The advantages and disadvantages of merging derived from the interviews were classified in the following categories: stewardship, financing, population, basic benefit package, structure, operational processes, and interaction with providers. Key advantages and disadvantages of merging health insurance funds in Iran, emerged from interviews, are presented in Table 2.
Stewardship
In 2004, by creating the Supreme Council of Health Insurance (SCHI) under the MoCLSW, a purchaser-provider split occurred in the Iranian health system to move towards strategic purchasing and boost competition among health care providers. According to the studies, after this split, incoordination between two ministries caused new challenges for MoHME to devise and implement health reforms without control of financial resources (25). Apart from this, Fragmentation in health insurance caused each insurance scheme to behave differently and follow different health policies and also implement policies issued by the SCHI differently. According to the interviews, merging can solve these challenges to a great extent. According to the findings, merging and creating single national health insurance can provide a situation in which it is easier to control total health care expenditures and formulate and implement more reliable health policies for the health system.
"…I'm really tired of attending meetings of the family physician and referral system. I've probably attended more than 50 large meetings regarding launching a family physician and referral system myself. We saw that the IHIO representative wants something different, the SSO' agent speaks differently, and the AFMSIO's representative said something else. If I, as MoHME, want to implement family physician referral system, whose opinion should I accept? ..." (P2 a policy maker from the health insurance system)
"…Social Security Organization don't implement whatever approved by HCHI or implement with delay…" (A parliamentarian, Nabz, TV program about Iran health system problems)
"…wherever the monopoly is formed, the accountability would be reduced. Because all people have to get their services only from one organization with the same quality and quantity, and this leads to reducing the responsiveness as this organization has no competitor. … the same thing that happened to our car industry as a result of monopoly. …" (P20, one of the health insurance organizations' managers)
Financing
Fragmentation in health financing in Iran has caused each health insurance scheme to follow its policies. In the long run, it has led to differences in contribution rates, out-of-pocket payments rates, coinsurance rates, different levels of financial protection, and an uneven distribution of public subsidies among different insured groups. Apart from reducing the inequities, interviewees believed that merging could improve the way through it, the financial resources are collected, managed, pooled, and allocated to purchase health services for the beneficiaries.
"… About 23 million rural citizens are covered freely by IHIO, the government pays for them, is there this advantage for the workers? Are they not Iranian? is it not discrimination?" (Nabz, TV program about Iran health system problems, a key policy actor)
"When you have duplication in coverage, more public budget is spent, it means that the government pays twice as employer for the same part of population…" (P38 A policy maker from Supervisory Organizations)
Population
In the population area, the following subjects are the main topics that merging of health insurance funds may bring about positive or negative impacts: extending coverage for those without health insurance and removing the problem of duplication in population coverage.
"… When the supervisory and legislative agencies requested (health insurance schemes for) the number of the insured persons, adding the numbers together, we saw that the result was more than the whole population of the country and at the same time we had ten million people uninsured. …" (P38A policy maker from Supervisory Organizations)
"… One of the merits of merging is unifying the population's information. According to the Iranian census, 77 million people are known; when you combine and unify all health insurance databases, it will make those people without insurance coverage clear. Why making it clear is not possible now! Because they are scattered in 17 databases, merging makes it clear who has several insurance cards and who has no coverage …" (P26 A parliamentarian)
"… The Fragmentation and duplication of health insurance coverage make it difficult to calculate the per capita expenditures accurately. As a result, the computation of insurance premiums will be blurred. …" (P17, A former manager from one of the health insurance organizations)
Basic Benefit package
The first advantage that most of the interviewees mentioned in this aspect were providing equitable basic benefits package for all Iranians. According to the interviews, high inequity in benefit packages under the coverage of insurance schemes has led to high dissatisfaction among people, which is unacceptable and is against national values and constitution. The existing discrepancies between various demographic groups in terms of the types of health services that they can receive, the amount of financial compensation offered for each health service, and the number and types of health care facilities (public or private health sector) where they can get their services will be abolished by providing a single health insurance system for all demographic.
"… We (health insurance experts in Iran) say we are moving towards public health-based services (conserving health status), but what we are doing now is hospital-based services…" (A manager from one of the Health Insurance Organizations) "…the main focus of some health insurance funds is business, not health…" (A parliamentarian, Nabz, TV program about Iran health system problems)
Structure
The interviewees' main advantages in this section were related to reducing the administrative and overhead costs as a result of eliminating parallel structures of insurance in the provinces and reducing the number of top managers and employees.
"… all insurance funds also have their own offices in different provinces. Different insurance companies have their own offices, general directors, secretaries, cars, traveling costs, seminars, and so on. …" (P7 A parliamentarian)
"… Meanwhile, these 18 have created their specific funds, they pay high salaries for the CEO and board of directors, if merged, instead of having 18 board of trustees including 60 to 70 top managers, we face one board of trustees. …" (A parliamentarian, Nabz, TV program about Iran health system problems)
Operational processes
Eliminating different instructions applied by health insurance funds to review claims and better supervision and management of health care providers by merging their health profile in a single database were the main advantages stated by the interviewees.
"… Overall, the Fragmentation of insurances has many challenges. One of the challenges is that there are different guidelines and rules. It confuses the providers; it confuses even the medical Association, the regulations that exist in IHIO vary from social security organization (SSO), one covering different/more health services from/than the other one. The depth of coverage of the armed forces is the most. The physician must make several lists for different insurance schemes, which means both he and his secretary should put more time to preparing them; these increase the administrative costs. …" (P18 A policy maker from health insurance system)
"… The pharmacy says that when I buy a drug, I get a fee list from the IHIO website, and also I have to check out the fee list of SSO. For example, for Albumin, IHIO accepts 31,000 Tomans, Imam Khomeini Foundation accepts 38,000 Tomans and Social Security 27,000 Tomans. …" (P5 one of the health insurance organizations' managers)
Interaction with providers
Merging and creating health insurance schemes can influence the interaction with health care providers in various ways. Merging can positively influence the following areas: competition among health care providers, strategic purchasing and supervising health care providers, reimbursement and moving towards new payment methods, and the principles of contraction with providers.
"… The next problem is that medical fraud is easier to occur in a fragmented health insurance context because providers' medical profile is not centralized in a single database. Someone may misuse an insurance scheme, and it takes time this fraud to be known by other health insurance schemes. …" (P17 A former manager from one of the health insurance organizations)
"… When the profile of a physician is centralized in one database, you can see how much drugs or paraclinical diagnostic tests they have prescribed, and you can supervise them better. Doctors are intelligent; they obey health insurance schemes with strict rules, but they may play games with other schemes. With single insurance, doctors are reimbursed by a single-payer (so you can execute taxation affairs easier), the current fragmented situation is better for those doctors who want to escape from paying taxes" (P18 A policy maker from one of the health care provider associations).
The advantages and disadvantages of merging derived from the interviews were classified in the following categories: stewardship, financing, population, basic benefit package, structure, operational processes, and interaction with providers. Key advantages and disadvantages of merging health insurance funds in Iran, emerged from interviews, are presented in Table 2.
Stewardship
In 2004, by creating the Supreme Council of Health Insurance (SCHI) under the MoCLSW, a purchaser-provider split occurred in the Iranian health system to move towards strategic purchasing and boost competition among health care providers. According to the studies, after this split, incoordination between two ministries caused new challenges for MoHME to devise and implement health reforms without control of financial resources (25). Apart from this, Fragmentation in health insurance caused each insurance scheme to behave differently and follow different health policies and also implement policies issued by the SCHI differently. According to the interviews, merging can solve these challenges to a great extent. According to the findings, merging and creating single national health insurance can provide a situation in which it is easier to control total health care expenditures and formulate and implement more reliable health policies for the health system.
"…I'm really tired of attending meetings of the family physician and referral system. I've probably attended more than 50 large meetings regarding launching a family physician and referral system myself. We saw that the IHIO representative wants something different, the SSO' agent speaks differently, and the AFMSIO's representative said something else. If I, as MoHME, want to implement family physician referral system, whose opinion should I accept? ..." (P2 a policy maker from the health insurance system)
"…Social Security Organization don't implement whatever approved by HCHI or implement with delay…" (A parliamentarian, Nabz, TV program about Iran health system problems)
"…wherever the monopoly is formed, the accountability would be reduced. Because all people have to get their services only from one organization with the same quality and quantity, and this leads to reducing the responsiveness as this organization has no competitor. … the same thing that happened to our car industry as a result of monopoly. …" (P20, one of the health insurance organizations' managers)
Financing
Fragmentation in health financing in Iran has caused each health insurance scheme to follow its policies. In the long run, it has led to differences in contribution rates, out-of-pocket payments rates, coinsurance rates, different levels of financial protection, and an uneven distribution of public subsidies among different insured groups. Apart from reducing the inequities, interviewees believed that merging could improve the way through it, the financial resources are collected, managed, pooled, and allocated to purchase health services for the beneficiaries.
"… About 23 million rural citizens are covered freely by IHIO, the government pays for them, is there this advantage for the workers? Are they not Iranian? is it not discrimination?" (Nabz, TV program about Iran health system problems, a key policy actor)
"When you have duplication in coverage, more public budget is spent, it means that the government pays twice as employer for the same part of population…" (P38 A policy maker from Supervisory Organizations)
Population
In the population area, the following subjects are the main topics that merging of health insurance funds may bring about positive or negative impacts: extending coverage for those without health insurance and removing the problem of duplication in population coverage.
"… When the supervisory and legislative agencies requested (health insurance schemes for) the number of the insured persons, adding the numbers together, we saw that the result was more than the whole population of the country and at the same time we had ten million people uninsured. …" (P38A policy maker from Supervisory Organizations)
"… One of the merits of merging is unifying the population's information. According to the Iranian census, 77 million people are known; when you combine and unify all health insurance databases, it will make those people without insurance coverage clear. Why making it clear is not possible now! Because they are scattered in 17 databases, merging makes it clear who has several insurance cards and who has no coverage …" (P26 A parliamentarian)
"… The Fragmentation and duplication of health insurance coverage make it difficult to calculate the per capita expenditures accurately. As a result, the computation of insurance premiums will be blurred. …" (P17, A former manager from one of the health insurance organizations)
Basic Benefit package
The first advantage that most of the interviewees mentioned in this aspect were providing equitable basic benefits package for all Iranians. According to the interviews, high inequity in benefit packages under the coverage of insurance schemes has led to high dissatisfaction among people, which is unacceptable and is against national values and constitution. The existing discrepancies between various demographic groups in terms of the types of health services that they can receive, the amount of financial compensation offered for each health service, and the number and types of health care facilities (public or private health sector) where they can get their services will be abolished by providing a single health insurance system for all demographic.
"… We (health insurance experts in Iran) say we are moving towards public health-based services (conserving health status), but what we are doing now is hospital-based services…" (A manager from one of the Health Insurance Organizations) "…the main focus of some health insurance funds is business, not health…" (A parliamentarian, Nabz, TV program about Iran health system problems)
Structure
The interviewees' main advantages in this section were related to reducing the administrative and overhead costs as a result of eliminating parallel structures of insurance in the provinces and reducing the number of top managers and employees.
"… all insurance funds also have their own offices in different provinces. Different insurance companies have their own offices, general directors, secretaries, cars, traveling costs, seminars, and so on. …" (P7 A parliamentarian)
"… Meanwhile, these 18 have created their specific funds, they pay high salaries for the CEO and board of directors, if merged, instead of having 18 board of trustees including 60 to 70 top managers, we face one board of trustees. …" (A parliamentarian, Nabz, TV program about Iran health system problems)
Operational processes
Eliminating different instructions applied by health insurance funds to review claims and better supervision and management of health care providers by merging their health profile in a single database were the main advantages stated by the interviewees.
"… Overall, the Fragmentation of insurances has many challenges. One of the challenges is that there are different guidelines and rules. It confuses the providers; it confuses even the medical Association, the regulations that exist in IHIO vary from social security organization (SSO), one covering different/more health services from/than the other one. The depth of coverage of the armed forces is the most. The physician must make several lists for different insurance schemes, which means both he and his secretary should put more time to preparing them; these increase the administrative costs. …" (P18 A policy maker from health insurance system)
"… The pharmacy says that when I buy a drug, I get a fee list from the IHIO website, and also I have to check out the fee list of SSO. For example, for Albumin, IHIO accepts 31,000 Tomans, Imam Khomeini Foundation accepts 38,000 Tomans and Social Security 27,000 Tomans. …" (P5 one of the health insurance organizations' managers)
Interaction with providers
Merging and creating health insurance schemes can influence the interaction with health care providers in various ways. Merging can positively influence the following areas: competition among health care providers, strategic purchasing and supervising health care providers, reimbursement and moving towards new payment methods, and the principles of contraction with providers.
"… The next problem is that medical fraud is easier to occur in a fragmented health insurance context because providers' medical profile is not centralized in a single database. Someone may misuse an insurance scheme, and it takes time this fraud to be known by other health insurance schemes. …" (P17 A former manager from one of the health insurance organizations)
"… When the profile of a physician is centralized in one database, you can see how much drugs or paraclinical diagnostic tests they have prescribed, and you can supervise them better. Doctors are intelligent; they obey health insurance schemes with strict rules, but they may play games with other schemes. With single insurance, doctors are reimbursed by a single-payer (so you can execute taxation affairs easier), the current fragmented situation is better for those doctors who want to escape from paying taxes" (P18 A policy maker from one of the health care provider associations).