National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 1 4 2019 2 1 The Role of Health Technology Assessment in Determining the Benefits Package: A Review 111 116 FA Saeed Heydari Health Promotion & Development Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran Maryam Seyed-Nezhad Department of Health Management & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Mohammad Moradi-Joo National Center for Health Insurance Research, Iran Health Insurance Organization, Tehran, Iran 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.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 1 4 2019 2 1 Health System Costs in Iran, How to Manage it 117 127 FA Iravan Masoudi Asl Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran Mohammad Bakhtiari Aliabad Islamic Parliament Research Center of the Islamic Republic of Iran, Tehran, Iran Ali Akhavan Behbahani Islamic Parliament Research Center of the Islamic Republic of Iran, Tehran, Iran Maryam Rahbari Bonab Community Based Participatory Research Center, Iranian Institute for Reduction of High–Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran 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.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 1 4 2019 2 1 Supplementary Insurance and Out of Pocket Payment: The Satisfaction of War Survivors and Their Families 128 134 FA Farzaneh Maftoon Population Health Research Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, Tehran, Iran Batool Mousavi Janbazan Medical and Engineering Research Center, Tehran, Iran Mohammadreza Soroush Janbazan Medical and Engineering Research Center, Tehran, Iran Kazem Mohammad Epidemiology and Statistical Department, Health Faculty, Tehran University of Medical Sciences, Tehran, Iran Mojgan Sharifan Population Health Research Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, Tehran, Iran Fatemeh Naghizadeh Moghari Population Health Research Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, Tehran, Iran Introduction: The rate of out of pocket in health services has particular importance in health system. The aim of this study was to assess the rate of out of pocket and also the satisfaction with reimbursement process. Methods: This study was across- sectional one which was done in 2018. At all 1177 war survivors and their families whom were covered by supplementary insurance were studied and they were selected randomly. In this study the questionnaire which was used in similar previous study, used for collecting data. Results: At all 1177 veterans, their families and martyrs' families were studied. About 53 percent (622 persons) of them had paid out of pocket for health services during the one year. In reimbursement process the satisfaction of 622 studied persons with the waiting time, providers, service place and repayment process was 33%, 69%, 54% and 39%.respectively. Also the waiting time and situation of cost repayment effected on satisfaction with reimbursement process. Conclusions: Base on this study results decreasing the rate of out of Pocket Payment and increasing the satisfaction with reimbursement Process are important. For next study it is recommended appropriate project resulted in strategies for improving reimbursement Process.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 1 4 2019 2 1 Exploring Influential Factors on Unnecessary Medical Interventions: The Viewpoints of Iranian Health System Experts 135 142 FA Parinaz Doshmangir Tabriz Health Services Management Research Center, Department of Health Services Management, Iranian Centre of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran Leila Doshmangir Tabriz Health Services Management Research Center, Department of Health Services Management, Iranian Centre of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran 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.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 1 4 2019 2 1 A Localized Model for Sustainable Financing in Iranian Health Insurance Organization: A Resilient-Economy-Based Approach 143 152 FA Mohammadreza Rezaee School of Management, Islamic Azad University, Isfahan Branch (Khorasgan), Isfahan, Iran Saeid Daei Karimzadeh School of Management, Islamic Azad University, Isfahan Branch (Khorasgan), Isfahan, Iran Mehdi Fadaei Payame Noor University, Isfahan, Iran Akbar Etebarian School of Management, Islamic Azad University, Isfahan Branch (Khorasgan), Isfahan, Iran Introduction: The Iran Health Insurance Organization (IHIO) was established to develop the Iran Health Insurance Sector. Currently, this organization lacks the adequate funding and faces challenges in providing the required resources due to the imposed unilateral sanctions; therefore, it is necessary that this organization take proper measures within the framework of state policies regarding the resilience economy in order to finance itself and cover more population in accordance with the Iranian operating laws. The objective of the present study was to propose a financing model for the IHIO based on the resilience economy. Methods: This was a qualitative study based on the Grounded Theory (GT), and the data were collected from framework documents, open and in-depth interviews, and a review of the lectures given by 31 experts. The validity was first examined by the interviewees and then approved by the experienced professors. The reliability was determined to be 73% via process auditing. The data were analyzed through a GT-based methodology and constant comparison over three stages of open, axial, and selective codings. Results: The examination of the qualitative date revealed that there are many factors in action in the IHIO’s financing process and this organization needs to review and revise its structure and methodology. Taking into consideration the current sanctions and lack of funds, the IHIO should change the following seven components within the framework of notified resilience economy policies: organizational management, financial management, research, structural change, cultural revision, and regulatory procedures. Conculsions: There has been a remarkable increase in the IHIO’s insured parties recently, and more people have been receiving healthcare services. Thus, it is highly essential to propose a model to change the IHIO’s approach towards commercialization and make it produce more revenues and finance in accordance with the current economic situation in Iran.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 1 4 2019 2 1 Discover self-referral between Doctors and Pharmacists Based on Network Mining 153 158 FA Hassan Askarzadeh Department of Information Technology, Payame Noor University, Tehran, Iran Mohammad Jafar Tarokh Department of Information Technology, Khaje Nasir Al-Din Tusi University, Tehran, Iran 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.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 1 4 2019 2 1 Investigate the Change in the Behavior of Supplementary Insurers and Insured Individuals Before and after the Implementation of the Health System Reform in Mashhad University of Medical Sciences Hospitals 159 164 FA Shapour Badiee Aval College of Traditional and Complementary Medicine, Mashhad University of Medical Sciences, Mashhad, Iran Amin Adel Social Determinates of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran Hosein Ebrahimipour Social Determinates of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran Akbar Javan Biparva Social Determinates of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran Elaheh Askarzadeh Social Determinates of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran Introduction: Since supplementary insurance patients should benefit from the benefits of insurance, they do not receive health subsidies, the behavior of supplementary insurance organizations and their insured may be endangered for supplementary insurance. The purpose of this study was to investigate the change in the behavior of supplementary insurers and insured individuals before and after the implementation of the health system reform in Mashhad University of Medical Sciences hospitals. Methods: This descriptive study was conducted on a retrospective cross-sectional study in 2012-2017. The population of the study consisted of 2099499 admitted and under-observed patients in 24 public hospitals affiliated to Mashhad University of Medical Sciences. The data were collected by referring to the hospital discharge department and patient information through HIS in each hospital. The accuracy of the data was evaluated. Data analysis was performed using SPSS v16 and EViews v10 software. Results: The share of supplementary insurance in the year 2012 was about 1, and in the year 2013, Implementation of the health system reform program has reduced the share of supplementary insurance, And by the end of the year 2017, the trend has been declining to 0.2. Conclusions: It seems that supplementary insurance contracts should be integrated with university hospitals and patients' insurance coverage should be done electronically.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 1 4 2019 2 1 Factors Affecting Organizations Affiliated to Iran's Supportive Health Insurance System 165 172 FA Masoud Kavosi Faculty of Science and Technology, Department of Science and Research, Islamic Azad University, Tehran, Iran Seyed Jamaledin Tabibi Faculty of Science and Technology, Department of Science and Research, Islamic Azad University, Tehran, Iran Mahmoud Mahmoudi Majdabadi Farahani Faculty of Science and Technology, Department of Science and Research, Islamic Azad University, Tehran, Iran Kamran Hajinabi Faculty of Science and Technology, Department of Science and Research, Islamic Azad University, Tehran, Iran Introduction: The boundaries of providing heath care to patients have become so widespread that provide all these services in the form of health insurance at least not economically feasible. In many countries, supplementary insurance is used to provide health care. This research has been conducted to determine the effective factors on organizations supporting the supplementary health insurance system in selected countries and Iran. Methods: The present study is a descriptive-analytic, cross-sectional and applied study. The data of this study were collected through a questionnaire by checking texts and field studies. Reliability of the questions was confirmed by experts and limited content validity method. The data were entered into SPSS software version 25 for the purpose of calculating descriptive and inferential statistics. Then, the exploratory factor analysis was confirmed through the AMOS software program. Results: The present study showed that men with a postgraduate degree and 17 years of service experience have contributed to this research. In this regard, supportive organizations such as the Ministry of Health and Medical Education, and the subsidy targeting organization, have the least impact on supplementary care insurance had. Conclusions: The results of this research indicate that the Ministry of Health and Medical Education has played a significant role in optimal utilization of supplementary health insurance and improved patient satisfaction as well as improved community health.