Unboxing the "Black Box": Guoxin Health's Full-Value Chain Management in the DRG Era for High-Quality Hospital Development

Reading Guide for This Article

· I. Compass: Healthcare Reform in Deep Waters — Quality + Cost Control + National Performance EvaluationTriple Most”, DRG Engine as the Navigation Path

· II. The Helmsman: More Than Just a Tool, DRG/DIP Application Capabilities Will Become the Key Lever for “Steering”

· III. Value Perspective: Comprehensive Healthcare Insurance Governance Facilitates High-Quality Hospital Development and the Return of Medical Value to Its Essence

-1. From “Digital Quantity” to “Digital Governance”: Data Infrastructure Drives Systematic Layout

-2. Meeting the needs of 500+ hospitals without fail: Co-building consultative services with hospitals, aligned in value

-3. From Point to Surface: The Refined Effects of DRG/DIP Regional Models in Facilitating Policy Implementation Are Becoming Evident

-4. Pioneering the Exploration of a Composite Payment System for Outpatient Medical Insurance, with “Health Performance” Deepening the Connotation of High-Quality Development

During the Two Sessions, public welfare concerns took center stage, and healthcare reform once again topped trending searches. On March 6, the Ministry of Finance and the National Health Commission jointly issued the Notice on Organizing Applications for Central Fiscal Support Demonstration Projects for Public Hospital Reform and High-Quality Development, clearly stating that each demonstration project may receive a central fiscal subsidy of up to RMB 500 million (with 10% allocated as special performance-based incentive funds). Among these,Deepen the reform of medical insurance payment methods, strengthen comprehensive, end-to-end, and multi-dimensional budget performance management in hospitals, and promote the efficient allocation and utilization of resources., is one of the key areas of focus for the demonstration project.

In alignment with the “New Three-Year Task” for DRG/DIP progressively issued by the National Healthcare Security Administration and its provincial and municipal counterparts, it has been clearly stipulated that by the end of 2025, DRG/DIP payment methods will cover all eligible medical institutions providing inpatient services. As an “economic lever,” healthcare insurance payment has become the core engine driving the deepening of healthcare reform.

Faced with the shift from the extensive expansion of the past, where detailed knowledge was “unnecessary,” to today’s refined management, where such knowledge often remains “elusive”; shouldering the dual burdens of practicing fiscal austerity while strategizing for development; and navigating the “multi-faceted management” challenges of curbing unreasonable growth in medical expenses alongside pursuing high-quality development through performance evaluation—where exactly lies the space for hospitals’ survival and growth? Amidst the myriad complexities occupying hospital presidents, can they systematically deconstruct and analyze, step by step, the seemingly impenetrable “black box” of modern hospital management?

From "Healthy China" to high-quality development, China’s healthcare sector is entering a development trajectory characterized by precision, refinement, and lean management. By achieving the “three shifts”—from scale expansion to quality improvement and efficiency enhancement, from extensive management to refined management, and from emphasis on material factors to emphasis on talent and technological factors—the sector aims to realize the “three improvements” in quality, efficiency, and driving forces, with the core objective beingBalanced Health Economics and High-Quality Health Outcomes。

The "general equilibrium theory" introduced here was proposed by the American economist Kenneth J. Arrow and has since been adopted as an economic tool for analyzing healthcare pricing systems. Due to the uncertainty inherent in healthcare (including diseases, treatment modalities, and outcomes) and information asymmetry, calculating costs is challenging. Therefore, precise algorithms or big data are utilized to determine the mean healthcare costs, thereby objectively and effectively reflecting the extent of healthcare resource consumption, a concept referred to as stochastic equilibrium.

Subsequently, in the 1970s, the Yale University Health Services Research Center proposed Diagnosis-Related Groups (DRGs) through an analytical study of 700,000 medical records from 169 hospitals. Based on factors such as patient age, gender, length of stay, clinical diagnosis, conditions, procedures performed, disease severity, comorbidities and complications, and outcomes, cases with similar clinical processes and comparable resource consumption were categorized into 500–600 diagnostic-related groups. By studying patterns of resource utilization, this approach transformed previously incomparable disease categories into comparable ones, thereby determining the appropriate reimbursement levels for hospitals under health insurance payment systems. Later, DRGs were extended to applications in public hospital management and government resource allocation.

From this perspective, neither “payment models,” “budget schemes,” nor “quality control measures” can comprehensively encapsulate the DRG system in essence. Ultimately,DRG is a “healthcare management tool” that leverages pricing (reimbursement) mechanisms to regulate clinical practices, optimize case-mix structure, enhance resource efficiency, and implement clinically appropriate and cost-controllable care pathways, thereby achieving high patient satisfaction and superior value-based outcomes.

This aligns precisely with the underlying logic of China’s push for high-quality development in public hospitals, shifting from “quantitative accumulation” to “qualitative improvement.” Key implementation pathways and supporting elements of high-quality development—such as medical quality, cost control, resource utilization efficiency, healthcare service capacity, organizational management and institutional development, and patient satisfaction—often present hospital administrators with a dilemma where these factors appear contradictory and mutually constraining. However, within the hospital performance evaluation system built around Diagnosis-Related Group (DRG)-based payment, these elements will be systematically integrated and interconnected. If healthcare institutions can effectively leverage DRGs and use them as a foundation to integrate incentives, stimulate innovation, and strengthen institutional capabilities, the “triple maximization” challenge of balancing quality, cost containment, and national performance assessments will be unraveled step by step, accelerating the positive virtuous cycle of the “medical flywheel.”

From an external perspective, DRG is conducive to controlling unreasonable medical expenses and facilitating macro-level forecasting. It effectively reduces the administrative costs for health insurance agencies and provides a scientific, reference-based classification method for evaluating healthcare quality.

Looking inward, within a measurable and traceable innovation quality management system, efficiency gains must precede revenue growth. In this logical context, the endogenous drive for healthcare institutions to enhance the “value-added” quality of their development will be significantly strengthened:“Cost Control”, optimize the allocation of medical resources to ensure "optimal quality," guide departments to prioritize cost considerations, and establish a scientific cost control system.“Efficiency Improvement”, by transforming care delivery models through the adoption of disease-specific/expert outpatient clinics, MDT clinics/centers for consultation on complex and rare diseases, and the integration of internet hospitals, ambulatory surgery centers, and robotic systems, thereby reducing length of stay and improving service efficiency.“Adjusting the Structure”, leveraging DRG implementation to assess the complexity and breadth of diseases within departments, establishing a tiered allocation scheme to optimize the case-mix structure, gradually guiding physicians to improve medical quality, performing Level III and IV surgeries to increase the Case Mix Index (CMI), thereby enhancing the hospital’s core competitiveness while securing reimbursement incentives from health insurance payers.

In the critical year for implementing the 14th Five-Year Plan and the pivotal year for advancing high-quality development of medical security, the national top-level design has vigorously re-promoted healthcare payment reforms represented by DRG/DIP. The core objective is to guide medical institutions in understanding the fundamental logic of “health economic regulation and high-quality, efficient development,” effectively utilizing this management tool to reduce unreasonable medical costs while better reflecting clinical value, thereby enhancing the public’s sense of gain and satisfaction.

So, does procuring and establishing a DRG system equate to effective utilization of DRGs? As the pace of reform accelerates, an increasing number of healthcare institutions have deployed “hardware” infrastructure; however, the development, implementation, and realization of value in the “soft environment” remain less than ideal. Against this backdrop, the exploratory and demonstrative role of pilot programs is particularly valuable, potentially yielding experience in capacity building that is scalable, replicable, and sustainable.

A large national benchmark hospital in the Yangtze River Delta region (hereinafter referred to as “the Hospital”), with technical support from Guoxin Health, has proposed a “full medical value chain” based on DRG logic. This initiative not only integrates and plans various elements of high-quality development—such as quality, efficiency, and talent momentum—but more importantly,The “DRG Intelligent Management System” connects clinicians, department heads, operational managers, and hospital decision-makers across the entire workflow, fostering a unified, organization-wide approach to collaborative innovation.In other words, only when all relevant stakeholders possess the capability to adopt uniform standards, implement synchronized usage, conduct classified analysis, and make tiered decisions can this systemic “course-correction” initiative achieve steady and long-term success.

Tracing back to its origins, this value chain takes clinical operations as its foundational starting point. Based on homogeneous, standardized, and authentic medical record data, especiallyQuality Improvement of the Medical Record Face Sheet,“Activate Medical Records,” “Commitment Fulfilled.” By integrating with Guoxin Health’s Intelligent Medical Record Quality Control Management System, hospitals have shifted the quality control of medical record front pages to the physician interface, providing real-time data prompts during clinical consultations. This enables immediate, accurate, and standardized “management alongside clinical practice, and optimization alongside management.” Meanwhile, it effectively addresses key pain points such as clinicians’ lack of familiarity with medical record coding rules, insufficient staffing for medical record management, and suboptimal record quality that fails to meet health insurance administration requirements.

During the implementation of Diagnosis-Related Groups (DRGs), hospitals have found that management faces a “black box” dilemma: processes are too lengthy to allow for phased and timely corrective actions, data are too coarse to enable precise pinpointing of issues, and responses are too slow to facilitate real-time adaptation.To address these issues, Guoxin Health has introduced a DRG/DIP grouping prediction and early warning system for hospitals. Based on the disease group management requirements and objectives of the hospital or specific departments, the system configures benchmark values and alert information related to disease group management. Without interfering with the clinical treatment process or increasing the workload of clinicians, it provides references and early warnings for optimizing resource allocation, thereby meeting the demand for lightweight, non-intrusive intelligent services.

This means that the long and arduous journey of modern hospital management, guided by a backward-design approach, is broken down into management units and objectives best suited to each hospital’s unique characteristics. Like a long-distance run, it involves real-time “pace reporting,” continuous benchmarking, and timely adjustments—gradually unwrapping the “black box” to enable clear-eyed progress.

The entire process is equivalent to providing hospitals with real-time, intelligent “consulting services,”Ensure that every aspect of management is guided by the best interests of patients. Without compromising medical quality or service standards, strengthen awareness of rational cost control across the entire care continuum, improve the efficiency of health insurance fund utilization, reduce the financial burden on patients, and achieve optimization of clinical pathways and enhancement of operational efficiency.

Precise data positioning identifies problems, while the ability to mine data, conduct effective analysis, and distill actionable recommendations supports decision-making in problem-solving.The DRG/DIP-based intelligent hospital management system for retrospective comprehensive analysis is designed to meet the needs of various managerial roles by providing analytical dimensions such as pooling areas and case types, thereby achieving holistic monitoring of in-hospital DRG/DIP management and cost structures. Furthermore, building upon existing hospital performance management models, Guoxin Health has developed a performance evaluation framework based on DRG/DIP metrics. This framework conducts a multidimensional comprehensive assessment of hospitals, departments, and physicians in terms of service breadth, service complexity, service quality, and service efficiency, enabling medical staff to achieve higher compensation for superior performance and truly reflecting the value of their labor and technical expertise.

Consequently, management feeds back into clinical practice; a comprehensive PDCA-based pathway for refined DRG control in hospitals can be implemented in phases and steps, while also enabling systematic and coordinated deployment.

It can be seen from this that,Synergy between DRG-based payment and high-quality development requires the thorough implementation of disease-specific cost accounting and performance evaluation, leveraging these as tools to precisely define disciplinary positioning and scientifically plan operational strategies. In this process, Guoxin Health has evolved from merely providing a DRG payment system to offering a composite healthcare quality and operational control framework.This symbiotic partnership, which collaborates with hospitals to drive optimization and present “proposals” to the entire industry and the public, has effectively facilitated the iteration of integrated collaborative systems, thereby supporting the development of a high-quality, efficient, and integrated healthcare delivery system.

Since the implementation of DRG-based payment, the hospital has maintained continuous and scientific management. A comparison between 2019 and 2021 reveals significant improvements in various DRG indicators. From 2019 to 2021, the hospital’s Case Mix Index (CMI) increased by 11.29%, while the average length of stay decreased by 8.41%, indicating a marked enhancement in both the complexity and quality of care. Meanwhile, the average cost per case declined by 4.09%, and the proportion of material costs dropped from 25% to 23%, thereby achieving the cost-containment targets.

From the “Opinions on Deepening the Reform of the Medical Security System” to the “14th Five-Year Plan for National Healthcare Security,” and culminating in November 2021 with the National Healthcare Security Administration’s issuance of the “Three-Year Action Plan for DRG/DIP Payment Method Reform,” healthcare security reforms have progressively converged like concentric circles. Healthcare payment scenarios are increasingly integrated with the “three medicals” (medical care, health insurance, and pharmaceuticals), while healthcare security data permeates diverse business units. Underpinning this transformation is a new paradigm of industry collaboration and industrial division of labor among various service providers and ecosystem resources. Achieving the integration of hospital information flows, data flows, and resource flows into a unified system, as well as the tripartite alignment of business processing, data governance, and economic management, requires comprehensive fusion across all roles, processes, and resources, along with systematic coordination spanning multiple disciplines, departments, and organizations.

VCBeat has observed that big data processing capabilities and informatization development, driven by refined demands, not only pose new challenges to medical institutions but also accelerate the explosive release of industrial momentum within the healthcare sector. Currently, most enterprises are concentrated in the “product functionality camp,” whereas technological, service, and business model innovations—based on value transition—that further stimulate management and systemic innovations deserve particular attention. As a mainstream DRG/DIP information system provider for hospitals, Guoxin Health has made significant efforts to deliver industry value.

In the Application of Technological Innovation, industry experts believe that the optimization of clinical pathways and refined hospital operations, which correspond to high quality and efficiency, represent a process evolving from informatization to digitalization and then to intelligence; the digital foundation is determined by knowledge graphs and digital governance capabilities formed through the long-term accumulation of massive data and multidimensional databases.

Possessing the currentSupported by a comprehensive, specialized clinical knowledge base with large-scale data in ChinaThe hospital’s DRG/DIP intelligent management system is the culmination of Guoxin Health’s nearly 20 years of continuous professional accumulation, independent research and development, and proprietary intellectual property rights. In terms of medical knowledge, pharmaceutical knowledge, standardized data, and evidence-based medicine alone, the total volume of data exceeds 2.9 million entries, while the database of health insurance fund regulatory rules contains approximately 86.07 million entries.

From Data Asset Accumulation to Knowledge Asset Extraction, artificial intelligence has become the “whetstone” for the data foundation. The GXH Health–Peking University Medical Artificial Intelligence Joint Laboratory has constructed a massive healthcare knowledge graph comprising more than 50 entity types (including diagnoses, surgical procedures, medications, coding, and individual characteristics), over 23 million entities, and more than 2.2 million relationships. Taking medical record rules as an example, by building upon the original framework of 3 major categories, 25 subcategories, and 480,000 detailed medical record rules, integrating these rules with algorithms, and selecting the most suitable deep neural network models, the accuracy of its intelligent medical record validation system has been significantly improved.

From Knowledge Asset Conversion and Application to System Solutions, from refining data depth to solidifying the "data foundation,"Guoxin Health’s high-quality clinical data governance capabilities have begun to stand out in the industry.2022 will undoubtedly be a “year of matched strength” and a watershed moment for the comprehensive governance of medical insurance and the high-quality development of public hospitals. Healthcare institutions will increasingly leverage lean performance evaluation to drive cost control and high-quality development, while DRG/DIP payment reforms will propel the transition from extensive management to in-depth, refined operations.

Only through a systematic layout based on the industry value chain can data-driven realization of healthcare value be truly achieved.Guoxin Health has taken the lead in deploying solutions in areas such as cost management, performance assessment and distribution in public hospitals, annual DRG data analysis, and data platform governance, addressing the pain points and practical needs of hospitals in medical insurance services and operational management., providing hospital administrators with essential big data-driven decision support, formulating strategic plans and decomposing objectives starting from the “National Performance Evaluation,” and using its indicators as the endpoint of a closed-loop management system. This approach establishes an operation-oriented, integrated business-finance refined operational management system, ensuring comprehensive and systematic preparedness to empower the lean development of modern hospital management.

Meanwhile, with the advent of the digital economy era, the security and reliability of medical and health data are receiving increasing attention. For this “lifeline,”Guoxin Health has always held that data authenticity is the prerequisite, while data security is the lifeline of its development.— As early as 2014, Guoxin Health obtained certification for its Information Security Management System. In August 2021, it was approved as one of the inaugural member units of the “Medical Technology Security Laboratory,” audited by the Security Research Institute of the China Academy of Information and Communications Technology (CAICT). Leveraging years of professional, objective, and neutral experience in medical insurance services, all business lines of Guoxin Health strictly adhere to the highest standards of confidentiality. The sense of responsibility and self-discipline demonstrated by this central state-owned enterprise in serving the coordinated reform of healthcare, health insurance, and pharmaceutical supply (“Three-Medical Linkage”) fully ensures data security and the long-term stability of its services.

In Terms of Safeguarding the Service Philosophy“You have never let our needs fall through the cracks.” This persuasive evaluation of Guoxin Health’s services was made by an administrator at a leading national hospital. It is understood that such professional and immediate responsiveness is supported by Guoxin Health’s localized service teams, which span seven major regions and 28 provinces across China, with a total workforce of over one thousand employees. The team members come from multidisciplinary backgrounds, including IT, data science, clinical practice, and medical records management. They provide on-site services staffed by dedicated technical personnel who are well-versed in clinical workflows, thereby offering valuable knowledge transfer to hospitals lacking specialized coding professionals.

It is evident that, throughout this process, Guoxin Health has established a strong symbiotic relationship with its clients. Guided by actual needs, the two parties have jointly optimized and developed solutions, distilled common requirements into standardized frameworks to drive product iteration, and broadly disseminated their management philosophy.

From the perspective of Guoxin Health, each question raised by a client often serves as “guidance” and “advice,” rather than merely a “request.” Only by leveraging professional core knowledge assets and extensive industry experience to demonstrate a professional attitude and capability—rather than providing “simple responses”—can trust be built. Furthermore, only by offering hospitals open, systematic, and diversified comprehensive solutions, thereby instilling a sense of security, can lasting trust value be cultivated.

Currently, the Guoxin Health medical team assists hospitals in implementing refined management measures to support policy execution, servingincluding Qilu Hospital of Shandong University, the Second Hospital of Shandong University, Zhejiang Provincial People's Hospital, Nanjing Drum Tower Hospital, Xijing Hospital, the Second Affiliated Hospital of Air Force Medical University, Guangdong Provincial Maternal and Child Health Hospital, the Second Affiliated Hospital of Guangxi Medical University, Hefei Second People's Hospital, etc.more than 500 hospitals, including benchmark hospitals with national influence. From Liaoyuan City in the north to Danzhou City in the south, from Aksu in the west to Shandong, Jiangsu, and Zhejiang provinces in the east, Guoxin Health is systematically laying out its strategy based on a panoramic view of the broader health ecosystem. It has covered more than 70 cities across 25 provinces in China and accumulated experience in providing refined DRG/DIP management services for over 100 hospitals.

A Single Spark Can Start a Prairie Fire. As understanding of DRG/DIP deepens,In the Implementation of Regional Models, an increasing number of pilot regions are demonstrating the value and effectiveness of localized characteristics. Nationwide, many regional healthcare security administrations have already initiated management measures such as hospital-side pre-audit of medical records, DRG grouping, and pre-settlement. The effects of regional cost reduction, efficiency improvement, and refined operations are beginning to emerge. As a state-owned enterprise deeply engaged in comprehensive services for healthcare security funds, Guoxin Health has always been a staunch supporter of national policies.Firmly Practice, has consistently been at the forefront of DRG/DIP payment system exploration and practice, supporting payment operations in multiple regions.

From February 23 to 28, 2022,Shanwei CityExperts from the Healthcare Security Administration, the Municipal Healthcare Security Center, and the Guoxin Health DRG Team conducted on-site guidance in various counties (cities, districts) and selected designated medical institutions. They identified and analyzed issues related to the quality of uploaded healthcare settlement lists for DRG-based payments, the implementation of standardized coding for fifteen items, and information systems. As a provincial pilot for DRG payment method reform in Guangdong Province, Shanwei City has made further progress in the implementation of its DRG payment method reform.

January 2022,Nanjing CityThe DRG-based health insurance payment reform has been officially implemented. “Taking the lead in China to clearly define 51 specialized TCM DRG groups and allocating more points to support TCM” — this is not only a “Nanjing characteristic” of DRG grouping, but also the best embodiment of Guoxin Health’s deep industry expertise and symbiotic partnership with clients: Introducing DRG into Traditional Chinese Medicine (TCM) places high demands on data governance and group development capabilities; Guoxin Health has worked closely with clients to successfully achieve this professional innovation by leveraging its technological advantages.

A Single Leaf Foretells the Arrival of Autumn: Seeing the Big Picture from Small Details. The pioneering implementation of innovative solutions stems from the synergistic resonance between the proactive strides of co-creators and the evolving demands of industry development. Guoxin Health continuously refines its DRG/DIP product portfolio, offering a comprehensive suite that encompasses data collection and standardization, medical record auditing and validation, disease grouping, settlement, and quality-of-care evaluation for specific conditions, along with an intelligent DRG/DIP audit system. This provides health insurance clients with an integrated solution that balances payment mechanisms with healthcare quality. From the perspective of application value, it organically integrates health insurance fund management with healthcare quality management, as well as internal cost control and performance management within medical institutions. This truly achieves a closed-loop service ecosystem for the industry, empowering medical institutions to operate with greater efficiency and lower resource consumption, while striving to address the fundamental challenges of “difficulty in accessing medical care” and “high medical costs” faced by the public.

In January of the same year,Hefei CityFollowing the initial implementation of actual DRG-based payments for inpatient services at the first batch of 17 pilot medical institutions, the second batch of 75 pilot institutions will also transition to actual payment. Data from the first pilot phase show that from January to August 2021, the total expenditures paid by local employee and resident basic medical insurance funds (including basic medical insurance and critical illness insurance) decreased by 3.12% and 5.48%, respectively, compared with the same periods in 2019 and 2020. Meanwhile, the out-of-pocket share for individuals dropped by 0.17 and 0.22 percentage points, respectively, against the same periods in 2019 and 2020. In addition, the implementation of DRG-based payment has significantly improved the quality of medical insurance data. Hefei City became the first in Anhui Province to pass the national acceptance review for the standardization work conducted by the National Healthcare Security Administration.

Underpinning this achievement is a technological strategy deployed two years in advance: Hefei City partnered with Guoxin Health to actively undertake the development of information systems for the “Intelligent Monitoring System for Medical Services” and components of the “DRG All-Disease Payment System.” In this process, leveraging DRG payment reform, Hefei established a set of scientific and efficient audit rules to address issues such as fragmented hospitalizations, lowered admission criteria, and improper coding practices (including upcoding and downcoding). Meanwhile, the city also instituted a public review system for DRG payments and a random inspection system for inpatient medical records, incorporating matters such as annual regional budgets, subgrouping schemes, calculation of disease group points, case-by-case reviews for special conditions, coefficient adjustments, and annual settlements into the scope of public review.

Compared with the DRG system, which has undergone pilot testing for a longer period, the DIP system has a shorter pilot duration and relatively limited exploratory experience. Against this backdrop, Dongying City, designated as a DIP training base by the National Healthcare Security Administration, made a prominent appearance at the inaugural China CHS-DRG/DIP Payment Conference, which drew significant attention from across the industry. With technical support from Guoxin Health,Dongying CityA “Three-Comprehensive” intelligent supervision system for medical insurance has been established, leveraging the advantages of big data technology to extend the reach of intelligent monitoring and expand intelligent regulatory functions. This system provides comprehensive, full-process, and round-the-clock coverage across pre-event, in-process, and post-event stages. In August 2021, the actual payment under the Diagnosis-Intervention Packet (DIP) system was officially implemented in Dongying City.

Since the implementation of actual payment, the total inpatient medical expenses in the city for the first three quarters of 2021 increased by 3.8% year-on-year compared to 2020, which is significantly lower than the 8.12% year-on-year increase observed in 2020 compared to 2019. Meanwhile, there was a notable reduction in out-of-pocket medical costs for patients at high-level medical institutions (such as Grade A tertiary hospitals). Taking Dongying People's Hospital as an example, after the implementation of Diagnosis-Intervention Packet (DIP) payment, the hospital saw a significant increase in various indicators in October 2021, including the number of discharges, Level 4 surgeries, and minimally invasive surgeries. Despite this growth, the average cost per discharged patient decreased by more than 1,000 yuan year-on-year.

In terms of DIP payment, Guoxin Health has successively supported cities such as Guangzhou, Huai’an, and Xiamen in their pilot programs for diagnosis-intervention packet (DIP)-based hospitalization reimbursement, helping each locality develop its own model for high-quality growth.

Currently, Guoxin Health’s third-party services for DRG/DIP payment systems cover more than 50 DRG pooling areas and over 20 DIP pooling areas across China. Meanwhile, it has provided refined DRG/DIP management services to more than 100 medical institutions in over 30 cities. This demonstrates that, by rapidly responding to dynamic adjustments in DRG grouping or payment schemes and seamlessly integrating management tools amid policy transitions across multiple DIP pilot cities, Guoxin Health exhibits strong cross-regional capabilities and high efficiency. It is able to integrate and configure optimal solutions from different regions in a manner best adapted to local characteristics.

With the full implementation of the “Three-Year Action Plan for Reforming Healthcare Insurance Payment Methods,” the DRG-based healthcare value chain, co-developed by Guoxin Health and the industry, will take root and flourish in more regions. This initiative will support medical institutions in steadily, pragmatically, and innovatively entering the new era of DRG/DIP payment systems, while promoting high-quality hospital development through comprehensive healthcare insurance governance.

From the perspective of healthy industry development, the implementation of Diagnosis-Related Groups (DRG) and Big Data Diagnosis-Intervention Packet (DIP) payment systems for inpatient care will place significant management pressure on outpatient medical insurance. In terms of the healthcare service system, one of the core objectives of reforming medical insurance payment methods is to optimize resource allocation, address the “inverted pyramid” siphon effect, and truly achieve tiered diagnosis and treatment. An analysis of the Guiding Opinions on Promoting High-Quality Development of Family Doctor Contract Services, jointly released five days prior to publication by six ministries and commissions including the National Health Commission and the National Healthcare Security Administration, reveals that through “enhancing primary healthcare service capabilities” and “improving the quality of basic public health and health management services,” as well as by “prioritizing medical service items that reflect tiered diagnosis and treatment and possess high technical and labor value,” and by “promoting capitation-based payment for outpatient visits at primary healthcare institutions to guide patients to actively seek care at the primary level,” it can be seen thatThe Essence of Medical Value Is Rooted in the Perspective of Health Governance, prioritizing the shift of focus upstream and prevention-first strategies, strengthening health promotion for key populations through standardized diagnosis and treatment, whole-process management, integration of medical care and prevention, and health education, thereby driving the formation of a “Health Community.”

Technological innovation extends beyond mere solutions; it lies more in the realization of industry value. Built upon years of accumulated knowledge assets and practical experience,In the exploration of service scenarios, Guoxin Health assisted Jinhua City in pioneering the pilot reform of APG-based outpatient payment, forming a closed loop with inpatient payment reform and facilitating the establishment of a comprehensive management model for medical insurance funds. This will also become the only solution in China currently offering full coverage from inpatient to outpatient care through the integration of “DRG + DIP + APG.”

Thus,Guoxin Health Further Explores Refined, Multi-Layered Composite Payment Services for Outpatient Medical Insurance, by implementing tiered positioning and categorized design for tertiary hospitals and primary care institutions, and leveraging three core technologies—ACG (Adjusted Clinical Groups) capitation grouping, APG (Ambulatory Patient Groups) case grouping, and population health assessment—a comprehensive outpatient payment scheme has been developed. This scheme integrates precise capitation budget allocation, refined outpatient payment, and detailed performance evaluation for contracted services. It explores the establishment of a composite payment system that adopts diagnosis-related group (DRG)-based payments for tertiary hospitals and capitation-based payments for primary care institutions, thereby driving a service mechanism in which tertiary hospitals are accountable for disease diagnosis and treatment, while primary care institutions are responsible for the health of insured individuals.

It is projected that, following the implementation of outpatient and inpatient service delivery reforms in a certain region, the annual growth rate of basic medical insurance fund expenditures for outpatient services can be controlled within 10%, significantly lower than the approximately 20% observed prior to the reform. After implementing Ambulatory Payment Groups (APG), the medical insurance fund achieved a surplus of nearly RMB 10 million compared to the initial annual budget, providing positive incentives for healthcare institutions to retain such surpluses. Meanwhile, capitation-based budgeting and lump-sum payments were implemented for primary healthcare institutions. As a result, both the proportion of enrolled patients seeking outpatient care at primary healthcare facilities and the share of primary healthcare institutions’ outpatient expenses in the total regional outpatient expenditure showed an upward trend, thereby effectively shifting medical resources and patient-seeking behavior toward the primary care level.

It can be said that in its conceptualization and practice across the entire healthcare value chain, Guoxin Health has demonstrated a profound sense of responsibility aligned with national priorities and a people-first philosophy—not only through the breadth of its business layout but also through the depth of its service offerings and the height of its industry value. Rooted in medical insurance yet extending far beyond it, the company is firmly committed to preventing “process-oriented indicators,” such as medical insurance management and clinical management, from overshadowing the “outcome-oriented indicators” that truly reflect the health outcomes of the general public.Rather than expanding the surplus of basic medical insurance funds, it is better to grow the balance of health accounts for insured individuals., thereby establishing a comprehensive health management system encompassing the entire process of “prevention, screening, diagnosis, treatment, and rehabilitation.”

This initiative has also been recognized by the highest industry regulatory authority: on March 3, 2022, the National Healthcare Security Administration announced the final results of the “Smart Healthcare Insurance Solutions Competition,” in which Guoxin Health’s “Refined Multi-Layer Composite Payment Service Solution for Outpatient Healthcare Insurance” was honored.

The ultimate aim of reform is to serve the people. The core essence of governance lies in achieving a balance of responsibilities, rights, and interests among stakeholders, establishing risk-sharing mechanisms, and fostering collaborative partnerships. Guided by this philosophy, health insurance reform must be patient-centered, with a coherent design for an “integrated health insurance” system. By establishing standardized clinical pathways to ensure rational diagnosis and treatment tailored to patients’ conditions, optimizing resource allocation, improving service quality, and incentivizing collaboration, we can ultimately achieve tripartite coordination among health insurance, healthcare delivery, and pharmaceuticals, thereby steering the healthcare service system toward sustainable and sound operation.Guoxin Health’s DRG-based full medical value chain services enable simultaneous cost control, expense reduction, quality assurance, and efficiency improvement.Leveraging “pre-event, in-event, and post-event” closed-loop management and real-time intervention to unravel the “black box” of healthcare management.

Standing at the outset of the “New Three-Year Plan for Healthcare Security Reform,” the industry urgently needs to leverage the typical practices and advanced experiences from national pilot cities and demonstration regions—such as the “Jinhua Model,” “Dongying Template,” and “Nanjing Characteristics,” jointly established by China Reform Health Care and the industry—to play a demonstrative and leading role. By integrating local practices, we can create a portfolio of development opportunities. Only through collaboration among government, industry, academia, research, and application; coordinated linkage among healthcare security, medical services, and pharmaceuticals; and data governance driven by digital intelligence, can we realize the intrinsic value of healthcare and answer the fundamental question of high-quality development: ensuring fair and equitable health security services for all.