This study aimed to compare the global surgery tariffs with the actual cost in Hazrate Rasoole Akram Hospital in the third quarter of 2017. 463 outpatient files and 715 inpatient files were studied. The highest rate of health insurance coverage for people undergoing global surgery in this period was related to the Social Security Organization (45%). The majority of global surgeries were related to ophthalmic surgeries (57%). In this surgical group, the hospital lost 276 Dollar per case. The findings of this study are inconsistent with the results of a study conducted by Hosseini et al. who showed that ophthalmology department, with an 18% share out of total global surgeries, was profitable in 99.6% of the cases . General surgery (16%) accounts for the second largest number of global surgeries. The average actual bills in the general surgery ward were 601 Dollar higher than the global bills and the average hospital stay was 3 days. In a study carried out by Radin Manesh, the average stay in the general surgery ward was 4.1 and 5.6 days in Hospital A and B respectively. Compared to the present study, it is likely that different hospitals have different global surgeries, or some hospitals are better at reducing hospital stays due to better patient management. His results also revealed that hospital stays might differ significantly for identical surgeries. For example, the average number of stay for “total thyroidectomy” was 5 days In Hospital A, while it was 7.8 days in Hospital B. Concerning “cholecystectomy”, the number of hospital stay was 4 and 5.8 days in Hospital A and Hospital B respectively. It was the case for other surgeries. Therefore, it can be said that hospital policies and management are fundamentally different in various hospitals. The study also found that there was a large discrepancy between the actual costs and global tariffs in the general surgery wards of both hospitals, and that the hospitals lost a considerable amount of money in this regard . The results of the study by Hosseini et al. are not in line with the results of the present study; they stated that, in the general surgery ward with a 20% share out of total surgical procedures, the cost difference was profitable in 92% of the cases (Rahil Hosseini). The results of this study depicted that, in some cases, the difference between the hospital stay and the standards determined in the global system was 3 to 5 days and less than the standard level .
Concerning the difference between the average hospital cost and the global tariff, Chatruz et al. found out that the cost of surgical procedures was 3 to 312% higher than the approved global tariff in all cases (61 cases) except for 7 surgeries, with the highest difference (312%) being related to septoplasty. This difference was more than 50%  in 22 surgical procedures; the final result of this study was similar to the results of the study conducted at Rasoole Akram Hospital.
Contrary to the findings of the present study, Hosseini et al. concluded that the cost of global surgery was beneficial for the hospital in 86% of the cases (96% of the differences were significant). They also found that the average hospital stay was less than the standard hospital stay in more than 99% of the cases (it was significant in 64% of the cases) .
Owing to the decreased length of stay in global surgical procedures, revision of the reimbursement system seems necessary, and a prospective reimbursement system must be implemented for other diagnoses and surgical procedures.
The results showed that there was a significant relationship between independent variables such as costs of the operating room, nursing services, anesthesia and other services and the difference between the actual bill and the global bill; these results were consistent with the results of a study carried out in two hospitals affiliated to Tehran University of Medical Sciences. In his study in 2013, Radin Manesh found that there was a significant and positive relationship between costs of medicine and consumables, the operating room and surgery and the difference between tariffs and bills. He also showed a significant and positive relationship between the hoteling and paraclinical costs and the difference between tariffs and bills . In other words, as the above-mentioned independent variables increased, the difference between the actual bill and the global bill decreased, and vice versa. It should be noted that the significance of variables indicates a strong relationship between these types of relationships.
Among the insurance companies, the Relief Committee, Rural Treatment Services and Foreigners had a significant relationship with the difference between the actual bill and the global bill of inpatients. Studies on insurance status and its relationship with the differences between the global and actual bill in two different hospitals showed that patients with Iranian Insurance cover experienced a greater difference in tariffs and bills . Surgical procedures performed in gynecology, ophthalmology and ENT departments had a significant relationship with the difference between actual and global bills. Comparing inpatient and outpatient departments revealed that the type of insurance had a different role and relationship with the difference between the actual and global bill in both departments, and that the most important reasons for this difference included increased length of stay, increased hospital deductions, increased patient’s costs for the hospital and thus decreased payments by the insurance companies.
The prevailing reimbursement system in Iranian hospitals is often based on the retrospective reimbursement method, and only a limited number of medical procedures use a prospective (global) payment system. According to the results of the present study, the hospital global bill was less than the patient’s actual bill, indicating that some components must be taken into account in determining the expenses and tariffs for Tehran referral university hospitals that usually treat complex patients.
In his study, Margani showed that there was a significant difference between the costs of medicine and medical consumables and anesthesia and the bill cost of each surgery in the hospitals owned by Tehran Social Security Organization . Godari et al. revealed in their study that the costs of surgical procedures for hospitals increased over the years 2004–2014 . In their study, Hosseini et al. concluded that global surgery was beneficial in 86% of the cases . A study conducted at Tehran University of Medical Sciences by Chatruz et al. showed that 61 cases (out of 68) of global surgical procedures were detrimental, and hospitals experienced no loss only in 7 cases . Reviewing previous studies, it is clear that large specialized and sub-specialized hospitals are more susceptible to losses resulted from the difference between global tariffs and actual bills due to the admission of patients with more complex medical problems, increased length of stay, higher hoteling costs and higher costs of consumables; therefore, they need to revise their global tariffs proportional to the increasing costs.
Comparing the cost of global surgery with the actual cost at the Cancer Institute, Arab et al. stated that there was a significant difference between the cost of global surgery and its actual cost in each of the years 2003 and 2004 (actual costs were far more than global costs) . In his study in Hormozgan, Hosseini acknowledged that the cost difference in 1286 cases was beneficial to the hospital in 86% of the cases . In a similar study conducted in one of the hospitals in Bushehr in 2001, Omrani Khoo stated that the bill cost of 570 (out of a total of 1667 patients) patients (34.2%) was higher than their approved tariffs, and the approved tariff of 1097 patients (65.8%) was higher than their bill costs; the difference between bill costs and global tariffs was significant .
Sharifian also regarded this point as one of the disadvantages of the global payment system. He mentioned that some variables such as age, sex, presence or absence of complications and associated diseases, specific level of complications and associated diseases, infant’s birth weight and infant’s weight at the time of admission did not exist in this system. In addition, the severity of the disease/patient’s clinical complexity level and the risk level of death cannot be determined with respect to this system . In recent years Iran made greater investments in health care and its core outcomes than most comparable nations  and To better manage these finance resources the structure of Iran’s health system, types of basic and complementary insurance policies, the payment system, the people’s consumption and payment pattern, the severity of diseases and patient’s clinical complexity level should be taken into account in determining health service tariffs . Tariffing is a process which must be taken into consideration through negotiations between health system trustees, insurance agency representatives, and service provider representatives. The reimbursement method of medical expenses is effective in the financial management and control of hospital costs. One of the essentials of the health system in Iran is to transform the global system into a case system based on indigenous diagnostic groups .