DRG/DIP Payment 3.0 Adjustment Plan Released - What Impact Does It Have on the Pharmaceutical Industry?

Daily Economic News Reporter | Zhang Hong Daily Economic News Editor | Zhang Yiming

On March 20, the National Healthcare Security Administration announced the adjustments to the Version 3.0 of the Diagnosis-Related Group (DRG) payment grouping plan.

In July 2024, the National Healthcare Security Administration issued Version 2.0 of the DRG payment grouping plan, which refined and optimized the 1.0 version released in 2020. In August 2025, the administration formulated the “Interim Measures for the Management of Medical Insurance Payment by Diagnosis-Related Groups,” clarifying that the grouping plan will generally be adjusted every two years.

The Daily Economic News (hereinafter referred to as “the reporter”) notes that this adjustment merges or splits some disease groups, while also considering medical development and the application of new technologies. To accommodate the widespread use of robot-assisted orthopedic surgeries, a new dedicated code “17.4100 Open Robotic Assistance Procedures” has been added to the disease groups under review. Special focus has been placed on groups with high clinical demand, such as “M17 Knee Joint Diseases,” “S32 Lumbar Spine and Pelvic Fractures,” and “S72.0 Femoral Neck Fractures.”

According to the latest news from the National Healthcare Security Administration, Version 3.0 of the DRG payment grouping plan is expected to be released this July and is planned to be officially implemented in January 2027.

What impacts will this have on the industry?

Which adjustments are worth noting? How will this impact the pharmaceutical and healthcare industries?

Senior healthcare insurance expert Tian Haoling told the reporter that the fundamental logic of the DRG 3.0 adjustment remains unchanged. The more detailed grouping—such as by disease type, treatment method, and severity—maximizes the benefits for all major stakeholders involved in healthcare payment, allowing the fund’s efficiency to be fully realized. The biennial adjustment cycle and iterative updates of the grouping version not only promote rapid policy implementation but also enable precise, dynamic valuation of medical technologies.

She believes there are several key directions worth attention in this disease grouping adjustment.

First, refined surgical grouping will drive innovation in high-value consumables and surgical techniques.

Separately grouping bilateral/unilateral or combined surgeries (such as bilateral knee replacements or combined liver-pancreas resections) avoids treating high-resource-consuming cases the same as ordinary cases. This means high-value consumable companies need to develop products better suited for complex surgical scenarios, like specialized prostheses for bilateral joint replacements. Hospitals will prefer cost-effective consumables, shifting industry focus from “price competition” to “value competition.” The value of advanced technologies like surgical robots will be recognized more accurately, providing related companies with greater market opportunities.

Second, incorporating full-course management into grouping creates new opportunities for innovative drugs and off-site markets.

Including the entire treatment pathway for malignant tumors—such as radiotherapy, chemotherapy, targeted therapy, and immunotherapy—allows the value of innovative drugs to extend from inpatient use to full-course management, facilitating the promotion of anti-tumor medications. This can be achieved through dual-channel outpatient pharmacies providing in-depth services to insured patients with needs.

Third, differentiating disease weights based on populations such as children, chronic disease patients, the elderly, rare diseases, and severe cases, while also refining groups for critical and severe cases. This will stimulate R&D enthusiasm among related pharmaceutical companies and better focus on product value.

Exploring the integration of DRG and DIP

Guidance team leader He Yazhen explained that DIP (Diagnosis-Intervention Packet) is a regional point-based total budget and diagnosis-related payment method, used by healthcare insurance for inpatient cost settlement at designated medical institutions. It leverages big data to establish a healthcare payment management system, including regional total budgets, disease groupings, payment standards, cost settlement, and supervision. It features significant advantages in theory, grouping strategies, and technical methods, representing an original Chinese healthcare payment model with distinctive characteristics of the era.

This adjustment is based on recent real settlement data, maintaining the basic rule of “main diagnosis + main procedure (+ related surgical procedures).” About 80% of disease groups will be automatically clustered according to this rule. Meanwhile, the grouping process is optimized, following the overall principle of “coarse when coarse, fine when fine,” exploring the integration of DRG (Diagnosis-Related Groups) and DIP. This includes adopting practices from DRG grouping, such as exclusion lists and preliminary grouping, to refine grouping rules through merging, splitting, and auxiliary factors.

“Coarse when coarse” refers to merging related surgical procedures and diagnoses into groups; “fine when fine” involves more detailed grouping based on clinical practice, considering individual features as auxiliary factors. Specifically, this includes four aspects: first, merging related procedures performed during the same hospitalization that meet clinical standards; second, merging diagnoses with similar procedures and resource consumption; third, subdividing diagnoses with significant resource differences due to severity; and fourth, grouping based on auxiliary factors like age, complications, and severity when primary diagnosis codes do not fully reflect resource use.

Tian Haoling pointed out that the implementation of DRG 3.0 will promote hospitals toward lean operations—through precise clinical pathway management, cost accounting for disease groups, and quality control of medical records—reshaping a performance system centered on “quality first, cost controllable.” For pharmaceutical companies, this will mark the end of the “price war” era—innovative drugs will need to demonstrate clinical value through real-world data and gain market access via dynamic negotiations, special agreements, and insurance catalog pathways. Mature drugs should focus on their advantageous disease groups and collaborate with clinicians to optimize product structures. Ultimately, patients will benefit from transparent medical costs and balanced resource allocation, ensuring sustainable healthcare funds, improving service efficiency, and encouraging innovation in the pharmaceutical industry to maximize win-win outcomes for insurance, healthcare, pharmaceuticals, and patients.