Abstract
The National Health Insurance Program or Jaminan Kesehatan Nasional (JKN) managed by the Health Social Security Administration Agency or Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS Kesehatan) has entered its eighth year of implementation. Since 2014, PT Askes (Persero) has transformed into BPJS Kesehatan, this also has an impact on changes in the payment system from Retrospective Payment System to Prospective Payment System with INA-CBG (Indonesian-Case Based Groups) rates. The difference between INA-CBG rates and hospital real rates is a fundamental problem, so hospitals must make efforts to achieve quality control and cost control. The real rate is the rate used by the hospital based on service of each service according to local regulations. Meanwhile, INA-CBG is a case-based health financing package by grouping various types of services into one unit. There is a difference between the INA-CBG rates and the hospital's real rates for paying JKN claims for Advanced Inpatient (RITL) and Advanced Outpatient (RJTL) services as a whole. This study is a descriptive-analytic quantitative research. The data used is secondary data obtained from the list of hospital JKN claims on the BPJS Kesehatan Claims Digital Verification application. The results of the study indicate that there is a negative difference between the total INA-CBG rate and the total hospital real rate for inpatient services of Rp. -25,654,787,895 or -36% of the INA-CBG rate. In outpatient services there is a negative difference of Rp. -6,144,370,328,- or -13% of the INA-CBG rate. Based on these findings, we recommend that hospitals should conduct a utilization review of health services, as well as calculate the appropriate unit cost for each type of service. The hospital carries out quality control of services by paying attention to the diagnosis and action and treatment provided, so that there are no unnecessary services.
Highlights
In the health financing system in hospitals, Indonesia developed the Casemix system in 2006 under the name INA-DRG (Indonesian-Diagnosis Related Group)
Indonesia Case Based Groups (INA-CBG) rates for hospitals are applied according to the Minister of Health Regulation No 52 of 2016 concerning Standard Rates for Health Services in the Implementation of the Health Insurance Program (Kementerian Kesehatan Republik Indonesia, 2016)
Indonesian-Case Based Group (INA-CBG) rate is the amount of claim payment by BPJS Kesehatan to Advanced Level Referral Health Facilities or Fasilitas Kesehatan Rujukan Tingkat Lanjutan (FKRTL) for service packages based on disease diagnosis groupings and procedures
Summary
In the health financing system in hospitals, Indonesia developed the Casemix system in 2006 under the name INA-DRG (Indonesian-Diagnosis Related Group). Implementation of hospital payments with INA-DRG began on 1 September 2008 at 15 vertical hospitals. In September 2010 the nomenclature was changed from INA-DRG to INA-CBG (IndonesianCase Based Group) in line with the change in grouper from 3M Grouper to UNU (United Nation University) Grouper (Wibowo, 2014). Indonesia Case Based Groups (INA-CBG) rates for hospitals are applied according to the Minister of Health Regulation No 52 of 2016 concerning Standard Rates for Health Services in the Implementation of the Health Insurance Program (Kementerian Kesehatan Republik Indonesia, 2016). Indonesian-Case Based Group (INA-CBG) rate is the amount of claim payment by BPJS Kesehatan to Advanced Level Referral Health Facilities or Fasilitas Kesehatan Rujukan Tingkat Lanjutan (FKRTL) for service packages based on disease diagnosis groupings and procedures. There are a number of aspects that affect the cost of INA-CBG, namely the primary diagnosis, the presence of a secondary diagnosis in the form of comorbidities or complications, the severity, the form of intervention, and age of the patient
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