A Critical Analysis of Purchasing Arrangements under BPJS in Indonesia

Yulita Hendrartini, University of Gadjah Mada , IndonesiaiHEA, Milan; Tuesday 14 July, 2015

Gadjah Mada University

Introduction: Roadmap to UHC in Indonesia

Transformation from 4 existing schemes to BPJS Kesehatan (JPK Jamsostek, Jamkesmas,

Askes PNS, army)

Coverage of various existing schemes

148,2mio

121,6 M covered by

BPJS Keesehatan

50,07 M covered by

other schemes

257,5 M (all

Indonesian people)

covered by BPJS

Kesehatan

Activities: Transformation, Integration,

Expansion

86,4 M poor

2

Consumer satisfaction measurement every 6 monthBenefit package and sevices

review annually

Key actors in SHI

National Social SecurityCouncil Financial Autority

Agencycontrol control

KEY ACTOR

Social Health InsuranceNational

government agencies

(MoH, MoF, MoS,

Provincial and district

governmentsProviders of care

Insurer (BPJS)

Oversight of scheme X Financing scheme x XSetting parameters (benefits package, definitions of poor, etc.) X XAccreditation/Empanelment of providers X XEnrollment x X X XFinancial management/planning X X Actuarial analysis / premium setting X Setting rate schedules for services/reimbursement rates X X

Claims processing and payment X X (District level)

Service delivery X XDeveloping clinical information system for monitoring/eval X x xMonitoring local-level utilization and other patient information X xMonitoring national aggregate information XCustomer service x X X

ROLE OF KEY ACTORS

Health Financing in SHIResource collection Pooling Purchasing

Government contribution for poor and near poor: Rp. 19.225 (USD 1.5) PMPM

BPJS as single purchaser

PHC public & private providers: capitation

Public and private Hospitals : DRGs (INA-CBG) based payments vary according to region

3 rd class IP for poor2 nd class IP for non poor1st class for non poor (depends on premium)

Civil servant and military: 5% of monthly wages

2% from employee 3% from employer

Laborers: 5% of monthly wages 1% from employee4% from employer

Self funded / informal sector: From Rp 25.500 – 59.500 PMPM(2.0 USD – 4.5 USD)

Summary: Mechanism for strategic purchasing

Principle agent relationship on going proccess Key Challenge

Purchaser - government

• Organizational structure• Capacity building for DHO • Negotiated budget

• Unclear role of stakeholder• Lack of data for monitoring• Updating• Lack of health facilities

investment

Purchaser - citizen • Review benefit package annually

• Patient satisfaction review

• Lack of citizen voice• Limitation of Customer rights

Purchaser - provider • Prospective Payment• Selection and

credentialing• Setting indicator

• Capitation not effective• DRG tariff inadequate• Inequity provider distribution • Lack of quality control• Lack of fraud prevention

Gaps in government actions to promote strategic purchasing

• Unclear organizational roles• Accountability lines between BPJS / purchaser and the

Ministry of Health (and District Health Office)

• Inadequte monitoring activities• Data limitation and lack of DHO capacity to monitor the

program

• Problems in reducing the inequity of services. • Limited budget to developing new health service

infrastructure and deploy strategic human resources

Gaps in relation to role of citizens and population in strategic purchasing

• The needs, preferences and priorities of citizens in determining service entitlements is not clear in the policy design and implementation. Many regions where community needs are not met indicates

that there is no mechanism to ensure beneficiaries can access available services, especially the marginalized groups

Lack of evidence on health needs no evidence that citizens can participate in the process of determining health needs and priorities

No representation in purchasing boards Limitation of patients’ rights legislation

Gaps in relation to providers in strategic purchasing

• Purchaser (BPJS) has inadequate credentials and capacity to contract especially in government providers

• Poor monitoring mechanisms to control health services moral hazard (potential fraud)• No fraud regulation

• Provider response to prospective payment system (capitation and DRG payment) problems: Provider ability/capacity to respond to incentives accept

limitationLines of accountability detection potential Fraud

Factors affecting first year of SHI implementation in Indonesia

The SHI system is quite new, so actors will need time to settle into new relationships and respond to incentives

BPJS is a new office to managed huge membership need more staff, developt IT system to monitor provider performance and governance stewardship

Strengthened and developed PHC role as gatekeeper and capacity building DHO to supervised New Drug formulary for PHC Skill Training and refreshing course to promote

primary doctor competencies

Strategic purchasing: Conclusion

SUPPORTING FACTORS

•Strong political support for BPJS

•The benefit package under the scheme will be clearly defined and includes full spectrum of health concerns.

• Autonomy for purchaser in day-to-day management decision-making and operations

•BPJS capacity to claim audit timely payments to providers (max 14 days)

CONSTRAINING FACTORS

•Limited BPJS resources regular operation of the BPJS offices

•Limited of BPJS capacity to purchase stragically pricing policy regulated by MOH capitation payment too high for PHC govrnment

•Limited capacity of BPJS to monitor provider performance, service utilization & quality, and publicly report on provider & purchaser performance

Recommendations

• Strategic purchasing alone cannot deal with the problems of underlying inequity in distribution of infrastructure need the collaboration between central and district government to built infrastructure

• Ensure structural or functional integration of public health programs into purchasing

• Enforce purchaser accountability by making data accessible to the public and relevant stakeholders

• Strengthen the quality control of health service and fraud prevention, detection and prosecution.

• Indicators related to strategic purchasing need to be added in to the SHI and BPJS monitoring system

• Change the management culture of command and control

www.wpro.who.int/asia_pacific_observatoryhttp://resyst.lshtm.ac.uk@RESYSTresearch

The research is a collaboration between RESYST and the Asia Pacific Observatory on Health Systems and Policies.

RESYST is funded by UK aid from the UK Department for International Development (DFID). However, the views expressed do not necessarily reflect the Department’s official policies.

More information: http://resyst.lshtm.ac.uk/research-projects/multi-country-purchasing-study