tarif kemkes
DESCRIPTION
KEMENKESTRANSCRIPT
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JAMINANKESEHATANNASIONAL
Perkembangan Tarif INA-CBG
Jakarta, 18 September 2014
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JAMINANKESEHATANNASIONAL 2
Sistimatika Penyajian
1.Metode Pembayaran Dengan INA-CBG
2.Penyesuaian Tarif INA-CBG
3.Pengembangan INA-CBG kedepan
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1. Metode Pembayaran Dengan INA-CBG
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Payment Method Untuk Sustainabilitas
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Tunai/FFS/User FeesTunai/FFS/User Fees JKNJKN
yankesyankes
FaskesFaskes
RpRp
Peserta/PPeserta/Pasienasien
yankesyankes
RpRp
RpRp
= Lokus Resiko Source: W. Hsiao
“Sharing Risk” Dalam Jaminan Kesehatan
Retrospektif Prospektif
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JAMINANKESEHATANNASIONAL
Apa Itu Sistem DRG/CBG? (1)
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JAMINANKESEHATANNASIONAL
Choosing a PCS: copied, further developed
or self-developed?
Patient classification system
• Diagnoses• Procedures• Severity• Frequency of revisions
The great-grandfather
The grandfathers
The fathers
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JAMINANKESEHATANNASIONAL
Group of patients with homogenous
resource consumption
= DRG
patient variablesmedical and management
decision variables
mix and intensity of procedures, technologies and human
resource use
The DRG logic1st step = patient classification / grouping
gender, age,main diagnosis, other
diagnoses, severity
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JAMINANKESEHATANNASIONAL
cost weight base rate=DRG reimbursement
X
patient variablesmedical and management
decision variables
gender, age,main diagnosis, other
diagnoses, severity
mix and intensity of procedures, technologies and human
resource use
2nd step = Price setting (I)
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JAMINANKESEHATANNASIONAL
cost weight base rate=DRG reimbursement
X
patient variablesmedical and management
decision variables
gender, age,main diagnosis, other
diagnoses, severity
mix and intensity of procedures, technologies and human
resource use
e.g. size, teaching status; urbanity; wage level
structural variables on hospital/ regional/
national level
adjustment factors
+
determinants of hospital costs
2nd step = Price setting (II)
CAVE confusing terminology across countries!
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JAMINANKESEHATANNASIONAL
• Merupakan Sistem Casemix yang di Implementasikan di Indonesia saat ini (Casemix/DRG: Diagnosis Related Group)
• Dasar Pengelompokan dengan menggunakan :• ICD – 10 Untuk Diagnosa (14.500 kode)• ICD – 9 CM Untuk Prosedur/Tindakan (7.500 kode) Dikelompokkan menjadi 1.077 kode group INA-CBG (789 kode rawat inap dan 288 kode rawat jalan)
• Pengelompokan (algoritme) dijalankan dengan menggunakan Grouper
Apa Itu Sistem INA-CBG?(3)
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JAMINANKESEHATANNASIONAL
DTPK 12
Perbandingan FFS vs INA-CBG
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JAMINANKESEHATANNASIONAL
Komponen Klaim Dengan Sistem INA-CBG
• Klasifikasi (Ketepatan) Diagnosis, menggunakan ICD-10
• Klasifikasi (Ketepatan) Prosedur, menggunakan ICD-9 CM
• Software Grouper (termasuk costing)• Kelengkapan berkas administrasi • Software Verifikasi
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Medical Record
CBGGroupCoding
Elemen Penting INA-CBG
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Manajemen Dokter
Efisien Efektifitas
Cost Quality
INA-CBG’s
Perbedaan Perspektif
Clinical Pathway
Input OutputProses
Membangun Sistem Kendali Biaya dan Kendali Mutu
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Prinsip Dasar: Perubahan Paradigma Ru
piah
Rupi
ah
Volume Pelayanan Volume Pelayanan
Tarif
Cost Cost
Pembayaran prospektif(fix price)
Tarif
Profit Profit
Loss
FFS CBG’s
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JAMINANKESEHATANNASIONAL 17
Cost Containment Di RS
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• Farmasi
• Alat medik habis pakai
• Pemeriksaan penunjang
• Lama rawat (LOS)
• overhead cost dll
Kurangi atau hilangkan potensi inefisiensi di RS
Peningkatan Efisiensi
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Hal Lainnya
• Perubahan pembayaran jasa berbasis fee for service ke remunerasi
• Tingkatkan pemahaman konsep INA-CBG level manajemen, level dokter dan seluruh staf di RS
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2. Penyesuaian Tarif INA -CBG
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1. Perbaikan tarif dilakukan berdasarkan masukan dan konsultasi dengan Perhimpunan RS, Asosiasi RS Swasta, Ikatan Profesi, dll untuk beberapa kelompok tarif yg dirasakan kurang memadai (mencakup 39 CBG’s) seperti tarif:
• Pelayanan bedah ortopedi• Pelayanan bedah saraf• Pelayanan rawat jalan (dengan pemeriksaan penunjang,
prosedur, kasus kronik, kemoterapi)• Pemeriksaan dgn Petscan • Pelayanan mata
2. Untuk memenuhi Pasal 39 butir d Perpres 12/2013 maka dalam hal perbaikan tarif dilakukan koordinasi dgn Kemenkeu
Penyesuaian Tarif Beberapa Kelompok INA-CBG
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Skenario Penyusunan Tarif
Penyesuaian tarif INA-CBG dilakukan atas dasar bukti-bukti empiris telah disusun beberapa skenario penyesuaian tarif & mengkaji dampak dari setiap skenario tsb thd:
1. Kondisi keuangan BPJS (Klaim Rasio)2. Pendapatan RS3. Fairness tarif antar RS
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Dana Jaminan Sosial Kesehatan (DJSK)
Dana BPJS Kesehatan
1. Iuran (peserta, pemberi kerja, pemerintah)
2. Pengalihan asset PT Askes3. Sumber lain (surplus, hibah,
bantuan /talangan)
1. Pemerintah (pemberian modal awal, 500M)
2. Pengalihan asset PT Askes3. Sumber lain (surplus, hibah,
bantuan)
Biaya Kesehatan (Manfaat FKTP & FKTL) sebesar 90% dari iuran
1. Penyelenggaraan2. Pengadaaan barang jasa3. Peningkatan pelayanan
Biaya
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Pendapatan & Pengeluaran
Sumber
Pokok & Hasil Investasi
Operasional (6.25% iuran)
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Permenkes 69/2013
(Tarif)
PP 87/2013 (Aset JSK)
Skema Pengeluaran JKN
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Simulasi: berapa tarif Permenkes 69/2013
yg menyerap maksimal 90% iuran?
1. Dana iuran JKN digunakan untuk biaya kesehatan, pengelolaan dan cadangan
2. Biaya kesehatan mencakup biaya pelayanan kesehatan peserta di FKTP (Kapitasi & NonKapitasi) dan FKTL (CBGs dan Non CBGs)
3. Biaya kesehatan dipengaruhi oleh tarif dan utilisasi layanan kesehatan. Apa implikasi tarif Permenkes 69/2013 dan rencana revisi kenaikan tarif tsb?
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Distribusi Sampel: Jumlah RS & Kasus INA-CBG
Sebaran Sampel Rumah Sakit
A B C D RK RURegional-I 419 10 70 160 176 2 1 Regional-II 167 7 23 84 53 - - Regional-III 327 8 47 146 126 - - Regional-IV 29 2 3 13 11 - - Regional-V 137 1 12 48 76 - - NASIONAL 1,079 28 155 451 442 2 1
REGIONAL TOTALTipe RS
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SEBARAN SAMPEL KASUS CBGS
RITL RJTL TOTALRegional-I 287,059 1,548,577 1,835,636 Regional-II 101,281 518,520 619,801 Regional-III 190,236 750,905 941,141 Regional-IV 12,575 53,974 66,549 Regional-V 67,982 194,067 262,049 NASIONAL 659,133 3,066,043 3,725,176
REGIONAL Jumlah Kasus
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Dampak Skenario Penyesuaian Tarif INA-CBG Terhadap Klaim Rasio & Pendapatan RS
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TARIFPERMEN 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
Klaim Rasio (%) 91.82% 92.52% 91.65% 91.18% 91.32% 91.74% 91.75% 91.61% 91.73% 0.77% -0.19% -0.70% -0.54% -0.09% -0.07% -0.23% -0.10%
A 106.39 104.72 103.41 98.57 100.03 100.47 102.21 100.99 102.32 -1.57% -2.81% -7.35% -5.98% -5.56% -3.93% -5.08% -3.82%B 53.64 55.05 54.21 54.21 54.21 54.21 54.46 54.44 53.88 2.62% 1.06% 1.06% 1.06% 1.06% 1.53% 1.49% 0.44%C 19.15 19.31 19.05 19.04 19.05 19.30 19.13 19.12 19.30 0.81% -0.55% -0.58% -0.57% 0.74% -0.14% -0.19% 0.75%D 5.85 5.91 5.83 5.82 5.83 5.90 5.85 5.85 5.85 1.02% -0.33% -0.39% -0.37% 0.92% 0.05% -0.01% 0.01%RU & RK 317.14 319.66 311.91 296.94 301.76 302.58 308.60 304.35 308.98 0.79% -1.65% -6.37% -4.85% -4.59% -2.69% -4.03% -2.57%
Seluruh RS 21.75 22.00 21.69 21.52 21.57 21.72 21.72 21.67 21.72 1.17% -0.29% -1.07% -0.83% -0.14% -0.11% -0.35% -0.16%
Delta thd Tarif Permen (%)SKENARIO REVISI TARIF PERMEN 69/2013SKENARIO REVISI TARIF PERMEN 69/2013
Rerata Pendapatan RS (Milyar) per type Rs per tahun
KRITERIA EVALUASI
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Hasil Final Penyesuaian Tarif INA-CBG
8. Kombinasi kenaikan dan penurunan tarif INA-CBG: 1.Naik tarif 39 INA-CBG (kenaikan maks 80% CBG “M”)2.Turun 60 jenis INA-CBG RANAP sebesar: (a) 22.8% RS A & Rujukan; (b) angka mean plus 2.5 standar deviasi nilai statistik dari 60 jenis INA-CBG RANAP RS B; (c) 21.89% di RS tipe C; 3. Turun sebesar 4.5% tarif CBG di RS A & Rujukan
Klaim Rasio 91,73
%
1s/d7
Berbagai skenario penyesuaian tarif dan dampak terhadap kecukupan iuran
Klaim Rasio
91,18% - 92,52%
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3. Pengembangan Tarif INA –CBG kedepan
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Perbaikan Tarif INA-CBG
• Roadmap Bertahap yang akan dikembangkan selama 3 tahun mendatang yang perlu ditingkatkan, yakni:
• Klasifikasi -- Grouper• Coding (Penentuan Kode) -- Standarisasi• Costing (Penentuan Biaya)- Perbaikan
Template dan Data Costing
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Dukungan Yang Diperlukan
• Penyiapan SDM• Perbaikan Standar Pelayanan• Sistim Informasi• Perencanaan Anggaran• Pengawasan Terpadu
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JAMINANKESEHATANNASIONAL
TERIMA KASIH