Laksono IAKMI FInance 2015 Minggu1c

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



Tujuan mempelajari kasus JKN di

tahun 2014

Memahami makna:

• Revenue Collection

• Pooling

• Purchasing

2



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

3



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.



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

5



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?

6



The Analysis

• Revenue Collection

• Pooling

• Purchasing

7



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)



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



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



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



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

12



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



Specialists Distribution



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



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



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

17



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)



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

19



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

20



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)

21



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)



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%



• Wheter UHC can be

achieved in 2019?

24



Scenario 1:Optimistic

Scenario 2:

Pessimistic.



UHC pessimistic scenario

2014 2015 2016 2017 2018 2019

DIY

NTT

Zero

JKN increases geographical

inequity,

and also socio-economicinequity



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).

27



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)



Proposed Strategic Policies in

Financing to reduce in-equity

29



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


Kementerian

lain

PBI

Pemda

30

Askes

Swasta



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



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



More MoH budget for redistribution of Specialist



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



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



To reduce in-equity: there

should be fundamental

change in BPJS

36



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)

37



Compartment in

BPJS

APBN

BPJS

Pajak

Pendapatan

Negara

bukan Pajak

Non-PBI Mandiri

Pelayanan

Primer:

Pelayanan

Rujukan

Non-PBi PNS,

Jamsostek dll dll

Kemenkes


Kementerian

lain

PBI

Pemda

38

Rp

Rp

Rp

Pendapatan

Asli Daerah

Askes

Swasta



Thank-you

39

Laksono IAKMI FInance 2015 Minggu1c

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