Designing a pragmatic model for strategic purchasing of health services in health insurance companies

Abstract

Purpose The purpose of this paper is to identify the most important factors for strategic purchasing of health services in the health sector by the Iran Health Insurance Company and to provide an applicable model for other similar organizations in developing countries. Design/methodology/approach The present qualitative study was conducted in 2017 to identify the factors affecting the implementation of strategic purchasing of health services in the health sector by the Iran Health Insurance Company and to provide an indigenous and practical model through two phases: semi-structured interview followed by a Delphi process. Findings According to the findings of this study, Ministry of Welfare, Labor and Social Security plays a central role in the strategic purchasing. In addition, this was also approved by the representatives of citizens in communities concerning professional associations, insurance agencies and representative of the Council of Ministers. Model development explored 9 themes and 54 sub-themes. Research limitations/implications Based on the model, most attention has been paid to consumer role and inter-sector leadership of the company with other relevant organizations and systems including other insurance organizations and the welfare ministry. More importantly, the health insurance company should be able to communicate with providers and to choose the best providers, receiving price information through competition in the most appropriate mechanism. Guided by this model, it can strategically buy the best and the most effective services for its insured population. Social implications It might help developing societies to promote their health systems based on targeting the health budgeting and financial constraints so that it is prioritized according to the strategic purchasing criteria and consequently, economic evaluation. Originality/value The linchpins of the present study are as follow: first, the pragmatic model presented in the paper could help developing health systems to overcome the impediment in the implementation progress of strategic purchasing. Second, the model satisfies the need of enough knowledge to apply strategic purchasing in the health system. Third, the indigents have long been given special protection and consideration in the model that has continued to capture the attention of every policy-maker, in particular, developing countries, the portion of which is significant. Fourth, based on this model, attention has been paid to consumer role and inter-sector leadership of organization with other relevant organizations and systems. Fifth, this model could be correspondent for every insurance company in countries with similar developing conditions.

Forty years review of upstream documents of the Islamic Republic of Iran's health sector on strategic purchasing of advanced-expensive medical equipment

“…The potential for a fair contract between the buyer and the service provider has been emphasized in many studies as a strategic purchasing requirement. For example, Reza Pour et al formulated a criterion for the selection of providers by the insurance organization and the ability to select a service provider and its payment mechanism, which are among the main terms of the contract as influencing components of the pragmatic model in purchasing expensive medical equipment (Rezapour et al, 2018). Dehnouyeh et al have identified the existence of a retrospective contractual mechanism between insurance organizations and health care providers as a major problem in the absence of strategic purchasing in Iran (Bastani et al, 2018;Dehnavieh et al, 2016).…”

“…Reviewing the related literature, it seems that strategic purchasing can bring many benefits to health care systems. For instance, according to Rezapour et al (2018), if national purchasers (the health insurance companies) are able to communicate with providers and to choose the best providers, receiving price information through competition in the most appropriate mechanism they can strategically buy the best and the most effective services for its insured population (Rezapour et al, 2018). Ogbuabor and Onwujekwe (2018) emphasized that some significant criteria such as strategic vision, participation and consensus, orientation, rule of law, transparency, responsiveness, equity and inclusiveness, effectiveness and efficiency, accountability and intelligence and information as well as ethics should be considered as governance framework principles to purchase strategically (Ogbuabor and Onwujekwe.…”

“…In this regard, one of the most important insurance solutions that are neglected in the health sector is the proper use of tools such as strategic purchasing contracts (Hakimzadeh et al, 2018). Strategic purchasing is considered as an active, evidence-based and continuous seeking of needed health services with a real, competitive and fair price applying the best payment system as the incentives from the best suppliers or providers (Rezapour et al, 2018). The evidence suggests that strategic purchasing has the potential to significantly improve efficiency, equity and quality in the health sector (Patcharanarumol et al, 2018).…”

“…Iranian national upstream documents in health care purchasing A review of the country's upstream documents shows that strategic purchasing debate has always been a requirement in the health service provision, for example under Article 32 (c) of the Fifth Development Plan of the country, a comprehensive health care system based on the primary health care and the focus Fifth Development Plan on family physicians, the system of service classification, strategic purchasing of services, assignment of tenure under Article 13 of the Civil Service Management Act with emphasis on performance-based payment by the Ministry of Health and Medical Education (Rezapour et al, 2018). In addition, under paragraph z of Article 38 of this plan, the health insurance organization is required to comply with the system of referral and classification of services under the policies adopted, to strategically purchase health services from public and non-governmental sectors (Mehralian and Bastani, 2015).…”