Evaluation of efficiency enhancement in Iran Health Insurance Organization: a policy brief for pharmaceutical cost containment

Summary Background Rapid increasing pharmaceutical spending on the one hand and limited budgets on the other hand are problems confronting health expenditure. Policymakers have realized that without the negative effect on quality of care, they can control pharmaceutical spending. Methods The study methodology involved a targeted review of the literature on cost containment policies, their implementation issues, advantages, and disadvantages. Then, all proposed strategies were investigated through interviewing insurance experts. Finally, these policies were prioritized with respect to their adherence to the main issues of performance. Results Considering implementation costs, durability, and feasibility, six policy options have been proposed as follows: stopping non‐prescription medicine reimbursement, using a tiered‐coinsurance mechanism, establishing prescription‐guidelines, implementing cost‐effectiveness‐studies, employing scientific bargaining methods, and using different levels of reference pricing. Conclusions Despite the possibility of some physicians' resistance, preparing prescription guidelines and their gradual enforcement is considered as the first choice. Next, it seems that reference pricing is the most feasible policy. It is in spite of some confusion and dissatisfaction, which might arise due to lack of knowledge and an increase in out‐of‐pocket expenses. Then, all pricing methods, including cost‐effectiveness studies and internal and external reference pricing, should be used as negotiation leverage with pharmaceutical companies. Afterward, stopping non‐prescription medicine reimbursement should be implemented by good media communication in view of its effects on a wide range of population. Finally, implementation of tiered‐coinsurance mechanism should be considered with special attention to some inherent technical complexity.