Aligning insurance payment with public value: outcome-based payment for traditional Chinese medicine advantage diseases under China’s DRG/DIP reform
Year: 2026
Type: article
Abstract: Background China’s DRG/DIP payment reform has strengthened prospective case-based reimbursement, but conventional grouping metrics may not fully capture the patient-perceived and TCM-specific value of Traditional Chinese Medicine (TCM) for TCM-advantage diseases. Objective This study evaluated whether outcome-based payment for TCM-advantage diseases improved patient-centered public value compared with conventional DRG/DIP payment. Methods A multicenter, mixed-methods quasi-experimental study was conducted using medical insurance settlement data, discharge abstracts, electronic medical records, patient questionnaires, and semi-structured interviews. The administrative cohort included 7,985 inpatient cases across five TCM-advantage disease cohorts, and the patient-reported component included 545 questionnaires. Ten stakeholders were interviewed to contextualize the quantitative findings. A Patient-Centered Public Value Index (PCPVI) was constructed across five dimensions and analyzed using propensity score matching and difference-in-differences estimation. Results Outcome-based payment was associated with a 4.85-point increase in the PCPVI (95% CI: 3.32 to 6.38; p < 0.001). It was also associated with reductions of 520 RMB in total hospitalization expenditure and 300 RMB in out-of-pocket payment per admission. The reimbursement ratio and TCM treatment cost proportion increased by 2.40 and 4.90 percentage points, respectively. The insurance fund payment estimate was −130 RMB (95% CI: −361 to 101; p = 0.270), and the EQ-5D-5L estimate was 0.021 (95% CI: −0.001 to 0.043; p = 0.061). Neither was statistically significant. No statistically significant differences were detected in 30-day readmission or in-hospital complications. Patient satisfaction and perceived insurance benefit were higher in the outcome-based payment group. Conclusion In the Taiyuan study setting, outcome-based payment was associated with better financial protection, a higher PCPVI and more favorable patient experience. Increased TCM expenditure share indicates a change in service composition, rather than direct evidence of TCM-specific therapeutic efficacy. Effects on generic health-related quality of life, insurance fund payment and short-term safety outcomes remain uncertain. Longer follow-up and external validation are needed before drawing conclusions about fund sustainability or transferability.
Source: Frontiers in Public Health
Authors: Zhongyang Pei, Anxia Hu, Zhiguang Duan
Language: English
Subfield: Finance
Domain: Social Sciences
Open Access status: gold
Estimated APC paid: $3,801
OpenAlex ID: W7223107356