The Jakarta Post
The government is redefining primary healthcare needs and the standards of service at hospitals eligible for the National Health Insurance (JKN) to ensure the deficit-stricken program’s sustainability.
Health Minister Terawan Agus Putranto said the ministry was working on finishing a benefits package for policyholders that was based on primary health needs, as mandated by a 2004 law on the national social security system (SJSN), and was expecting to realize it by the end of June.
He also presented the plan on Thursday before a hearing with the House of Representatives' Commission IX overseeing health care and manpower.
"The benefits package, which is based on primary health needs, will not reduce the benefits received by the people but rather optimize the benefits principles by reducing unnecessary treatments [...]," Terawan told the hearing.
He said such excessive services were in contrast to the principles of social insurance, which aims at providing basic health care for all eligible Indonesians.
Unnecessary treatments have reportedly inflated medical bills under the JKN.
Terawan said the new benefits package would contain a list of what the JKN could and could not cover, as well as what it could cover with restrictions.
The ministry will further discuss the package with the Healthcare and Social Security Agency (BPJS Kesehatan), which manages the JKN, to take into account the social security fund managed by the agency and to avoid “aggravating” its deficit further.
As deficits continue to batter the agency, totaling Rp 13 trillion (US$920 million) last year alone, the government issued in early May a presidential regulation to almost double JKN premiums roughly two months after the Supreme Court annulled an earlier regulation on similar premium increases.
The new regulation will take effect in July but to the opposition of lawmakers and experts who not only accused the government of undermining the rule of law but also criticized its timing, as millions of people had been badly hit by the pandemic.
BPJS Kesehatan president director Fahmi Idris said that with the premium hikes, the agency would still see a deficit of Rp 185 million by the end of 2020 — but this was better than the Rp 3.9 trillion deficit projected if it maintained the old premiums.
However, relying only on the increases would not be enough, Fahmi said, as they were still below the actuarial estimates for premiums, ranging between Rp 137,221 and Rp 286,085. Thus, managing the agency's spending by defining primary health needs and classes of JKN services, among other measures, was necessary and also mandated by the new presidential regulation.
Achmad Choesni, the head of the National Social Security Council (DJSN) overseeing the BPJS, said the council was still mulling over the criteria for JKN hospitalization classes, which was expected to be gradually implemented starting at the end of this year before coming into full force by 2022.
It remained to be seen whether there would be only one service class for all policyholders or two, such as by separating the recipients of contribution assistance (PBI) — low-income patients whose premiums are fully paid by the state — from non-PBI participants. What is certain is that those willing to upgrade their plans could do so by paying the remaining fees on their own or by other insurances.
Currently, there are three types of JKN plans, with the third-class service also covering a large number of PBI recipients. Non-PBI policyholders can choose to pay the premiums by themselves or have them partly paid by their employers.
"Some of the output will be to [...] reduce the potential of INA-CBG [diagnostic rate] claim fraud," Achmad said.
Much of the concern, however, was directed toward whether the country's hospitals would be able to adjust their wards to the planned JKN service class.
If the prevailing third-class JKN service was to be used as the baseline for the new categorization, then the number of hospital beds for the third-class service should also be increased to accommodate 270 million Indonesians, said National Mandate Party (PAN) lawmaker Saleh Daulay.
JKN now covers some 220 million participants, but the government is aiming for all its citizens to join the program to help close the gap between claims and benefits.
“We need a review of our hospital beds, especially now that the COVID-19 pandemic is taking up many of them," Saleh said.
The Health Ministry’s director general for health services, Bambang Wibowo, said his office had requested that hospitals add third-class beds even before the pandemic struck to anticipate policyholders downgrading their insurance plans following the previous premium hikes.
Some 127,000 beds, or 47 percent of the country's 270,000 hospital beds, are available for third-class policyholders, which is more than the mandatory 30 percent. Following the previous premium hikes, the ministry targeted to have 60 percent of hospital beds for this category by 2021.
Activist Timboel Siregar from BPJS Watch said the government must first ensure that the planned categorization would not lead to a shortage of hospital beds because even “with the current three insurance classes”, many hospitals still do not have enough beds for inpatient care. He doubted that hospitals would be able to renovate their wards as that would be costly.
The Corruption Eradication Commission (KPK) found in a recent study that the BPJS could save as much Rp 12.2 trillion through stricter insurance claim management, including by limiting claims for noncommunicable diseases, which puts the heaviest burden on the JKN. It found that readjusting hospital classes could also help the BPJS avoid making unnecessary payments.