From expansion to intelligent governance: structural transformation and regulatory paradigm reconstruction in China’s health insurance reform: a systematic literature review on the evolution and future trajectories of health insurance fund supervision
- 1Department of Medical Insurance and Pricing, The First Affiliated Hospital of Guangdong Medical University
Abstract
Background: Over the past quarter century, China has undergone three transformations in healthcare financing: from employer-sponsored coverage to universal enrollment, then toward quality- and intelligence-oriented governance. This review examines the evolution and future of medical insurance fund supervision in China.
Methods: Five databases were searched on June 15, 2025. Included publications addressed fund supervision, payment reform, intelligent technology, sustainability, equity, or anti-corruption in China. MMAT and AMSTAR-2 criteria were used for quality appraisal. Each publication was independently assessed by two reviewers using the MMAT screening questions and domain ratings; disagreements were resolved through consensus discussion, with an independent third assessor arbitrating unresolved cases. Inter-rater reliability on a 20% random subset yielded substantial agreement (Cohen’s κ = 0.82). PRISMA 2020 guidelines were followed; no PROSPERO registration was made.
Results: Three core findings emerged via the Intelligent Supervision Integration (ISI) framework (data, algorithm, institution layers). First, fund supervision evolved through three phases, with the 2018 NHSA establishment as pivotal. Second, DRG/DIP reforms contained costs but generated upcoding and cost-shifting. Third, ML-based and blockchain-based fraud detection have transitioned to operational deployment.
Conclusion: The ISI framework explains China’s transition to intelligent governance. Six prospective trends are identified: (1) data-driven supervision, (2) federated learning for privacy-preserving analytics, (3) blockchain-based full-chain supervision, (4) intelligent actuarial early warning systems, (5) institutionalized integrity governance, and (6) localization-optimized payment reform.
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BibTeX
@article{zhu2026from,
title = {{From expansion to intelligent governance: structural transformation and regulatory paradigm reconstruction in China’s health insurance reform: a systematic literature review on the evolution and future trajectories of health insurance fund supervision}},
author = {Zeyu Zhu},
journal = {Frontiers in Public Health},
year = {2026},
month = oct,
doi = {10.3389/fpubh.2026.1904242},
url = {https://www.frontiersin.org/articles/10.3389/fpubh.2026.1904242/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - From expansion to intelligent governance: structural transformation and regulatory paradigm reconstruction in China’s health insurance reform: a systematic literature review on the evolution and future trajectories of health insurance fund supervision
AU - Zeyu Zhu
PY - 2026
DA - 2026/10/30
JO - Frontiers in Public Health
DO - 10.3389/fpubh.2026.1904242
UR - https://www.frontiersin.org/articles/10.3389/fpubh.2026.1904242/full
AB - Background: Over the past quarter century, China has undergone three transformations in healthcare financing: from employer-sponsored coverage to universal enrollment, then toward quality- and intelligence-oriented governance. This review examines the evolution and future of medical insurance fund supervision in China. Methods: Five databases were searched on June 15, 2025. Included publications addressed fund supervision, payment reform, intelligent technology, sustainability, equity, or anti-corruption in China. MMAT and AMSTAR-2 criteria were used for quality appraisal. Each publication was independently assessed by two reviewers using the MMAT screening questions and domain ratings; disagreements were resolved through consensus discussion, with an independent third assessor arbitrating unresolved cases. Inter-rater reliability on a 20% random subset yielded substantial agreement (Cohen’s κ = 0.82). PRISMA 2020 guidelines were followed; no PROSPERO registration was made. Results: Three core findings emerged via the Intelligent Supervision Integration (ISI) framework (data, algorithm, institution layers). First, fund supervision evolved through three phases, with the 2018 NHSA establishment as pivotal. Second, DRG/DIP reforms contained costs but generated upcoding and cost-shifting. Third, ML-based and blockchain-based fraud detection have transitioned to operational deployment. Conclusion: The ISI framework explains China’s transition to intelligent governance. Six prospective trends are identified: (1) data-driven supervision, (2) federated learning for privacy-preserving analytics, (3) blockchain-based full-chain supervision, (4) intelligent actuarial early warning systems, (5) institutionalized integrity governance, and (6) localization-optimized payment reform.
SN - 2296-2565
ER -