International Journal of Health Policy and Management

International Journal of Health Policy and Management

Association Between China’s DRG Reform and Value-Based Healthcare Orientation: Evidence From Inpatients With Acute Myocardial Infarction and Cancer in Tertiary Hospitals in Western China

Articles in Press

Document Type : Original Article

Authors
Haoran Li 1, 2
Fukun Zhu 1
Tao Xie 3
Ning Zhang 4
Austen El-Osta 2
Zhonghan Wang 1
Ying Mao 1
1 School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
2 School of Public Health, Imperial College London, London, UK
3 School of Political Science and Public Administration, Wuhan University, Wuhan, China
4 Vanke School of Public Health, Tsinghua University, Beijing, China
Abstract
Background
Implementing diagnosis-related groups (DRGs) reform under the guidance of value-based healthcare (VBH) is of great significance for China to curb the rapid rise of medical costs and promote the allocation and utilization of medical resources. However, current research evaluating the effectiveness of China’s DRGs reform lacks a valuebased oriented approach to healthcare and has not yet explored whether different types of diseases and population characteristics will affect policy implementation.

Methods
A total of 16 564 acute myocardial infarction (AMI) and 74 356 cancer inpatients were included in this singlecenter study during 2018-2022. Interrupted time series models were used to estimate post-reform level and slope changes. Exploratory subgroup analyses were conducted by gender, age, and disease type. Hospital-level outcomes included riskadjusted success per cost (SPC), cost per success (CPS), and net monetary benefit (NMB). Individual-level outcomes included total hospitalization cost, length of stay, mortality, successful outcomes, and 30-day readmission.

Results
DRG reform was associated with changes in VBH indicators, with AMI mainly showing slope changes and cancer mainly showing level changes. However, individual-level analyses showed that some clinical outcomes did not improve consistently, which differed from the hospital-level results.

Conclusion
The findings suggest that DRG reform was associated with changes in selected hospital-level VBH indicators, while some individual-level clinical outcomes did not show consistent improvement. Future payment reform should combine disease-specific clinical pathways, stronger risk adjustment, and routine monitoring of patient-level quality outcomes, especially for acute and high-risk conditions.
Keywords
Value-Based Healthcare
Diagnosis-Related Groups
Interrupted Time Series
Acute Myocardial Infarction
Cancer
Western China
  1. Miller T. Redefining health care: creating value-based competition on results. Health Aff (Millwood). 2006;25(5):1448-1450. doi:10.1377/hlthaff.25.5.1448
  2. Porter ME. Health care 2009: a strategy for health care reform - toward a value-based system. N Engl J Med. 2009;361(2):109-112. doi:10.1056/NEJMp0904131
  3. Porter ME. Value-based health care delivery. Ann Surg. 2008;248(4):503-509. doi:10.1097/SLA.0b013e31818a43af
  4. Douglas AO, Senkaiahliyan S, Bulstra CA, Mita C, Reddy CL, Atun R. Global adoption of value-based health care initiatives within health systems: a scoping review. JAMA Health Forum. 2025;6(5):e250746. doi:10.1001/jamahealthforum.2025.0746
  5. World Bank, World Health Organization. Healthy China: Deepening Health Reform in China: Building High-Quality and Value-Based Service Delivery. Washington, DC: World Bank; 2019. doi:10.1596/978-1-4648-1263-7
  6. Yip WC, Hsiao W, Meng Q, Chen W, Sun X. Realignment of incentives for health-care providers in China. Lancet. 2010;375(9720):1120-1130. doi:10.1016/s0140-6736(10)60063-3
  7. Wang X, Tao Y, Gao S, et al. Effects of DRG/DIP payment reform on hospital pharmacy administration and pharmaceutical services in China: a multicenter cross-sectional study. Front Public Health. 2025;13:1585279. doi:10.3389/fpubh.2025.1585279
  8. Wang J-Y, Chen M-E, Wei X-X, Lu X-Z, Zhu Y-R, Yang J-Y. Do the diagnosis-related group payment reforms have a negative impact?-an empirical study from Western China. Front Public Health. 2025;13:1550480. doi:10.3389/fpubh.2025.1550480
  9. Zou K, Li HY, Zhou D, Liao ZJ. The effects of diagnosis-related groups payment on hospital healthcare in China: a systematic review. BMC Health Serv Res. 2020;20(1):112. doi:10.1186/s12913-020-4957-5
  10. Zhang T, Liu J, Wang X, Liu C. County hospital responses to funding reforms in zhejiang, China: an interrupted time-series analysis. Health Syst Reform. 2023;9(1):2258770. doi:10.1080/23288604.2023.2258770
  11. Wang H, Xiang X. Evaluating the effect of health insurance reform on health equity and financial protection for elderly in low- and middle-income countries: evidences from China. Global Health. 2024;20(1):57. doi:10.1186/s12992-024-01062-8
  12. Zhang L, Sun L. Impacts of diagnosis-related groups payment on the healthcare providers' behavior in China: a cross-sectional study among physicians. Risk Manag Healthc Policy. 2021;14:2263-2276. doi:10.2147/rmhp.S308183
  13. Ding S, Jiang X, Zheng Y, et al. Improving the clinical ability and quality of endocrinology department with diagnosis-related groups tool. Ann Transl Med. 2022;10(4):167. doi:10.21037/atm-22-147
  14. Liu X, Liu F, Wang L, Wu M, Yang L, Wei L. Performance evaluation of medical service for breast cancer patients based on diagnosis related groups. BMC Health Serv Res. 2021;21(1):496. doi:10.1186/s12913-021-06439-8
  15. Jian W, Lu M, Liu G, Chan KY, Poon AN. Beijing's diagnosis-related group payment reform pilot: Impact on quality of acute myocardial infarction care. Soc Sci Med. 2019;243:112590. doi:10.1016/j.socscimed.2019.112590
  16. Luo M, Li H, Li R, Wu Y, Lan Y, Xie S. The impact of DRG payment reform on inpatient costs for different surgery types: an empirical analysis based on Chinese tertiary hospitals. Front Public Health. 2025;13:1563204. doi:10.3389/fpubh.2025.1563204
  17. Li M, Yang J, Shen J, Xu J, Gu D. Analysis of the impact of China Healthcare Security diagnosis-related groups payment reform on the hospitalization costs for uvulopalatopharyngoplasty in obstructive sleep apnea patients at Hospital C. BMC Health Serv Res. 2024;24(1):1514. doi:10.1186/s12913-024-11997-8
  18. Iribarren SJ, Cato K, Falzon L, Stone PW. What is the economic evidence for mHealth? A systematic review of economic evaluations of mHealth solutions. PLoS One. 2017;12(2):e0170581. doi:10.1371/journal.pone.0170581
  19. Peresu E, De Graeve D, Heunis JC, Kigozi NG. Cost-consequence analysis of ambulatory clinic- and home-based multidrug-resistant tuberculosis management models in Eswatini. PLoS One. 2024;19(4):e0301507. doi:10.1371/journal.pone.0301507
  20. Saruta M, Kawaguchi I, Ogawa Y, et al. Assessing the economics of biologic and small molecule therapies for the treatment of moderate to severe ulcerative colitis in Japan: a cost per responder analysis of upadacitinib. J Med Econ. 2024;27(1):566-574. doi:10.1080/13696998.2024.2333683
  21. Shafrin J, May SG, Skornicki M, et al. Use of net monetary benefit analysis to comprehensively understand the value of innovative treatments. Value Health. 2016;19(7):A731. doi:10.1016/j.jval.2016.09.2202
  22. Bottomley C, Ooko M, Gasparrini A, Keogh RH. In praise of Prais-Winsten: An evaluation of methods used to account for autocorrelation in interrupted time series. Stat Med. 2023;42(8):1277-1288. doi:10.1002/sim.9669
  23. Werdin S, Fink G, Rajkumar S, et al. Impact of four integrated self-management interventions on psychiatric readmissions in patients at suicide risk: An interrupted time series analysis in Switzerland. J Affect Disord. 2025;388:119604. doi:10.1016/j.jad.2025.119604
  24. Hategeka C, Ruton H, Karamouzian M, Lynd LD, Law MR. Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review. BMJ Glob Health. 2020;5(10):e003567. doi:10.1136/bmjgh-2020-003567
  25. Bernal JL, Cummins S, Gasparrini A. Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol. 2017;46(1):348-355. doi:10.1093/ije/dyw098
  26. West NKD. A Simple, Positive Semi-Definite, Heteroskedasticity and Autocorrelation Consistent Covariance Matrix. Econometrica. 1987;55(3):703-708.
  27. Davidian M. Hierarchical Linear Models: Applications and Data Analysis Methods. Publications of the American Statistical Association. 2002;98(463):767-768.
  28. Dong X, He X, Wu J. Can DRG payment under global budget with price adjustment curb the soaring healthcare costs? Insights from China's reform and its underlying mechanism. BMC Public Health. 2025;25(1):3891. doi:10.1186/s12889-025-25236-0
  29. Du L, Fang S, Zhang Q. Trend analysis of medical expenses under DRG payment reform in China. Sci Rep. 2025;15(1):36961. doi:10.1038/s41598-025-20902-0
  30. Peng Z, Chen X, Lu X, Coyte PC, Sha X. The trade-off between cost containment and quality enhancement under the DRG payment model. BMC Health Serv Res. 2026;26(1):188. doi:10.1186/s12913-026-14006-2
  31. Dong X, Wu J. Does DRG-based payment lead to unintended effects on care quality? A case under global budget with price adjustment in China. BMC Health Serv Res. 2025;25(1):1448. doi:10.1186/s12913-025-13625-5
  32. Greenland S, Morgenstern H. Ecological bias, confounding, and effect modification. Int J Epidemiol. 1989;18(1):269-274. doi:10.1093/ije/18.1.269
  33. Jackson C, Best N, Richardson S. Improving ecological inference using individual-level data. Stat Med. 2006;25(12):2136-2159. doi:10.1002/sim.2370
  34. Kara P, Valentin JB, Mainz J, Johnsen SP. Composite measures of quality of health care: Evidence mapping of methodology and reporting. PLoS One. 2022;17(5):e0268320. doi:10.1371/journal.pone.0268320
  35. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177. doi:10.1093/eurheartj/ehx393
  36. Guerchicoff A, Brener S, Fahy M, et al. Impact of Delay to reperfusion on Infarct Size and Clinical Outcomes in Patients with STEMI: The INFUSE-AMI Trial. J Am Coll Cardiol. 2013;62(18):B75-B75. doi:10.1016/j.jacc.2013.08.965
  37. Huang X, Rosenthal MB. Overuse of cardiovascular services evidence, causes, and opportunities for reform. Circulation. 2015;132(3):205-214. doi:10.1161/circulationaha.114.012668
  38. Katz DA, Williams GC, Brown RL, et al. Emergency physicians' fear of malpractice in evaluating patients with possible acute cardiac ischemia. Ann Emerg Med. 2005;46(6):525-533. doi:10.1016/j.annemergmed.2005.04.016
  39. Rathore SS, Curtis JP, Chen J, et al. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study. BMJ. 2009;338:b1807. doi:10.1136/bmj.b1807
  40. Bynum J, Lewis V. Value-based payments and inaccurate risk adjustment-who is harmed? JAMA Intern Med. 2018;178(11):1507-1508. doi:10.1001/jamainternmed.2018.4142
  41. Park JH, Kang D, Nam SJ, et al. Effectiveness of a clinical pathway for breast cancer patients undergoing surgical operation on clinical outcomes and costs. Quality Improvement in Health Care. 2024;30(1):120-131. doi:10.14371/qih.2024.30.1.120
  42. van Hoeve JC, Vernooij RWM, Lawal AK, et al. Effects of oncological care pathways in primary and secondary care on patient, professional, and health systems outcomes: protocol for a systematic review and meta-analysis. Syst Rev. 2018;7(1):49. doi:10.1186/s13643-018-0693-x  
International Journal of Health Policy and Management

Articles in Press, Accepted Manuscript
Available Online from 14 July 2026

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  • Received Date 09 December 2025
  • Revised Date 06 June 2026
  • Accepted Date 12 July 2026
  • First Published Date 14 July 2026
  • Published Date 14 July 2026