HEALTH FINANCING : revenue collection, pooling and

purchasing

Yulita HendrartiniMagister Kebijakan Pembiayaan dan Manajamen Asuransi Kesehatan

Universitas Gadjah Mada

Agents in health care financing

Definition of health carefinancing

Definition of health care financing

• mobilization of funds for health care

• allocation of funds to the regions and population groups and for specific types of health care

• mechanisms for paying health care

(Hsaio, W and Liu, Y, 2001)

Financing is More Than Mobilize Money

Mobilize

& collect Pool the Risk

Funds

Allocate

Resources

Purchaser

Fungsi dan Tujuan Pembiayaan Kesehatan

Fungsi Tujuan

Revenue Collection

Pooling

Purchasing & Payment

Meningkatkan dana untukkesehatan secara cukup danberkesinambungan. Dana ini untukmembiayai pelayanan paketesensial dasar dan perlindungankeuangan dari penyakit dan biaya katastropik berdasarkan aspekpemerataan

Mengelola dana-dana tersebut dalam pool risiko kesehatan yang efisien dan merata

Menjamin pembelian/pemerolehan dan pembayaran pelayanan kesehatan yang efisien secara teknis dan alokatif

Hsiao 2013

Mekanisme Revenue CollectionMelalui mekanisme

pemerintah/lembaga asuransi kuasi pemerintah

• Pajak langsung atau tidaklangsung

• Pendapatan pemerintah yang berasal dari bukan pajak

• Kontribusi asuransi wajib danpotongan gaji

• Pembayaran premi kepemerintah

• Grant dan pinjaman luar-negeri

Dari masyarakat

• Dari kantong pasien perorangan

• Yayasan-yayasan kemanusiaan

6

Apa yang terjadi dalamPengumpulan dana

Kesehatan

APBN

BPJS

Paja

k

Pendapatan

Negara

bukan Pajak

Non-PBI

Mandiri

Pelayanan Primer:

Pelayanan Rujukan

Non-PBi PNS,

Jamsostek dll

dll

Kemenkes

Dana dari Masyarakat langsung

Kementerian

lain

PBI

Pemda

7

Pendapatan

Asli Daerah

Askes

Swasta

(67,5 T)

NHA 2009 (dana

masyarakat

langsung) (18 T)

Kab/K

ota 489

( 72.9

T)

18.89T

2.24T

19.93T

Trisnantoro, 2014

Pooling

• Pooling yaitu bagaimana pengumpulan danadibagikan yang mempunyai risiko kesehatan diantarapengumpul dana /atau anggota kelompok (poolmember) (World Bank, 2014).

• Dana yang dikumpulkan untuk kesehatan akandibayarkan ke provider kesehatan,

• tempat penampungan (pools) dana bisa berbagaimacam, seperti anggaran pemerintah pusat danpemerintah daerah, asuransi kesehatan publik danswasta, dan asuransi kesehatan berbasis masyarakat.

8

Pooling dana kesehatan

9

1. APBN

• Kemenkes (47,5 T)—termasuk PBI

• Kementrian Lain (13,5 T)

• Pemda (6.5 T dari APBN)

2. BPJS Kesehatan

• PBI (19,9 T) plus

• Non PBI-ex Askes,Jamsostek (18.89T)

• Non PBI-Mandiri (2.24T)

Dua Pool

besar:

1. APBN

2. BPJS

Apa yang terjadidalam Pooling

APBN

BPJS

Pajak

Pendapatan

Negara

bukan Pajak

Non-PBI

Mandiri

Pelayanan Primer:

Pelayanan Rujukan

Non-PBi PNS,

Jamsostek dll

dll

Kemenkes

Dana dari Masyarakat

langsung

Kementerian

lain

PBI

Pemda

10

Pendapatan

Asli Daerah

Askes

Swasta

Trisnantoro, 2014

Pooling & Purchasing Functions Not Separated by Revenue

Health Purchaser or Purchasers

Unified or Coordinated Benefits Package

Unified or Coordinated Provider Payment Systems

National

BudgetLocal

Budget

Payroll

Tax

Donor

Funds

Private

Funds

Pooling of Funds Pooled

or not

Pooled

Revenue Collection

Pooling

of Funds

Health

Purchasing

Providers

Population

Purchasing with Health Budget Funds

• Input-based line item budgets funding public facilities can be problematic if low budget level doesn’t fund all services provided in health facility– Not clear to provider what services funded and what not

funded

• Health budget purchasing better targeting or matching priority services & poor populations– Output-based provider payment systems

• Key is unit of service—not building but services for people

– Financial incentives for desired service delivery improvements

– Align rather than fragment health purchasing– Better targeting budget funds to priority services opens

space or clear role for private funds

Pemahaman Purchasing

Purchasing:

•Mekanisme pembayaran ke fasilitas kesehatan dan penyedia layanan kesehatan

•3 komponen yaitu alokasi sumber daya, paket manfaat dan mekanisme pembayaran provider (Preker and Langenbrunner, 2005)

Desain ini merupakan komponen kunci yang sangat penting

untuk pemerataan akses yang adil dan perlindungan terhadap

resiko keuangan. 13

RASIO KLAIM 2014 - PELAYANAN (DIKURANGI BIAYA OPERASIONAL BPJS )

(JUTA RUPIAH)

IURAN PELKESRASIO KLAIM

40.719.862 46.665.539 114,60 %

38.242.870 46.665.539 122,02 %

LAPORAN BOA, CPR & KEUANGAN DIOLAH

• Rasio klaim berdasarkan bulan pelayanan sebesar 114,60 % dengan beban klaim 12 bulan

• Bila dikurangi biaya operasional maka rasio klaim akumulasi 122,02%.

• Berdasarkan bulan pelayanan iuran POPB : 27.198 dan Biaya manfaat POPB : 30.486

• Bila tanpa peserta PBPU, rasio klaim 84,29%

RASIO KLAIM 2014 - PEMBEBANAN(JUTA RUPIAH)

IURAN PELKESRASIO KLAIM

40.719.862 42.658.702 104,76 %

38.242.870 42.658.702 111,55 %

LAPORAN AKUNTANSI AUDITED

Purchasing dalam JKN

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Biaya manfaat 2014

42.658.702 *

Peserta 133.273.918

Biaya Pelayanan Primer

Rp. 8.347.850

Biaya Pelayanan

Rujukan

Rp. 30.439.572

Jlh faskes primer :

17.492

Puskesmas : 9.788

DPP : 3.984Klinik pratama : 2.388Faskes TNI-POLRI : 1.324RS pratama : 8

Jlh Faskes Rujukan : 1. 681

RS Pemerintah : 776RS TNI-POLRI : 143RS Swasta : 652RS BUMN : 42Klinik Utama : 68

Biaya Non

Kapitasi

Non CBG’s,

promprev

Rp. 3.871.280

PBI –N : 86.399.836 PBI-D : 8.649.830 BP : 4.885.140 PPU : 24.288.688 PBPU : 9.050424

Rata rata biaya per

faskes Rp.39.77

juta/bulan

Rata rata biaya per

faskes

Rp. 1,509 M/bulan* Cash basis

Biaya manfaat sd Juni 2015

27.178.466 *

Peserta 147.675.544

Biaya Pelayanan Primer

Rp. 4.953.108

Biaya Pelayanan Rujukan

Rp. 22.270.069

Jlh Faskes Rujukan : 1.783

RS Pemerintah : 692RS TNI-POLRI : 147RS Swasta : 903RS BUMN : 41

Biaya Non

Kapitasi

Non CBG’s,

promprev

Rp. 816.879

PBI –N : 86.426.543

PBI-D : 10.613.788

PPU swasta 18.347.445

Eks Askes : 19.534.154

PBPU : 12.753.614

Rata rata biaya per

faskes Rp.44,99

juta/bulan

Rata rata biaya per faskes

Rp. 2,081 M/bulan

Jlh faskes primer : 18.347

Puskesmas : 9.814

DPP : 4.314Klinik pratama : 2.923Faskes TNI-POLRI : 1.288RS pratama : 8

* Cash basis

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Fund Collection Indicators

Indicators Purpose

•The formal sector share of GDP

•Natural resources revenue as a share

of total public budget

• Total health expenditure % GDP

• Potential resources available to

finance public health spending

• Public sector spending as % GDP

•External health sector aid as % of

GDP

•To measure resources specially

available to the public sector

•The share of public health to total

public expenditures

•Per capita total and public health

expenditures

•To measure public sector allocation

decisions, additional resources, and

potential constraints

•The share of total health

expenditures that are prepaid

•A broad measure of financial protection

against out-of-pocket expenses

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Pooling Indicators

Indicators Purpose

Means and distribution measure

of:

•Share of co-payments to total

health expenditures in each pool

•Membership in each pool

•Per capita spending in each pool

•Measures of the scale, depth of

financial coverage, and existence

of compensatory mechanisms

across pools

•Share of administration

expenses out of total spending in

each pool

•Average ratio of transfers to

estimated shortfall (or surplus)

•To measure the efficiency of

pool management and

effectiveness of compensatory

mechanisms

19

Purchasing Indicators

Indicators Purpose

•Share of expenditures accounted

for by “strategic” purchasing

•Characterizing the pool-purchaser

relationship

•Number of purchasers

•Mean and distribution of total

expenditures across purchasers

•Mean and distribution of the

number of providers who are

contracted or hired by each

purchaser

•To characterize the structure of

interaction between purchasers and

providers

•Share of total funds spent with

different payment mechanisms (e.g.

salaries, fee-for-service, capitation)

•To measure the financial incentives

embedded in payments to providers

Health Financing Schemes

Health

care

services

Tax-based

financing

Social health

insurance

Other prepayment

schemes

Out-of-

pocket

payments

1. General tax or

other revenue

2.Payroll tax

3.Contribution or

premium

4. Direct payment

Household

External resource

Financing mechanisms Financing sources

Natural resource revenue

Issues in Health Financing

What's the nation's ethical foundation for health care? Is equity a priority over efficiency?

For whom you allocate resources and for what services/drugs?

How much would the program cost? Who pays?

Can the nation's transform money into effective and efficient services?

Is financing scheme sustainable?