Referral Burden and Cost of Outpatient Care of Patients Covered by the Rural Insurance Fund before and after the Implementation of Electronic Referral System in Golestan Province

Abstract

Background: Part of the major health costs is related to outpatient care. Since the costs of diagnosis and treatment are increasing rapidly and increasingly, this study was conducted to determine the referral burden and cost of outpatient care of patients covered by the Rural Insurance Fund before and after the implementation of the electronic referral system in Golestan province. Methods: This was a cross-sectional and descriptive study conducted based on the information collected from the specialized clinics of all hospitals and offices of specialized and sub-specialized physicians, imaging centers, laboratories, physiotherapy, radiotherapy, and pharmacies in public and private sectors of Golestan province in the first 6 months of 2017 and 2016 . The study was a census and included the information of all patients covered by the Health Insurance Fund who referred to the second level to receive services. To collect the required data, the existing information systems and documents of the General Directorate of Health Insurance and Excel software were used. Results: The number of visits to the specialists in the public and private sectors decreased by 23.2 % and 32.6 % in the first 6 months of 2017 compared to the same period in 2016 in all funds and rural funds, respectively. The number of visits to the specialists in the private sector decreased by 53.2% and 93% in the first 6 months of 2017 compared to the same period in 2016 in all funds and rural funds, respectively. The cost of visits in the public and private sectors decreased by 23.6 % and 48 % in all funds, respectively. In rural funds, the costs reduced by 30.6 % and 91.2 % in the public and private sectors, respectively. Conclusion: According to the results, the capacity of electronic health records and the continuation of services to patients covered by family physicians should be improved throughout the country. Consequently, the unnecessary costs will be reduced, as one of the important goals of the referral system.

Keywords

• referral
• ambulatory care
• insurance
• drug costs