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?

China’s National Healthcare Security Administration released a statistical bulletin on the development of medical insurance for 2025 on March 16.

The bulletin shows that by the end of 2025, the version 2.0 grouping plan for diagnosis-related group (DRG) payments has been implemented in all regions across the country. 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 reform of the “diagnosis-related group” payment method. In December last year, the National Medical Security Work Conference was held in Beijing, where it was announced that the version 3.0 grouping plan for DRG payments will be released in 2026.

Senior healthcare expert Tian Haoling told the Daily Economic News in an interview on March 16 that once diagnosis-based payments are nearly fully implemented, the reform has moved from “building the framework” to “full-scale construction” in deeper waters.

Tian Haoling: Further narrowing regional payment standard differences is necessary

What is the next focus after achieving near full coverage of diagnosis-related group payments?

Tian Haoling told the Daily Economic News: “I believe the next phase 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 grouping plan, 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 plan is also under scientific calculation and validation.

Second, extend scenarios and address outpatient shortcomings. Currently, reforms mainly cover 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, full-cycle healthcare保障体系.

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完善特例单议、除外支付等机制，激励医疗机构主动提升质量、控制成本，实现医保、医疗、患者三方共赢。

Last year, 2.74 billion yuan of医保基金was recovered through举报渠道

In terms of insured population, by the end of 2025, the basic medical insurance coverage reached 1.3306814 billion people, an increase of 4.06 million from the previous year, with a coverage rate of 95%. Employee medical insurance covered 385.607 million people, and resident medical insurance covered 942.1208 million people.

Regarding revenue and expenditure, in 2025, the total income and expenditure of the basic medical insurance fund (including maternity insurance) were 3,587.311 billion yuan and 3,000.938 billion yuan, respectively, representing increases 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; expenditures totaled 1,935.231 billion yuan, with pooled fund expenditures 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 of医保基金, including 27.8 billion yuan through review and verification, with 1,626 fraud organizations identified, 1,678 cases transferred to judicial authorities, 19,000 cases transferred to disciplinary and supervisory agencies, and 59,000 cases transferred to health and other administrative departments. Joint efforts with public security authorities led to 3,776 cases of medical insurance fraud being investigated, and 10,357 suspects arrested. Smart supervision subsystems recovered 3 billion yuan in losses.

In 2025, a total of 1.558 million yuan in举报奖励金was issued, and 2.74 billion yuan of医保基金was recovered through举报渠道.