What Kinds of Advantages and Disadvantages May Merging Health Insurance Funds Bring About? A Qualitative Policy Analysis from Iran CURRENT STATUS:

Background: In countries with health insurance system, the number, the size of insurance funds and the amount of risk distribution among them is a major concern. One possible solution to overcome problems resulting from fragmentation is combining risk pools together to create fewer and larger ones, ideally a single pool. This study aims to realize what kind of advantages and disadvantages merging health insurance funds together may bring about to the health insurance system in particular and health system in general. Methods: In this qualitative study, nesting purposive sampling with maximum variation was used to obtain representativeness and rich data. Sixty face-to-face interviews were conducted. Documentary review was used as supplementary source of data collection. Content analysis using the ‘framework method’ was used to analyze the qualitative data. For assuring the quality of results, four trustworthiness criteria including credibility, transferability, dependability and confirmability were used. Results: The results of this study indicated that there are diverse positive and negative consequences for merging of health insurance funds in Iran which are categorized into seven categories including governance/stewardship, financing, population, benefit package, structure, operational procedures and interaction with providers. These themes are subdivided further into thirty-seven sub-categories which represent a wide range of different policy aspects which need close attention to deal with the merging of health insurance funds. Conclusions: Implementation of merging health insurance schemes in Iran would be influenced by a wide range of potential merits and drawbacks, so to facilitate the process and lessen the opposition of opponents, policy makers should act as brokers taking into account the contextual factors and adopting tailored policies to maximize the benefits and minimize the potential drawbacks of consolidation in Iran.


Background
In countries in which health insurance is a main source of health financing, the number, the size of insurance funds and the amount of risk distribution among them is a major concern.(1-3) Health financing experts should bear in mind the degree of fragmentation in health financing as it may lead to inequity in access to health care services for different groups of population.
Fragmentation should not be considered as a problem by itself but differences among health insurance schemes in the following aspects should be taken into account by health policy makers to see whether the situation is satisfactory or not. These criteria include the percent of the whole population under coverage of each health insurance scheme; the extent of differences in the contribution rates, benefit package, quality of health care received by members of different risk pools, and more importantly variations in user charges and amount of out-of-pocket payments paid by different beneficiaries belong to different insurance schemes for the same health services they use (4). The bigger gaps, the more health financing experts should be worried about the health equity impacts of the fragmentation. One possible solution to overcome problems resulting from fragmentation is combining risk pools together to create fewer and larger ones, ideally a single pool (5)(6)(7). Reducing fragmentation provides more financial protection from a given level of prepaid funds, which is the key objective of universal coverage (7).

Health Insurance System in Iran and the challenge of fragmentation
Health insurance Organizations in Iran are divided into 3 groups according to functions they play:

1.
Basic health insurance organizations: such as Iran Health Insurance Organization (previously it was called Medical Services Insurance Organization) with several separate sub-funds for government employees, rural residents, the self-employed and their dependents, the poor, and other sectors (such as students, some professional associations and so on), Social Security Organization covering all the people employed in the formal private sector and their dependents, and Armed Forces Medical Services Insurance Organization(8)

2.
Institutional organizations: including about 17 funds such as the municipality, Petroleum Industry Health Organization, the National Broadcasting Organization, banks and other organizations. Each organization provides required insurance services for their own employees individually as a fringe benefit, and (9) 3.
Commercial organizations: such as Iran, Asia, Alborz, Mellat, Pasargadae, Atieh Sazane Hafez of which the latter group often operates in the form of voluntary supplementary private insurance. (10)(11)(12)(13)(14)(15) Facing chronic problems attributed directly or indirectly to the fragmentation in the Iranian health financing system including inequity in health services utilization and financial protection among different groups of people (13,16); high out-of-pocket expenditures (12,13,17); high occurrence and intensity of catastrophic health expenditures (18,19); low financial protection against health services for the insured persons (10,20); population coverage duplication (10,12), failing to reach universal health coverage and lack of transparency and no reliable data in population coverage and per capita health expenditures and contribution rates(10) made policy makers to pass a law 2010 in order to merge all the existing health insurance funds (basic health insurance schemes and institutional funds) into the Medical Services Insurance Organization aiming to create a single health insurance organization (9,21).

Objectives of the study:
The aim of this study is to realize what kind of advantages and disadvantages merging health insurance funds together in Iran may bring to the health insurance system in particular and health system in general. Considering this issue is context-sensitive and to date advantages and disadvantages the merging the health insurance has received scant attention particularly in terms of qualitative analyses in the research literature, it may provide important insights into moving toward a decision on the merging health insurance in developing countries such as Iran. Lessons from this study can be applicable for policy makers from other countries, especially those with low-and middleincome, trying to merge existing health insurance schemes in order to strengthen risk pooling.

Methods
This qualitative study was conducted in 2014-2015. This paper is part of a larger study about "analysis for policy" of merging social health insurance (SHI) funds in Iran.

Participants
Nesting purposive sampling with maximum variation was used to obtain representativeness and rich data by including a wide range of extremes. As the use of maximum variation sampling is a wellestablished approach to limit the possibility of selecting narrow or few cases from one with wide

Conceptual framework
A semi-structured interview guide was used to conduct the interviews. For the purpose of the study, to develop the interview guide questions and finding an appropriate conceptual framework to cover all aspects of merging and to organize the findings, a conceptual framework was derived from the World Bank (22). The World Bank framework includes eight elements to design and establish a health insurance system: feasibility of insurance design, financing mechanisms, population coverage, benefits package, provider engagement, organizational structure, operational processes, and monitoring and evaluation. We used the framework to classify the advantages and disadvantages of merging of health insurance schemes in Iran. The interview guide was pilot tested by doing 3 introductory interviews.

Data collection
At the start of each interview, by explaining the purpose of the study and ensuring the confidentiality of the content of the interviews and anonymity, interviews were taped with 2 voice recorders.
Interviewees were free to choose where they liked to be interviewed which in all cases, interviews were done in the workplace of the interviewees. Besides the researcher and participants, no one else was attended during the interviews. In three cases, the participants did not allow voice-recording (they were afraid as the topic was political), therefore notes of the main points were taken down. Also field notes were made during and/or after the interviews to get most out of the interviews. The minimum, maximum and average times of interviews were 10, 120 and about 50 minutes respectively. In seven cases, the interviews lasted for two or three sessions because interviewees were busy trying to finish the interview in one session, some of them were eager to give more information, and in some cases the interviewer had to refer again later for more details or to complete omitted information. To collect documents, the list of related documents and their source for collection were identified. Websites of organizations including Majlis, MoHME, Iranian Medical Council, and Health Insurance organizations were reviewed and related in print documents were also collected in person.

Data analysis
Content analysis using the 'framework method' was used to analyze the qualitative data. It is worth mentioning that this method can also be applied in deductive, inductive, or combined types of qualitative analysis. (23) The five-stage process of qualitative data analysis was done: understanding (familiarization), identifying a thematic framework (thematic), coding (indexing), charting and mapping and interpretation.(24) All the interviews were done, transcribed and initially indexed by one author (MB). Interviews were analyzed with the World Bank framework (both inductive and deductive approach) using MAXQDA12 software. .

Trustworthiness:
For assuring the quality of results, we employed four trustworthiness criteria suggested by Lincoln and Guba. Credibility was met with a prolonged engagement whereby the principal investigator (MB) continuously worked nearly 12 months with the qualitative data. Furthermore, member-checking validation was used by delivering some transcribed interviews to the respective participants and asked them to ensure that there is a good correspondence between their findings and the perspectives of participants. To improve credibility, particularly for the purpose of this study, we focused on the negative and opposite cases to provide a comprehensive picture derived from pros and cons of merging. The research team search for and discuss elements of the data that do not support or appear to contradict patterns or explanations that are emerging from data analysis and deviant cases in findings were incorporated in the analysis process until it can explain or account for a majority of cases. Transferability and reflexivity of our qualitative findings was enhanced through maximum variation sampling technique and thick descriptions of the topic context of health insurance in Iran. Dependability of the research was assured by an auditing approach in which the VYF accompanying by an external auditor engaged in critical comments in coding process and analyzing of transcribed interviews as well as cross-checked the data we collected. To increase confirmability, we employed a methods triangulation approach including document review, interviews with key informants and other informative sources to check out the consistency and complementary of findings generated by different data collection methods.

Results
The advantages and disadvantages of merging derived from the interviews were classified in the following categories: stewardship, financing, population, benefit package, structure, operational processes, and interaction with providers.

Stewardship:
In Fragmentation in health financing in Iran has caused each health insurance scheme to follow their own policies and in the long run it has led to differences in contribution rates, out-pocket-payments rates, coinsurance rates, different level of financial protection and also uneven distribution of public subsidies among different groups of insured. Apart from reducing the inequities, interviewees believed that merging can improve the way through it the financial resources are collected, managed, pooled, and allocated to purchase health services for the beneficiaries.

Discussion
The The international experiences show that the single payer system is more powerful and more efficient in controlling the total health care expenditures(31, 32). Regarding risk pooling efficiency and financial stability, the single payer is more preferable (32, 33). The collection of contributions will be integrated with other social insurance funds as a result of merging. In addition to the improvement of equity in contributions and reduction of administrative costs(34), the single-payer system has more power in bargaining with providers through creating a monopolistic purchaser(22, 27). The single insurance has the capacity and inclination to purchase medical care cautiously, which will improve the efficiency of the new system (27, 30). Also, the single insurance system will increase the competition among providers, since the single insurance is the only payer and provides a free choice of providers for the insured(31).
The single insurance system can enhance insurance packages and extend the coverage in favor of the poor and the members of weaker insurances. For instance, it is expected that in Indonesia, the uniform service package for civil servants and the private sector employees will create better clarity, equity, and understanding of the package for providers and members(31).
It is also worth mentioning that experience of other countries moved toward merging shows that the single insurance system can provide an opportunity to highlight some neglected health insurance policy decisions previously in the fragmented health insurance system at a national level(27).
According to the interviews, currently the main focus of health insurance schemes in Iran is on hospital based services. Although PHC and primary health care services in Iran are financed by the government and provided by the district health network, but the interviewees criticized the current situation as they believe health insurance system has failed to address public health and preventive services and also preserving health at the first step which in turn has led to high health care expenditures. In the current fragmented situation, health insurance schemes struggle to cover more secondary and tertiary health services, but merging can help focusing on public health services and prevention as a policy to move towards financial resources management by controlling health care expenditures in the long term.
Normally, one of the consequences of the multiple insurances is that despite existing different health insurance organizations alongside each other, a part of the populations is not covered by any insurance for different reasons(35, 36). By creating a single health insurance database, it would be easier to eliminate duplication and identify those who have no coverage which will pay the way moving toward reaching universal coverage.
Beside the positive effects, merging may cause unpredicted side-effects in the health system in the short and long run, which need to be predicted to prevent. A single payer may reduce efficiency due to increasing the bureaucracy and decreasing responsiveness; however, in Iran where people do not have real right to choose between different funds (people are assigned to different insurance funds according to their job status or where they live), the efficiency lost as a result of merging may not be significant(27). In a single payer system, the insured do not have the chance of choosing and changing the insurer when the health services are not satisfactory which can lead to dissatisfaction, especially in rich families. However, we need to know that the right to choose the provider is much more important and significant than the right to choose the insurer. Insurers are only payers, and have little effect on the process and outcomes of the treatment. In the single payer system, the free choice of the provider and increased competition among providers can increase the satisfaction of the beneficiaries(30, 31).
According to the consolidation law in Iran, it is supposed that by merging, all health insurance schemes are responsible for collecting their contributions and allocating their share to IHIO. Some of interviewees were concerned about the unwillingness of SSO to collect premiums as actively as before because the financial resources are not going to be managed and spent by the SSO. In south Korea also health experts concerned that as the financial resources are going to be shared with the whole population, collection of the contributions from the self-employed after merging may not be done as actively as before (27).
In contraction with health care providers, interviewees mentioned that currently each health insurance scheme follows its own regulations for contracting and also for reviewing claims and reimbursement. Apart from increasing complexity, hospitals have to appoint specific employees to deal with different regulations issued by different health insurance schemes which increase administrative costs. By creating a single insurance, it would be much easier and simpler to work with one insurance and one set of rules. Recently, since the second half of 2019, IHIO has started to launch new projects to review claims and also manage referral system based on an electronic system, although these are good initiatives to increase the speed and accuracy of utilization review process and referral system, other main health insurance such as SSO and Armed forces health insurance organization use non-electronic systems which make it more difficult for health care providers to work with health insurance organizations with different systems.
Interviewees mentioned contradictory ideas about the impact of merging on the reimbursement process. Merging may improve or even worsen the time of reimbursement. Some indicated that currently health insurance schemes behave differently in terms of time of payment and amount of payment for the same health services. Health care providers express their concern about how merging is going to change the process of payment. Health care providers said currently they are paid by several schemes on different periods of time, in the case of delay in payment by one or two schemes, health care providers resort to other schemes with on time reimbursements. But they worry that by creating a single payer, in the case of delay in reimbursement, the financial security of health care providers would be jeopardized.

Study Strength and limitations
A key strength of the present study is that we interviewed with a maximum variation of stakeholders with confirming and disconfirming perspectives about the advantages and disadvantages which may enhance the trustworthiness of results. This helps clarify the path of moving toward implementation of consolidation law in Iran. This study was conducted after passing the Consolidation Law in Iran when the government was mandated to implement the law. Whereas, no action has yet been taken, it provides a natural policy environment in which the expectations of the stakeholders in implementation of the law, as well as their conflicting interests, could be better captured in the study.
Of course, these data must be interpreted with caution because it is not certain which advantage or disadvantage mentioned by interviewees may occur in real world after the implementation of the law. This means that we also contend that key stakeholders interviewed might have been affected by a social desirability and position bias, which refers that they may have described what they thought we want to hear, rather than the reality. Also, some of them may have provided politically acceptable and satisfactory responses with respect to their roles and responsibilities. In deal with these problems, we used triangulation of data collection methods including interviews and document analysis and some mass media sources and also comparing people with different viewpoints, both opposing and supporting the policy, as triangulation of sources and as well as providing ample opportunities to the interviewees to express their deep understandings of the context, to raise the credibility, confirm-ability and reflexivity of the results.
Last but not least, these findings may be somewhat limited by subjectivity. Although we used different sources of data and analyzed the data by peer debriefing in order to enhance trustworthiness of the results, the interpretations may persist subjective and our results cannot claim a whole truth. As the research philosophical paradigm is a constructive approach rather a positivism one, this situation is unavoidable and is defensible.

Conclusions
The present study was designed to explore the viewpoints of different stakeholders about advantages and disadvantages of the health insurances funds consolidation law, a law passed but not implemented. The most obvious finding to emerge from this study is that consolidation implementation in Iran may influenced by a wide range of merits and drawbacks in governance/stewardship, financing, population, benefit package, structure of health insurance, operational procedures, and interaction with providers. This study helps to inform policy makers in low resource settings about the potentially expected benefits and detriments when moving toward the implementation of this law. Given all these results is highly context-sensitive and there is trade-off between benefits and drawbacks before and after consolidation, policy makers should act as brokers taking into account the contextual factors and adopting tailored policies to maximize the benefits and minimize the drawbacks of consolidations.

Declarations
Ethics approval and consent to participate: This study has been approved by the ethics committee of Tehran University of Medical Sciences. The consent we obtained from the study participants was verbal as the study was qualitative and we got their verbal consent to participate in the study and to be interviewed. Verbal consent is accepted by the ethics committee.

Consent for publication:
We got consent of the interviewees to participate and record their voice and for direct quotes from their interviews to be published in this manuscript with protection of their anonymity and confidentiality.
Availability of data and materials: All raw data and also the file of thesis have been prepared in Persian (not English). But the corresponding author will gladly provide any supporting materials upon request.  Reducing administrative and overhead costs by removing parallel structures of insurance in the provinces Reducing the current costs of manpower and high salaries of 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 together and there would be no need to recruit the same number of personnel as before. Reducing the supervisory costs by unifying the content of contractions with providers.
No tangible administrative costs reduction in the sort run due to political resistance against downsizing Emphasizing on reduce administrative costs is an inadequate target for insurance merging.

Operationa l procedures
Monitoring and supervision of health care providers Drug interactions are better recognized here. Fragmentation in health insurance funds and in turn fragmentation of centers of utilization review increase the potentiality of abuse and fraud by the provider Easier monitoring and control of providers by creating a single central profile for each provider