ارزیابی مقایسه‌ای روش‌های پرداخت کارانه و سرانه در هزینۀ خدمات بیمه‌ای خانوار: چهارچوب نظری و کاربرد

Background and Objectives: Payment methods of fee-for-service and per capita affect financial incentives of service providers differently, and hence, can produce excess or shortage of healthcare services and expenses for the health insurance organization and the insured. This study assessed expenses of healthcare services for households in the Iranian provinces regarding the payment methods of fee-for-service and per capita for the same indicator value of the insured satisfaction. Materials and Methods: In this study, the proposed assessment of the payment methods of fee-for-service and per capita was carried out using the record data from the Iranian health insurance organization and the optimizing model of compensated demand for healthcare services. In this model, the contract between the insurance organization and the insured could be specified by a certain level of expenses and indicator value for users’ satisfaction. Hence, the demand for health insurance services could be determined independent of the supply of services by healthcare providers. Results: It was shown that at the same indicator value of satisfaction in the two payment methods in 1391, the average expenses of household for sum of outpatient and inpatient services for per capita payment method in 22 provinces of 31 are less than the expenses for fee-for-service payment method. Conclusion: Providing a contract between the insurance organization and the insured that represents minimum expenses for insurance services at a certain value of satisfaction indicator could be considered a plausible target for the both sides, irrespective of the providers’ incentive. This helps the insurance organization and the insured to choose the payment method that minimizes the difference between average unit cost of insurance services against the average cost in the market for health services, or minimizes the risk of healthcare costs.