The Effectiveness, Experience, and Prospects of Traditional Chinese Medicine DRG Payment Reform in Nanjing

In the wave of diagnosis related groups (DRG) payment reform, the characteristics and value of traditional Chinese medicine (TCM) have not been fully reflected. Since 2022, Nanjing has been pioneering the TCM-DRG payment, and the effectiveness of the reform urgently needs systematic evaluation. This article evaluates the effectiveness of the TCM-DRG payment reform in Nanjing from three dimensions: service accessibility, quality and effectiveness reliability, and cost controllability. The results show that after policy implementation, diseases of TCM characteristics included in TCM-DRG payment show significant advantages in service accessibility, quality and effectiveness reliability, and cost controllability overall. The institutional coverage, disease group coverage, and number of disease group cases have all significantly increased, the quality and efficiency of TCM medical services have significantly improved, and the support of the medical insurance fund for diseases of TCM characteristics included in the DRG payment has been increasing year by year. The experience of the TCM-DRG payment reform in Nanjing mainly lies in the combination of disease and syndrome, scientific coding, incentive measures, and data empowerment, but there are still shortcomings in group balance, syndrome classification, and value embodiment. In the future, it is recommended to further expand the scope of DRG payment and improve service accessibility; strengthen management inside medical institutions and improve quality and effectiveness reliability; strengthen the guidance of medical insurance payment policies and improve the controllability of expenses; explore the value evaluation system for TCM efficacy and improve payment efficiency.