Practice of Health Insurance Services by Pharmacists in Saudi Arabia

Objectives: To illustrate the Practice of Health Insurance Services by Pharmacists in Saudi Arabia. Materials and Methods: It analyzes a cross-sectional survey that discussed the Pharmacist practice of health insurance in Saudi Arabia. The survey consisted of respondents’ demographic information about pharmacists and types of Health insurance coverage, present items for health insurance pharmacists at any healthcare institution, and Health insurance pharmacist practice implementation


INTRODUCTION
Implementing health insurance policies and procedures is required for all health institutions emphasizing pharmaceutical care services. That's to prevent loss or add unnecessary costs for healthcare diseases. [1][2][3][4][5][6][7][8][9][10] The Council of Cooperative Health Insurance (CCHI) in Saudi Arabia released various regulations and guidelines for health insurance practice emphasizing medication therapy or Issuance Drug Formulary (IDF). [11][12][13][14][15] Each healthcare organization has a different system during implementation, and appropriately, several elements of medication health insurance should be developed. However, it might there are some differences or discrepancies among all healthcare providers including the pharmacy staff. [9,[11][12][13][14][15] Therefore, the asses of the pharmacy practice of healthcare insurance are necessary (16). Besides, the various application of healthcare insurance in pharmacy give different experiences and more opportunities to expand the services in medicine coverage by healthcare insurance. Limited availability of studies about pharmacist practice of healthcare in medicine internationally. [1][2][3][4][5][6][7][8][9]16] The majority of studies discussed the pharmacy benefit of a hospital drug formulary. The authors are unfamiliar with any local investigations about pharmacists practicing health insurance in or gulf and all Arabic countries except one study. [16] The current cross-sectional survey aims to examine pharmacist's practice at health insurance in Saudi Arabia.
International Journal of Pharmacology and Clinical Sciences, Vol 11, Issue 4, Oct-Dec, 2022

MATERIALS AND METHODS
It analyzes a cross-sectional survey that discussed the Pharmacist practice 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 and types of Health insurance coverage, present items for health insurance pharmacists at any healthcare institutions, and Health insurance pharmacist practice implementation. [1][2][3][4][5][6][7][8][9][16][17][18][19][20][21][22][23] The 5-point Likert response scale system was used with closed-ended 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 of 10%. As a result, the sample size will equal 380-420 with a power of study of 80%. [24][25][26] The response rate required for the calculated sample size is at least 60-70 % and above. [26,27] 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 reliability, McDonald's ω, Cronbach alpha, Gutmann's λ2, and Gutmann's λ6 been done with the study. The data analysis of the Pharmacist practice of health insurance 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 present items for health insurance pharmacist at any healthcare institutions, and Health insurance pharmacist practice implementation 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. [28,29]

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). Most responders did not practice or work as Heath insurance pharmacists 346 (88.27%), with statistically significant differences between all answers (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 health insurance implemented at responder's healthcare organizations is average, covering 59.2% of the patients, 33.6% of medications, and 34.6% of medication devices ( Table 3). The average score of practice items for health insurance pharmacists at any healthcare institution (is 1.78). The element "Heath insurance and high-risk medications " obtained the highest score (1.85). The aspect "Heath insurance pharmacist and home healthcare medications" was (1.84). In contrast, the lowest score was obtained for the element "The vision of health insurance pharmacist " (1.74). The score for the component "health insurance pharmacist and research " was (1.74) with a statistically significant difference between the responses (p<0.000). All aspects of practice items for health insurance pharmacists at any healthcare institution between responses was a statistically significant difference between the responses (p<0.000) ( Table 4). The average score of Health insurance pharmacist practice implementation (is 3.29). The element "The health insurance pharmacist employee as a staff member of Heath insurance departments or pharmacy services " obtained the highest score (3.53). The aspect "The Heath insurance pharmacist had an active role in health insurance departments " was (3.53). In contrast, the lowest score was obtained for the element "I attended several courses or workshops about the role of the pharmacist in Heath insurance" (2.59). The score for the component "There are various of Heath insurance pharmacist resources in practice" was (3.05) with a statistically significant difference between the responses (p<0.000). All aspects of the perception of pharmacists about Health insurance pharmacist practice implementation were statistically significant between responses (p<0.000) ( Table 5). The score for single-test reliability analysis of McDonald's ω was 0.951, Cronbach's α was 0.948, Gutmann's was λ2, 0.957, Gutmann's λ6 was 0.974, and Greater Lower Bound was 0.986 with statistically significant (p<0.05).

Factors affecting the health insurance pharmacists at healthcare institutions
Factors affecting the present items for health insurance pharmacists at healthcare institutions were analyzed. We adjusted the significant values using the independent samples Kruskal-Wallis test and the Bonferroni correction for multiple tests. The factors that might affect health insurance pharmacists at healthcare institutions include location, worksite, age (years), gender, years of experience, position held, practice area in a pharmacy career, Health   insurance coverage, and Years of Health insurance coverage. Five locations affected present items of health insurance pharmacists with statistically significant differences between regions (p=0.004) with the highest scores (2.1465) of the southern area. Sixteen worksites affected the present items of health insurance pharmacists. The working site affected the factors of current things of health insurance pharmacist a statistically significant difference between working sites (p=0.002) with the highest score (2.8722) of security forces hospital. The age of the responders affected the present items of health insurance pharmacists with statistically significant differences (p=0.023). There is a non-significant difference among all age levels. The gender did not affect the present items of health insurance pharmacists with nonsignificant differences between males and females (p=0.975). Six levels of work experience non-affected current things of health insurance pharmacists with non-significant differences (p=0.111). Four levels of the position were affected, with the highest score (2.7971) with the assistant director of pharmacy with a statistically significant difference between all levels (p=0.000). The pharmacy practice affected present items of health insurance pharmacists with statistically significant differences (p=0.006) and the non-statistically significant difference among all pharmacy practice areas. The presence of health insurance coverage for pharmacists affected the present items of health insurance pharmacists with statically significant differences (p=0.007) with the highest score (1.9109) of current items of health insurance pharmacists. The number of years of health coverage did not affect the present elements of health insurance pharmacists with nonstatistically significant differences (p=0.362) ( Table 6). The relationship between the health insurance pharmacists at healthcare institutions 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 weak relationship (R=0.288 with p=0.034) between items for health insurance pharmacists at any healthcare institution and its factors. Seven out of nine were nonsignificant differences (p>0.05). However, multiple regression analysis confirmed that one factor (i.e., work site ) explained 21.4 % of the negative relationship to the variation in items for health insurance pharmacists at any healthcare institution, with a statistically significant difference (p=0.040). The bootstrap model was also confirmed. Furthermore, the relationship was verified by the non-existence of multicollinearity with a variance inflation factor (VIF) of 2.396 less than three or five as a sufficient number of VIF (Table  7). [30][31][32] Factors affecting the Health insurance pharmacist practice implementation Factors affecting the Health insurance pharmacist practice implementation were analyzed. We adjusted the significant values using the independent samples Kruskal-Wallis test and the Bonferroni correction for multiple tests. The factors that might affect Health insurance pharmacist practice implementation include location, worksite, age (years), gender, years of experience, position held, practice area in a pharmacy career, Health insurance coverage, and Years of Health insurance coverage. Five locations did not affect health insurance pharmacist implementation with nonstatistically significant differences between regions (p=0.841). Sixteen worksites affected health insurance pharmacist implementation. The working site did not affect the factors of health insurance pharmacist implementation, with a non-statistically significant difference between working sites (p=0.189). The responders' age did not affect the health insurance pharmacist implementation with non-statistically significant differences (p=0.907). The gender did not affect the present items of health insurance pharmacists with non-significant differences between males and females (p=0.477). Six levels of work experience affected health insurance pharmacist implementation with significant differences (p=0.040) and nonstatistically significant differences among all levels of experience. Four levels of the position did affect health insurance pharmacist implementation, with a statistically non-significant difference between all levels (p=0.963). The pharmacy practice did not affect health insurance pharmacist implementation with nonstatistically significant differences (p=0.611). The presence of health insurance coverage for pharmacists did not affect the health insurance pharmacist implementation with non-statically significant differences (p=0.250). The number of years of health coverage affected the health insurance pharmacist implementation with statistically significant differences (p=0.019) with the highest score (3.9815) of > 12 years of health insurance coverage. The relationship between the Health insurance pharmacist practice implementation and factors such as   In contrast, the relationship was verified by the existence of multicollinearity with a variance inflation factor (VIF) of 4.299, more than three or equal to five as a non-acceptable number of VIF (Table 8). [30][31][32]

DISCUSSION
The practice of health insurance is expanding day by day in the kingdom of Saudi Arabia. [11][12][13][14]33] All healthcare professionals emphasize the pharmacist might play a vital role in Heath insurance-related issues. The pharmacist can revise the medication whether included in the insurance drug formulary or not. [15] The pharmacist can review Saudi Food and Drug Authority (SFDA) registration and the approved indications locally or internationally. [1][2][3][4][5][6][7][8][9]16] The pharmacist might review whether the medication is included in the management guidelines. Besides, the pharmacist can check the cost of brand or generic medicines and related coverage by Heath insurance. Moreover, the pharmacist can provide a therapeutic exchange of non-available medications or shortage drugs or medications that cause the adverse event to patients. Besides, setup up the vision, mission, and scope of pharmacy insurance. [1][2][3][4][5][6][7][8][9]16] Thus, the exploration of pharmacist practice of health insurance is necessary. The current study can answer the previous objective through cross-sectional investigations of the survey distributed to all pharmacists working at various sites and practice areas. Besides, multiple age ranges, different experiences, and positions with calculated sample sizes are better than the previous study [9] and almost similar to other research. [2] Those differences in demographic factors reflected the whole pharmacy society. The findings showed the average practice of Heath insurance items was poor. Most responders developed health insurance for high-risk medication and home care facilities. The findings showed the average score of Heath insurance pharmacist practice implementation was acceptable. Most health insurance pharmacists were part of the pharmacy staff not specialized in health insurance and had an active role in the health insurance department at a healthcare organization. That means most pharmacists wish to work as health insurance pharmacists. However, some obstacles might prevent pharmacists from continuing their work in Heath insurance, such as education and tearing. [2] Thus, most pharmacists lacked education and training in health insurance and references to Heath insurance in pharmacy practice. Both were essential to developing health insurance pharmacists to implement many services in Heath insurance through pharmacy services. Thus, there is no previous investigation to compare with the current findings.
The majority of demographic factors did not affect the health insurance pharmacist implementation. However, the pharmacist's experience might affect the Heath insurance pharmacist. That's expected because they are non-expert with all Heath insurance regulations. At the same time, new pharmacists are more familiar with the new health insurance system and barriers and solutions to implementing health insurance in pharmacy practice. In addition, the length of health insurance coverage might affect the Heath insurance pharmacist, especially those over 12 years. The most dependable factors affecting health insurance pharmacists were the working site and length of the health insurance coverage. Thus, there is no previous investigation to compare with the current findings

Limitations
The current study of the practice of Heath insurance services at pharmacies is critical. It has value and benefits of improving the pharmacy health insurance services locally. However, the study had various limitations. The sampling method was not randomized, containing a wide range of responders' demographic characteristics and not representative of all pharmaceutical care sectors. In addition, the research crossexamined references which can be changed with time. Further studies conducted with random sampling techniques with in-depth details practice are needed to perform in the practice of pharmacy services.

CONCLUSION
The practice of pharmacists in Heath insurance services was insufficient. Most pharmacists focused on high-risk and home care medications of Heath insurance system. In contrast, the vision, mission, and strategic plan of Heath insurance in pharmacy practice had a negative response. The other Heath insurance pharmacist implementations were appropriate, zooming in on the presence of Heath insurance pharmacists with an active role in healthcare organizations. In addition, the pharmacist lacked education and training in the pharmacy health insurance pulse appropriate recommended references. Various factors might affect the pharmacist in Heath insurance systems, such as working site, experiences, and implementation of Heath insurance at healthcare facilities. They're different pharmacy health insurance implementations among healthcare organizations. Therefore, the standardized system of Heath insurance in pharmacy practice is warranted, plus undergraduate and postgraduate education about pharmacy Heath insurance services is highly recommended for implementation in Saudi Arabia.