How Much of Social Security’s Treatment Costs Do Cancer Patients Account For?

The Social Security Organization has so far identified 817,000 special and difficult-to-treat patients. Although they make up less than one percent of insured patients, they account for 10 percent of the organization’s treatment costs.

Ambassador of Arjan-Social Group: On Monday, at the "Co-Creation Mondays" meeting on the topic of examining the issues of special and incurable patients, Siddajed Sadeghirad, referring to the share of these patients in the treatment costs of the Social Security Organization, stated: Despite the small population, this group of insured persons takes a significant share of the organization's treatment resources due to their illness conditions and the need to receive specialized services.

Referring to the statistics of medical services provided in 1404, he added: In this year, extensive services in direct and indirect treatment were provided to the insured, and special and incurable patients also received a part of these services.

Stating that the treatment costs of the organization are significant in various fields of diseases, Sadeghirad continued: The Social Security Organization has had a plan to support specific patients since 2000 and by identifying and marking the patients, it has provided the basis for providing services tailored to their treatment needs.

Cancer patients' share of referrals and treatment costs

Director General of Treatment of the Social Security Organization, referring to the statistics of cancer patient referrals, said: In total, about 637,000 referrals for receiving medical services were related to cancer patients, which includes about 1.1% of the referrals; The share of expenses related to these referrals is also announced as 1.45%.

He added: About 175,000 referrals related to these patients were registered in the department of receiving medical services, and their share of the provided services was about 2.6%.

Referring to the statistics of the first five months of 1405, Sadeghi Rad stated: In this period of time, about 253 billion Tomans have been paid in one of the expenses related to patients; However, to accurately determine the title of the cost and its relationship with the total costs of cancer patients, it is necessary to compare the presented statistics with the original file.

Providing medical services to special and incurable patients

Referring to the need to support special and incurable patients, the General Director of Treatment of the Social Security Organization said: The examination of the share of these patients in referrals, services and treatment costs shows that their need to receive specialized and continuous services should be taken into account in the organization's treatment plans.

He also pointed to the online implementation of drug-related processes and said: Part of the pharmaceutical services are done through online systems, and this process has been followed with the aim of facilitating the provision of services to patients.

Referring to the increase in the number of diseases covered by the special and incurable patients fund, Sadeghirad said: After the establishment of this fund, the number of covered diseases increased and now 133 disease groups have been identified in this fund. The number of patients is about 2.5 million people, which changes continuously due to the changing conditions of the patients.

He added: Currently, 721 types of drugs and 5,688 types of services have been identified within the framework of the fund for special and incurable patients. Out of the total number of identified diseases, a service package has been defined for some of them, and 64 cases do not have a service package, and the expenses related to them must be covered from miscellaneous damages.

Referring to the problems of paying for patients without a service package, the General Director of Treatment of the Social Security Organization stated: We are facing challenges in this department, and the insured, especially terminally ill patients, sometimes wait for a long time to receive their treatment fees, which has caused them dissatisfaction and complaints.

Stating that an important part of the demands of the social security organization is related to the share of the fund for special and incurable patients, Sadeghirad said: since the foundation of the fund in 1401, about 1,400 billion tomans have been paid to the social security organization from this fund, but there are still more than 500 billion tomans left from the organization's claims.

He added: About 51,000 medical cases related to special and intractable patients are still not determined and their expenses are still waiting for the fund's share. In these cases, the social security organization has paid the share of its obligations, but the share of the fund has not yet been paid.

The General Director of Treatment of the Social Security Organization emphasized: The delay in the payment of the fund's share, especially in inpatient cases and paraclinical services, is one of the important issues that has caused difficulties in the process of settling the treatment costs of patients.

He also pointed to the difference in the share paid in different parts of the treatment and said: the amount of obligations of the fund and the social security organization is different in various services; For example, the fund's share in some drugs related to transplantation is about seven percent and in some cancer drugs, it is 0 percent.

Referring to the measures taken to facilitate the payment of medical expenses for special and incurable patients, Sadeghi Rad said: The Social Security Organization has defined a system for recording and tracking various damages to handle the expenses of these patients, but there are still problems in the process of paying claims from the fund for special and incurable patients.

He added: Although the information and amounts related to about 50,000 cases have been reflected to the Health Insurance Organization and have been processed, the payment of these claims has been delayed for a long time. This delay has created dissatisfaction for certain patients who are facing multiple treatment costs, and the social security organization is not able to pay these amounts due to the lack of relevant resources.

The General Director of Treatment of the Social Security Organization stated that one of the existing problems is the inconsistency of the online pharmaceutical systems and said: Currently, the insured go to the pharmacy to receive medicine and the process of paying the health insurance contribution is done in the relevant system, but the possibility of online inquiry and exchange of information with the Social Security Organization system is not fully available.

He continued: The Social Security Organization has repeatedly announced its readiness to establish a system connection and has demanded the provision of the necessary technical access to establish communication between the systems so that the process of drug inquiry and payment of the insurance contribution can be done without interruption.

Referring to the situation of inpatient services in hospitals, Sadeghi Rad said: Online processes have been established in university hospitals, but this possibility has not yet been fully implemented in private hospitals of the contract parties. As a result, some of the processes related to the insurance contribution of the social security organization in these centers face problems.

He said that one of the challenges is not being informed at the same time about the changes in the list of covered drugs and he said: sometimes some drugs are excluded from the insurance coverage, but these changes are not notified to the social security organization in time; While it is necessary to inform the organization of the changes in drug coverage at the same time so that the insured do not face problems when they go to receive the drug.

The General Director of Treatment of the Social Security Organization further pointed out the problems of manpower in the case handling department and added: despite the increase in services and duties related to the purchase of medical services, a proportional review of the manpower of this department has not been done and the employees with the existing forces are responsible for handling sensitive and specialized cases of patients.

Sadeghirad expressed his hope that with the cooperation of the Health Insurance Organization and the Ministry of Health, systemic problems, delays in payment of claims and lack of manpower in the process of dealing with the cases of special and incurable patients will be resolved.