مجله بیمه سلامت ایران
پیاپی 2-1 (بهار و تابستان 1397)

The growing diversity of health services, which often costs a lot, and the inability of governments to provide benefits to citizens. in all areas of health, clearly show the need for the presence and development of complementary health insurance in the health market. Private supplementary health insurance is usually provided in bulk, voluntarily, and extendable until the end of life. The purpose of this study was to provide solutions to improve the quality of complementary health insurance services and reduce government dependence. The supplementary health insurance function dedicate the second rank of the nongovernmental insurance market also, with the growth of 34.6% is the second highest growth rate in 2015. The coefficient of damage in this sector with 86.1% indicates its profitability in this year. By reviewing the patterns and models presented in the studies, in order to improve the level of health and complementary insurance, solutions were presented in 20 clauses. According to the present study, it is recommended to offer various insurance packages considering the age, gender, health status of individuals, geographical status, literacy level, income level, employment status etc.

Health system reforms are designed and implemented according to the situational conditions of each country. Recently health reforms have focused on resources and costs in the health sector for governments; they would be as the tools for making the necessary changes and improvements. Governments have designed and implemented health reforms step by step to completing the coverage of health services in terms of geographic accessibility, service affordability, and avoiding health impoverishments, catastrophic poverty from the use of health services in recent two decades. Objectives other than completing public coverage, improving quality and the quality of health services and care, and the logical reduction in costs and the optimal use of resources. Objectives other than completing public coverage, improving quality The quality of health services and care has not had a reasonable reduction in costs and the optimal use of resources. Comparing the spending costs of hospitalization in the years before and after the Iranian Healthcare Reforms Plan in 2014 has could show that the efficiency and cost of spending. This study seeks to examine the average cost of each hospitalization case in the years before and after the Iranian Healthcare Reforms Plan to compare the impact of the costs on health insurance funds.

The present study was a cross sectional study. The population of the study has included the sum of the inpatient bed day of health insurers admitted in hospitals of in 31 provinces over the past 5 years from 2010 to 2015. In this study, survey was being conducted, and accessible data resources in the databases were used for data collecting process and analyzing. The analysis has been conducted by using Excel 2010.

The highest of growth rate of the cost of inpatient bed day of health insurers in the first year of the Iranian Healthcare Reform Plan was Included respectively to the rural fund (88.4%), governmental employees fund (75.2%), self-employed fund (73.17%) and other populations fund (73.10%), and the self-employed fund shown third ranking in growth rate, although growth rate of the cost spending in all funds was more than 73%. In the first year of Iranian Healthcare Reform Plan has shown more inpatient costs growth rate than 73 percent’s for all the Iranian Health Insurance Funds.

The average of total inpatient spending cost has increasing trend in all funds of Iran Health Insurance and if there is not be a serious review of the Reform Plan, the health insurance organization may been faced serious financial problems. Therefore, by reviewing the Reform plan, it is possible to improve the plan as well as to ensure health insurance regarding sustainability of financial resources.

The culture of prescribing and drug usage as a strategic commodity, which plays a fundamental role in the economy and health of the family and society, is an important issue that should be addressed by health system policymakers.

The present study is a cross-sectional prevalence survey of all medical prescriptions of insured persons in a health insurance organization which were accepted and registered in the medical documentation system in the contract pharmacies with health insurance departments in all provinces of the country in the medical records system during 2014 and 2014.

80% of health insurance expenditures have been consumed by 93.84% in 2014 and 94.88% in 2015 year. An average amount of medicine in 2014, and 2015 years, were respect, 226 and 185 number. In all provinces, 30 to 40 percent of drug costs have been consumed by 30 drugs in each of both years.

Control and monitoring this amount of drug items can optimize 80 percent of pharmaceutical costs in each province and at the level of the health insurance organization. Considering, if each province controls its first 30 medicines, it will lead to optimize about 40% of its pharmaceutical costs.

Monitoring the quality of services in the insurance service purchase can be crucial for improving patients' satisfaction, avoiding unnecessary referral to health centers and Subsequent expenditure, and imposing them on insurance. This study aimed to evaluate the quality of public health clinic services.

This cross-sectional study was performed in Tehran during 2015, 2016 years. The research population consisted of patients referred to general practitioners in Tehran. A multi-stage cluster method was used for sampling. Overall, 394 samples were obtained from patients referred to general practitioners were included in the study. Researcher-made questionnaire was the data collection method. The questionnaire was prepared based on interviews with experts. The collected data were analyzed statistically using SPSS 22 software.

Based on the results of the research, the quality score of the clinics from 125 to 160 defined in the high range and the importance of quality dimensions from the viewpoint of patients from 131 to 160 were placed in the high range as well. Examining the service quality dimensions indicated, access point (85.5%) and then effectiveness (85.3%) were earned the highest score. Moreover, the effectiveness was earned the highest score in terms of importance. The results showed, a significant relationship between income level and questions of importance. It seems that, quality items are considered different for people according to their income.

Findings of this study indicate that, patients referring to general practitioners high-rated the received services' quality. The results of this evaluation can lead to improvement in the quality of services and reduce the burden on visits for insured persons and also reduce charges imposed on duplicate visits. Besides, it can lead to active purchasing for the health insurance organization.

 Identifying the extent of misuse of health services in hospitalization is the first step in implementing health control and restriction programs without damage to the quality of these services. This study was carried out in Valiasr Hospital of Meshkin shahr City with the aim of assessing the rate of admission and unnecessary hospitalization of insured persons and the amount of expenses incurred by this phenomenon to the health insurance organization.

 This cross-sectional study was conducted in July 2016 in Valiasr Hospital in Meskine Shahr. The statistical population in this study was composed of all insured persons covered by the health insurance organization from all the funds referred to the hospital at the time of the study. Overall, 330 samples were selected for sampling in this study. An appropriateness Evaluation Protocol (AEP) was used for data collection.

 The results obtained showed that, 56.33% of the insured persons (186 men) and 43.7% of the insured persons were hospitalized (144) were women. From the total of 330 evaluated admissions, 129 cases (39%) were inexpedient, with the highest inexpedient acceptance in the internal ward with 66% and the lowest uncontrolled acceptance was in the surgical ward with a 12% rate. In 2016, the health insurance organization paid 6,133,840,000 Rials for unplanned days of admission in these three parts.

 According to the results of this study, the AEP protocol has a good reputation for evaluating of admission and hospitalization days. The health insurance organization and other insurer organizations are essential to reduce and optimize the number of admissions and inexpedient hospitalization days by applying the AEP protocol as a regulatory tool for evaluating hospital admissions documents.

Coronary artery disease (CAD) is the Non-contagious leading cause of mortality worldwide, as more than 1 million heart attacks and strokes occur every year, of which about 30% of them die. The use of invasive methods such as angiography for the diagnosis of coronary artery disease has been reached with high costs due to the cost of this method and its complications, and on the other hand, non-invasive methods such as echocardiography is more cost-effective and has fewer side effects.

This descriptive retrospective cross-sectional study was performed in selected hospitals in Yazd in the second six months of 2014. All cases were collected from patients admitted for angiography and echocardiography, and in total 1801 records/files were submitted for examination.

Assessment of patient’s records indicated, the echocardiography results in 38% of patients and exercise test results in 30% of the patients and the result of the angiography in 72% of patients, were abnormal .

The results showed that, 38% of the echocardiographic results and 72% of the angiographic results were abnormal. Performing non-invasive tests, such as echocardiography and exercise testing, resulted in a loss of cost due to a small number of positive cases and also may cause an anxious in patients. This result has been shown more likely in women and young individuals.