) was 2,464.671 billion yuan, with pooled fund income of 1,831.766 billion yuan; fund expenditure was 1,935.231 billion yuan, with pooled fund expenditure of 1,357.417 billion yuan.

The urban and rural residents’ basic medical insurance fund income was 1,122.640 billion yuan, with expenditures of 1,065.707 billion yuan.

Regarding fund supervision, in 2025, the national medical insurance system recovered a total of 34.2 billion yuan in medical insurance funds, including 27.8 billion yuan recovered through review and verification, and 1,626 fraud organizations identified. Judicial authorities transferred 1,678 cases, disciplinary inspection and supervision agencies transferred 19,000 cases, and health administrative departments transferred 59,000 cases. Police investigated 3,776 medical insurance cases, arresting 10,357 suspects. Using intelligent supervision subsystems, 3 billion yuan in losses were recovered.

In 2025, a total of 1.558 million yuan in reward funds were issued for reporting, and 2.74 billion yuan of medical insurance funds were recovered through reporting channels.