مجله بیمه سلامت ایران
سال ششم شماره 1 (پیاپی 20، بهار 1402)

Financing is strongly believed to be the main function of any health system and insurance organizations play a critical role in the health financing system of all countries. Accordingly, in order to enable the insurance companies to take steps towards meeting the assigned goals, creation of a balance in the budget and also financial management of their resources and expenses are needed. Therefore, the current research is conducted with the purpose of analyzing the factors affecting the budget balance of health insurance organizations.

This research which is considered an experimental study has used the monthly data of premium, coinsurance, treatment, and overhead costs, and the number of services purchased by the Iran Health Insurance Organization during 2008 - 2019, and the vector error correction model (VECM) to analyze short and long-run relationships, estimate parameters and predict relationships. In addition, the approach of the present research in the selection of variables is based on the mediating role of this organization in the expenditure reimbursement, behavior management, and the purchasing of healthcare services.

The results indicated that in the long term, the insured's coinsurance and the premium paid to the Iranian Health Insurance Organization have a negative effect on the budget deficit, respectively -0.27 and -0.9. In contrast, the budget deficit is positively impacted by treatment and overhead costs with a coefficient of 2.41 and 0.67 and the number of services purchased by Iran Health Insurance Organization with a coefficient of 139576.

According to the findings of this study, the health insurance organization can use strategies such as increasing premiums and coinsurances, reducing treatment and overhead costs, and also the number of purchased services, to control and minimize its budget deficit.

In crisis situations, when production and economic growth are faced with negative impulses, the increase in unemployment causes the loss or reduction of income of many people. The unemployment insurance fund prevents the poverty of the unemployed by making regular payments, and through the job search mechanism, it can cause the unemployed to re-enter the labor market. Therefore, unemployment insurance plans are important tools in the economy to deal with crises.

In this research, by modeling the resources and expenses of the social security organization with the system dynamics method, the effects of the COVID-19 disease on the unemployment insurance fund and also forecasting the conditions of this organization in the coming years have been investigated. Investigations were carried out in the form of 3 scenarios: “current conditions of the unemployment insurance fund without government assistance”, “current conditions of the unemployment insurance fund with government assistance” and “help to the company to maintain human resources”.

According to the findings of this research, the scenario of helping the company to maintain human resources, i.e. paying 50% of the unemployment allowance from the fund and paying the other 50% from the employer, i.e. accepting the dual conditions of unemployment and employment at the same time, can Put the unemployment insurance fund in a better position compared to the other two scenarios.

The findings showed that the rules of unemployment insurance in the country are generous and the mechanism of monitoring the process of employment of the beneficiaries is not designed efficiently. Also, the investigations of this study generally show that if the goal is to maintain the human resources of the companies, the situation of the unemployment fund will be in a more favorable condition.

Today, health insurance plays an important role in improving the health of society and the level of well-being of people. Moreover, the World Health Organization also pursues important goals to improve the state of health and public health in countries. In our country, health insurances have shortcomings, many of which are related to policy issues and defects in the strategic management of such insurances, which require correction and improvement. In this regard, this article has been prepared with the aim of presenting and explaining a strategic model for the promotion of insurance policies in Iran’s health system.

which is developmental-applicative in terms of its purpose and is placed in the group of analytical and cross-sectional studies. In the qualitative phase, using the topic analysis method to design the research model, 26 academic and executive experts in the field of health insurance were interviewed in a targeted manner, and in the quantitative phase, structural equation modeling and Smart PLS software were used. The sample size was calculated using Cochran’s formula and 186 managers and professionals active in the field of health insurance were randomly asked for their opinions with a questionnaire.

After analyzing and coding the responses, findings including five strategies for improving macro management in health insurance, improving insurance services, improving insurance justice, managing resources and using a sustainable approach were identified, which form the basis of the designed model of variables related to drivers, factors They are contextual, strategies and consequences. The data analysis of these findings with the structural equation modeling method showed that the components of the research model were approved and all the estimated path coefficients were significant.

In the end, the results obtained from the different stages of the research indicate that by providing the interests of the beneficiaries and also considering all the variables influencing the policy making, it is possible to take a path towards improvement and improvement in the policy making process of health insurance in the country.

Despite the importance of the issue of empowerment, insurance organizations in Iran do not seek to empower their insureds due to reasons such as the lack of clarity in the meaning and concept, ignorance of the involved and influential factors, and the lack of scientific and functional status. For this reason, the present study was carried out to identify and prioritize the factors affecting the empowerment of the insured of the Iran Health Insurance Organization.

This study was conducted using a mixed method with a sequential design (first the qualitative Delphi method and then the quantitative survey method) and the participation of 15 health insurance and empowerment specialists in the Delphi method and the participation of 414 insured people of the health insurance organization. In accordance with each of the mentioned methods, sampling and validation methods were also used. Exploratory factor analysis technique was used to discover factors and Friedman’s test was used to compare factors.

After determining 60 important variables and identifying 10 main factors influencing the empowerment of the insured, which are: self-reliance, job satisfaction, feeling of alienation, social health, decision-making power, health education, access to services health and treatment, quality of life relationships, power of foresight and improvement of the level of health-oriented attitude, it was found that “improvement of the level of health-oriented attitude” and “power of foresight” had the greatest and least effect on the empowerment of Iran’s health insurance policyholders, respectively.

The insured people of the Iran Health Insurance Organization believe that in order to empower the insured people, the level of attitude of all levels involved in this field should be improved and “health-oriented approach” should be replaced by “treatment-oriented” in the society.

The implementation of the family physician program in Iran Health Insurance Organization will change the payment system, reduce payments at the first level of service provision, and create a referral system. This study has been conducted with the aim of investigating the factors influencing the adoption of the referral system and the family physician of health insurance, including the adoption of the referral system, the creation of infrastructure and reforms, management factors, public interests, appropriate health system policies, appropriate health insurance structure and satisfaction.

The current research is descriptive and correlational in terms of applied purpose and data collection method. 184 people were included in the study by census. The data collection tool is a questionnaire with closed questions. After confirming the face validity and construct validity and reliability of the research instrument (Cronbach’s alpha 0.848), data analysis was performed using structural equation modeling (PLS-SEM).

The findings of this research showed that the insurance structure in the health system was the most influential factor on the acceptance of the referral system and the family physician, and the effect path coefficient was estimated at 0.231. In addition to these policies included in the guidelines of the family physician program, infrastructure and reforms in society, management factors, public interest and satisfaction are other factors that have been confirmed to have an effect on the adoption of the family physician and referral system.

According to the findings, in addition to the appropriate health insurance structure, management and satisfaction factors are more important in accepting the referral system and the family physician. It seems that the insurance structure can create a sense of justice for people regarding health insurance because the plan of the referral system and family physician is based on necessities such as establishing proper access to the people of the country, equality in benefiting from health and treatment services, as well as the purposefulness of providing services and productivity. It is formed from the available human resources.

Due to the very weak coverage of basic treatment in the dental insurance sector, such services are considered as luxury services for people and the indicators of oral and dental health in Iran are not very favorable. With regard to the supplementary excess treatment coverage by commercial insurances, in this research, the factors affecting the use of dental services were investigated.

The research method was descriptive, analytical and cross-sectional, the statistical population of the present study included patients referred to Tehran clinics in 2022. The sample size in this study was equal to 383 people who were selected by cluster sampling method. The information was collected through a questionnaire and the data were analyzed at the level of descriptive and inferential statistics, one population and binomial t-tests and Friedman’s test.

There is a relationship between insurance coverage of dental services and oral health of people (P=0.000; t=23.99). There is a relationship between the amount of patients' out-of-pocket payments for dental services and oral health status (P=0.000; t=16.117). The amount of insurance payment for dental services has an effect on the amount of use of dental services (P=0.000; t=29.73). The demographic characteristics of the insured (DMFT index, age, gender, education level, marital status) have an effect on the use of dental services (P=0.000; t=33.04).

Due to the relationship between insurance coverage, payment amount, age and education level of people with oral and dental health, the officials and practitioners of oral and dental health should consider appropriate decision and policy regarding this matter.

The Resource-Based Relative Value Scale (RBRVS) payment basis, combined with the unorganized increase in the payment rate with the Fee-For-Service (FFS) payment method that stimulates service supply and leads to an increase in induced demand, creates a crisis for the health system, which wastes the limited resources. The present study looked briefly at the challenges caused by the health service pricing system in Iran and has provided policy recommendations to improve it. The national payment system based on the RBRVS in Iran lacks important cost control tools of the main model, including the Sustainable Growth Rate, Budget Neutralization Factor, and forecasting the growth rate of Rial value of the relative value conversion factor in the annual budget laws. A number of technical challenges exist in the national model of the RBRVS include changing the ratio of Physician Work to the Practice Expense, removing the Geographic Practice Cost Indices, removing the budget neutralization factor, the lack of an allowable payment to determine the Rial value of the conversion factor. There are also policy challenges, the most important of which is the disassociation of the Supreme Council of Health Insurance and the Supreme Council of Welfare and Social Security as a part of comprehensive welfare and social security system structure. All of the challenges are the root of the malpractice of the health service pricing system in Iran. Dissociation between health financing policies and macroeconomic policies of the country necessitates the adoption of policies to strengthen the governance of the payment system, including reforming the existing pricing system by returning to the principles governing the original model, changing the payment method to improve behavior on two supply and demand sides and institutional reform to strengthen the regulatory function for health services pricing.