Volume 21, Issue 81 (8-2021)
refahj 2021, 21(81): 129-166 |
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Research code: 20991992
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karimi A, Mohammadi E, Mohammadi M. (2021). Designing a Model for Providing Supplementary Health Insurance in the Social Security Organization. refahj. 21(81), 129-166.
URL: http://refahj.uswr.ac.ir/article-1-3616-en.html
URL: http://refahj.uswr.ac.ir/article-1-3616-en.html
Keywords: Insurance, Basic health insurance, Supplementary health insurance, Social Security Organization, Direct treatment of the organization.
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Extended Abstract
Introduction: In order to help people with the disease condition and arising from costs, various health insurance plans are provided as a complementary, separately by different insurers. The insured people covered by basic insurance are forced to buy supplementary insurance services from other insurance funds due to the gap in access to full health care. This action, in addition to the impossibility of most insured persons and pensioners to receive supplementary insurance services and obligations (due to the provision of the said insurance in groups and the impossibility of providing supplementary insurance for insured persons working in self-employed jobs with group supplementary insurance conditions, except in some insurance companies, subject to higher premium payments), confuse and waste the time of the insured to apply to different insurance companies (in order to establish supplementary insurance or receive medical expenses), with different insurance premiums and rates. (the amount of liabilities and the premium rate depends on the number of members of the applicant group). In addition to the above, the Social Security Organization, spends a lot of money on free medical services (without obtaining a franchise from the insured) in the direct treatment department (medical centers of the organization), unfortunately due to the impossibility of providing this type of service in the whole country. Many insured and retired people living or working in small towns and areas without the organization’s medical facilities cannot enjoy this benefit, and this injustice in the distribution of insurance obligations and free medical care has led to their dissatisfaction. So today, despite all the benefits that social insurance has, they alone are not able to meet the needs of all members of society; therefore, it is necessary to have a multi-layered social security system (in the treatment sector) in the organizations implementing basic insurance, especially in the Social Security Organization as the largest organization providing basic insurance services and the organization that most single and uninsured employers (without conditions) having supplementary group insurance, covered, designed, and implemented, each layer of which meets one of the income groups of the society and can meet the increasing expectations of the society from the social security system. The purpose of this study is to identify the consequences of providing supplementary insurance in the Social Security Organization of Iran to solve the health insurance problems of the target community as well as the organization itself in this area.
Method: this research is an applied research with a qualitative approach, based on a data-driven approach with a focus on semi-structured interview. In the qualitative stage, the integration between opinions and theoretical foundations according to the desired problem has been achieved, and in the quantitative stage, these results have been tested to confirm and generalize the findings. Its statistical population includes managers and experts in the field of health insurance in the country’s social security organization, whose sampling was purposeful and continued in the qualitative section until the categories reached saturation (15 samples). In this study, the criteria of validity, transferability, reliability, and verification were used to validate the qualitative part and Cronbach’s alpha was used for the quantitative part.
Findings: In this research, the interviews were examined line by line using content analysis and based on the similarities, concepts, and commonalities between open source, concepts, and categories were identified. Through open coding, 225 concepts were extracted based on expert opinion. Based on axial coding, these concepts were classified into 42 sub-categories and the categories were centered around 17 main categories. This process is presented in 8 separate tables in the research findings section. Then an open coding category (simultaneous provision of basic insurance and treatment supplement) became the main phenomenon in the center of the process and main categories under the headings: causal factors (the huge costs of medical services of the organization and its target community, the lack of fairness in the coverage and obligations of health insurance, the lack of focus on basic and supplementary health insurance and the lack of a clear boundary between them), bedrock factors (high demand due to the welcome of the target community and the exclusive conditions of the organization, the exclusive capacity of the organization to implement the plan and the possibility of providing other conditions for implementation), intervening factors (lack of transparency in Legal and financial scope of basic and supplementary health insurance and prevention of competitors and some stakeholders), strategies (providing supplementary health insurance by the Social Security Organization with a clear border and financial independence, reforming and improving the organization’s health care processes, expanding supplementary insurance umbrellas and discounts its premiums and consequences (satisfaction of the insured, creating competition in the health insurance market, improving the financial situation of the organization, expanding the health insurance umbrella and other positive changes in the organization) were related to it and the final model was drawn.
Then, according to the confirmation of the assumptions in the qualitative section, we used exploratory factor analysis and one-sample t-test to evaluate the validity and reliability of the research questions. According to the fit indicators of the model, the data of this research had a good fit with the factor structure and theoretical basis of the research and this indicated that the questions were in line with the theoretical structures.
Discussion: The Social Security Organization, considering the causal factors and issues and problems in the field of health insurance, especially the treatment costs of the organization and the target community, can be based on its unique potential and actual capacities (including the presence of experienced and capable manpower in this field. Necessary and sufficient facilities and equipment, existence of real estate medical centers, covered population, communication and access to information of more than half of the country’s population, financial capacity, electronic and in-person insurance services, high competitiveness in insurance, structure and appropriate culture, etc.) in order to implement the mentioned plan. Besides, by implementing this plan and providing supplementary health insurance along with basic insurance, the three benefits of profitability, reducing medical costs, and justice in the distribution of health insurance obligations for the organization, as well as reducing the purchase price of supplementary insurance, satisfaction, removing some restrictions, and reducing and bringing medical expenses to the target community (insured and pensioners).
Ethical Considerations
Authors ’contributions:
The authors contributed effectively to this article.
Funding:
This article does not receive any financial support for its publication by any entity or organization.
Conflicts of interest:
In the present study, the authors showed no conflict of interest.
Acknowledgments:
In this article, in addition to observing the principles of professional conduct, all rights related to the sources cited are respected and the references are carefully cited.
Introduction: In order to help people with the disease condition and arising from costs, various health insurance plans are provided as a complementary, separately by different insurers. The insured people covered by basic insurance are forced to buy supplementary insurance services from other insurance funds due to the gap in access to full health care. This action, in addition to the impossibility of most insured persons and pensioners to receive supplementary insurance services and obligations (due to the provision of the said insurance in groups and the impossibility of providing supplementary insurance for insured persons working in self-employed jobs with group supplementary insurance conditions, except in some insurance companies, subject to higher premium payments), confuse and waste the time of the insured to apply to different insurance companies (in order to establish supplementary insurance or receive medical expenses), with different insurance premiums and rates. (the amount of liabilities and the premium rate depends on the number of members of the applicant group). In addition to the above, the Social Security Organization, spends a lot of money on free medical services (without obtaining a franchise from the insured) in the direct treatment department (medical centers of the organization), unfortunately due to the impossibility of providing this type of service in the whole country. Many insured and retired people living or working in small towns and areas without the organization’s medical facilities cannot enjoy this benefit, and this injustice in the distribution of insurance obligations and free medical care has led to their dissatisfaction. So today, despite all the benefits that social insurance has, they alone are not able to meet the needs of all members of society; therefore, it is necessary to have a multi-layered social security system (in the treatment sector) in the organizations implementing basic insurance, especially in the Social Security Organization as the largest organization providing basic insurance services and the organization that most single and uninsured employers (without conditions) having supplementary group insurance, covered, designed, and implemented, each layer of which meets one of the income groups of the society and can meet the increasing expectations of the society from the social security system. The purpose of this study is to identify the consequences of providing supplementary insurance in the Social Security Organization of Iran to solve the health insurance problems of the target community as well as the organization itself in this area.
Method: this research is an applied research with a qualitative approach, based on a data-driven approach with a focus on semi-structured interview. In the qualitative stage, the integration between opinions and theoretical foundations according to the desired problem has been achieved, and in the quantitative stage, these results have been tested to confirm and generalize the findings. Its statistical population includes managers and experts in the field of health insurance in the country’s social security organization, whose sampling was purposeful and continued in the qualitative section until the categories reached saturation (15 samples). In this study, the criteria of validity, transferability, reliability, and verification were used to validate the qualitative part and Cronbach’s alpha was used for the quantitative part.
Findings: In this research, the interviews were examined line by line using content analysis and based on the similarities, concepts, and commonalities between open source, concepts, and categories were identified. Through open coding, 225 concepts were extracted based on expert opinion. Based on axial coding, these concepts were classified into 42 sub-categories and the categories were centered around 17 main categories. This process is presented in 8 separate tables in the research findings section. Then an open coding category (simultaneous provision of basic insurance and treatment supplement) became the main phenomenon in the center of the process and main categories under the headings: causal factors (the huge costs of medical services of the organization and its target community, the lack of fairness in the coverage and obligations of health insurance, the lack of focus on basic and supplementary health insurance and the lack of a clear boundary between them), bedrock factors (high demand due to the welcome of the target community and the exclusive conditions of the organization, the exclusive capacity of the organization to implement the plan and the possibility of providing other conditions for implementation), intervening factors (lack of transparency in Legal and financial scope of basic and supplementary health insurance and prevention of competitors and some stakeholders), strategies (providing supplementary health insurance by the Social Security Organization with a clear border and financial independence, reforming and improving the organization’s health care processes, expanding supplementary insurance umbrellas and discounts its premiums and consequences (satisfaction of the insured, creating competition in the health insurance market, improving the financial situation of the organization, expanding the health insurance umbrella and other positive changes in the organization) were related to it and the final model was drawn.
Then, according to the confirmation of the assumptions in the qualitative section, we used exploratory factor analysis and one-sample t-test to evaluate the validity and reliability of the research questions. According to the fit indicators of the model, the data of this research had a good fit with the factor structure and theoretical basis of the research and this indicated that the questions were in line with the theoretical structures.
Discussion: The Social Security Organization, considering the causal factors and issues and problems in the field of health insurance, especially the treatment costs of the organization and the target community, can be based on its unique potential and actual capacities (including the presence of experienced and capable manpower in this field. Necessary and sufficient facilities and equipment, existence of real estate medical centers, covered population, communication and access to information of more than half of the country’s population, financial capacity, electronic and in-person insurance services, high competitiveness in insurance, structure and appropriate culture, etc.) in order to implement the mentioned plan. Besides, by implementing this plan and providing supplementary health insurance along with basic insurance, the three benefits of profitability, reducing medical costs, and justice in the distribution of health insurance obligations for the organization, as well as reducing the purchase price of supplementary insurance, satisfaction, removing some restrictions, and reducing and bringing medical expenses to the target community (insured and pensioners).
Ethical Considerations
Authors ’contributions:
The authors contributed effectively to this article.
Funding:
This article does not receive any financial support for its publication by any entity or organization.
Conflicts of interest:
In the present study, the authors showed no conflict of interest.
Acknowledgments:
In this article, in addition to observing the principles of professional conduct, all rights related to the sources cited are respected and the references are carefully cited.
Type of Study: orginal |
Received: 2020/04/1 | Accepted: 2021/05/11 | Published: 2021/09/14
Received: 2020/04/1 | Accepted: 2021/05/11 | Published: 2021/09/14
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