National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 8 4 2026 3 1 Designing a Risk Profile Framework for Supplementary Health Insurance in Iran: An Analysis of Institutional, Data, and Technological Requirements 285 296 FA Esmaeel Safarzadeh Department of Economics, Faculty of Social Sciences and Economics, Alzahra University, Tehran, Iran Khadijeh Ebrahimnezhad Department of Economics, Faculty of Social Sciences and Economics, Alzahra University, Tehran, Iran Mitra Ghanbarzadeh Department of Personal Insurance, Insurance Research Center, Tehran, Iran Nasrin Hozarmoghadam Department of Personal Insurance, Insurance Research Center, Tehran, Iran This study aims to design a localized and practical framework for developing a risk profile for supplementary health insurance in Iran. The framework is intended to systematically identify, assess, and manage financial, operational, and legal risks, with the goal of enhancing insurers’ resilience, improving decision-making, and supporting the development of more efficient insurance products. The research was carried out in three stages: (1) extraction of risk profile components from specialized literature, (2) a comparative study of experiences from leading countries and international indicators, and (3) analysis of the current status of Iran’s insurance industry in terms of human, technological, legal, and institutional infrastructure to provide a locally adaptable and practical risk profile. The findings indicate that the risk profile can serve as a strategic tool for effective insurance risk management. The proposed framework consists of seven steps: defining objectives and scope, gathering key stakeholders, environmental scanning, risk identification, risk assessment and measurement, development of risk responses, and monitoring and reporting. This structure facilitates the identification and forecasting of high-cost medical risks, prioritization of threats, and targeted allocation of resources. Furthermore, international experiences highlight the critical role of advanced technologies and robust legal frameworks in enhancing the efficiency of risk management systems. Implementing a systematic risk profile in supplementary health insurance can promote fair pricing, strengthen financial resilience, and improve the quality of insurance services. However, challenges such as the lack of structured data, weak technological infrastructure, shortage of specialized personnel, and absence of comprehensive legal frameworks require simultaneous development of data, legal, human, and technological infrastructures, along with improved coordination among insurers and regulatory bodies.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 8 4 2026 3 1 Implicit Rationing vs. Explicit and Transparent Rationing in the Health System with an Insurance Approach 297 300 FA Alireza Arabi National Center for Health Insurance Research, Tehran, Iran Maryam Seyed-Nezhad National Center for Health Insurance Research, Tehran, Iran Mohammad Moradi-Joo Social Determinants of Health Research Center, Yasuj University of Medical Sciences, Yasuj, Iran Healthcare systems worldwide face resource constraints against ever-increasing demand, necessitating some form of rationing. Implicit rationing, implemented through long waiting lists, high out-of-pocket payments, and geographical barriers, has significant negative consequences including severe inequities in access, heavy financial burdens on households, economic inefficiency, and erosion of public trust. In contrast, explicit rationing based on transparent, evidence-based, and accountable criteria can lead to greater equity and efficiency. Successful experiences from countries such as England with NICE, New Zealand with PHARMAC, and Thailand with its Universal Health Coverage package demonstrate the feasibility and effectiveness of this approach. This policy brief presents five key recommendations for transitioning Iran's health insurance system to explicit rationing: establishing an independent health technology assessment agency, developing an essential health insurance benefits package, ensuring transparency and stakeholder participation, strengthening information and research infrastructure, and implementing a comprehensive change management and public communication program. Implementation of these recommendations can lead to a more equitable, efficient, and sustainable health system.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 8 4 2026 3 1 A Comparative Study of the Indices of Utilizing Supplemental Health Insurance Services in a Semi-Public Non-Governmental Organization (2018-2021) 301 310 FA Faranak Farzadi Department of Women's Health, Academy of Medical Sciences of the Islamic Republic of Iran, Tehran, Iran Ali Asghar Haeri-Mehrizi Health Services Management Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran Afsoon Aeenparast Health Services Management Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran Hoda Tafazoli Harandi Health Services Management Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran Fatemeh Riazi Health Services Management Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran Hasan Baslanpour Department of Human Capital Excellence and Welfare Development, Logistical Deputy, Academic Center for Education, Culture and Research (ACECR), Tehran, Iran Abolfazl Taghavizadeh Department of Human Capital Excellence and Welfare Development, Logistical Deputy, Academic Center for Education, Culture and Research (ACECR), Tehran, Iran Mahsa Behravesh Department of Human Capital Excellence and Welfare Development, Logistical Deputy, Academic Center for Education, Culture and Research (ACECR), Tehran, Iran Introduction: This study aims to analyze the status of utilizing supplemental health insurance services by members of the Academic Jahad Organization during the years 2018 to 2021. Methods: This research was a cross-sectional study. Data related to the extent of utilization of supplemental insurance services were extracted and analyzed within a specific time frame. No sampling was conducted in this study; instead, all extracted data from the database were analyzed. Descriptive statistics were used to describe the current status and to compare the indices across different time periods. Results: The findings of the study indicated that during the period from December 2018 to December 2019, the highest usage of supplemental health insurance services was allocated to medical visits, followed by medications. The annual per capita demand for utilizing supplemental health insurance services was estimated at approximately 12 requests, while the per capita monetary coverage for the entire Academic Jahad Organization exceeded 13 million rials per year. In the third period of supplemental insurance (2020–2021), this changed to less than 12 requests and 38 million rials. Conclusion: Supplementary health insurance is a useful way to improve health status and satisfaction of organizations’ workforce. Service coverage should be defined by assessing the utilization of health services. this assessment will improve the effectiveness of the resourse allocation in this field as well as proper utilization of health services.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 8 4 2026 3 1 The Role of Motor Activity and Motor Skills in Predicting Health Services Utilization Among Older Adults Covered by Health Insurance 311 318 FA Masoumeh Faghfouriazar Department of Physical Education, Ga.C., Islamic Azad University, Garmsar, Iran Introduction: The increasing population of older adults is accompanied by prevalence of non-communicable diseases and decline in motor function, which may elevate health services utilization and impose financial burden on insurance systems. This study aimed to examine the role of physical activity and motor function in predicting health services utilization among older adults covered by health insurance. Methods: This cross-sectional, descriptive–analytical study included 250 men and women aged ≥60 years under health insurance coverage in Tehran, selected via multistage cluster sampling. Physical activity was assessed using the IPAQ-E questionnaire, motor function with the Timed Up and Go (TUG) test, and health services utilization with a self-reported form including general practitioner visits, specialist visits, hospital admissions and daily medication use. Data were analyzed using Pearson correlation and simultaneous multiple regression in SPSS version 20. Results: Physical activity was significantly negatively correlated with all indices of health services utilization (P<0.01), while TUG time was significantly positively associated. Multiple regression analysis showed that 28% of the variance in health services utilization was explained by the predictor variables (R²=0.28). Motor function was the strongest predictor (β=0.38, P<0.001), and physical activity was also a significant negative predictor (β=-0.31, P<0.001). Conclusion: Higher levels of physical activity and better motor function are associated with reduced health services utilization among older adults. Investment in structured physical activity programs and routine motor function screening may be an effective strategy to decrease healthcare costs and improve quality of life in health-insured older populations.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 8 4 2026 3 1 Analyzing Factors Related to Breast Cancer Screening in Iran: Application of a Social Marketing Approach 319 331 FA Khatereh Berahmoghadam Department of Health Service Administration, ST.C., Islamic Azad University, Tehran, Iran Shaghayegh Vahdat Department of Health Service Administration, ST.C., Islamic Azad University, Tehran, Iran Somayeh Hesam Department of Health Service Administration, ST.C., Islamic Azad University, Tehran, Iran Introduction: Breast cancer is the most common malignancy in women, and despite the high incidence rate in Iran, participation in screening programs remains low. Previous studies of breast cancer have paid less attention to structural and systemic analysis using management models. The aim of this study was to identify and comprehensively analyze the factors affecting the promotion of women’s participation in breast cancer screening programs in health centers using the integrated service marketing (7P) conceptual framework. Methods: This qualitative study, employing thematic analysis, involved 22 participants (12 service providers and 10 service recipients) in Razavi Khorasan Province. Data were collected through semi-structured interviews and analyzed using Braun and Clarke’s six-stage thematic analysis method. Results: Within the seven main components of the 7P model, the most important findings were: the need to define operational bottlenecks and link insurance to healthcare (frequency of 49.8%) and focusing on effective education regarding breast cancer screening activities (frequency of 41.5%) in the Product component; utilizing digital media and local networks (frequency of 41.6%) in the Promotion component; fear of cancer diagnosis (approximately 65%) and access costs (91.6%) as major barriers in the Price component; the necessity of training and motivating staff (58.3%) and the quality of human interactions (50%) in the People component; access challenges (36.3%) and unsuitable physical space (45.4%) in the Place and Physical Evidence components; weaknesses in the follow-up and referral system (36.3%) and the need to simplify procedures (41.6%) in the Process component. Overall, “the psychological costs of fear of diagnosis” and “failure in the follow-up and referral process,” as well as weaknesses in “continuous promotion” and “quality of human interaction,” were identified as key barriers. Conclusion: The success of breast cancer screening programs in Iran requires a systemic and comprehensive approach. Designing multifaceted and integrated interventions based on the seven dimensions of the 7P model can help address the identified barriers and increase the effective coverage of this vital program. To promote women’s participation, interventions to reduce fear and psychological costs, improve systemic follow-up processes, and enhance human interactions must be designed.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 8 4 2026 3 1 The Effect of Cost Management Interventions on Hospital Costs in the Dimensions of Human Resources, Hoteling, and Consumable Office Supplies 332 345 FA Parastoo Karamiankhah Faculty of Medical Science and Technology, Science and Research Branch, Islamic Azad University, Tehran, Iran Leila Riahi Department of Health Services Management, Science and Research Branch, Islamic Azad University, Tehran, Iran Seyed Jamaleddin Tabibi Department of Health Services Management, Science and Research Branch, Islamic Azad University, Tehran, Iran Introduction: Given the increasing health costs and the necessity of cost management, this study evaluates the effect of management intervention on the costs of three main areas: human resources, hoteling, and administrative consumables. A descriptive before-after design was used to examine cost changes. Methods: Two six-month periods (before: first half of 2018; after: first half of 2019), including 43 inpatient units and financial data extracted from the hospital accounting system. Interventions were divided into three broad categories: (1) administrative savings, (2) reduction of hoteling and consumables costs, (3) reforms in human resources. Analyses were conducted descriptively and paired t-tests were used for pre-post comparisons. No control group was used. The reliability of data from financial reports and its validity were strengthened with objective data. Results: The mean total hospital costs in the three domains before the intervention were 10,077,578,333.93 Rials and after the intervention were 9,498,523,261.39 Rials (reduction ≈ 579,055,072.54 Rials; P<0.001). The before-after correlation for the three domains was r= 0.996, 0.996 and 0.914 (P<0.001), respectively, and the results of the paired t-test showed that the mean differences in each domain decreased significantly (P<0.001 to P<0.003). Due to the lack of control variables, causal inference is limited. Conclusion: Cost management interventions, despite the design without control variables, have led to a reduction in total hospital costs in the three domains. However, for future causal inference, it is recommended to use quasi-experimental designs (ITS/DiD) and include service quality indicators in future studies to accurately assess the effects of interventions.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 8 4 2026 3 1 Current Challenges and Future of Reimbursement Policy in Iranian Health System 346 348 FA Leila Zarei Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran Nazila Yousefi School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran Mohammadjavad Foroughi Moghadam Kamran Bagheri Lankarani Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 8 4 2026 3 1 The Endless Path of Payment Reform in the Health System 349 351 FA Mahya Razimoghadam National Center for Health Insurance Research, Tehran, Iran