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Ahad Bakhtiari, Nader Jahanmehr, Reyhan Izadi,
Volume 4, Issue 2 (8-2021)
Abstract

Introduction: The increasing costs of health care systems will be reduced significantly if preventive services are developed at levels of prevention. The experience of countries in the world in using preventive services and raising awareness of the related benefits can play a motivating role among the stakeholders in implementing such a policy in Iran. This study aimed to identify the most critical interventions covered by insurance organizations active in the world's health systems.
Methods: This study is a systematic review of studies related to a diverse range of preventive services in the health system and insurance organizations and provides evidence-based information on the benefits of developing this category of services and interventions. The study was done by defining the search keywords in the main database between December 30, 2004, to January 2019, carried out in 2020.
Results: Different categories of disease prevention services are being offered around the world that has brought significant benefits to communities. Among the most important benefits of developing such services are reducing costs, reducing health inequalities, increasing quality of life, and higher job productivity. In addition, different groups in the community, such as specific occupations or specific age and gender groups, while having specific preventive services, have developed their insurance policies that provide related preventive services. Therefore, insurance organizations play an essential role in the benefit and effective coverage of preventive services in communities, which has made the possibility of a person with insurance to use preventive services far more than people without insurance or with treatment-oriented insurance.
Conclusion: The benefits of preventive services in the world health systems have been proven, and some countries have adopted a law requiring the provision of such services to insurance organizations. On the other hand, insurance companies are facing increasing health costs, which has led the attention of policy makers of insurance companies to control costs. With the relevant evidence documented, it is time to move to preventive services.

Leila Izadi, Shaban Elahi, Alireza Hassanzadeh, Sanaz Shafiee,
Volume 7, Issue 2 (Summer 2024)
Abstract

Introduction: Health insurance, as one of the pillars of the health system and responsible for financially protecting individuals in society against the risk of diseases, also requires an effective monitoring system. This research aims to examine the issues of supervision in health insurance and provide steps to achieve a monitoring and evaluation framework towards Intelligence supervision.
Methods: In this study, data were collected from qualitative interviews with health insurance experts and the analysis of secondary data. The proposed PAVA model in health insurance was designed and evaluated based on key indicators extracted from previous studies. Experts were selected using the snowball method until data saturation was reached, resulting in a total of 24 interviews. During the interviews, notes were taken, and the interviews were recorded and analyzed using Atlas.ti8 software. Based on the steps of PAVA and business intelligence, the steps to create the PAVA framework in health insurance were presented.
Results: The health insurance organization has various systems such as medical records, the Omid system, Didban system, eligibility assessment, business partner systems, and electronic prescription. Monitoring is conducted both in-person and remotely. Data analysis from the interviews revealed that monitoring in health insurance faces several challenges. These challenges include the need for data collection, aggregation, and cleansing, the need for data analysis, and the need for an integrated and interactive monitoring system. Specifically, issues such as the lack of comprehensive electronic data, the need for better access to data, and the need for more precise data analysis to identify fraud and misuse were identified.
Conclusion: The results of this study can be used by senior managers of health insurance organizations, managers and experts in the supervision departments, IT managers and experts, organizational knowledge managers, and knowledge workers of the organization, as well as the National Health Insurance Research Center. These findings help improve the efficiency and effectiveness of the supervision system, thereby enhancing the overall performance of the health insurance organization


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