Analisis Kesesuaian Klaim dengan Realitas Pembayaran Ppk Rujukan dalam Jaminan Kesehatan Masyarakat Miskin

Ingan Ukur Tarigan • Endang Indriasih
Journal article Buletin Penelitian Sistem Kesehatan • Oktober 2008 Indonesia


The main goal of health development in lndonesia is providing quality health care and assuring community access to equal health services for all citizen (universal coverage). In assuring the access to health services for the poor. Ministry of Health has launched special health insurance program for the poor (Askeskin). PT Askes was assigned by MOH to manage this program. Therefore, it is very important to improve facilities and management capabilities of health insurance administering bodies and health care providers. These include, improvement in case management, hospital accounting system, medical record, etc. This will be very useful for verification process and reducing the fraud and abuse. This study was conducted in order to provide valuable input for the Improvement of financing mechanism and payment system of referral providers in health insurance program for the poor (Askeskin). The objectives of this study are to calculate hospital claim on case management of Askeskin members and its real payment by PT Askes and to calculate the differences between claim and reimbursement (real payment) based on hospital components. The study design is cross-sectional. A Stratified Random Sampling method was conducted to select the study sites based on Human Development Index (HOI) and Fiscal Capacity (refers to Ministry of Finance Data) of district and city. Districts and cities were then classified into high, middle, or low level. The 3 selected study sites were: Kampar District (HPI 34,1) in Riau Province which represent high HOI; North Bengkulu District (HPI: 30.4) in Bengkulu province which represent middle HOI, and Pontianak City (HPI: 27.7) in West Kalimantan Province which represent low HOI. The results show that tariff agreement of case management for Askeskin members was not in accordance with local real condition. Therefore, clear operational and technical Askeskin guidelines are needed to gain similar perception between PT Askes and health care providers· beside Improvement of socialization activities to the community. The amount of differences between claim and reimbursement varied among study sites. The difference was influenced by following factors: (1) existed guidelines that were not suitable with local specific real demand and (2) disparity among hospital facilities. Hospital with limited facility has difficulty to refer patient to another closed hospital which doesn't have contract with PT Askes. Furthermore, in some cases hospital with good facility cannot optimalize using their advanced equipment for treatment, because not stated in the contract with PT Askes. Contract review, tariff adjustment, and re-negotiation between hospitals and PT Askes should be encouraged to provide better services for Askeskin members.


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Buletin Penelitian Sistem Kesehatan

Buletin Penelitian Sistem Kesehatan diterbitkan sejak 1994 dan sejak tahun 2006 terbit dengan fre... tampilkan semua