National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 2 1 2019 6 1 Assessment of the Fairness in Financial Contribution Index in Iranian Health System from 2007 to 2017 1 6 FA faroogh na'emani Department of Health Management & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Shahram Tofighi Department of Future Studies and Theory Building, Iranian Academy of Medical Sciences, Tehran, Iran Jafar Yahyavi Dizaj Department of Health Management & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Majid Safaei Lari Department of Health Management & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Pedram Noorizade Department of Health Management & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Introduction: Fairness in financial contribution is a fundamental objective for the health systems, which can improve access to health care services and health outcomes. Due to the importance of this issue, the current study aimed at assessing the fairness in financial contribution index (FFCI) in Iranian Health System from 2007 to 2017. Methods: The current retrospective and cross-sectional study was conducted based on the annual income-expenditure survey of household data provided by the Statistics Center of Iran, from 2007 to 2017. The Statistics Center of Iran used a three-step clustered random method in the current study. The Fairness in Financial Contribution Index (FFCI) was calculated based on the formula presented by the World Health Organization (WHO) and using Excel software. Results: The findings of the current study showed that the FFC index for the whole study period on average was 0.84, 0.82 and 0.83, in urban, rural and total country, respectively. In addition, in 2009 and 2010, the FFC index declined in rural and urban areas and across the country. In 2011, both in rural and urban areas, tangible incremental changes were observed in the FFC index. The FFC index dropped from 2012-2014, and in 2016 it remained unchanged compared to 2015. In 2017, the FFC index had a significant increase, and reached 0.86 for the country. Conclusions: According to the current study results, the policies adopted in the health sector from 2007 to 2017 including the development of treatment insurance, the economic reform plan (2009), and the health reform plan (2014) failed to achieve the goals of the National Development Plan on Financing Justice In the health system (FFCI = 0.9), there was a significant difference, especially in rural areas, with the specified target. Therefore, the health system requires attention and specified planning by government and policymakers to promote this index.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 2 1 2019 6 1 Estimation of Supplementary Health Insurance Demand in Iranian Urban Household: Probit Model with Sample Selection 7 13 FA Mahdi Shahraki Department of Economics, Faculty of Management and Human Science, Chabahar Maritime University, Chabahar, Iran Introduction: The increasing variety and costs of health services, the high share of out of pocket, and the quantity and quality of services covered by basic insurances increased the demand for supplemental health insurance. Considering the importance and necessity of supplementary health insurance, its demand growth and its impact on improving the quality of life, the present study amed at investigating the demand of supplementary health insurance in the urban household of Iran. Methods: The present descriptive-analytical and applied study with cross sectional design was conducted in 2016 employing the probit econometric model with sample selection and maximum likelihood method. The sample size was 18,809 urban households in Iran's provinces selected via the three-stage sampling method on a systematically randomized basis by the Statistical Center of Iran. Data were extracted from the cost-income questionnaire of urban households and the coefficients of the model were estimated with Stata 14 software. Results: The results showed that the increase in age, education, the level of literacy, and the marital status of the head of the household increased the probability of demanding for the supplementary health insurance by 0.6%, 0.17%, 6.6%, and 5.3%, respectively. Also, the number of family supporters, having a child under seven years old, and owning a private house increased this probability by 16%, 3.7%, and 0.85%, respectively. The increase in health and medical expenses, as well as income and educational expenditures had a negligible positive effect, while the squared index of the age and education of the head of the household had a negative impact on the demand for supplementary health insurance. Conclusions: Marital status, age, education level of the head of the household, the number of family supporters, increased health costs per capita, increased education expenditures and the per capita income had a positive impact on the demand for supplementary health insurance by households. Among these variables, the number of family supporters, marital status, and the age of the head of the household had the highest impact and per capita income and education expenditures of the family members had the lowest effect on the demand for supplementary health insurance. Also, the demand for supplementary health insurance by Iranian urban households was a quadratic concave function of the age and education level of the head of the household. Thus, it is recommended to identify and classify households based on the factors affecting their demand and determine the appropriate conditions for the health services coverage corresponding to each class of household. It is particularly necessary to support the elderly in the treatment costs.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 2 1 2019 6 1 Identification of Financial Incentives in Irrational Use and Prescribing of Drugs: A Qualitative Study 14 20 FA Neda Shojaeizadeh Student Research Committee, School of Management and Medical Information, Isfahan University of Medical Sciences, Isfahan, Iran Mahmoud Keyvanara Department of Health Services Management, School of Management and Medical Information, Isfahan University of Medical Sciences, Isfahan, Iran Leila Safaeian Department of Pharmacology and Toxicology, School of Pharmacy and Pharmaceutical Sciences, Department of Research and Development, Vice Chancellery for Food and Drug, Isfahan University of Medical Sciences, Isfahan, Iran Saeed Karimi Department of Health Services Management, School of Management and Medical Information, Isfahan University of Medical Sciences, Isfahan, Iran Introduction: Irrational use and prescribing of medications is a major problem in healthcare systems worldwide. The factors affecting prescribing and use of drugs can be assessed in educational, management, supervision and financial areas. Present study was designed to investigate the role of financial incentives in this field. Methods: This qualitative study was conducted using a semi-structured interview in 2016. Participants included those who were well-informed and experienced in the field of rational use of drug. Sampling was done in a targeted way and 16 people were interviewed. Interviews were evaluated after the implementation of the theme analysis method. Results: In this qualitative study, four main themes and 12 sub themes were obtained. The main topics were: 1. Financial incentives for physicians (including: motivation for attracting more patients, earning more money, health insurance organizations' liabilities, community expectations of physicians' financial position, physician financial problems, and shifting physician's role from factor to performer), 2. Financial incentives for pharmacies (including: pharmacies' economic problems, health insurance organizations' liabilities, earning more money through over-the-counter sales of all medications, patient insistence and pharmacists' security), 3. Financial incentives for patients (including: self-medication and community poverty) and 4. Financial incentives for pharmaceutical companies (including: earning more profit by selling a particular brand). Conclusions: Financial motivators are among the important intervening factors in irrational use and prescribing of medications. Providing appropriate financial solutions by policy makers and improving economic situation of the community can help the quality of medical services and improve status of prescribing and usage of medications.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 2 1 2019 6 1 Relationship of Provision Financial Resources, Physical and Legal Infrastructures, and Manpower in Implementing "Health Insurance of Villagers and Nomads Program" Developed by Iran Health Insurance Organization 21 29 FA Mohammadreza Rezaee Department of Management, faculty of Management, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran Said Daei-Karimzadeh Department of Management, faculty of Management, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran Mehdi Fadaei Payame Noor University, Isfahan, Iran Akbar Etbarian Department of Management, faculty of Management, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran Hamid Bahrami Department of Management, faculty of Management, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran Introduction: The family physician program and the referral system in health insurance of Iranian villagers and nomads were implemented in 2005 by the Iran Health Insurance Organization, after being approved by the Islamic Consultative Assembly. Financial resources and other physical and legal infrastructures as well as human resources are the essential requirements for implementing this program. The present study aimed at examining the factors contributing to the success of this national program in the described areas, considering their ease, accessibility, and role in the success of the family physician program and the referral system in health insurance of Iranian villagers and nomads in 2017. Methods: In the current study, the variables involved in the physical and legal infrastructures, manpower, and provision of financial resources were first examined using Delphi method according to the experts' opinion including practitioners involved in the rural programs, inspectors, and supervisors of health insurance plan as well as experts and managers of Khuzestan, Isfahan, Lorestan, Ilam, Kermanshah, Chaharmahal va Bakhtiari, and Kohgiluyeh va Boyer-Ahmad provinces selected based on the purposive and chain sampling methods. Student t-test was then used to compare the responses with standard tables. Results: In the provision of financial resources, physical and legal infrastructure and manpower after several years of implementating the program were approved by the indices such as the timely allocation of funds and provision of service packages, the determination of the actual per capita and the payment of services per capita, approval of referral system law and upstream laws, the payment of franchises at levels 2 and 3, and the number of specialists in the villages, their appropriate distribution on the basis of population density and the expansion of health centers based on this density, appropriate training, and long-term contracts, which create a sense of usefulness and ease of using services in insures and has a significant relationship with changing the family physician program and the success of the project. Conclusions: After several years of implementing rural family physician program, the project has a relatively appropriate performance in terms of financing and other infrastructures. However, the referral system is still not implemented properly and feedbacks from specialized physicians are not sent to family physicians.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 2 1 2019 6 1 Investigating Effects of Economic and Social Factors on Entry of Households in the Health Market and their Health Expenditures: Study of Urban and Rural Households Living in Tehran and Neighboring Provinces 30 39 FA Masoumeh Esmaeeli Department of Public Administration, Faculty of Humanities, Islamic Azad University, Saveh Branch, Saveh, Iran Ali Askari Faculty of Economics and Accounting, Islamic Azad University, Central Tehran Branch, Tehran, Iran Zein-Al-Abedin Amini Sabegh Department of Management, Faculty of Humanities, Islamic Azad University, Saveh Branch, Saveh, Iran Ehsan Sadeh Department of Management, Faculty of Humanities, Islamic Azad University, Saveh Branch, Saveh, Iran Introduction: Improving level of health and increasing life expectancy of people requires investment on health through use of health products. Since the health products benefits need to be financed, it can be said that health expenditure is necessary for a healthy society. Therefore, the purpose of this study was to investigate factors affecting on entry of households in the health market and their health expenditures. Methods: This study considering the health expenditures characteristics of urban and rural households living in Tehran province and neighboring provinces, to identify the factors influencing entry of households in the health market and their health expenditures has been used sample selection model and Hackman's two-step estimation method. It is worth noting that given difficulty in choosing a sample, it is necessary to use sample selection models to obtain reliable estimates. Results: The results show that gender, health insurance services, tobacco costs, head of household status, education, number of children, youth and elderly and urbanization are among most important factors affecting on entry of households in the health market and their health expenditures; but education cannot affect decision of these households to enter the health market. Conclusions: According to the current situation, for households with low income, households with more members, older households and households with a predominant gender (women) should be considered special support schemes.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 2 1 2019 6 1 Determination of the Rate of Utilization from Health Services among New Iranian Health insured after Health Care Improvement Plan in Tabriz City; 2015-2016 40 47 FA Elham Shami Iranian Center of Excellence for Health Management, Faculty of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran Shirin Nosratnejad Iranian Center of Excellence for Health Management, Faculty of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran Alireza Pirestani Iran Health Insurance Organization, Tehran, Iran Introduction: Getting and receiving health care services is called health care utilization. Health system management depends on decisions that are right and conscious, Utilizing knowledge of health services and studies in this area is mandatory for allocating financial resources and health planning. Access has an important role in the utilization and use of health services. One of the most important factors in increasing access to services is the people’s insurance coverage. The aim of this study was determine health care utilization among new insured people of the Iranian health insurance plan after the implementation of Health Care Improvement Plan. Methods: The present study is a cross-sectional study with a sample size of 400 households from Tabriz with random sampling. The study was conducted using a telephone conversation (retrospective information) questionnaire on the rate of utilization of outpatient and inpatient care services among the Iranian health insurers of Tabriz during one-year period. Data were analyzed using descriptive and analytical statistics and analyzed using STATA 11 and EXCEL software. Results: The relative frequency of outpatient and inpatient services were 98.49, 98.75%, respectively. Also, access to services in the use of outpatient and inpatient services was 93% and 90%, respectively. Satisfaction rate for outpatient services was 51%. Satisfaction rate for receiving hospital services was 56%. Conclusions: Health insurance in Iran has led to the benefit of people without health insurance, which is higher in inpatient services. Moving toward universal health coverage can be a better way to cover people uninsured and the community.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 2 1 2019 6 1 Investigation the Status of Prescribing Growth Hormone for Patients under the Coverage of the Iranian Health Organization in Ilam Province during 2007-2017 48 52 FA Morad Nasri National Center for Health Insurance Research, Iran Health Insurance Organization, Tehran, Iran Introduction: Human growth begins since the formation of the embryo and ends with death. Growth hormone is secreted from the pituitary gland and involved in the growth process. 11 to 28 percent of short stature in Iran and about 10 percent in the world is related to growth hormone deficiency. In this article, the status of prescribing growth hormone for those under the coverage of Iranian Health Insurance was investigated in Ilam province during 2007-2017. Methods: This was a cross-sectional descriptive and retrospective study and conducted according to the available documents in the General Directorate of Iranian Health Insurance. The statistical population of the study included all medical prescriptions of growth hormone to those under the coverage of the Iranian Health Insurance during 2007-2017 sent by pharmacies to the general directorate of Ilam Health Insurance. Using the records in the database and the health insurance processor, and by census method, the data entered Excel 2007 and analyzed using SPSS version 21. Results: The number of prescribed hormone in 2007 was 1858 which increased to 4485 in 2017, showing a 2.82 folds increase. Also, the number of prescriptions in 2007 was 66 totally, which increased by 78.7 times to 513 prescriptions. The average cost of each version containing the growth hormone in Ilam province was 3,699.606 Rials in 2007 that increased to 14.972.125 Rials in 2017. Conclusions: Growth hormone is one of the expensive drugs in the health insurance organization. The drug in the studied years of 2007-2017 has always been at the top ranks with a significant role in medical expenses of Ilam health insurance, and has been one of the top 20 costing items in the province. Also, over time, its cost ranking increased and reached to the first in 2016-2017. More control and supervision on how to prescribe would be effective in optimizing the pharmaceutical costs of the general directorate of health insurance of Ilam province.

National Center for Health Insurance Research Iranian Journal of Health Insurance 2645-8225 2 1 2019 6 1 Diagnosis-Related Group (DRG) Based Payment: Entering Era of Innovative Health Care Payment Systems 53 54 FA Mahdi Naderi Ministry of Health and Medical Education, Tehran, Iran