Table 2 The advantages and disadvantages of merging health insurance funds in Iran derived from the interviews
Theme | Sub-theme | Pros of Merging Health Insurance Funds in Iran | Cons of Merging Health Insurance Funds in Iran |
|---|---|---|---|
Governance/Stewardship | The accountability of health insurance regarding insureds’ needs and demands | • Increasing the accountability of the health insurance system regarding how to generate and use financial resources to meet insureds’ needs by creating a single health insurance fund | • The risk of objection by workers as they may consider the social security organization responsible for their treatment • The bad memory of the past related to the Ministry of Health and Medical Education (MoHME) for not being responsive to how and where it spent the health premiums of the social security organization’s beneficiaries • Reducing accountability by the creation of a monopoly in the health insurance system like what happened in the car industry in Iran |
The control of health care expenditures | • Multiple health insurance schemes, leading to an increase in inflation and purchase of health services at higher prices • Reducing the cost of the health insurance system by eliminating duplication in insurance coverage and solving the problem of using health insurance cards by those without insurance coverage • Cost control by implementing strategic purchasing • Better supervision of health care providers by centralizing their profiles in a single database, reducing fraud, and controlling the volume of provided health care services | ||
The power of health insurance supervision | • Providing a better chance to enhance supervision by reducing delay in payment and timely reimbursement of health care providers • Improving the quality of health services by providing better supervision and higher purchasing power • Improving the supervision by adding personnel merged into the regulatory area | • The lack of chance for enhancing the supervisory role of health insurance schemes as they have no real power to supervise the quality of health services at the current situation • Not envisaging the task of supervision for health insurance in the Merger Law in the Fifth National Economic, Social, and Cultural Development Plan Act • Reducing the control of other health insurance schemes on how the Iran Health Insurance Organization (IHIO) spends health insurance premiums • The risk of increasing supervision costs for other health insurance schemes to examine how their premiums are spent by IHIO (the same experience happened in 1983, when a commission was established in each province to supervise the quality of treatment for the social security organization’s beneficiaries provided by the regional health centers of the Ministry of Welfare and Wellbeing) • The risk of not being able to supervise and control the national insurance scheme as it may become so powerful | |
The health system management | • Easier alignment of a single insurance scheme with the policies of MoHME • Easier implementation of clinical guidelines • The interaction of MoHME with a single insurance scheme with a single set of instructions • Putting an end to different policies issued by different insurance schemes in dealing with health problems (e.g., updating the table for prices of medicines • Eliminating the challenge of unifying health insurance schemes with different regulations as an obstacle to implement health reforms such as a family physician program • Improving the health financing equity by setting the same coinsurance rates for different population groups | ||
The transparency of health information and policy making | • Providing a more reliable planning and policy making strategy by centralizing health insurance information in a single data bank • Making a more precise prediction of financial resources and annual budget required for the health insurance system by providing transparency in per capita health insurance expenditures and eliminating duplication in population coverage | ||
Policy making and stewardship in the basic health insurance system | • Increasing the power of the health insurance system to formulate and implement health policies • An easier and faster process of making health policies by creating a single scheme • Organizing different health policies and decisions issued by different health insurance schemes by merging | ||
Financing | Health insurance premiums | • Reducing premiums as a result of reducing costs | |
The ability to create new resources | • Other health insurers may lose motivation to collect premiums and transfer them to IHIO (the unwillingness of the social security organization to collect insurance premiums from workers) | ||
Per capita premiums and actuary calculations | • More reliable calculations of per capita premiums by removing duplication in insurance coverage | ||
Patient risk pooling | • Equity in risk pooling for all population groups as rich schemes have no contribution in the whole risk pooling | • Not considering merging as a solution to improve risk pooling because more than 90% of the whole population is under coverage of IHIO and SSO | |
Financial inflows and outflows | • Easier monitoring of accounting and financial processes • More transparent and stable insurance financial inflows and outflows as a redult of merging health insurance funds | • More transparent financial flows in the current fragmented situation as each scheme has its own separate financial flows • Keeping separate financial accounts for sub-funds under IHIO for higher transparency in revenues and expenses | |
The estimation and management of financial resources in the health insurance system | • Easier estimation of the amount of required financial resources for the following year by creating a single insurance system • Better management of health insurance premiums by pooling them in one place • Saving the public budget by removing coverage duplication • Being able to define a new role for health premiums by centralizing them in a single fund • Obtaining more financial support from the government for basic health insurance | ||
Patient financial protection | • Paying lower premiums for the treatment of low-income people as a result of merging • Expanding benefits packages by saving resources • Better controlling the high cost of health services • Reducing out-of-pocket payments by purchasing health services at lower prices with single insurance | • The need to increase premiums and resources to reduce people’s payments | |
The financial stability of health insurance | • Increasing the financial viability of the whole health insurance system by using single insurance | • The appropriate size of IHIO and SSO at the current fragmented situation (IHIO and SSO are big enough and there is no need for consolidation) | |
Saving financial resources | • Increasing financial resources and improving health benefits packages by reducing administrative costs • Organizing financial resources spent by the government as the employer for different population groups by merging | ||
Equity in the distribution of subsidies in the health insurance system | •Difficulty in providing all population groups with the same share of governmental subsidies in a fragmented health insurance system | ||
A more efficient use of health insurance premiums | • Imposing expenditures by non-contracted health care providers at the current fragmented system • Paying for luxury and expensive private hospitals’ health services at the current fragmented system • Relying on fee-for-services payment method without having effective supervision and control on the amount and quality of provided health services at the current fragmented system • Using health premiums more efficiently by eliminating induced demands and moral hazards Paying higher prices for health care services by well-off and small insurance schemes due to not having any chance to follow strategic purchasing in the current fragmented situation | Having no chance to implement real strategic purchasing unless setting real medical tariffs according to real prices | |
Population | Reaching universal coverage | • Fragmentation in the health insurance system as a barrier to reach universal coverage in the three areas of population, health services, and financial protection | |
Population coverage duplication | • Eliminating duplication in population coverage • Eliminating inequity in access to health services due to health insurance coverage duplication; currently, due to this issue, different groups of people use different benefit packages with different services and financial protection belonging to various health insurance schemes) • Centralizing health profiles and health expenditure profiles of beneficiaries in a single database • Reducing the misuse of multiple health insurance cards by health service providers and patients | ||
The number of insured people | • Providing precise and reliable statistics about the number of insured people by creating a single database and removing duplication | ||
Basic Benefit Package | The focus of health provision (primary health services or hospital-based services) | • Neglecting prevention and public health services as a result of fragmentation • Providing a better chance to focus on and pay more attention to public health and preventive services by creating a single health insurance | |
The distinction between basic and supplementary health insurance | • Eliminating the current interference between basic and supplementary health insurance (in Iran, according to the national health laws supplementary are supposed to cover only those health services not covered by basic health insurance funds) | ||
Equity in the basic benefits package | • Strengthening benefits packages for underprivileged groups by setting the same benefits package for all population groups • Putting an end to discrimination and provision of generous health services for privileged groups • Currently, various funds react differently to changes in prices of medicines and medical equipment, and also, to changes in the basic benefits package. In the case of high fluctuation or high inflation in prices, the health insurance funds may update the prices they cover in different time lags which causes different population groups pay different amount of out-of-pocket expenditures for the same medicines or medical supplies. | • The lack of justice due to poor infrastructure and health care facilities in villages and deprived areas • No justification for providing the same benefits to all insureds (different population groups with different health needs, expectations, and affordability) | |
The satisfaction of insured people | • Increasing the satisfaction of insured people by strengthening and upgrading the basic benefits package • Resolving dissatisfaction among the public as a result of disparity and injustice in benefits packages in the current fragmented situation • Increasing satisfaction by improving competition among health service providers • Providing equal access to health care for all insured people | • Increasing dissatisfaction among population groups enjoying generous benefits package in the current fragmented situation • Concerns about sharing privileges with other groups of insured people (e.g., sharing free-of-charge health services in health centers and hospitals belonging to SSO) | |
Structure | Creativity, innovation, and dynamism in insurance | • Increasing the dynamics and creativity in devising new mechanisms to run activities with creation of single insurance (no chance to use creativity made by other health insurance funds) | • Killing creativity, as, currently, each health insurance fund attempts to improve the quality of its own services |
Administrative and overhead costs | • Reducing administrative and overhead costs by removing parallel structures of insurance in all the provinces (each social health insurance scheme has its own headquarter in each province) • Reducing administrative costs by reducing the number of employees and top managers • Reducing personnel costs in the long run as all departments and employees in each health insurance fund with the same job description would be merged and there would be no need to recruit the same number of personnel as before • Reducing supervisory costs by unifying the content of contractions between health insurance schemes and hospitals with health care providers | • No tangible reduction in administrative costs in the short run due to political resistance against downsizing • Emphasis on reducing administrative costs as an inadequate target for insurance merging | |
Operational procedures | The monitoring and supervision of health care providers | • Better recognizing drug interactions • Resolving the issue of abuse and fraud by health care providers in the current fragmented situation • Easier monitoring and control of providers by creating a single central profile for each provider | |
Administrative and financial instructions | • Unifying financial and administrative regulations and instructions and reducing the complexity of different regulations for health care providers • Unifying operational instructions to enhance the the whole health insurance system performance • Formulating new regulatory instructions for the private health sector • Formulating new regulations to organize a supplementary health insurance market by creating a strong single basic health insurance fund | ||
Interaction with providers | Competition in the health system | • Creating competition among providers by creating a single-payer system • Improving the performance of health insurance system by merging as there is no real competition among health insurance funds in the current fragmented situation | • Eliminating competition between basic health insurance schemes |
The control of providers | • Changing providers’ behavior by making financial leverage • Reducing costs imposed by non-contracted providers • Resolving the issue of the non-compliance of private health care providers due to the fragmented health insurance system • Resolving the issue of the need for small insurance to contract with the provider at a higher price due to fragmentation | • The risk of putting health care providers into difficulty by misusing the power of monopsony and not fulfilling commitments | |
Bargaining power | • Increasing the bargaining power of insurers by moving from a multiple-payer system to a single-payer system | • The lack of authority of insurance funds to bargain and determine medical tariffs | |
Strategic purchasing | • Boosting strategic purchasing, as each insurance fund follows a certain approach in the current fragmented situation • Increasing fund flexibility by pooling financial resources • Enhancing strategic purchasing by improving financial resources and faster reimbursement • Improving strategic purchasing by avoiding higher payments by small insurance funds • Providing better financial resource management by creating a single-payer system and mass purchasing • Better controlling the private sector by strategic purchasing | • The lack of need to subject strategic purchasing to single insurance • The inability to buy health services at lower prices due to low and unrealistic tariffs • The unavailability of insurance at affordable prices and single-rate sales by MoHME | |
Reimbursement to the provider | • Making timely reimbursement of providers | • The risk of putting more financial pressure on providers in case of delay in reimbursement by the single-payer (currently, providers are reimbursed by different insurance funds with different time tables) • The risk of putting more financial pressure on providers by following strict financial regulations | |
Modifying the payment system | • Providing a better opportunity to design and implement new payment methods by a single insurance fund | ||
The interaction of health insurance system with health care providers and hospitals | • Formulating new single instructions for providers and finishing different intricate details of regulations of multiple insurance funds • The lack of need to appoint different staff to audit different medical health records belonging to different health insurance funds • Unifying the regulations of purchasing health care services from providers • Unifying the details of basic benefits packages (using the same services, using the same prices for pharmaceuticals and medical supplies, using the same reference pricing, using the same exceptions, using the same coinsurance rates for different services and patients, etc.) for all hospitals • Reducing transaction costs and preparing different insurance bills | ||
Organizing private health sectors | •Resolving the issue of low and delayed reimbursement provided by basic health insurance funds |