1. Introduction
Today, the increase in the elderly population has become one of the most important economic, social, and health challenges [1]. The increase in the number of elderly has increased the burden of disease, duration, and frequency of hospitalization and, consequently, increased hospitalization and treatment costs [2, 3]. Considering the growth of the elderly population in Iran [4] and the fact that the elderly receive a significant share of health services and consequently have higher health expenditures; Therefore, managing the health expenditures of the elderly and also preventing the occurrence of devastating health costs is very important and necessary. Therefore, considering the importance and necessity of supplementary insurance to improve the quality of life of the elderly family and also the structure of basic insurance in Iran, this study was conducted to investigate the effect of supplemental health insurance on out-of-pocket payments for elderly households in urban areas of Iran.
2. Methods
The present descriptive-analytical and the applied study was conducted at the national level with the Hackman two-stage econometric method in 2020. The sample size included 6171 households with elderly members whom the Statistics Center of Iran randomly selected based on a three-stage sampling method, city, block, and household selection [4]. The sample size information was collected by the Statistics Center of Iran using the “Urban Household Expenditure and Income Survey Questionnaire” through the direct reference of the statisticians to the sample household and in the presence of the head of the household. The information required for this study was extracted from the raw data of different sections of the questionnaire for 2019 and processed in Excel software. The coefficients of the research models were also estimated in Stata 16 software.
3. Results
The decision equation in Hackman’s two-stage method in this study showed the factors affecting the out-of-pocket payment of the elderly family to purchase health goods and services, the results of which are presented in Table 1.



The results of Table [1] showed that increasing age and the level of education of the head of the household led to an increase in payments from the pocket of the elderly household by 61164 and 84466 Rials per month, respectively, but having a private home led to a decrease in out-of-pocket payments by 1193467 Rials monthly. Elderly households with supplementary health insurance had more out-of-pocket payments of 606207 Rials per month than other elderly households. Also, an increase of one Rial per capita income per month led to an increase in out-of-pocket payments by the elderly household by 0.030 Rials per month. Elderly families living in developed provinces had more out-of-pocket payments of 849,739 Rials per month than other elderly families.
4. Discussion
The results showed that increasing the head of household’s age and level of education, increasing per capita income, and living in developed provinces led to increased out-of-pocket payments for the elderly household. Not only were older households less inclined to purchase supplemental health insurance than other households, but having supplementary health insurance by the elderly household also led to an increase in out-of-pocket payments compared to other older households. Therefore, to reduce out-of-pocket payments for the elderly with supplementary health insurance, it is recommended to increase the coverage of health goods and services needed by the elderly and fewer franchises. In order to reduce out-of-pocket payments, it seems necessary to have an efficient system for controlling and monitoring the quality of health services so that people do not have to use private services to enjoy the same level of services. Increasing the age of the head of the household and the head of the household by the elderly member had a positive effect on the probability of purchasing basic health insurance and increasing out-of-pocket payments to the elderly family. Therefore, it is recommended to support elderly families, especially elderly families under the head of an elderly person, and increase supplementary insurance coverage to avoid facing debilitating health expenses.
Ethical Considerations
Compliance with ethical guidelines
In the present study, secondary data were used and all ethical considerations, including the condition of fidelity, honesty and non-plagiarism, were observed.
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 
Author's contribution
All authors equally contributed to preparing this article.
Conflicts of interest
The authors declared no conflict of interest.