This study revealed the challenges of the payment reduction directive for hospitalized patients in public hospitals from an economic perspective.
Some of the challenges in the first 3 months are not mentioned in the 1-year period interview indicating that they might be resolved. The most important of them is coordination of insurance companies, due to the fact that in the first few months,, some insurance companies decreased their obligations as reported by the participants.
On the other hand, in the 1-year period interview, some new challenges were added. Insurance companies experienced higher expenditures, as their obligations extended with initiation of the plan. Increased tariffs related to the third phase of the plan, however, created new challenges for insurers, which play important roles in this directive. They believe that because new tariffs are higher than before, they should pay more, without any reliable financial resources. Furthermore some outpatients who cannot afford the costs might be hospitalized instead and therefore the rate of hospitalization increased.
The most important complaint of hospitals in this time was delay in subsidy payment. Delay in personnel payments is another financial challenge associated with late subsidy payment. One of committee officials believes that the challenge of budget deficit has resulted from additional obligations, including expensive drugs and equipment.
There are also some questions, which have remained unchanged. The most important of them was how long the budget for the plan is going to be paid? Increasing delay on budget payment has escalated this concern. Governments’ expenses are increasing and according to the interviewees, this plan, while focusing on patients, has incurred numerous costs with few cost control mechanisms. Hospitals suffered from worn-out equipment and facilities. Surge of patients referring to hospitals for therapy exacerbated this problem. Thus, improving infrastructures is of greater importance.
Maziar Moradi-Lakeh et al. in their research titled “Health Sector Evolution Plan in Iran; equity and sustainability concerns” concluded that securing financial sources and fairness of the financial contribution to the new programs are the main concerns of policy-makers. Healthcare providers’ concerns (as powerful and influential stakeholders) potentially threat the sustainability and efficiency of the plan. Previous experiences on extending health insurance coverage show that they can lead to a regressive healthcare financing and threat financial equity. To secure financial sources and to increase fairness, the contributions of people to new interventions should be progressive by their income as well as wealth to increase sustainability of the reform programs (
4). Researcher’s focus on results of “continuing of financial plan”, “limited financial resources and allocations”, and “volatile financing and following the goals along with permanent injection of financial resources”, which are consistent with the findings of the study above.
Kiaei et al. examined the viewpoint of hospital managers regarding the recent health care reform in teaching hospitals. As they said, more than half of the administration staff stated that this plan was not successful in the decreasing payment rate (
3), which is not consistent with this study, due to the fact that our study period is wider than theirs.
Viroj Tangcharoensathien investigated the challenges facing realization of public health insurance within implemented reforms in Southeast Asia. Results indicated that Laos and Cambodia were the 2 countries with limited and poor resources, which relied on health equity funds to service the poor and faced 2 major challenges of reliable investment as well as identification of qualified poor people in expanding public health insurance (
5). In the present study, high dependency of health insurance system on government resources, non-cooperation among insurance companies, and their complaints about ambiguities regarding the resources of compensating tariffs were some of the problems with insurance and consequently realization of public insurance coverage.
Shanlian Hu studied challenges and opportunities of reform in payment methods for healthcare in China. Results indicated that China should develop and establish more powerful measures for expenses and fundamentally rebuild the payment system of providers to be successful. As long as Chinese providers are paid based on FFS (Fee-For-Service), increased costs will undermine (
6). This research also presented irregular increasing costs and dependency of continuing plan to governmental sources as important challenges.
Reshani et al. reviewed the challenges of HTP in a review study. Their results showed that this plan was very costly and has a high dependency on economic conditions; it does not have a road map and was inconsistent with macro policies of our country (
7). In the present study the results of “increased government expenditures” and “following the goals along with permanent injection of financial resources” are consistent with the above study.
Khammarnia et al. in their research, review the challenges of HTP from viewpoint of experts in health system. Lack of sustainable resources for this plan was one of the presented challenges that are in accordance with our research.
We have some limitations in this study:
1- Planning and the timing of interviews with participants given the high workload created many restrictions for us.
2- In some cases, the interviewees did not allow audio recording, therefore we had to make notes during interviews
3- A few researches have been done in this area yet, thus, there were some problems when comparing our results with others. We had to use the articles that were financing reform in health sectors.
Finally, the present study found increased costs and continuous dependency of the plan of government resources as important barriers to the continuation of the plan, which require more attention. The pay for the performance plan started a year after the initiation of payment reduction directive and it is said to be closer to justice.
Finally, the present study found increased costs and continuous dependency of the plan of government resources as important barriers to the continuation of the plan. The pay for performance paying mechanism is a new way, which started a year after the initiation of payment reduction directive and it is said to be closer to justice.
The HTP was implemented with a particular focus on financial protection. An important goal of inpatient payment reduction directive is financial protection of people that is so desirable but very costly. Challenges trends over times show that some part of challenges are changing. For example, 3-months after the onset of HTP coordination of insurances was highlighted, while after 1year, insurance payment delay has become important.
Generally, challenges interact with each other and could be avoided just by appropriate planning.
The most important part of the problems probably belong to the challenges, which were constant on both times, as the continuation of the plan budget and increased government expenses. Therefore considering the experts emphasis on continuing the financing plan, the sheer injection of financial resources cannot be a proper solution, due to the fact that it may raise future expectations. Thus, the government should forecast sustainable resources to reduce future challenges.
HTP, like other plans, has both advantages and challenges. Although after implementation, the outcomes of plans would be more apparent, it would rather avoid future challenges by mitigating preparations at the time of planning. Using opinions of individuals involved in the plan at different levels (from university to hospitals) can helps overcome the challenges and minimize the criticisms.
Implication for health policy makers/practice/research/medical education: The results of this study can help policy makers remove barriers and lead to a better implementation of this plan. The variety of the participants’ views will also be important for the officials.