Identifying structures related to changes in out-of-pocket payments for medical services insured in Iran from the point of view of the state insurer

Abstract:

Introduction: Today, the lack of financial protection in health is known as a disease of health systems; The clearest sign of this is that households suffer not only from the burden of disease, but also from the burden of destruction and economic poverty, in other words, facing the back-breaking costs and poverty of financing their health. Many quantitative studies have been conducted in Iran to understand the amount of out-of-pocket payments and the factors related to the creation of back-breaking expenses at the household level, but no coherent study has been done at the policy-making level. In the present study, our attempt is to identify the structures related to the change in out-of-pocket payments from the insurer's point of view, in order to determine the plan to solve this problem. . Sampling was done in a targeted and quota manner. In this way, the financial manager of the medical service insurance organization of the armed forces was selected for each province. The sample size is 30 people, including 24 provinces of the country, and 6 people were selected in Tehran headquarters. The data was collected through an open questionnaire and an in-depth interview designed. In this study, the data analysis stage was performed using MAXQDA2007 software. Findings: The findings of this study have extracted related structures in the two sections of increasing and decreasing factors of out-of-pocket payments. The weakness of treatment monitoring systems, the large difference between the public and private sector tariffs, insufficient insurance coverage, the lack of responsiveness of government centers to the needs and expectations of patients, and the weakness of the information and consultation system of insurance organizations have been mentioned as factors that increase out-of-pocket payments, and in order to reduce out-of-pocket payments, attention should be paid to the development of insurance resources and coverage, the development of a health-oriented approach in insurance organizations, the strengthening of supervision of medical centers and insured persons, and the development of treatment information and consultation systems.

discussion and conclusion: in order to reduce the out-of-pocket payments of the insured, it is not correct to only focus on increasing the budget of the health sector in the form of tariff increases, but all health systems, including the resource production system, the service delivery system, the service consumption system, the monitoring and control system, should be paid attention to along with the financing system.

Introduction and statement Problem:

Health is known as one of the main preconditions of social welfare systems. In addition to having a healthy lifestyle, people are forced to use health services and in other words buy those services in order to improve and restore their health in case of illness (1). Based on the type of health system, benefiting from these services imposes different financial pressures on people in different societies, these costs cause financial problems for households and may trap them in poverty (2).

The World Health Organization[1] has introduced the fairness index in financial participation[2] to define the distribution of the burden of health payments in society, which can vary between zero and one; Zero indicates maximum unfairness and one indicates the most complete form of fairness (3)

The goal of many countries in the world is to design their health financing system in such a way as to protect people from health care costs (4) In many developing countries, only a part of the people are protected against the financial risk caused by the need for health services (5), the most important reason being the lack of commitment on the part of government officials, the lack of financial resources to cover the entire population, and the lack of ability It is a management system for managing insurance funds. (6) Today, the lack of financial protection in health is known as a disease of health systems; The clearest sign of this is that households suffer not only from the burden of disease but also from the burden of destruction and economic poverty (7), in other words, facing back-breaking costs [3] and poverty caused by financing their health. Disease can have a significant economic impact on a family, as an impact it can cause continuous reduction of capital, debt and reduction of expenses.(6) Today, the lack of financial protection in health is known as a disease of health systems; The clearest sign of this is that households suffer not only from the burden of disease but also from the burden of destruction and economic poverty (7), in other words, facing back-breaking costs [3] and poverty caused by financing their health. Illness can have a significant economic impact on a family, as an impact it can cause a continuous reduction of capital, becoming indebted and reducing necessary expenses (8).

Based on the type of interest health system Many of these services impose different financial pressures on people in different societies; The economic costs related to the disease can be divided into two main groups: the costs of the services used to diagnose and treat the disease and the decrease in income due to the loss of productivity and work capacity of the sick person. In any case, these costs have caused financial problems for households and may trap them in poverty. Over the past decade, a lot of attention has been paid to analyze and understand the performance of the health system in achieving this goal. Analysis of the result of household financial participation in the health system can be done by two approaches: income approach and financial burden approach. In the income approach, the change in income distribution is examined in terms of household financial payments for the health system, which is measured based on the change in the number of households that have been pushed below the poverty line due to health payments. In the second approach, health payments are examined in terms of its effect or disturbing experiences caused by it on the household, such as calculating the fairness index in financial participation and the percentage of households facing back-breaking payments (9)

Therefore, timely diagnosis of this disease by measuring and monitoring the amount of back-breaking costs in the health system and recognizing the factors that put a household at risk of facing these costs, health system policy makers in choosing preventive policies and treatment methods will help for this disease. Health services may impose a reduced cost burden on families, especially in developing countries (10 and 11).

Despite all the efforts that have been made in this area, it is still observed that the financing of health services in developing countries is dominated and dominated by direct payments from the pocket and the relative lack of prepayment mechanisms such as taxes and health insurance. Unfortunately, one of the unfortunate results of this method of financing is the imposition of heavy or so-called back-breaking costs when families are faced with illness. (12)

The discussion about how and the composition of financing health services has always been one of the basic challenges facing health system planners and policymakers, especially in developing countries (13)

Attention to the volume of payments Directly and from the pockets of households and the subsequent occurrence of back-breaking costs of health services are two important factors that should always be taken into account in calculations related to planning and policy-making of health services (14,15). In health economics texts, the back-breaking costs of health services are defined as: "the amount of expenditure spent on health services that exceeds a certain level of income (household consumption costs)" (16) According to the definition of the World Health Organization, if the costs of health services More than 40% of the household's income (paying ability) is considered back-breaking (1)

Spending a large part of the household's resources to receive health services can threaten the standard of living in the short and long term, as in the short term the household must ignore the current consumption of other goods and services, and in the long term, consequences such as selling and auctioning assets, exhausting savings, or accumulating debt await the household. (17)

Some of the consequences of prevailing unfair conditions in the health system are as follows :

Households, especially the vulnerable groups, face a lot of suffering and hardship due to financing the access to medical services, and in exchange for providing these expenses, they reduce their other necessary expenses. This issue will degrade the welfare conditions of the household.

The financial burden of health expenses due to the reduction of savings and less allocation of household income to other expenses, especially items such as proper food or education and training, which has an undeniable effect as the accumulation of human capital, especially for the children of households, reduces the production capacity of households as the most key factor in the national production process.