According to the Chairman of the Association of Health Insurance Management Expert Indonesia (Pamjaki) dr Dr. Hasbullah Thabrany, JPKM current equal to the commercial health insurance. It was seen from the transfer of risk that is characteristic of insurance and executed form of limited liability entity that would profit-oriented.
With a relatively high premium, around Rp 400,000 to Rp 500,000 per capita per year for the basic package, the existing JPKM is accused were like ordinary insurance and not push revenue antargolongan cross-subsidies, because the middle-lower class is almost certainly not pay the premium. This model is considered not be able to ensure equal health care.
Hasbullah opinion, the ideal form to ensure public health is managed social insurance, social insurance health is controlled, such as Social Security Workers (Social Security) and Medicare (Askes).
Social insurance is the insurance held or regulated by the government to ensure equitable health care and fair and to protect the economically weak. In operate, characterized by social insurance mandatory for group membership or the entire population, the size of the premium stipulated by law, is generally proportional to income, the same package for all income groups and according to medical need.
"With this mechanism of cross subsidy would occur in the truest sense. The rich pay more than the poor, but received the same package. This is more in tune with our principles of justice and mutual cooperation," said Hasbullah who is also Secretary General Board of Ikatan Dokter Indonesia (PB IDI).
Organized by the social health insurance should not the government. Private entity but can be social or non-profit. Not profit-oriented corporation. While health service providers (KDP), ie hospitals and clinics, can also be done by the government and private sectors.
In the UK, providers of financing and health service providers is the government. Canada and Taiwan provinces impose monopoly system and the state of a single entity known as the organizer of the National Health Insurance. Germany and Japan were imposed Law Un-dang (Act) social insurance compulsory health with many organizers from the nonprofit private parties. As KDP in the four countries that are private parties.
"For the most current work with the formal sector. Jamsostek had worked on five percent of the population. If the overhaul and service package, people will join. Participants may be extended through cooperatives such as cloves or pepper cooperatives. The farmers had no fixed income. When is not possible for the informal sector. It should be realistic. It took 20-25 years. If consistent, all residents can secure their health costs. "
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DIRECTOR-General of Health Department of Public Health Prof. Dr. Azrul Azwar dr MPH states, allegations were not entirely correct.
Azrul admit, Health Law No. 23/1992 which regulates JPKM has weaknesses. Among other things, membership is not required. "If voluntary, JPKM will not grow. People have not minded insurance. Therefore be compulsory," he said.
Currently the Ministry of Health was brewing Plan JPKM Act. Azrul admitted, because the regulation is unclear, many provider agencies (Bapel) JPKM applicable as regular insurance companies.
"Not all agencies to apply the style organizer JPKM. For example, payments to the KDP did not capitation (payment in advance for a group of people), but the fee for service with the tariff agreement. They have no family doctor, nor do preventive-promotional efforts. In fact there Bapel naughty. Although his permission JPKM, who sold insurance products, "he explained.
Director General of Public Health Centers calls for JPKM Bapel JPKM immediately apply the principle of pure, so as to avoid a bad image for JPKM. If enacted JPKM Act, Azrul added, Bapel have to adjust or change a regular insurance company.
JPKM stance, according JPKM Director General of Public Health Directorate Ministry of Health, Dr. Wibisana Widyastuti MSc (PH) on separate occasions, the two funds control style. Namely, payment in advance (prepayment) of the participants and the prospective payment of Bapel to the KDP. One style meets all the health needs of participants, a comprehensive health services (plenary). Four quality control style. That is, make contracts, to keep the cycle of quality with reasonable medical standards and medical services, handling complaints and monitoring utilization.
Control the government. "At every level there is a body builder will assess Bapel performance," said Widyastuti.
In the context of preparing the bill JPKM, continued Azrul, proposed two new concepts. First, change the membership of the voluntary-compulsory, the premium is not fixed for all participants but the percentage of income, residents can not afford the premiums are borne by the government, the collection of premiums by the government through income taxes for the formal sector and the property tax for the informal sector, paid in KDP face (prospective payment) by way of capitation.
The second concept, just like the first draft, mandatory participation, the population can not borne by the government, payments to capitation KDP done. Different, the same premium value (not based on a percentage of revenue) and payments made directly to the Bapel participants, to monitor the evidence used as a prerequisite for membership renew ID cards, driver's license and go to school.
The calculation of the premium if the membership was compulsory and the government subsidized, meaning salaries and health center doctors and hospitals are paid government-provided medicine community only have to pay USD 1300 per capita per month for complete health services, including outpatient, inpatient, and emergency support emergency. If it is not subsidized by the government, the public pays USD 5350 per capita per month.
"In order for the entire population of Indonesia immediately obtain the standard package of health. We must dare to start," said Azrul.
In this case the Ministry of Health to encourage the formation of Bapel with the Social Safety Net fund the Health Sector (JPSBK) to serve the poor at the health center level. Bapel management personnel trained Ministry of Health. Expected from Bapel-Bapel that there are developed into a general Bapel able to raise funds from the community.
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WIDYASTUTI states, the implementation of existing JPKM currently do not make health care costs will be cheaper. But make efficient. With fee for service (cash payment for each service) that goes like this tend to do a PPK or excessive prescribing expensive drugs.
In JPKM, payments made in advance, so that the KDP driven control costs. Still can not carelessly KDP in providing services, because there are quality control mechanisms and the handling of complaints by Bapel.
While there are several benefits package offered Bapel JPKM. From the standard until the plus (silver, gold, platinum) according to KDP facilities provided to respond to community needs. Currently there are around 25 Bapel the MOH permission.
"If the membership compulsory, according to the law of large numbers (the law of large numbers) premiums can be reduced. Calculation of us, if the entire population of Indonesia to participate JPKM, premiums could be USD 5333 per capita per month," said Widyastuti.
Quality Assurance Manager Health Benefits of PT International Indonesia (IHBI), Dr. L Tobing MPH Bisara feae states, premiums for the standard package defined Bapel JPKM where she worked around Rp 400,000 per capita per year. The premium is calculated based on the experience rating of the health service fee is. "Because the participants were still slightly, the fall is costly. If the number of participants lot, premiums can be reduced," he said.
Of about 50,000 participants who joined the JPKM IHBI, 95 percent come from the company. The rest are individual participants generated through multi-level marketing (MLM).
Tobing admitted payment to the KDP has not fully capitation, partial capitation plus but carving out, the fee for service with special rates. Paid by carving out such routine laboratory outside, X-rays, immunizations. Drugs also can not be determined standards, still depends on the doctor.
"The problem is, the KDP did not want to capitation entirely. The reason they are difficult to calculate unit cost, because the price of consumables such as reagents, for x-ray films are not fixed and the participants were still little, so they are difficult to calculate cash flow," he explained.
The hospital is still very dependent on the specialists, so that in making management decisions is to consider their opinions. On the other hand Bapel weak bargaining position. For the hospital is more favorable if the patient pays a fee for service.
According Tobing, the new company has about 20 family physicians from 70 clinics around the incoming network. Cause, expensive training family physicians.
Therefore, preventive efforts to run their own promotional selectively. Way, giving health education to corporate clients and distribute the newsletter "Healthy Warkat" to the participants. Also published in "Bulletin of the Family Doctor" for the doctors of topics relating to managed care, informed consent, treatment based on the evidence base and so on.
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NOT all Bapel in the "gray areas" such as IHBI. PL / PK Bapel JPKM like St. Carolus, as stated Widyastuti, committed to the principles of pure JPKM. To the extent that when asked to PT still insisted the foundation because it is nonprofit.
On the other hand, there is a sell JPKM Bapel separate package of outpatient and inpatient. For example, PT Jasa Medika Satyasiaga that sell packages with premium outpatient Rp 200,000 per capita per year and the premium package Rp 230,000 hospitalizations per capita per year. That is, Bapel JPKM did not do a complete health maintenance as stipulated in the Regulation of the Minister of Health No. 527 / Menkes/Per/VII/1993 of Health Care Package in JPKM Program Implementation.
In Article 6, paragraph 1 Permenkes was mentioned basic health care package must be held Body Organizer. The definition of basic health care package under article 8 is outpatient, inpatient, and emergency support.
According to health economists, Prof. dr Ascobat Gani MPH PhD, ideally JPKM compulsory membership. But the reality, Indonesia's health ministry has not been equitable, particularly in rural areas outside Java. Therefore JPKM must be implemented in a gradual, such as a district that was ready, whether public, or KDP Bapel JPKM it. The entire population of the relevant district or city required to JPKM, the government subsidized poor.
Implementation JPKM need to consider the community's ability to pay, availability of professional staff to manage Bapel and precondition of the KDP. How to apply JPKM Baduy In areas, the interior of Borneo, or Papua, for example, while health services are still difficult to achieve. On the other hand, the behavior of KDP was used to fee for service. The factors that need to be addressed.
According to Ascobat, premiums should be determined based JPKM community rating and experience rating, not the insurance risk rating as usual. If there is a set Bapel JPKM premiums based on risk rating, would have violated the principle of JPKM.
In this case the premium is determined based on pool of risk from a group of people. That is, the calculated incidence of outpatient and inpatient, there are patterns of disease, how much it costs for health care, and then divided by the number of participants. That figure is then added to the loading factor (operational costs and return on investment) Bapel JPKM.
Premiums are set Bapel JPKM currently generally quite high. Maybe because participants had little or calculated based on the risk rating and its load factor is high, such as the majestic Bapel office, so the need is greater operational costs. "This should be controlled by the Ministry of Health, YLKI and society," said Ascobat.
