Discussion the Master’s Degree thesis, “Perceptions of healthcare providers toward the new Iraqi health insurance plan: a mixed method study“, by Hayder Naji Sameer and the supervisor, Dr. Ali Azeez Al-Jumaili, in the Clinical pharmacy Department. Health insurance is defined as an insurance system that covers medical expenses by a third party. The Iraqi Health Insurance Law (IHIL) has been approved for 2021. Most insured patients should pay a co-insurance of 25% for prescriptions, lab tests, X-rays, and medical dental services. They also should pay 10% of the physician visit fees. The Health Insurance Authority (HIA) is a governmental entity that regulates Iraqi health insurance. The insurance network can include healthcare providers (HCPs) from both the private and public sectors. Study objectives: The aims of the study were to explore HCPs’ insights toward the impact of prospective implementation of the national health insurance program on patients, HCPs, and the Iraqi health system in addition to identifying the potential challenges facing its implementation. Methods: This was an exploratory mixed-methods study where phase 1 was qualitative (semi-structured face-to-face interviews) and phase 2 was quantitative (an electronic survey). The interviews were conducted with Iraqi specialist physicians and pharmacists who had experience in the public and private healthcare sectors. The interview guide included open-ended questions about the impact of the Iraqi Health Insurance Program (IHIP) on patients and HCPs at three levels: quality of services, costs, and frequency of visits. Potential challenges facing the implementation of IHIP were also discussed. The Interviews were conducted in six provinces from April to September 2022. Thematic analysis was used to analyze the interview findings and generate themes and subthemes. The interviews lasted between 20 and 45 minutes. In the quantitative phase, an electronic survey (English and Arabic versions) was developed and posted on Facebook medical groups twice weekly during September 2022. It consisted of five parts: the perception of HCPs regarding the IHIL, the effect of the plan on insured people, HCPs, and the healthcare system. In addition, potential barriers facing the program’s implementation and their recommendations for proper implementation of the IHIP. The multiple linear regression analysis was used to determine the factors influencing HCPs’ support for the IHIP. Results: The phase 1 (qualitative) recruited 26 physicians (22 men and 4 women) and 21 experienced pharmacists (16 men and 5 women) until the saturation point was reached. The majority of the participating HCPs (16 physicians and 20 pharmacists) were aware of the IHIL. All the physicians and pharmacists were supporters of the health insurance implementation. Most participants believed that the IHIP would enhance the quality of services by creating competition among HCPs. In addition, most of them believed that the prospective program would enhance affordability and accessibility to private health services. The potential challenges facing the IHIP implementation may include mismanagement, convincing people having private businesses to join the program, potential delays in the payment to HCPs, the provision of comprehensive medical services to insured people, patient moral hazard (overuse of healthcare services), provider-induced demands (ordering unnecessary tests/ services), and difficulties in claims processing. In quantitative phase, 508 HCPs completed the survey (57.1% men and 42.9% women) from 16 provinces and most of them were pharmacists (65%) and physicians (19.3%). Only one-third of the participants (32.3%) were aware of the IHIL, and 60% of them supported its implementation. In addition, 64.3% of the participants were interested to be part of the IHIP. More than half of the surveyed HCPs (56.3%) believed that the program would improve the quality of services, and according to 58.2% of participants, the program would adopt new technologies. The majority of the HCPs (64.3%) confirmed that the program would improve access to private services and increase the income of HCPs’ who would sign a contract with HIA. In addition, 76.4% believed that the IHIP would decrease the financial burden on the insured people. One other hand, 62.6% of the participants believed that co-insurance would decrease the workload on HCPs and also 74 % of them confirmed that the family doctor would reduce the workload on specialists. In addition, 79% of participants agreed that the program would put more burden on the Iraqi health system if it was not implemented properly. They expected there would be several potential challenges facing the IHIP, which are mismanagement (82.7%), patient moral hazard (51.2%), provider-induced demand (60%), delay in the reimbursement process (62.8%), and inadequate number of registered medicines to cover the prescriptions of insured individuals (48.2%). The majority (78.6%) agreed that the program should be piloted in one or few provinces, and 87.6% confirmed that electronic health records (EHRs) should be used to facilitate the documentation and submission of medical bills to HIA. According to 73.4% of them, HIA should hire an international team to help in the processing of claims. Conclusions and recommendations: The program has several potential advantages, including the ability to enhance the quality of healthcare services and subsidize service fees. Thus, the program should be well-studied before being implemented at the national level. It needs to be piloted in a few provinces to identify and address any difficulties and technical problems. An electronic health system must be adopted to facilitate transferring data to the HIA. Hiring international experts to help manage medical claims is pivotal to avoid delays in processing. Finally, the HIA needs to raise the awareness of HCPs and people about the program.
