The growing diversity of health services, which often costs a lot, and the inability of governments to provide benefits to citizens. in all areas of health, clearly show the need for the presence and development of complementary health insurance in the health market. Private supplementary health insurance is usually provided in bulk, voluntarily, and extendable until the end of life. The purpose of this study was to provide solutions to improve the quality of complementary health insurance services and reduce government dependence. The supplementary health insurance function dedicate the second rank of the nongovernmental insurance market also, with the growth of 34.6% is the second highest growth rate in 2015. The coefficient of damage in this sector with 86.1% indicates its profitability in this year. By reviewing the patterns and models presented in the studies, in order to improve the level of health and complementary insurance, solutions were presented in 20 clauses. According to the present study, it is recommended to offer various insurance packages considering the age, gender, health status of individuals, geographical status, literacy level, income level, employment status etc.

Introduction: Monitoring the quality of services in the insurance service purchase can be crucial for improving patients' satisfaction, avoiding unnecessary referral to health centers and Subsequent expenditure, and imposing them on insurance. This study aimed to evaluate the quality of public health clinic services.
Methods: This cross-sectional study was performed in Tehran during 2015, 2016 years. The research population consisted of patients referred to general practitioners in Tehran. A multi-stage cluster method was used for sampling. Overall, 394 samples were obtained from patients referred to general practitioners were included in the study. Researcher-made questionnaire was the data collection method. The questionnaire was prepared based on interviews with experts. The collected data were analyzed statistically using SPSS 22 software.
Results: Based on the results of the research, the quality score of the clinics from 125 to 160 defined in the high range and the importance of quality dimensions from the viewpoint of patients from 131 to 160 were placed in the high range as well. Examining the service quality dimensions indicated, access point (85.5%) and then effectiveness (85.3%) were earned the highest score. Moreover, the effectiveness was earned the highest score in terms of importance. The results showed, a significant relationship between income level and questions of importance. It seems that, quality items are considered different for people according to their income.
Conclusions: Findings of this study indicate that, patients referring to general practitioners high-rated the received services' quality. The results of this evaluation can lead to improvement in the quality of services and reduce the burden on visits for insured persons and also reduce charges imposed on duplicate visits. Besides, it can lead to active purchasing for the health insurance organization.

Introduction: Identifying the extent of misuse of health services in hospitalization is the first step in implementing health control and restriction programs without damage to the quality of these services. This study was carried out in Valiasr Hospital of Meshkin shahr City with the aim of assessing the rate of admission and unnecessary hospitalization of insured persons and the amount of expenses incurred by this phenomenon to the health insurance organization.
Methods: This cross-sectional study was conducted in July 2016 in Valiasr Hospital in Meskine Shahr. The statistical population in this study was composed of all insured persons covered by the health insurance organization from all the funds referred to the hospital at the time of the study. Overall, 330 samples were selected for sampling in this study. An appropriateness Evaluation Protocol (AEP) was used for data collection.
Results: The results obtained showed that, 56.33% of the insured persons (186 men) and 43.7% of the insured persons were hospitalized (144) were women. From the total of 330 evaluated admissions, 129 cases (39%) were inexpedient, with the highest inexpedient acceptance in the internal ward with 66% and the lowest uncontrolled acceptance was in the surgical ward with a 12% rate. In 2016, the health insurance organization paid 6,133,840,000 Rials for unplanned days of admission in these three parts.
Conclusions: According to the results of this study, the AEP protocol has a good reputation for evaluating of admission and hospitalization days. The health insurance organization and other insurer organizations are essential to reduce and optimize the number of admissions and inexpedient hospitalization days by applying the AEP protocol as a regulatory tool for evaluating hospital admissions documents.

Introduction: Health system reforms are designed and implemented according to the situational conditions of each country. Recently health reforms have focused on resources and costs in the health sector for governments; they would be as the tools for making the necessary changes and improvements. Governments have designed and implemented health reforms step by step to completing the coverage of health services in terms of geographic accessibility, service affordability, and avoiding health impoverishments, catastrophic poverty from the use of health services in recent two decades. Objectives other than completing public coverage, improving quality and the quality of health services and care, and the logical reduction in costs and the optimal use of resources. Objectives other than completing public coverage, improving quality The quality of health services and care has not had a reasonable reduction in costs and the optimal use of resources. Comparing the spending costs of hospitalization in the years before and after the Iranian Healthcare Reforms Plan in 2014 has could show that the efficiency and cost of spending. This study seeks to examine the average cost of each hospitalization case in the years before and after the Iranian Healthcare Reforms Plan to compare the impact of the costs on health insurance funds.
Methods: The present study was a cross sectional study. The population of the study has included the sum of the inpatient bed day of health insurers admitted in hospitals of in 31 provinces over the past 5 years from 2010 to 2015. In this study, survey was being conducted, and accessible data resources in the databases were used for data collecting process and analyzing. The analysis has been conducted by using Excel 2010.
Results: The highest of growth rate of the cost of inpatient bed day of health insurers in the first year of the Iranian Healthcare Reform Plan was Included respectively to the rural fund (88.4%), governmental employees fund (75.2%), self-employed fund (73.17%) and other populations fund (73.10%), and the self-employed fund shown third ranking in growth rate, although growth rate of the cost spending in all funds was more than 73%. In the first year of Iranian Healthcare Reform Plan has shown more inpatient costs growth rate than 73 percent’s for all the Iranian Health Insurance Funds.
Conclusion: The average of total inpatient spending cost has increasing trend in all funds of Iran Health Insurance and if there is not be a serious review of the Reform Plan, the health insurance organization may been faced serious financial problems. Therefore, by reviewing the Reform plan, it is possible to improve the plan as well as to ensure health insurance regarding sustainability of financial resources.

Introduction: Implementation of the Health Transformation plan (HTP) has had many effects so far. The analysis of these impacts can help policymakers and planners to continuously improve the health system's ultimate goals. Considering that, health financing is one of the most impressive of health system functions from the HTP, the present study examines the effect of the HTP on supplementary health insurance as part of financial providers in the health system in Iran.
Methods: This is a descriptive study carried out using secondary data in 2017. Data were gathered using information systems of health insurance organizations and the statistical yearbook of central insurance of the country. Data analysis was performed using Excel and SPSS software. To analyze and report these data, descriptive statistics and analytical tests were used.
Results: The effect of the HTP on the share of health care providers has shown that in private financing, the share of households is the highest, and during the period 2002-2004, the average share of households from the total private sector share was 86.5%. During the period of 2002-2003, the share of the domestic government as the public sector was 54% on average. Findings in relation to supplementary health show that the net loss has been ascending and premium rate has been increasing.
Conclusions: The share of households in health expenditures has decreased since the implementation of the HTP, but the average pocket spending in the public and private sector has not decreased by more than 10%. The goal of creating competition and improving the quality of the public sector with the private sector and increasing the incentive for people to go to the public sector has largely been met by changing the frequency of contributions made by the financiers. In the long run, with the continuation of the implementation of the health system reform plan and the elimination of the way in which supplementary health insurers benefit from health subsidies, a high percentage of supplementary health insurance funds in the private sector is consumed, while it is better to adopt measures for the use of this resource in the public sector.

Introduction: The performance of employees has an important role in productivity of organizations. The performance of employees is affected by a wide range of individual and organizational factors. Recognition of the effective factors has an important role in improving the performance of employees. The aim of this study was investigating the relationship between provision of welfare facilities and performance of health care network of Rey City.
Methods: This was a cross-sectional study. The study population were employees of Rey health network. All the population were selected for the study. 100 employees were studied. The data collection tool was a researcher made questionnaire. The questionnaire contained three main components: demographic questions, performance investigation questions and welfare facilities question. The questionnaire validity and reliability was tested and confirmed. The data of this study were analyzed using SPSS statistical software.
Results: The results of the current study showed that there is no significant difference in employees’ performance between sexuality, different age groups, education, marriage, employment condition, work experience, and job position. Investigating the relationship between the performance of employees and provision of welfare facilities including health insurance, cultural and sport facilities, transportation facilities, tourism facilities, and welfare benefits showed that there is a significant relationship (P < 0.05).
Conclusions: The results of the study depicted that the performance of employees is not influenced by factors such as population and income level of the participants. However, provision of welfare facilities can be effective on employees’ performance improvement. However, in order to gain the maximum performance of the employees, it is necessary to consider welfare matters so that they work with higher motivation in order to improve the health condition of the community.

From a social point of view, insurance is an economic tool for reducing and eliminating risk factors via integrating a number of identical risks to predict the probable losses of a group as a whole. Social insurance is based on the belief that there are people in the community who face major risks that they cannot afford it lonely. The purpose of the Social Security Insurance Scheme is to distribute the income to those people who cannot deal with these risks. The principles governing social insurance are such that the failure to comply with any of its three principles, including social solidarity, cross subsidy, legal coercion, undermines the structure of this kind of insurance, and diverts society from the its goals that is “social justice”. Health insurance systems have completed three transition periods in their life history, based on the location of financial risk. Insurance is a trilateral relationship between the patient, the provider and the insurer. In historical systems: there is a direct relationship between the patient and the services provider and the location of the financial risk is the patient himself. In traditional systems: a person pays a sum to an insurance institution during the healthy life period and insures himself against the financial risk arising from it, and therefore the place of occurrence of the financial risk is the insurer. In modern systems: the place of financial risk is insurance company and the provider of services together, and it prevents the appearance of information asymmetry phenomena, moral hazard and induced demand. In conclusion, based on the documents and upstream laws, priority actions are being proposed to reform the insurance system.

Introduction: One of the most important measures to ensure achieving Universal Health Coverage (UHC) is expanding health insurance coverage to all population. Accordingly, the present study was conducted with the aim of investigating the effect of having health insurance on the utilization of outpatient services provided by physicians using the data of the utilization of health services survey (2015).
Methods: This study is a secondary analysis of the utilization of health services survey data that was conducted in two groups of the insured and uninsured to examine the differences between these two groups in outpatient healthcare utilization provided by physicians. The variables were insurance status as an independent variable and the number of physician visit as a dependent variable. This analysis was disaggregated by place of residence and income.
Results: The visit per capita for outpatient services was lower in all uninsured groups. The visit per capita in insured people was almost two times more than that of uninsured individuals, which was 4.25 and 2.61 among insured and uninsured individuals, respectively. Therefore, the lack of basic health insurance decreased the utilization of outpatient services by 50 percent. General physician visits per capita for insured people living in urban and rural areas were 11.2 and 0.35, respectively.
Conclusions: Based on the results of this study, the visit per capita is directly related to the insurance status of the individuals. Therefore, it is necessary to ensure the equity in utilization of outpatient services provided by the physicians among various groups of population.

Introduction: The health insurance organizations in Iran are an important part of the health system. However, they are not conscious to many unnecessary costs incurred by providers and recipients, and the health system suffers from a lack of an efficient health insurance system. Therefore, it is essential to assess the performance of insurers and implement appropriate measures. This study aims to investigate the performance of Iranian health insurance organization and present solutions to the challenges.
Methods: This study employed an explanatory sequential mixed method. The quantitative part of the research is a descriptive cross-sectional study and the qualitative section is conducted through qualitative content analysis. Quantitative data were collected by a researcher-made tool and analyzed based on descriptive statistics. For the qualitative section, the focus group discussion method was used for collecting data.
Results: Quantitative results show an increase in the population covered, especially in Self-employed fund, and increase in the number of contracting providers except physicians and dentists. The analysis of indicators related to utilization of health services indicates that the distribution of health facilities varies in different provinces which Sistan and Baluchestan Province has the lowest ranking. Also, financial indicators show that overhead costs and medical expenses of health insurance organization have been rising significantly since 2014. The analysis of qualitative data led to identification of three themes including: factors affecting budget deficit, suggested solutions for health insurance organization and suggested solutions for the health system. Based on the findings, the increasing of tariffs, population covered and benefit packages coverage are the most important factors in increasing costs, which strategic purchasing and revising of basic benefit package can play a significant role in meeting challenges.
Conclusions: In recent years, the population covered by the health insurance organization and the number of contracting providers have risen, and the utilization of health services has increased. On the other hand, the costs of this organization experiencing a significant increase for various reasons. Therefore, it is vital to design and implement appropriate strategies to manage the costs.

Introduction: Today, growing increase of costs is one of the challenges for health systems. The purpose of this study is to investigate the health costs trend in Iran and the policies adopted to manage them better.
Methods: This descriptive-analytic study was carried out in two steps: 1- General review of the Iran's health system costs trend based on National Health Accounts. 2-identification of Experts views on factors lead to increasing health costs in Iran and the strategies used to manage these costs better in last few decades, through simple and accessible sampling and semi-structured interviews. Data analysis was done 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 has increased over the past years, and various strategies have been used to manage these costs that 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, growing 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: A significant amount of treatment cost is paid by health insurance organization. Insurance companies, mostly, use certified people to consider documents, but according to the number of documents and the limitation of time and human resource, consider documents carefully is almost impossible and more importantly, some infringements are not identifiable According to only one document but is 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 this research, data warehouse was prepared by using Tehran health insurance data until 1396 and then after eliminating faulty data, according to network mining methods, actions for detecting anomalistic referrals on the network, data filtering and weighing the edges of the network based on certified people views, were taken. This method was implemented in Knime environment and a short list was presented to health insurance organization’s monitoring department for considering.
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: The design of a benefit package is a key tool for directing health systems to the universal health coverage. Deciding 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, this study aimed to determine the role of health technology assessment in the package of designing.
Methods: This review study has been used to collect and analyze 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 articles studied, only 2 studies were selected according to inclusion and exclusion criteria. These two studies describe the experience of Thailand and the Netherlands in the role and application of health technology assessment in determining the benefits package. The Thai study describes the hierarchy and sequence of how to determine the choice of services to be included in the benefits package, and in the Dutch study, it refers to the policy and implementation levels and the infrastructure needed to establish a health technology assessment system to determine the benefits package.
Conclusions: Given 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 for informing health system decision makers about package coverage because it increases transparency, participation and accountability in the process. Accordingly, a 5-step model is recommended to determine the benefits package.

Introduction: Making medical interventions over the actual needs of patients, not only waste existing resources and cause more costs but also threaten people’s health. Identifying, removing and preventing factors affecting unnecessary medical interventions have a main role in its controlling. So, this study aimed to explore factors affecting this phenomenon from the viewpoints of Iranian health system experts.
Methods: To collect data, Focus Group Discussions, 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. Making evidence informed policy interventions in payment system, insurance system, tariff system and education system in the country, management of conflict interests, making culture and informing community are the factors that are influential on controlling and decreasing side effects of this phenomenon.
Conclusions: effort to identifying factors influential on unnecessary medical interventions can help establishing accurate supervision and reporting system and cause preventive interventions to reduce more unnecessary costs and inappropriate outcomes resulted from this phenomenon.