The advantages and disadvantages of merging health insurance funds derived from the interviews were classified in the following categories: stewardship, financing, population, basic benefits package, structure, operational processes, and interaction with providers. The key advantages and disadvantages of merging health insurance funds in Iran obtained from the interviews are presented in Table 2.
Stewardship
In 2004, by creating the Supreme Council of Health Insurance (SCHI) under the Ministry of Cooperatives, Labor and Social Welfare, a purchaser-provider split occurred in the Iranian health system to move toward strategic purchasing and boost competition among health care providers. According to studies, after the split, lack of coordination between two the ministries caused new challenges for Ministry of Health and Medical Education to devise and implement health reforms without control of financial resources(27). 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 SCHI differently. According to the interviews, merging can solve these challenges to a great extent. According to the findings, merging and creating a single national health insurance system can provide a situation, in which it is easier to control total health care expenditures as well as to 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 wanted something different, the SSO' agent spoke differently, and the AFMSIO's representative said something else. If I, as MoHME, wanted to implement a family physician referral system, whose opinion should I accept? ..." (P2, a policy maker in the health insurance system)
"…The Social Security Organization doesn’t implement whatever approved by HCHI or implement them with delay…" (A parliamentarian, Nabz, a TV program about the Iran health system problems)
"…wherever monopoly is formed, accountability is reduced. Since all people have to get their services only from one organization with the same quality and quantity, this causes reduced responsiveness as this organization has no competitors. … the same thing happened to our car industry as a result of monopoly. …" (P20, a manager in one of the health insurance organizations)
Financing
Fragmentation in health financing in Iran has caused each health insurance scheme to follow its policies. In the long run, it led to differences in contribution rates, out-of-pocket payment rates, and coinsurance rates; different levels of financial protection; and an uneven distribution of public subsidies among different insured groups. Apart from reducing inequities, the interviewees believed that merging could improve the collection, management, pooling, and allocation of financial resources to purchase health services for beneficiaries.
"… About 23 million rural citizens are covered freely by IHIO; the government pays for them. Is there this advantage for workers? Aren’t they Iranian? isn’t it discrimination?" (Nabz, a TV program about the 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 the employer for the same group of population…" (P38, a policy maker in one of the supervisory organizations)
Population
In the population area, the following subjects were the main topics, on which merging of health insurance funds may have 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 insured people, adding the numbers together, we saw that the total number was larger than the whole population of the country, and at the same time, we had ten million people uninsured. …" (P38A, a policy maker in one of the 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 is making it clear impossible now!? Since 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 in one of the health insurance organizations)
Basic Benefits Package
The first advantage mentioned by most of the interviewees in this aspect was providing an equitable basic benefits package for all Iranians. According to the interviews, high inequity in benefits packages under the coverage of insurance schemes has led to high dissatisfaction among people, which is unacceptable and against national values and constitution. The existing discrepancies between various demographic groups in terms of types of health services that they can receive, amount of financial compensation offered for each health service, and number and types of health care facilities (public or private health sector) where they can receive their services will be abolished by providing a single health insurance system for all demographic groups.
"… We (health insurance experts in Iran) believe that we are moving toward public health-based services (conserving health status); but, what we are doing now is providing hospital-based services…" (A manager in one of the Health Insurance Organizations)
"…the main focus of some health insurance funds is on business, and not on health…" (A parliamentarian, Nabz, a TV program about the Iran health system problems)
Structure
The interviewees believed that main advantages in this section were related to the reduced administrative and overhead costs as a result of eliminating parallel structures of insurance in the provinces of Iran and reducing the number of top managers and employees.
"… all insurance funds 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 companies have created their specific funds; they pay high salaries to their CEOs and boards of directors. If they are merged, instead of having 18 boards of trustees including 60 to 70 top managers, we face one board of trustees. …" (A parliamentarian, Nabz, a TV program about the Iran health system problems)
Operational Processes
Eliminating different instructions applied by health insurance funds to review claims and provide better supervision and management of health care providers by merging their health profiles in a single database was the main advantage 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 providers; it even confuses the medical association; regulations existing in IHIO are different from those in the social security organization (SSO), with one covering different and more health services compared to the other one. The depth of coverage of the armed forces is the most. A physician must make several lists for different insurance schemes, which means that both the physician and his secretary should put more time to prepare them; this increases administrative costs. …" (P18, a policy maker in the health insurance system)
"… when I [pharmacist] 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 charges 31,000 Tomans, Imam Khomeini Foundation charges 38,000 Tomans, and Social Security charges 27,000 Tomans. …" (P5, a manager in one of the health insurance organizations)
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 toward 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 profiles are not centralized in a single database. Someone may misuse an insurance scheme, and it takes time to recognize this fraud based on other health insurance schemes. …" (P17, a former manager in 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 system. So, you can conduct taxation affairs easier. The current fragmented situation is better for those doctors who want to avoid paying taxes" (P18, a policy maker in one of the health care provider associations).