Solution for JKN Financing
.
The government’s implementation of the National Health Insurance (JKN) program has been hampered by a funding shortage or financing deficit.
In the third year of its implementation, the funding deficit continues to increase. In order to be able to ensure the sustainable implementation of the JKN program, especially with the limited fiscal capacity in coping with the risks arising from financing uncertainty, the JKN program should be evaluated in a more comprehensive and accurate manner.
At least two major factors must receive immediate and decisive action. The expansion of participant groups who have better health levels and the ability to pay long-term contributions, such as workers of business entities (PPU-BU), should become the main objective for the near and medium term.
This will improve the membership structure in sustaining the continuity of the JKN program. Expanding the membership to cover the entire population of Indonesia (universal health coverage/UHC), which is not supported by salaried workers, will lead to further increase in deficit risks. Another strategic step that must also be taken immediately is the evaluation of the overall financing system of the JKN program.
The JKN program’s financing is based on the capitation system for first-tier health facilities (FKTP) such as public health centers or puskesmas, joint clinics, and individual medical practices.
Based on this system, all JKN participants are distributed to FKTP facilities in accordance with their choices regarding factors of proximity to residence or workplace. While the INA-CBG system is applied for care and treatment at advanced health facilities (FKTL) in hospitals, both outpatient and inpatient, in which the payment is made in a package in accordance with the average cost required in the A diagnosis group.
In practice, many problems exist in relation to the capitation and INA-CBG systems. The fundamental problems that arise in the implementation of the capitation system – often found in a number of areas – are the accumulation of membership at certain FKTPs, high levels of reference to FKTL, low referral rates from FKTL to FKTP, as well as the gap between the technical skills of doctors at FKTPs compared to demand. On the other hand, outpatient financing or inpatient care at FKTLs based on the INA-CBG system presents a much more complex issue with enormous consequences for cost.
FKTP Financing
Basically, the implementation of the JKN program is expected to be supported by the FKTP health care system. According to the Health Minister’s Regulation No. 5/2014, each FKTP is required to handle 155 non-specialist diagnoses. Thus, advanced care at FKTLs is only referred for participants who cannot be handled by a FKTP. Under these circumstances, the implementation of the capitation system is a very effective strategy for BPJS Health to control the financing for its participants.
In its implementation, FKTPs have not been fully able to serve as the main support of the JKN program, so there have been a high number of referrals for continuing treatment from FKTPs to FKTLs. This is generally a result of nontechnical factors.
Many participants have not fully understood the health care concept of the JKN program. On the presumption that treatment at an FKTL gives more hope for a speedy recovery, many JKN participants go to an FKTP just to obtain a reference letter to an FKTL. In some areas outside Java, many JKN participants even go directly to an FKTL, and then ask for a reference letter from an FKTP.
The opposite situation also occurs when JKN participants who have received further treatment are not referred back to their FKTP and remain "maintained" by the FKTL. This certainly cannot be continued because it will lead to duplicate financing by BPJS Health. In addition, the high level of referrals is also a result of the gap between the expectation to meet 155 non-specialist diagnoses, as well as the fact thatFKTP capabilities are lower than the Indonesian Medical Council (KKI) standards, covering only 144 diagnoses under level 4A.
Another fundamental issue which has directly or indirectly caused the inability to fully implement the capitation system, is the uneven and disproportionate distribution of JKN participants. Many areas have seen the accumulation of membership at a particular FKTP, which has caused problems of service quality as well as inefficient and ineffective financing.The accumulation of JKN membership can be found at several health centers located in Jakarta and its buffer zones.
On the one hand, the utilization rate – the ratio between the volume of participants\' visits compared to the number of participants covered – is quite low. On the other, the volume of references from FKTP to FKTL, for both outpatient and inpatient care, is quite large. Even if efforts are made to improve the utilization of FKTPs, the quality of health services remains a problem because of the limited number of health facilities and doctors.
To overcome this imbalance, BPJS Health should be given the authority to redistribute membership to cope with the abuse. This will not only help improve the quality of services, but also improve the efficiency and effectiveness of financing the JKN program.
Although BPJS Health has modified the capitation system for FKTP performance (performance-based capitation) and has succeeded in reducing the financing based on the capitation system, the result is not significant enough to help reduce the deficit.
Therefore, the FKTP and educational programs for participants to optimize the utilization of FKTPs need to be done on a broader scale. In addition, it is time for more intense discussions of alternative financing systems, such as free for service (FFS) or other more efficient and effective combined systems.
However, the level of morbidity and actual disease patterns must first be identified accurately, so that the JKN financing can be predicted more accurately. The welfare of doctors, health workers, and other supporting personnel also need to be taken into consideration.
FKTL Financing
The basic principle of the JKN program implementation on the optimal utilization of FKTPs has not been fully realized, because in reality, its function is shifting to FKTLs.
As reflected in the amount of health financing by BPJS Health in 2016, which reached Rp 79.1 trillion, only 15 percent as used to finance the treatment and care of JNK participants at FKTPs.The rest was used mostly to pay for outpatient or inpatient care at FKTLs, especially for advanced care.
Many basic problems that could actually be avoided are still found in the financing of FKTL outpatient and inpatient care based on the INA-CBG system. Problems include the different treatment FKTL facilities provide to JKN participants, the requirement to pay out of pocket, the limitation duration of hospitalization to the work necessary atBPJS Health to verify the results of a doctor\'s examination.
In addition, due the limited number of FKTLs, especially outside big cities, the existingFKTL facilities should be utilized, regardless of their condition, because of the lack of other alternatives.
Given its enormous financial impact and public image, the implementation of the FKTL financing system must be evaluated comprehensively. Without serious and coordinated efforts among all stakeholders, the JKN program will continue to suffer funding deficits.
TAUFIK HIDAYAT
Member of DJSN and Lecturer of Master of Management Program at Ahmad Dahlan University, Yogyakarta
