Physicians’ Behavior in Referring National Health Insurance Patients to Hospital

Natalia Natalia,Haerawati Idris

doi:10.7454/eki.v6i2.5279

Abstract

Physicians’ decision to refer patients in primary health care is vital in supporting the referral system. The increase of referral cases impacted the claims cost and hospital workload. This study aimed to analyze the physicians’ behavior in referring National Health Insurance (NHI) patients to hospitals. This study employed a qualitative method; 18 informants were selected using purposive sampling and analyzed using content analysis. The data were validated by triangulating method, source, and data. Physicians referred patients when the cases could not be handled; there were indications of severe disease and required further examination. The obstacles in the referral system were pressure from NHI patients that wanted to be referred and diagnosed differently from ICD 10. In referring NHI patients, physicians had followed referral procedures and criteria. High referrals were caused by patients being forced to be referred, coming with complaints of severe disease, having examined in a hospital, and some cases should not be referred to but still referred by entering a similar diagnosis into the ICD 10. It is expected that public health centers will educate NHI patients related to tiered referral procedures in health services.

Highlights

General Practitioner (GP) referral level is a crucial determinant in secondary health services utilization (Førde, Breidablik, & Øgar, 2011)
This study interviewed 18 informants consisting of physicians at the Dempo Public Health Center (PHC), referral officers, referred National Health Insurance (NHI) patients during the study, and one person in charge of the primary benefits guarantor in Palembang
Physicians referred patients when the cases could not be handled at the PHC; there were indications to be referred and required further examination

Summary

Introduction

General Practitioner (GP) referral level is a crucial determinant in secondary health services utilization (Førde, Breidablik, & Øgar, 2011). Physicians’ Behavior in Referring National Health times for many people (Ringberg, Fleten, Deraas, Hasvold, & Førde, 2013). Many countries and the World Health Organization adopted strategies to improve primary care services as a response to the increase of health quality and maintenance costs (Coyle, Hanley, & Sheerin, 2011). A study conducted by Thorsen (2017) reported that doctors experienced pressure from patients to be referred, especially younger doctors, as a reason for referral. Young male doctors experienced more workload and pressure from patients when referring to hospitals. A study conducted in Norwegia stated that female doctors referred significantly more frequently than male doctors and salaried doctors referred more frequently than private doctors (Ringberg et al, 2013)

Objectives

Methods

Results

Conclusion