health financing : revenue collection, pooling and...
TRANSCRIPT
HEALTH FINANCING : revenue collection, pooling and
purchasing
Yulita HendrartiniMagister Kebijakan Pembiayaan dan Manajamen Asuransi Kesehatan
Universitas Gadjah Mada
Agents in health care financing
Definition of health carefinancing
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)
Financing is More Than Mobilize Money
Mobilize
& collect Pool the Risk
Funds
Allocate
Resources
Purchaser
Fungsi dan Tujuan Pembiayaan Kesehatan
Fungsi Tujuan
Revenue Collection
Pooling
Purchasing & Payment
Meningkatkan dana untukkesehatan secara cukup danberkesinambungan. Dana ini untukmembiayai pelayanan paketesensial dasar dan perlindungankeuangan dari penyakit dan biaya katastropik berdasarkan aspekpemerataan
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
Mekanisme Revenue CollectionMelalui mekanisme
pemerintah/lembaga asuransi kuasi pemerintah
• Pajak langsung atau tidaklangsung
• Pendapatan pemerintah yang berasal dari bukan pajak
• Kontribusi asuransi wajib danpotongan gaji
• Pembayaran premi kepemerintah
• Grant dan pinjaman luar-negeri
Dari masyarakat
• Dari kantong pasien perorangan
• Yayasan-yayasan kemanusiaan
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Apa yang terjadi dalamPengumpulan 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
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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
Pooling
• Pooling yaitu bagaimana pengumpulan danadibagikan yang mempunyai risiko kesehatan diantarapengumpul dana /atau anggota kelompok (poolmember) (World Bank, 2014).
• Dana yang dikumpulkan untuk kesehatan akandibayarkan ke provider kesehatan,
• tempat penampungan (pools) dana bisa berbagaimacam, seperti anggaran pemerintah pusat danpemerintah daerah, asuransi kesehatan publik danswasta, dan asuransi kesehatan berbasis masyarakat.
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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
Apa yang terjadidalam 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
Pooling & Purchasing Functions Not Separated by Revenue
Health Purchaser or Purchasers
Unified or Coordinated Benefits Package
Unified or Coordinated Provider Payment Systems
National
BudgetLocal
Budget
Payroll
Tax
Donor
Funds
Private
Funds
Pooling of Funds Pooled
or not
Pooled
Revenue Collection
Pooling
of Funds
Health
Purchasing
Providers
Population
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
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
RASIO KLAIM 2014 - PELAYANAN (DIKURANGI BIAYA OPERASIONAL BPJS )
(JUTA RUPIAH)
IURAN PELKESRASIO 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 PELKESRASIO KLAIM
40.719.862 42.658.702 104,76 %
38.242.870 42.658.702 111,55 %
LAPORAN AKUNTANSI AUDITED
Purchasing dalam JKN
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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 : 3.984Klinik pratama : 2.388Faskes TNI-POLRI : 1.324RS pratama : 8
Jlh Faskes Rujukan : 1. 681
RS Pemerintah : 776RS TNI-POLRI : 143RS Swasta : 652RS BUMN : 42Klinik 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
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 : 692RS TNI-POLRI : 147RS Swasta : 903RS 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 : 4.314Klinik pratama : 2.923Faskes TNI-POLRI : 1.288RS pratama : 8
* Cash basis
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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
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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
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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
Health Financing Schemes
Health
care
services
Tax-based
financing
Social health
insurance
Other prepayment
schemes
Out-of-
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
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?