Table 2 Health Care Services Purchasing challenges of Iranian Insurance Companies

Policy making Challenges

External and political forces on insurers for contracting with providers

ambiguities in strategic purchase policies

lack of regulations, evaluation instructions and ranking providers of services

Lack of purposefulness of subsidies for purchasing agencies

lower per capita income in those under medical services coverage

High rate of out of pocket because of low coverage of services

great number of households facing catastrophic costs especially in outpatient services

Executive Challenges

lack of effective referral system based on family physician in the whole country

different prices for the same service by insurance organizations

heterogeneous distribution of medical experts in different parts of the country

lack of realization of universal health coverage

lack of exclusive use of power of purchase (use of inactive purchase).

Intersectional Challenges

Low level of relations between insurance organizations and scientific& expert associations

lack of competition among insurance organizations

lack of clarity in the relationships among producers of health services, providers, policy-makers, supervisor and purchaser of services in the country

the existence of supplementary insurances which buy basic services several times that of the original price

Natural Challenges

The existence of high induced demand in outpatient and drug sections

Existence of spiral of death because of adverse selection outbreak

Radar syndrome because of the lack of continuity in offering services level

Cream scheming in some insurance companies

Legal Challenges

Lack of an exact and scientific basis in assessing insurance rights and tariffs

The high range of inpatient in patient costs

Persist on implementing the governmental model of family physician and referral system

lack of regulations and instructions of health care delivery

Informational Challenges

lack of a comprehensive information bank

lack of sufficient familiarity with successful health systems experiences in strategic purchase of health services