مجله بیمه سلامت ایران
سال سوم شماره 3 (پیاپی 10، پاییز 1399)

Global outbreak of the coronavirus since late 2019, has had a significant impact on the global economy and in this way has affected the insurance industry regarding its role in risk management and compensation for effects of such crises. Among these, according to the direct and indirect effects of the pandemic on people’s health and livelihood, three types of insurance namely life, health and travel insurance can be considered as susceptible sectors of the insurance industry to the current crisis, which strengthens the need for research in this field. In this regard, using the descriptive exploratory qualitative research, it is shown that the coronavirus can impact on life insurance through various channels such as increase in the death risk, sale and surrender of life insurance, underwriting process and financial aspects; and on health insurance through employerschr('39') insurance costs, medical expenses, demand for new medical services and special insurance policies, as well as changes in health insurance rates. Furthermore, COVID 19 pandemic can influence on travel insurance through travel reduction, change in loss and sale market, change in demand for coverage of travel insurance, change from registration of policy sale to registration of request for change of travel date, renewal of travel insurance and change in travel insurance distribution channels.

Budget is derived from the fact that facilities are limited and needs are unlimited, and the contradiction of this fact has forced human beings to plan and budget. The Ministry of Health and Medical Education is no exception to this rule. The credit of the Ministry of Health and Medical Education is analyzed in the Budget Law of 1399.

This research is a descriptive study and applied research. The data collection tool is a checklist consisting of two parts which, after examining the content validity, has been used to collect data related to the budget law book of 2020 and 2019 of the whole country under study. Data were categorized and analyzed using Excel 2013 software.

In the budget law of 2020, the total credit of the Ministry of Health, Treatment and Medical Education was equal to 863180 billion Rials, of which 379757 billion Rials were expenditure credits, 441213 billion Rials were special income credits and 42210 billion Rials were capital asset acquisition credits. Universities and faculties of medical sciences and health services account for about 72% of the total funding of the Ministry of Health (growth of 13% compared to the previous year) and concentrated rows of headquarters 18% (growth compared to the previous year). 6%) and miscellaneous 9% (growth of 16% compared to the previous year) and health care devices with 2% growth (25% compared to the previous year). In 2020, the credit of the Health Insurance Organization is 136140 billion Rials, which has increased by 9% compared to the previous year, which is equal to 11130 billion Rials. Most of these credits (99%) are expenditure credits and less than 1 Percentage of credit is the acquisition of capital assets.

Comparing the trends and table of this article shows the high financial burden of the Ministry of Health and Medical Education in 2020 compared to 2019 despite the inflation and corona discussion, which affects this sector unintentionally. The great determination and effort of all of the organizers, planners and executives of this sector are required to be able to make the best of their health problems this year. However, due to corona disease, they allocate one billion Euros to the health sector and credit directly from the Program and Budget Organization to medical sciences universities and health services are paid to cover the costs of corona disease.

 Hospitals, as one of the main organizations providing health services, have a special sensitivity and importance in the economy and health. Full attention to the efficiency of the hospital as the largest and most costly operational unit of the health system is of particular importance, so the evaluation of hospitals is one of the most important issues for health policy makers.

Data Envelopment Analysis (DEA) is a method for evaluating the efficiency and productivity of decision units. If a network is composed of interdependent steps to generate outputs. Therefore, in this study, we have evaluated the relative efficiency of hospitals with output weight constraints for those outputs that have non-linear values. Equivalently, in the cover form, the give-and-take principle is used to take into account the output constraints. In this way, an ascending weight sequence is considered for larger output values of nonlinear value. This study is examined in a secret network. In this study, using the network data envelopment analysis approach, a system performance evaluation model has been designed that considers the relationship between weights as a reliable area in the evaluation.

In this article, the efficiency of 10 hospitals is examined with a new approach, of which only the fourth hospital has obtained an efficiency score of 1. An important feature is the change in the type of classification of efficient and inefficient units in the findings. The results showed that the proposed method is more accurate because by considering nonlinear pricing, it reduces the error that results from linear pricing in evaluations.

The resulting efficient and inefficient units are different from the previous classical methods, so different policies for the units must be considered by managers.

 Fraud has direct and indirect effects on insurers and insured. Due to the nature of the insurance industry, the decisions of managers and officials will not achieve the desired result without conducting sufficient research. Therefore, this research has studied and investigated fraud in complementary health insurance and ways to deal with it through a practical approach.

In this regard, by comparative study of successful experiences of leading countries in the fight against fraud in the field of complementary health insurance and also interviews with experts in this field, processes, underlying factors and effects of fraud in complementary health insurance, obstacles and challenges in these processes was identified. Finally solutions were provided to prevent and control this phenomenon. The interviews were uploaded in text format to MAXQDA software and then analyzed.

In total, 34 factors that cause fraud in the complementary health insurance industry have been identified and divided into six groups of “Rules and Regulations”, “Process Solutions”, “Technology Solutions”, and “Solutions related to institutions and organizations, “Educational Strategies” and “Cultural Strategies”. Findings showed that among the underlying factors of fraud, the most influential factor was “inefficiency of central insurance of Iran” and “ignoring the phenomenon of insurance fraud.

If insurance companies design and launch comprehensive and integrated systems, it will be possible to prevent a high level of fraud.

 Achieving a healthy society was one of the ideals of every human society. Achieving this important goal and achieving health in communities depends on the participation of health elites and trustees in health decision-making and policy-making. Because the elites of any society was the creators and drivers of great changes.

this qualitative research has been conducted with the ultimate goal of designing a model of participation of elites and trustees in the field of health (studied by Iran Health Insurance) with the data method of the foundation. For this purpose, while conducting open interviews with 8 university professors in the field of management and 15 elites and trustees in the field of health and paying attention to the concepts of participation and decision making, a set of basic themes (855 themes) were collected during the coding process. And categories (15 categories) were extracted from their hearts.

In the axial coding stage, the link between these categories is under the headings of causal conditions (weakness in policy-making, weakness in laws and supervision, financial problems, payment system), axial phenomenon (need for mechanisms for attracting and using elites and trustees), action strategies and Interaction (participation of elites and trustees in the field of health), context (preparation of infrastructure, design of financial and legal mechanisms, formation of policy room), intervening conditions (problems of inter-sectoral communication and culture-building-management-infrastructure-organizational conditions) And the consequences of elite participation (design and establishment of elite participation model- value creation and attention to the experience, skills and expertise of elites- organizational development and increase of efficiency and effectiveness-welcoming elite plans and solutions-creating identity and patriotism among elites - Preventing brain drain, realizing the vision and missions of the organization) was determined in the form of coding paradigm, then the components of the coding paradigm were described, the storyline was drawn and theory was created.

The findings showed that strategic purchasing has the greatest impact on the participation of elites and trustees and also increase the motivation of elites and trustees to participate in decisions; some characteristics and special conditions of this phenomenon are provided.

Greater awareness of longevity risk and health expenses due to improvements in medical technology, have created some problems for health insurance and make it one of the riskiest insurance industries. Therefore, determining the exact health expense model is the most requirement in the field of health insurance. The social insurer must monitor the expenses trend carefully and predict future health expenses using the financial approach.

This article will propose a good model for projecting average seasonal laboratory health insurance expenses based on Christiansen et al. paper, using health insurance data from 2015 to 2019. Therefore, the results of this article can improve health insurance for modelling health costs.

According to the findings, the average of seasonal laboratory health expenses has a relatively symmetrical distribution and depends on “age” and “time” factors. The results show that the average of seasonal laboratory health expenses has higher values around birth and at young adult ages, and then monotonically increasing at older ages.

Lack of a proper model for health costs is one of the reasons for the failure of the health plan. This paper solves this problem by proposing a suitable model for the average seasonal laboratory health costs.

Due to the growth of costs and the variety of health problems, insurance is considered to be highly critical in all countries. Health insurance literacy, as a novel type, refers to the awareness of the insured of insurance-related practices and decisions. Therefore, an attempt was made to measure and examine the level of insurance literacy and the affecting factors in the insured of Ilam Health Insurance
Organization.

In this descriptive-analytical, cross-sectional study, a standardized researcher-developed questionnaire was used to measure the health insurance literacy. Data were collected randomly from a sample of 426 insured persons visiting the four government counter offices in contract with the Ilam City Health Insurance Office. Descriptive and inferential statistics were used to analyze the data using SPSS software.

Approximately 74% of the insured in Ilam had a high level of insurance literacy. Health insurance literacy was further significantly associated with the gender, age, type of insurance, education and the income
of the insured.

Insurance literacy could be one of the key variables in the optimal use of health insurance services. Therefore, its measurement and promotion should be one of the priorities of insurance organizations, health care providers and policy makers in assessing and designing related trainings and planning practices.

 The patients ‘satisfaction with health service is one of the five indicators of quality evaluation in health care programs. This study aimed to identify the attributes related to the non-satisfaction of insurance coverage among patients visited to dental clinics.

In the framework of a qualitative study conducted in Tehran city, six private and public dental clinics were selected in regions with variant socio-economic status. Face-to-face interviews with the head of household or their spouses who visited to selected dental clinics were carried out and sampling continued until saturation. Data collection lasted from October until February 2018. Thematic analysis was used for content analysis and MAXQDA12 software was applied for data analys

54 interviews were conducted and overall 14 codes were extracted. Peculiarity and non-peculiarity attributes were identified as two main attributes related to dissatisfaction of the basic and complementary health insurance. To more detail, both basic and complementary insured interviewees expressed dissatisfaction with high premiums, inadequate service packages, as well as rarity of contract centers. Moreover, the interviewees with basic insurance were highly dissatisfied with quality of health services, and those of complementary coverage were dissatisfied with reimbursement system of insurance.

The findings suggest that in order to improve the level of satisfaction with insurance coverage, it is necessary for policy makers to consider the affordability of insurance coverage, insurance packages, and also the quality of health services provided by insurers.