随着医疗服务加速向虚实融合、持续交互与平台化形态演进，以元宇宙医学为代表的新型医疗范式，正对根植于传统线下诊疗逻辑的支付体系提出根本性质疑与结构性挑战。不同于早期数字医疗对支付渠道的简单线上化迁移，元宇宙医学通过重塑服务过程、价值创造与责任网络，暴露了现有支付体系在过程计量、实时协调与多主体分配上的深层局限。传统上将支付视为“中性结算基础设施”的理论预设，已难以解释和支撑元宇宙医学的发展需求。本文突破“工具中性”视角，将支付体系重新定位为医疗治理的内生性制度安排。通过制度分析与比较制度分析，系统审视了现有支付工具（如CBDC、稳定币）在应对虚实融合、过程化服务时的适配边界，并构建了以“制度合规性—技术灵活性—治理嵌入深度”为核心的三维分析框架。 研究发现，元宇宙医学驱动支付体系发生三重根本性转变：功能上从事后结算工具转向过程协调机制；设计逻辑上从统一规则转向动态可编程协议；制度角色上从配套支撑转向核心治理基础设施。基于此，本文提出面向元宇宙医学的支付体系重构是一个跨层级的系统工程，需要在制度层确立其治理属性，在机制层发展按过程与效果付费的动态模型，在技术层审慎利用可编程与协议化能力作为支撑。研究结论表明，支付问题的解决是元宇宙医学可持续发展的先决条件，其演化路径并非单一技术替代，而是技术可能性、医疗价值理性与制度约束协同互构的复杂过程。这为理解数字时代医疗服务的组织变革与制度创新提供了新的理论视角。

The rapid evolution of healthcare services toward virtual– physical integration, continuous interaction, and platform-based organization is fundamentally challenging the premises of traditional healthcare payment systems, which are grounded in episodic, in-person care. Unlike the mere digitization of payment channels in early digital health, metaverse medicine reconstitutes service delivery, value creation, and accountability networks, thereby exposing deep-seated structural inadequacies of existing payment systems in process measurement, real-time coordination, and multi-actor value distribution. The conventional theoretical presumption of payments as a “neutral settlement infrastructure” has become insufficient to explain and support the development of metaverse medicine. Moving beyond the “tool-neutrality” perspective, this paper repositions the payment system as an endogenous institutional arrangement within healthcare governance. Employing institutional analysis and comparative institutional analysis, it systematically examines the applicability limits of current payment instruments (e.g., CBDCs, stablecoins) in virtual– physical, process-oriented service contexts. It constructs a three-dimensional analytical framework centered on “institutional compliance – technical flexibility – depth of governance embeddedness.” The study reveals that metaverse medicine drives three fundamental shifts in the payment system: in function, from an ex-post settlement tool to a process coordination mechanism; in design logic, from uniform rules to dynamic, programmable protocols; and institutionally, from a supporting ancillary to a core governance infrastructure. Consequently, this paper argues that restructuring the payment system for metaverse medicine constitutes a cross-layer, systemic endeavor. It requires, at the institutional level, affirming its governance role; at the mechanism level, developing dynamic models for payment based on process and outcomes; and at the technical level, prudently leveraging programmable and protocol-based capabilities as enablers. The conclusion underscores that resolving payment issues is a prerequisite for the sustainable development of metaverse medicine. Its evolution is not a matter of simple technological substitution but a complex process of co-construction among technological possibilities, medical value rationality, and institutional constraints. This analysis provides a novel theoretical lens for understanding healthcare’s organizational and institutional transformations in the digital age.