How to Manage the Conflict of Interests in Health System Payment Methods? A Mixed-Method Study in Iran
-
Parisa Yoshari
,
Hossein Jabbari Beirami
,
Roya Alipour Olyaei
,
Hossein Masoumi
,
Seyed Mohammad Amin Mousazadeh
,
Rahim Khodayari-Zarnaq
Abstract
Background: Efficient payment systems are vital for reducing health system costs while improving service quality. This study aimed to examine how to manage the conflict of interests in payment methods and propose payment recommendations for the health system staff in Iran.
Methods: This mixed-method study was conducted at Tabriz University of Medical Sciences (2023) using a scoping review, semi-structured interviews, and Delphi method. The scoping review followed the Arksey and O’Malley protocol. Experts were interviewed to adapt global evidence to Iran. Thematic analysis was used to generate and evaluate policy options for managing the conflict of interests in health system payment methods. Moreover, the Delphi process and analytic hierarchy process prioritized these options based on effectiveness, feasibility, economic efficiency, and budget requirements.
Results: Overall, 1,031 articles were initially identified, with 22 meeting the inclusion criteria after a rigorous selection process. Three policy options were evaluated, including modified per capita with pay for performance (MPCP4P), modified salary with P4P, and modified fee for service with P4P. MPCP4P emerged as the top choice due to its superior economic benefits and effectiveness. It was revealed that MPCP4P mitigates financial risks for providers while ensuring high-quality care, making it the most suitable option for the country’s payment system.
Conclusion: The MPCP4P method, with risk adjustment and quality indicators, reduced conflicts and service reduction in capitation systems. The implementation solution includes determining quality and performance indicators, establishing a risk adjustment framework, and managing referrals. Rigorous oversight and continuous evaluation are also essential.
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19. Wong SL, Green LA, Bazemore AW, Miller BF. How to write a health policy brief. Families, Systems, & Health 2017;35(1):21–4.doi:10.1037/fsh0000238
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21. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology 2005;8(1):19–32. doi:10.1080/1364557032000119616
22. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016;5(1):210. doi:10.1186/s13643-016-0384-4
23. Control CfD, Prevention. CDC’s policy analytical framework. Atlanta, GA, US Department of Health and Human Services. 2013. Available from: https://stacks.cdc.gov/view/cdc/25335
24. Ishizaka A, Labib A. Analytic Hierarchy Process and Expert Choice: Benefits and limitations. OR Insight 2009;22(4):201–20. doi:10.1057/ori.2009.10
25. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev 2021;10(1):89. doi:10.1186/
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26. Ghazaryan E, Delarmente BA, Garber K, Gross M, Sriudomporn S, Rao KD. Effectiveness of hospital payment reforms in low- and middle-income countries: a systematic review. Health Policy Plan 2021;36(8):1344–56. doi:10.1093/heapol/czab050
27. Khezri A, Mahboub-Ahari A, Tabrizi JS, Nosratnejad S. Weight of Risk Factors for Adjusting Capitation in Primary Health Care: A Systematic Review. Med J Islam Repub Iran 2022;36:2. doi:10.47176/mjiri.36.2
28. Mjåset C, Ikram U, Nagra NS, Feeley TW. Value-Based Health Care in Four Different Health Care Systems. Catalyst non-issue content 2020;1(6). doi:doi:10.1056/CAT.20.0530
29. Emanuel EJ, Mostashari F, Navathe AS. Designing a Successful Primary Care Physician Capitation Model. Jama 2021;325(20):2043–4. doi:10.1001/jama.2021.5133
30. Reid RO, Tom AK, Ross RM, Duffy EL, Damberg CL. Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems. JAMA Health Forum 2022;3(1):e214634. doi:10.1001/jamahealthforum.2021.4634
31. Heath J. Ethical Issues in Physician Billing Under Fee-For-Service Plans. J Med Philos 2020;45(1):86–104. doi:10.1093/jmp/jhz029
32. Cooper Z, Nguyen H, Shekita N, Morton FS. Out-Of-Network Billing And Negotiated Payments For Hospital-Based Physicians. Health Aff (Millwood) 2020;39(1):24–32. doi:10.1377/hlthaff.2019.00507
33. Youens D, Doust J, Ha TN, O’Leary P, Slavotinek J, Wright C, et al. Association of regulatory body actions and subsequent media coverage with use of services in a fee-for-service system: a longitudinal cohort
study of CT scanning in Australia. BMJ Open 2022;12(4):e057424. doi:10.1136/bmjopen-2021-057424
34. Russel SM, Carter TM, Wright ST, Hirshfield LE. How Do Academic Medicine Pathways Differ for Underrepresented Trainees and Physicians? A Critical Scoping Review. Acad Med 2023;98(11s):S133–s42. doi:10.1097/acm.0000000000005364
35. Agarwal R, Liao JM, Gupta A, Navathe AS. The Impact Of Bundled Payment On Health Care Spending, Utilization, And Quality: A Systematic Review. Health Aff (Millwood) 2020;39(1):50–7.doi:10.1377/hlthaff.2019.00784
36. Aghajani M, Oliayi-Monsh A, Manavi S, Ronasian R, Yousefvand M, Mani Y, et al. Evaluating the effectiveness and implementation process of the new performance-based payment system compared to the new hospital management system in the health system reform plan. Hakim Res J. 2018;20(4):213-25.
37. Jabbari A, Karimi S, Javadi M, Tavakkoli M. Economic Reform Strategies to Improve the Performance of Surveillance and Infrastructure for Implementation of New Fee for Service Guidelines, 2014: A
Qualitative Study. Journal of Qualitative Research in Health Sciences 2017;6(2):112–23.
38. Marchildon GP, Allin S, Merkur S. Canada: Health System Review. Health Syst Transit 2020;22(3):1–194.
39. Nuno FMTF, Gradim AC, da Costa Dias AA, Polónia DF. Value-Based Healthcare and Radiology: How can Value be
Measured? Journal of Health Management 2022;24(4):556–65. doi:10.1177/09720634221128075
40. Memari B, Talebian M, Fatemi Ardestani F. Instances of Conflict of Interest in iran’s Health system. Iranian Journal of Public Policy 2022;8(2):67–82. doi:10.22059/jppolicy.2022.87948
2. Mohamadi E, Takian A, Olyaeemanesh A, Rashidian A, Hassanzadeh A, Razavi M, et al. Health insurance benefit package in Iran: a qualitative policy process analysis. BMC Health Serv Res 2020;20(1):722. doi:10.1186/s12913-020-05592-w
3. Holmes DR, Jr., Firth BG, James A, Winslow R, Hodgson PK, Gamble GL, et al. Conflict of interest. Am Heart J 2004;147(2):228–37. doi:10.1016/j.ahj.2003.12.001
4. Rodwin MA. Medicine, money, and morals: physicians’ conflicts of interest. Oxford University Press, USA; 1995.
5. Brody H. Clarifying conflict of interest. Am J Bioeth 2011;11(1):23–8. doi:10.1080/15265161.2011.568587
6. Global Burden of Disease Health Financing Collaborator Network. Trends in future health financing and coverage:
future health spending and universal health coverage in 188 countries, 2016-40. Lancet 2018;391(10132):1783–98. doi:10.1016/s0140-6736(18)30697-4
7. Mosadeghrad AM, Abbasi M, Abbasi M, Heidari M. Sustainable health financing methods in developing countries: a scoping review. Journal of School of Public Health & Institute of Public Health Research 2023;20(4):fa358–fa77, en78.
8. Tummalapalli SL, Estrella MM, Jannat-Khah DP, Keyhani S,Ibrahim S. Capitated versus fee-for-service reimbursement and quality of care for chronic disease: a US cross-sectional analysis. BMC Health Serv Res 2022;22(1):19. doi:10.1186/
s12913-021-07313-3
9. Jan CF, Lee MC, Chiu CM, Huang CK, Hwang SJ, Chang CJ, et al. Awareness of, attitude toward, and willingness to participate in pay for performance programs among family physicians: a cross-sectional study. BMC Fam Pract 2020;21(1):60. doi:10.1186/s12875-020-01118-9
10. Nundy S, Cooper LA, Mate KS. The Quintuple Aim for Health Care Improvement: A New Imperative to Advance Health Equity. Jama 2022;327(6):521–2. doi:10.1001/jama.2021.25181
11. Gaál P, Jakab M, Shishkin S, Kutzin J, Cashin C, Jakab M. Strategies to address informal payments for health care. Implementing health financing reform: lessons from countries in transition. Copenhagen: World Health Organization. 2010:327-60.
12. Hadian M, Rezapour A, Mazaheri E, Asiabar AS. Barriers in the performance-based payment in Iran health system: Challenges and solutions. Journal of Education and Health Promotion 2021;10(1):106. doi:10.4103/jehp.jehp_797_20
13. Jegers M, Kesteloot K, De Graeve D, Gilles W. A typology for provider payment systems in health care. Health Policy 2002;60(3):255–73. doi:10.1016/s0168-8510(01)00216-0
14. Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does payfor-performance improve the quality of health care? Ann Intern Med 2006;145(4):265–72. doi:10.7326/0003-4819-145-4-200608150-00006
15. Khullar D, Schpero WL, Bond AM, Qian Y, Casalino LP. Association Between Patient Social Risk and Physician Performance Scores in the First Year of the Merit-based Incentive Payment System. Jama 2020;324(10):975–83. doi:10.1001/jama.2020.13129
16. Eldridge C, Palmer N. Performance-based payment: some reflections on the discourse, evidence and unanswered questions. Health Policy Plan 2009;24(3):160–6. doi:10.1093/heapol/czp002
17. Fainman EZ, Kucukyazici B. Design of financial incentives and payment schemes in healthcare systems: A review. Socio-Economic Planning Sciences 2020;72:100901. doi:10.1016/j.seps.2020.100901
18. Tricco AC, Lillie E, Zarin W, O’Brien K, Colquhoun H, Kastner M, et al. A scoping review on the conduct and reporting of scoping reviews. BMC Med Res Methodol 2016;16:15. doi:10.1186/s12874-016-0116-4
19. Wong SL, Green LA, Bazemore AW, Miller BF. How to write a health policy brief. Families, Systems, & Health 2017;35(1):21–4.doi:10.1037/fsh0000238
20. Bunn S, Boon P, Brock M, Schofield N, Bennett J, Davis J, Finlayson CM, Froend RH, Hall R, Lloyd LN, Lukacs G. Scoping Review. Occasional Paper. 1997. Available from: https://library.dbca.wa.gov.
au/Journals/082185/082185-1997.01.pdf
21. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology 2005;8(1):19–32. doi:10.1080/1364557032000119616
22. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016;5(1):210. doi:10.1186/s13643-016-0384-4
23. Control CfD, Prevention. CDC’s policy analytical framework. Atlanta, GA, US Department of Health and Human Services. 2013. Available from: https://stacks.cdc.gov/view/cdc/25335
24. Ishizaka A, Labib A. Analytic Hierarchy Process and Expert Choice: Benefits and limitations. OR Insight 2009;22(4):201–20. doi:10.1057/ori.2009.10
25. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev 2021;10(1):89. doi:10.1186/
s13643-021-01626-4
26. Ghazaryan E, Delarmente BA, Garber K, Gross M, Sriudomporn S, Rao KD. Effectiveness of hospital payment reforms in low- and middle-income countries: a systematic review. Health Policy Plan 2021;36(8):1344–56. doi:10.1093/heapol/czab050
27. Khezri A, Mahboub-Ahari A, Tabrizi JS, Nosratnejad S. Weight of Risk Factors for Adjusting Capitation in Primary Health Care: A Systematic Review. Med J Islam Repub Iran 2022;36:2. doi:10.47176/mjiri.36.2
28. Mjåset C, Ikram U, Nagra NS, Feeley TW. Value-Based Health Care in Four Different Health Care Systems. Catalyst non-issue content 2020;1(6). doi:doi:10.1056/CAT.20.0530
29. Emanuel EJ, Mostashari F, Navathe AS. Designing a Successful Primary Care Physician Capitation Model. Jama 2021;325(20):2043–4. doi:10.1001/jama.2021.5133
30. Reid RO, Tom AK, Ross RM, Duffy EL, Damberg CL. Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems. JAMA Health Forum 2022;3(1):e214634. doi:10.1001/jamahealthforum.2021.4634
31. Heath J. Ethical Issues in Physician Billing Under Fee-For-Service Plans. J Med Philos 2020;45(1):86–104. doi:10.1093/jmp/jhz029
32. Cooper Z, Nguyen H, Shekita N, Morton FS. Out-Of-Network Billing And Negotiated Payments For Hospital-Based Physicians. Health Aff (Millwood) 2020;39(1):24–32. doi:10.1377/hlthaff.2019.00507
33. Youens D, Doust J, Ha TN, O’Leary P, Slavotinek J, Wright C, et al. Association of regulatory body actions and subsequent media coverage with use of services in a fee-for-service system: a longitudinal cohort
study of CT scanning in Australia. BMJ Open 2022;12(4):e057424. doi:10.1136/bmjopen-2021-057424
34. Russel SM, Carter TM, Wright ST, Hirshfield LE. How Do Academic Medicine Pathways Differ for Underrepresented Trainees and Physicians? A Critical Scoping Review. Acad Med 2023;98(11s):S133–s42. doi:10.1097/acm.0000000000005364
35. Agarwal R, Liao JM, Gupta A, Navathe AS. The Impact Of Bundled Payment On Health Care Spending, Utilization, And Quality: A Systematic Review. Health Aff (Millwood) 2020;39(1):50–7.doi:10.1377/hlthaff.2019.00784
36. Aghajani M, Oliayi-Monsh A, Manavi S, Ronasian R, Yousefvand M, Mani Y, et al. Evaluating the effectiveness and implementation process of the new performance-based payment system compared to the new hospital management system in the health system reform plan. Hakim Res J. 2018;20(4):213-25.
37. Jabbari A, Karimi S, Javadi M, Tavakkoli M. Economic Reform Strategies to Improve the Performance of Surveillance and Infrastructure for Implementation of New Fee for Service Guidelines, 2014: A
Qualitative Study. Journal of Qualitative Research in Health Sciences 2017;6(2):112–23.
38. Marchildon GP, Allin S, Merkur S. Canada: Health System Review. Health Syst Transit 2020;22(3):1–194.
39. Nuno FMTF, Gradim AC, da Costa Dias AA, Polónia DF. Value-Based Healthcare and Radiology: How can Value be
Measured? Journal of Health Management 2022;24(4):556–65. doi:10.1177/09720634221128075
40. Memari B, Talebian M, Fatemi Ardestani F. Instances of Conflict of Interest in iran’s Health system. Iranian Journal of Public Policy 2022;8(2):67–82. doi:10.22059/jppolicy.2022.87948
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| Issue | Vol 10 No 1 (2026) | |
| Section | Articles | |
| Keywords | ||
| Conflict of interests Health services Reimbursement Incentive Fee-for-service plans Health | ||
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How to Cite
1.
Yoshari P, Jabbari Beirami H, Alipour Olyaei R, Masoumi H, Mousazadeh SMA, Khodayari-Zarnaq R. How to Manage the Conflict of Interests in Health System Payment Methods? A Mixed-Method Study in Iran. Health Tech Ass Act. 2026;10(1).
