China’s NHSA Releases Interim Measures for Medical Case-Based Payment Management

The National Healthcare Security Administration (NHSA) issued the “Interim Measures for Medical Security Case-Based Payment Management” on August 15, 2025. These measures took effect immediately and apply to the management of inpatient medical expenses settled by medical insurance departments with healthcare institutions using a case-based payment model. The payment methods include Diagnosis-Related Groups (DRG) payment and Disease-Specific Payment (DIP).

Disease Grouping and Payment Mechanisms
The NHSA is responsible for formulating and adjusting the national disease grouping schemes. The DRG grouping consists of Major Diagnostic Categories (MDCs), core groups, and subgroups. MDCs are determined based on anatomical location and disease nature. Core groups are primarily adjusted through clinical verification, which can be conducted by relevant academic associations or through multidisciplinary joint evaluations. The DIP disease library includes core diseases and comprehensive diseases. A threshold for the number of cases is used to distinguish between core and comprehensive diseases. Disease combinations with a case count above the threshold are categorized as core diseases and serve as the main payment units for DIP settlements.

Exception Review Mechanism
Medical insurance departments will establish an exception review mechanism and improve related systems to standardize the criteria, application procedures, review processes, and settlement methods for these exceptions. In alignment with national policies supporting the development of innovative drugs and medical devices, this mechanism will encourage medical institutions to admit complex and critically ill patients and to appropriately use new drugs and technologies. Cases eligible for exception review include those unsuitable for standard case-based payment due to long hospital stays, high resource consumption, the reasonable use of new drugs and technologies, complex and critical illnesses, or multidisciplinary joint treatment. The number of exception cases should not exceed 5% of the total DRG discharges or 5‰ of the total DIP discharges in a given planning area.-Fineline Info & Tech