Estimation of financial burden caused by referral system non-adherence by outpatients in Iranian health system

Abstract

Abstract

Introduction: Benefiting from family physician services and adherence to a referral system ensures the integrity and continuity of care that reduces the need for specialized services. Aim: The aim of this study was to estimate of financial burden caused by referral system non-adherence by outpatients in Iranian health system. Methods and Materials: This is a quantitative, cross-sectional study. Rural and urban population of 4 provinces including East Azarbaijan, Fars, Mazandaran, and West Azerbaijan were studied and the burden of visit, medication, laboratory test, and medical imaging services were extracted over a 1-year period. The associated financial burden was estimated by calculating the fraction attributable to self-referral in rural samples and the fraction attributable to implementation of family physician program in urban areas. Estimates were generalized to the entire population insured by the health insurance organization and predicted for the next two years. Results: The overall self-referral rate in the rural population was 36.8%. The utilization rate of visit, medication, laboratory test, and medical imaging in the self-referral group were significantly higher than the referral group (p <0.05). In urban samples, the utilization rate of visit, medication, and laboratory test in Fars and Mazandaran provinces were significantly higher than East Azarbaijan and West Azarbaijan provinces (p <0.05). The calculation of the fraction attributable to self-referral showed that 32% of the financial burden of rural samples was due to self-referral. In urban samples, 60.4% of outpatient referral costs were due to the implementation of the urban family physician program. Conclusion: More than one-third of the rural samples were self-referral. In the rural population, utilization rate were higher in referral groups than self-referral ones. Therefore, it is necessary to implement effective interventions in accordance with extracted reasons of self-referral to reduce it’s prevalence. Public awareness of the consequences of the self-referral is also important. Finally, given the increasing financial burden of outpatient services following implementation of urban family physician program, it is imperative that any decision to expand the program be made through considering its financial implications to ensure stability in future plans and resource sustainability.