A comparative study of hospital services payment mechanism by insurance organizations in some selected countries and devising an appropriate plan for Iran
Notice bibliographique
Résumé
Regarding an increase in the number of insured people and costs of treatment services, insurance organizations encounter problems in paying claims of their contractees. So that a delay in the payment of contractee hospital costs has made them reluctant in accepting and visiting the insured people. In order to compensate their fiscal deficit and prevent its increase, insurance organizations in Iran have restricted their commitments in front of insured people. Besides, they have increased the amount of money (franchise) paid by patients. These organizations believe that the difference between the income and costs of treatment services is because of low insurance cost per capita and increase of costs of treatment services. This research is an applied study and its administration is descriptive and is conducted as a comparative study. Data are collected from the study of documents, books, articles and information banks. The proposed plan in devised considering the opinions and comments of qualified experts in health care sectors and findings of other countries under this study. The Delphi technique is used to test the mentioned plan. Tariffs for treatment services and medicines are usually determined in Canada, Germany, Japan, France, England and South Korea based on fixed prices and calculated profit, and hospital activities are made in agreement with bazaar system. However, the tariff in public sectors is determined in Islamic republic of Iran, Pakistan and Turkey regarding the governmental subsides and below the fixed prices. Insurance organizations are more influencing in countries of Canada, Germany, France, South Korea, Japan and England in comparison with Iran, Turkey, Pakistan and Indonesia and play more powerful role in determining different tariffs. Definite paying of claims in contractee hospitals in Germany, England, Indonesia, South Korea, Japan and Canada lasts at most two months, but it is done with great delay in Iran. Insurance organizations in countries under our study employ control methods such as setting reference systems of patients, family physician, determining commitment area and the patient portion, and penalizing and nullifying contract of hospitals. Based on proposed plan in this study, tariffs are determined considering opinions of users in homogenized diseases' groups, hospitalization costs, and the features of different areas. Besides, factors such as fixed prices of hospital services and use pattern of treatment services for insured people affect the proposed plan. The proposed plan is applied in both direct and indirect treatment and the independence of insurance organizations from the government and providers of treatment services increases the usefulness and efficiency.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,002 | 0,006 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,003 | 0,004 |
| Études des sciences et des technologies | 0,001 | 0,001 |
| Communication savante | 0,001 | 0,001 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,002 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».