فهرست مطالب sajad ramandi

Monitoring the performance of hospitals is one of the most important actions of the insurer in order to cost control. The aim of this study was to investigate the effect of Monitoring in reducing the average length of hospital stay through the control of services and unnecessary hospitalizations in hospitals contracted supplementary insurance company.

this study is a semi-experimental type, that was conducted using before and after design in 22 provinces. presence at the 15,721 patient’s bedside in 103 hospitals, insurance experts examined the medical records and the treatment process using a researcher-made questionnaire. According to the initial results, supervisory interventions were carried out in two ways: “ hospital discharge “ or “ non-approval of medicine and consumables “. before and after data of the study were analyzed through paired t-test using R-Studio version 9.2 software.

According to the findings, 85.3% (n=13,401) of the hospitalizations did not require supervisory intervention and 14.7% (2320 patients) had supervisory interventions. Based on the ownership, the highest rate of unnecessary hospitalization was in private hospitals (80درصد; (n=1850)) and the highest rate of monitoring interventions was related to discharge from the hospital (46% of the financial savings of monitoring interventions). Non-approval of medicine and consumables has been the most frequent (1,102; 47.5%). The average length of stay and standard deviation were 23.74 and 48.58 before the intervention and 10.69 and 12.14 after the intervention.

continuous monitoring of hospitals, especially using the appropriateness evaluation protocol, will significantly reduce the average length of stay of patients.

Insurance plays a significant role in health systems financing. The existence of multiple risks has led to an increase in the costs of insurance organizations.

The study aimed to identify cost management strategies in health insurance.

A scoping review was conducted by focusing on published studies in Farsi and English languages in the field of health insurance through the world by the end of June 2020. Search was performed using valid keywords in PubMed, Scopus, Web of Science, SID, Magiran, Google and Google scholar search engines. A list of credible sources and journals were assessed, too. Finally, 51 articles fulfilled the inclusion criteria, were reviewed and analyzed using MAXQDA software.

In total, 97 cost management strategies were identified which were classified into 3 groups: providers, insured people and insurance organizations. Modification of payment methods to providers and monitoring of services provided and medications prescribed in the field of providers, cost sharing, deductible, consumption management and culture building in using services in the field of insured people, strategic purchasing, coverage constraints, internal controls, using risk management and employing specialized personnel were among the most important cost management strategies in the field of insurance internal processes. Other institutions that make policy and oversee the insurance industry will also play a significant role in reducing the costs.

Understanding the solutions to cost control in health insurance helps policymakers and managers to plan and apply corrective interventions and appropriate changes that lead to reduce the costs of insurance companies.

The covid-19 pandemic has affected the health insurance industry in numerous ways.

The present study aimed to examine the impacts of the covid-19 on the referral times of insurance policyholders to hospitals and diagnostic centers throughout the country.

This was a cross-sectional descriptive study conducted on the data collected from a private insurance company. The statistical population included all insured individuals covered by the insurer in 31 provinces throughout the country who have used the services provided in hospitals and other diagnostic centers from March 21, 2019 to September 21, 2019 (1,699,930 insured people), considered as the pre-covid-19 incidence period, and from March 20, 2020 to September 20, 2020 (1,862,657 insured people), as the post-covid-19 incidence period. Data were analyzed using the SPSS and GIS statistical software.

In the 2019 half-year, 10,416,591 medical expense records have been filed in the country, which decreased by 17.1% in the same period in 2020 to 8,633,613 records. The average referral times in the pre-covid-19 period was 7.02, which decreased by 32.9% during the post-covid-19 period, falling to 4.71.

The overall frequency of referrals to receive all services covered by the insurer, including visits, medicine, hospital services (general surgeries), and laboratory services in the post-covid-19 period decreased significantly, compared to a similar period in the previous year. It seems that in many different provinces, non-emergency patients avoided referring to healthcare centers and unnecessary visits to medical centers. Moreover, the number of general surgeries decreased because of the therapists’ cautiousness and the changing behaviors of the patients, making diagnostic and medical services more real.

 Fraud has direct and indirect effects on insurers and insured. Due to the nature of the insurance industry, the decisions of managers and officials will not achieve the desired result without conducting sufficient research. Therefore, this research has studied and investigated fraud in complementary health insurance and ways to deal with it through a practical approach.

In this regard, by comparative study of successful experiences of leading countries in the fight against fraud in the field of complementary health insurance and also interviews with experts in this field, processes, underlying factors and effects of fraud in complementary health insurance, obstacles and challenges in these processes was identified. Finally solutions were provided to prevent and control this phenomenon. The interviews were uploaded in text format to MAXQDA software and then analyzed.

In total, 34 factors that cause fraud in the complementary health insurance industry have been identified and divided into six groups of “Rules and Regulations”, “Process Solutions”, “Technology Solutions”, and “Solutions related to institutions and organizations, “Educational Strategies” and “Cultural Strategies”. Findings showed that among the underlying factors of fraud, the most influential factor was “inefficiency of central insurance of Iran” and “ignoring the phenomenon of insurance fraud.

If insurance companies design and launch comprehensive and integrated systems, it will be possible to prevent a high level of fraud.

This study was conducted to compare the main performance indicators of Hasheminejad hospital before and after implementing PPP model.

This cross sectional study was conducted in Iran in 2015. Performance indicators of Hasheminejad hospital, the only Iranian unit that implemented PPP model, were applied. Data were collected based on a researcher-designed checklist after ensuring its validity and reliability. Data were analyzed applying SPSS21, and the Shapiro-Wilk test was used to examine the relevant data normalization. After confirming the normality of the data, descriptive statistics and paired t test were used to analyze the data at a significant level of 0.05.

Dramatic variations were observed in the status of the studied indicators after the implementation of PPP in Hasheminejad hospital, and the changes were statistically significant in all these indicators (p<0.05).

It seems that implementing PPP in Hasheminejad hospital can be considered as a successful experience in Iran’s health sector. The significant improvement in this hospital’s performance indicators can emphasize the effective role of PPP in administration of this hospital. However, service quality and patient satisfaction should be considered as qualitative indicators, along with the present quantitative indicators because better judgment about the changes was achieved in this hospital after implementing PPP.