Table 2.

Health Care Services Purchasing challenges of Iranian Insurance Companies

Themes	Sub Themes
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