ISSN 2097-4205 CN 31-2200/R
Objective The study aims to review national and Shanghai municipal policies related to the international medical services and to conduct case studies, thereby providing a reference for optimizing international medical service policies in Shanghai. Methods Relevant policies issued from 2017 to 2025 were systematically reviewed. Using policy instrument theory as the theoretical framework, quantitative analysis of policy texts was applied to conduct a systematic study on international medical policies. Case studies were conducted at representative international medical institutions, supplemented by key informant interviews. Thematic analysis was used to analyze the qualitative findings. Results A total of 55 policies were included, yielding 830 content analysis units. Of these, environmental-oriented, supply-oriented, and demand-oriented policy instruments accounted for 66.5%, 30.6%, and 2.9%, respectively. Environmental-oriented policy instruments dominated, accounting for approximately two-thirds of all instruments, while demand-oriented policy instruments were underutilized. The case studies reveal that international medical services in Shanghai face institutional challenges including a shortage of a shortage of skilled professionals, restricted access to drugs and medical devices, distorted pricing mechanisms, obstacles in commercial insurance cooperation, and insufficient promotion efforts. Conclusions Both supply- oriented and demand-oriented policy instruments remain relatively underutilized in the development of international medical services in Shanghai. The study recommends that policies provide more effective support for medical insurance cooperation, human resource development, and investments in drugs and medical devices. It is also crucial to develop a distinctive brand identity for Shanghai’s international medical services, strengthen promotion, and develop infrastructure standards aligned with international practices.
Objective This study aims to analyze the formulation characteristics of fertility support policies in Shanghai and to provide references for optimizing Shanghai’s fertility support policy system, further improving residents’ fertility intentions. Method Based on the perspective of policy instruments, a three-dimensional analytical framework encompassing policy instruments, policy categories, and policy intervention stages was constructed to systematically evaluate fertility support policy documents issued in Shanghai from 2014 to 2025. Results A total of 89 policy documents were collected, yielding 429 coded analysis units. Among them, supply-oriented policy instruments accounted for the largest share (173, 40.33%), followed by environment-oriented policy instruments (170, 39.63%), while demand-oriented policy instruments accounted for the smallest share (86, 20.04%). In terms of policy intervention stages, the largest proportion of policy measures targeted the fertility stage (220, 51.28%), whereas the marriage stage received the fewest (13, 3.03%), indicating a pattern of greater emphasis on the fertility than on marriage. Conclusions Fertility support policies in Shanghai exhibited an imbalanced distribution of policy instruments and uneven coverage across intervention stages. Further efforts are needed to optimize the mix of policy instruments, improve coordination across policy intervention stages, refine policy categories, and strengthen policy communication, so as to foster a more supportive fertility environment and promote fertility intentions.
Implementing the Health-first Strategy and refining public health promotion policies constitute the core tasks in comprehensively advancing the Healthy China Initiative. By reviewing and analyzing the evolutionary trajectories and key characteristics of national health promotion policies in the United States and Japan, this study aims to provide valuable insights and references for establishing and improving a sound policy and institutional framework for health promotion in China. The evolution of national health promotion policies in both the U.S. and Japan exhibits significant commonalities, characterized by a foundation in scientific management and decision-making. These policies prioritize collaborative efforts among diverse stakeholders, hold a consistent commitment to the concept of health across the life course, and focus on the role of physical activity in health promotion. In formulating and implementing China’s 15th Five-Year Plan for Health Development, China should adopt a Health in All Policies approach and refine the scientific evaluation of health promotion initiatives; construct a multi-entities policy implementation system characterized by joint development, governance, and benefit-sharing; maintain people-centered approach to health and provide robust policy safeguards; and promote evidence-based concepts while exploring innovative models for leveraging physical activity to promote health, thereby comprehensively advancing the Healthy China Initiative.
Objective This study aims to systematically review digital health technology (DHT) assessment guidelines published by international official departments and integrate their content onto an established health technology assessment (HTA) model to provide recommendations for constructing a DHT assessment system in China. Methods PubMed and grey literature were searched using keywords related to HTA, assessment frameworks, and DHT, covering the period from January 2010 to June 2024. The included guidelines were systematically reviewed and characterized, and the EUNetHTA HTA Core Model (version 3.0) was selected as the assessment framework to provide a detailed summary of DHT-specific content. Results A total of 24 DHT-related guidelines published by international official HTA departments were included. Most of the guidelines covered key domains such as clinical effectiveness (92%) and safety (100%), but only a few addressed domains such as cost economic evaluation (25%) and patient and societal aspects (42%). The included frameworks recommended DHT-specific content for 20 of the 145 questions in the HTA Core Model, covering all 9 HTA domains. This study additionally identified 12 DHT-specific issues not currently addressed by the HTA Core Model. Conclusions Existing HTA frameworks have limitations in assessing DHT and there is a need to develop more comprehensive and targeted assessment methods. China should establish a comprehensive DHT assessment framework, clarify assessment standards and procedures, and fully evaluate the safety, effectiveness, economic value, and ethical impact of DHT to promote its sound development and application.
Objective This study aims to evaluate the health benefits and economic value of serum 25(OH)D screening among adults aged 65 and above in China. Methods A decision tree and a Markov model were developed to simulate the health benefits and costs of the “screening” strategy (screening group) versus the “non-screening” strategy (non-screening group) in the Chinese population aged 65 years and older. In both strategies, supplementation of vitamin D and calcium was based on individual willingness, except for vitamin D-sufficient individuals identified in the screening group, who did not supplement. Key baseline, clinical, cost, and utility parameters were derived from published literature, public databases, and expert interviews. One-way and probabilistic sensitivity analyses were conducted to assess parameter uncertainty. 3 scenario analyses performed, targeting perimenopausal women, a region with a severely aged population (Sichuan Province), and varying levels of supplementation willingness. Results In the non-screening group, the willingness to supplement vitamin D and calcium among 25(OH)D-deficient individuals was 25.00%; in the screening group, the willingness rose to 65.00% among the same deficient population. Compared with the non-screening group, the screening group gained 0.014 incremental QALYs per person and saved 197.12 CNY in total lifetime costs per person. One-way sensitivity analysis showed that the incremental cost-utility ratio (ICUR) consistently remained below the willingness-to-pay threshold (95 749 CNY/QALY) regardless of parameter variation. Probabilistic sensitivity analysis showed that the screening strategy was dominant in 88.32% of simulations. Across all three scenarios — high-risk perimenopausal women (≥50 years), a region with a severely aged population (Sichuan Province), and varying assumptions regarding patient willingness to supplement— the screening strategy consistently demonstrated either cost savings (dominance) or a favorable cost-utility profile. Conclusion 25(OH)D screening in adults aged 65 and above can reduce fracture risk, improve health outcomes, and alleviate economic burden, representing a dominant strategy.
Objective Taking the spinal fusion surgery group (IB 29) as a case study, this paper explores the synergistic impacts of Diagnosis-Related Groups (DRG) payment reform and centralized volume-based procurement of medical consumables on the average total inpatient medical costs, cost composition and patients’ personal financial burden. It further evaluates their effects on curbing irrational medical cost growth, adjusting medical expense structure, and alleviating patients’ economic burden, so as to provide evidence for relevant policy optimization. Methods Data on basic patient characteristics and medical expenditures were obtained of inpatients undergoing spinal fusion surgery (IB 29 group) from November 2021 to November 2023. Data were drawn from the hospital information system (HIS) and electronic medical record system of a tertiary hospital in Chongqing, as well as the DRG information system and settlement information system of the Healthcare Security Administration. The implementation of DRG payment reform in November 2022 and centralized volume-based procurement of orthopedic spinal consumables in June 2023 were defined as intervention time points. An interrupted time series (ITS) model was applied to analyze the trends in the average total hospitalization cost per case, the structure of hospitalization cost, and patients’ financial burden before and after policy implementation. Results After the DRG reform, the average inpatient medical cost per case for IB 29 group decreased by 2.35%, showing a modest reduction. Following the implementation of the centralized volume-based procurement policy for orthopedic spinal medical consumables, the average inpatient medical cost per case dropped by 35.12% compared with the level before the DRG reform, representing a substantial decrease. After the implementation of centralized volume-based procurement for spinal consumables, the average medical consumables costs decreased by 19,686.78 CNY. The proportion of medical consumables costs fell to 46.99%, a decrease of 14.95 percentage points compared with the period before the DRG payment reform, while the proportion of medical service fees increased to 24.55%, an increase of 5.31 percentage points. ITS analysis showed that after the implementation of the consumables centralized volume-based procurement policy for orthopedic spinal consumables, both the average medical cost per case (β₂ = −18,495.65, P<0.05) and the average medical consumables cost per case (β₂ = −18,256.66, P<0.05) decreased significantly. In addition, after the implementation of centralized volume-based procurement for orthopedic spinal consumables, the copayment per patient decreased by 9,446.45 CNY, and the average out-of-pocket expenses decreased by 12,857.15 CNY. Conclusion The synergistic implementation of the DRG payment reform and centralized volume-based procurement of medical consumables effectively reduced the average hospitalization cost per case for patients in the IB 29 group, achieving the expected outcomes of optimizing the medical expenditure structure and reducing patients’ financial burden.
Objective This study attempts to develop an Onion Model-based competency evaluation index system for family doctor team leaders in primary healthcare institutions based on the onion model, so as to provide a basis for the selection, training, and evaluation of family doctor team leaders. Methods A preliminary item pool was generated through literature review, semi-structured interviews, and focus group discussions. A questionnaire survey was conducted among managers, family doctor team leaders, and team members at community health centers in Nanjing. Cronbach’s α,exploratory factor analysis, and confirmatory factor analysis and were used to assess the reliability and validity of the index system. Structural equation modeling (SEM) was applied to validate relationships among competency factors. Results A preliminary item pool comprising 5 dimensions and 32 items was constructed. A total of 842 participants were surveyed. Exploratory factor analysis (n = 300) extracted 5 common factors with a cumulative variance contribution rate of 90.563%. After deleting 4 items with cross-loadings, a final index system comprising 5 dimensions and 28 items were established: 6 items for personality traits, 4 items for values, 8 items for role and attitude, 6 items for implicit knowledge and skills, and 4 items for explicit knowledge and skills. Confirmatory factor analysis (n = 542) showed good model fit (χ²/df = 3.892, root mean square error of approximation = 0.067, comparative fit index = 0.928, Tucker-Lewis index = 0.914). Reliability analysis of questionnaire data yielded a Cronbach’s α of 0.994 and a split-half coefficient of 0.972, both above 0.9, demonstrating good reliability of scale items. Structural equation modeling revealed path coefficients ranging from 1.026 to 1.134 among all dimensions (P<0.001). Conclusion The evaluation system, developed based on the Onion Model framework, demonstrates good reliability and validity, and can be used as an assessment tool for evaluating the job competency of family doctor team leaders in primary healthcare institutions.
Objective This study aims to analyze the equity and efficiency of medical resource allocation in Guizhou Province from 2015 to 2023, and to provide a reference for optimizing medical resource allocation. Method The Gini coefficient was used to analyze the equity of medical resource allocation, and the data envelopment analysis (DEA)-BCC model and DEA-Malmquist model were applied for static and dynamic efficiency analysis, respectively. Results From 2015 to 2023, the population-based Gini coefficient of medical resources in Guizhou Province ranged from 0.038 5 to 0.147 9, while the geographic area-based Gini coefficient ranged from 0.212 9 to 0.386 8. Static analysis indicated that, among the cities and prefectures in 2023, 4 were DEA efficient, 2 were weakly DEA efficient, and 3 were DEA inefficient. Dynamic analysis showed that, from 2015 to 2023, the average total factor productivity change of medical resource allocation in Guizhou Province was 0.993, with total factor productivity change exceeding 1 in three cities and falling below 1 in six. Conclusions From 2015 to 2023, investment in medical resources in Guizhou Province shows an overall increasing trend, and the equity of medical resource allocation across the population dimension has been continuously improved. Some cities and prefectures have relatively high efficiency in medical resource allocation, but the overall provincial efficiency remains suboptimal. It is recommended to further scientifically plan the structure of medical resources, allocate medical resources, and enhance the overall balance and allocation efficiency.
Objective This study aims to reveal changes in health supervision efficiency across 16 cities and prefectures in Yunnan Province, and to provide a scientific basis for health supervision decision-making. Methods Data on the basic characteristics and supervision activities of health supervision institutions in Yunnan Province between 2019 and 2023 were extracted from the National Health Supervision Information Reporting System. Input indicators included the number of supervision institutions, number of health supervision personnel, expenditure, and total floor area of supervision institutions; output indicators included the number of inspected entities, the completion rate of national random sampling inspections, and the number of cases investigated and handled. The DEA-Malmquist index model was then used to statistically analyze the efficiency of health supervision across the province. Results From 2019 to 2023, the number of health supervision organizations in Yunnan Province increased from 143 to 150. The number of health supervision personnel remained generally stable, reaching 1 758 in 2023. The total floor area of supervision institutions showed an overall decreasing trend but rebounded in 2023. The mean total factor productivity across the cities and prefectures of Yunnan Province from 2019 to 2023 was 1.115, representing an overall increase in operational efficiency of 11.5%. During this period, the total factor productivity change index exceeded 1 in 14 cities and prefectures, while it was below 1 in two prefectures, Dehong Dai and Jingpo Autonomous Prefecture and Nujiang Lisu Autonomous Prefecture. Conclusions Between 2019 and 2023, the overall efficiency of health supervision in Yunnan Province exhibited an upward trend; however, substantial variations were observed across cities and prefectures. To enhance the efficiency of health supervision and enforcement, it is necessary to dynamically address human resource shortages, establish regional coordination mechanisms to improve technical efficiency, innovate regulatory models, and strengthen institutional safeguards.
Objective This study aims to analyze the growth trend and structural characteristics of total health expenditure in the Xinjiang Uygur Autonomous Region from 2013 to 2022, and to explore the factors influencing this growth and their degree of association, with a view to optimizing the financing structure and providing a basis for effectively controlling the growth of health expenditure. Methods Data on Xinjiang's total health expenditure were obtained from 2013 to 2022, along with the influencing factors of this health expenditure. Structural variation analysis was used to evaluate changes in the composition of health expenditure, and grey relational analysis was applied to identify the main influencing factors. A GM(1,1) model was then established to forecast the trends of total health expenditure and GDP in Xinjiang from 2023 to 2027. Results From 2013 to 2022, the average annual growth rate of total health expenditure in Xinjiang was 11.13%. The share of out-of-pocket (OOP) showed an overall declining trend, with a structural change value of -6.44%. While the shares of government health expenditure and social health expenditure showed increasing trends, with structural change values of 5.85% and 0.59%, respectively together indicating a clear optimization of the health financing structure. The per capita disposable income of rural residents, per capita GDP, per capita disposable income of urban residents, and per capita hospitalization expenses ranked as the top four factors most closely associated with Xinjiang's total health expenditure, with correlation coefficients of 0.649 9, 0.633 7, 0.633 2, and 0.632 9, respectively. The GM(1,1) model provided a good fit to the data and was identified as the optimal model. Total health expenditure was projected to increase to 291.337 billion CNY by 2027, with the proportion of health expenditure to GDP reaching 10.82%. Conclusions The growth of total health expenditure in Xinjiang has been reasonable, with continued optimization of its structure, although sustainability challenges remain. It is recommended that relevant departments formulate targeted measures addressing the main influencing factors, and improve health financing policies by establishing a financing mechanism tailored to the characteristics of frontier regions, deepening medical reform to strengthen cost control, and establishing a sustainable monitoring system.
Objective This study aims to investigate current multi-disciplinary team (MDT) diagnosis and treatment practices in Shanghai’s public hospitals, with a focus on disease coverage, service capacity, and operation models Methods In March-April 2024, the first round of questionnaires was distributed to 43 public hospitals. In July 2025, the second round was distributed to 119 editorial board members of Shanghai Medicine Journal. The questionnaires covered basic information of MDT teams, diagnosis and treatment management models and systems, operational indicators and service effectiveness. Results A total of 160 valid responses were received after the two rounds. Respondents were affiliated with 31 medical institutions; of these, 142 respondents reported having established MDT teams, with a total of 152 MDT teams formed. Among the 142 respondents, 63 were from pilot hospitals (i.e., hospitals participating in the MDT pilot program) and 79 from non-pilot hospitals. These MDT teams spanned multiple medical specialties. Fixed MDT teams accounted for 91.55% of the total, and teams with senior-title staff comprising more than 50% accounted for 79.58% of the total. The proportion of oncology MDT teams was higher in pilot hospitals than that in non-pilot hospitals (χ² = 3.931, P = 0.047). The proportion of MDT teams established for pediatrics, obstetrics and gynecology, traditional Chinese medicine, medical technology, and other disciplines was higher in non-pilot hospitals than that in pilot hospitals (P<0.001). In pilot hospitals, the proportions of institutions conducting annual performance evaluations of MDT teams, and of teams undergoing review, supervision and quality control evaluation by the institution’s MDT expert committee, were both significantly higher than those in non-pilot hospitals (all P<0.05). No statistically significant differences were found between pilot and non-pilot hospitals in team operation status, self-evaluation of patient outcomes, or other management quality indicators (all P>0.05). Based on the subjective evaluations of medical staff, after MDT diagnosis and treatment, the proportions of patients experiencing changes in diagnosis and treatment plans, interdisciplinary referrals, and prognostic changes showed a consistent trend. However, the proportion of patients with satisfaction levels increasing to >75% to 100% was higher than that of the previous three items (all P<0.001). Compared with MDT diagnosis and treatment teams that did not undergo review, supervision, and quality control evaluation conducted by the MDT diagnosis and treatment expert committee of medical institutions, the proportion of patients experiencing changes in diagnosis and treatment plans after diagnosis and treatment was higher in the accepted teams (P<0.001). Conclusions Current MDT teams in Shanghai’s public hospital demonstrate diverse disease coverage and sound diagnostic and therapeutic capacity. The pilot work has effectively expanded the scale and elevated the quality of local MDT services. In response to existing challenges in team formation, operation, and management, this study recommends further improving MDT service quality by standardizing the purpose and structure of team formation, setting reasonable consultation durations, enhancing the efficiency of information platform use and strengthening incentive mechanisms and team building.
Objective This study attempts to construct an operation evaluation index system for demonstration community rehabilitation centers in Shanghai, so as to guide the improvement of service quality, provide a practical tool for evaluating community rehabilitation centers, and to offer a reference for refining relevant policies. Methods Based on Avedis Donabedian's "Structure-Process-Outcome" healthcare quality evaluation model and relevant domestic and international literature on community rehabilitation, a preliminary pool of indicators for the operation evaluation system was established. The Delphi method was employed to screen and refine the evaluation index system, and the expert positive coefficient, expert authority coefficient, and Kendall's coefficient of concordance were used to verify the reliability and consistency of the index system. Results A total of 15 experts from relevant fields including rehabilitation medicine and health management, participated in the consultation. The expert positive coefficient was 100% in the two rounds of consultation, the expert authority coefficient was 0.930 and 0.928 in the first and second rounds, respectively, and the Kendall coordination coefficient increased from 0.319 to 0.511 (P<0.001), indicating a high degree of consistency among expert opinions. The final operation evaluation index system for demonstration community rehabilitation centers in Shanghai comprised 3 first-level indicators (structure, process, and outcome), 15 second-level indicators (including 4 structural indicators, 7 process indicators, and 4 outcome indicators), and 85 third-level indicators (including policy support, resource allocation, service efficiency, patient satisfaction, and other aspects). Conclusion The index system constructed in this study is both scientifically grounded and reasonable, and can serve as a standardized tool for the operational evaluation, quality improvement and policy optimization of demonstration community rehabilitation centers in Shanghai, while also offering a reference for the development of community rehabilitation system in other regions.
Medical accompaniment service is not only a growing social demand under the background of aging, but also a critical window reflecting the efficiency of the linkage between the medical service system and social care. Based on desk research and in-depth interviews with core participants including community workers, medical accompaniment service providers and service users, this paper systematically examines the current supply-demand situation and prominent issues of medical accompaniment services in Shanghai. The findings reveal an overall supply-demand imbalance, with market-led and government-led services differing significantly in target populations, service models, content, and pricing. Meanwhile, the services are confronted with uneven quality, inadequate laws and regulations, low public awareness, limited accessibility, insufficient supply of multiple services, and poor service integration. In response, this paper proposes multidimensional optimization pathways: establishing industry standards, enhancing the protection of rights and interests, strengthening service innovation and promotion, and improving cost management and payment security mechanisms. To address the problems of incomplete service processes and insufficient effective coordination, the paper explores the creation of a tripartite collaboration model among “community-medical accompaniment service institutions-medical institutions,” aiming to improve the healthcare service network and achieve dynamic matching and efficient connection between the supply and demand sides.
Objective This study attempts to assess the current status and structural characteristics of the competencies of primary-level staff engaged in infectious disease emergency response in Shanghai, identify the key influencing factors, and propose targeted strategies for competency improvement. Methods From September 15 to 19, 2025, a questionnaire survey was conducted among 578 primary-level infectious disease emergency staff from four districts of Shanghai (Huangpu, Xuhui, Minhang, and Songjiang) using cluster sampling. The questionnaire covered general information, including demographic characteristics, routine work status, and emergency work status, as well as emergency competency across four dimensions: knowledge reserve, professional skills, personal qualities, and trait motivation. Univariate analysis was used to compare differences in overall emergency competency and its individual dimensions among different groups. Multiple linear regression and random forest analysis were used to identify factors affecting the total competency score. A conditional inference tree was applied to capture interactions among factors and to identify the characteristics of groups in urgent need of competency improvement. Results A total of 578 emergency personnel were enrolled, with a total emergency competency score of (150.76 ± 29.41) points. Scores for each dimension were as follows: 3.84 for trait motivation, 3.63 for personal qualities, 2.92 for knowledge reserve, and 2.92 for professional skills. Statistically significant differences were found across all four competency dimensions among staff from different types of health emergency teams, including district CDC core teams, district CDC reserve teams, core community personnel, community reserve personnel, and other emergency staff (all P<0.05). The frequency of emergency drills (β = 18.530), training hours (β = 9.515) and training satisfaction (β = 21.101) were positive predictors of the total competency score (all P<0.05). Working in suburban areas (β = 6.726) and holding senior professional titles (β = 31.406) exerted positive effects on competency, while working in inspection posts (β = −11.027, P = 0.038) showed a negative effect. A negative quadratic trend was also observed for emergency duty experience (β = −5.708, P = 0.037). Random forest analysis indicated that the frequency of participating in drills (importance score: 70.6%) and training satisfaction (importance score: 58.2%) were the most critical factors affecting the overall competency of emergency personnel. The conditional inference tree identified three high-risk groups. Among them, personnel working in urban areas with less than 8 hours of training and no experience in emergency drills constituted the largest high-risk group, with 58.4% classified as urgently needing competency improvement. Conclusions Primary-level emergency staff in this megacity exhibit a structural shortfall characterized by relatively strong soft skills but weaker hard skills. This study recommends establishing a hierarchical and categorized training system, implementing regular scenario-based drills, and strengthening dynamic competency monitoring along with targeted resource allocation.
Objective This study aims to analyze the risk characteristics of fraud in China’s basic medical insurance fund and to propose suggestions for further optimization of its regulatory system. Method Data on medical insurance fraud cases from March 2009 to July 2025 were collected, and descriptive analyses were conducted on fund fraud behaviors, supervision policies, and supervision methods. Results Among 2,274 medical insurance fund fraud cases, violations of designated medical institutions mainly involved improper charging (24.94%), out-of-scope settlement (16.08%), substitution of diagnosis and treatment items (15.31%), and overprovision of medical and pharmaceutical services (13.56%). Insurance fraud by these institutions mainly involved fabricating medical and pharmaceutical service items (11.27%), with a relatively higher incidence in private hospitals. Violations of designated pharmacies mainly involved selling drugs beyond the scope of medical insurance payment coverage (55.53%), and their insurance fraud behaviors mainly involved falsifying drug dispensing records (26.04%). Fraud by insured individuals mainly included duplicate claims for medical insurance benefits (34.22%), seeking treatment or purchasing drugs under another person's identity (25.00%), forging medical insurance reimbursement documents (21.85%), and reselling diverted insurance-subsidized drugs (10.19%). Fraud by medical insurance agencies included embezzling medical insurance funds (37.50%), forging reimbursement documents (37.50%), and fabricating medical and pharmaceutical services (25.00%). In addition, the primary methods for detecting medical insurance fund fraud included special inspections, social oversight,, on-site inspections, referral-based investigations, unannounced inspections, and routine supervision, each accounting for more than 11% of cases. Conclusions Perpetrators of basic medical insurance fund fraud include designated medical institutions, designated pharmacies, insured individuals, and medical insurance agencies. Their risk characteristics and economic motivations are heterogeneous, and the current regulatory system and oversight measures require further improvement. It is suggested that efforts be continuously made to optimize the medical insurance regulatory system by strengthening the legal framework for medical insurance, deepening reform of regulatory rules, establishing a full-chain supervision mechanism, and advancing the credit system.
Objective This study attempts to analyze the problems of the DRG grouping scheme in actual case grouping, propose countermeasures, and provide a basis for improving the case grouping scheme used in medical insurance payment. Methods A total of 11,987 pulmonary tumor cases from 5 hospitals were selected and grouped according to the DRG grouping scheme (Versions 1.0 and 2.0) released by the National Healthcare Security Administration (NHSA). Specific problems encountered during grouping were analyzed. Univariate analysis and multiple linear regression analysis were used to identify cost-related factors influencing unassignable cases, and the grouping rates and coefficient of variation (CV) values for each subgroup were compared between the two versions. Results The grouping rate under DRG 2.0 was 92.22%, higher than the 85.29% rate under DRG 1.0. Among the unassignable cases under DRG 2.0, 228 surgical cases and 136 diagnostic or therapeutic procedure cases lacked corresponding names or codes in the DRG 2.0 grouping standards and could therefore only be assigned to the non-surgical group; An additional 535 cases involving surgeries or procedures were assigned to non-pulmonary disease groups, of which 79 cases could have been assigned to different pulmonary tumor groups based on their second or third surgery or procedure. Cost inversion was observed in groups EJ13, EJ15, ET11, ET13, and ET15. For groups ET, EV, and ER, the adjusted R² value in the linear regression analysis of cost-related factors was relatively low(0.325). After introducing the DIP grouping concept and regrouping the ER group, the CV values of some subgroups decreased significantly. Conclusion DRG 2.0 offers more refined and reasonable grouping then DRG 1.0; however, the grouping scheme requires further improvement and optimization, including: incorporating surgical and therapeutic procedure cases into finer disease subgroups, assigning cases eligible for grouping by secondary or tertiary surgeries or procedures according to the grouping principle applied to primary surgeries or procedures; and further subdividing the ER groups based on the DIP grouping principle.
Objective This study aims to systematically analyze the trajectories of price and payment scope changes for national medical insurance negotiated drugs during the renewal process, to assess the actual effectiveness of the “Negotiated Drug Renewal Rules” in stabilizing price expectations and implementing differentiated adjustments, and to propose optimization strategies. Methods This study examined 334 renewal drugs (comprising a total of 488 renewal records) involved in the catalog adjustments to the National Reimbursement Drug List from 2019 to 2024. Data on prices, payment scopes, and renewal types were collected from government official websites and relevant databases. Descriptive statistical methods were used to analyze the characteristics of price changes during renewal, and univariate analyses were conducted to compare differences in the magnitude of price reductions across drugs with different renewal types and registration categories. Results From 2019 to 2024, the number of renewal drugs continuously increased, while the average price reduction rate decreased from 24.0% to 5.2%. The price reduction for renewals involving adjusted payment scopes was significantly higher than that for agreement-expiration renewals (P<0.001). Differences in the magnitude of price reductions were observed across drugs with different registration categories. In particular, the price reduction for innovative drug renewals was significantly higher than that for modified drugs and other categories (P<0.001), and the price reduction for antineoplastic drug renewals was substantially higher than that for non-antineoplastic drugs (P<0.001). Conclusions The “Negotiated Drug Renewal Rules” have played a positive role in standardizing the renewal process and stabilizing price expectations. Differences remain in the extent of price adjustments across drugs with different renewal types and registration categories. In the future, the renewal mechanism for medical insurance negotiated drugs could be further improved by enhancing the granularity of renewal price management and strengthening the application of real-world evidence.
Objective This study aims to explore the influence mechanism of health risk cognitive bias on commercial health insurance purchase behavior, and to provide a reference basis for improving relevant policies. Methods A multi-stage stratified random sampling method was employed, targeting residents aged 18 to 64 years. Two provinces were randomly selected from the eastern, central, and western regions. Binary logistic regression models, robustness tests, a mediating effect model, and a moderating effect model were utilized to investigate the influence mechanism of health risk cognitive bias on commercial health insurance purchase behavior. Results Health risk cognitive bias has a significant negative impact on the purchase behavior of commercial health insurance (β = −1.347, P<0.001). Optimistic individuals are more likely not to purchase insurance, while pessimistic individuals are more likely to purchase insurance. Willingness to purchase plays a mediating role between health risk cognitive bias and purchase behavior of commercial health insurance (β1 = −0.370, P<0.001; β2 = −1.088, P<0.001; β3 = 1.042, P<0.001). Risk preference plays a moderating role between health risk cognitive bias and willingness to purchase (β= 0.052, P<0.05). Conclusion Health risk cognitive bias not only directly affects residents' purchase behavior of commercial health insurance, but also indirectly influences the purchase behavior through the mediating effect of willingness to purchase and the moderating role of risk preference.
Drawing on advanced theoretical approaches and the experiences of representative countries, and informed by the practical work of China's National Reimbursement Drug List (NRDL) adjustment, this paper examines, from the dual perspectives of working mechanisms and implementation pathways, the application prospects of real world data (RWD) and real world evidence (RWE) in NRDL adjustment. Through literature review and expert interviews, the paper classifies RWE into four categories: cost analysis, epidemiology and current diagnosis and treatment status, safety and effectiveness, and other supporting evidence. This paper systematically illustrates the application modes of each evidence type under different decision-making scenarios and proposes a phased implementation path. These findings aim to offer a scientifically sound decision-making reference for the dynamic adjustment of NRDL, thereby facilitating the high-quality development of medical security.
In the context of the digital economy era, health and medical big data has become an important national strategic resource, and its cross-border flow constitutes a crucial component of data factor circulation. In the Guangdong-Hong Kong-Macao Greater Bay Area, the cross-border flow of health and medical big data is subject to 2 major constraints: first, the relatively high regulatory intensity on the Chinese mainland side, which results in asymmetry in data flows; and second, the lack of refined matching mechanisms in data export rules, reflecting insufficient institutional supply. Based on the conceptual connotations of health and medical big data and the fundamental principles governing cross-border data flows, this article explores regulatory pathways for cross-border health and medical big data in the Greater Bay Area along two dimensions: rule improvement and rule connectivity. It proposes improving the identification and recognition of health and medical big data for cross-border purposes, adhering to a data export security assessment regime that is both scientific and proportionate, and optimizing the institutional tension between risk control and data mobility. Furthermore, by embedding a four-dimensional functional pathway, encompassing clinical diagnosis and treatment, public health, health products, and scientific research, this study seeks to construct a logic of regulatory connectivity among the three jurisdictions of the Greater Bay Area along this functional chain, thereby enhancing institutional compatibility and regulatory coherence.
Real world evidence (RWE) is an important source of evidence for addressing the limitations of traditional clinical trials and supporting precision medicine as well as drug research and development. However, the vast volume of unstructured clinical text generated in routine practice is difficult to efficiently transform into analyzable and usable research information, constituting a key bottleneck restricting the generation of high-quality RWE. The rapid development of large language models (LLMs) offers a new solution to this challenge; however, practical applications and performance validation in multicenter, large-scale healthcare settings remain limited. In response, this study explores the role of LLMs in enabling gastric cancer RWE research, and presents a collaborative practice jointly advanced by hospitals and industry partners. Centered on the domestically developed LLM Qwen2.5, the study established an automated data governance pipeline integrating end-to-end quality control and human-machine collaboration mechanisms, enabling the efficient transformation of massive multicenter clinical text into high-quality structured data and providing reliable support for gastric cancer RWE research. This project curated data from 100 000 patients with gastric cancer, yielding 263 core research variables. At the application level, the data processing cycle was shortened, and the extraction accuracy for key fields exceeded 90%, demonstrating the potential of LLMs in processing unstructured data, reconstructing complex medical variables, and supporting RWE research. Furthermore, this study summarizes practical experience regarding model selection, data standardization, and mutually beneficial hospital-industry collaboration, while also identifying real-world challenges including computing power constraints, structural heterogeneity across source databases, the absence of industry standards, and insufficient model interpretability. Based on these findings, this study proposes a synergistic innovation ecosystem comprising hospitals, universities, and enterprises, advancing the standardization of data governance and model evaluation, and strengthening interdisciplinary talent development and investment in core infrastructure. These efforts aim to further the translation of LLMs into a reliable infrastructure that empowers the RWE research and advances precision medicine and pharmaceutical research and development.
Social prescribing, an innovative practice model of primary healthcare, shows strong potential for improving population physical and mental health, promoting health equity, optimizing resource integration and reducing health expenditure. This paper systematically reviews global research and practice on social prescribing and finds that the target population primarily includes individuals with mild to moderate psychological problems, socially isolated individuals, patients with chronic diseases, older adults, those facing complex life difficulties, individuals with obesity, and populations with unhealthy lifestyles. Service content encompasses arts and cultural prescribing, educational and daily life support prescribing, nature and exercise prescribing, health management support prescribing, as well as social support and participation prescribing. Service can be jointly delivered by both medical and non-medical personnel. Social prescribing has demonstrated considerable effectiveness in improving mental health, enhancing social connectedness, improving quality of life and optimizing healthcare service utilization. However, challenges remain in limited-service coverage, underdeveloped evaluation system, and insufficient financial sustainability. The study recommends exploring the localized application of social prescribing in China, expanding service coverage for vulnerable populations, activating a diversified service delivery system, leveraging digital and intelligent technologies, strengthening social worker capacity and improving financing and evaluation mechanisms, in order to build a replicable and scalable social prescribing model that supports the development an integrated healthcare service system.
This study provides a systematic overview of the development and practical application of the shared decision-making (SDM) system in the United Kingdom. It outlines the comprehensive support system that has emerged through coordinated efforts in legislative safeguards, long-term planning, and guideline development, as well as the practical framework of “organizational collaboration, practice guidelines, and decision aids”. By comparing the status of SDM systems in China and the UK, this study analyzes the underlying causes of these differences from three perspectives: cultural foundations, institutional adaptation, and public participation. Drawing on China’s actual conditions, this study proposes a series of systematic recommendations, including establishing a legal framework for SDM to strengthen top-level design and policy guidance; developing localized clinical guidelines to facilitate the establishment, promotion, and updating of SDM models; optimizing the allocation of medical resources to enhance institutional management and staff training; and developing patient decision aids. These recommendations aim to provide a reference for transforming China’s “patient-centered” healthcare model and advancing the systematic development of SDM.
