Knowledge of Pharmacists about Health Insurance in Saudi Arabia

Objectives: To explore the knowledge of pharmacists about health insurance in Saudi Arabia. Materials and Methods: It analyzes a cross-sectional


INTRODUCTION
Over several years of implementing Saudi vision 2030, healthcare strategic planning, and pharmaceutical care plan in Saudi Arabia, [1][2][3] There have been various outcome occurrences like moving toward Ambulatory care services more than inpatient healthcare services. Ambulatory care services had advantages over acute care services, including pharmaceutical care. It is less of an economic burden on the healthcare system, which was proposed several years back in pharmacy practice. [3][4][5] The supposed number of Ambulatory care prescribes increased while inpatient and acute prescriptions decreased. [3,5] Moreover, pharmacy health insurance had critical value in the health care system. [6][7][8][9][10][11][12][13] A new organization was approved and released by a corporate company by name health corporate component administration, and all medical clusters overall in Saudi Arabia as planned. [1,2] The health insurance center expected organized all Saudi citizens under coverage by corporate health companies with regulations of the Council of Cooperative Health Insurance. [1,2] Thus, all healthcare providers, including pharmacists, should be familiar with the healthcare insurance system. The Council of Cooperative Health Insurance organizes the healthcare insurance system. It is responsible for all regulations or policies, and procedures of the healthcare insurance system in Saudi Arabia. [14][15][16][17][18] There are various diseases and their drug therapy covered by healthcare insurance, such as endocrinology, cardiovascular disease, and obstetrics and Gynecology diseases. Besides psychiatric illness and other chronic conditions. [14] All those medications coverage should be aware of all pharmacy staff emphasizing Insurance Drug Formulary (IDF). [15][16][17][18][19] Few studies have been conducted locally about pharmacy knowledge of health insurance systems emphasizing medications. [6,[20][21][22][23][24][25][26][27][28] The authors are unfamiliar with any investigation conducted locally or in gulf countries or Arabia about the current topic. The objective of the present cross-sectional study is to assess the pharmacist knowledge of health insurance in Saudi Arabia

MATERIALS AND METHODS
It analyzes a cross-sectional survey discussing pharmacists' knowledge of health insurance in Saudi Arabia. It self-reported an electronic survey of the pharmacist, including pharmacists from internship to consultant, pharmacist specialties, and Saudi Arabia. All non-pharmacist or students, non-completed, non-qualified surveys will be excluded from the study. The survey consisted of respondents' demographic information about pharmacists, The health insurances assessment of primary and advanced knowledge, and The Resources used about the High risk or highalert medications. [7][8][9][10][11][12][13][20][21][22][23][24][25][26][27][28] The 5-point Likert response scale system was used with closedended questions. According to the previous litterateur with an unlimited population size, the sample was calculated as a cross-sectional study, with a confidence level of 95% with a z score of 1.96 and a margin of error of 5%, a population percentage of 50%, and drop-out rate 10%. As a result, the sample size will equal 380-420 with a power of study of 80%. [29][30][31] The response rate required for the calculated sample size is at least 60-70 % and above. [31,32] The survey was distributed through social media of what's applications and telegram groups of pharmacists. The reminder message had been sent every 1-2 weeks. The survey was validated through the revision of expert reviewers and pilot testing. Besides, various tests of the reliability of McDonald's ω, Cronbach alpha, Gutmann's λ2, and Gutmann's λ6 were done with the study. The data analysis of pharmacist's knowledge about health insurance in Saudi Arabia is done through the survey monkey system. Besides, the statistical package of social sciences (SPSS), Jeffery's Amazing Statistics Program (JASP), and Microsoft Excel sheet version 16. It included a description and frequency analysis, good of fitness analysis, correlation analysis. Beside, inferential analysis of factors affecting pharmacists and The health insurances assessment of basic and advance knowledge with linear regression. The STROBE (Strengthening the reporting of observational studies in epidemiology statement: guidelines for reporting observational studies) guided the reporting of the current study. [33,34]

RESULTS
A total number of 398 pharmacists responded to the questionnaire. Of them, more than onethird responded from the Central region (137 (34.51%)), and one Quarter responded from the western part (109 (27.46%)), with statistically significant differences between the provinces (p=0.000). Most of the responders were from Ministry of Health Hospitals (96 (24.37%)), Pharmaceutical companies (87 (21.86%)), and community pharmacies (69 (17.34%)), with a statistically significant difference between working sites (p=0.000). Males responded more than females (239 (60.35%)) versus 157 (39.65%)), with statistically significant differences between all levels (p=0.000). Most of the responders were in the age group of 24-30 years (271 (68.26%)) and 31-35 years (56 (14.11%)), with statistically significant differences between all age groups (p=0.000). Most of the pharmacists were staff pharmacists (300 (75.76%)) and pharmacy supervisors (43 (10.86%)), with statistically significant differences between all levels (p=0.000). Most of the responders held Bachelor in pharmacy (192 (48.36%)) and Pharm D (146 (36.78%)). Most pharmacists had a work experience of 1-3 years (160 (40.20%)) and >1 year (104 (26.13%)), with a statistically significant difference between years of experience (p=0.000). Most pharmacists work at an outpatient pharmacy (79 ((23.58%)) and inpatient pharmacist (63 ((18.81%)). Almost one-half of pharmacists currently have health insurance coverage (239 ((60.05%)) with equal or less than one year (108 ((42.52%)), or 2-3 years (81 ((31.89%)), have you been associated with your current insurance provider with statistically significant differences between all levels (p=0.000). There was a medium positive correlation between age (years) and years of experience based on Kendall's tau_b (0.686) and Spearman's rho (0.753) correlation coefficients, with a statistically significant difference between the two factors (p<0.000). There was a medium positive correlation between age (years) and length of health insurance coverage based on Kendall's tau_b (0.482) and Spearman's rho (0.526) correlation coefficients, with a statistically significant difference between the two factors (p<0.000). There was a medium positive correlation between years of experience and length of health insurance coverage based on Kendall's tau_b (0.682) and Spearman's rho (0.733) correlation coefficients, with a statistically significant difference between the two factors (p<0.000). There was a medium positive correlation between the site of work and practice area based on Kendall's tau_b (0.514) and Spearman's rho (0.627) correlation coefficients, with a statistically significant difference between the two factors (p<0.000). There was a medium negative correlation between the site of work and who currently have health insurance coverage based on Kendall's tau_b (0.404) and Spearman's rho (0.461) correlation coefficients, with a statistically significant difference between the two factors (p<0.000) (Tables 1 and 2). The average score of basic knowledge of pharmacists about health insurance was (1.91). The element "the ethics used in health insurance pharmacist" obtained the highest score (2.19). The aspect "the health insurance system covered the medications errors sentinel event" (2.05). In contrast, the lowest score obtained for the element "In Saudi Arabia, the health insurance pharmacist gets more salary than regular pharmacist" was (1.67). The score for the component "know the Health insurance pharmacist at pharmaceutical companies" was (1.76), with a statistically significant difference between the responses (p<0.000). All aspects of the basic knowledge of pharmacists about health insurance were statistically significant between responses (p<0.000) ( Table 3). The average score of advanced knowledge of pharmacists about health insurance was (1.95). The element "the knowledge of medications covered by health insurance" obtained the highest score (2.38). The aspect "the knowledge of the medications devices and health insurance" was (2.17). In contrast, the lowest score for the element "the knowledge about the clinical Heath insurance pharmacist" was (1.79). The score for the element "the knowledge of the resources of Health insurance pharmacist " was (1.79), with a statistically significant difference between the responses (p<0.000). All aspects of the advanced knowledge of pharmacists about health insurance were statistically significant between responses (p<0.000) (

Answered question 397
Skipped question 1

Factors affecting the basic knowledge of pharmacists about health insurance
Factors affecting the perception were analyzed. We adjusted the significant values using the independent samples Kruskal-Wallis test and the Bonferroni correction for multiple tests. Pharmacists' basic knowledge of pharmacists about high-risk medications includes location, worksite, age (years), gender, position held, years of experience, practice area in a pharmacy career, Health insurance coverage, and Years of Health insurance coverage. Five locations affected basic knowledge of health insurance with statistically significant differences between regions (p=0.013) with a non-significant difference among all five areas. Sixteen worksites affected the basic understanding of health insurance. The working site affected the factors of fundamental knowledge with a statistically significant difference between working sites (p=0.011) without any significant difference among all working sites. The responders' age affected the pharmacist's basic knowledge of health insurance with statistically significant differences (p=0.006).
There is a non-significant difference among all age levels. Gender did not affect the basic knowledge of health insurance, with nonsignificant differences between males and females (p=0.245). Six levels of work experience non-affected basic knowledge of health insurance with non-significant differences (p=0.165). Four levels of the position held were affected with the lowest score (1.7909) and (1.8056) by pharmacy staff and director of the pharmacy, respectively, with statistically significant differences between all levels (p=0.000). The pharmacy practice affected basic knowledge of health insurance with statistically significant differences between them (p=0.000), with the lowest score with pharmacy quality management (1.0000) with statistically significant difference (p<0.05). The present health insurance coverage for pharmacists did not affect the basic knowledge of health insurance with nonstatically significant differences (p=0.107). respectively. The bootstrap model was also confirmed. Furthermore, the relationship was verified by the non-existence of multicollinearity with a variance inflation factor (VIF) of 2.398 and 1.198, respectively, less than three or five as a sufficient number of VIF (Table 6). [35][36][37] Factors affecting the advanced knowledge of pharmacists about health insurance Factors affecting the perception were analyzed. We adjusted the significant values using the independent samples Kruskal-Wallis test and the Bonferroni correction for multiple tests.
Pharmacists' advanced knowledge of pharmacists about health insurance includes location, worksite, age (years), gender, position held, years of experience, practice area in a pharmacy career, Health insurance coverage, and Years of Health insurance coverage. Five locations affected advanced knowledge of health insurance with statistically significant differences between regions (p=0.002) and non-significant differences among all five areas. Sixteen worksites did not affect the advanced knowledge of health insurance with non-statistically significant differences (p>0.05). The working site affected the factors of advanced knowledge with a statistically significant difference between working sites (p=0.035) with the highest score (2.8231) at security forecasts hospital (p<0.05). The age of the responders affected the pharmacist's advanced knowledge of health insurance with statistically significant differences (p=0.006) with the lowest score (1.6928) of age > 50 years. Gender did not affect the basic knowledge of health insurance, with non-significant differences between males and females (p=0.653). Six levels of work experience affected advanced knowledge of health insurance with significant differences (p=0.005), with the lowest score (1.6210) with age > 12 years old. Four levels of the position were affected, with the highest score (2.9388) by the assistant director of pharmacy, with a statistically significant difference between all levels (p=0.000). The pharmacy practice affected the basic knowledge of health insurance with statistically significant differences (p=0.046) with non-statistically significant differences between them (p>0.05). In addition, the presence of health insurance coverage for pharmacists affected the basic knowledge of health insurance with statistically significant differences between them (p=0.000) with the highest score (2.0659) of present health insurance coverage. Finally, the number of years of health coverage affected the basic knowledge of health insurance with statistically significant differences (p=0.005) with nonsignificant differences among all years levels (p>0.05).
The relationship between the advanced knowledge of pharmacists about health insurance and factors such as location, worksite, age (years), gender, position held, years of experience, practice area in a pharmacy career, Health insurance coverage, and Years of Health insurance coverage. The multiple regression analysis considered perception as the dependent variable and factors affecting it as an expletory variable. There was a medium relationship (R=0.404 with p=0.000) between the advanced knowledge of pharmacists about health insurance and its factors. Seven out of nine were non-significant differences (p>0.05). However, multiple regression analysis confirmed that one factor (i.e., working site) explained 37.3 % of the negative relationship to the variation in knowledge, with a statistically significant difference (p=0.000). The bootstrap model was also confirmed. Furthermore, the relationship was verified by the non-existence of multicollinearity with a variance inflation factor (VIF) of 2.398, less than three or five as a sufficient number of VIF (Table 7). [35][36][37]

DISCUSSION
Healthcare insurance is expanding and updating the regulations more frequently in the kingdom of Saudi Arabia. [14][15][16][17][18] The laws start from simple coverage to more coverage of common medical diseases and surgeries. [14][15][16][17][18] Thus, more medicines are covered by health insurance with advanced medications and various indications. [15][16][17][18][19] Therefore, the pharmacist's knowledge of the health insurance system and regulations is necessary. Thus, the cross-sectional study about pharmacist's understanding of health insurance. It is done through a calculated sample size, with high reliability of the questionnaires and convenience sampling techniques which are better than the previous study [28] and almost similar to other research. [22] The study involved the various locations, working sites, age levels, experiences, and positions. That's reflected in the pharmacy society. The average basic knowledge of health insurance was poor.
Most pharmacists are familiar with the ethics of Heath insurance and medication error sentinel events. That's reflected in elementary   and essential information about insurance in pharmacy practice. In contrast, the pharmacist is not familiar with health insurance pharmacist salary and how the pharmaceutical companies relate coverage by health insurance, and what the processes to include in health insurance coverage through the Council of Cooperative Health Insurance. [14][15][16][17][18][19] Moreover, the pharmacist had inadequate knowledge about narcotics medicine and health insurance, the role of a pharmacist at health insurance companies, the patent and generic medicines coverage by Heath insurance, and the job description of a health insurance pharmacist. All those topics are essential in the healthcare system and for any pharmacist in the health insurance companies. [14][15][16][17][18][19]  Other factors that affected the knowledge was working sites like security forces hospital highest score of knowledge of health insurance system because of more developed system at their sites. The age might affect the knowledge of health insurance, with the lowest knowledge of age more than 50 years old because the old pharmacist generation had limited experience with health insurance and did not discuss it during the school of pharmacy. The expertise might affect the advanced knowledge of health insurance; the experience of more than 12 years had the lowest knowledge because health insurance is almost new for them. In addition, the position might affect the advanced knowledge of pharmacists, such as assistant director having the highest knowledge compared with other positions. That's related to how the assistant director takes care of health insurance in the pharmacy department. Finally, the presence of health insurance and length of coverage of Heath insurance might increase the advanced knowledge of health insurance. That's expected because they are much deal with health insurance. Thus, there is no previous investigation to compare with the current findings.

Limitation
The current investigation contained a comprehensive analysis of pharmacy health insurance services. However, it had various limitations; such sampling methods were randomized and selected with non-equal subjects from each working site or location or the demographic data of the responders. Therefore, future investigations to avoid any limitations in the future are highly recommended to implement.

CONCLUSION
The knowledge of pharmacists about Heath insurance system was insufficient. Most pharmacists were familiar with sentinel drug-related problems and medications with their devices covered by Heath insurance regulations. In contrast, the pharmacist is unfamiliar with the pharmacist's role in Heath insurance services or related job descriptions and international guidelines of Heath insurance pharmacists. Besides, therapeutics guidelines, unapproved indications, and some medications such as oncology drugs, herbal medicines, and pharmacy health insurance. Various factors might affect pharmacist knowledge about Heath insurance services, such as work sites and Heath insurance coverage. Targeting revision and standardization of pharmacy Heath insurance services are highly recommended. Besides, undergraduate and undergraduate education and training in Heath insurance in pharmacy practice are highly suggested in Saudi Arabia