Indonesian National Health Insurance Research Articles

Endovascular Aneurysm Repair (EVAR) in Rupture of the Infrarenal Abdominal Aortic Aneurysm (AAA) with Severe Neck Angulation in Conscience of National Health Coverage in Tertiary Referral Hospital in Indonesian: Case Report

AbstractAn aortic aneurysm is a condition with focal dilation of 50% or more over the normal aortic diameter. The most frequent form of aortic aneurysms is infrarenal. Endovascular aortic aneurysm repair is a valid treatment for treating patients with abdominal aortic aneurysm. Abdominal aortic aneurysms (AAAs) are electively repaired to prevent rupture. We present a case of an elderly man with an impending rupture of intraluminal infrarenal AAA with bilateral common iliac arteries aneurysms. Overall, the patient had completed the procedure and made a good postoperative recovery with fully coverage of Indonesian national health insurance.

When the smoke gets in your lungs: short-term effects of Indonesia’s 2015 forest fires on health care use

BackgroundThe forest fires that ravaged parts of Indonesia in 2015 were the most severely polluting of this century but little is known about their effects on health care utilization of the affected population. We estimate their short-term impact on visit rates to primary and hospital care with particular focus on visits for specific smoke-related conditions (respiratory disease, acute respiratory tract infection (ARTI) and common cold).MethodWe estimate the short-term impact of the 2015 forest fire on visit rates to primary and hospital care by combining satellite data on Aerosol Optical Depth (AOD) with administrative records from Indonesian National Health Insurance Agency (BPJS Kesehatan) from January 2015–April 2016. The 16 months of panel data cover 203 districts in the islands of Sumatra and Kalimantan before, during and after the forest fires. We use the (more efficient) ANCOVA version adaptation of a fixed effects model to compare the trends in healthcare use of affected districts (with AOD value above 0.75) with control districts (AOD value below 0.75). Considering the higher vulnerability of children’s lungs, we do this separately for children under 5 and the rest of the population adults (> 5), and for both urban and rural areas, and for both the period during and after the forest fires.ResultsWe find little effects for adults. For young children we estimate positive effects for care related to respiratory problems in primary health care facilities in urban areas. Hospital care visits in general, on the other hand, are negatively affected in rural areas. We argue that these patterns arise because accessibility of care during fires is more restricted for rural than for urban areas.ConclusionThe severity of the fires and the absence of positive impact on health care utilization for adults and children in rural areas indicate large missed opportunities for receiving necessary care. This is particularly worrisome for children, whose lungs are most vulnerable to the effects. Our findings underscore the need to ensure ongoing access to medical services during forest fires and emphasize the necessity of catching up with essential care for children after the fires, particularly in rural areas.

Role of local government officers in the implementation of national health insurance for poor peoples

This study explains the performance of the local government in implementing the Indonesian national health insurance policy model for the poor. This study used qualitative research methods. In addition, in-depth interviews, observations, and document studies were used for data collection. The data analysis consisted of data reduction, display, conclusion drawing, and verification. The study results revealed the performance patterns of local government officials, such as local government officials' capabilities, bureaucratic culture, political interests, principles of universality, and financing of health coverage. Implementing a national health insurance policy for the poor people in Bandung City, West Java, Indonesia, has implications for a broader dimension, such as political, legal, economic, social, and cultural research, which has implications for the development of health resources, improvement of the population administration system, financing and quality, and cost control.

Theory-practice gap of capitation payment in the Indonesian national health insurance: toward universal health coverage

PurposeThis study aims to present a comprehensive integrative review of capitation payment for primary healthcare (PHC) in the Indonesian national health insurance (Jaminan Kesehatan Nasional,JKN).Design/methodology/approachWhittemore and Knafl’s integrative review method is used within this review and analysis framework. Multiple types of academic literature were included in this review, including all studies related to capitation payment in the JKN from 2014 until 2022.FindingsThis review found that several practices of capitation payments in the JKN in Indonesia deviate from basic economic concept of capitation. It does not yet incentivize PHC to create a competitive environment in attracting members and it does not incentivize health promotion and prevention. Moreover, the capitation model uses the same scope of primary care services for all PHC throughout the country – which in fact has disparities in providing 155 medical conditions as required competencies for PHC. The authors recommend that the JKN apply bottom-up costing and pricing methods to set market prices of capitation rates.Originality/valueThis is the first study that reviews theory-practice gap of the capitation payment model using an integrative review that covers academic literature, journal articles and regulations in Indonesia.

Healthcare Quality Received by Insured Patients in Two Indonesian Regional Public Hospitals.

Background: Hospitals are required to improve the quality of health services provided to patients. Purpose: Evaluating and comparing the healthcare quality received by insured patients hospitalized in two Indonesian regional public hospitals. Methods: Secondary data analysis used the 2019 and 2020 Indonesian National Health Insurance e-claim databases of Hospital A and Hospital B. Descriptive and crosstabs analyses were used to determine INA-CBGs diagnoses that were categorized as high volume, high risk, and high cost. Results: The admissions that caused financial loss at the Hospital A were 21.1% in 2019 and 19.8% in 2020, while 30.3% in 2019 and 27.5% at the Hospital B. More than 60% of these admissions were placed in the 3rd class of inpatient wards of the two hospitals. Of these admissions, < 5% at the Hospital A and >5% at the Hospital B were readmitted within 30 days, although more than 90% were previously discharged based on physicians' approval. Conclusions: Inadequate healthcare quality received by insured patients. Hence, an integrated clinical pathways based professional nursing practice model is highly recommended to increase patient outcomes and decrease 30 days hospital readmission rates.

National health insurance contribution to family planning program funding in Indonesia: A fund flow analysis.

Launched in 2014, Indonesia's national health insurance system (JKN) aimed to provide universal health coverage, including contraceptive services, to its population. We aim to evaluate the contribution of JKN to the overall spending for the family planning program in Indonesia. Data from the Indonesian Demographic Health Survey, Survey on Financial Flows for Family Planning, Indonesia Motion Tracker Matrix, World Population Prospect, and Indonesian ministries' budget accountability reports were entered into the CastCost Contraceptive Projection Tool to define budgetary allocation and spending for the family planning program at the national level in 2019. Indonesia's family planning program in 2019 was financed mostly by the national budget (64.0%) and out-of-pocket payments (34.6%). There were three main ministries responsible for family planning financing: the National Population and Family Planning Board (BKKBN) (35.8%), the Ministry of Finance (26.2%), and the Ministry of Health (2.0%). Overall, JKN contributed less than 0.4% of the funding for family planning services in Indonesia in 2019. The majority of family planning spending was by public facilities (57.3%) as opposed to private facilities (28.6%). JKN's contribution to funding Indonesia's family planning programs in 2019 was low and highlights a huge opportunity to expand these contributions. A coordinated effort should be conducted to identify possible opportunities to realign BKKBN and JKN roles in the family planning programs and lift barriers to accessing family planning services in public and private facilities. This includes a concerted effort to improve integration of private family planning providers into the JKN program.

Effects of the COVID-19 pandemic on healthcare utilization among older adults with cardiovascular diseases and multimorbidity in Indonesia: an interrupted time-series analysis

BackgroundThe COVID-19 pandemic has disrupted healthcare utilization globally, but little is known about the effects among patients with cardiovascular diseases (CVDs) and other multimorbidities. This study analyzed the impacts of COVID-19 on healthcare utilization for patients aged 30 years and older with cardiovascular diseases (CVDs) with or without other chronic disease comorbidities in Indonesia.MethodsWe designed a retrospective cohort study based on the Indonesian National Health Insurance (NHI) sample data from 2016–2020. We defined healthcare utilization as monthly outpatient and inpatient visits related to chronic diseases at the hospital and primary healthcare levels per 10,000 NHI members. We used interrupted time series analysis to evaluate how the healthcare utilization patterns had changed due to the COVID-19 pandemic.ResultsOverall, hospital outpatient visits decreased by 39% when the pandemic occurred (95% Confidence Interval (CI): 0.48,0.76), inpatient visits by 28% (95% CI: 0.62,0.83), and primary healthcare visits by 34% (95% CI:0.55, 0.81). For patients with CVDs and multimorbidity, hospital outpatient and inpatient visit rates were reduced by 36% and 38%, respectively and primary healthcare visits by 32%. Some insignificant differences in the reduction of out-and inpatient visits were observed across diagnosis groups and regions.ConclusionHealthcare utilization among patients with chronic diseases decreased significantly during COVID-19 and consistently across different chronic diseases and regions. To cope with the unmet needs of healthcare utilization in the context of the pandemic, the healthcare system needs to be strengthened to cater to the needs of the population-at-risk, especially for patients with CVDs and multimorbidity.

Income Disparity and Healthcare Utilization: Lessons from Indonesia's National Health Insurance Claim Data.

Indonesia's National Health Insurance Program, known as Jaminan Kesehatan Nasional (JKN), has a variety of membership pathways for those wishing to gain access. Claim data from JKN offers a cost-effective way of observing who is accessing healthcare services and what types of services are being used. This study is a novel attempt to measure disparities amongst JKN users in their engagement with services, providing an opportunity to reflect on patterns of use. Using claims data collected from JKN users between 2015-2016, we used the Ordinary Least Square estimation model to compare health services utilization among subsidized and non-subsidized users. We focused primarily on the individual use of the hospital for outpatient and inpatient treatment. Analysis reveals that subsidized users access primary healthcare services more frequently than non-subsidized users. Conversely, non-subsidized users access secondary and tertiary health care services more frequently than other users. Subsidized users who utilize secondary and tertiary health care tend to suffer more severe health illnesses than non-subsidized members. This study concludes that income disparity affects healthcare utilization. Non-subsidized members are more likely than subsidized members to access secondary and tertiary health care services. Our study offers evidence of the potential underutilization of secondary and tertiary healthcare (STHC) by subsidized members, which could lead to inefficiency since subsidized members seeking STHC treatment had severe health conditions, thus needing to be treated longer and requiring higher healthcare expenditures.

Predictors of Indonesian National Health Insurance Knowledge: A Cross-Sectional Study Among Public Health Students in Palembang

Students, as agents of change, are expected to assist in reaching the success of the Indonesian National Health Insurance/Jaminan Kesehatan Nasional (JKN) program. Therefore, this study aimed to analyze the JKN knowledge among public health students and the associated factors in Palembang City, Indonesia. A cross-sectional online survey was conducted to collect data from 279 students at Universitas Sriwijaya in Palembang City, Indonesia. The analyzed variables included gender, age, marital status, residence, family size, income, study level and period, as well as source of JKN information. Additionally, statistical analysis using binary logistic regression, presenting odds ratio and 95% CI, was conducted to identify the determinants of JKN knowledge with significance set at a p-value &lt;0.05. The results showed that 92.47% of respondents had low JKN knowledge with the following characteristics; female (93.83%), aged &gt;20 years (92.93%), not married (93.75%), living in urban areas (90.24%), having family members &gt;4 people (91.39%), income ≤UMR (93.38%), undergraduate level (93.70%), study period ≤2 years (93.89%), and receiving information from the Social Security Administration Agency for Health (BPJSK) (94.32%). The most associated variable with JKN knowledge was residence after being controlled by gender, study period, and information source variables. Specifically, respondents residing in urban areas (aOR = 10.73; 95% CI: 1.32–86.89) showed a higher likelihood of having good JKN knowledge than those in rural areas.

Exploring Inequalities in the Use, Quality, and Outcome of the Diabetes Management Program of Indonesian National Health Insurance.

Access to diabetes management programs is crucial to control the increasing contribution of diabetes to the global burden of disease. However, evidence regarding whether such services are equally accessible for all population groups is still lacking, particularly in the context of low-middle-income countries and under the National Health Insurance (NHI). This study aimed to assess the extent of socioeconomic and geographical inequalities in the use, quality, and outcome of a diabetes management program for beneficiaries of Indonesian NHI. A total of 628 participants in the NHI diabetes management program in Banyumas District, Indonesia, were included in 2021 in this cross-sectional study. The main variables measured were regular visits to primary care facilities, standard medication, and glycemic control. The rate difference and rate ratio of age-sex standardized prevalence rates, as well as multiple logistic regressions, were used to measure the extent of inequalities. Around 70% of participants regularly visited primary care facilities and received standard medication, but only 35% had good glycemic control. Highly educated participants were more likely to have regular visits compared to low-educated participants (odds ratio [OR] 1.92; 95% confidence interval [95% CI]: 1.04-3.56). Based on employment and type of NHI beneficiaries, a small extent and even reverse inequalities were found although these findings were insignificant statistically. Urban residents were also more likely to have regular visits (OR 6.61; 95% CI: 2.90-15.08), receive standard medication (OR 9.73; 95% CI: 3.66-25.90), and have good glycemic control (OR 3.85; 95% CI: 1.68-8.83) compared to rural residents. Evidence on the extent of socioeconomic inequalities is inconclusive but substantial geographical inequalities in the use, quality, and outcome of diabetes management programs exist among Indonesian NHI beneficiaries. Future implementation policies of the program should consider particularly the geographical characteristics of participants to avoid and reduce inequalities and, hence, the disease burden of diabetes.

Prediction of patient length of stay using random forest method based on the Indonesian national health insurance

Prediction of patient length of stay using random forest method based on the Indonesian national health insurance

Cetuximab as first-line treatment for metastatic colorectal cancer (mCRC): a model-based economic evaluation in Indonesia setting

ObjectivesTo assess the cost-effectiveness of cetuximab in combination with chemotherapy fluorouracil, oxaliplatin, and leucovorin (FOLFOX) or fluorouracil, irinotecan and leucovorin (FOLFIRI) compared to standard chemotherapy alone as a first-line treatment for metastatic colorectal cancer (mCRC) with positive KRAS wild type patients in Indonesia.MethodsA cost-utility analysis applying Markov model was constructed, with a societal perspective. Clinical evidence was derived from published clinical trials. Direct medical costs were gathered from hospital billings. Meanwhile, direct non-medical costs, indirect costs, and utility data were collected by directly interviewing patients. We applied 3% discount rate for both costs and outcomes. Probabilistic sensitivity analysis was performed to explore the model’s uncertainty. Additionally, using payer perspective, budget impact analysis was estimated to project the financial impact of treatment coverage.ResultsThere was no significant difference in life years gained (LYG) between cetuximab plus FOLFOX/FOLFIRI and chemotherapy alone. The incremental QALY was only one month, and the incremental cost-effectiveness ratio (ICER) was approximately IDR 3 billion/QALY for cetuximab plus chemotherapy. Using 1–3 GDP per capita (IDR 215 million or USD 14,350) as the current threshold, the cetuximab plus chemotherapy was not cost-effective. The budget impact analysis resulted that if cetuximab plus chemotherapy remain included in the benefits package under the Indonesian national health insurance (NHI) system, the payer would need more than IDR 1 trillion for five years.ConclusionsThe combination of cetuximab and chemotherapy for mCRC is unlikely cost-effective and has a substantial financial impact on the system.

Early Detection of Breast Cancer in Indonesia: Barriers Identified in a Qualitative Study.

The lack of early detection in breast cancer management has been identified as the primary factor contributing to the high mortality rate. The introduction of BPJS Kesehatan, Indonesia's national health insurance, was intended to ensure the provision of adequate health services for breast cancer patients. This study aimed to investigate the current state of health services in Indonesia concerning the early detection of breast cancer, following the implementation of BPJS Kesehatan introduction. The study was conducted in 2017 in Yogyakarta, Indonesia. Subjects were recruited using a purposive sampling technique with maximum variation. The sample comprised breast cancer patients, health care professionals (HCPs), and healthy women from the general population with no history of breast cancer. The subjects' experiences and knowledge of health services regarding the early detection of breast cancer were investigated through in-depth interviews. Thematic analysis was used to synthesize the results from interviews with 25 participants. This study identified several issues that hinder the timely detection of breast cancer. The lack of both screening and diagnostic procedures emerged as a prominent obstacle in breast cancer management. The study identified the following barriers: (1) limited community knowledge about early detection; (2). lack of urgency among patients to seek medical treatment; (3) limited access to health facilities; and (4) inconsistent adherence among health care professionals to guidelines for both screening and diagnostic procedures. This study revealed multiple factors contributing to the delay in breast cancer detection in Indonesia, leading to suboptimal management of the disease. It is crucial for the government to prioritize the improvement of enabling factors across all levels of care for early detection. These factors include initiatives to increase public awareness, improve access to health services, strengthen the referral system, and enhance health facilities.

Effects of performance-based capitation payment on the use of public primary health care services in Indonesia

The Indonesian national health insurance agency BPJS Kesehatan, the largest single-payer system in the world, is among the first to combine capitation-based payments with performance-based financing. The Kapitasi Berbasis Komitmen (KBK) scheme for puskesmas (community health centres) was implemented in province capitals between August 2015 and May 2016. Its main goal was to incentivize the substitution of secondary by primary care use. We evaluate its effect on its three incentivized outcomes: the fraction of insured visiting the puskesmas, the fraction of chronically ill with a puskesmas visit and the hospital referral rate for insured with a non-specialistic condition. We use BPJS Kesehatan claims data from 2015 to 2016 from a stratified one percent sample of its members. Comparable control districts were identified using coarsened exact matching. We adopt a Difference-in-Differences (DID) study design and estimate a two-way fixed effects regression model to compare 27 intervention districts to 300 comparable non-capital control districts. We find that KBK payment increased the monthly percentage of enrolees contacting a puskesmas with 0.578 percentage points. This is a sizeable increase of 48 percent compared to the baseline rate of just 1.2% but it still leaves most puskesmas far below the “sufficient” KBK threshold of 15%. For chronically ill patients, a small increase of 1.15 percentage points was estimated, but it leaves the rate even further below the program's “sufficient” threshold of 50%. We find no statistically significant effect on referral rates to hospitals for conditions not requiring specialist care. While we find positive effects of KBK on two out of three outcomes, all estimated effect sizes leave the actual rates far below the program targets. Our findings suggest that the KBK performance-based capitation reform has not been very successful in substituting secondary care use by greater primary care use.

Does the Implementation of a National Health Insurance Program Result in Rationing Care for Ischemic Stroke Management? Analysis of the Indonesian National Health Insurance Program.

There are 2.2 million stroke patients in Indonesia, and ischemic stroke represents 87% of all strokes. Ischemic stroke is one of the covered diseases (INA-CBGs) in the National Health Insurance (JKN). Based on the Indonesian Ministry of Health's data, stroke uses up 1% of the yearly budget. This study compares clinical outcomes and treatment patterns before and during the JKN era. A cross-sectional analytical study of ischemic stroke medical records treated at Hasan Sadikin Hospital in 2013 and 2015 as representatives of the before and during JKN era. Chi-Square is used for data processing relationship analysis. 164 ischemic stroke patients were treated, 75 before implementing the JKN program and 89 after implementing the JKN program. There was a significant difference between treatment patterns (p<0.001) and clinical outcomes (p=0.046) of ischemic stroke patients before and after implementing The Indonesian National Health Insurance. There was no significant difference in length of stay (LOS). There is significant different between treatment pattern and clinical outcome of ischemic stroke patients before and after implementing The Indonesian National Health Insurance. This program has improved clinical outcomes concerning the purpose of the JKN program to provide social protection and welfare in terms of health.

Socio-economical Characteristics and Determinants of Indonesian National Health Insurance Subsidized By The Government in Jakarta

The National Health Insurance Program (Jaminan Kesehatan Nasional - JKN) is a social health insurance managed by the National Health Insurance Agency (Badan Penyelenggara Jaminan Sosial Kesehatan – BPJS Kesehatan), aiming to provide health insurance for all Indonesian people. Community groups that receive subsidies from the government are referred to as Contribution Assistance Recipients (Penerima Bantuan Iuran - PBI) participants. One of the issues regarding the JKN program so far is the inaccuracy of PBI targets. Therefore, a study is needed to evaluate the relationship between JKN PBI ownership with their socioeconomic status and history of receiving social aid.

PROPOSED ADDITIONAL HEALTH INSURANCE SCHEME AS SUPPLEMENTARY EMPLOYEE BENEFIT : CASE STUDY FOR PUBLIC SERVANTS IN INDONESIA

Access to health care has been a constant concern in developing countries due to inequitable distribution. As demonstrated in industrialized nations with reassuring outcomes, insurance is a true instrument for mitigating these issues. In order to address this issue, Indonesia implemented the BPJS Kesehatan national health insurance plan. Acceptance and contentment with the BPJS Kesehatan, on the other hand, are impediments to the attainment of its goals. The study's goal is to measure the level of acceptability and satisfaction with Indonesia's national health insurance program among public servants in the Ministry of Finance. A cross-sectional descriptive research was undertaken in Indonesia among government servants who presently use BPJS Kesehatan services. Proposed modelling of insurance scheme were established as a solution bridging to be elaborated and implemented in the near future.&#x0D; &#x0D; Keywords : Employee Benefit, Health Insurance, Public Servants, Insurance Model&#x0D;

The effect of health insurance and socioeconomic status on women’s choice in birth attendant and place of delivery across regions in Indonesia: a multinomial logit analysis

BackgroundEvidence suggests that women gave birth in diverse types of health facilities and were assisted by various types of health providers. This study examines how these choices are influenced by...

PRESCRIPTION COST ANALYSIS IN PATIENTS WITH HYPERTENSION AND TYPE 2 DIABETES MELITUS AFTER THE IMPLEMENTATION OF INDONESIAN NATIONAL HEALTH INSURANCE

Chronic disease is a long-term health condition that requires on-going medical attention, and is classified as a non-communicable disease. The long-term medical treatment for chronic diseases, such as type 2 diabetes mellitus and hypertension is considerably costly. This study aims to determine the real cost and pattern of drug prescribing as well as the factors affecting the real Prescription Cost for hypertension and type 2 diabetes mellitus after the implementation of Indonesian National Health Insurance (JKN) as seen from the practice of Independent Physicial in collaboration with BPJS Kesehatan (Healthcare and Social Security Agency). This is a non-experimental (observational) study. The data were collected using purposive sampling method with 147 medical prescriptions as the research samples for each type of disease from the patient's medical record. Data were analyzed descriptively to determine Prescription Costs and spearman's rho test was used to determine the factors that influence Prescription Costs. The study revealed that the average Prescription Cost for type 2 DM patients was Rp17,806,- and Rp12,946 for hypertensive patients. Factors that affected Prescription Cost were diagnosis (p= 0.026), type of medicine (p= 0.000) and drug items (p= 0.000). This study concludes that patients with diabetes mellitus were treated with the drug prescription pattern of a combination of metformin and glimepiride, while patients with hypertension were provided with amlodipine. The real Prescription Cost is influenced by several factors, including; the patient's diagnosis, the type of drug given and the number of drug items provided to patients.

Temperature and non-communicable diseases: Evidence from Indonesia's primary health care system.

Climate change induced rising temperatures will pose a detrimental threat to decent health in the coming decades. Especially at risk are individuals with chronic diseases, since heat can exacerbate a variety of health conditions. In this article, I examine the heat-morbidity relationship in the context of Indonesia, focusing on chronic, non-communicable diseases, namely diabetes, cardiovascular and respiratory diseases. Using a novel dataset from the Indonesian national health insurance scheme Jaminan Kesehatan Nasional/Badan Penyelenggara Jaminan Sosial (BPJS) and linking it with meteorological data on the daily-district level, I estimate the causal effect of high temperatures on the daily number of primary health care visits. The results show that on a hot day all-cause visits and visits with a diagnosis of diabetes and cardiovascular diseases increase by 8%, 25% and 14%, respectively. These increases are permanent and not offset by visit displacement or 'harvesting'. Visits related to respiratory diseases seem not to be affected by high temperatures. I use several climate change scenarios to predict the increase in visits and costs by the end of the century, which all forecast a substantial financial burden for the health care system. These results might have relevance for other middle-income countries with similar climatic conditions.