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The challenges of supervision on providing health services from the viewpoint of the insurer: a qualitative study.

Introduction

The mission of the health system is to maintain and return the health and well being of the people and this is only possible by improving the quality of performances, as well as a proper management system and supervision on providing health services. (1) The insurer organizations supervise the service providers as the financing steward, with the objective of assuring the proper performance of the contract contents, assuring the quality of the provided services, proper utilization of the financial resources, preventing financial abasements from the insured etc. (2)

The health system steward for the proper supervision requires strategies such as data collection, stakeholder's advocacy and creating motivation by means of direct techniques or by designing suitable organizational structures; therefore stewardship in the health system must shift from the orders and control system to the assurance of the existence of proper motivational system. (3)

One of the problems of the health sector is lack of information asymmetry between the provider and receiver of the services (4); whereas moral hazard is another issue which can lead to unnecessary consumption of the services and decrease in the level of providing insurance services. (5) The insurance organizations act as the representative of the insured and as an expert supervisor with the objective of improving the quality of the services, as well as reducing the costs needed to apply super-visional techniques.

Lack of staff expertise and insufficient funds is one of the factors that leads to the deficiency of the super-visional frameworks in remaining up to date. (6) Furthermore, lack of sufficient commitment and financing will limit the capacity of the government in providing services; therefore capacity building for signing the contracts and supervision on providing services both by means of hiring expert staff as well as improving their capabilities is considered as essential. (3)

In Egypt and the Latin America most of the physicians work simultaneously in both public and private sectors, therefore most of their performance is hidden from the view point of supervision. In India, strategies for supervising the private sector have not been developed in its proper pace irrespective of the concerns in this area. The health experts are aware of the regulations related to practicing medicine but they also know that these laws do not have executive value and the performance of the private assemblies which are in charge of self regulation is not effective as well. (3)

When the public providers take illegal benefits from the public facilities to provide special care to private patients, the public sector is in fact, informally paying subsidy to the private sector. It will not be efficient to restrict all the performances of the public physicians in the private sector, but many strategies can be utilized to assure that physicians are competing fairly and are not working in the private sector at the cost of the public sector. (7-8) The important issue in organizing the public-private sector relations is to assure that patients, general public, media and the service providers are aware of the related laws and regulations. (7-8)

Many physician are working simultaneously in the private and public sector. (9-11) Regardless of the plenty of attempts which have been taken previously to prevent this phenomenon (12), currently a considerable number of the physicians are active in both sectors which makes the supervision on their performance very challenging. (10) The supervision on providing health services is also another concern for the health system of Iran. (10,13) So far studies have focused on supervision on providing health services from the view point of the medical sciences universities and insured, this study aims at investigating the subject from the perspective of the insurer. The aim of this study is to investigate the current condition of supervision on providing medical services and its challenges from one of the insurer organizations in Iran.

Method

The current research is a qualitative study, the participants of which are senior and mid-level managers of large social health insurance organizations in Iran. Data collection has been performed through semi-structured interviews. The interview questions were designed with the cooperation of expert teams in the realm of management and health economics. Purposive sampling was executed through interviewing with an informed person in the organization in the preliminary stages. Then, based on the requirements of the subjects, using a snowball sampling method, other participants were selected from various sections of the organizations (20 participants).

Interviews continued until a saturation level was reached. For the data analysis the framework analysis was applied. This method consists of several phases, namely indexing, charting, mapping and interpretation. (14) The interviews were digitally-recorded and in order to minimize the errors all the interviews were transcribed in the MS Word and analyzed using MAXQDA 2007 software. Most interviews were done in their work office and in Persian language. No remuneration was paid to interviewees for their contribution.

Results

In investigating the current situation and the challenges of supervision on providing health services from the viewpoint of the insurer organizations in Iran 7 themes and 20 sub-themes were explored. (Table 1)

Theme 1: the objectives of supervision

Investigating the violations, their contexts, prevention strategies and confronting the wrongdoers are among the objectives of the supervision. Supervision results in preventing waste of resources, more efficient offering of services, and improved quality provided services. One participant in this respect says:

Supervision on medical society can result in directing the performances... (P5) and quality improvement (P9)

Theme 2: supervisors

Findings show that supervision on providing health services has been assigned to various organizations i.e.: Ministry of Health, family physician, the medical system organization, and insurance organizations. Each of these organizations has responsibilities which are listed in table 2. The most important responsibility in this regard has been assigned to the ministry of health and medical education. Some participants believed that this ministry has not been successful enough in this respect.

Supervision on providing services is the responsibility of the ministry of health but along with the development of service providing centers and the existing doubts, no remarkable success has been considered. (P3)

Theme 3: the supervisee

The insurance organizations must supervise various groups and organizations. The kind of supervision differs based on the group which is being supervised. The investigated groups are: the service providers in the private sector contractual parties, non-contract beneficiary organizations, the insured, executive units, insurance organization committees, public services provider's centers.

Contractual centers

This group, according to the contract, is obliged to act upon the defined tariffs. But practically due to unrealistic tariffs more franchise is paid by the patients. The organizations do not perform any specific supervision and can only nullify the contract which in many circumstances is not possible.

Non-contractual centers

Not following the private sector tariffs is the most important challenge on the supervision of these centers. Although these centers do not have contracts with the insurance companies, they are making some costs for the insurance companies, as they can prescribe drugs and diagnostic devices in the insurance notebooks of the patients.

The insured (receiver of the services)

The insured themselves are also subjects of supervision from the insurance organization in respect of the way they use their insurance notebooks, since they might give their patients' ID cards to other people or a physician might abuse their notebooks in various ways.

Theme 4: subject of supervision:

The findings show that the insurance organizations must consider many variables while supervising, such as quality of providing services, services tariffs, induced demands and financial resources.

Quality of provided services

Currently the insurance organizations do not do any special activities in respect of the quality of services and this is the responsibility of the ministry of health and medical education and the medical sciences universities and in this area as well the ministry of health hasn't been successful.

"Supervision on the quality of the services has been assigned to the ministry of health and in this area, as well, this ministry hasn't been successful"

The ministry of health and ministry of welfare are two policy making organizations in respect of tariffs in health services of Iran; however, these two organizations are in disagreement regarding the definition of tariffs. Ministry of welfare which is in charge of financing the heath system tries to keep the tariffs as lowers as possible to offer less financial resource to the service providers. But the ministry of health as the biggest service provider organization in the country ties to define the tariffs in its highest possible level in order to increase the income of its service provider units. Therefore this disagreement makes rhea defining of the tariffs as a place of dispute between the service providers and financing organizations.

Another problem is that the defined tariffs by the government are not obeyed in the private sector, this sector based on the excuse that the tariffs are not realistic for the health sector, sell their services with a higher price than the ratified tariffs which is mostly paid as the out of pocket by the consumer of the services or in some cases the private sector for its inpatient services do not sign a contract and the patients are required to pay the charges with uninsured prices, this is also partly intensified due to the lack of proper supervision of the government.

In the Para clinical sector as well, since the prices are affected by the turbulences of the rate of currency exchange and the country's sanctions, it is not possible to define a definitive tariff and the tariff tool is not efficient in this sector.

"Some of the public centers as contractual parties, are looking for an excuse to accept the patients with normal rates (non subsidies) and this is in fact due to the unrealistic tariffs defined by the government" (P5)

"The instruments of the preclinical sector are included in the free market listing prices and wherever the prices changes globally or the country accepts a sanction these prices changes as well, therefore it is not possible to define tariff for this sector " (P6)

Induced demands

The payment system of Iran which is mostly fee for service system and per case has made the physicians to encourage their patients to induced demands. The existence of the insurance notebook is like a plain cherub notebook which the physician can write whatever he likes in it and this issue has worsen the situation.

"80% of the payments to the private sector are the result of induced demands which is considered as a covert fraud. (P6) we have no supervision on the proper prescription of the services which are abundantly produced around the world and enter our health system" (P5)

Financial resources

Supervision on the way of consuming the financial recourse and the income of the organization are considered as very important factors in supervision. This issue from the viewpoint of the amount of the allocated resources to the health sector and the necessity of the preventative care approach, gap between the levels of incomes and costs, deficiency of the information system of the insured, resource management, and delay in paying the claims are regarded as challenges of this sector.

"Another problem of the insurance organization is in respect to the lack of appropriateness between the income and the costs and it cants be realized considering the predictions on the incomes. " (p4)

Theme 5: type of supervision

The subcategories are: field supervision, qualitative supervision and systematic supervision.

Field supervision

In these method supervisions such as the violation investigator officer visits from the centers of providing services, investigating the medical documents and also the visits of the insurance representatives in the hospitals from the patients who are inpatient and checking the insurance notebooks with the patients are done.

"There are some staff staying in the hospitals who are in charge of comparing and contrasting the invoices sent to the insurance organizations with the clinical profiles of the patients, and they also go to visit the patients in the hospital in regular basis to check on the services that are being offered to them." (P10)

Quality supervision

This kind of supervision is mostly the responsibility of the ministry of health and medical education and the medical system organization and the insurance organizations are less engaged in it.

"A minor part is the quality supervision which is not very much the responsibility of the insurance organizations." (P8)

Systematic supervision

In this type of supervision, the logical relation between the insured and drug as well as method of prescription, amount of the consumed drug and the utilization of services by the insured is supervised by the insurance organizations, based on the defined software for the insurance organizations.

"By means of the existing software in the organization, we focus on the physicians who have increasing prescription statistics, the ones who are producing costs are recognized" (P8)

Theme 6: Supervision tools:

There are various tools for supervision on services being provided which are: ranking of the service providers, data system, defining the tariffs, planning, signing contracts and legal tools, direct care, treatment protocols and financial contributions of the insured.

Ranking of the service providers:

The ministry of health, evaluates its service provider centers based on the checklists annually, this ranking influences the income of these centers especially the hospitals.

"The tariff for the hospitals differs from one another based on their rankings ". (P10) Information system (data base)

One of the most important tools for supervision is the existence of a comprehensive data base. Currently the insurance systems use these databases for the investigation of the sheets of the insurance notebooks and controlling the probable unnecessary prescriptions and informing the service providers, but due to the non universality of this instrument as well as non mechanization of all the procedures from signing the contract until reimbursing the costs, needs to be upgraded.

"We are trying to include eve thing in the network, from signing the contract until the time that the insured receives the service and all the payments we make must be included, if something is out of the system is out of supervision." (P2)

"When we use electronic health the aim is to solve are supervision challenges in a systematic way nod by means of software." (P7) "by means of information technology the monitoring of the unnecessary prescription of the physicians becomes possible". (P2)

Defining the tariffs

Universal policymaking on defining the tariffs, making the tariffs realistic, defining proper tariffs according to the rankings of the service provider centers are among the instruments of the insurance organizations.

"Wherever we have been successful in correcting the tariffs the disobediences have been reduced as well. If the tariffs are not appropriately defined that organization will try to compensate for its claims in other ways to receive what it needs" (P3)

Signing contract and legal instruments

While signing a contract the insurance organizations must define the conditions of the contract in a way that they can claim regarding the disobedience in the court of justice and use this as an instrument for controlling the service provider. There must also be information providing to the providers of the services and the supervision part must be included in the contracts.

"The supervision section must be included in the contracts ". (P6)

Direct care

When the affecting tools of the insurance organizations for the service providers are insufficient, some of the insurance organization has been chosen to use direct care and establish hospitals and centers for health service providing.

Treatment protocols

The treatment protocols or guidelines are the supervision tools on the diagnostic procedures the lack of which is considered as a major challenge in the supervision section of the insurance organizations.

"A major part of the financial credits wasting in the treatment area in all of the insurance organizations in the country is due to lack of having scientific standards and guidelines in respect to medical practices," (P10)

The financial contribution of the insured

One of the monitoring instruments in the insurance organizations for reducing the moral hazard problem is implementing the financial contribution of the insured.

"Franchise is an efficient controlling tool in preventing the unnecessary referrals". (P8)

Theme 7: the essentials of supervision

Efficient supervision has various requirements among the most important of them, from the perspective of the contributors in this study are: The cooperation of the stakeholders, the requisite organizational structure, culture of supervision and legal necessities.

The cooperation of the Stakeholders

The health system has various Stakeholders and their cooperation is one of the pre requisites of an efficient supervision, the main beneficiaries are: insurance organizations, ministry of health, service providers, insured, etc.

"Supervision in health system requires the comprehensive cooperation of all sectors of the health system ". (m5)

"Supervision requires a culture which we lack. For instance when MRI is prescribed and our physician wants to reject the idea of the main physician the patient becomes defensive saying that you are not in place to disregard and reject my physicians recommendation". (P1)

Requisite organizational structure:

Considering the organizational status, and required financial and human recourses in the supervision sector of the insurance organizations are among the other requirements.

"From the perspective of the organizational status we do not have a strong supervision on the insurance organizations" (P9)

"Considering the number of available staff, the number of insured the number of the contractual centers and unfortunately the inappropriate supervision in the country we have very insufficient capability for proper supervision". (P6)

Legal necessities

Defining the necessary regulations for supervision is among the most important necessities of an efficient supervision.

Discussion

The current study is a qualitative study which has been conducted with the objective of investigating the challenges of supervision on the health system from the view point of the insurer. One of the major problems in the insurance organizations of Iran is lack of unified direction of the policies. One of the policy making instruments is having a proper database. (15) The overlap of the statistics on the insured and lack of precise data on the number of insured is another important problem in Iran. (15) The current study emphasizes the universality of the data in the insurance organizations and creating proper connections among the insurance organizations and service providers from the perspective of data as a strategy for controlling financial recourses. Lack of periodical reporting for the sake of recognizing the sources of deviation and not having a mechanized system have been recognized as reasons for the weakness of the financial system in the health sector. (16)

Lack of universal policy making is the reason for not having realistic tariffs in Iran; because the insurance organizations do not follow the same ways and procedures due to various interests regarding the increase in tariffs. (15)

The out of pocket for the patients are divided into two categories of formal and informal; and economical challenges are among the reasons for the increase in the out of pocket. (17) Various studies emphasize on the existence of informal out of pocket. (18-20) Some studies have estimated the amount of informal out of pocket as much as half of the household income. (21)

Regarding the issue of out of pocket, insufficient coverage of the services, induced demands, unrealistic tariffs and bribery payments are known as influential factors. (15)

The findings of the current study recognizes the lack of universal policy making in defining the tariffs between the ministry of welfare and ministry of health, lack of proper supervision from ministry of health and the medical system organization on the obedience from the tariffs on the services from the physicians as a reason for the increase in the informal out of pocket payments from the service provider centers. Furthermore the unrealistic tariffs have been recognized incentive for the service providers for not obeying the defined tariffs and the insurance regulations. Lack of treatment guidelines and induced demands are among the other reasons that influence the increase in the out of pocket. (15)

One of the reasons for having unrealistic tariffs in Iran relates to the direct allocation of the financial resources to the public hospitals which results in unclear ultimate costs of the public hospitals and different tariffs for the public and private sectors. (15) Nasiripour et al. have recognized this issue as an obstacle for improving efficiency, effectiveness and equality in the health system. (22) Therefore correcting the flow of financial recourses in the public sector, providing services and making the tariffs realistic in this sector can help in reducing the inefficiency of the public sector and patients referrals from the public sector to the private sector.

In a study, Ibrahimipour emphasizes the insensitivity of the service providers to costs as a reason for the service providers to encourage providing more services and regards the change of per case payment to per capita as a solution. (15) Nasiripour as well, in a study recognizes a proper payment system as a strategy for preventing waste of resources and providing unnecessary services to the consumers. And in the first level recommends the per capita and fee for services and in the other levels based on the ranking system as fee for service. (22)

The present study recognizes the reason for illogical prescription of the physicians due to the weakness of the supervisory organs and outdated instructions and the supervision procedures and suggest the electronically health instruments in all the cycles of receiving services as a network to exclude insurance notebooks to improve the systematic supervision, establishing a referral system and family physician, the ranking of the service provider organizations and signing contracts with proper tariffs based on each center and based on the costs.

Lack of treatment guidelines and standards is among the major reasons for the weaknesses in the qualitative supervision system of the insurance organizations in Iran. Ibrahimipour et al. consider defining guidelines as the responsibility of the insurance organizations (15), bur based on the findings of this study the insurance organizations in Iran currently do not have the possibility of designing and monitoring the guidelines and believe that approaching this issue requires the participation of all the insurers, Ministry of Health and medical system organization and regard the ministry of health as the main responsible organ for the quality of the providing services.

Lack of supervision on patients referrals in another problem and its main reason is that the family physician system is not comprehensive and universal, and the referring of the physician is the key factor for the next decision of the patient, since the patient is ready to follow the recommendations of the physician even if he has to pay more out of pocket and considers this as a way for making better ties with his physician. (23)

Findings show that creating a goal keeper system can prevent the costs in the health system for up to 6%. (15) Furthermore, the ownership of the profit seeking healthcare corporations by the physicians may result in the increase of the referrals of the patients to these corporations and eventually more costs. (24) The physicians who have diagnostic radiology instruments in their own clinics have had 7 times more self referrals than the ones without these instruments. (25)

Supervision on the insured and supervision on the observance of the tariffs are among the responsibilities of the insurance organization, of course in confronting the violations there is no possibility for nullifying the contract (2), the results of the current study show that due to the non universality, incomprehensiveness of the policy making and unrealistic tariffs even in the public hospitals and specially in the hospitals which are being regulated by the board of trustees, the tariffs on some of the specialized and ultra specialized services are not being observed. But since the contracts are not nullified with them, other tools such as ranking, various tariff pricings and empowerment of the supervision on contracts must be implemented.

One of the instruments for making the quantity of the consumed services logical is using Franchise. (26-27) the results of the studies show that regulating 25% franchise for visiting the physicians has reduced this service for 37%. Furthermore it has been confirmed that the influence of 5 $ franchise payment is 8.3% decrease in the total visits, 3, 3% specialists visits and 10.9% optometrist visits. (24) Of course while regulating the franchise the negative consequences of it such as increase in inequality, inhomogeneous quality of care and inefficiency must be considered as well

Study Limitations

Similar to all qualitative studies, the results of this study is not applicable to other insurance organizations in Iran and other countries. Furthermore, this study has been conducted in one of the insurance organizations of Iran and if other managers from the insurance sector of the country were also included in this study, more comprehensive findings could be achieved.

Conclusion

Universality in policy makings for supervision on service providers is one of the necessities of defining the strategies of supervision in the health sector. Furthermore implementing various strategies requires providing the requisites of that strategy.

Implementing electronically health services and standardizing the services by means of defining treatment guidelines, proper tariffs and ranking of the centers can be considered as efficient strategies of the insurance organizations in supervision on the provided health services. Lack of universality in policymaking is considered as a threat which must be solved by means of the universal insurance funds and unified policy makings in the health sector.

Conflict of interests: None declared.

Acknowledgement: We should thank the managers of studied insurance organization for their kind cooperation with the researchers.

References

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Mohammadkarim Bahadori [1] Hossein Ibrahimipour [2], Ali Farzaneh **

[1] Health Management Research Centre, Baqiyatallah University of Medical Sciences, Tehran, Iran

[2] Health Sciences Research Center, Department of Health and Management, School of Health, Mashhad University of Medical Science, Mashhad, Iran

* Corresponding author: Ali Farzaneh

Address: Health Management Research Centre, Baqiyatallah University of Medical Sciences, Mollasadra Street, Tehran, Iran

Tel: +98.2182482416 | Fax: +98.2188057022 | Email: alifarzaneh87@yahoo.com
Table 1: Themes and subthemes in supervision of health care service
delivery by insurer organizations

Themes              Subthemes

Objective of        --
supervision

Supervisors         --

The supervisee      Non contractual centers, the insured (received of
                    the services)

Subject of          Quality of provided service, induced demands,
supervision         financial resources,

Type of             field supervision, qualitative supervision and
supervision         systematic supervision

Supervision tools   ranking of the service providers, data system,
                    Defining the tariffs, planning, signing contracts
                    and legal tools, direct care, treatment protocols
                    and financial contributions of the insured

the essentials of   The cooperation of the Stakeholders, the requisite
supervision         organizational structure, culture of supervision
                    and legal necessities

Table 2: Role of health system Stakeholders in supervision of health
care service delivery from insurer perspective

      Supervisors         Quality   Prescription   Tariff   Referral
 Supervision function

Ministry of Health          Yes          No         Yes        No
Family Physician            No           No          No       Yes
Insurance Organizations     No          Yes         Yes        No
The Medical council         No          Yes         Yes        No
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Author:Bahadori, Mohammadkarim; Ibrahimipour, Hossein; Farzaneh, Ali
Publication:International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH)
Article Type:Report
Geographic Code:7IRAN
Date:Sep 1, 2012
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