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 2004, by creating High Council of Health Insurance (HCHI) under the MoCLSW, a purchaser-provider split occurred in the Iranian health system in order to move towards strategic purchasing and boost competition among health care providers. According to the studies, after this separation, incoordination between two ministries effected new challenges for MoHME to devise and implement health reforms without control on financial resources (25). Apart from this, fragmentation in health insurance caused each insurance scheme behave differently and follow different health policies and also implement policies issued by the HCHI differently. According to the interviews, merging can solve these challenges to great extent. According to the findings, merging and creating a 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 in meetings of the family physician and referral system. I've probably attended more than 50 large meetings regarding launching family physician and referral system myself, we saw that the Iran Health Insurance Organization representative wants something different, the Social Security organization’ agent speaks differently, and the Armed Forces Insurance Organization’ representative was saying something else. If I, as Ministry of Health, want to implement family physician referral system, whose opinion should I accept?...” (P2, Head of high council of health insurance)
“…Social Security Organization don’t implement whatever approved by HCHI or implement with delay…” (The parliament representative, Nabz, TV program about merging)
“…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 lead 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, A manager from Social Security Organization)
Financing:
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.
“… About 23 million rural citizens are covered freely by Iran Health Insurance Organization (IHIO), government pays for them, is there this advantage for the workers? are they not Iranian? is it not discrimination?” (Nabz, TV program about merging, the representative of worker house)
“when you have duplication in coverage, more public budget is spent, it means that the government pays twice as employer for a part of population…” (P38, A manager from Plan and Budget Organization of the Islamic Republic of Iran)
Population:
In the population area the following subjects are the main topics which merging 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. …” (P38, A manager from Plan and Budget Organization of the Islamic Republic of Iran)
“… One of the merits of merging is unifying the information of population, now according to the census of the Iranian, 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, one of the parliament representative)
“… The fragmentation and duplication of health insurance coverage makes it difficult to calculate the per capita expenditures accurately. As a result, the computation of insurance premiums will be blurred. …” (P17, One of the former general director of IHIO)
Benefit package:
The first advantage that most of interviewees mentioned in this aspect was providing equitable basic benefit package for all Iranians. According to the interviews, high inequity in benefit packages under coverage of insurance schemes has led to high dissatisfaction among people which is not acceptable and is against national values and constitution. The current differences among different groups of population in terms of the verity of health services they can access, the level of financial coverage provided for each health service, the number and variety of health facilities (public or private health sector) which they can get their services would be removed by creating a single health insurance scheme for all population.
“… 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 Armed Forces Health Insurance Organization) “…the main focus of some health insurance funds is business, not health…” (The parliament representative, Nabz, TV program about merging)
Structure:
The main advantages mentioned by the interviewees 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 in turn 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, one of the parliament representative)
“… Meanwhile these 18 have created their own 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. …” (NABZ TV program about merging health insurance funds)
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 data base were the main advantages stated by the interviewees.
“… Overall, 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 for preparing them, these increase the administrative costs. …” (P18, A manager from The Medical Council of Islamic Republic of Iran)
“… 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, A manager from Imam Khomeini Relief Committee)
Interaction with providers:
Merging and creating health insurance schemes can influence the interaction with health care providers in various ways. Merging can influence the following areas in positive way: 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 occurred in a fragmented health insurance context because the medical profile of providers is not centralized in a single database. Someone may misuse an insurance schemes and it takes time this fraud to be known by other health insurance schemes. …” (P17, One of the former general directors of IHIO)
“… When the profile of a physician is centralized in one database, you can see how much drugs or paralcinical diagnostic tests they have prescribed, you can supervise them better. Doctors are intelligent; they obey regulations of health insurance schemes with strict rules but they may play game with other schemes. With a 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 manager from The Medical Council of Islamic Republic of Iran)