Based on the findings of this study, FPP has led to a significant reduction in the utilization of health services both in the short term and long term. The findings showed that the number of specialist visits, number of imaging services, and number of laboratory tests utilized by population covered by Social Security Insurance were significantly reduced immediately after the implementation of this program. This decline is also evident in long-term horizons, and FPP has been able to significantly reduce the utilization of imaging services, laboratory tests, and hospitalizations. Although there has been an increase in the utilization of some services in the short term or long term, these increases have not been significant.
FPP, which was aimed at better management of the referral system, has reduced the number of referrals to specialized levels. According to the findings of other studies, it can be observed that FPP can help improve quality of health care services and reduce their cost. For example, Simo et al. (2010) found that referrals to family physicians not only improved the prescription practices, but also reduced the financial burden to the patient and the community (10). In addition, according to the results of a study in Iran, the implementation of FPP led to the relative progress in the delivery of family health services including women's periodic examinations and pap smear sampling, and increased referral to the physician for medical services, that indicated improvements in the quality of services (11).
It is worth noting that FPP has not been able to reduce hospitalization in the short term, rather it has experienced an insignificant relative increase. In the short term, the access to family physicians might have helped to identify many of the unmet medical needs of the people that have resulted in referral to higher levels. However, in the long term, there has been a significant decrease in hospitalization. This finding is not surprising because FPP changes physicians from a therapist to an active health care provider that, along with him, health care providers also observe the health status of the community. Improving people’s access to primary health care and prevention services, in the long term, can reduce the burden of diseases and reduce the need for hospitalization (12, 13). Improving people’s access to services via the implementation of FPP is a findings that have been cited by many researchers (14-16). The launch of this project in Iran has helped to increase people’s access to primary health care, especially in rural areas (17). A review study on 19 papers similarly reported that family physicians can guarantee the durable delivery of services, improved counseling time, improved physician-patient relationship, implementing preventive measures, and ultimately reduce the burden of diseases (18).
On the contrary, HTP has increased the utilization of health services in the short term. The HTP has also significantly increased the utilization of imaging services and laboratory tests both in the short term and the long term; nevertheless, the increase in the utilization of other services including hospitalization services, medicine, and specialist visits has been insignificant. Several studies have confirmed that HTP has increased the utilization of services (19, 20). Pirozi et al. (2019), for example, confirmed the increased utilization of hospitalization services as a result of the implementation of HTP (21) Nonetheless, some studies have reported the existence of socioeconomic differences in the utilization of health services after the launch of HTP (22).
In fact, the goal of HTP is somewhat different from that of FPP and, consequently, it has had different achievements. The plan, as one of the major reforms in Iran health system in recent years, has been aimed at removing financial barriers facing service recipients. Therefore, the increase in the utilization of health services and the decrease in out-of-pocket payments (23) are not far from our expectations (24). This has intensified in the absence of clinical guidelines (25).
Concerning the costs, FPP has led to a reduction in costs in the short term, and the reduction has been significant in the costs of specialist visit, drugs, and radiology services, and laboratory tests. However, in the long term, the effects of the FPP have shown different findings for services. In the long term, the costs of general practitioners visit, specialist visit, and drugs have increased significantly. The cost of radiology services and laboratory tests has also experienced a significant decline both in the short term and the long term.
The reduction in health care expenditure in the short term can be attributed to the rationalization and reduction of service utilization due to the presence of family physicians as health system gatekeepers. In fact, family physicians have made great efforts in controlling referrals, especially at the beginning of the plan, which has reduced the utilization of services at the next levels of the health system. In a comprehensive study, it became clear that FPP could reduce costs and improve the cost-effectiveness of health interventions (18). However, the increase in costs in the long term which was reported in another study (26) may be attributed to rising inflation in the country in the late 2000s and early 2010s, which has also resulted in an inflation in the health sector (27).
However, in the short term, HTP has mainly led to an increase in costs, except for the cost of a general practitioner visits and drugs. A similar increasing trend in costs in the long term was also observed, but the cost of the general practitioner visits and drugs decreased significantly. The increase in costs, especially the increase in the cost of outpatient services, has also been reported in other studies (28). In fact, the rise of costs can be justified by the increase in the utilization of services after the launch of HTP (19-21). On the other hand, this plan increased the share of health system in the general budget and raised health services tariffs based on publishing the book of relative value (which puts new values on health services tariffs), which resulted in a remarkable increase in health system expenditures (19, 29). Thus, the increase in health service costs can be attributed to the increase in the share of health from GDP and the increase in health care expenditures.
Despite the improvements in people’s access to health services, HTP has failed to be successful in providing financial protection for health services. For example, Homaie Rad et al. (2017) showed that as a result of HTP, out-of-pocket payments for outpatient services increased and the costs of other services did not change significantly. However, there was no significant improvement in equity and utilization indices (28). In a national study, the amount of exposure to catastrophic health care costs has been reported to be increased from 2.57% in 2008 (before HTP) to 3.25% in 2015 (after HTP) (30). The same findings were reported in another study (31). One of the main reasons for this finding is the high emphasis of HTP on inpatient services and the abandonment of outpatient services and services provided in private hospitals (32), while the share of these services in the entire health care system has grown in recent years (33).
This study was carried out on population covered by social security insurance organization, which covers more than half of Iran's population (about 45 million people). People under the coverage of the Iran health insurance (with a population almost equal to people under the coverage of social security organization) are expected to follow a similar pattern due to relatively similar policies. However, it should be kept in mind that generalizing the research findings to the entire Iranian population (some of which are still not covered by any insurance scheme) should be done with caution.