Implementation of Casemix System as Prospective Provider Payment Method in Social Health Insurance: a Case Study of Acheh Provincial Health Insurance

Dr Irwan Saputra, Prof Dr Syed Mohamed Aljunid

Description

The Government of Aceh Province in Indonesia has established the Social Health Insurance (SHI) called Jaminan Kesehatan Aceh (JKA) in 2006 that provide health coverage to all 4.6 million population of the province. Fee-for-service was initially used as the provider payment method in the programme until 2013. In 2014, in line with the National Health Insurance of Indonesia (Jaminan Kesehatan Nasional JKN), INA-CBG (Indonesia Case-Based Group) casemix system was adopted by JKA to replace the Fee-for-Service method. This book presents outcome of the evaluation done using a combination of qualitative and quantitative methods on the implementation of JKA programme. The quantitative study was conducted to assess income of three selected hospitals (Type B, C and D) reimbursed using INA-CBG groups covering more than 17,000 cases. Quantitative data analysis revealed that overall, the hospitals received 32.4% higher income when reimbursed with casemix system (INA-CBG) as compared to fee-for-service. Type D hospital is the biggest gainer with 81.0% increase in income. In conclusion, the use of Casemix (INA-CBG) as a prospective payment method has benefitted the hospitals a lot. It is hope that additional resources gained through this programme will allow the hospitals to provide optimum care to the population.

Sujets

• Employabilité, métiers et formations
• Insurance
• Indonesia
• Economics
• Health
• Business
• Aceh
• Indonésie

Informations

• Publié par: Partridge Publishing Singapore
• Date de parution: 20 novembre 2022
• Nombre de lectures: 0
• EAN13: 9781543771985
• Langue: English

Extrait

IMPLEMENTATION OF CASEMIX SYSTEM AS PROSPECTIVE PROVIDER PAYMENT METHOD IN SOCIAL HEALTH INSURANCE: A CASE STUDY OF ACHEH PROVINCIAL HEALTH INSURANCE
 
PROF DR SYED MOHAMED ALJUNID & DR IRWAN SAPUTRA
 
 

 
 
Copyright © 2022 by Prof Dr Syed Mohamed Aljunid & Dr Irwan Saputra.
 
ISBN:
Softcover
978-1-5437-7197-8

eBook
978-1-5437-7198-5
 
 
All rights reserved. No part of this book may be used or reproduced by any means, graphic, electronic, or mechanical, including photocopying, recording, taping or by any information storage retrieval system without the written permission of the author except in the case of brief quotations embodied in critical articles and reviews.
 
Because of the dynamic nature of the Internet, any web addresses or links contained in this book may have changed since publication and may no longer be valid. The views expressed in this work are solely those of the author and do not necessarily reflect the views of the publisher, and the publisher hereby disclaims any responsibility for them.
 
 
 
 
 
 
www.partridgepublishing.com/singapore
Contents
Acknowledgements
Chapter 1     Introduction
1.1   Intoduction
1.2   Study Justification
1.3   The Scope Of Study
1.4   Study Objectives
1.4.1   General objective
1.4.2   Specific objectives
1.4.3   Hypothesis
1.5   Conclusion
Chapter 2     Literature Review
2.1   Introduction
2.2   Social Health Insurance
2.2.1   Definition Social Health Insurance (SHI)
2.2.2   The Objectives of Social Health Insurance
2.2.3   Social Insurance Scheme
2.2.4   Development of Schemes
2.2.5   Benefit Package
2.2.6   Social Insurance in Indonesia
2.2.7   Civil Servant Social Health Insurance Scheme (Askes)
2.2.8   Private Employee Social Health Insurance Scheme (Jamsostek)
2.2.9   Community Health Insurance For the Poor (Jamkesmas)
2.2.10   The Aceh Health Insurance (JKA)
2.3   Reimbursement Of Health Care
2.3.1   Characteristics of Reimbursement
2.3.2   Types of Healthcare Reimbursement Methodologies
2.3.3   Retrospective Payment
2.3.4   Fee for Service Method
2.3.5   Prospective Payment Methods
2.3.6   Capitation Payment Method
2.3.7   Global Payment Method
2.4   Casemix And Diagnosis Related Group (DRG)
2.4.1   Casemix and Casemix Management
2.4.2   Hospital Casemix
2.4.3   History of Diagnosis Related Group (DRG)
2.4.4   Definition of DRG
2.4.5   Data in DRG
2.4.6   The Purpose of DRG
2.4.7   The Advantages of DRG
2.4.8   Major Diagnostic Category (MDC)
2.4.9   Type of DRG
2.4.10   The Components DRG System
2.4.11   Guide to Implement DRGs
2.4.12   Strategies for Casemix Implementation System in the Hospital
2.5   The Experiences of High And Low Income Countries in Implementing the Casemix System
2.6   Conceptual Framework
2.7   Conclusion
Chapter 3     Methodology
3.1   Introduction
3.2   Background of Study Area
3.3   Duration of the Study
3.4   Study Design
3.4.1   Qualitative Study
3.4.2   Quantitative Study
3.5   Ethical Approval
3.6   Conclusion
Chapter 4     Results
4.1   Introduction
4.2   Evaluation the JKA Programme.
4.2.1   The Government Commitment in JKA Financing Programme
4.2.2   The Impact of JKA Financing to Other Publicly Funded Programmes
4.2.3   The Adequacy of Financing JKA Programme
4.2.4   Hospital Tariff under JKA
4.2.5   Technical Capacity of Claims Verificators
4.2.6   The Impact of JKA Financing on Health Care Services
4.3   Assessment of Feasibility in Implementing the Casemix System.
4.3.1   The Commitment and Government Policy in Casemix Implementation.
4.3.2   The Readiness of Hospital in Implementing Casemix Sytem
4.4   The Comparison of JKA and INA CBGs Tariff.
4.4.1   Hospital Selection.
4.4.2   Data Collection.
4.4.3   Data Trimming Process.
4.4.4   The Tariff Comparison Based on Type of Hospital.
4.5   Conclusion
Chapter 5     Discussion and Conclusion
5.1   Introduction
5.2   Background of Respondents
5.3   The Government Commitment in JKA Financing Programme.
5.4   The Evaluation of JKA Programme Financing
5.5   The Impact of JKA Financing on Health Care Services
5.6   Assessment of Feasibility in Implementing Casemix System
5.6.1   The Preparation of JKA Implementation Based on Aceh-CBGs
5.7   The Readiness of JKA integrated with the JKN Based on INA CBGs
5.8   The Comparison of JKA and INA CBGs Tariff.
5.8.2   Data Collection.
5.8.3   Casemix Data
5.8.4   Comparison of Hospital Tariff
5.9   The Limitation of the Study
Chapter 6    Conclusion and Recommendation
6.1   Introduction
6.2   Conclusion
6.3   Recommendations
Refferences
List of Figures
Figure 2.1: A theory of change due to health insurance
Figure 2.2: Use of DRGs by Stages
Figure 2. 3: Typical DRG structure for a Major Diagnostic Category
Figure 2.4: The Implementation of DRG
Figure 2.5: Conceptual Framework
Figure 3.1: Map of Aceh
Figure 3.2: Qualitative Study Design
Figure 3.3: Quantitative Study Design
Figure 4.1: Financial Allocation of JKA Programme in 2010 - 2014
List of Tables
Table 2.1: Status of Social Health Insurance in Low-and Middle-Income Countries
Table 2.2: List of Major Diagnostic Category (MDC)
Table 3.1: Population Census of Aceh Province in 2010
Table 3.2: List of Respondents
Table 3.3: List of Type B, C and D Public Hospitals in Aceh Province
Table 4.1: Budget Realization* of JKA in 2010
Table 4.2: Allocation and Realization of JKA Funds Based on Type of Services 2010
Tabel 4.3: Allocation and Realization of JKA Funds Based on Type of Services 2011 (January – August)
Table 4.4: Basic Information Of Three General Hospitals in Aceh (B, C and D)
Table 4.5: Total Number of Inpatients Cases In The Three Hospitals
Table 4.6: Gender Distribution of Patients in The Three Hospitals
Table 4.7: Mean Age (Years) of Patients in TheThree Hospitals
Table 4.8: Length of Stay of Patients in The Three Hospitals
Table 4.9: Distribution of Length of Stay in The Three Hospitals
Table 4.11: Distribution Patients by CMG
Table 4.11: Top Ten CBGs in Cut Meutia General Hospital and Length of Stay (LOS)
Table 4.12: Top Ten CBGs in Tgk Chik Di Tiro General Hospital and Length of Stay (LOS)
Table 4.13: Top Ten CBGs in Sabang General Hospital and Length of Stay (LOS)
Table 4.14: Discharge Status in INA-CBGs
Table 4.15: Discharge Status of Patients in The Three Hospitals.
Table 4.16: Severity of Illness of Patients in The Three Hospitals
Table 4.17: ALOS by Severity of Illness in The Three Hospitals.
Table 4.18: Distribution of Data Inliers and Outliers in The Three Hospital
Table 4.19: The Tariff Comparison in Cut Meutia General Hospital (Type B)
Table 4.20: The Tariff Comparison in Tgk Chik Di Tiro General Hospital (Type C)
Table 4.21: The Tariff Comparison in Sabang General Hospital (Type D)
Table 4.22: The Tariff Comparison in Cut Meutia General Hospital (Type B) Based on Type of CBGs
Table 4.23: The Tariff Comparison in Tgk Chik Di Tiro General Hospital (Type C) Based on Type of CBGs
Table 4.24: The Tariff Comparison in Sabang General Hospital (Type C) Based on Type of CBGs
Table 4.25: Different in Hospital Tariff between INA CBGs and JKA( fee-for-service) based on Top 5 in Hospital Type B
Table 4.26: Difference in Hospital Tariff between INA CBGs and JKA( fee-for-service ) based on Top 5 in Hospital Type C
Table 4.27: Different in Hospital Tariff between INA CBGs and JKA( fee-for-service ) based on Top 5 in Hospital Type D
Table 4.28: Difference in Hospital Tariff between INA CBGs and JKA( fee-for-service ) Based on Severity Level in Hospital Type B
Table 4.29: Different in Hospital Tariff between INA CBGs and JKA( fee-for-service ) Based on Severity Level in Hospital Type C
Table 4.30: Different in Hospital Tariff between INA CBGs and JKA( fee-for-service ) Based on Severity Level in Hospital Type D
Table 4.31: Different in Hospital Mean Tariff between INA CBGs and JKA( fee-for-service ) each type of Hospitals
Table 4.26: Difference in Hospital Income Comparing Tariff between INA CBGs and JKA in Each Type of Hospitals
Table 5.1: Projection of Gas and Special Autonomy Funds 2011-2027
List of Appendices
Appendix 1 Interview Guide For Qualitative Study
Appendix 2 List Of In-Depth Interview Respondents
Appendix 3 The Fee-For Service and INA-CBG Tariff of Cut Meutia General Hospital
Appendix 4 The Fee-For Service and INA-CBG Tariff of Tgk Chik di Tiro General Hospital
Appendix 5 The Fee-For Service and INA-CBG Tariff of Sabang General Hospital
Acknowledgements
It gives us great pleasure in expressing our gratitude to all those people who have supported us and had their contributions in making this book possible. First and foremost, we must acknowledge and thank The Almighty Allah for His blessing, protecting and guiding us throughout this period. We could never have accomplished this without the faith we have in the Almighty.
We would like to express our special thanks to Prof. Hasbullah Thabrany, The Head of Health Economic Study Center, Faculty of Public Health, Universitas Indonesia and Prof. Supeni, Faculty of Public Healt