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Showing 68 results for Health Insurance
Manal Etemadi, Saeed Shahabi, Mahan Mohammadi,
Volume 4, Issue 4 (3-2022)
Volume 4, Issue 4 (3-2022)
Abstract
Introduction: Given the high expenditure of universal long-term care for elderly and the challenge of financing it for most countries, this article intends to examine leading countries to provide solutions for Iran.
Methods: The present study is a comparative study using domain review and examines the evidence related to the insurance for long-term care in the selected countries in six dimensions: type of insurance, type of membership, contribution rate / premium, inclusion criteria for coverage, the scope of services covered, and ultimately cost sharing through studies reviewed in the electronic databases.
Results: The results in the six countries showed that long-term care insurance requires public sector support in full or partly in combination with the private sector. This insurance’ being consistent with basic insurance coverage, its mandatory nature, the combination of government and individual financing (deduction from salaries or taxes) and the existence of a limited user fee to receive services, have saw in all these countries. The type of coverage is defined either universally or only for the elderly, and finally the scope of services in these insurances is graded based on the degree of dependence, the time required and the place of receiving the service.
Conclusion: In all studied countries, compulsory insurance coverage for long-term care was designed to allow for cross-subsidization. Consolidation and reduction of fragmentation of resources and expansion of integrated risk sharing is an important prerequisite for designing long-term care insurance in Iran. It is necessary to implement of the law requiring supplementary insurance to only cover services outside the basic insurance package and redesign both the basic and complementary insurance packages to determine what can be defined in the form of long-term care insurance package.
Methods: The present study is a comparative study using domain review and examines the evidence related to the insurance for long-term care in the selected countries in six dimensions: type of insurance, type of membership, contribution rate / premium, inclusion criteria for coverage, the scope of services covered, and ultimately cost sharing through studies reviewed in the electronic databases.
Results: The results in the six countries showed that long-term care insurance requires public sector support in full or partly in combination with the private sector. This insurance’ being consistent with basic insurance coverage, its mandatory nature, the combination of government and individual financing (deduction from salaries or taxes) and the existence of a limited user fee to receive services, have saw in all these countries. The type of coverage is defined either universally or only for the elderly, and finally the scope of services in these insurances is graded based on the degree of dependence, the time required and the place of receiving the service.
Conclusion: In all studied countries, compulsory insurance coverage for long-term care was designed to allow for cross-subsidization. Consolidation and reduction of fragmentation of resources and expansion of integrated risk sharing is an important prerequisite for designing long-term care insurance in Iran. It is necessary to implement of the law requiring supplementary insurance to only cover services outside the basic insurance package and redesign both the basic and complementary insurance packages to determine what can be defined in the form of long-term care insurance package.
Seyed Morteza Alizadeh Razavian,
Volume 5, Issue 1 (3-2022)
Volume 5, Issue 1 (3-2022)
Abstract
The limitation of resources in the face of the unlimited needs of society is the origin of economic decisionmaking. The characteristics of health needs and the economic situation and service delivery system have led to the development of different models in prioritizing needs and providing resources for health needs. Knowing the patterns can help you choose the right method. In the UK, Canada, Sweden and Chile the structure is tax-based. The structure in Germany and Turkey is based on two pillars, tax and premium. In the United States, with the exception of government-funded people with disabilities, the rest of society uses private insurance. Sri Lanka, Malaysia and Brazil were forced to provide universal health coverage through tax revenues. Low-income countries are in the same group. In Thailand, Mexico and Kyrgyzstan, premiums from official employees, along with tax revenues, are the basis for the general population's access to health services. In developing countries, financing is mainly through out-of-pocket payments, but due to the injustice created, they are moving to rely on tax resources. In developed countries, the private sector is growing gradually, and even governments with national medical systems have allowed out-of-pocket payments to increase. Financing is related to the level of economic development. In countries with low per capita incomes, high informal employment rates, and unfair wealth redistribution, tax regimes work better. A variety of other methods, such as labeled taxes, special duties, and bond sales, can help provide better financial resources for health.
Developing a Policymaking Model for Empowering the Insured of the Iran Health Insurance Organization
Masoud Pakniyat Rad, Mohammadbagher Tajeddin, Karam Habibpour Gatabi,
Volume 5, Issue 2 (8-2022)
Volume 5, Issue 2 (8-2022)
Abstract
Introduction: The present study seeks to design a health insurance empowerment model so that the insured can achieve an acceptable level of capabilities. The reason for choosing this group of insured persons is their large and considerable population in the country, which now include about 50% of Iran’s population.
Methods: The methodological approach of this research is qualitative and based of the grounded theory, deep and semi-structured interview data retrieval techniques. For data mining, the theoretical coding method was used, which aims to achieve the main and secondary categories in line with the theoretical model setting. The sample number is 15 health insurance experts who were selected purposefully.
Results: The results show that the central phenomenon is community-oriented empowerment, which is based on causal conditions, contextual conditions, intervening conditions and strategies. The most important strategies are the right of the insured to access insurance services and opportunities. In the discussion of background conditions, important elements such as agency, sense of equality and inclusion (integration) and capacity building are emphasized. Also, the findings show that components such as maintaining the rights of the insured, enabling resources and the efficiency and quality of insurance services are considered as causal conditions.
Conclusion: According to the findings of the present study, three main categories of education and information, social participation and social support have been proposed as intervening conditions. Completing the chain of the paradigm model of the present study is based on the data theory method of the Consequences Foundation, which analysed the empowerment in four main sections of social empowerment, cultural empowerment, economic empowerment and psychological empowerment of the insured.
Methods: The methodological approach of this research is qualitative and based of the grounded theory, deep and semi-structured interview data retrieval techniques. For data mining, the theoretical coding method was used, which aims to achieve the main and secondary categories in line with the theoretical model setting. The sample number is 15 health insurance experts who were selected purposefully.
Results: The results show that the central phenomenon is community-oriented empowerment, which is based on causal conditions, contextual conditions, intervening conditions and strategies. The most important strategies are the right of the insured to access insurance services and opportunities. In the discussion of background conditions, important elements such as agency, sense of equality and inclusion (integration) and capacity building are emphasized. Also, the findings show that components such as maintaining the rights of the insured, enabling resources and the efficiency and quality of insurance services are considered as causal conditions.
Conclusion: According to the findings of the present study, three main categories of education and information, social participation and social support have been proposed as intervening conditions. Completing the chain of the paradigm model of the present study is based on the data theory method of the Consequences Foundation, which analysed the empowerment in four main sections of social empowerment, cultural empowerment, economic empowerment and psychological empowerment of the insured.
Sudeh Bagheri Rizi, Mohammad Ahmadi, Mahtab Shahbazi, Rohollah Javadi,
Volume 6, Issue 1 (6-2023)
Volume 6, Issue 1 (6-2023)
Abstract
Introduction: The implementation of the family physician program in Iran Health Insurance Organization will change the payment system, reduce payments at the first level of service provision, and create a referral system. This study has been conducted with the aim of investigating the factors influencing the adoption of the referral system and the family physician of health insurance, including the adoption of the referral system, the creation of infrastructure and reforms, management factors, public interests, appropriate health system policies, appropriate health insurance structure and satisfaction.
Methods: The current research is descriptive and correlational in terms of applied purpose and data collection method. 184 people were included in the study by census. The data collection tool is a questionnaire with closed questions. After confirming the face validity and construct validity and reliability of the research instrument (Cronbach’s alpha 0.848), data analysis was performed using structural equation modeling (PLS-SEM).
Results: The findings of this research showed that the insurance structure in the health system was the most influential factor on the acceptance of the referral system and the family physician, and the effect path coefficient was estimated at 0.231. In addition to these policies included in the guidelines of the family physician program, infrastructure and reforms in society, management factors, public interest and satisfaction are other factors that have been confirmed to have an effect on the adoption of the family physician and referral system.
Conclusion: According to the findings, in addition to the appropriate health insurance structure, management and satisfaction factors are more important in accepting the referral system and the family physician. It seems that the insurance structure can create a sense of justice for people regarding health insurance because the plan of the referral system and family physician is based on necessities such as establishing proper access to the people of the country, equality in benefiting from health and treatment services, as well as the purposefulness of providing services and productivity. It is formed from the available human resources.
Methods: The current research is descriptive and correlational in terms of applied purpose and data collection method. 184 people were included in the study by census. The data collection tool is a questionnaire with closed questions. After confirming the face validity and construct validity and reliability of the research instrument (Cronbach’s alpha 0.848), data analysis was performed using structural equation modeling (PLS-SEM).
Results: The findings of this research showed that the insurance structure in the health system was the most influential factor on the acceptance of the referral system and the family physician, and the effect path coefficient was estimated at 0.231. In addition to these policies included in the guidelines of the family physician program, infrastructure and reforms in society, management factors, public interest and satisfaction are other factors that have been confirmed to have an effect on the adoption of the family physician and referral system.
Conclusion: According to the findings, in addition to the appropriate health insurance structure, management and satisfaction factors are more important in accepting the referral system and the family physician. It seems that the insurance structure can create a sense of justice for people regarding health insurance because the plan of the referral system and family physician is based on necessities such as establishing proper access to the people of the country, equality in benefiting from health and treatment services, as well as the purposefulness of providing services and productivity. It is formed from the available human resources.
Davood Danesh Jafari, Samira Ghanbari, Hamid Amadeh,
Volume 6, Issue 1 (6-2023)
Volume 6, Issue 1 (6-2023)
Abstract
Introduction: Financing is strongly believed to be the main function of any health system and insurance organizations play a critical role in the health financing system of all countries. Accordingly, in order to enable the insurance companies to take steps towards meeting the assigned goals, creation of a balance in the budget and also financial management of their resources and expenses are needed. Therefore, the current research is conducted with the purpose of analyzing the factors affecting the budget balance of health insurance organizations.
Methods: This research which is considered an experimental study has used the monthly data of premium, coinsurance, treatment, and overhead costs, and the number of services purchased by the Iran Health Insurance Organization during 2008 - 2019, and the vector error correction model (VECM) to analyze short and long-run relationships, estimate parameters and predict relationships. In addition, the approach of the present research in the selection of variables is based on the mediating role of this organization in the expenditure reimbursement, behavior management, and the purchasing of healthcare services.
Results: The results indicated that in the long term, the insured's coinsurance and the premium paid to the Iranian Health Insurance Organization have a negative effect on the budget deficit, respectively -0.27 and -0.9. In contrast, the budget deficit is positively impacted by treatment and overhead costs with a coefficient of 2.41 and 0.67 and the number of services purchased by Iran Health Insurance Organization with a coefficient of 139576.
Conclusion: According to the findings of this study, the health insurance organization can use strategies such as increasing premiums and coinsurances, reducing treatment and overhead costs, and also the number of purchased services, to control and minimize its budget deficit.
Methods: This research which is considered an experimental study has used the monthly data of premium, coinsurance, treatment, and overhead costs, and the number of services purchased by the Iran Health Insurance Organization during 2008 - 2019, and the vector error correction model (VECM) to analyze short and long-run relationships, estimate parameters and predict relationships. In addition, the approach of the present research in the selection of variables is based on the mediating role of this organization in the expenditure reimbursement, behavior management, and the purchasing of healthcare services.
Results: The results indicated that in the long term, the insured's coinsurance and the premium paid to the Iranian Health Insurance Organization have a negative effect on the budget deficit, respectively -0.27 and -0.9. In contrast, the budget deficit is positively impacted by treatment and overhead costs with a coefficient of 2.41 and 0.67 and the number of services purchased by Iran Health Insurance Organization with a coefficient of 139576.
Conclusion: According to the findings of this study, the health insurance organization can use strategies such as increasing premiums and coinsurances, reducing treatment and overhead costs, and also the number of purchased services, to control and minimize its budget deficit.
Masoud Pakniyat Rad, Mohammadbagher Tajeddin, Karam Habibpour Gatabi,
Volume 6, Issue 1 (6-2023)
Volume 6, Issue 1 (6-2023)
Abstract
Introduction: Despite the importance of the issue of empowerment, insurance organizations in Iran do not seek to empower their insureds due to reasons such as the lack of clarity in the meaning and concept, ignorance of the involved and influential factors, and the lack of scientific and functional status. For this reason, the present study was carried out to identify and prioritize the factors affecting the empowerment of the insured of the Iran Health Insurance Organization.
Methods: This study was conducted using a mixed method with a sequential design (first the qualitative Delphi method and then the quantitative survey method) and the participation of 15 health insurance and empowerment specialists in the Delphi method and the participation of 414 insured people of the health insurance organization. In accordance with each of the mentioned methods, sampling and validation methods were also used. Exploratory factor analysis technique was used to discover factors and Friedman’s test was used to compare factors.
Results: After determining 60 important variables and identifying 10 main factors influencing the empowerment of the insured, which are: self-reliance, job satisfaction, feeling of alienation, social health, decision-making power, health education, access to services health and treatment, quality of life relationships, power of foresight and improvement of the level of health-oriented attitude, it was found that “improvement of the level of health-oriented attitude” and “power of foresight” had the greatest and least effect on the empowerment of Iran’s health insurance policyholders, respectively.
Conclusion: The insured people of the Iran Health Insurance Organization believe that in order to empower the insured people, the level of attitude of all levels involved in this field should be improved and “health-oriented approach” should be replaced by “treatment-oriented” in the society.
Methods: This study was conducted using a mixed method with a sequential design (first the qualitative Delphi method and then the quantitative survey method) and the participation of 15 health insurance and empowerment specialists in the Delphi method and the participation of 414 insured people of the health insurance organization. In accordance with each of the mentioned methods, sampling and validation methods were also used. Exploratory factor analysis technique was used to discover factors and Friedman’s test was used to compare factors.
Results: After determining 60 important variables and identifying 10 main factors influencing the empowerment of the insured, which are: self-reliance, job satisfaction, feeling of alienation, social health, decision-making power, health education, access to services health and treatment, quality of life relationships, power of foresight and improvement of the level of health-oriented attitude, it was found that “improvement of the level of health-oriented attitude” and “power of foresight” had the greatest and least effect on the empowerment of Iran’s health insurance policyholders, respectively.
Conclusion: The insured people of the Iran Health Insurance Organization believe that in order to empower the insured people, the level of attitude of all levels involved in this field should be improved and “health-oriented approach” should be replaced by “treatment-oriented” in the society.
Sohrab Osta, Behrooz Badpa,
Volume 6, Issue 2 (9-2023)
Volume 6, Issue 2 (9-2023)
Abstract
Introduction: Performance evaluation is the basis of many decisions and plans that can lead to the success of the organization, and efficiency is considered a very suitable criterion for evaluating the performance of companies and organizations. Based on this, the purpose of this research is to investigate the performance of agencies and counter offices of the contracting party of the Health Insurance Organization by measuring efficiency using the technique of data envelopment analysis.
Methods: In this study, the data of the representative offices and counter branches of the contracting government of Iran Health Insurance Organization in Ilam province, Iran in the third quarter of 2021 were analyzed. For data analysis, non-radial data envelopment analysis model was used, in which evaluation indicators were selected using confirmatory factor analysis method and using Smart PLS software. The SBM model was used to determine the efficiency, and finally, the Super-SBM method was used to rank the efficient units.
Results: The research showed that among the examined units, during the evaluation period, 4 units had efficient performance and 12 ineffective units, among the efficient units, the unit with the best performance was determined and among the inefficient units, the unit with the worst performance was determined.
Conclusion: In the evaluation period, the number of inefficient units was more compared to efficient units. It is recommended to measure the efficiency and productivity of the counter offices and branches of health insurance contracting parties in different cities of Iran, especially the provincial centers, on an annual basis, so that by providing practical solutions, the situation of the agencies and offices can be improved. It is also necessary for them to be fully aware of their expectations and to be more responsive to their clients.
Methods: In this study, the data of the representative offices and counter branches of the contracting government of Iran Health Insurance Organization in Ilam province, Iran in the third quarter of 2021 were analyzed. For data analysis, non-radial data envelopment analysis model was used, in which evaluation indicators were selected using confirmatory factor analysis method and using Smart PLS software. The SBM model was used to determine the efficiency, and finally, the Super-SBM method was used to rank the efficient units.
Results: The research showed that among the examined units, during the evaluation period, 4 units had efficient performance and 12 ineffective units, among the efficient units, the unit with the best performance was determined and among the inefficient units, the unit with the worst performance was determined.
Conclusion: In the evaluation period, the number of inefficient units was more compared to efficient units. It is recommended to measure the efficiency and productivity of the counter offices and branches of health insurance contracting parties in different cities of Iran, especially the provincial centers, on an annual basis, so that by providing practical solutions, the situation of the agencies and offices can be improved. It is also necessary for them to be fully aware of their expectations and to be more responsive to their clients.
Mohammad Jafari, Kheirollah Parvin, Mohammad Sadeghi,
Volume 6, Issue 3 (12-2023)
Volume 6, Issue 3 (12-2023)
Abstract
Health is one of the most basic needs of all humans, and the main function of the health system of any country is to provide services in this area. The purpose of this research was to answer the question of how health services are provided, by which institution and according to what principles. After the victory of the Islamic Revolution, the expansion of social security in the 29th principle of the constitution, based on the fact that all people enjoy the benefits of social security as a universal right, was put on the agenda. Based on this, the main institutions, organizations, institutions and funds in the fields of insurance, support and aid of this system were obliged to carry out their executive and business affairs in the field of production and provision of services and related legal obligations by means of contracts whose terms are proposed by the Ministry of Cooperatives. Work and social welfare and the approval of the Supreme Council of Welfare and Social Security will be assigned to brokerage institutions. Although in Iran’s legal system, various institutions are responsible for providing health services to different sections of the society, but the main institutions that provide insurance services are the Iran Health Insurance Organization and the Social Security Organization, and each of these organizations, according to the duties and obligations are responsible for providing health services in the community.
Vida Aghayari, Gholamreza Memarzadeh Tehran, Morteza Musakhani, Seyed Jamaleddin Tabibi,
Volume 6, Issue 3 (12-2023)
Volume 6, Issue 3 (12-2023)
Abstract
Introduction: This study was conducted with the aim of evaluating the dimensions and components of health insurance policies in the field of recruitment and recruitment.
Methods: The current study was descriptive-analytical and cross-sectional, which was conducted in 2023. The statistical population included managers and consultants of Iran Health Insurance Organization. 10 people were selected as study samples in a purposeful way and the data were collected using a researcher-made questionnaire and analyzed using the 22nd edition of SPSS software.
Results: Descriptive indicators related to the importance coefficient show the degree of conflict and ambiguity of policies from legal documents (policies). Also, the average obtained from the samples in most of the subjects (policies) was higher than the theoretical average (2.5).
Conclusion: By creating a comprehensive evaluation system of human resource development policies and understanding the extracted factors and using them in a valid evaluation system, the efficiency and effectiveness of the organizations can be improved.
Methods: The current study was descriptive-analytical and cross-sectional, which was conducted in 2023. The statistical population included managers and consultants of Iran Health Insurance Organization. 10 people were selected as study samples in a purposeful way and the data were collected using a researcher-made questionnaire and analyzed using the 22nd edition of SPSS software.
Results: Descriptive indicators related to the importance coefficient show the degree of conflict and ambiguity of policies from legal documents (policies). Also, the average obtained from the samples in most of the subjects (policies) was higher than the theoretical average (2.5).
Conclusion: By creating a comprehensive evaluation system of human resource development policies and understanding the extracted factors and using them in a valid evaluation system, the efficiency and effectiveness of the organizations can be improved.
Rahim Radmehr, Yousef Mohammadi Moghadam, Marzieh Mohammadi, Hassan Soltani,
Volume 6, Issue 3 (12-2023)
Volume 6, Issue 3 (12-2023)
Abstract
Introduction: Electronic human resource management includes electronic tools that enable human resource managers to manage human resource data and information and also provide the possibility for the beneficiaries to have access to specific information and tasks of human resources through the Internet. Therefore, this research was conducted to identify the effective factors of electronic human resources management in the Iranian Health Insurance Organization using the fuzzy Delphi approach.
Methods: The current research, which was carried out in 2023, has a mixed approach and an inductive paradigm. The statistical population of the research in the qualitative and quantitative part are academic experts and (senior) managers of the health insurance organization in Tehran province, and 30 of them were selected as sample members based on the principle of theoretical saturation. The data collection tool in the qualitative part of the research is a semi-structured interview and in the quantitative part, a fuzzy Delphi questionnaire. In this research, to analyze the data in the qualitative part, the content analysis method and coding approach using MAXQDA software was used and in the quantitative part, the fuzzy Delphi method was used. The validity and reliability of the interview were confirmed using content validity and intra-coder inter-coder reliability and the validity and reliability of the questionnaire were confirmed using content validity and inconsistency rate.
Results: The results of the qualitative part indicate the identification of 15 factors as effective factors in electronic human resources management in Iran's health insurance organization. On the other hand, the results of the quantitative part using the fuzzy Delphi approach show that human resources architecture, structure and process reform, integration of human resources processes, reduction of administrative bureaucracy, the existence of financial support, and the creation of a suitable culture as the most important factors on the effective management of electronic human resources in Iran's health insurance organization.
Conclusion: The application of electronic human resources management in the current changing conditions helps the health insurance organization more than ever in achieving its goals and agility.
Methods: The current research, which was carried out in 2023, has a mixed approach and an inductive paradigm. The statistical population of the research in the qualitative and quantitative part are academic experts and (senior) managers of the health insurance organization in Tehran province, and 30 of them were selected as sample members based on the principle of theoretical saturation. The data collection tool in the qualitative part of the research is a semi-structured interview and in the quantitative part, a fuzzy Delphi questionnaire. In this research, to analyze the data in the qualitative part, the content analysis method and coding approach using MAXQDA software was used and in the quantitative part, the fuzzy Delphi method was used. The validity and reliability of the interview were confirmed using content validity and intra-coder inter-coder reliability and the validity and reliability of the questionnaire were confirmed using content validity and inconsistency rate.
Results: The results of the qualitative part indicate the identification of 15 factors as effective factors in electronic human resources management in Iran's health insurance organization. On the other hand, the results of the quantitative part using the fuzzy Delphi approach show that human resources architecture, structure and process reform, integration of human resources processes, reduction of administrative bureaucracy, the existence of financial support, and the creation of a suitable culture as the most important factors on the effective management of electronic human resources in Iran's health insurance organization.
Conclusion: The application of electronic human resources management in the current changing conditions helps the health insurance organization more than ever in achieving its goals and agility.
Rajabali Daroudi, Ebrahim Jaafaripooyan, Houshang Golzar,
Volume 6, Issue 4 (3-2024)
Volume 6, Issue 4 (3-2024)
Abstract
Introduction: In recent decades, the field of health insurance has emerged as one of the vital components of the healthcare system, propelled by continuous advancements in technology and the increasing complexity of medical services and technologies. With the advent of new challenges in this industry, there has been a heightened effort to find innovative solutions to enhance service quality, optimize resource management, and increase the satisfaction of insured individuals. One significant approach in improving this domain involves the application of data mining techniques to identify behavioral patterns among health insurance policyholders during outpatient visits to diagnostic and treatment facilities.
Methods: The present study is a descriptive cross-sectional study. The claim data of health insurance in Bushehr province of Iran was used. After data preparation, analysis was performed using SPSS Clementine12.0 software. The values of insurance start time, number of visits, and the value of the type of insurance were used to model the K-means algorithm in two modes including demographic mode and Recency-frequency-monetary (RFM). Sampling was done by census method. The statistical population includes the information of all outpatient referrals of the insured covered by health insurance of Bushehr province to 1,420,579 referrals to diagnostic and medical centers in 2018, which has been prepared by the researcher’s direct referral to the database of medical records.
Results: The root mean square deviation values for RFM-based clustering and demographics are 21 and 21.65, respectively. And the Dunn’s Index confirmed the better RFM-based clustering. The RFM-based K-Means algorithm classified the data into four clusters, with 44% of the insured in Cluster One, 4% in Cluster Two, 22% in Cluster Three, and 30% in Cluster Four. Based on this, cluster 2 insured, including women with insurance of other classes with 4% of the population, were identified as the most referred, and cluster 3, including women with rural insurance, with 22% of the population, were identified as the least referred insured.
Conclusion: The obtained model divided the insured into 4 clusters. This model allows the organization to predict the referral patterns of each insurer based on their age, gender, and type of insurance and provide appropriate services for different clusters. By using these models and technique in decision making process, the insurers satisfaction will be improved.
Methods: The present study is a descriptive cross-sectional study. The claim data of health insurance in Bushehr province of Iran was used. After data preparation, analysis was performed using SPSS Clementine12.0 software. The values of insurance start time, number of visits, and the value of the type of insurance were used to model the K-means algorithm in two modes including demographic mode and Recency-frequency-monetary (RFM). Sampling was done by census method. The statistical population includes the information of all outpatient referrals of the insured covered by health insurance of Bushehr province to 1,420,579 referrals to diagnostic and medical centers in 2018, which has been prepared by the researcher’s direct referral to the database of medical records.
Results: The root mean square deviation values for RFM-based clustering and demographics are 21 and 21.65, respectively. And the Dunn’s Index confirmed the better RFM-based clustering. The RFM-based K-Means algorithm classified the data into four clusters, with 44% of the insured in Cluster One, 4% in Cluster Two, 22% in Cluster Three, and 30% in Cluster Four. Based on this, cluster 2 insured, including women with insurance of other classes with 4% of the population, were identified as the most referred, and cluster 3, including women with rural insurance, with 22% of the population, were identified as the least referred insured.
Conclusion: The obtained model divided the insured into 4 clusters. This model allows the organization to predict the referral patterns of each insurer based on their age, gender, and type of insurance and provide appropriate services for different clusters. By using these models and technique in decision making process, the insurers satisfaction will be improved.
Saed Salehi, Norouz Nourollahzadeh, Seyedeh Mahboubeh Jafari,
Volume 6, Issue 4 (3-2024)
Volume 6, Issue 4 (3-2024)
Abstract
Introduction: One of the fundamental challenges faced by various societies is the easy and affordable access to healthcare services. In this context, a plan known as Universal Health Coverage was proposed by the World Health Organization, prompting diverse countries to implement various measures in response. A critical need for the execution of this plan is the availability of sufficient financial resources. Therefore, this research aims to identify and evaluate financing policies for Universal Health Coverage.
Methods: This study first reviews recent research literature, followed by conducting focused group interviews with research experts. After identifying stakeholders' needs and various policies, the policies were weighted and prioritized using a Fuzzy Quality Function Deployment (QFD) approach. To enrich the data for the Fuzzy QFD questionnaire, insights from 18 experts with at least five years of experience in insurance and macroeconomic policies were utilized.
Results: The research findings indicate that the number of insured individuals and the percentage of services covered by insurance are the most critical needs of the system's stakeholders. Accordingly, reducing the insurance service copayment rate, stratifying the number of insured individuals, and allocating a portion of the base insurance share to private insurance companies are prioritized in the identified policies.
Conclusion: Based on the study's findings, it is concluded that for the government to provide sustainable health services to the public, the private sector should also be involved to bear the service provision costs in exchange for appropriate revenue. Health services should be stratified to meet varied needs effectively.
Methods: This study first reviews recent research literature, followed by conducting focused group interviews with research experts. After identifying stakeholders' needs and various policies, the policies were weighted and prioritized using a Fuzzy Quality Function Deployment (QFD) approach. To enrich the data for the Fuzzy QFD questionnaire, insights from 18 experts with at least five years of experience in insurance and macroeconomic policies were utilized.
Results: The research findings indicate that the number of insured individuals and the percentage of services covered by insurance are the most critical needs of the system's stakeholders. Accordingly, reducing the insurance service copayment rate, stratifying the number of insured individuals, and allocating a portion of the base insurance share to private insurance companies are prioritized in the identified policies.
Conclusion: Based on the study's findings, it is concluded that for the government to provide sustainable health services to the public, the private sector should also be involved to bear the service provision costs in exchange for appropriate revenue. Health services should be stratified to meet varied needs effectively.
Mansour Askary, Mostafa Rajabi, Sharam Tofighi, Maryam Sharifdoust, Bahar Hafezi,
Volume 7, Issue 1 (6-2024)
Volume 7, Issue 1 (6-2024)
Abstract
Introduction: Relying on out-of-pocket payments for health care services increases the financial burden and back-breaking costs of medical services for families. It results in poverty. Considering the necessity of sustainable medical insurance for informal jobs, the present study evaluated the willingness to pay medical insurance for informal jobs in Isfahan province for two groups of informal jobs in income deciles one to three and deciles four to six.
Methods: In this study, the conditional valuation method (CVM) was used to estimate the willingness to pay. The maximum willingness to pay is equal to the compensatory interest, that is, the decrease in income that maintains the initial level of the respondent's utility if insurance coverage is provided. In this research, library and field methods were used to collect data, and since the dependent variable (willingness to pay) was ranked, the econometric methods of ordered probit and Tobit were used to estimate the model.
Results: The results showed that in both groups of income deciles, the variable of education level has no significant effect on the willingness to pay, but other variables such as age, average household income, age and average medical expenses have an effect on the willingness to pay. The effect of changing household size was also negative. In the following, the practical suggestions obtained from the results were presented.
Methods: In this study, the conditional valuation method (CVM) was used to estimate the willingness to pay. The maximum willingness to pay is equal to the compensatory interest, that is, the decrease in income that maintains the initial level of the respondent's utility if insurance coverage is provided. In this research, library and field methods were used to collect data, and since the dependent variable (willingness to pay) was ranked, the econometric methods of ordered probit and Tobit were used to estimate the model.
Results: The results showed that in both groups of income deciles, the variable of education level has no significant effect on the willingness to pay, but other variables such as age, average household income, age and average medical expenses have an effect on the willingness to pay. The effect of changing household size was also negative. In the following, the practical suggestions obtained from the results were presented.
Efat Mohamadi, Ahad Bakhtiari, Mohammad Mehdi Nasehi, Mohammad Effatpanah, Mehdi Rezaei, Zahra Shahali, Amirhossein Takian, Alireza Olyaeemanesh,
Volume 7, Issue 1 (6-2024)
Volume 7, Issue 1 (6-2024)
Abstract
Introduction: The performance evaluation of the Iranian Health Insurance Organization (IHIO), considering the responsibilities, objectives, and duties outlined in the higher-level documents and laws, is an important issue that has received less attention. Given the importance of systematic monitoring and evaluation to facilitate planning based on overarching domestic policies, it is necessary to adopt a suitable approach to monitor programs and policies and to respond to higher-level authorities to fulfill assigned tasks. The present study aims to identify performance indicators for IHIO based on the analysis of relevant higher-level documents and laws.
Methods: This study was conducted qualitatively and based on content analysis of documents, policies, and executive activities related to monitoring the performance of IHIO, from the year the Universal Health Insurance Law of the country was passed (1373) until 1402, in the year 1402 (Solar Hijri calendar, equivalent to 2023/2024 Gregorian calendar). The Scott method was used to examine the validity of the documents, and qualitative content analysis and the deductive approach were employed to analyze the data.
Results: Nine policies related to monitoring the performance of the IHIO were identified, with 11 themes and total of 188-indicators identified as follows: Population indicators (8 indicators), National Health Accounts (NHA) (13-indicators), Covered population (25-indicators), Covered health services (19-indicators), Covered costs/financial participation status (11-indicators), Organization’s financial resources (26-indicators), Contracted centers (11-indicators), Cost trends, cost burden, and visit burden (23-indicators), Monitoring indicators (11-indicators), Operational efficiency of the organization (30-indicators), Access to services and health outcomes (11-indicators).
Conclusion: In order to conduct a thorough and comprehensive evaluation of the Iranian Health Insurance Organization's performance, which aims to enhance transparency and public trust in the organization, it is imperative to take into account a diverse range of indicators that encompass all operational and performance aspects of a health insurance entity. Additionally, national macro indicators, including population metrics and national health accounts, play a crucial role in this process. Failing to consider these indicators may lead to challenges and biases when assessing the organization's performance.
Methods: This study was conducted qualitatively and based on content analysis of documents, policies, and executive activities related to monitoring the performance of IHIO, from the year the Universal Health Insurance Law of the country was passed (1373) until 1402, in the year 1402 (Solar Hijri calendar, equivalent to 2023/2024 Gregorian calendar). The Scott method was used to examine the validity of the documents, and qualitative content analysis and the deductive approach were employed to analyze the data.
Results: Nine policies related to monitoring the performance of the IHIO were identified, with 11 themes and total of 188-indicators identified as follows: Population indicators (8 indicators), National Health Accounts (NHA) (13-indicators), Covered population (25-indicators), Covered health services (19-indicators), Covered costs/financial participation status (11-indicators), Organization’s financial resources (26-indicators), Contracted centers (11-indicators), Cost trends, cost burden, and visit burden (23-indicators), Monitoring indicators (11-indicators), Operational efficiency of the organization (30-indicators), Access to services and health outcomes (11-indicators).
Conclusion: In order to conduct a thorough and comprehensive evaluation of the Iranian Health Insurance Organization's performance, which aims to enhance transparency and public trust in the organization, it is imperative to take into account a diverse range of indicators that encompass all operational and performance aspects of a health insurance entity. Additionally, national macro indicators, including population metrics and national health accounts, play a crucial role in this process. Failing to consider these indicators may lead to challenges and biases when assessing the organization's performance.
Maryam Yaghoubi, Mohammad Meskarpou-Amiri,
Volume 7, Issue 1 (6-2024)
Volume 7, Issue 1 (6-2024)
Abstract
Introduction: The number of scientific publications is the most important quantitative indicator of the development and progress of any country. The purpose of this study is to investigate the growth trend of scientific productions in the field of health insurance in Iran and the world during the last two decades.
Methods: The present study was a quantitative and applied study with a scientometric approach. Certain criteria were considered for extracting articles in the Scopus database, which included: publication date (2000-2024), scientific originality of the findings (originality of the article), the presence of the main keywords of health insurance in the title or keyword of the article. In order to describe the publication status of health insurance articles, dispersion indices and trend analysis were used in Excel 2017 software.
Results: Scientific publications in the field of health insurance follow an upward trend as a polynomial function with degree 2 (R2=0.96). The United States published 46% of articles in the field of health insurance, with a significant difference compared to other countries. After that, Germany with 5% and England with 3% contributed the most in publishing articles. In terms of the number of articles, Iran was ranked 201st.
Conclusion: Universal coverage of health insurance in Iran provides a good capacity for the dissemination of experiences in this field in Iran, with detailed planning and existing scientific capacities, the dissemination of experiences related to the issue of health insurance will be promoted.
Methods: The present study was a quantitative and applied study with a scientometric approach. Certain criteria were considered for extracting articles in the Scopus database, which included: publication date (2000-2024), scientific originality of the findings (originality of the article), the presence of the main keywords of health insurance in the title or keyword of the article. In order to describe the publication status of health insurance articles, dispersion indices and trend analysis were used in Excel 2017 software.
Results: Scientific publications in the field of health insurance follow an upward trend as a polynomial function with degree 2 (R2=0.96). The United States published 46% of articles in the field of health insurance, with a significant difference compared to other countries. After that, Germany with 5% and England with 3% contributed the most in publishing articles. In terms of the number of articles, Iran was ranked 201st.
Conclusion: Universal coverage of health insurance in Iran provides a good capacity for the dissemination of experiences in this field in Iran, with detailed planning and existing scientific capacities, the dissemination of experiences related to the issue of health insurance will be promoted.
Shahram Tofighi, Jahanara Mamikhani, Sedigheh Khadem, Mohammad Effatpanah, Mohammadjavad Kabir, Mehdi Rezaee,
Volume 7, Issue 2 (9-2024)
Volume 7, Issue 2 (9-2024)
Abstract
Introduction: The burden of psychological disorders and its financial burden has increased in the world and in Iran. Usually, these patients need financial support to improve their mental health. Sometimes basic insurance organizations hesitate to include psychological counseling services in the insurance package. The assistance of the Welfare Organization and the Ministry of Health is not enough.
Methods: It is a descriptive study with financial calculations. Using the data of the Iranian Statistics Center, demographic information until 2031 and using the data of the mental health survey reports of the Ministry of Health in 2011 and 2021, the annual growth for the 90s was calculated. Then, with the discount formula, the growth of prevalence of disorders, different severity of disorders, the number of referrals to different centers, the number of referrals was estimated up to 2031. Assuming an annual tariff growth rate of 20%; The insurer's share is 30%, 50%, and 70%; 50% and 10% annual growth in the number of clients after providing insurance coverage, the estimate was completed
Results: The financial burden of insurance organizations for psychological counseling was estimated from 708.2 million tomans (insurance share 30% in 2024, fixed rate of clients) to 23,534 million tomans (insurance share 70%, annual growth of 10% clients in 2031).
Conclusion: Psychological counseling is both necessary and cost-effective to be covered by insurance organizations. By developing a right service package, psychological counseling can be covered according to the severity of the disorder, the location of the service provision, and the different shahres of the insurance organizations. It would be wise that some disorders, considered important, be covered by basic insurance organizations, for other cases supplementary insurance along with other supportive and welfare services such as subsidies would be rational.
Methods: It is a descriptive study with financial calculations. Using the data of the Iranian Statistics Center, demographic information until 2031 and using the data of the mental health survey reports of the Ministry of Health in 2011 and 2021, the annual growth for the 90s was calculated. Then, with the discount formula, the growth of prevalence of disorders, different severity of disorders, the number of referrals to different centers, the number of referrals was estimated up to 2031. Assuming an annual tariff growth rate of 20%; The insurer's share is 30%, 50%, and 70%; 50% and 10% annual growth in the number of clients after providing insurance coverage, the estimate was completed
Results: The financial burden of insurance organizations for psychological counseling was estimated from 708.2 million tomans (insurance share 30% in 2024, fixed rate of clients) to 23,534 million tomans (insurance share 70%, annual growth of 10% clients in 2031).
Conclusion: Psychological counseling is both necessary and cost-effective to be covered by insurance organizations. By developing a right service package, psychological counseling can be covered according to the severity of the disorder, the location of the service provision, and the different shahres of the insurance organizations. It would be wise that some disorders, considered important, be covered by basic insurance organizations, for other cases supplementary insurance along with other supportive and welfare services such as subsidies would be rational.
Leila Izadi, Shaban Elahi, Alireza Hassanzadeh, Sanaz Shafiee,
Volume 7, Issue 2 (9-2024)
Volume 7, Issue 2 (9-2024)
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
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
Rahim Radmehr, Yousef Mohammadi Moghadam, Marzieh Mohammadi, Hassan Soltani,
Volume 7, Issue 2 (9-2024)
Volume 7, Issue 2 (9-2024)
Abstract
Introduction: Electronic human resources management can be implemented in the organization with different intentions and goals. In other words, cost reduction, optimal use of human resources, and high ability to change and innovate can be examples of electronic human resource management goals. The current research was carried out with the aim of developing electronic human resource management scenarios in Iran's health insurance organization.
Methods: In terms of orientation, the current research is applied, which falls under the category of exploratory research, and its methodology is mixed. The statistical population includes academic experts and managers of health insurance organizations in Tehran province, 30 of them were selected as sample members using the purposeful sampling method and based on the principle of theoretical adequacy. In the qualitative part, research indicators were obtained through literature review and interviews with experts. In the quantitative part, a questionnaire was used in order to prioritize the indicators, and the consensus index, importance and dispersion of the coefficient of changes were used to compile the scenarios.
Results: The findings of this research are presented in two parts, qualitative and quantitative. The first part includes the identification of the key components of electronic human resources management, and 15 components are determined in this section, respectively, human resource architecture with an importance index (100) and consensus index (0.66) and structure and process modification with an importance index (95). and the consensus index (0.43) were identified as the two main components and the basis of electronic human resource management scenarios in Iran's health insurance organization. Also, the second part of the results shows that 1) Tsunami of change (indicating the possibility of modifying the structure and process and architecture of human resources), 2) Cloud without rain (refers to a situation where the organizational structure is efficient but human resources are ineffective), 3) Silent volcano It indicates a situation where the structure and resources of the organization are inefficient) and 4) the land in danger of drought (refers to a situation in which the structure of the organization is inefficient but the human resources of the organization are efficient), the scenarios of electronic human resource management in health insurance
Conclusion: The results showed that human resource architecture and structure and process modification are the most important drivers of electronic human resource management and the basis of electronic human resource management scenarios in Iran's health insurance organization. One of the most important solutions that can be used to improve and apply human resources architecture is job analysis and matching. Also, if necessary, the organizational structure should be modified to apply the necessary improvements in processes and decisions.
Methods: In terms of orientation, the current research is applied, which falls under the category of exploratory research, and its methodology is mixed. The statistical population includes academic experts and managers of health insurance organizations in Tehran province, 30 of them were selected as sample members using the purposeful sampling method and based on the principle of theoretical adequacy. In the qualitative part, research indicators were obtained through literature review and interviews with experts. In the quantitative part, a questionnaire was used in order to prioritize the indicators, and the consensus index, importance and dispersion of the coefficient of changes were used to compile the scenarios.
Results: The findings of this research are presented in two parts, qualitative and quantitative. The first part includes the identification of the key components of electronic human resources management, and 15 components are determined in this section, respectively, human resource architecture with an importance index (100) and consensus index (0.66) and structure and process modification with an importance index (95). and the consensus index (0.43) were identified as the two main components and the basis of electronic human resource management scenarios in Iran's health insurance organization. Also, the second part of the results shows that 1) Tsunami of change (indicating the possibility of modifying the structure and process and architecture of human resources), 2) Cloud without rain (refers to a situation where the organizational structure is efficient but human resources are ineffective), 3) Silent volcano It indicates a situation where the structure and resources of the organization are inefficient) and 4) the land in danger of drought (refers to a situation in which the structure of the organization is inefficient but the human resources of the organization are efficient), the scenarios of electronic human resource management in health insurance
Conclusion: The results showed that human resource architecture and structure and process modification are the most important drivers of electronic human resource management and the basis of electronic human resource management scenarios in Iran's health insurance organization. One of the most important solutions that can be used to improve and apply human resources architecture is job analysis and matching. Also, if necessary, the organizational structure should be modified to apply the necessary improvements in processes and decisions.
Shahram Tofighi,
Volume 7, Issue 2 (9-2024)
Volume 7, Issue 2 (9-2024)
Abstract
Mohammad Mahdi Molaei, Mansoor Fatehi,
Volume 7, Issue 3 (12-2024)
Volume 7, Issue 3 (12-2024)
Abstract
The health insurance sector is undergoing a revolution with the help of digital technologies that are creating new ways of improving the quality of services and reducing costs. This study explores how modern solutions such as artificial intelligence, big data, the Internet of Things, and health informatic systems can transform health insurance's future. These technologies have already demonstrated their potential. They are assisting the insurers in enhancing the risk appraisal, providing individualized care, and minimizing the hospital expenses—especially when integrated with a digital strategy. But the journey is not simple. Data security, global compliance, and algorithmic bias are a few of the significant challenges that have been highlighted. In Iran, the development has been made, but there are still some issues. Challenges include; limited IT infrastructure, poor referral systems, and limited internet access. To address these challenges, there is the need to enhance the current inadequate digital infrastructure, to review the existing legal framework and to train a workforce that will be conversant with these technologies. The final success of digital transformation will depend on the perfect balance, meaning the right combination of advanced technologies and the ability to provide quality care at an affordable cost for all. Ultimately, these efforts can lead to development of a healthcare system that works for all stakeholders.
Related Websites
- Ministry of Health and Medical Education (MOHME)
- Deputy of Research and Technology (Ministry of Health and Medical Education)
- Iran Health Insurance Organization
- National Center for Health Insurance Research (NCHIR)
- Scientific Publications Commission (Ministry of Health and Medical Edication)
- Scientific Publications Commission (Ministry of Science, Research and Technoligy)
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