Laksono Trisnantoro
Chairman, Department of Health Policy and Management
Faculty of Medicine, Universitas Gadjah Mada
1
JKN
and
Content
1. Health Insurance
Utilization
2. Why In-equity may
worsened
3. The case of Indonesia
Principle of Insurance and
Equity
•
Depends of
Benefit Package
•
Premium
•
Supply side
readiness
•
Family economic
status and the
payment from
the scheme
•
May in favor of the
rich compared to
the poor
What is happening in
Indonesia
Wrong Targeted Subsidy
Claim Ratios:
For Poor Member <100%
Informal Non-Poor : > 500%
APB
N
BPJ
S
Tax-income
Non-tax
income
Primary
Care
Referral
Care
Non-PBI,
Ex..PT Askes
and formal
sector
Mo
H
Out of Pocket
Ideological Question:
•
Is it proper that PBI fund (for the
poor) is used by non-poor?
•
Is it proper that the non-poor
informal sector receive APBN?
Indonesian tax system is not
progressive
Tax Situation
- 2,000,000.00 4,000,000.00 6,000,000.00 8,000,000.00 10,000,000.00 12,000,000.00 14,000,000.00 GDP Nasional (harga berlaku) Penerimaan Pajak Penerimaan Bukan Pajak Hibah TahunM
il
ia
r
R
u
p
ia
h
Sumber:
Indone-sia dalam Angka
2015, BPS; UU
APBN 2016
Kementerian
Keuangan RI
GDP
Tax
Revenue
Non-Tax
Revenue
Problems in
tax collection
More
Inequity is increasing
Causes:
•
Mal-distribution of Supply side
•
Large Benefit package
•
Premium price is too low for non-poor
informal (PBPU)
Supply side (hospital)
•
Primary Care
•
Referral Care
Hospital Growth
Note:
Region 1: DKI, Jabar, Jateng, DIY, Jatim, Banten
Region 2: Sumbar, Riau, Sumsel, Lampung, Bali, NTB
Region 3: NAD, Sumut, Jambi, Bengkulu, Kepri, Kalbar, Sulut, Sulteng,
Sulsel, Sultra, Gorontalo, Sulbar
Region 4: Kalteng, Kalsel
Region 5: Kep. Babel, NTT, Kaltim, Maluku, Malut, Papua Barat, Papua
2012
2013
2014
Updated (Dec 2015)
-
200
400
600
800
1,000
1,200
1,400
Pertumbuhan RS per Regional
Classes of Hospitals
No Region
A
B
C
D
Non
Clas
s
Per Dec 2015
1
Region 1
39 208 442 240 355
2
Region 2
8
32 140
70
81
3
Region 3
8
78 213
86 189
4
Region 4
2
6
25
11
11
5
Region 5
2
16
67
67
65
Region 1: DKI, Jabar, Jateng, DIY, Jatim, Banten
Region 2: Sumbar, Riau, Sumsel, Lampung, Bali, NTB
Region 3: NAD, Sumut, Jambi, Bengkulu, Kepri, Kalbar, Sulut, Sulteng, Sulsel, Sultra, Gorontalo, Sulbar
Region 4: Kalteng, Kalsel
Number of Specialists
Ketersediaan spesialis di DKI Jakarta, Jawa Barat, Jawa Tengah, Sumatera Utara, Banten lebih
banyak dibanding di provinsi lain, di NTT hanya 0.2% dari total jumlah spesialis 4 dasar
tersebut.
Per Dec
2015
DK
I J
ak
ar
ta
Ja
w
a
Te
ng
ah
Ja
w
a
Ti
m
ur
Su
m
at
er
a
Ba
ra
t
Su
m
at
er
a
Se
la
ta
n
Ba
li
NA
D
Ja
m
bi
Ke
pr
i
Su
la
w
es
i U
ta
ra
Su
la
w
es
i S
el
at
an
Su
la
w
es
i B
ar
at
Ka
lim
an
ta
n
Se
la
ta
n
NT
T
M
al
uk
u
Pa
pu
a
Ba
ra
t
-
200
400
600
800
1,000
1,200
Spesialis 4 Dasar per Provinsi
13
Sumber : BPJS Kesehatan, Jan 2014 s/d
Maret 2015
Ratio:
Divre 6: Divre 12: around
16 times
Ratio:
Divre 6: Divre 12: around
7 times
Claim comparison across
DivRe
14
Large
Bene
fit
Packa
ge
Benefit Package At Current
InpatientServices
Tertiary/ Super specialtyinpatient services Yes Secondary-level Inpatient hospital services Yes EmergencyServices Yes ChildBirth / Maternity/ Delivery Yes
OutpatientServices
Publichealth services, such asimmunizations Yes Outpatient primarycarecontacts
Yes
Outpatient specialist contactsYes
Pharmaceuticalsfor outpatient services
Yes
Clinical laboratorytestsYes
Diagnosticimagingfor outpatient services
Yes
Otherservices
Eyeglasses
Yes
Dental careYes
Mental health/behavioral
Yes
Dialysis
Yes
The maths of PBI in one remote District:
1 D-Class hospital with 1 specialist:
180.000 people. Member of BPJS PBI: around
101 ribu.
BPJS-Non-PBI: around 12.500
Expenditure by BPJS in 2015:
•
Capitation Rp 7.5 Billion
•
Claim Rp 5.5 B di RS Kab A
•
Claim in Hospital B in District is
assumed around Rp 4 Billion
•
Total expenditure: around Rp 17 B.
How much BPJS budget should be
spent in this district?
•
PBI: 101.000 x Rp 19.500 x 12
month= around RP 24 B.
•
Non-PBI: 12.500 x Rp 45.ribu (on
average) x 12 month = Rp 6 B .
•
Total budget from BPJS: around Rp
30 B.
15
Unspent budget:
Rp 13 B (Rp 30 B –
What is happening in
the last 2 and half year?
•
In-equity is not well
treated in JKN
•
Needs new
policies for
reducing
in-equity
Future Policies
(expectation):
Short term:
1.
PBPU policy should be
changed
2.
Basic Benefit Package,
Caps, and catastrophic
insurance
3.
Compensation Policy
Long-term: Investment for
health infrastructure and
human resources
1. The Policy of PBPU
•
Treat PBPU to
minimize the
use of PBI
budget
•
Only 2 types:
PBI-class and First
Class
•
PBI-Class is fixed.
No class upgrading
•
Increase the PBPU
first Class using
actuarial data
•
Marketing as an
insurance
2. Manage the Basic Benefit
Package
19
Benefit
Packag
e
Propinsi-propinsi
maju seperti DKI
Propinsi-propinsi sulit
At current:
Future: Needs Basic Benefit Package
20
Basic Benefit package
Benefit
Packag
e
Propinsi-propinsi
maju seperti DKI
Needs caps for the PBPU (rich)
21
Basic Benefit package
Benefit
Packag
e
Catastrophic Insurance
Propinsi-propinsi
maju seperti DKI
22
Needs
Caps
Benefit Package At Current
InpatientServices
Tertiary/ Super specialtyinpatient services Yes Secondary-level Inpatient hospital services Yes EmergencyServices Yes ChildBirth / Maternity/ Delivery Yes
OutpatientServices
Publichealth services, such asimmunizations Yes Outpatient primarycarecontacts
Yes
Outpatient specialist contactsYes
Pharmaceuticalsfor outpatient services
Yes
Clinical laboratorytestsYes
Diagnosticimagingfor outpatient services
Yes
Otherservices
Eyeglasses
Yes
Dental careYes
Mental health/behavioral
Yes
Dialysis
Yes
3. Compensation policy to under
developed regions should be
implemented
23
Basic Standard
Package
Benefit
Packag
e
Developed Regions
Under Developed
Regions
Compensation fund by BPJS
(SJSN Laws in 2004)
Diatur lebih lanjut dengan Permenkes no 71 tahun 2013
Bagian Kedelapan Permenkes 2013
Pemberian Kompensasi
Pasal 30
(1) Dalam hal di suatu daerah belum tersedia Fasilitas Kesehatan yang
memenuhi syarat guna memenuhi kebutuhan medis sejumlah Peserta,
BPJS Kesehatan wajib memberikan kompensasi.
(2) Penentuan daerah belum tersedia Fasilitas Kesehatan yang
memenuhi syarat guna memenuhi kebutuhan medis sejumlah Peserta
ditetapkan oleh dinas kesehatan setempat atas pertimbangan BPJS
Kesehatan dan Asosiasi Fasilitas Kesehatan.
(3) Kompensasi sebagaimana dimaksud pada ayat (1) diberikan dalam
bentuk :
•
penggantian uang tunai;
•
pengiriman tenaga kesehatan; dan
(4) Kompensasi dalam bentuk penggantian uang tunai
sebagaimana dimaksud pada ayat (3) huruf a berupa
penggantian atas biaya pelayanan kesehatan yang diberikan
oleh Fasilitas Kesehatan yang tidak bekerja sama dengan BPJS
Kesehatan.
(5) Besaran penggantian atas biaya pelayanan kesehatan
sebagaimana dimaksud pada ayat (4) disetarakan dengan
tarif Fasilitas Kesehatan di wilayah terdekat dengan
memperhatikan tenaga kesehatan dan jenis pelayanan yang
diberikan.
(6) Kompensasi dalam bentuk pengiriman tenaga kesehatan
dan penyediaan Fasilitas Kesehatan tertentu sebagaimana
dimaksud pada ayat (3) huruf b dan huruf c dapat bekerja
sama dengan dinas kesehatan, organisasi profesi kesehatan,
dan/atau asosiasi fasilitas kesehatan.
Model of Compensation
Policy
•
Sister Hospitals
•
Working together with
Residency trainings
•
Mobile Hospitals and
Mobile Clinics
•
Telemedicine
…..
Closing:
•
Equity in JKN is a real problem.
•
Against the Laws and the Constitution
But….policy makers and BPJS leaders:
27
Accept
I hope:
InaHEA members should
advocate this equity issues
using welfare economics
principles, and
social-justice ideology
Many thanks
