Fair Prospective Payments to Hospitals Current Problems and Proposed Changes Sutoto & Daniel Budi Wibowo Indonesian Hospitals Association (PERSI)
INA-HEA, Jakarta April 9, 2015
Prospective Payment Systems • A prospective payment system (PPS) is a term used to refer to several payment methodologies where means of determining insurance reimbursement is based on a pre-determined payment, regardless of the intensity of the actual service provided. • It includes a system for paying hospitals based on predetermined prices. Payments are typically based on codes provided on the insurance claim
Fundamental Fairness Payment Question.
Indonesian hospital : It should be as “Public Health Obligation” (subsidized) ? or
Hospitals as Health “Industry” (for profit)
Following Question :
Is it proper and fair to treat government (subsidized) hospital and Private (for profit) hospital with the same scheme on JKN (National Health Insurance) ?
Fair Hospital Prospective Payment System Hospital
Health Profesion als
Fairness
BPJS Kesehatan
Patients
Fairness Aspects of Hospital Prospective Payment System Tariffs
Veriffication process
Regulation
Payment
Quality and equality Service
Fraud Controlling
INA-CBG’s Tariffs • Rigid – didn’t acomodate geographic conditions (hospital wage index, supply handicaps, etc), high cost outliers, private hospital incentives. • Cost weight and grouping in INA-CBG is not proper. • Based on hospital total costing’s data , even costing data from hospitals suspected not accurate and case distribution data were questionable. • Did not allow cost sharing for better medical consumables , except for patient upgrading room facility to VIP Class, (all or none principles). • No differentiation on tariff and BPJS’s facilitation between government and private hospital.
Verification Process • Done by BPJS Kesehatan’s staffs, it should be done by third party management in order to be objectives. • For certain hospitals, especially on east part of Indonesia, coding process for claim still a problem, because lack of medical records expert.
Quality and service • There are no official standard on medical and nursing services for all cases from Ministry of health or BPJS Kesehatan. • BPJS’s patients has comprehensive benefits but minimal standard medical care quality , because of efficiency and tariffs structure. • There are no external quality assurance system , except from internal hospital quality assurance.
Payment • So far, there are not much complaining about payment, some hospitals have difficulties in claim administration process, kind of human resources problems.
Fraud Prevention and Controlling • Fraud prevention should be fair to hospitals and managed by hospitals management and non litigious approach / threat. • It should have certain parameters and protocols to indicates fraud in hospital prospective payments. • Communication between BPJS Kesehatan and hospitals should be more intense, before penalties.
Proposed changes : Accelerated roadmap to same standardized basic hospital care and facilities for all patients.
PETA JALAN ASPEK PELAYANAN KESEHATAN • Distribusi blm merata • Kualitas bervariasi • Sistem rujukan blm optimal • Cara Pembayaran blm optimal
2012
-Perluasan & Pengemb. faskes & nakes secara komprehensif -Evaluasi & penetapan pembayaran
2013
Rencana aksi pengembangan faskes, nakes, sistem rujukan & infrastruktur
2014
KEGIATAN-KEGIATAN:
2015
2016
2017
•Jumlah mencukupi • Distribusi merata • Sistem rujukan berfungsi optimal • Pembayaran dg cara prospektif dan harga keekonomian untuk semua penduduk
2018
2019
Implementasi roadmap: pengembangan dan pemantauan faskes, nakes, sistem rujukan, infrastruktur lainnya.
Kajian berkala BPJS Kesehatan terhadap fasyankes (pemberi pelayanan kesehatan) terhadap standar yang ditetapkan Penyusunan Standar, prosedur dan pembayaran faskes
Peningkatan upaya kesehatan promotif preventif baik masyarakat maupun perorangan Implementasi pembayaran Kapitasi dan INA-CBGs serta penyesuaian besaran biaya dua tahunan dengan harga keekonomian
13
PETA JALAN ASPEK MANFAAT DAN IURAN Manfaat bervariasi belum komprehensif sesuai kebutuhan medis
- Manfaat standar - Komprehensif sesuai keb medis -- Berbeda non medis
Iuran bervariasi
Iuran : Masih berbeda PBI dan Non PBI
2012 Konsensus manfaat
2013 Penetapan manfaat dlm Perpes JK, termasuk koordinasi manfaat
2014
Manfaat sama untuk semua penduduk
KEGIATAN-KEGIATAN
2015
2016 Penyesuaian Perpres Jamkes
2017
2018
2019
Penyesuaian Perpres Jamkes
Kajian berkala tahunan tentang upah , iuran, efektifitas manfaat , dan pembayaran antar wilayah Telaah utilisasi kontinyu untuk menjamin efisiensi, menurunkan moral hazard, dan kepuasan peserta dan tenaga/fasilitas kesehatan 14
Principles of changes : 1. Every one has same right to access hospitals, if needed. 2. BPJS Kesehatan provide standard care and formularium, but only applied for standard inpatient room, not 2nd or 1 st class. 3. Payment using modified INA-CBG Tariffs, accomodates hospital’s wage index, supply handicaps, high cost outliers cases, private hospital’s incentive, etc, and proper cost weights on diagnose grouping, also rational out patient tariffs. 4. Commercial health insurances have Coordination of Benefits (CoB) scheme with BPJS Kesehatan. They have their own standard of care and formularium for partner clinics and hospitals .
Principles of changes : 5. Every member that by their choices or already have higher class inpatient room than standard room ,their premium splitted. Basic premium goes to BPJS Kesehatan and top up premium going to other health insurance. The premium tariffs could be differ between insurances, depend on standard facilities and schemes they offered. 6. Hospitals split their claim. Basic claim should be paid by BPJS Kesehatan and top up claim paid by insurance. Verification could be done by third party. The payment method still prospective payment, except for VIP Class, use retrospective payment. 7. For certain part of Indonesia, BPJS Kesehatan allowed to pay the hospital using budget scheme, because lack of competence administrative officer.
Basic Benefits Group (Poor and Non formal by choices)
PREMIUM
BPJS Kesehatan
INA-CBG
Standard Room facilities
Health Provider
Top Up Benefits Group (PNS, formal worker, by choices) BPJS KESEHA TAN
BASIC CARE PAYMENT
INA - CBG HEALTH PROVIDER
PREMIUM Health Insurance
INSURANCE Standard of CARE PROSPECTIVE TOP-UP PAYMENT
Benefits of proposed changes • Every people has access to standard health care. • BPJS Kesehatan only pay for basic clinic and hospital care, standard class , easier to manage the premium and provider payment. • Commercial health insurance will be enthusiatic, because they could back on market. • Indonesian Pharmaceutical industry will recovered, because not only Fornas can be used, depend on commercial health insurance standard. • Hospital will be happy, because they have space to negotiate rational top up tariffs with commercial health insurance. • Patients also happy, because they can choose of health care’s level and facilities. • Health proffesionals also happy, because they can apply evidence based approach proffesionally.
THANK YOU
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