Study on the reform effect of payment based on curative effect value for TCM dominant diseases in China: an...

Anorectal diseases, as prevalent and recurrent conditions for which Traditional Chinese Medicine (TCM) demonstrates distinct advantages, are closely associated with patients' quality of life. The current Diagnosis-Related Group (DRG) payment system struggles to fully capture the unique value of TCM, whereas Value-Based payment models grounded in therapeutic efficacy offered a viable pathway for reforming payment mechanisms for TCM-dominant diseases.

This study included a total of 5,304 patients diagnosed with hemorrhoids, anal fistulas, and other anorectal diseases who were admitted to the Proctology Department of a tertiary hospital in Hunan Province from August 2022 to August 2024. Interrupted Time Series (ITS) analysis was conducted, featuring two intervention points: January 2023 (DRG reform) and September 2023 (Value-Based payment reform). Nine indicators spanning three dimensions-Resource consumption (average inpatient cost per case, average length of stay), Cost structure (average TCM preparation cost per case, average TCM drug cost per case, average TCM diagnostic and treatment cost per case) and TCM characteristics (proportion of preparation cost in total drug revenue, proportion of TCM drug cost in total drug revenue, proportion of TCM diagnostic and treatment cost, proportion of discharged patients treated mainly with TCM)-were analyzed to evaluate both short-term and long-term effects of the dual policies, supplemented by age subgroup analysis.

After DRG reform, average inpatient cost per case (instantaneous decrease of CNY 1,131.27, p = 0.007) and average length of stay (instantaneous decrease of 1.69 days, p = 0.022) significantly decreased. However, average TCM drug cost per case exhibited an upward trend (an increase of CNY 19.46 per half-month, p < 0.001), and the proportion of discharged patients treated mainly with TCM decreased (a 2.16% reduction per month, p = 0.006) Following the implementation of Value-Based payment, average inpatient cost per case decreased instantaneously by CNY 910.82 (p = 0.006), and the average length of stay decreased instantaneously by 1.30 days (p = 0.024). Notably, the average TCM diagnostic and treatment cost per case increased significantly (an increase of CNY 100.21 every half month, p < 0.001); the proportion of TCM diagnostic and treatment cost in total revenue rose (an increase of 0.73% every half month, p < 0.001); and the proportion of discharged patients treated mainly with TCM increased instantaneously by 22.23% (p < 0.001). Subgroup analysis showed that the group under 60 years of age had a more significant response to the policies.

Under the DRG framework, the Value-Based payment reform tied to therapeutic efficacy can effectively curb medical costs while incentivizing the application of TCM-specific services. Nevertheless, sustained monitoring is needed to evaluate its long-term impacts, particularly regarding age-related disparities in outcomes. These findings offer insights for refining TCM-inclusive medical insurance reimbursement policies.