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Peer-reviewedCC BY 4.0Frontiers in Public Health

Aligning insurance payment with public value: outcome-based payment for traditional Chinese medicine advantage diseases under China’s DRG/DIP reform

  • Zhongyang Pei1,2
  • Anxia Hu1,2
  • Zhiguang Duan1
  1. 1School of Management, Shanxi Medical University
  2. 2School of Health Services and Management, Shanxi University of Chinese Medicine
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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.

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Cite

BibTeXRIS
BibTeX
@article{pei2026aligning,
  title = {{Aligning insurance payment with public value: outcome-based payment for traditional Chinese medicine advantage diseases under China’s DRG/DIP reform}},
  author = {Zhongyang Pei and Anxia Hu and Zhiguang Duan},
  journal = {Frontiers in Public Health},
  year = {2026},
  month = oct,
  doi = {10.3389/fpubh.2026.1902781},
  url = {https://www.frontiersin.org/articles/10.3389/fpubh.2026.1902781/full},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Aligning insurance payment with public value: outcome-based payment for traditional Chinese medicine advantage diseases under China’s DRG/DIP reform
AU  - Zhongyang Pei
AU  - Anxia Hu
AU  - Zhiguang Duan
PY  - 2026
DA  - 2026/10/21
JO  - Frontiers in Public Health
DO  - 10.3389/fpubh.2026.1902781
UR  - https://www.frontiersin.org/articles/10.3389/fpubh.2026.1902781/full
AB  - 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.
SN  - 2296-2565
ER  -