According to new regulations recently issued by China's National Healthcare Security Administration, the country will establish a dynamic adjustment mechanism for disease grouping schemes under medical insurance payment by disease type, with adjustments made in principle every two years.

Medical insurance payment by disease type refers to implementing "bundled payments" from medical insurance to medical institutions through disease diagnosis and treatment grouping or conversion values. With the rapid development of medical technology, disease-based payment systems also need dynamic adjustments to adapt to clinical changes. Therefore, the recently issued "Interim Measures for Medical Security Payment by Disease Type Management" proposes regular adjustments based on factors such as objective data, opinions and suggestions, clinical characteristic patterns, and policy adjustment changes.

"The two-year adjustment cycle balances maintaining stability of grouping schemes for a certain period while improving the matching relationship between grouping updates and clinical technology development," said a relevant official from the National Healthcare Security Administration.

Payment by disease type includes two forms: Diagnosis Related Groups (DRG) payment and Disease Index Points (DIP) payment. DRG grouping scheme adjustments focus on adjusting core groupings and sub-groupings while maintaining relative stability of major diagnostic categories; DIP disease database adjustments primarily include core diseases and comprehensive diseases.

Notably, the new regulations dedicate an independent chapter to the "special case discussion" mechanism, clarifying that cases applying for special case discussion include but are not limited to those with long hospitalization periods, high resource consumption, reasonable use of new drugs and technologies, complex critical conditions, or multidisciplinary joint diagnosis and treatment that are unsuitable for disease payment standards. Additionally, medical insurance departments are required to streamline special case discussion reception channels, improve working systems, optimize workflows, simplify reporting materials, and enhance review efficiency.

"This demonstrates the firm determination of medical insurance to support medical institutions in reasonably using new drugs and technologies and treating difficult and critical patients," said the relevant official from the National Healthcare Security Administration.

Furthermore, to fully leverage the incentive role of disease surplus retention funds, the new regulations clarify that surplus funds obtained by medical institutions through standardizing service behaviors and actively controlling costs can be treated as business income.

It is reported that in 2019, the National Healthcare Security Administration launched pilot reforms for payment by disease type, which now basically cover all coordinated regions.