H

ospitals are suspected of abusing the national health insurance (JKN) program to gain profits, including by encouraging pregnant women to deliver their babies via C-section, according to a study by the University of Indonesia’s (UI) public health department.

The department’s researcher, Budi Hidayat, came to the conclusion after analyzing data of hospital claims from the Health Care and Social Security Agency (BPJS Kesehatan) between January 2014, when the JKN program started, and July 2015.

He found that the number of babies delivered via C-section under the JKN program was abnormally high.

From 1.5 million babies, 54 percent of them were delivered via C-section. “I think this is irrational because according to medical terminology, the C-section percentage normally less than 10 percent [of all deliveries],” Budi told The Jakarta Post.

More alarmingly, the number of deliveries by C-section has increased, from 47 percent at the start of the JKN program in January 2014, he added.

“The trend is increasing. That’s my concern. This might be on purpose to earn more money,” Budi said.

According to the hospital fees set by the government for the JKN program, a C-section costs between Rp 5 million (US$377) and Rp 11 million depending on the class and difficulties of the procedure.

Meanwhile, a normal childbirth costs between Rp 2 million and Rp 5 million.

During the period of the study, hospitals claimed Rp 5.51 trillion in childbirth services to BPJS Kesehatan. Seventy percent of them, or Rp 3.8 trillion, were C-sections.

BPJS Kesehatan research and development head Togar Siallagan is aware of the trend.

“Therefore, we will warn [hospitals] and implement procedures [to make sure all C-section are truly necessary]. That’s also why we’re trying to develop childbirth through midwives,” he said.

Besides indications of unnecessary C-sections, Budi also found indication of other types of fraud.

Hospital readmission is when a patient who has been discharged from a hospital is admitted again within a specified time interval.

According to Budi, there were 47.5 million hospital visits during the period of the study and 75.8 percent of those were readmission. “But not all of those readmission were dangerous. Only 43.5 percent of them needed to be investigated further,” he said.

The 43.5 percent, or 20.6 million hospital visits, are problematic because it is suspected that the hospitals purposefully make patients pay multiple visits even though it is unnecessary to do so. Furthermore, the visits cost BPJS Kesehatan Rp 6.9 trillion.

Besides readmission, there is also indication of hospitals practicing “bloody discharge”. A bloody discharge is when a hospital discharges a patient when treatment is not yet complete.

According to the study, there were 8.8 million hospital admissions between 2014 and 2015, of which 4.4 percent were bloody discharge cases, costing BPJS Kesehatan Rp 1.86 trillion.

“To charge the patients more than once, the patients are discharged before treatment is complete,” Budi said.

Another type of fraud is upcode, which is when a patient is diagnosed with an illness that is attached to higher fees.

Dumping, meanwhile, is when hospitals reject JKN members because treating their illnesses would cost them, as the fees set by the government are too low, according to Budi.

“So, a lot of patients are referred to other hospitals not because the hospital in question could not handle the patient but because the fee is too low. Sometimes, other hospitals won’t accept that patient either. That’s the reality,” he said.