HEALTH INSURANCE
Year:2019 | Volume:1 | Issue:4 |Papers Count:8

Introduction: The design of a benefit package is a key tool to direct health systems to the universal health coverage. Decision making on service prioritization takes into account information on cost-effectiveness, the impact of financial protection, and equity in access to services. To this end, health technology assessment (HTA), which has legal backing and evidence-based protocols, can be used. Therefore, the current study aimed at determining the role of health technology assessment in the package of designing. Methods: The current review study collected and analyzed the available evidence. The search was conducted to identify related studies in the electronic database (Cochrane Library, Scopus, PubMed, Trip, and Google Scholar) without any time limit and by August 2018 with proper keywords and strategies for each database. Results: Out of the 132 studied articles, only two studies were selected according to the inclusion and exclusion criteria. These two studies described the experience of Thailand and the Netherlands regarding the role and application of health technology assessment in determining the benefits package. The Thai study described the hierarchy and sequence of how to determine the choice of services to be included in the benefit package, and the Dutch study referred to the policy and implementation levels and the infrastructure needed to establish a health technology assessment system to determine the benefit package. Conclusions: According to the advancement of technologies (drugs, equipment, and diagnostic tests), cost growth, and the lack of resources in the health system, it is suggested to select a benefit package focusing on health technology assessment studies. HTA is useful to inform health system decision makers about package coverage since it increases transparency, participation, and accountability in the process. Accordingly, a five-step model is recommended to determine the benefit package.

Introduction: Today, the increase of costs is one of the challenges for health systems. The current study aimed at investigating the health costs trend in Iran and the policies adopted to manage them better. Methods: The current descriptive-analytical study was conducted in two phases: 1-General review of the Iran's health system costs trend based on National Health Accounts. 2-identification of experts` views on factors leading to increasing health costs in Iran and the strategies used to manage these costs better in the last few decades, through simple and accessible sampling and semi-structured interviews. Data analysis was performed through deductive / inductive hybrid framework, and a thematic framework was developed during the analysis. The NVivo software was used to manage and categorize data. Results: Health costs in Iran increased over the past years, and various strategies are employed to manage these costs among which extending primary health care, expanding insurance coverage, implementing a family physician program in small towns, villages, and among nomads are the most important ones. Conclusions: Despite the adoption of some strategies to control the health costs in Iran in different periods, increase in health costs is a concern. Therefore, health policy makers need to make and implement appropriate polices in order to manage these costs better, while improving access, quality of service, and eventually welfare of patients.

Introduction: The rate of out of pocket in health services has particular importance in health system. The aim of this study was to assess the rate of out of pocket and also the satisfaction with reimbursement process. Methods: This study was across-sectional one which was done in 2018. At all 1177 war survivors and their families whom were covered by supplementary insurance were studied and they were selected randomly. In this study the questionnaire which was used in similar previous study, used for collecting data. Results: At all 1177 veterans, their families and martyrs' families were studied. About 53 percent (622 persons) of them had paid out of pocket for health services during the one year. In reimbursement process the satisfaction of 622 studied persons with the waiting time, providers, service place and repayment process was 33%, 69%, 54% and 39%. respectively. Also the waiting time and situation of cost repayment effected on satisfaction with reimbursement process. Conclusions: Base on this study results decreasing the rate of out of Pocket Payment and increasing the satisfaction with reimbursement Process are important. For next study it is recommended appropriate project resulted in strategies for improving reimbursement Process.

Introduction: Performing medical interventions over the real needs of patients, not only a waste of resources and more costs, but also threaten people's health. Identifying, removing, and preventing the factors that affect unnecessary medical interventions have the main role in controlling them. Therefore, the current study aimed at exploring factors affecting this phenomenon from the viewpoints of Iranian health system experts. Methods: To collect data, focus group discussions, and semi-structured face-to-face interviews were conducted. The participants were selected through purposeful sampling. Related documents were also collected. Content analysis (inductive-deductive) was used for data analysis. Results: Four themes and 16 subthemes were extracted. Evidence-informed policy making interventions in payment, insurance, tariff, and education systems, management of conflict of interests, culture making, and informing the community are the factors influencing the control and decrease of this phenomenon consequences. Conclusions: The effort to identify factors influential on unnecessary medical interventions can help to establish accurate supervision and reporting system and cause preventive interventions to reduce more unnecessary costs and inappropriate outcomes resulted from this phenomenon.

Introduction: The Iran Health Insurance Organization (IHIO) was established to develop the Iran Health Insurance sector. Currently, this organization lacks the adequate funding and faces challenges in providing the required resources due to the imposed unilateral sanctions; therefore, it is necessary that this organization takes proper measures within the framework of state policies regarding the resilience economy in order to finance itself and cover more population in accordance with the Iranian operating laws. The present study aimed at proposing a financing model for the IHIO based on the resilience economy. Methods: The current qualitative study was based on the grounded theory (GT), and the data were collected from framework documents, open and in-depth interviews, and a review of the lectures given by 31 experts. The validity was first examined by the interviewees and then approved by the experienced professors. The reliability was determined to be 73% via process auditing. The data were analyzed through a GT-based methodology and constant comparison over three stages of open, axial, and selective coding. Results: The examination of the qualitative date revealed many factors in action in the IHIO’ s financing process and that this organization needs to review and revise its structure and methodology. According to the current sanctions and lack of funds, the IHIO should change the following seven components within the framework of notified resilience economy policies: organizational management, financial management, research, structural change, cultural revision, and regulatory procedures. Conclusions: There is a remarkable increase in the IHIO’ s insured parties recently, and more people receive healthcare services. Thus, it is highly essential to propose a model to change the IHIO’ s approach towards commercialization and make it produce more revenues and finance in accordance with the current economic situation in Iran.

Introduction: A significant amount of treatment cost is paid by health insurance organization. Insurance companies mostly use reliable people to audit documents, but due to the very high number of documents and the limitation of time and human resource, it is almost impossible to consider documents carefully and more importantly, some infringements are not identifiable according to only one document, but identifiable by accumulation of documents and intelligent analysis based on data mining. Detection of beneficial referral (self-referral and kickback) that a doctor refers a patient to a specific pharmacy that has benefits for him, is one of these things. Methods: In the current study, data pool was prepared using Tehran Health Insurance data until 2017 and then after eliminating faulty data, according to network mining methods, actions were taken to detect anomalistic referrals on the network, data filtering, and weighing the edges of the network based on the views of reliable people. This method was implemented in the Knime environment and a short list was presented to monitoring department of the health insurance organization. Results: In this research, according to the importance of detected interactions during network mining‘ s process between doctors and pharmacies, and using visual tools in Knime, 73 doctors were detected that had meaningful relation with 26 pharmacies. Conclusions: Inspectors of health insurance organization can have a more accurate and more effective examination with spending less time and human resource according to examination patterns based on network mining and visualization.

Introduction: A significant amount of treatment cost is paid by health insurance organization. Insurance companies mostly use reliable people to audit documents, but due to the very high number of documents and the limitation of time and human resource, it is almost impossible to consider documents carefully and more importantly, some infringements are not identifiable according to only one document, but identifiable by accumulation of documents and intelligent analysis based on data mining. Detection of beneficial referral (self-referral and kickback) that a doctor refers a patient to a specific pharmacy that has benefits for him, is one of these things. Methods: In the current study, data pool was prepared using Tehran Health Insurance data until 2017 and then after eliminating faulty data, according to network mining methods, actions were taken to detect anomalistic referrals on the network, data filtering, and weighing the edges of the network based on the views of reliable people. This method was implemented in the Knime environment and a short list was presented to monitoring department of the health insurance organization. Results: In the current study, according to the importance of detected interactions during network mining process between doctors and pharmacies, and using visual tools in Knime, it was observed that 73 doctors had significant relationships with 26 pharmacies. Conclusions: Inspectors of health insurance organization can have a more accurate and more effective examination by spending less time and human resource according to examination patterns based on network mining and visualization.

Introduction: The boundaries of providing health care to patients are so widespread that providing all these services in the form of health insurance is not feasible, at least economically. In many countries, supplementary insurance is used to provide health care. The current study aimed at determining the effective factors on organizations supporting the supplementary health insurance system in the selected countries and Iran. Methods: The current study had descriptive-analytical, cross sectional design with applied approach. The study data were collected using a questionnaire to check texts and field studies. Reliability of the questionnaire was confirmed by experts and limited content validity method. The data were transferred into SPSS version 25 to analyze descriptive and inferential statistics. Then, the exploratory factor analysis was performed with AMOS software. Results: Men with a postgraduate degree and 17 years of service experience contributed to the current study. Supportive organizations such as the Ministry of Health and Medical Education, and the targeting subsidy organization, had the least impact on supplementary care insurance. Conclusions: The results of the current study indicated that the Ministry of Health and Medical Education played a significant role in optimal utilization of supplementary health insurance and improved patient satisfaction as well as community health.