Budi Eko Siswoyo Capitation Fund Management final

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CAPITATION FUND MANAGEMENT

(M & E OF NATIONAL HEALTH INSURANCE IN INDONESIA)

M. Faozi Kurniawan, Budi Eko Siswoyo, Faisal Mansur,

Wan Aisyah, Dedy Revelino, Welly Gadistina

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Outline

1.

Background

2.

Objective

3.

Method

4.

Result

5.

Bottleneck

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Background

2014

2015

2019

2016

UU 40/ 2004



SJSN



JKN

UU 24/ 2011



BPJS Kesehatan

Perpres 111/ 2013



Social Health Insurance

Perpres 32/ 2014

Permenkes 19/ 2014

Permenkes 59/ 2014

Permendagri 37/ 2014

SE MDN 900/2280/SJ

Perbpjsk 2/ 2015

Capitation-based performance

1

/

3

of health care cost in JKN



(4)

Objective

To analyze the management of capitation fund

in PHC including the bottlenecks & to generate

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Method

Study design

descriptive – cross sectional

Study sites

20 districts in 7 regional

Study participants

384 PHC (public and private)

Data collection techniques

Secondary data (2014-mid 2015)

from PHC and BPJS Kesehatan

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Membership in Puskesmas > Clinic > DPP

Membership growth in Clinic > DPP > Puskesmas

Membership of JKN Program, Jan 2014 – Jul 2015

Type of PHC

Mean

Trend (%)

2014

2015

Puskesmas BLUD

12.734

1,31%

2,85%

Puskesmas Non BLUD 14.356

1,07%

2,30%

DPP

(individual

physician practice)

2.718

3,19%

5,40%

(7)

PMPM in the clinic is the highest (IDR 8.000 – 10.000)

Distribution of PMPM in JKN Program

-2,000

4,000

6,000

8,000

10,000

12,000

Puskesmas

BLUD

Puskesmas

Non BLUD

Praktek

Dokter

Perorangan

Klinik

Pratama

Puskesmas

BLUD

Puskesmas

Non BLUD

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Total revenue of capitation fund in Puskesmas > Clinic > DPP

Revenue growth in Clinic > DPP > Puskesmas

Capitation Fund Revenue, Jan 2014 – Jul 2015

Type of PHC

(IDR/ Month)

Mean

Trend (%)

2014

2015

Puskesmas BLUD

79,1 M

1,71%

2,57%

Puskesmas Non BLUD

76,3 M

0,88%

1,83%

DPP

23,8 M

3,24%

5,73%

(9)

-5

10

15

20

Puskesmas

BLUD

Puskesmas

Non BLUD

Praktek

Dokter

Perorangan

Klinik

Pratama

No later than 15

th

and the earliest at 11

th

monthly

The Time of Disbursement of Capitation Fund

Puskesmas

BLUD

Puskesmas

Non BLUD

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Puskesmas Puskesmas

Plan of Action (PTP) Plan of Action (PTP)

DHO

DHO Local Government

Local

Government DPRDDPRD

Plan of Activity (RKA) Plan of Activity (RKA)

DHO DHO

Budget Planning (DPA) Budget Planning (DPA)

Puskesmas Puskesmas District Finance Administrator (DPPKAD) District Finance Administrator (DPPKAD) DHO DHO Puskesmas Puskesmas

Planning and Budgeting

Disbursement and Reporting

BPJS Kesehatan BPJS Kesehatan Capitation Fund Capitation Fund Operational Cost Operational Cost Cost of Service Cost of Service

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Puskesmas Puskesmas

Plan of Action (PTP) Plan of Action (PTP)

Business Plan (RBA) Business

Plan

(RBA) DHODHO DPRDDPRD

RBA

RBA Legal RBA_{Legal RBA}

Puskesmas Puskesmas District Finance Administrator (DPPKAD) District Finance Administrator (DPPKAD) DHO DHO Puskesmas Puskesmas BPJS Kesehatan BPJS Kesehatan Capitation Fund Capitation Fund Operational Cost Operational Cost Cost of Service Cost of Service

Puskesmas Report Puskesmas Report Report Report Report Report BPJS Kesehatan BPJS Kesehatan

Planning and Budgeting

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DPP DPP

Previous Expenditure Data Previous Expenditure Data

Business Plan (RBA) Business Plan (RBA) DPP DPP BPJS Kesehatan BPJS Kesehatan Capitation Fund Capitation Fund Operational Cost Operational Cost Cost of Service Cost of Service

Document / Note Document /

Note

• Price List • Market Mechanism

• Estimation • Price List • Market Mechanism

• Estimation

Planning and Budgeting

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Management of Clinic Management

of Clinic

Previous Expenditure Data Previous Expenditure Data

Business Plan (RBA) Business Plan (RBA) Clinic Clinic BPJS Kesehatan BPJS Kesehatan Capitation Fund Capitation Fund Operational Cost Operational Cost Cost of Service Cost of Service

Document / Note Document /

Note

• Price List • Market Mechanism

• Estimation • Price List • Market Mechanism

• Estimation

Management

Management Clinic Owner_{Clinic Owner}

Management of Clinic Management

of Clinic Clinic OwnerClinic Owner BPJS

Kesehatan BPJS Kesehatan

Planning and Budgeting

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0%

5%

10%

15%

20%

25%

30%

35%

1

2

3

4

5

6

7

8

9

10 11 12 13 14 15 16 17 18

Puskesmas BLUD

Puskesmas Non BLUD

Dokter Praktek Perorangan

Klinik Pratama

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Type of PHC

Actual

PKM BLUD

119.522

PKM Non BLUD 191.467

Clinic

78.006

DPP

78.999

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Local regulation (Perbup/ Pergub) become the main legal

basis for capitation fund management in Puskesmas

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Refer to local regulation,

some districts allocate the

cost of service is less than

60%

Most of the districts have

allocated + 60% of the

capitation funds for the

cost of service

District - A

District - B

District - C

District - D

District - E

District - F

District - G

District - H

District - I

District - J

District - K

District - L

District - M

District - N

District - O

District - P

District - Q

District - R

District - S

District - T

Cost of

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•

Capitation fund still insufficient for 24-hour service

•

Misperception for benefit package of promotion-preventive

•

Guidelines on the use of capitation still ambiguous

•

Budget mechanisms disrupted (especially for APBD)

•

Lack of socialization on capitation fund management

•

Lack of human resources in implementation of P-CARE

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•

Capitation

fund

should

be

increased

(especially for DPP and clinic as private PHCs)

•

Local government need to develop the guidelines or policies

related to the mechanism of capitation fund management

•

Continuous monitoring and evaluation of capitation fund by

BPJS Kesehatan, DHO, and independent organizations

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Jakarta.

2. __________,2004. Undang - Undang Nomor 15 Tahun 2004 Tentang Pemeriksaan, Pengelolaan dan Tanggung Jawab

Keuangan Negara, Pemerintah RI, Jakarta.

3. _________, 2011. Undang-Undang Nomor 24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial, Pemerintah RI,

Jakarta.

4. _________,Peraturan Menteri Kesehatan Republik Indonesia Nomor 59 Tahun 2014 Tentang Standar Tarif Pelayanan Kesehatan Dalam Penyelenggaraan Program Jaminan Kesehatan, Pemerintah RI, Jakarta.

5. _________,Peraturan Presiden Nomor 32 Tahun 2014 Tentang Pengalokasian dan Pemanfaatan Dana Kapitasi Jaminan Kesehatan Tingkat Pertama (FKTP) Milik Pemerintah dan Dukungan Biaya Operasional FKTP Milik Pemerintah Daerah, Pemerintah RI, Jakarta.

6. _________, 2005. Peraturan Pemerintah No 23 Tahun 2005 tentang Badan Layanan Umum, Pemerintah RI, Jakarta.

7. __________,2007. Peraturan Menteri Dalam Negeri Nomor 61 Tahun 2007 tentang Pedoman Teknis Pengelolaan

Keuangan Badan Layanan Umum Daerah, Pemerintah RI, Jakarta.

8. __________,2014. Surat Edaran Menteri Dalam Negeri Nomor 900/2280/SJ. Tanggal 5 Mei 2014 Tentang Petunjuk Teknis Penganggaran, Pelaksanaan dan Penatausahaan, serta Pertanggungjawaban Dana Kapitasi Jaminan Kesehatan Nasional pada Fasilitas Kesehatan Tingkat Pertama Milik Pemerintah Daerah, Pemerintah RI, Jakarta.

9. __________,2014. Peraturan Menteri Kesehatan Republik Indonesia Nomor 28 Tahun 2014 Tentang Pedoman

Pelaksanaan Program Jaminan Kesehatan Nasional, Pemerintah RI, Jakarta.

10. __________,2014. Permenkes 19/2014 tentang penggunaan Jaminan Kesehatan Nasional untuk Jasa Pelayanan Kesehatan dan Dukungan Biaya Operasional pada Fasilitas Kesehatan Tingkat Pertama Milik Pemerintah Daerah, Pemerintah RI, Jakarta.

11. Berwick, D.M., 1996. Payment by Capitation and the Quality of Care. N eng J Med, 335(16), pp.1227-1231. Available

at: http://dx.doi.org/10.1056/nejm199610173351611

12. Glazier. R.H, Geltink, J.K, Kopp. A, Sibley. L.M. 2009, Capitation and enhanced fee-for-service models for primary care reform: a population-based evaluation, CMAJ and is available at www.cmaj.ca/cgi/content/full/180/11/E72/DC2

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