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7/21/2019 Laksono IAKMI FInance 2015 Minggu1c
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Kebijakan
Strategis untukmengurangi
ketidak adilan
dalam mencapaiUniversal Health
Coverage
Laksono Trisnantoro
Universitas Gadjah Mada
InaHEA 2nd National Meeting,
Jakarta, 9th April 2015
1
Strategic Policy
for narrowinginequity in
Universal Health
Coverageprograms
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Tujuan mempelajari kasus JKN di
tahun 2014
Memahami makna:
• Revenue Collection
• Pooling
• Purchasing
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What Happened in 2014
• JKN dimulai 1 Januari2014
• Situasi supply-side dalamkeadaan tidak seimbang.
- SDM dokter dan kesehatantidak merata
- Pelayanan kesehatan tidakmerata
• Di awal tahun 2015,
berbagai sumbermenyatakan bahwa BPJSkekurangan 2 – 5 Triliun
• JKN started in January2014
• Supply side is extremelynot well distributed
across Indonesia- Human resources
- Health facilities
- In 2015 some reportshows that BPJS is
shortage of 2-4 Triliun
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The Shortage of BPJS
• Pardede, 2015 4
Sumber : Data klaim Bulan Pelayanan Jan s/d Des 2014 (Bulan Pembebanan s/d Jan 2015) dari BPJS, Maret 2015.
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Who Gets What in 2014?
• Siapa yang
mendapatkan dana
BPJS?
• Apakah masyarakatyang
membutuhkan?Ataukah
justru masyarakat
menengah ke atas di
kota-kota besar?
• Who get what from
BPJS expenditure?
• Whether the poor or
the better ofcommunity?
• Whether people in the
remote area or in the
big cities
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In more specific, which member
group?• Kelompok masyarakat
miskin yang dibayarmelalui PBI?
• Kelompok Non-PBI eks PT
Askes Indonesia dan PTJamsostek?
• Kelompok Non-PBIMandiri (Pekerja BukanPenerima Upah)?
Bagaimana isu Ketidakadilan?
• Poor community paid bycentral governmentbudget (PBI)?
• The ex PT Askes and PT
Jamsostek members andformal sector?
• The Non-PBI Mandiri?
How is equity issue ismanaged?
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The Analysis
• Revenue Collection
• Pooling
• Purchasing
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Health Financing
(simplified)
APBN
BPJS
Tax
Income
Non-tax
Income
Non-PBI Mandiri
Primary
Care
Referral Care
Non-PBI ex
PT Askes
MoH
Out of pocket
Other
Ministries
PBI
Pemda
8
Local Gov
Private
Insuran
ce
(19.93 T)
NHA 2009 : (18 T)
489 (
72.9 T)
l.K20 T
4 T
(67,5 T)
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Revenue Colllection
APBN
BPJS
Tax
Income
Non-tax
Income
Non-PBI Mandiri
Primary
Care
Referral Care
Non-PBI ex
PT Askes
MoH
Out of pocket
Other
Ministries
PBI
Pemda
9Local Gov
Private
Insuran
ce
(67,5 T)
NHA 2009 : (18 T)
489 (
72.9 T)
4 T
(19.93 T)
+-20 T
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Pooling
10
1. APBN
1. MoH (47,5 T)—incl. PBI
• Other Ministries (13,5 T)
• Local Government (6.5 T ofAPBN)
2. BPJS Kesehatan
• PBI (19,8 T) plus
• Non PBI-ex PT Askes
• Non PBI-Mandiri
Two Big
Pools
1. Ministry
of Health
1. BPJS
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What happened in the
two Big Pools?
APBN
BPJS
Tax
Income
Non-tax
Income
Non-PBI Mandiri
Primary
Care
Referral Care
Non-PBI ex
PT Askes
MoH
Out of pocket
Other
Ministries
PBI
Pemda
11
Local Gov
Private
Insuran
ce
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Ministry of Health
In 2014:
• Small Budget for
Hospital Investment
• Human Resources
budget stagnant
Pada tahun 2014
• Dana investasi kecil
untuk penambahan
pelayanan kesehatandan sumber daya
kesehatan
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Kemkes Pemprov Pemkab Pemko
Kementeri
an lain TNI POLRI
Swasta
non profit Swasta BUMN
2012 32 85 411 86 3 105 29 654 237 77
2013 32 89 447 88 3 115 39 727 468 75
2014 33 96 455 92 3 118 41 724 599 67
Updated 34 97 459 92 5 127 43 733 694 66
-
100
200
300
400
500
600
700
800
R S
The new Hospital financed by private
sector
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Specialists Distribution
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BPJS:APBN
BPJS
Tax
Income
Non-tax
Income
Non-PBI Mandiri
Primary
Care
Referral Care
Non-PBI ex
PT Askes
MoH
Out of pocket
Other
Ministries
PBI
Pemda
15
Local Gov
Private
Insuran
ce
More Sick
Membersin the
Voluntary
Group
Kelompok
sakitKelompok
sehat
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Adverse Selection
problems in Non-PBI
Mandiri
APBN
BPJS
Pajak
Pendapatan
Negara
bukan Pajak
Non-PBI Mandiri
Pelayanan
Primer:
Pelayanan
Rujukan
Non-PBi PNS,
Jamsostek dll dll
Kemenkes
Dana dari Masyarakat langsung
Kementerian
lain
PBI
Pemda
16
Pendapatan
Asli Daerah
Kelompoksakit
Kelompoksehat
Askes
Swasta
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The health risk in BPJS pool
• Non-PBI-Mandiri
(Voluntary Group)
Not poor, some rich .
• PBI members (poor member)
• Non-PBI (ex PT Askes )More Healthymembers
Kelompok
sakit
Kelompok
sehat
Kelompok
sakitKelompok
sehat
Kelompok
sakitKelompok
sehat
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What Happened in
Purchasing?
APBN
BPJS
Tax
Income
Non-tax
Income
Non-PBI Mandiri
Primary
Care
Referral Care
Non-PBI ex
PT Askes
MoH
Out of pocket
Other
Ministries
PBI
Pemda
18
Local Gov
Private
Insuran
ce
489 (
72.9 T)
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BPJS, Purchasing and Payment
Mechanism
• Kapitasi untuk
pelayanan kesehatan
primer, dan
• Klaim untuk pelayanan
kesehatan rujukan
berbasis INA-CBG.
• Capitation for Primary
Care
• Claim, based on INA-
CBG (DRG) type of
payment
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The facts in 2014
• Kapitasi tidak terkait kinerjaFKTP
• Tidak ada batas atas(plafond) di RS dalammelakukan klaim.
• Sistem Pencegahan danPenindakan Fraud belumberjalan
• Daerah dengan SDMlengkap, RS banyak,
teknologi tinggi akanmenyerap dana BPJS banyak
• Capitation is not linked withperformance indicators
• There is no upper limit forhospital in claiming theservices
• Fraud Prevention,Detection, deterrence, andprosecution system is notyet established
• Regions which have many
doctors, health services,and high technologyequipment get the fundmore
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The Risk of this current condition of
financing• Health facilities in remote
areas become more laggedbehind
• The distribution of humanresources for health will suffer
• Not efficient primary care• Fraud will be uncontrollable
and make the use of resourcesbecome less efficient
• Adverse selection problems
•
PBI budget is used by themiddle and higher incomegroup
• Pembangunan RS dan faskes didaerah terpencil tidak dapatmengejar ketinggalan
• SDM kesehatan semakin tidakmerata
• FKTP tidak efisien• Klaim INA-CBGs tidak dijamin
efisiensinya karena fraud tidakterkendali
• Problem Adverse Selectionsemakin meningkat
• PBI (APBN) disinyalirmenanggung biaya pelayanankesehatan Non PBI (mandiri)
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Who get the most from
BPJS
APBN
BPJS
Tax
Income
Non-tax
Income
Non-PBI Mandiri
Primary
Care
Referral Care
Non-PBI ex
PT Askes
MoH
Out pof pocket
Other
Ministries
PBI
Pemda
22
Local Gov
Private
Insuran
ce
In Nov
2014:Claim
Ratio is
around
1300%
Claim
Ratio
Less than
90% (Nov
2014)
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The possibility:
PBI Budget is used by Non-PBI
Mandiri (Pekerja Bukan
Penerima Upah)
APBN
BPJS
Tax
Income
Non-tax
Income
Non-PBI Mandiri
Primary
Care
Referral Care
Non-PBI ex
PT Askes
MoH
Out of pocket
Other
Ministries
PBI
Pemda
23
Local Gov
Private
Insuran
ce
In Nov
2014:Claim
Ratio is
around
1300%
Claim
Ratio
Less than
90%
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• Wheter UHC can be
achieved in 2019?
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Scenario 1:Optimistic
Scenario 2:
Pessimistic.
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UHC pessimistic scenario
2014 2015 2016 2017 2018 2019
DIY
NTT
Zero
JKN increases geographical
inequity,
and also socio-economicinequity
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Proposed Strategic Policy to reduce
inequity
1. Using more reform
approach in JKN; Not only
Financing;
2. Short term
recommendation in
Financing Policy (Revenue
Collection, Pooling andPurchasing).
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More Strategic Policy using
Health Sector Reform Concept
Access
Quality
Efficiency
• Pembiayaan/Fin
ancing• Pembayaran/Payme
nt
• Pengorganisasian/O
rganizing
• Regulasi/Regulation
• Promosi/Promotion
Status Kesehatan/
Health Status
Kepuasan Publik/
Public
Satisfaction
Perlindungan
Resiko/
Risk Protection
Cost
GoalControl Knobs
28
Equity?
(Harvard University-WB)
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Proposed Strategic Policies in
Financing to reduce in-equity
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Short-term Policy
recommendation in
Financing
APBN
BPJS
Pajak
Pendapatan
Negara
bukan Pajak
Non-PBI Mandiri
Pelayanan
Primer:
Pelayanan
Rujukan
Non-PBi PNS,
Jamsostek dll dll
Kemenkes
Dana dari Masyarakat langsung
Kementerian
lain
PBI
Pemda
30
Askes
Swasta
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More Budget for MoH
to improve the supply
side
APBN
BPJS
Tax
Income
Non-tax
Income
Non-PBI Mandiri
Primary
Care
Referral Care
Non-PBI ex
PT Askes
MoH
Out of pocket
Other
Ministries
PBI
Pemda
31
Local Gov
Private
Insuran
ce
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Kemkes Pemprov Pemkab Pemko
Kementeri
an lain TNI POLRI
Swasta
non profit Swasta BUMN
2012 32 85 411 86 3 105 29 654 237 77
2013 32 89 447 88 3 115 39 727 468 75
2014 33 96 455 92 3 118 41 724 599 67
Updated 34 97 459 92 5 127 43 733 694 66
-
100
200
300
400
500
600
700
800
R S
More MoH and local government budget to finance
new health services and hospitals
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More MoH budget for redistribution of Specialist
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Do not increase the
premium for PBI
APBN
BPJS
Tax
Income
Non-tax
Income
Non-PBI Mandiri
Primary
Care
Referral Care
Non-PBI ex
PT Askes
MoH
Out of pocket
Other
Ministries
PBI
Pemda
34
Local Gov
Private
Insuran
ce
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Increase the premium
for the middle and rich
members
APBN
BPJS
Tax
Income
Non-tax
Income
Non-PBI Mandiri
Primary
Care
Referral Care
Non-PBI ex
PT Askes
MoH
Out pof pocket
Other
Ministries
PBI
Pemda
35
Local Gov
Private
Insuran
ce
Aim:
To reduceClaim
Ratio
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To reduce in-equity: there
should be fundamental
change in BPJS
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Needs compartment in BPJS
• In BPJS there
should be
compartment
based on source
of income and
expenditure
Aim:
•
To prevent the budgetfrom PBI to be used byNon-PBI-mandirimembers
(State budget for the poorshould be used by thepoor)
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Compartment in
BPJS
APBN
BPJS
Pajak
Pendapatan
Negara
bukan Pajak
Non-PBI Mandiri
Pelayanan
Primer:
Pelayanan
Rujukan
Non-PBi PNS,
Jamsostek dll dll
Kemenkes
Dana dari Masyarakat langsung
Kementerian
lain
PBI
Pemda
38
Rp
Rp
Rp
Pendapatan
Asli Daerah
Askes
Swasta
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Thank-you
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