Kendali Mutu Kendali Biaya BPJS Bidang Kesehatan

Kendali Mutu Kendali BiayaBPJS Bidang KesehatanAscobat GaniKetua TKMKB BPJS-KPertemuan Ilmiah Tahunan & Mukernas Perhimpunan Doketer Umum Indonesia (PDUI), Jakarta 17 19 April 2-15

Penguataan Profesionalisme Dokter di Tingkat Pelayanan Primer Menyongsong Pasar Bebas Asean dalam era JKN untuk Mewujudkan Ketahanan Nasional di Bidang KesehatanTema PIT & Mukernas PDUI 2015:Pasar Bebas AseanJKNProfesionalismeDokter di Pelayanan PrimerKetahanan di Bidang Kesehatan (*)Key words:(*) Mandiri ? Berdaulat ? Trust > (mendapat kepercayaan Harapan/AsumsiPerdagangan bebas akan :Meningkatkan persainganMenurunkan harga (efisiensi)Meningkatkan mutu pelayananMeningkatkan alih kemampuanEconomies of scalePilihan konsumer semakin banyak5 pilar utama MEA2008:Brunei DarussalamIndonesiaMalaysiaPhilipinaSingapuraThailand2012CambodiaMyanmarLaos PDRMyanmarVietnam625 juta pddkBarangJasaTenaga terampilInvestasiModalSatu pasar(single market)Minimalisasi biaya transaksiMaksimisasiPerolehan perdagangan21345Total penduduk625 jutaLPP1.30%GDP total (2013)2.40 Triliun USDGDP Growth (2013)5.1%Belanja kesehatan/thn89 milyar USDSumber: WHO, WBPddk (2013) (juta)Belanja Kes/th (milyar USD)Belanja kes/cap (USD)Pertumbuhan blnja kesehtanRS PemerinthRS SwastaSingapura5.413.52.5121587Malaysia29.712.041211141220Indonesia249.926.6108171.562666Thailand67.014.421581.000+320+Myanmar53.31.120201.000+100+Vietnam89.710.211515900+110+Philipine98.411.511915700+1.000+Sumber: WHO, WBCore ElementPrincipal Considerations1. Free flow of goods* Zero tariff and removal of Non-tariff Barriers; * Single licensing with harmonization of standards; * Differential pricing of pharmaceuticals and medical devices across ASEAN nations2. Free flow of services* Legal status of Cross-border health services; * information flow; * issues related to mutual recognition3. Free flow of investment; * Impact of private investment on public healthcare services- manpower egress, * demonstration effect; * consequences of consolidation and mega-healthcare services groups; * acceptability of healthcare services providers under foreign ownership4. Free flow of capital5. Free flow of skilled labor (Recognition Agreements)* Impact of South to North manpower flows; * Harmonization of Standards; * MRA does not lead to free flow of skilled labor- still many barriers to overcome(MRA = Mutual Recognition Arrangement)AFAS(Asean Framework Agreement on Service)11 Sektor155 sub- Sektor5 sub-sektor kesehatanPelayanan medis dan gigiVeterinaryKeperawatan dan KebidananPelayanan RSPel. Lain (ambulans, patologi, dll)Modus-1: Pelayanan lintas batas (misal: tele- medicine)Modus-2: Berobat ke luar Modus-3: Investasi di negara lain

Modus-4: Bekerja di negara lain2006 2012.

Survey /April 2014DH = Director HospitalDN = Director NursesPelayanan cepat dan nyamanPenguasaan bahasaKetrampilan penggunaan teknologi baru/canggih digital, nano, genomSistem Informasi PasienPelayanan kontinum (continuity of care)Peningkatan sistem RSSistem pembayaranPengawasan file pasienSistem pengobatanSurveylance, sistem pengamanan/proteksiPengendalian infeksiModifikasi tarif medisKomunikasiPersiapan emergensi* Institusi pendidikan* Institusi pelayanan* Ikatan profesi* Individu profesiTantangan dan StrategiCepat/ramahMutu pelayananEfisienABCAAABBBBBBBBCCBAAStrategiAkreditasi institusi pendidikan SDMK: nasional, ISO, JciAkreditasi Faskes (RS KARS, Puskesmas/Klinik ?)Ujian kompetensi standar internasionalPeningkatan a. kemampuan teknis medis b. Kemampuan soft skill c. Serikat SDMKJKN (Jaminan Kesehatan Nasional)Amanat konstitusi (1945) Universal Health Coverage atau UHC (WHO, 2010)UU45 SJSN (Kematian, Hari Tua, Kecelakaan Kerja, Kesehatan)BPJS-KesehatanPrinsip Asuransi Sosial right based, nir-labaBukan Asuransi Komersial risk basedGotong Royong/Solidaritas Sosial

Ancaman Thd sistem asuransi

Inflasi Biaya KesehatanHealth Care Cost Inflation RatesIndonesiaAmericasAsia PacificGlobal

Proyeksi Penduduk Indonesia 2015 - 2019COST DRIVERSAGING POPULATION

Supplier push; over utilizationDemand pull; over utilizationWeak preventive servicesHigher cost med. techProviders profit motiveEconomic environmentProviders & member behaviorExtenal factorsCOST DRIVERSCOST DRIVERSPelayanan Primer Puskesmas cenderung mengutamakan Rawat InapUn-necessary referral merujuk yang tidak seharusnya dirujuk Fraud up-coding, dllKendali Biaya kesehatan (Controlling Health Care Cost Inflation) Makro: a. Beyond Health sektor lain; lingkungan, tobacco tax dll b. Promotif/Preventif kesling, PHBS, skrining2. Mikro : [1] Supply a. Gate keeper & Sistem Rujukan b. Quality Improvement program c. UR d. Audit Medik e. Etika dan disiplin profesi f. HTA g. Dewan Pertimbangan Medis investasi klaim h. Clinical Advisory Board [2] Payment Strategic Purchasing a. Kapitasi b. CBG [3] DemandcostUn-structuredStructuredUtilizationCostServices sophisticationSelf carePrmotionPreventionBasic/Primary CareSecondary CareTertiary CareUtilization structure in health insurance systemGATE KEEPER155 D/ + PHPosisi KMKB dalam JKNKesehatan pesertaKepuasanSustainablePel.KesEfektifEfisienBermutuOutcomeOutputPPKSosialisasi kewenangan nakes sesuai kompetensiURAudit MedisPembinaan etikaDisiplin profesi123TKMKBPromotifPreventifKuratifRehabObat & BMHP* PKT-I* PKT-II & IIIPre- & Post adoptionRekomendasi Teknis Medis PelkesHTACABMedical judgmentClaim investigationDPMMicro strategy/ approachMacro strategy/ approachStrengthening PHCPHBSBeyond healthTax policyEtcHealth Technology AssessmentClinidal Advisory BoardDewan Pertimbangnan MedisTim Kendali Mutu Kendali BiayaSheet1201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420350-423,454.423,680.923,852.723,994.224,086.824,065.523,960.123,848.423,729.623,604.923,475.823,339.523,193.823,039.822,878.322,711.022,543.622,381.022,223.722,071.921,926.121,786.621,652.821,524.121,400.421,279.85-922,518.022,632.422,767.322,931.923,109.523,330.423,559.523,733.923,878.523,974.023,955.623,853.023,743.723,627.723,505.523,378.523,244.223,100.422,948.322,788.622,622.922,457.022,295.822,139.721,989.321,844.510-1422,165.622,230.122,280.922,309.822,360.222,461.522,577.122,713.122,878.723,057.123,278.623,508.223,683.323,828.423,924.423,907.023,805.523,697.123,581.623,460.123,333.823,200.223,057.022,905.522,746.422,581.315-1921,558.121,678.321,812.121,931.222,024.722,095.422,161.022,212.922,242.922,294.222,396.222,512.422,649.022,814.822,993.423,214.923,444.623,619.823,765.123,861.123,844.123,743.223,635.323,520.623,399.723,274.014.020-2420,939.421,039.021,148.721,250.721,352.421,447.921,569.021,703.621,823.321,917.621,989.022,055.422,108.122,138.922,190.922,293.222,409.622,546.222,711.922,890.323,111.323,340.523,515.423,660.523,756.523,739.816.025-2920,589.920,636.620,646.620,663.820,716.320,810.420,911.421,022.221,125.321,228.021,324.421,446.221,581.221,701.421,796.121,868.221,935.021,988.322,019.722,072.122,174.522,290.822,427.322,592.622,770.522,990.822430-3419,987.220,105.920,240.520,348.120,430.920,448.320,497.020,509.120,528.220,582.220,677.520,779.520,891.120,994.921,098.321,195.221,317.321,452.521,572.821,667.721,740.021,807.121,860.721,892.521,945.222,047.41,500.035-3918,514.118,829.019,104.319,365.919,587.119,816.119,936.520,072.520,181.520,265.820,285.020,335.120,348.820,369.320,424.320,520.220,622.520,734.420,838.520,942.021,039.021,161.021,295.821,415.921,510.621,582.9336,000.040-4416,564.316,958.417,332.817,683.218,004.718,295.118,609.318,884.219,145.419,366.719,595.419,716.719,853.219,963.020,048.020,068.520,119.420,134.220,155.820,211.320,307.220,409.420,521.020,624.720,727.820,824.645-4914,165.314,585.115,015.215,447.015,867.416,266.516,657.017,028.017,375.417,694.317,982.618,294.218,567.118,826.319,046.019,273.019,394.119,530.219,639.919,724.919,746.319,797.419,813.019,835.319,890.919,986.250-5411,479.511,980.012,440.612,877.213,313.713,766.514,179.014,601.515,025.415,438.115,830.316,213.716,578.116,919.417,232.817,516.217,822.518,090.718,345.618,561.718,784.718,904.519,038.919,147.619,231.619,253.655-598,546.39,015.29,515.710,026.010,518.110,972.711,457.111,903.312,326.612,749.813,188.313,588.313,997.614,408.014,807.615,187.315,558.315,911.016,241.416,545.016,819.517,116.117,376.117,623.117,832.718,048.860-646,156.76,432.56,753.47,116.87,518.87,955.38,397.88,870.59,352.89,818.210,248.610,707.311,130.111,531.511,932.612,347.712,726.813,114.113,502.213,880.014,239.214,589.714,923.115,235.515,522.615,782.465-694,651.24,775.64,908.55,062.85,253.45,489.65,742.86,035.46,365.96,731.87,130.07,532.57,963.08,402.68,826.99,219.59,638.110,024.210,391.010,757.211,135.611,481.511,834.612,188.112,532.012,859.370-743,375.53,469.43,565.33,661.73,757.03,852.03,963.54,082.24,218.64,384.94,588.54,807.55,058.55,340.95,653.95,995.46,339.16,707.37,083.37,446.47,782.58,140.98,471.98,786.59,100.59,424.375+3,853.33,942.34,040.64,147.84,263.84,388.54,526.94,670.14,817.24,967.05,120.65,294.95,475.75,670.55,887.66,133.26,403.96,700.77,028.77,393.77,798.48,218.18,671.99,150.09,640.010,132.7Total238,518.8241,990.7245,425.2248,818.1252,164.8255,461.7258,705.0261,890.9265,015.3268,074.6271,066.4273,984.4276,822.3279,577.4282,246.6284,829.0287,324.5289,732.1292,049.5294,274.0296,405.1298,444.0300,390.6302,242.2303,996.7305,652.4

68,138.068,543.468,900.969,235.969,556.569,857.470,096.770,295.470,486.870,636.070,710.070,700.770,620.870,495.970,308.269,996.569,593.369,178.568,753.668,320.667,882.867,443.867,005.666,569.366,136.165,705.611,880.012,187.312,514.412,872.313,274.213,730.114,233.214,787.715,401.716,083.716,839.117,634.918,497.219,414.020,368.421,348.122,381.123,432.224,503.025,597.326,716.527,840.528,978.430,124.631,272.532,416.3158,500.8161,260.0164,009.9166,709.9169,334.1171,874.2174,375.1176,807.8179,126.8181,354.9183,517.3185,648.8187,704.3189,667.5191,570.0193,484.4195,350.1197,121.4198,792.9200,356.1201,805.8203,159.7204,406.6205,548.3206,588.1207,530.5Dep ratio50.5%50.1%49.6%49.3%48.9%48.6%48.4%48.1%47.9%47.8%47.7%47.6%47.5%47.4%47.3%47.2%47.1%47.0%46.9%46.9%46.9%46.9%47.0%47.0%47.2%47.3%1.982.002.012.032.042.062.072.082.092.092.102.102.112.112.112.122.122.132.132.132.132.132.132.132.122.12< 524,065.523,960.123,848.423,729.623,604.9SD/SLTP45,791.946,136.646,447.046,757.247,031.1SLTA/PT22,095.422,161.022,212.922,242.922,294.2Usia Kerja141,823.5143,816.3145,724.4147,531.1149,242.5Lansia (>60)21,685.422,631.023,658.224,754.525,901.9Klp. Umur201520162017201820190-424,065.523,960.123,848.423,729.623,604.95-923,330.423,559.523,733.923,878.523,974.010-1422,461.522,577.122,713.122,878.723,057.115-1922,095.422,161.022,212.922,242.922,294.220-2422,447.921,569.021,703.621,823.321,917.625-2920,810.420,911.421,022.221,125.321,228.030-3420,448.320,497.020,509.120,528.220,582.235-3919,816.119,936.520,072.520,181.520,265.840-4418,295.118,609.318,884.219,145.419,366.745-4916,266.516,657.017,028.017,375.417,694.350-5413,766.514,179.014,601.515,025.415,438.155-5910,972.711,457.111,903.312,326.612,749.860-647,955.38,397.88,870.59,352.89,818.265-695,489.65,742.86,035.46,365.96,731.870-743,852.03,963.54,082.24,218.64,384.975+4,388.54,526.94,670.14,817.24,967.0Total256,461.7258,705.0261,890.9265,015.3268,074.6< 524,065.523,960.123,848.423,729.623,604.9SD23,330.423,559.523,733.923,878.523,974.0SLTP/SLTA44,556.944,738.144,926.045,121.645,351.3PT22,447.921,569.021,703.621,823.321,917.6Usia Kerja120,375.6122,247.3124,020.8125,707.8127,324.9Lansia (>60)21,685.422,631.023,658.224,754.525,901.9

0.880.900.900.900.90

Sheet2Tahun20102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035Dep ratio50.5%50.1%49.6%49.3%48.9%48.6%48.4%48.1%47.9%47.8%47.7%47.6%47.5%47.4%47.3%47.2%47.1%47.0%46.9%46.9%46.9%46.9%47.0%47.0%47.2%47.3%

Sheet3