مجله بیمه سلامت ایران
سال دوم شماره 2 (پیاپی 5، تابستان 1398)

The use of appropriate health payment system is one of the priorities for all countries. The aim of this study was to survey the features of diagnosis related groups (DRGs) and ambulatory payment classifications (APCs) in order to provide a framework for calculating inpatient and outpatient care costs in Iranian hospitals.

This review article conducted by searching bibliographic databases including PubMed،Science direct, SID and Cochrane library. Google scholar and other relevant websites were also searched. Studies restricted to English and Persian language. There was no study design and date limitation.

Of all retrieved studies, 108 studies were selected. Seven DRGs systems have been developed primarily for inpatient services that had various elements for determining payment and were made to address particular limitations in the original DRGs. Different countries often have used their native inputs such as ICD clinical codes. DRGs approaches are converted the clinical code to the financial for determining costs. Finally, Payments for each condition or diseases are estimated based on Adjustment factors, Expenditure ceiling, and Cost weights set. In the APC system would be assigned specific current procedure terminology and ICD clinical codes for each patient who visited the physician and had procedures perform. The APCs approaches are converted the clinical code to the financial for determining costs. Finally, Payments for each condition or diseases are estimated based on Adjustment factors, Expenditure ceiling, and Cost weights set.

Using well-defined prospective payment systems such as native DRG and APC which cover inpatient and outpatient service costs are considered as an effective step in reforming Payments in Iran health care system.

As the pharmaceuticals play a decisive role in promoting health of the community, its consumption and cost puts the burden on society. Regarding the role of insurance organizations in health system financing and the lack of a description of the costly services of the health insurance organization in Iran, the present study aims to identify the most costly pharmaceutical items of the health insurance organization and provide solutions to reduce the consumption of identified items.

The present study was a descriptive cross-sectional study conducted in 2017 based on 2015 data. Information was obtained from the medical documentation software of the provincial health insurance offices throughout the country. In order to improve the accuracy of the information and the accuracy of the selection of the most costly services, duplications were identified and corrected. Data analysis was done using Excel 2013 software. The initial questionnaire containing 20 costly services identified at the previous stage was completed by the chief of provincial health insurance offices and relevant responsible experts. The proposed interventions were reviewed and, after removing duplicates, were classified as special interventions for each service and non-specific interventions for all of them.

The cost of 20 items of costly pharmaceuticals has accounted for 35% of total pharmaceuticals costs of health insurance organization in 2015. Among the most important non-specific interventions identified, recording drug prescription (more monitoring of drug use), proper education of rational drug prescription, the presence of a trusted physician to approve drugs, staggered franchising, the pharmaceuticals cost-effectiveness studies and culture empowerment in Prescribing and consumption of medication (increasing general information).

With the knowledge of costly services, in order to balance the costs of the health insurance organization, it is necessary that various policies be put in place by the health insurance organization in order to control costs.

Trying to contain hospital costs is one of the biggest challenges facing the Iranian health system. In this study, we attempted to identify the key factors affecting hospital costs, hospital cost containment approaches, and to tailor intervention packages accordingly.

This study was conducted in three stages. In the first stage, by searching databases and expanding the total cost formula for a hospital from the health system perspective, key factors affecting hospital costs were identified. In the second stage, cost control approaches, intervention packages, and their prioritization criteria were identified in a panel of experts with the participation of 4 faculty members of the School of Management and Medical Informatics. In the third stage, the matrix scoring for intervention packages was completed and prioritized by 21 hospital managers.

By expanding the formula of the total cost (C=P×Q), three factors of technology, productivity, and inflation in the Price field (P), and three factors of covered population, Utilization and overuse in the Quantity field (Q) were identified. For these key factors, 17 components were identified, which 9 components were intervenable. Then, based on expert panel members' opinion, 10 intervention packages were defined. These packages were prioritized by five criteria including: "effectiveness, appropriateness, feasibility, efficiency, and painlessness". Finally, the five most important intervention packages were selected as: "prevention of inappropriate use of services", "production of low-cost hospital services", "reducing inpatient costs", " containing drug costs" and " containing capital medical equipment costs" respectively.

Considering financing problems of the Iran health system, attention to cost containment approaches is very important especially from the health system perspective. This study showed that by identifying key cost factors and cost control approaches, special intervention packages could be formulated that are relatively painless and in line with upstream policies.

Evidence-based decision making plays an important role in the health system. Decision-making is based on observable results and real information, and it will naturally be easier to achieve the desired output. Therefore, this study aimed to identify and prioritize evidence-based decision making in health policy.

This is a descriptive-analytic study that was carried out in 2019. The population of the study consisted of all experts in the health system of Iran. Twenty people were selected through targeted sampling. The data gathering tool is a pairwise comparison questionnaire. Data were analyzed using Expert Choice Version 11 software.

According to the findings of this study, external factors, data factors and evidence-based models with the highest weight of 0.649 have the highest weight. In addition, in internal factors, the IT factor with the weight of 0.415 have the highest weight. In general, data and evidence-based models and IT and IT have the highest weight and communication and trust respectively of 0.015 and 0.013, respectively, among the lower limitations of the number of factors derived from evidence-based decision-making methods in the field of health management.

The results of this study showed that a total of 10 structures in evidence-based decision making in the health system of Iran. Therefore the managers and policy makers can identify the best evidence and make the best decisions in an evidence-based decision-making process.

Inequalities in the health system that are defined as the differences between individuals in the enjoyment of health and its facilities, is one of the determinants of health among individuals and groups. The purpose of this study was evaluate the inequality in payment of health insurance in Iran during 2011 to 2017.

The present descriptive-analytical study was designed and conducted as cross-sectional study in 2018 year, using the National Household Expenditure Survey data which is done annually by the Iranian Statistics Center. In the present study, inequality in payment of Iranian health insurance during 2011-2017 was measured. For this purpose, the average household expenditures for health insurance and average household expenditures were calculated, and by the Lorenz curves, the Gini coefficient of these expenditures was calculated. Then, in order to assess the fairness of insurance payments, the Kakwani index was calculated.

The average Gini index for health insurance payments between urban and rural households during the whole study period was 0.34 and 0.47, respectively. Kakwani index values were always positive for rural areas throughout the study period, while urban areas were negative for 2012-2014. In addition, the trend of average changes in the Kakwani index across the country declined from 2011 to 2013, indicating an uneven trend in insurance payments in those years. But in the years 2014-2016 the trend of these changes was incremental.

The findings of the present study showed that the equity status of Iranian households' insurance payments was not favorable especially in urban areas; and it is necessary to achieve equity in the payments of family health insurance, planners and policymakers while reviewing the redistribution of resources in the country's insurance sector by redistributing resources in urban areas, along with improving the quality of covered health services. Proper insurance provides adequate financial protection for Iranian households.

Infectious diseases were the biggest health complication of the world in the last decades but nowadays non infectious diseases are the major health complications. Coronary artery diseases are a major problem in the world. This study aim to compare the expenses covered by IHIO for angioplasty surgery in three hospitals based retrospective System.

This is a cross-sectional descriptive-analytical study to works on 532 patients hospitalized for angioplasty surgery in three hospitals A, B and C in March 2018 who was insured by IHIO. For findings that are more accurate the expenses covered by the insurance categorized to hospital stay, surgery, drug and equipment, paraclinic and angiography and other costs and data analyzed by SPSS 22. After applying the normality test on the data of each hospital separately it was clear that data distribution was not normal so Kruskal–Wallis test was used for comparison between groups.

The average expenses covered by IHIO for hospital A, B and C were 9.9, 8.7 and 10.6 million Tomans orderly. Also the most expenses portion were for the drug and equipment which were 54%, 52% and 58% for A, B and C hospitals in orderly. The results demonstrated that the selected hospitals had acted differently in stay, drug and equipment, paraclinic measures and other costs. Finally there was a significant difference between the average expenses covered by IHIO for A, B and C hospitals.

The payment methods in health system affect the behavior of service providers and the service quality and hospitals are different in patients treatment, therefor it is essential applying the prospective reimbursement (Global payment system for prevalent surgical that patterned from diagnosis related group systems).

According to the law costs associated with disasters and accidents, it is the responsibility of the Ministry of Health and Medical Education for up to two months after discharge. But because there is no specific mechanism to identify the outpatient costs of these patients, these costs are imposed on the health insurance organization. The purpose of the study is to determine that; how the referral times and outpatient costs of the insured by the health insurance organization caused by driving accidents during the essential visits period in Ilam province.

The study was conducted retrospectively and descriptively. The statistical population includes insured that referred to Imam Khomeini Hospital in Ilam city during the first quarter of 2018 caused by accidents driving. The referral times and outpatient costs of 454 insured covered by health insurance were reviewed and recorded, coded and entered into the computer by census. Data were analyzed by SPSS 21 software and the tables and graphs were designed and extracted by central tendency indicators and data descriptions were performed.

During the essential visits period the insured of health insurance that have been injured due to driving accidents during the first quarter of 2018, a total they had 888 visits times and had cost 7,979,319,264 Rials. Each study sample had 1.96 times outpatient visits at the time of the study and has produced a cost of 2,082,582 Rials for the Health Insurance Organization.

The results of the study per year show that on average the 3216 times visit an amount of 1,057,278,832 Rials will be imposed to the Health Insurance Organization. It is suggested that the Health Insurance Organization adopts a method that this costs to be covered by the Ministry of Health and from the sources from the 10% third party premiums from the paragraph B of Article 37 of the Fifth Plan law.