Perkembangan Tarif INA-CBG Jakarta, 18 September 2014

Sistimatika Penyajian Metode Pembayaran Dengan INA-CBG Penyesuaian Tarif INA-CBG Pengembangan INA-CBG kedepan 2 2

1. Metode Pembayaran Dengan INA-CBG

Payment Method Untuk Sustainabilitas

“Sharing Risk” Dalam Jaminan Kesehatan Tunai/FFS/User Fees JKN Peserta/Pasien Rp yankes Pasien Badan Penyelenggara Faskes yankes Rp Rp Faskes Retrospektif Prospektif = Lokus Resiko Source: W. Hsiao

Apa Itu Sistem DRG/CBG? (1)

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

The DRG logic 1st step = patient classification / grouping medical and management decision variables patient variables gender, age, main diagnosis, other diagnoses, severity mix and intensity of procedures, technologies and human resource use Group of patients with homogenous resource consumption = DRG The first fundamental buidling block of any DRG system: the patient classification system: - DRGs were developed in the US in the 1970s as patient classification systems. Intention: Describe and measure hospital activity, i.e. to define the product of hospitals. Define what purchasers wanted to buy: Not interested in specific services but interested in the treatment of patients. Not possible to compare individual patients: Different age, different comorbidities, different severity: But possible to see if different patients with similar characteristics consume similar amounts of resources. -> objective: define groups of patients that are medically meaningful and have similar resource consumption = homogenous resource consumption / costs only looking at diagnoses is not enough to explain resource consumption: what the hospital does with these patients needs to be considered to a certain extent. Also otherwise very strong incentives to undertreat patients. - Based on these groups of medically meaningful and economically homogenous patients, defining the hospital product, the payment mechanism was designed:

medical and management decision variables 2nd step = Price setting (I) medical and management decision variables patient variables gender, age, main diagnosis, other diagnoses, severity mix and intensity of procedures, technologies and human resource use DRG reimbursement = X cost weight base rate The second fundamental buidling block of any DRG system is the price setting mechanism. Most DRG systems work as shown in this slide: The diagnosis related group defined by the classification system receives a cost weight. The cost weight reflects the costs of treating the group of patients assmebled in the specific DRG. The cost weight can then be multiplied with a base rate in order to calculate hospital payment for the treatment of one patient belonging to a specific DRG. Some countries directly calculate the price for a specific DRG. However, using a cost weight approach makes it possible to more easily adapt the calculated cost weights to different settings by changing the base rate. Objective: To provide fair reimbursement of hospital costs (not too much but not too little) Hospitals should have enough resources to provide all necessary care to patients  important to consider the determinants of hospital costs

2nd step = Price setting (II) determinants of hospital costs structural variables on hospital/ regional/ national level medical and management decision variables patient 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 DRG reimbursement = X cost weight base rate Hospital costs determined on the one hand by patient varaibales and medical and managemtn decision variables  reflected in the cost weights. Prior EU research project looking at the determiants of hospital costs found that structural variables are also important determinants of hospital costs. If these variables are not considered when calculating hospital reimbursement, hospitals may systematically receive too little money for providing good services. consequently, some countries adjust for these structural variables. Others provide additional reimbursements based for teaching hospitals (-not linked to DRG system) Objective: To provide fair reimbursement of hospital costs (not too much but not too little): important also when considering the level of detail of the PCS + adjustment factors CAVE confusing terminology across countries!

Apa Itu Sistem INA-CBG?(3) 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

Perbandingan FFS vs INA-CBG DTPK

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

Elemen Penting INA-CBG Medical Record CBG Group Coding

Membangun Sistem Kendali Perbedaan Perspektif Manajemen Dokter Membangun Sistem Kendali Biaya dan Kendali Mutu INA-CBG’s Efisien Efektifitas Input Proses Output Cost Quality Clinical Pathway

Prinsip Dasar: Perubahan Paradigma Rupiah Volume Pelayanan Tarif Cost Pembayaran prospektif (fix price) Profit Loss FFS CBG’s

JKN Cost Containment Di RS 17 Manaje men Bangunan Alat Medik Alat non medik Obat dan BHP Administr Makanan Liistrik/ Telp Air Kendara an Pemeliha raan 17

Peningkatan Efisiensi Kurangi atau hilangkan potensi inefisiensi di RS Farmasi Alat medik habis pakai Pemeriksaan penunjang Lama rawat (LOS) overhead cost dll

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

2. Penyesuaian Tarif INA -CBG 20

Penyesuaian Tarif Beberapa Kelompok INA-CBG 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 21 21

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: Kondisi keuangan BPJS (Klaim Rasio) Pendapatan RS Fairness tarif antar RS

Pendapatan & Pengeluaran Iuran (peserta, pemberi kerja, pemerintah) Pengalihan asset PT Askes Sumber lain (surplus, hibah, bantuan /talangan) Pemerintah (pemberian modal awal, 500M) Sumber lain (surplus, hibah, bantuan) Sumber Pokok & Hasil Investasi Dana Jaminan Sosial Kesehatan (DJSK) Dana BPJS Kesehatan Operasional (6.25% iuran) Biaya Kesehatan (Manfaat FKTP & FKTL) sebesar 90% dari iuran Penyelenggaraan Pengadaaan barang jasa Peningkatan pelayanan Biaya

berapa tarif Permenkes 69/2013 yg menyerap maksimal 90% iuran? Skema Pengeluaran JKN Nilai Iuran (100%) Biaya Kesehatan (90%) FKTP FKTL Biaya Loading (10%) Operasional Fee (6.25) Cadangan (3.75%) Permenkes 69/2013 (Tarif) Simulasi: berapa tarif Permenkes 69/2013 yg menyerap maksimal 90% iuran? PP 87/2013 (Aset JSK) Dana iuran JKN digunakan untuk biaya kesehatan, pengelolaan dan cadangan Biaya kesehatan mencakup biaya pelayanan kesehatan peserta di FKTP (Kapitasi & NonKapitasi) dan FKTL (CBGs dan Non CBGs) Biaya kesehatan dipengaruhi oleh tarif dan utilisasi layanan kesehatan. Apa implikasi tarif Permenkes 69/2013 dan rencana revisi kenaikan tarif tsb?

Distribusi Sampel: Jumlah RS & Kasus INA-CBG (Populasi RS BPJS) 1,079 (68%) RS (Sampel RS BPJS) 3,725,176 (Sampel Kasus CBGs)

Dampak Skenario Penyesuaian Tarif INA-CBG Terhadap Klaim Rasio & Pendapatan RS Tabel ini merupakan gambaran Dampak Skenario Penyesuaian Tarif Terhadap Klaim Rasio dan Pendapatan Rumah Sakit

Hasil Final Penyesuaian Tarif INA-CBG 1 s/d 7 Berbagai skenario penyesuaian tarif dan dampak terhadap kecukupan iuran Klaim Rasio 91,18% - 92,52% 8. Kombinasi kenaikan dan penurunan tarif INA-CBG: Naik tarif 39 INA-CBG (kenaikan maks 80% CBG “M”) 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%

3. Pengembangan Tarif INA –CBG kedepan 28

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

Dukungan Yang Diperlukan Penyiapan SDM Perbaikan Standar Pelayanan Sistim Informasi Perencanaan Anggaran Pengawasan Terpadu

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