insurance organizations

The increasing costs of health care systems will be reduced significantly if preventive services are developed at levels of prevention. The experience of countries in the world in using preventive services and raising awareness of the related benefits can play a motivating role among the stakeholders in implementing such a policy in Iran. This study aimed to identify the most critical interventions covered by insurance organizations active in the worldchr('39')s health systems.

This study is a systematic review of studies related to a diverse range of preventive services in the health system and insurance organizations and provides evidence-based information on the benefits of developing this category of services and interventions. The study was done by defining the search keywords in the main database between December 30, 2004, to January 2019, carried out in 2020.

Different categories of disease prevention services are being offered around the world that has brought significant benefits to communities. Among the most important benefits of developing such services are reducing costs, reducing health inequalities, increasing quality of life, and higher job productivity. In addition, different groups in the community, such as specific occupations or specific age and gender groups, while having specific preventive services, have developed their insurance policies that provide related preventive services. Therefore, insurance organizations play an essential role in the benefit and effective coverage of preventive services in communities, which has made the possibility of a person with insurance to use preventive services far more than people without insurance or with treatment-oriented insurance.

The benefits of preventive services in the world health systems have been proven, and some countries have adopted a law requiring the provision of such services to insurance organizations. On the other hand, insurance companies are facing increasing health costs, which has led the attention of policy makers of insurance companies to control costs. With the relevant evidence documented, it is time to move to preventive services.

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.

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.

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.

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.

Regarding an increase in the number of insured people and costs of treatment services, insurance organizations encounter problems in paying claims of their contractees. So that a delay in the payment of contractee hospital costs has made them reluctant in accepting and visiting the insured people. In order to compensate their fiscal deficit and prevent its increase, insurance organizations in Iran have restricted their commitments in front of insured people. Besides, they have increased the amount of money (franchise) paid by patients. These organizations believe that the difference between the income and costs of treatment services is because of low insurance cost per capita and increase of costs of treatment services. This research is an applied study and its administration is descriptive and is conducted as a comparative study. Data are collected from the study of documents, books, articles and information banks. The proposed plan in devised considering the opinions and comments of qualified experts in health care sectors and findings of other countries under this study. The Delphi technique is used to test the mentioned plan. Tariffs for treatment services and medicines are usually determined in Canada, Germany, Japan, France, England and South Korea based on fixed prices and calculated profit, and hospital activities are made in agreement with bazaar system. However, the tariff in public sectors is determined in Islamic republic of Iran, Pakistan and Turkey regarding the governmental subsides and below the fixed prices. Insurance organizations are more influencing in countries of Canada, Germany, France, South Korea, Japan and England in comparison with Iran, Turkey, Pakistan and Indonesia and play more powerful role in determining different tariffs. Definite paying of claims in contractee hospitals in Germany, England, Indonesia, South Korea, Japan and Canada lasts at most two months, but it is done with great delay in Iran. Insurance organizations in countries under our study employ control methods such as setting reference systems of patients, family physician, determining commitment area and the patient portion, and penalizing and nullifying contract of hospitals. Based on proposed plan in this study, tariffs are determined considering opinions of users in homogenized diseases' groups, hospitalization costs, and the features of different areas. Besides, factors such as fixed prices of hospital services and use pattern of treatment services for insured people affect the proposed plan. The proposed plan is applied in both direct and indirect treatment and the independence of insurance organizations from the government and providers of treatment services increases the usefulness and efficiency.