The challenges and techniques expressed by the individuals concerning the 2 capabilities of managing and financing the well being system are offered individually in Tables 2 and three.
Stewardship operate
According to Table 2, 4 important themes, ten subthemes, 22 challenges, and 24 methods have been recognized within the operate of the stewardship of the medical insurance ecosystem. The following are individuals’ opinions on the important challenges and techniques.
Challenges
Lack of stability within the construction and stewardship of the medical insurance system
“Previously, we have been initially beneath the supervision of the Ministry of Health for the final 25 years. After ten years, we have been beneath the supervision of the Ministry of Social Affairs, and after one other ten years, we returned to the Ministry of Health. We have skilled it many occasions in numerous constructions” (P: 35).
The multiplicity of insurance coverage funds
“The mistake was that we broke the insurance coverage again into items, whereas the insurance coverage is stronger. The insurance coverage system has energy worldwide, however we’ve blocked that energy by fragmenting insurance coverage” (P: 4).
Lack of health-oriented angle
“I stated that you must point out the insured place in your mission, and your mission is to supply well being providers. They stated our mission is barely remedy, and we can not enter well being. I stated why? He stated as a result of the regulation mentions remedy” (P: 43).
Traditional and non-flexible constructions
“What I see within the group in recent times because the bane of our human lives is routine. Any group that falls right into a routine means it’s going to collapse. An group that could possibly be very dynamic has turn into an on a regular basis group” (P: 10).
Lack of transparency of the foundations of insurance coverage organizations
“Armed Forces Health Insurance is at all times problematic, and it’s unclear what legal guidelines they comply with and in line with which legal guidelines they deduct insurance coverage funds.” (P: 52).
Conflict of curiosity as a result of a number of roles of the actors
“The authorities share on the board of social safety trustees has elevated lots. Why? Because he took the opposite two sides, the employer, and the employees, and launched them from the ministry” (P: 48).
Lack of coordination, cooperation and constructive interplay
“Supplementary medical insurance coverage, which makes up a good portion of our insurances, requires coordination with primary medical insurance” (P: 12).
Sectional and private decision-making
“Sectional and private selections are one case that doesn’t place the medical insurance group in its actual place “(P: 8).
The slender imaginative and prescient of the Ministry of Health within the stewardship
“An individual who’s positioned in health-oriented organizations and needs to make selections within the social subject mustn’t have gun barrel considering (restricted considering) however ought to have a complete view and excessive perceptive capabilities” (P: 10).
The existence of a number of and separate info programs
“Once we made an inventory of the software program and data programs within the headquarters and remedy administration. About thirty items of software program weren’t linked to one another. This signifies that once we want information, we’ve to seek for it in numerous programs” (P: 43).
Table 2 Challenges and techniques in stewardship operate of Iran’s medical insurance ecosystemStrategies
Creating a holistic and health-oriented angle
“A multifaceted view is prime in well being points, particularly for a company that has modified from medical service insurance coverage to medical insurance. Perhaps many elements, together with rehabilitation, aren’t a part of the insurance coverage obligations, however well being is a complete phrase, and we should make extra efforts to comprehend it” (P: 3).
Consolidation of insurance coverage funds
“I imagine that there isn’t a must unify all insurances as a result of there are nations the place all insurances aren’t the identical, and so they have good insurance coverage, such because the Netherlands, the place the essential insurances haven’t been unified, however they comply with a single coverage” (P:7).
Improving relations and cooperation and creating alignment in pursuits
“If the social safety group cooperates with us, we will assign the insured inhabitants to the medical doctors on the contract facet and notice the leveling of providers to obtain extra and higher providers by our insured” (P:2).
Decision-making and policy-making are based mostly on collective knowledge and scientific proof.
“This information mining ought to have a number of particular outputs. One output is to turn into a call assist system that helps make the precise resolution. We can not resolve till we’ve the precise information” (P: 10).
Implementation of the digital prescribing plan utterly
Unification and integration of data programs
“We had an organization that contracted with the Ministry of Welfare to information mine our info. Unfortunately, our info sources have been scattered and insular. Our info sources have been in such a manner that every province entered info individually. In one province, code 2 to the pharmacy was given code 3 in one other province. This firm had standardized all of the codes and gathered the knowledge for us with out our provinces realizing it” (P: 9).
Forming an digital well being report
Financing operate
Table 3 identifies three important themes, 12 subthemes, 17 challenges, and 16 methods within the financing operate. In the next, a pattern of the interviewees’ opinions is expressed.
Challenges
Imbalance between price and revenue of insurance coverage organizations
“The downside is that the group’s sources have by no means equaled the prices. The sources and prices aren’t in keeping with one another, so the group is at all times confronted with amassed losses and an absence of steadiness within the sources and prices. People and authorities sources are offered, public sources needs to be proportional to the folks’s potential to pay, and authorities sources normally face a scarcity. On the opposite hand, the bills are decided based mostly on the wants of the insured and the scientific strategies of medical doctors and medical service suppliers. The sources are calculated, estimated, and funded in a technique, and our prices are decided in one other manner, which makes the insurance coverage system a problem” (P: 19).
Multi-tariff providers
“The insured can get medical providers in a number of departments; we’ve a number of tariffs. One of them is the college’s authorities division, and our establishments are divided into 4 departments” (P: 44).
Unreality of service costs and tariffs within the insurance coverage system
“In the common insurance coverage regulation, it was foreseen that the federal government would set a tariff, but when the tariff is decrease than the actual value, it’s going to compensate for the distinction. The tariff will likely be decided based mostly on the folks’s pockets, financial situations of the nation, and the actual value, however are the tariffs is at present decided on the identical foundation? (This case deserves criticism).” (P: 8).
Insurance deductions
“The insurance coverage knowledgeable makes a deduction on the hospitalization file and sends the file to the income unit. The head of the income unit seems on the file and approves in the event that they settle for the knowledgeable’s deductions. The file is returned to the insurance coverage knowledgeable if they don’t settle for the knowledgeable’s deductions. The knowledgeable re-examines the file” (P: 32).
Overlap of the protection inhabitants
“The subsequent level is overlaps, which have been prevented to a big extent, however they nonetheless exist. When there’s overlap, some prices are the duty of 1 group and a few of one other group. Maybe nothing particular will occur, however properly, in some unspecified time in the future, the insured will abuse, and the share of insured and the insurance coverage payer will likely be completely different, particularly when we’ve free insurance coverage” (P:45).
Injustice attributable to the variation in service packages of various insurance coverage organizations
“The service bundle offered within the village is completely different from the town stage when it comes to its extent, availability, and price, and it isn’t offered wherever besides the village” (P: 6).
Table 3 Challenges and techniques within the financing operate of Iran’s insurance coverage ecosystemStrategies
Creating sustainable monetary sources for the insurance coverage system
“If we need to create an exquisite future for medical insurance, it needs to be deliberate for the monetary sources of medical insurance. It signifies that a monetary supply needs to be thought of for insurance coverage via the parliament or the federal government, which doesn’t change with the change of the federal government or the parliament. Every yr, taking note of the rise in costs and the price range of this group needs to be elevated in order that the insurance coverage managers can plan for the approaching years by counting on the authorized price range logically” (P: 23).
Establishing a break-even level and steadiness between prices and bills
“Resources within the medical insurance system are decided based mostly on the situations of the nation and folks, and the bills are decided upon the wants of the insured and the style of medical doctors and diagnostic and medical service suppliers. For this purpose, we by no means see a steadiness between these two circumstances. From these situations, we must always outline the insurance coverage premium beneath the service bundle and tariffs or the service bundle and tariffs beneath the insurance coverage premium to manage this case” (P: 19).
Unification and actualization of service tariffs and costs
“We should use the authorized potential to make actual medical tariffs. Suppose one thing desires to be added to the group’s obligations. In that case, the tariff knowledgeable teams will calculate the impact on the per capita, tariff, and monetary burden. A constructive step may be taken by making the tariff costs sensible” (P: 14).
Payment system reform
“The reform of the cost system, from the effectivity to the capita, will arrange the receipts of the medical doctors within the outpatient division. I feel that the idea for the reform of the cost system within the inpatient division has been offered, and we must always discover a shift from the environment friendly cost system to the DRG” (P: 2).
Development and implementation of scientific pointers
“Guidelines have constructive factors. On the one hand, their constructive facet is in treating sufferers and offering providers, which may trigger a relative discount in remedy and prices that return to insurance coverage. First, well being needs to be with us as a policymaker in well being and remedy to offer the suitable remedy protocol, timing of receiving providers, remedy strategies, and medical medication. The growth of protocols needs to be nationwide so the entire nation is aware of its obligation and everybody has the identical profit” (P: 45).
Review and enhance the essential service bundle
“One of an important instruments is the evaluation of the essential service bundle of the group. I shortly reviewed the essential service bundle of the group by going via the related steps” (P: 15).
Reforming the system of offering providers with the system of referral and household doctor
“One of those methods is the household doctor and the referral system, and when the referral system is launched, insurance coverage providers will definitely be offered effectively. Discussing the household doctor and the referral system is a constructive necessity that every one consultants agree, relying on the situation that it’s accomplished utterly and comprehensively” (P: 39).