The behavior of basic health insurance Organizations after the implementation of Relative Value of Health Services book in Iran: A qualitative study.

Abstract

Background: Since approximately 45% of basic health insurance (BHI) resources are spent and distributed based on the Relative Value of Health Services (RVHS) book, therefore, any revision in this book will most probably affect the behavior of health insurance organizations. The present study was prospected to determine the effect of revising RVHS on behavior of BHI funds as the main providers of treatment resources. Methods: This is a qualitative study in which data were analyzed using content analysis method. Semi-structured interviews were used to gather the required data. 27 interviewees were chosen using purposive sampling method. Finally, MAXQDA software was used to analyze and code the data. Results: According to the results, revision of RVHS influenced the behavior of health insurance organizations. The most important changes in the behavior of health insurance funds involved the following: formation of a committee for cost management and handling the insurance documents, creating a uniform coding system for health services, redesigning the handling process of documents, increased share of insurance funds from health expenditures, with 300 new services added to basic package and revising the package according to the new version of the book. Furthermore, the rest of the changes included in the global payment method based on the new book, delay in paying claims, increased deductions based on the payment of expensive services on treatment protocols, holding periodic training courses, and teaching the new book as well as the procedures for handling the documents. Conclusion: With regard to the revision of RVHS and considering the incremental approach in revision of relative values, the increased claims of health services delivery centers and delay in payment of these claims were the most important changes in the behavior of health insurance funds. Health policy makers can overcome such issues and provide proper financial conditions through reduction of conversion factor and mobilization of resources. Such policies will open the space for best management of the behaviors affected by revision of relative values.