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Fee-for-service vs fee-for-diagnosis
The Gakin program, which was introduced by then governor Sutiyoso and continued by his successor Fauzi Bowo, was similar to Governor Joko âJokowiâ Widodoâs popular Jakarta Health Card (KJS) scheme: Both offered free third-class medical services to disadvantaged Jakartans
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he Gakin program, which was introduced by then governor Sutiyoso and continued by his successor Fauzi Bowo, was similar to Governor Joko 'Jokowi' Widodo's popular Jakarta Health Card (KJS) scheme: Both offered free third-class medical services to disadvantaged Jakartans.
However, Jokowi cut the red tape by allowing people only to show their Jakarta ID card and family card to get the free service. Previously, individuals had to obtain a relief letter from the leader of his or her neighborhood unit to get a Gakin card.
Jokowi also replaced the old reimbursement system, a fee-for-service, with a fee-for-diagnostic
reimbursement system that is known as Indonesia case-based group (INA-CBG), and a localized diagnostic-related group reimbursement system widely used across the world.
The replacement was the result of a change in healthcare management, from Jakarta Health Agency's regional health insurance (Jamkesda) unit to state insurer PT Askes.
The city administration transferred management responsibilities of the healthcare system to the authorities and health funds to PT Askes after both signed a cooperation agreement in April.
PT Askes is now manager of Jakarta's healthcare funds, which total Rp 1.2 trillion (US$123.24 million), based on individual monthly premiums of Rp 23,000.
Askes' tasks include verifying claims, implementing an information management system for all the data for KJS participants and handling payments and complaints.
Jakarta Health agency head Dien Emmawati said the implementation of KJS was a prototype for the national healthcare program that would begin in January 2014, and be carried out by state-owned insurance company PT Askes under the 2011 Social Security Provider Law.
PT Askes was appointed as the agency to implement the Social Security Providers Law for the health sector as of Jan. 1, 2014, as mandated by the 2004 National Social Security System Law.
'My agency, in coordination with the Health Ministry, has set up an integrated team to evaluate implementation of this program. We have a monthly meeting to evaluate and monitor progress,' Dien said recently.
She added that the team would be dissolved by the end of the year, just before the Social Security Provider Law came into effect nationally next January.
Before the INA-CBG was introduced to the current healthcare scheme, Jamkesda applied the Essential Service Package fee-for-service reimbursement system, where services were unbundled and paid for separately.
This allowed physicians to provide further treatment because payment was based on the quantity, rather than quality of care. Under the system, the city administration reimbursed up to 90 percent of medical costs spent by hospitals serving Gakin patients.
Meanwhile, in fee-for-diagnosis, medical expenses by hospitals will only be reimbursed if they were made based on the prescribed clinical procedure of a specific illness.
'Such 'bundled payments' require accurate diagnoses and are more cost effective than the fee-for-service reimbursement system. We can control both the service quality and health budget,' PT Askes director for services Fajri Adinur told The Jakarta Post recently.
The clinical procedures and medical rates used in the case-based group system were determined by the National Case Mix Center (NCC), which is comprised of professionals and representatives of hospitals from across the country.
'We collect data from hospitals and input it to the [INA-CBG] system application to get an ideal amount of medical rates for respective diagnostic treatment,' NCC deputy chairman Achmad Soebagio said.
He added that the more data submitted to the application, the more ideal the result.
According to Fajri, medical rates will be evaluated and updated in regular periods of less than two years by the Health Ministry.
With KJS, the ideal medical rates are determined from data from all hospitals ' both state and private ' which are incorporated into the program.
Only about 20 percent of the required data has been collected so far.
Fajri said the issue of medical rates might be related to recent complaints from a number of private hospitals, which claimed that less than 50 percent of KJS medical expenses had been repaid by the city administration.
'This was likely due to the fact that every hospital has its own standard of medical rates [...] hence the gap between the unit costs applied by the city administration and the hospitals,' he said.
Two private hospitals, Thamrin and Admira, pulled out of KJS after failing to cope with losses from covering its patients' medical expenses.
Thamrin Hospital deputy president director Abdul Barry Radjak previously said that the city administration had only repaid about 30 percent of the medical expenses.
Achmad said that the NCC was looking for a solution.
'We will check the unit costs in hospitals across Jakarta and examine why there is such a wide divergence between the unit costs and reimbursement rates. However, we guarantee that we will never risk the quality of medical treatment,' he said.
The INA-CBG system also promises a shorter time for repayment and a more effective verification method.
'We use an online system where each hospital will only need to input the treatment online. Once the data has been verified and deemed complete by my team, the expenses will be reimbursed within 15 days,' Fajri said.
The reimbursement period was shorter than that of the previous system used in the Gakin program, which took between two and three months and which used a manual verification method.
