Abstract
Background. Designing a payment system for healthcare workers- doctors and nurses, in particular- in the hospitals is more intricate than that for other organizations. Beyond the legal compliance, the unique features of the medical professions and nursing work environment should be considered. Due to the lack of adequate researches on payment methods for doctors and nurses in Iran, especially regarding the recent changes in “fee for services” (FFS) payment, the present study aimed to investigate the payment challenges faced by the doctors and nurses in Iranian public hospitals.
Methods. Challenges were identified by interviews, and prioritized by adopting the MARCOS method. The study population included the hospital managers, healthcare payment method experts, and doctors and nurses in the public hospitals. Targeted sampling and semi-structured interviews were conducted to collect the data. In the MARCOS method, criteria determination, weighting, and scoring of the challenges were performed by five experts in the field of healthcare payment. Criteria included decreased motivation (25%), reduced productivity (15%), correction cost (40%), and implementation difficulty of the correction (20%). Calculations were performed using Excel software and determining the relevant priorities.
Results. A total of 16 interviews were conducted in this study, with 10 interviews about the academic faculty and hospital managers in Isfahan University of Medical Sciences, three about the nursing experts in Tehran, and three about the Ministry of Health experts. According to MARCOS method calculations, the top 4 challenges in compensating doctors were identified as: low FFS ceiling, lack of job difficulty incentives, the inadequate impact of full-time work, and the progressive taxing. Additionally, the 2 primary challenges in compensating nurses were: irregular payment of FFS, and collective payment of FFS instead of individual payment.
Conclusion. At the time of this study, Iranian public hospitals provided the doctors with individual rights, benefits, and allowances, while it provided the nurses with collective rights, benefits, and overtime pay. Although these compensation methods often posed different challenges, most of the issues were associated with the allowance payments. By prioritizing key challenges, authorities may have developed the necessary solutions for addressing the challenges as well as enhancing the satisfaction of doctors and nurses in Iranian public hospitals.
Extended Abstract
Background
The payment method has a direct impact on the quality and efficiency of the system. An effective payment method enhances the individual motivation, which is a crucial element in increasing both quality and productivity. In fact, individuals suffering a decrease in their work motivation due to inadequate or unfair compensation, experience a decline in their performance quality and become less productive. Designing payment methods for healthcare professionals– doctors and nurses, in particular– is a more intricate task than that for other organizations. This intricacy lies in the fact that it requires, in addition to the compliance with legal requirements, the consideration of the unique characteristics of medical jobs. Therefore, it is necessary to examine the current state of payment methods from various perspectives. It should be noted that no individual FFS had been considered for nursing services in Iranian public hospitals. Starting from the winter of 2021, however, this issue was put on the agenda of the Ministry of Health, and it was determined that tariffs should be established for nursing services, and the nurses should receive a specific FFS based on the tariffs. Given the limited existing research in this field specially regarding the recent changes, this study aimed to explore the challenges involving in payment methods for doctors and nurses in Iranian public hospitals.
Methods
In this applied study, challenges facing the payment methods were identified in the qualitative phase and prioritized in the quantitative phase of the study by adopting a mixed research method. The first phase was conducted during 2022-2023. The study population comprised two groups: payment method experts, including hospital managers and specialists, and healthcare professionals working in public hospitals. A purposive sampling was employed to select the participants, and semi-structured interviews with stakeholders were conducted. The interview guide was developed based on the research objectives, and a pilot interview was conducted to refine the process. A total of 16 interviews were conducted and continued until a data saturation was reached (i.e., no new perspectives were obtained). Data analysis involved thematic analysis of the interviews, and categorization of the challenges into main and sub-categories. To prioritize the challenges, the “MARCOS method” was adopted, which is a decision-making approach proposed by Stojic and Pamukar (2020), which involves "measuring and ranking the options based on compromise solutions" and is employed to rank research options. Then five experts on hospital payment were asked to determine the weighting and scoring of the challenges. These experts had extensive knowledge and expertise in the healthcare system, hospital affairs, and various payment methods. They were briefed on the nature and subject of the study in a session, and a consensus was reached on the criteria and their respective weights, which included: motivation reduction (25%), productivity decline (15%), cost of adjustment (40%), and implementation difficulty (20%). Subsequently, they were provided with a decision matrix, and were asked to assign scores to the challenge. The calculations were performed using Excel software, resulting in the final prioritization of each indicator.
Results
This study mainly investigated the challenges of compensating doctors, particularly regarding the payment of FFS for doctors, as well as “the new setting of FFS” in nurse payment. The study involved 16 interviews, with 10 interviews from academic faculty members and hospital managers in Isfahan University of Medical Sciences, three interviews from nursing experts in Tehran, and three interviews from the experts working in the Iran Ministry of Health. According to MARCOS method calculations, the top 4 challenges in compensating doctors were identified as: low FFS ceiling, lack of job difficulty incentives, the inadequate impact of full-time work, and the progressive taxing. Additionally, the 2 primary challenges in compensating nurses were: irregular payment of FFS, and collective payment of FFS instead of individual payment.
Conclusion
In Iranian public hospitals at the time of this study, the doctors are receiving salaries, and individual FFS, while the nurses are receiving salaries, collective FFS, and overtime. Although the challenges are often associated with these compensation methods, most of the challenges in this study were found to relate to the FFS payment. It was suggested that the authorities should pay extra attention to the priority challenges in order to find necessary solutions for addressing them, and increasing the satisfaction of doctors and nurses in public hospitals. In an organization that differed greatly from other organizations in terms of the education and skill categories, it was found natural to have conflicting viewpoints between job categories. Considering this fact, the "theory of expectation and justice" was followed by this organization, and it had a decisive effect on the satisfaction level. To put it simply, the hospital employees compared their incomes with those of others, which was suggestive of the fact that "payment comparison" was more important than "payment amount". To address these problems, it was recommended that the policymakers should determine effective payment policies in order to establish the balance among different professional groups. Revision of the taxing policies may have also proved useful in this regard. Furthermore, it was found necessary to regulate the diverse hiring practices in order to address the unfair differences in pay among the nurses fulfilling similar duties. To address these problems and dissatisfactions, finally, it was found necessary to establish cooperation and consensus among different institutions (e.g., the Ministry of Health, parliamentarians, and nurses' union representatives). Considering the importance of the health sector and the need for skilled and committed nurses and doctors, it was suggested that their payment challenges should be addressed and the balance in their payment should be promoted.