Ekonomi Kesehatan, Revenue Collection, Pooling dan Purchasing

1. HEALTH FINANCING :
revenue collection, pooling and
purchasing
Yulita Hendrartini
Magister Kebijakan Pembiayaan dan Manajamen Asuransi Kesehatan
Universitas Gadjah Mada

2. Agents in health care financing

3. Definition of health care
financing
Definition of health care financing
• mobilization of funds for health care
• allocation of funds to the regions and
population groups and for specific
types of health care
• mechanisms for paying health care
(Hsaio, W and Liu, Y, 2001)

4. Financing is More Than Mobilize Money
Mobilize
& collect
Pool the Risk
Funds
Allocate
Resources
Purchaser

5. Fungsi dan Tujuan Pembiayaan Kesehatan
Fungsi Tujuan
Revenue
Collection
Pooling
Purchasing
& Payment
Meningkatkan dana untuk
kesehatan secara cukup dan
berkesinambungan. Dana ini untuk
membiayai pelayanan paket
esensial dasar dan perlindungan
keuangan dari penyakit dan biaya
katastropik berdasarkan aspek
pemerataan
Mengelola dana-dana tersebut
dalam pool risiko kesehatan yang
efisien dan merata
Menjamin pembelian/
pemerolehan dan pembayaran
pelayanan kesehatan yang
efisien secara teknis dan alokatif
Hsiao 2013

6. Mekanisme Revenue Collection
Melalui mekanisme
pemerintah/lembaga asuransi
kuasi pemerintah
• Pajak langsung atau tidak
langsung
• Pendapatan pemerintah yang
berasal dari bukan pajak
• Kontribusi asuransi wajib dan
potongan gaji
• Pembayaran premi ke
pemerintah
• Grant dan pinjaman luar-
negeri
Dari masyarakat
• Dari kantong pasien
perorangan
• Yayasan-yayasan
kemanusiaan
6

7. Apa yang terjadi dalam
Pengumpulan dana
Kesehatan
APBN
BPJS
Paja
k
Pendapatan
Negara
bukan Pajak
Non-PBI
Mandiri
Pelayanan
Primer:
Pelayanan
Rujukan
Non-PBi PNS,
Jamsostek dll
dll
Kemenkes
Dana dari Masyarakat langsung
Kementerian
lain
PBI
Pemda
7
Pendapatan
Asli Daerah
Askes
Swasta
(67,5 T)
NHA 2009 (dana
masyarakat
langsung) (18 T)
Kab/K
ota 489
( 72.9
T)
18.89T
2.24T
19.93T
Trisnantoro, 2014

8. Pooling
• Pooling yaitu bagaimana pengumpulan dana
dibagikan yang mempunyai risiko kesehatan diantara
pengumpul dana /atau anggota kelompok (pool
member) (World Bank, 2014).
• Dana yang dikumpulkan untuk kesehatan akan
dibayarkan ke provider kesehatan,
• tempat penampungan (pools) dana bisa berbagai
macam, seperti anggaran pemerintah pusat dan
pemerintah daerah, asuransi kesehatan publik dan
swasta, dan asuransi kesehatan berbasis masyarakat.
8

9. Pooling dana kesehatan
9
1. APBN
• Kemenkes (47,5 T)—termasuk
PBI
• Kementrian Lain (13,5 T)
• Pemda (6.5 T dari APBN)
2. BPJS Kesehatan
• PBI (19,9 T) plus
• Non PBI-ex Askes,Jamsostek
(18.89T)
• Non PBI-Mandiri (2.24T)
Dua Pool
besar:
1. APBN
2. BPJS

10. Apa yang terjadi
dalam Pooling
APBN
BPJS
Pajak
Pendapatan
Negara
bukan Pajak
Non-PBI
Mandiri
Pelayanan
Primer:
Pelayanan
Rujukan
Non-PBi PNS,
Jamsostek dll
dll
Kemenkes
Dana dari Masyarakat
langsung
Kementerian
lain
PBI
Pemda
10
Pendapatan
Asli Daerah
Askes
Swasta
Trisnantoro, 2014

11. Pooling & Purchasing Functions Not Separated by Revenue
Health Purchaser or Purchasers
Unified or Coordinated Benefits Package
Unified or Coordinated Provider Payment Systems
National
Budget
Local
Budget
Payroll
Tax
Donor
Funds
Private
Funds
Pooling of Funds Pooled
or not
Pooled
Revenue
Collection
Pooling
of Funds
Health
Purchasing
Providers
Population

12. Purchasing with Health Budget Funds
• Input-based line item budgets funding public facilities
can be problematic if low budget level doesn’t fund all
services provided in health facility
– Not clear to provider what services funded and what not
funded
• Health budget purchasing better targeting or
matching priority services & poor populations
– Output-based provider payment systems
• Key is unit of service—not building but services for people
– Financial incentives for desired service delivery
improvements
– Align rather than fragment health purchasing
– Better targeting budget funds to priority services opens
space or clear role for private funds

13. Pemahaman Purchasing
Purchasing:
•Mekanisme pembayaran ke fasilitas kesehatan
dan penyedia layanan kesehatan
•3 komponen yaitu alokasi sumber daya, paket
manfaat dan mekanisme pembayaran provider
(Preker and Langenbrunner, 2005)
Desain ini merupakan komponen kunci yang sangat penting
untuk pemerataan akses yang adil dan perlindungan terhadap
resiko keuangan. 13

14. RASIO KLAIM 2014 - PELAYANAN
(DIKURANGI BIAYA OPERASIONAL BPJS )
(JUTA RUPIAH)
IURAN PELKES
RASIO
KLAIM
40.719.862 46.665.539 114,60 %
38.242.870 46.665.539 122,02 %
LAPORAN BOA, CPR & KEUANGAN DIOLAH
• Rasio klaim berdasarkan bulan
pelayanan sebesar 114,60 %
dengan beban klaim 12 bulan
• Bila dikurangi biaya
operasional maka rasio klaim
akumulasi 122,02%.
• Berdasarkan bulan pelayanan
iuran POPB : 27.198 dan Biaya
manfaat POPB : 30.486
• Bila tanpa peserta PBPU, rasio
klaim 84,29%
RASIO KLAIM 2014 - PEMBEBANAN
(JUTA RUPIAH)
IURAN PELKES
RASIO
KLAIM
40.719.862 42.658.702 104,76 %
38.242.870 42.658.702 111,55 %
LAPORAN AKUNTANSI AUDITED
Purchasing dalam JKN
14

15. Biaya manfaat 2014
42.658.702 *
Peserta 133.273.918
Biaya Pelayanan Primer
Rp. 8.347.850
Biaya Pelayanan
Rujukan
Rp. 30.439.572
Jlh faskes primer :
17.492
Puskesmas : 9.788
DPP : 3.984
Klinik pratama : 2.388
Faskes TNI-POLRI : 1.324
RS pratama : 8
Jlh Faskes Rujukan : 1. 681
RS Pemerintah : 776
RS TNI-POLRI : 143
RS Swasta : 652
RS BUMN : 42
Klinik Utama : 68
Biaya Non
Kapitasi
Non CBG’s,
promprev
Rp. 3.871.280
PBI –N : 86.399.836 PBI-D : 8.649.830 BP : 4.885.140 PPU : 24.288.688 PBPU : 9.050424
Rata rata biaya per
faskes Rp.39.77
juta/bulan
Rata rata biaya per
faskes
Rp. 1,509 M/bulan
* Cash basis

16. Biaya manfaat sd Juni 2015
27.178.466 *
Peserta 147.675.544
Biaya Pelayanan Primer
Rp. 4.953.108
Biaya Pelayanan Rujukan
Rp. 22.270.069
Jlh Faskes Rujukan : 1.783
RS Pemerintah : 692
RS TNI-POLRI : 147
RS Swasta : 903
RS BUMN : 41
Biaya Non
Kapitasi
Non CBG’s,
promprev
Rp. 816.879
PBI –N :
86.426.543
PBI-D :
10.613.788
PPU swasta
18.347.445
Eks Askes :
19.534.154
PBPU :
12.753.614
Rata rata biaya per
faskes Rp.44,99
juta/bulan
Rata rata biaya per faskes
Rp. 2,081 M/bulan
Jlh faskes primer : 18.347
Puskesmas : 9.814
DPP : 4.314
Klinik pratama : 2.923
Faskes TNI-POLRI : 1.288
RS pratama : 8
* Cash basis

17. 17
Fund Collection Indicators
Indicators Purpose
•The formal sector share of GDP
•Natural resources revenue as a share
of total public budget
• Total health expenditure % GDP
• Potential resources available to
finance public health spending
• Public sector spending as % GDP
•External health sector aid as % of
GDP
•To measure resources specially
available to the public sector
•The share of public health to total
public expenditures
•Per capita total and public health
expenditures
•To measure public sector allocation
decisions, additional resources, and
potential constraints
•The share of total health
expenditures that are prepaid
•A broad measure of financial protection
against out-of-pocket expenses

18. 18
Pooling Indicators
Indicators Purpose
Means and distribution measure
of:
•Share of co-payments to total
health expenditures in each pool
•Membership in each pool
•Per capita spending in each pool
•Measures of the scale, depth of
financial coverage, and existence
of compensatory mechanisms
across pools
•Share of administration
expenses out of total spending in
each pool
•Average ratio of transfers to
estimated shortfall (or surplus)
•To measure the efficiency of
pool management and
effectiveness of compensatory
mechanisms

19. 19
Purchasing Indicators
Indicators Purpose
•Share of expenditures accounted
for by “strategic” purchasing
•Characterizing the pool-purchaser
relationship
•Number of purchasers
•Mean and distribution of total
expenditures across purchasers
•Mean and distribution of the
number of providers who are
contracted or hired by each
purchaser
•To characterize the structure of
interaction between purchasers and
providers
•Share of total funds spent with
different payment mechanisms (e.g.
salaries, fee-for-service, capitation)
•To measure the financial incentives
embedded in payments to providers

20. Health Financing Schemes
Health
care
services
Tax-based
financing
Social health
insurance
Other
prepayment
schemes
Out-of-
pocket
payments
1. General tax or
other revenue
2.Payroll tax
3.Contribution or
premium
4. Direct payment
Household
External
resource
Financing mechanisms Financing sources
Natural
resource
revenue

21. Issues in Health Financing
What's the nation's ethical foundation for
health care? Is equity a priority over efficiency?
For whom you allocate resources and for what
services/drugs?
How much would the program cost? Who
pays?
Can the nation's transform money into effective
and efficient services?
Is financing scheme sustainable?