Budi Eko Siswoyo Capitation Fund Management final
1
CAPITATION FUND MANAGEMENT
(M & E OF NATIONAL HEALTH INSURANCE IN INDONESIA)
M. Faozi Kurniawan, Budi Eko Siswoyo, Faisal Mansur,
Wan Aisyah, Dedy Revelino, Welly Gadistina
Yogyakarta, March 4th 2015
2
Outline
1. Background
2. Objective
3. Method
4. Result
5. Bottleneck
6. Conclusion
3
Background
UU 40/ 2004 SJSN JKN
UU 24/ 2011 BPJS Kesehatan
Perpres 111/ 2013 Social Health Insurance
2014
Perbpjsk 2/ 2015
Capitation-based performance
Perpres 32/ 2014
Permenkes 19/ 2014 2015
Permenkes 59/ 2014
Permendagri 37/ 2014
SE MDN 900/2280/SJ
/3 of health care cost in JKN
expenditure for PHC (54% = capitation)
1
2016
2019
4
Objective
To analyze the management of capitation fund
in PHC including the bottlenecks & to generate
solutions in the implementation of JKN
5
Method
Study sites
descriptive – cross sectional
20 districts in 7 regional
Study participants
384 PHC (public and private)
Study design
Secondary data (2014-mid 2015)
Data collection techniques
from PHC and BPJS Kesehatan
Quantitative-qualitative approaches
Data analysis
6
Membership of JKN Program, Jan 2014 – Jul 2015
Type of PHC
Mean
Puskesmas BLUD
Puskesmas Non BLUD
DPP (individual
physician practice)
12.734
14.356
Klinik Pratama (clinic)
Trend (%)
2014
2015
1,31%
2,85%
1,07%
2,30%
2.718
3,19%
5,40%
3.690
3,91%
8,51%
Membership in Puskesmas > Clinic > DPP
Membership growth in Clinic > DPP > Puskesmas
7
Distribution of PMPM in JKN Program
12,000
10,000
8,000
6,000
4,000
2,000
Puskesmas Puskesmas
Puskesmas
Puskesmas
BLUD
Non BLUD
BLUD
Non BLUD
Dokter
Klinik
DPP
Clinic
Praktek
Pratama
Perorangan
PMPM in the clinic is the highest (IDR 8.000 – 10.000)
8
Capitation Fund Revenue, Jan 2014 – Jul 2015
Trend (%)
Type of PHC
Mean
(IDR/ Month)
2014
2015
Puskesmas BLUD
Puskesmas Non BLUD
DPP
Clinic
79,1 M
76,3 M
23,8 M
39,4 M
1,71%
0,88%
3,24%
4,42%
2,57%
1,83%
5,73%
9,20%
Total revenue of capitation fund in Puskesmas > Clinic > DPP
Revenue growth in Clinic > DPP > Puskesmas
9
The Time of Disbursement of Capitation Fund
20
15
10
5
Puskesmas
Puskesmas Puskesmas
Puskesmas
BLUD
Non
BLUD
NonBLUD
BLUD
Dokter
DPP
Praktek
Perorangan
Klinik
Clinic
Pratama
No later than 15th and the earliest at 11th monthly
10
Puskesmas Non BLUD
Planning and Budgeting
Plan
Plan of
of Action
Action (PTP)
(PTP)
Puskesmas
Puskesmas
Plan
Plan of
of Activity
Activity (RKA)
(RKA)
Local
Local
Government
Government
DHO
DHO
Budget
Budget Planning
Planning (DPA)
(DPA)
DPRD
DPRD
BPJS
BPJS
Kesehatan
Kesehatan
Puskesmas
Puskesmas
BPJS
BPJS
Kesehatan
Kesehatan
Disbursement and Reporting
Capitation
Capitation Fund
Fund
DHO
DHO
Cost
Cost of
of Service
Service
Puskesmas
Puskesmas
Report
Report
Puskesmas
Puskesmas
Operational
Operational
Cost
Cost
DHO
DHO
District
District Finance
Finance
Administrator
Administrator
(DPPKAD)
(DPPKAD)
11
Puskesmas BLUD
Planning and Budgeting
Plan
Plan of
of Action
Action (PTP)
(PTP)
RBA
RBA
Business
Business
Plan
Plan
(RBA)
(RBA)
Puskesmas
Puskesmas
Legal
Legal RBA
RBA
Puskesmas
Puskesmas
DPRD
DPRD
DHO
DHO
BPJS
BPJS
Kesehatan
Kesehatan
Disbursement and Reporting
Report
Report
Capitation
Capitation Fund
Fund
Cost
Cost of
of Service
Service
DHO
DHO
BPJS
BPJS
Kesehatan
Kesehatan
Puskesmas
Puskesmas
Report
Report
Puskesmas
Puskesmas
District
District Finance
Finance
Administrator
Administrator
(DPPKAD)
(DPPKAD)
Operational
Operational
Cost
Cost
Report
Report
12
DPP (individual physician practice)
Planning and Budgeting
Previous
Previous Expenditure
Expenditure Data
Data
Business
Business
Plan
Plan
(RBA)
(RBA)
DPP
DPP
••
•• Price
Price List
List
Market
Market Mechanism
Mechanism
•• Estimation
Estimation
Disbursement and Reporting
Capitation
Capitation Fund
Fund
BPJS
BPJS
Kesehatan
Kesehatan
Cost
Cost of
of Service
Service
Document
Document //
Note
Note
DPP
DPP
Operational
Operational
Cost
Cost
13
Klinik Pratama (clinic)
Planning and Budgeting
Previous
Previous Expenditure
Expenditure Data
Data
Business
Business
Plan
Plan
(RBA)
(RBA)
Management
Management
of
of Clinic
Clinic
••
Management
Management
•• Price
Price List
List
Market
Market Mechanism
Mechanism
•• Estimation
Estimation
Clinic
Clinic Owner
Owner
BPJS
BPJS
Kesehatan
Kesehatan
Disbursement and Reporting
Capitation
Capitation Fund
Fund
BPJS
BPJS
Kesehatan
Kesehatan
Cost
Cost of
of Service
Service
Document
Document //
Note
Note
Clinic
Clinic
Operational
Operational
Cost
Cost
Management
Management
of
of Clinic
Clinic
Clinic
Clinic Owner
Owner
14
Trend of Utilization Ratio, Jan 2014 – Jul 2015
35%
30%
25%
20%
15%
10%
5%
0%
1
2
3
4
Puskesmas BLUD
5
6
7
8
Puskesmas Non BLUD
9
10
11
12
13
14
Dokter Praktek Perorangan
15
16
17
18
Klinik Pratama
Utilization ratio in clinic > DPP > Puskesmas
15
Visit Cost vs Actual Capitation in Study Site
Type of PHC
PKM BLUD
PKM Non BLUD
Clinic
DPP
Actual
119.522
191.467
78.006
78.999
Actual Capitation Fund in Puskesmas > DPP > Clinic
16
Guideliness of Capitation Fund Management
Yes
No
Local regulation (Perbup/ Pergub) become the main legal
basis for capitation fund management in Puskesmas
17
Cost of Service vs Operational Cost in Capitation Fund
District - A
District - B
District - C
District - D
District - E
District - F
District - G
District - H
District - I
District - J
District - K
District - L
District - M
District - N
District - O
District - P
District - Q
District - R
District - S
District - T
Most of the districts have
allocated + 60% of the
capitation funds for the
cost of service
Refer to local regulation,
some districts allocate the
cost of service is less than
60%
Cost of
Service
Operational
Cost
18
Bottleneck
• Capitation fund still insufficient for 24-hour service
• Misperception for benefit package of promotion-preventive
• Guidelines on the use of capitation still ambiguous
• Budget mechanisms disrupted (especially for APBD)
• Lack of socialization on capitation fund management
• Lack of human resources in implementation of P-CARE
19
&
• Capitation
fund
should
be
(especially for DPP and clinic as private PHCs)
increased
• Local government need to develop the guidelines or policies
related to the mechanism of capitation fund management
• Continuous monitoring and evaluation of capitation fund by
BPJS Kesehatan, DHO, and independent organizations
20
Reference
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
_________, 2004. Undang - Undang Nomor 40 Tahun 2004 tentang Sistem Jaminan Sosial Nasional, Pemerintah RI,
Jakarta.
__________,2004. Undang - Undang Nomor 15 Tahun 2004 Tentang Pemeriksaan, Pengelolaan dan Tanggung Jawab
Keuangan Negara, Pemerintah RI, Jakarta.
_________, 2011. Undang-Undang Nomor 24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial, Pemerintah RI,
Jakarta.
_________,Peraturan Menteri Kesehatan Republik Indonesia Nomor 59 Tahun 2014 Tentang Standar Tarif Pelayanan
Kesehatan Dalam Penyelenggaraan Program Jaminan Kesehatan, Pemerintah RI, Jakarta.
_________,Peraturan Presiden Nomor 32 Tahun 2014 Tentang Pengalokasian dan Pemanfaatan Dana Kapitasi Jaminan
Kesehatan Tingkat Pertama (FKTP) Milik Pemerintah dan Dukungan Biaya Operasional FKTP Milik Pemerintah
Daerah, Pemerintah RI, Jakarta.
_________, 2005. Peraturan Pemerintah No 23 Tahun 2005 tentang Badan Layanan Umum, Pemerintah RI, Jakarta.
__________,2007. Peraturan Menteri Dalam Negeri Nomor 61 Tahun 2007 tentang Pedoman Teknis Pengelolaan
Keuangan Badan Layanan Umum Daerah, Pemerintah RI, Jakarta.
__________,2014. Surat Edaran Menteri Dalam Negeri Nomor 900/2280/SJ. Tanggal 5 Mei 2014 Tentang Petunjuk
Teknis Penganggaran, Pelaksanaan dan Penatausahaan, serta Pertanggungjawaban Dana Kapitasi Jaminan Kesehatan
Nasional pada Fasilitas Kesehatan Tingkat Pertama Milik Pemerintah Daerah, Pemerintah RI, Jakarta.
__________,2014. Peraturan Menteri Kesehatan Republik Indonesia Nomor 28 Tahun 2014 Tentang Pedoman
Pelaksanaan Program Jaminan Kesehatan Nasional, Pemerintah RI, Jakarta.
__________,2014. Permenkes 19/2014 tentang penggunaan Jaminan Kesehatan Nasional untuk Jasa Pelayanan
Kesehatan dan Dukungan Biaya Operasional pada Fasilitas Kesehatan Tingkat Pertama Milik Pemerintah Daerah,
Pemerintah RI, Jakarta.
Berwick, D.M., 1996. Payment by Capitation and the Quality of Care. N eng J Med, 335(16), pp.1227-1231. Available
at: http://dx.doi.org/10.1056/nejm199610173351611
Glazier. R.H, Geltink, J.K, Kopp. A, Sibley. L.M. 2009, Capitation and enhanced fee-for-service models for primary care
reform: a population-based evaluation, CMAJ and is available at www.cmaj.ca/cgi/content/full/180/11/E72/DC2
Hagland, Mark. 2015. How Does Your Doctor Get Paid? The Controversy Over Capitation,
http://www.pbs.org/wgbh/pages/frontline/shows/doctor/care/capitation.html, 07122015.17.00
21
Thank You
CAPITATION FUND MANAGEMENT
(M & E OF NATIONAL HEALTH INSURANCE IN INDONESIA)
M. Faozi Kurniawan, Budi Eko Siswoyo, Faisal Mansur,
Wan Aisyah, Dedy Revelino, Welly Gadistina
Yogyakarta, March 4th 2015
2
Outline
1. Background
2. Objective
3. Method
4. Result
5. Bottleneck
6. Conclusion
3
Background
UU 40/ 2004 SJSN JKN
UU 24/ 2011 BPJS Kesehatan
Perpres 111/ 2013 Social Health Insurance
2014
Perbpjsk 2/ 2015
Capitation-based performance
Perpres 32/ 2014
Permenkes 19/ 2014 2015
Permenkes 59/ 2014
Permendagri 37/ 2014
SE MDN 900/2280/SJ
/3 of health care cost in JKN
expenditure for PHC (54% = capitation)
1
2016
2019
4
Objective
To analyze the management of capitation fund
in PHC including the bottlenecks & to generate
solutions in the implementation of JKN
5
Method
Study sites
descriptive – cross sectional
20 districts in 7 regional
Study participants
384 PHC (public and private)
Study design
Secondary data (2014-mid 2015)
Data collection techniques
from PHC and BPJS Kesehatan
Quantitative-qualitative approaches
Data analysis
6
Membership of JKN Program, Jan 2014 – Jul 2015
Type of PHC
Mean
Puskesmas BLUD
Puskesmas Non BLUD
DPP (individual
physician practice)
12.734
14.356
Klinik Pratama (clinic)
Trend (%)
2014
2015
1,31%
2,85%
1,07%
2,30%
2.718
3,19%
5,40%
3.690
3,91%
8,51%
Membership in Puskesmas > Clinic > DPP
Membership growth in Clinic > DPP > Puskesmas
7
Distribution of PMPM in JKN Program
12,000
10,000
8,000
6,000
4,000
2,000
Puskesmas Puskesmas
Puskesmas
Puskesmas
BLUD
Non BLUD
BLUD
Non BLUD
Dokter
Klinik
DPP
Clinic
Praktek
Pratama
Perorangan
PMPM in the clinic is the highest (IDR 8.000 – 10.000)
8
Capitation Fund Revenue, Jan 2014 – Jul 2015
Trend (%)
Type of PHC
Mean
(IDR/ Month)
2014
2015
Puskesmas BLUD
Puskesmas Non BLUD
DPP
Clinic
79,1 M
76,3 M
23,8 M
39,4 M
1,71%
0,88%
3,24%
4,42%
2,57%
1,83%
5,73%
9,20%
Total revenue of capitation fund in Puskesmas > Clinic > DPP
Revenue growth in Clinic > DPP > Puskesmas
9
The Time of Disbursement of Capitation Fund
20
15
10
5
Puskesmas
Puskesmas Puskesmas
Puskesmas
BLUD
Non
BLUD
NonBLUD
BLUD
Dokter
DPP
Praktek
Perorangan
Klinik
Clinic
Pratama
No later than 15th and the earliest at 11th monthly
10
Puskesmas Non BLUD
Planning and Budgeting
Plan
Plan of
of Action
Action (PTP)
(PTP)
Puskesmas
Puskesmas
Plan
Plan of
of Activity
Activity (RKA)
(RKA)
Local
Local
Government
Government
DHO
DHO
Budget
Budget Planning
Planning (DPA)
(DPA)
DPRD
DPRD
BPJS
BPJS
Kesehatan
Kesehatan
Puskesmas
Puskesmas
BPJS
BPJS
Kesehatan
Kesehatan
Disbursement and Reporting
Capitation
Capitation Fund
Fund
DHO
DHO
Cost
Cost of
of Service
Service
Puskesmas
Puskesmas
Report
Report
Puskesmas
Puskesmas
Operational
Operational
Cost
Cost
DHO
DHO
District
District Finance
Finance
Administrator
Administrator
(DPPKAD)
(DPPKAD)
11
Puskesmas BLUD
Planning and Budgeting
Plan
Plan of
of Action
Action (PTP)
(PTP)
RBA
RBA
Business
Business
Plan
Plan
(RBA)
(RBA)
Puskesmas
Puskesmas
Legal
Legal RBA
RBA
Puskesmas
Puskesmas
DPRD
DPRD
DHO
DHO
BPJS
BPJS
Kesehatan
Kesehatan
Disbursement and Reporting
Report
Report
Capitation
Capitation Fund
Fund
Cost
Cost of
of Service
Service
DHO
DHO
BPJS
BPJS
Kesehatan
Kesehatan
Puskesmas
Puskesmas
Report
Report
Puskesmas
Puskesmas
District
District Finance
Finance
Administrator
Administrator
(DPPKAD)
(DPPKAD)
Operational
Operational
Cost
Cost
Report
Report
12
DPP (individual physician practice)
Planning and Budgeting
Previous
Previous Expenditure
Expenditure Data
Data
Business
Business
Plan
Plan
(RBA)
(RBA)
DPP
DPP
••
•• Price
Price List
List
Market
Market Mechanism
Mechanism
•• Estimation
Estimation
Disbursement and Reporting
Capitation
Capitation Fund
Fund
BPJS
BPJS
Kesehatan
Kesehatan
Cost
Cost of
of Service
Service
Document
Document //
Note
Note
DPP
DPP
Operational
Operational
Cost
Cost
13
Klinik Pratama (clinic)
Planning and Budgeting
Previous
Previous Expenditure
Expenditure Data
Data
Business
Business
Plan
Plan
(RBA)
(RBA)
Management
Management
of
of Clinic
Clinic
••
Management
Management
•• Price
Price List
List
Market
Market Mechanism
Mechanism
•• Estimation
Estimation
Clinic
Clinic Owner
Owner
BPJS
BPJS
Kesehatan
Kesehatan
Disbursement and Reporting
Capitation
Capitation Fund
Fund
BPJS
BPJS
Kesehatan
Kesehatan
Cost
Cost of
of Service
Service
Document
Document //
Note
Note
Clinic
Clinic
Operational
Operational
Cost
Cost
Management
Management
of
of Clinic
Clinic
Clinic
Clinic Owner
Owner
14
Trend of Utilization Ratio, Jan 2014 – Jul 2015
35%
30%
25%
20%
15%
10%
5%
0%
1
2
3
4
Puskesmas BLUD
5
6
7
8
Puskesmas Non BLUD
9
10
11
12
13
14
Dokter Praktek Perorangan
15
16
17
18
Klinik Pratama
Utilization ratio in clinic > DPP > Puskesmas
15
Visit Cost vs Actual Capitation in Study Site
Type of PHC
PKM BLUD
PKM Non BLUD
Clinic
DPP
Actual
119.522
191.467
78.006
78.999
Actual Capitation Fund in Puskesmas > DPP > Clinic
16
Guideliness of Capitation Fund Management
Yes
No
Local regulation (Perbup/ Pergub) become the main legal
basis for capitation fund management in Puskesmas
17
Cost of Service vs Operational Cost in Capitation Fund
District - A
District - B
District - C
District - D
District - E
District - F
District - G
District - H
District - I
District - J
District - K
District - L
District - M
District - N
District - O
District - P
District - Q
District - R
District - S
District - T
Most of the districts have
allocated + 60% of the
capitation funds for the
cost of service
Refer to local regulation,
some districts allocate the
cost of service is less than
60%
Cost of
Service
Operational
Cost
18
Bottleneck
• Capitation fund still insufficient for 24-hour service
• Misperception for benefit package of promotion-preventive
• Guidelines on the use of capitation still ambiguous
• Budget mechanisms disrupted (especially for APBD)
• Lack of socialization on capitation fund management
• Lack of human resources in implementation of P-CARE
19
&
• Capitation
fund
should
be
(especially for DPP and clinic as private PHCs)
increased
• Local government need to develop the guidelines or policies
related to the mechanism of capitation fund management
• Continuous monitoring and evaluation of capitation fund by
BPJS Kesehatan, DHO, and independent organizations
20
Reference
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
_________, 2004. Undang - Undang Nomor 40 Tahun 2004 tentang Sistem Jaminan Sosial Nasional, Pemerintah RI,
Jakarta.
__________,2004. Undang - Undang Nomor 15 Tahun 2004 Tentang Pemeriksaan, Pengelolaan dan Tanggung Jawab
Keuangan Negara, Pemerintah RI, Jakarta.
_________, 2011. Undang-Undang Nomor 24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial, Pemerintah RI,
Jakarta.
_________,Peraturan Menteri Kesehatan Republik Indonesia Nomor 59 Tahun 2014 Tentang Standar Tarif Pelayanan
Kesehatan Dalam Penyelenggaraan Program Jaminan Kesehatan, Pemerintah RI, Jakarta.
_________,Peraturan Presiden Nomor 32 Tahun 2014 Tentang Pengalokasian dan Pemanfaatan Dana Kapitasi Jaminan
Kesehatan Tingkat Pertama (FKTP) Milik Pemerintah dan Dukungan Biaya Operasional FKTP Milik Pemerintah
Daerah, Pemerintah RI, Jakarta.
_________, 2005. Peraturan Pemerintah No 23 Tahun 2005 tentang Badan Layanan Umum, Pemerintah RI, Jakarta.
__________,2007. Peraturan Menteri Dalam Negeri Nomor 61 Tahun 2007 tentang Pedoman Teknis Pengelolaan
Keuangan Badan Layanan Umum Daerah, Pemerintah RI, Jakarta.
__________,2014. Surat Edaran Menteri Dalam Negeri Nomor 900/2280/SJ. Tanggal 5 Mei 2014 Tentang Petunjuk
Teknis Penganggaran, Pelaksanaan dan Penatausahaan, serta Pertanggungjawaban Dana Kapitasi Jaminan Kesehatan
Nasional pada Fasilitas Kesehatan Tingkat Pertama Milik Pemerintah Daerah, Pemerintah RI, Jakarta.
__________,2014. Peraturan Menteri Kesehatan Republik Indonesia Nomor 28 Tahun 2014 Tentang Pedoman
Pelaksanaan Program Jaminan Kesehatan Nasional, Pemerintah RI, Jakarta.
__________,2014. Permenkes 19/2014 tentang penggunaan Jaminan Kesehatan Nasional untuk Jasa Pelayanan
Kesehatan dan Dukungan Biaya Operasional pada Fasilitas Kesehatan Tingkat Pertama Milik Pemerintah Daerah,
Pemerintah RI, Jakarta.
Berwick, D.M., 1996. Payment by Capitation and the Quality of Care. N eng J Med, 335(16), pp.1227-1231. Available
at: http://dx.doi.org/10.1056/nejm199610173351611
Glazier. R.H, Geltink, J.K, Kopp. A, Sibley. L.M. 2009, Capitation and enhanced fee-for-service models for primary care
reform: a population-based evaluation, CMAJ and is available at www.cmaj.ca/cgi/content/full/180/11/E72/DC2
Hagland, Mark. 2015. How Does Your Doctor Get Paid? The Controversy Over Capitation,
http://www.pbs.org/wgbh/pages/frontline/shows/doctor/care/capitation.html, 07122015.17.00
21
Thank You