Mengawal Sustainabilitas Jaminan Kesehatan Nasional (JKN) Donald Pardede Pusat Pembiayaan & Jaminan Kesehatan Kemkes R.I
Things To Share 1. Pendahuluan (Prinsip Dasar & Tujuan)
2. Tantangan Penyelenggaraan JKN 2014-2015 3. Upaya untuk meningkatkan efisiensi
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Determinant of the National Social Security System (SJSN)
Optimized cross-subsidy Optimizing the Law of the Large Number
Efficiency due to economics of scale
Correct Fragmentation
Appropriate risk prediction Ensuring Standardized Benefit
Determinant of the JKN SJSN
Large pool of members
Avoid Jealousy Ensuring Equity Objective
Revoke Partial Mandatory
Ensuring the UHC goals
Correct SHI Implementation
Ensuring SHI Principle
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JKN brings Indonesia to the Social Health Insurance scheme Do the social insurance an ideal policy option? What are the facts?
1. Ensure Universal Health Coverage 2. Avoid market failures
3. Gaining macro efficiency 4. Support health agenda
The Insurance Effects (Uninsured vs Insured) Prices (P) (D1) Uninsured P1 (D2) Insured w/ large cost-sharing
P2
(D3) Insured without cost-sharing P3
Q1
Q2
Q3
Medical care (Q)
Country
Author(s)
Insurance type
Main Results
Ecuador
Waters (1999)
GHI & SSC
Insurance
Columbia
Trujillo (2003)
Private & social insurance
improves demand
Indonesia
Hidayat B (2008)
Askes & Jamsostek
Universal Health Coverage (Membership Projection 2015-2019) Proyeksi (dalam jutaan)
Jumlah Penduduk, Target Peserta JKN & PBI-KIS 2015-2019
300.0
Tahun 2015 2016 2017 2018 2019
%Peserta JKN 60% 70% 80% 90% 95%
250.0
268.0 255.4
258.7
261.8
265.0 230.7
210.5
200.0
150.0 100.0
257.5
155.6 135.6 88.2
92.4
96.9
102.0
107.2
50.0 0.0
Penduduk (Jiwa) Peserta JKN (Jiwa) PBI-KIS (Jiwa)
2015 255.4 135.6 88.2
2016 258.7 155.6 92.4
2017 261.8 210.5 96.9
2018 265.0 230.7 102.0
2019 268.0 257.5 107.2 57
Healthcare Cost (Primary vs Second/Tertiary care) FKRTL menyerap lebih 73% biaya kesehatan. Kapitasi menyerap 18 % biaya kesehatan Non INA-CBG dan Non kapitasi menyerap 9%
Utilization & Claims in Secondary & Tertiary Level Care in 2014 Utilization
Claims (Rp Milyar)
TOTAL Kasus 31,626,510 RANAP 5,148,768
TOTAL Klaim Rp 32,194
RAJAL 26,477,066
RANAP Rp 24,969
RAJAL Rp 7,225
PBI 1,720,256
PBI 6,685,451
PBI 6,915
PBI 1,806
NPBI 3,428,512
NPBI 9,791,615
NPBI 18,054
NPBI 5,419
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9
Catastrophic Diseases 889.356
GINJAL
1.029.717
JANTUNG
138.779 30.520 232.010
STROKE
735.827
11.280 172.303 1.415
DIABET THALASEMI
70.584 285 53.948
HEMOFILIA KANKER
KASUS RANAP
KASUS RAJAL
8.755 12.170 88106 56.033 RAJAL
RANAP
Probability Rate (per 1.000 member per month): Estimation 2014-2019 • •
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Angka probabilitas 2014 sebesar 23.6 Angka prob tahun 2014 masih BELUM STABIL maka diasumsikan akan naik menjadi: – 7% (2015 & 2016) dan 3% (2017 & 2018) RANAP – 5% (2015 & 2016) dan 3% (2017 & 2018) RAJAL – Angka 2018 dan 2019 diprediksikan sudah optimal
Total Medical Claims
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Estimation 2014-2019
CATATAN: Estimasi biaya hanya memperhitungkan biaya pelkes, belum memasukkan biaya operasional dan pembentukan dana cadangan
Akan murah jika dipikul bersama. Nilai Rp PMPM hanya sbb:
Overcoming Financial Sustainability of JKN Program: Key Impetus 1. Challenge in PBPU’s segment 2. Demographic (elderly population) and epidemiological transition 3. Changes of epidemiological profile (growing NCD and Injuries) that lead to Double Burden Trend of Indonesian Burden of Disease; Risk factors of NCD 4. Inefficiency and fraudulent Issues
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Challenge in PBPU Segment Coverage in 2014
Tingginya kenaikan peserta dari kelompok PBPU mencerminkan kebutuhan pelayanan & antusiasme mereka menjadi peserta. Target UHC 2019 berpeluang besar dicapai. NAMUN…
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Titik Kritis: 1. Mereka berasal dari penduduk sakit; 2. Sustainabilitas pembayaran iuran meragukan
The demand for health services is expected to increase in the coming years due to the growth and change of population structure (shift to older population) New Threat to the JKN fund Population Pyramid of Indonesia in 2015 and 2019
Source: BAPPENAS, BPS, UNFPA 2013 • At present (2014) the total population is 248,818,100 and will become 255,461,700 by 2015 and 268,076,600 by 2019 (if TFR will continue to be stagnant) • Population aged >60 years in 2015 will be 21.695.400 and in 2019 25.901.900
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0.0
40.0
26.1
10.0 40.0
0.0 20.0
2007
Evidence: Proportion of population aged ≥ 10 years with lack of physical activity
20.0 14.2 2013
Bali Kalsel DIY Sulsel Jambi Sulbar Sultra Kal m Jateng DKI Ja m Papua Kalteng Riau Kep.Riau Kalbar Babel Indonesia Sulut Bengkulu Sumsel Lampung Banten Sumbar Sulteng Sumut Jabar NTB Gorontalo Aceh Maluku Pabar Malut NTT
Babel
Kalsel
Kaltim
Jabar
Gorontalo
Sulteng
Kalbar
Sulsel
Sulut
Kalteng
Jateng
Jatim
Sumsel
Indonesia
20.0
DIY
Lampung
Sumut
Jambi
NTB
Maluku
NTT
Banten
Sumbar
Sulbar
Sultra
Kep. Riau
Bengkulu
Aceh
Malut
Riau
Pabar
DKI
Bali
Papua
40.0
12
50.0
14
(<150 minutes/week), by Province, Indonesia 2013
80.0
60.0 44.2
80.0 DIY Lampung Papua NTT Ja m Jateng Pabar Maluku Malut Gorontalo Sumut Aceh Kalteng Kal m Indonesia Kep. Riau Bali Sulut Sultra Sulteng NTB DKI Bengkulu Kalbar Jambi Banten Jabar Babel Sumsel Sulsel Sumbar Sulbar Riau Kalsel
Bali Kalsel Babel Jateng DIY Ja m Banten Sumut Lampung Kalteng Jabar INDONESIA Sumsel Sulteng Sulbar NTT Sumbar Bengkulu Riau Sulsel Jambi Sulut Malut Gorontalo Kalbar Kep. Riau NTB Kal m Maluku Aceh Sultra Pabar Papua DKI
Evidence: Prevalence of Hypertension Based on Measurement, RISKESDAS 2007 & 2013*)
Evidence: Proportion of population aged ≥ 15 years who smoke and chew tobacco, by province, 2007-2013
2007 2010
Evidence: Proportion of population aged ≥ 10 years with poor consumption of fruits and vegetables, by province, 2007 & 2013
100.0 100.0
96.0
93.6
92.0
88.0
93.5
84.0
2007 2013
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100.0
31.7
30.0 80.0
25.8 60.0
36.3
34.7 34.2
0.0
*) Criteria of hypertension: systolic ≥140 mmHg, diastolic ≥ 90mmHg 2013
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Evidence: Total Number of CBGs Cases and Cost per Disease in 2014
Although heart diseases is the 11th rank of cases but it is 1st rank in spending (Rp. 3.5 triliun)
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Efforts to improve efficiency within JKN program to ensure sustainability of the JKN fund
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Ensure The Effectiveness of Prospective Payment (1)
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Strengthen Primary Care
The European Definition of General Practitioners/Family Medicine, WONCA Europe, 2002
Tujuan Pembiayaan Kapitasi di Primary Care 1. Pencapaian efisiensi: - Efisiensi teknis kontrol moral hazard - Efisiensi alokatif meningkatkan promosi, prevensi & deteksi dini 2. Peningkatan kualitas layanan primer - Harus ada kompetisi - Pemilihan FKTP oleh peserta 3. Stabilitas dan pemerataan pendapatan - Pendapatan dokter dan nakes stabil - Terjadinya pemerataan pendapatan dokter dan nakes
Ensure The Effectiveness of Prospective Payment (1) FFS
INA-CBG
Tarif
Rupiah
Rupiah
Tarif
Profit
Cost
Volume Pelayanan
Loss Profit
Pembayaran prospektif (fix price) Cost
Volume Pelayanan
Fraudulent Control è Fraud Diamond
Pendapatan
RS berupaya meningkatkan pendapatan (up-coding; penarikan biaya
Kemampuan (Ability)
Kesempatan (Opportunity)
Tekanan (Pressure)
Rasionalisasi (Ra onaliza on)
David T.Wolfe,2004
Tarif Rasional
Total Biaya
Pembayaran INA-CBG Mengurangi costs (Efektif/Efisien,)
LOS Rmengurangi LOS 22
Implementing a Comprehensive Economic Evaluation for Benefit Basket Technology Development ++Approval Stage++
Conventional 3 Hurdles
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Technology Adoption
++Patient Access Stage++
4th Hurdle
5th Hurdle
Element
CEA, CUA, and CBA CEA
Budget Impact BIA Analysis
Concept
Efficiency (value for money)
Purpose
Efficiency of the selected Financial impact of technology technology (new or existing) (new/alternative); [Cash-flow]
Perspective
Societal/payer
Payer
Outcome
Included QALY
Excluded QALY
Cost
Opportunity Cost
Financial Cost
End-point
ICER
Budget change
Affordability
Thank You Terima Kasih Donald Pardede
[email protected]
