In this study, we conducted 30 semi-structured interviews to investigate policy recommendations to improve the insurance coverage for physiotherapy services in Iran. Then, AHP approach was used to prioritize the recommendations in accordance with the six criteria (effectiveness, acceptability, cost, fairness, feasibility, and time).
Through the qualitative study, participants expressed a number of policy recommendations. These proposed recommendations for each component of conceptual framework are shown in Table 3. Stewardship, including inter-sectoral leadership and intra-sectoral governance, was highlighted by most of participants. They proposed several options to improve this domain such as moving to united stewardship, informing the policy-makers about physiotherapy services and their effects, participating the rehabilitation experts in decision- and policy-making process, etc. (Table 3(a)). Improving collection of funds or revenue collection is another main component of financing process that participants especially policy-makers and faculty members recommended various policy solutions for it such as value-added tax on luxury goods and services, considering higher insurance contributions (premiums) for families without any child, earmarking the allocated resources, etc. (Table 3(b)). Other policy recommendations in order to improve the pooling of funds, purchasing, and benefit package are shown in Table 3(c), Table 3(d), and Table 3(e), respectively.
Table 3
Recommendations to improve the insurance coverage for physiotherapy services
ID | Recommendation |
(a) Stewardship |
1 | Moving to united stewardship |
2 | Informing the policy-makers about physiotherapy services and their effects |
3 | Participating the rehabilitation experts in decision- and policy-making process |
4 | Improving health technology assessment (HTA) process |
5 | Facilitating the interdisciplinary collaborations |
6 | Conducting regular supervision and accreditation |
7 | Strengthening referral system |
8 | Conducting comprehensive need assessments |
9 | Establishing accurate information system |
10 | Transparent prioritizing and rationing |
11 | Promoting the interaction level between scientific associations and insurers |
(b) Collection of funds |
1 | Value-added tax on luxury goods and services |
2 | Tax on chemical and toxic industries |
3 | Tax on harmful substances such as tobacco, sugar, etc. |
4 | Considering higher insurance contributions for families without any child |
5 | Obligating the complementary health insurance for employed groups |
6 | Promoting the rehabilitation funding proportion from public budget |
7 | Earmarking the allocated resources |
8 | Considering a separate premium for rehabilitation services (including physiotherapy) |
(c) Pooling of funds |
1 | Moving the allocated resources to insurance (third party) mechanism |
2 | Integrating the insurance funds |
3 | Cross-subsiding across different groups at national level |
4 | Using individual medical saving accounts |
5 | Consolidation the small insurance funds |
(d) Purchasing |
1 | Separation between provider and purchaser |
2 | Using strategic purchasing |
3 | Considering quality indicators in purchasing process |
4 | Considering performance- or outcome-based payment system |
5 | Limiting the induced demands by payment and punishing mechanisms |
6 | Using rehabilitation experts in purchasing process |
7 | Correcting the tariffs based on economic situation |
8 | Reducing the co-payment rates |
9 | Using capitation mechanism to control the expenditures |
(e) Benefit package |
1 | Considering the cost-effectiveness interventions |
2 | Considering the preventive interventions |
3 | Considering needed interventions in golden time treatment after diseases |
4 | Considering the inpatient interventions |
5 | Coverage of physiotherapy services required for children up to the age of six |
6 | Coverage of physiotherapy services up to age of 18 |
Regarding the AHP session, the findings of the pairwise comparisons of the six criteria are presented in Table 4. As shown in the Table, the relative importance of criteria includes feasibility with a ratio of 0.258, which had the highest importance; acceptability with a ratio of 0.178; fairness with a ratio of 0.171; cost with a ratio of 0.138; effectiveness with a ratio of 0.131; and finally, time with a ratio of 0.124, which had the lowest importance. In the pairwise comparison of the six criteria compared with the goal, the inconsistency index was 0.09.
Table 4
Matrix of pairwise comparisons
Main criterion | Feasibility | Acceptability | Fairness | Cost | Effectiveness | Time | Relative importance |
Feasibility | 1 | 1 | 2 | 2 | 3 | 2 | 0.258 |
Acceptability | 1 | 1 | 1/2 | 1 | 2 | 2 | 0.178 |
Fairness | 1/2 | 2 | 1 | 2 | 1 | 1/2 | 0.171 |
Cost | 1/2 | 1 | 1/2 | 1 | 1 | 2 | 0.138 |
Effectiveness | 1/3 | 1/2 | 1 | 1 | 1 | 2 | 0.131 |
Time | 1/2 | 1/2 | 2 | 1/2 | 1/2 | 1 | 0.124 |
Then, policy recommendations of each component were paired compared in accordance with the six criteria. Supplemental Fig. 2 presents the prioritization of recommendations for stewardship based on each criterion. According to the Fig. 3, informing the policy-makers about physiotherapy services and their effects (0.128), had the highest priority and followed by participating the rehabilitation experts in decision- and policy-making process (0.115), promoting the interaction level between scientific associations and insurers (0.098), conducting regular supervision and accreditation (0.098), strengthening referral system (0.095), establishing accurate information system (0.084), conducting comprehensive need assessments (0.080), transparent prioritizing and rationing (0.080), improving health technology assessment (HTA) process (0.078), facilitating the interdisciplinary collaborations (0.073), and finally, moving to united stewardship (0.071) had the lowest priority. Performance sensitivity analysis of these recommendations also is demonstrated in Fig. 3.
Prioritization of policy recommendations for collection of funds based on six criteria are shown in Supplemental Fig. 3. Also, Fig. 4 shows the performance sensitivity analysis and overall prioritization of recommendations in accordance with criteria for this component. As presented, value-added tax on luxury goods and services (0.158), tax on harmful substances such as tobacco, sugar, etc. (0.144), considering a separate premium for rehabilitation services (including physiotherapy) (0.140), earmarking the allocated resources (0.140), tax on chemical and toxic industries (0.135), considering higher insurance contributions for families without any child (0.127), obligating the complementary health insurance for employed groups (0.086), and promoting the rehabilitation funding proportion from public budget (0.069), were ranked from highest to lowest.
Prioritization of policy recommendations for pooling of funds based on six criteria are also demonstrated in Supplemental Fig. 4. As the overall findings are shown in Fig. 5, moving the allocated resources to insurance (third party) mechanism (0.294), had the highest priority and followed by cross-subsiding across different groups at national level (0.199), integrating the insurance funds (0.180), consolidation the small insurance funds (0.173), and finally, using individual medical saving accounts (0.154), which had the lowest priority. In addition, you can see the performance sensitivity analysis based on the each criterion in Fig. 5.
Purchasing was other component of financing which a number of policy recommendations are provided to improve it. Supplemental Fig. 5 is shown the prioritization of obtained alternatives based on the six criteria. Furthermore, the performance sensitivity analysis and overall prioritization are demonstrated in Fig. 6. As shown, using strategic purchasing (0.162), correcting the tariffs based on economic situation (0.130), and considering quality indicators in purchasing process (0.127), were the top three priorities. In addition, limiting the induced demands by payment and punishing mechanisms (0.111), using rehabilitation experts in purchasing process (0.104), considering performance- or outcome-based payment system (0.097), reducing the co-payment rates (0.093), and using capitation mechanism to control the expenditures (0.093), were ranked from four to eight. Finally, separation between provider and purchaser (0.084) had the lowest priority, however, it was one of the top priorities according to effectiveness.
The last component was the benefit package which its policy recommendations are prioritize based on each criterion (Supplemental Fig. 6). As other components, the performance sensitivity analysis and overall prioritization are described in Fig. 7. The analyses are revealed that considering the preventive interventions (0.207) had the first rank. This was a notable finding. Further, coverage of physiotherapy services up to age of 18 (0.195) and considering the needed interventions in golden time treatment after diseases (such as stroke) (0.188) were the second and third priorities. Finally, coverage of physiotherapy services required for children up to the age of six (0.162), considering the inpatient (0.147) and cost-effectiveness interventions (0.101), were other alternatives to improve the benefit package of insurance institutes.