The Jakarta Post
Since its implementation on Jan. 1, national health insurance (JKN) has received much criticism from both patients and health practitioners.
Patients feel the new system forces them to visit community health centers frequently to refill limited prescriptions.
Others feel they receive less comprehensive benefits compared to the previous schemes of Askes for civil servants and Jamsostek for other employees. On the other hand, providers feel forced to change their practice or even lower their quality standard to comply with the new system.
We can thoroughly analyze that the system itself has been carefully designed: the capitation rate for primary care promotes preventive services; the Indonesia Case-Based Group (INA-CBG) system, which applies a fee-for-diagnostic reimbursement model, promotes efficient practice; the managed competition model improves quality and drives down costs; premium financing improves public awareness and political sustainability; while mandatory enrollment removes adverse selection. So what is wrong with the model that has created so much resistance from the public? It's the nominal value.
One function of the Social Security Management Agency (BPJS) is to manage the cash flow from premiums and expenditure. The current premium is simply too low to sustain decent-quality healthcare services. The top-down approach in deciding the premium has not been well accepted within the professional unions. For instance, the Indonesian Doctors Association (IDI) stated that the current capitation rate could potentially make physicians operate in a negative balance.
Similarly, the Indonesian Dentists Association (PDGI) stated that the current capitation rate at Rp 2,000 (16 US cents) covers less than 60 percent of their calculated needs. Further, the calculation of INA-CBG's rates is not transparent, making providers reduce quality in order to fit the rates.
Instead, the Health Ministry and the BPJS should simply let professional unions together with health facility associations transparently calculate the capitation and INA-CBG's rates. From these rates, the ministry and the social security agency could calculate a premium rate to sustain the expenditure.
This bottom-up approach will remove provider resistance and increase political support. Providers would feel empowered to practice using their 'common practice' as a quality benchmark. Patients will also understand that the calculations already take into account the pharmaceutical benefit they are entitled to. This will prevent quality deterioration, stimulate efficiency, remove drug coverage complaints and reduce problems of multiple visits and readmission of patients.
Raising premium rates will clearly create problems for the poor. This is where the government comes in to prove its commitment to provide care for them. The current national budget for health is still under 3 percent and this is the perfect time for the central government to raise it to at least 5 percent, as required by law.
While the government needs to cover all people below the poverty line, the provincial administrations can sustainably supplement this coverage in a top-up fashion as done in the previous national and local health insurances.
Raising the capitation and INA-CBG rate to the market level will solve current implementation problems, including the issue of the government-listed insured drugs. Drugs which are currently unsubsidized would be transparently calculated when the unions and associations create the rates.
This will also enlighten the Health Ministry on the current practices undertaken by the providers and would stimulate the ministry to cover calculated drugs in the subsidized essential drug list (DOE) to reduce the overall cost.
It's all about the money. If the ministry and BPJS decide to reduce their power and start a bottom-up approach, the adjusted premium nominal value will reflect the true cost of quality healthcare service.
After adjustments are made, the system will work its way, and the people would clearly observe the government's political will to do what is stated in the constitution: taking care of impoverished persons and neglected children.
The writer is a Harvard School of Public Health student in health policy in Cambridge, Massachusetts, the US, and a former staff member of the Health Ministry, dealing with healthcare reform.
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