CHALLENGES IN IMPLEMENTING THE INA CBG · 2018-11-09 · Z-3-27-0 PERAWATAN LUKA 1,708,425 333,013,131,000 194,924 Z-3-25-0 PROSEDUR ULTRASOUND GINEKOLOGIK ... and cost containment

CHALLENGES IN IMPLEMENTING

THE INA CBG

dr. Andi Afdal Abdullah, MBA, AAK

Deputy Director of Research and Development

Presented at the 2018 InaHEA

Jakarta, November 1, 2018

2

Health Insurance Expenses 2014 - 2017

42.6 T

57.1 T

67.2 T

84.4 T

Total Benefit Cost

4 years

IDR 251,3 T

Total INA-CBG

spending in 2017 was

IDR 66.6 T or 78.85%

of total annual

spending.

3

IMPLEMENTING HEALTH ECONOMICS IN EFFECTIVE FINANCING

FUNDSCARCE and

LIMITED

NEEDs/WANTsUNLIMITED

When fund is limited, we are forced

to do “trade-offs” or a compromise,

by:

Rationing budgeting

Prioritizing what medical

treatments do we need the

most?

THUS, DESIGNING BENEFIT

PACKAGE AND PURCHASING POLICY

TO MAKE OPTIMUM USE OF THE

LIMITED RESOURCES

Act No 40/2004 article 22:

JKN provides insurance and

financial protection for medical

necessities

JKN offers comprehensive

benefits

But benefit packages should be

adjusted to the people’s needs

and ability to pay of BPJS

The future of benefit

package design will

depends of ATP of BPJS

Kesehatan.

The ATP is strongly

related to price setting

and payment systems,

i.e the INA-CBG

4

THE INA-CBG CHALLENGES

Almost 5 years into implementation

Providers: resistance coping (hopefully) acceptance

Despite, the system is not quite well understood by providers (and other stakeholders)

• How the tariff is developed

• The logic of the grouper

• How much is HBR, casemix index, adjustment rate

Things to ponder:

Have we established a quality tracking system to prevent caveats, prevent unnecessary admissions

and readmission?

Have we improved the coding systems which fully utilize the ICD 10 and ICD 9-CM?

Have we improved the costing system so only robust and high quality data are used to develop the

tariff?

After almost 5 years in collecting and analyzing data, have we tried to improve the grouper and the

system to accommodate the local needs developing Indonesian own grouper?

Two main factors:

1. Capacity to develop and improve the groupers and the system

2. Political will of stakeholders

5

1. Low incentives to improve

performance• The price settings are in favor of hospital classes, not their performance nor

their compliance to standard

• Low incentive to prevent and deter the caveat of INA-CBG (bloody discharge,

readmissions, upcoding, etc)

• No national consensus of readmission (the interval of rehospitalization) and no

payment reduction mechanism toward the cases

43%

43%

13%

1%

Credentialing Compliance of Hospitals

<75% 75% s.d <86% 86% s.d <96% 96%-100%

These hospitals have the same

HBR if they belong to the same

class, regardless of whether

they have facilities or doctors

according to the standard

6

2. Low incentives to improve efficiency

• Low incentive to develop clinical pathway and/or compliance to clinical guidelines (if

any)

– The example of unintended effects:

• the case of neonates which are paid regardless of the resource consumption.

• Variations in providing care which way is the most effective and efficient considering the

available resources in the hospitals?

• Notes: the availability of clinical pathway in the hospitals is one of the consideration in credentialing

but there in no scheme to make sure that the hospitals comply with the CP.

• INA CBG is quite inefficient for outpatient admissions*

– Dumping to another hospitals due to low tariff

– Outpatient admitted to inpatients

– Recommendations*• Risk sharing with primary providers to reduce unnecessary referral for chronic diseases

• Tariff adjustment for high readmission rates groups (chronic groups, wound care, teeth care, etc)

• Urgent need for indicators to measure performance in outpatient setting such as : waiting time, availability of drugs, no illegal cost

sharing,

• Has costing data of the hospitals been assessed for efficiency? The need to assess of

the quality of data is not just taking out the outliers, but more to make sure that the

hospitals have done their best in improving the spending

*Kajian Sistem Pembayaran di RJTL selain INA-CBG, KP-MAK UGM

7

CMG DISTRIBUTION IN OUTPATIENT

SETTING

44% of CMG “M” (Musculoskeletal system & connective tissue Groups) dan 51% of CMG F (Mental

Health and Behavioral Groups) are treated in Class B hospitals.

Class C hospitals treated more than 50% of CMG O (Deliveries Groups) dan CMG P (Newborns &

Neonates Groups) cases.

Does the

distribution of

cases related to

high gap

between

hospitals

classes?

Reducing the

gap may improve

the distribution of

cases

8

THE CASES of NEONATES PRICE SETTING and CODING INDICATION of INEFFICIENCY?

2015 sd 2017

-

5,000

10,000

15,000

20,000

25,000

30,000

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

The number of cases increase

by 87%

The cost increase by 125%

The number of cases increase by

82%



241%


THE CASES OF NEONATES:

Neonates from caesarean delivery are coded and submitted as

individual cases, regardless of the condition of the baby

The average annual increase in the number of neonates submitted

as individual cases = 85% .

The number of neonates cases in 2017 = 270.719

The cost for neonates increases 151% annually.

The cost for neonates in 2015, 2016 and 2017 are Rp 175 M, Rp

394 M dan Rp 1 Trillions, respectively

9

THE CASES of MEDICAL REHABILITATION= AN INEFFICIENCY IN OUTPATIENT SETTING?

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

No of cases

The number of cases increase

by 48%



38%

The cost decrease by 5% due to

tariff adjustment


104%


MEDICAL REHABILITATION: The medical rehabilitation cases are one of many cases in which the

lack of clinical guidelines increase the number of admissions.

The medical rehab is the top 3 in the number of CBG cases in

outpatient setting, with the number of cases in 2017 went up to 7,5

million cases.

The annual increase in the number of cases up to 43%

The cost of medical rehab in 2015, 2016 and 2017 were Rp 794 M,

Rp 1,02 T dan Rp 973 M, respectively.

The cost of rehab in average is 6 % of the total outpatient spending

10

OTHER CHALLENGES

a. National coding standard for the last years BPJS and MoH has

developed manual coding, but it’s still far from perfect

b. Utilization review

Lack of data in drugs utilization how much is spent on drugs?

All multiple admitted chronic diseases in outpatient belong to one group needs

effort to evaluate which diseases in a group

25 KODES CBGS RJTL TERBANYAK

BULAN PELAYANAN DESEMBER 2017 s.d AGUSTUS 2018

KODE CBGS NAMA CBGS KASUS BIAYA UC

Q-5-44-0 PENYAKIT KRONIS KECIL LAIN-LAIN 29,928,786 6,235,386,876,490 208,341

M-3-16-0 PROSEDUR THERAPI FISIK DAN PROSEDUR KECIL MUSKULOSKLETAL 3,893,331 456,751,776,400 117,316

N-3-15-0 PROSEDUR DIALISIS 3,038,046 2,642,208,017,900 869,706

Q-5-42-0 PENYAKIT AKUT KECIL LAIN-LAIN 2,012,142 389,555,305,000 193,602

Z-3-12-0 PROSEDUR REHABILITASI 1,754,330 277,486,731,700 158,172

Z-3-27-0 PERAWATAN LUKA 1,708,425 333,013,131,000 194,924

Z-3-25-0 PROSEDUR ULTRASOUND GINEKOLOGIK 1,381,845 429,619,415,200 310,903

Q-5-18-0 KONSULTASI ATAU PEMERIKSAAN LAIN-LAIN 1,308,986 182,825,010,000 139,669

11

The challenges of INA CBG can be overcame with several approaches by the government as the regulator and the hospitals

as providers

The hospital management adapt to the current

system

There is commitment to improve the quality of

claim reimbursement (better coding practice,

better documentation, better claim submissions)

There is commitment to improve quality control

and cost containment strategy (SOP, clinical

pathways, formulary, etc)

There is commitment to provide high quality

costing and coding data

There is commitment to constantly monitor and

evaluate performance

HOSPITALS


evaluate the fairness and adequacy of tariff,

including tariff-induced moral hazard.

Tariff adjustments should be derived from

strong data analysis

There is commitment to drive tariff adjustment

to more performance based.


evaluate the performance of hospitals that

provide costing and coding data.

Making optimum use of health technology

assessment

Reducing the tariff gap between hospital

classess

GOVERNMENT

RECOMENDATIONS

ANDDEVELOP A MIXED PROVIDER PAYMENTS TO BALANCE MULTIPLE

OBJECTIVES SUCH AS IMPROVING THE QUALITY OF CARE AND COST

EFFICIENCY -INA CBG + GLOBAL BUDGET

12

Thank You

Now Everything is in Your Hands!

www.bpjs-kesehatan.go.id

13

The Government Has Proclaimed The Roadmap to National Health Insurance(Jaminan Kesehatan Nasional) Until 2019

20192014

1. Started to operate

2. 121,6 millions of

participants (49% of

population)

3. Standard medical

benefits and non-medical

benefits according to

the class of treatment

4. Health facilities contracts

5. Established technical

regulations

6. Participants

satisfaction index 75%

7. Health facility

satisfaction index 65%

8. BPJS is managed in an

open, efficient and

accountable manner

1. Operational Sustainability2. 257,5 millions of participants

(100% of population)3. Medical benefits and non-

medical standard4. The number of health

facilities is sufficient5. Regulations are revised

regularly6. Participants satisfaction

index 85%7. Health facility satisfaction

index 80%

8. BPJS is managed in an open, efficient and accountable manner

2017

79,5%

187,9 millions

of people

201775,7%

(72,7%)

77.02%

Roadmap of JKN

As of October 1, 2018The number of participants was

203,284,896

14

77.02%

22.98%JKN-KIS Participants

203.284.896 PeopleAs of October 1, 2018*Dukcapil data source:1st Semester of 2018, Indonesia's population is 263,950,794

The Growth Rate of JKN-KIS Membership until

October 1, 2018

Comparison Of The Participants Number With Another Countries

15

FKTP includes Community Health Centers (Puskesmas), Doctor of Individual Practices, TNI / POLRI Clinics, Primary Clinics,Primary D Hospital and Individual Practical Dentist

18.437

19.969

20.708

Information:

Primary Care Health Facilities (FKTP)

22,681Source: BI Data of BPJS Kesehatan October 1, 2018

Source : Data of Deputy for PEO

Nu

mb

er o

f FK

TP

2,446Source: BI Data of BPJS Kesehatan October 1, 2018

Referral Health Facilities (FKRTL)


Increase

The Growth of Contracted Health Facilities

2014-2017

Nu

mb

er o

f F

KR

TL

16

Amount of Contribution Income 2014 – 2017(In trillion)

2014 2015 2016 2017

40,72

52,69

67,40

74,25

Total contribution

4 years

IDR 235,06 T82,34 %

Escalation


17

Health service utilization for 4 years at all levels of service

as much640,2

Of Utilization

millions


Health Service Utilization

2014-2017

612.000Per Calendar Day

Or on average in 2017

2014

Dec Audited Rep.

2015

Dec Audited Rep.

2016

Dec Audited Rep.

2017

Dec Audited Rep.

252.877 401.198 487.123 612.055Total Utilization/

Calendar Day

Total Utilization/ Year

Utilization in Hospital

Inpatient Polyclinic

Utilization in Hospital

Outpatient Polyclinic

Utilization in FKTP

(Community Health Centers/ Doctor of

Individual Practices/ Primary Clinics)

92,3 Mil 146,7 Mil 177,8 Mil 223,4 Mil

4,2 Mil 6,3 Mil 7,6 Mil 8,7 Mil

21,3 Mil 39,8 Mil 49,3 Mil 64,4 Mil

66,8 Mil 100,6 Mil 120,9 Mil 150,3 Mil

18

Satisfaction Index 2017

Sample Respondent SurveyStratified random sampling method with a margin of error of 0.4%

126 Branch

Offices

238Cities/ DistrictsIn Indonesia

57.097Respondents at allService contact

PARTICIPANTS SATISFACTIONHIGH CATEGORY2017

Sample Respondent SurveyStratified random sampling method with a margin of error of 0.4%

126 Branch Offices

238Cities/ Districts

In Indonesia

4.766Health FacilitiesOf BPJS Kesehatan

SATISFACTION OF HEALTH FACILITIESHIGH CATEGORY2017

**) Benchmarks of various agencies' satisfaction results classification norms are calculated by internal PT SWASEMBADA Media Bisnis

*) Frontier Survey Results, 2017

** **

ACHIEVEMENT

Milions of People

ACHIEVEMENT

Milions of People Milions of People Milions of People

Documents

CHALLENGES IN IMPLEMENTING THE INA CBG · 2018-11-09 · Z-3-27-0 PERAWATAN LUKA 1,708,425 333,013,131,000 194,924 Z-3-25-0 PROSEDUR ULTRASOUND GINEKOLOGIK ... and cost containment