2016 Ekokes Sesi 8 YH Revenue Collection Pooling dan Purchasing
HEALTH FINANCING :
revenue collection,
pooling and purchasing
Yulita Hendrartini
Magister Kebijakan Pembiayaan dan Manajamen Asuransi Kesehatan
Universitas Gadjah Mada
Agents in health care financing
Definition of health care
financing
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
Funds
Pool the Risk
Allocate
Resources
Purchaser
Fungsi dan Tujuan Pembiayaan
Kesehatan
Fungsi
Revenue
Collection
Pooling
Purchasing
& Payment
Hsiao 2013
Tujuan
Meningkatkan dana untuk
kesehatan secara cukup dan
berkesinambungan. Dana ini
untuk membiayai pelayanan
paket esensial dasar dan
perlindungan keuangan dari
penyakit dan biaya katastropik
berdasarkan aspek
pemerataan
Mengelola dana-dana tersebut
dalam pool risiko kesehatan
yang efisien dan merata
Menjamin pembelian/
pemerolehan dan
pembayaran pelayanan
kesehatan yang efisien
Mekanisme Revenue Collection
Melalui mekanisme pemerintah/lembaga
asuransi kuasi pemerintah
• Pajak langsung atau tidak
langsung
• Pendapatan pemerintah yang
berasal dari bukan pajak
• Kontribusi asuransi wajib dan
potongan gaji
• Pembayaran premi ke
pemerintah
• Grant dan pinjaman luarnegeri
Dari masyarakat
• Dari kantong pasien
perorangan
• Yayasan-yayasan
kemanusiaan
6
Paja
k
Apa yang terjadi dalam
Pengumpulan dana
Kesehatan
Pendapatan
Negara bukan
Pajak
Non-PBi PNS,
Jamsostek dll
dll
APBN (67,5 T)
PBI
Kemenkes
Kab/K
ota 489
( 72.9
T)
Kementerian
lain
Pemda
Pendapatan
Asli Daerah
19.93T
BPJS
Non-PBI
Mandiri
18.89T
2.24T
Askes
Swasta
Pelayanan
Primer:
Pelayanan
Rujukan
NHA 2009 (dana
masyarakat
langsung) (18 T)
Dana dari Masyarakat langsung
7
Trisnantoro, 2014
Pooling
• Pooling yaitu bagaimana pengumpulan dana dibagikan
yang mempunyai risiko kesehatan diantara pengumpul
dana /atau anggota kelompok (pool member) (World
Bank, 2014).
• Dana yang dikumpulkan untuk kesehatan akan
dibayarkan ke provider kesehatan,
• tempat penampungan (pools) dana bisa berbagai
macam, seperti anggaran pemerintah pusat dan
pemerintah daerah, asuransi kesehatan publik dan
swasta, dan asuransi kesehatan berbasis masyarakat.
8
Pooling dana kesehatan
1. APBN
Dua Pool
besar:
1.APBN
2.BPJS
• 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)
9
Pajak
Apa yang terjadi
dalam Pooling
Pendapatan
Negara bukan
Pajak
Non-PBi PNS,
Jamsostek dll
dll
APBN
PBI
BPJS
Kemenkes
Kementerian
lain
Pemda
Pendapatan
Asli Daerah
Non-PBI
Mandiri
Askes
Swasta
Pelayanan
Primer:
Pelayanan
Rujukan
Dana dari Masyarakat
langsung
10
Trisnantoro, 2014
Pooling & Purchasing Functions Not Separated by Revenue
Revenue
Collection
Pooling
of Funds
Health
Purchasing
Providers
Population
National
Budget
Local
Budget
Payroll
Tax
Donor
Funds
Pooling of Funds
Health Purchaser or Purchasers
Unified or Coordinated Benefits Package
Unified or Coordinated Provider Payment Systems
Private
Funds
Pooled
or not
Pooled
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
Purchasing dalam JKN
RASIO KLAIM 2014 - PEMBEBANAN
(JUTA RUPIAH)
IURAN
PELKES
RASIO
KLAIM
40.719.862
42.658.702
104,76 %
38.242.870
42.658.702
111,55 %
LAPORAN AKUNTANSI AUDITED
RASIO KLAIM 2014 - PELAYANAN
(DIKURANGI BIAYA OPERASIONAL BPJS )
(JUTA RUPIAH)
IURAN
PELKES
RASIO
KLAIM
40.719.862
46.665.539
114,60 %
38.242.870
46.665.539
122,02 %
• 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%
LAPORAN BOA, CPR & KEUANGAN DIOLAH
14
Biaya manfaat 2014
42.658.702 *
Peserta 133.273.918
PBI –N : 86.399.836 PBI-D : 8.649.830 BP : 4.885.140 PPU : 24.288.688
Biaya Pelayanan Primer
Rp. 8.347.850
Jlh faskes primer :
17.492
Puskesmas
: 9.788
DPP
: 3.984
Klinik pratama : 2.388
Faskes TNI-POLRI : 1.324
RS Rata
pratama
: per8
rata biaya
faskes Rp.39.77
juta/bulan
Biaya Non
Kapitasi
Non CBG’s,
promprev
Rp. 3.871.280
* Cash basis
PBPU : 9.050424
Biaya Pelayanan
Rujukan
Rp. 30.439.572
Jlh Faskes Rujukan : 1. 681
RS Pemerintah
: 776
RS TNI-POLRI
: 143
RS Swasta
: 652
RS BUMN
:
42
Klinik Utama
:
68
Rata rata biaya per
faskes
Rp. 1,509 M/bulan
Biaya manfaat sd Juni 2015
27.178.466 *
Peserta 147.675.544
PBI –N :
86.426.543
PBI-D :
10.613.788
PPU swasta
18.347.445
Biaya Pelayanan Primer
Rp. 4.953.108
Jlh faskes primer : 18.347
Puskesmas
: 9.814
DPP
: 4.314
Klinik pratama : 2.923
Faskes TNI-POLRI : 1.288
RS pratama
:
8
Rata rata biaya per
faskes Rp.44,99
juta/bulan
Eks Askes :
19.534.154
PBPU :
12.753.614
Biaya Pelayanan Rujukan
Rp. 22.270.069
Biaya Non
Kapitasi
Non CBG’s,
promprev
Rp. 816.879
* Cash basis
Jlh Faskes Rujukan : 1.783
RS Pemerintah
: 692
RS TNI-POLRI
: 147
RS Swasta
: 903
RS BUMN
:
41
Rata rata biaya per faskes
Rp. 2,081 M/bulan
Fund Collection Indicators
Indicators
Purpose
•The formal sector share of GDP
• Potential resources available to finance
•Natural resources revenue as a share public health spending
of total public budget
• Total health expenditure % GDP
• 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 •A broad measure of financial protection
that are prepaid
against out-of-pocket expenses
17
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
18
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
•To measure the financial incentives
different payment mechanisms (e.g. embedded in payments to providers
salaries, fee-for-service, capitation)
19
Health Financing Schemes
Financing
mechanisms
Health
care
services
Financing sources
Tax-based
financing
1. General tax or
other revenue
Social health
insurance
2.Payroll tax
Other
prepayment
schemes
3.Contribution or
premium
Out-ofpocket
payments
Natural
resource
revenue
Household
4. Direct payment
Extern
al
resourc
e
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?
revenue collection,
pooling and purchasing
Yulita Hendrartini
Magister Kebijakan Pembiayaan dan Manajamen Asuransi Kesehatan
Universitas Gadjah Mada
Agents in health care financing
Definition of health care
financing
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
Funds
Pool the Risk
Allocate
Resources
Purchaser
Fungsi dan Tujuan Pembiayaan
Kesehatan
Fungsi
Revenue
Collection
Pooling
Purchasing
& Payment
Hsiao 2013
Tujuan
Meningkatkan dana untuk
kesehatan secara cukup dan
berkesinambungan. Dana ini
untuk membiayai pelayanan
paket esensial dasar dan
perlindungan keuangan dari
penyakit dan biaya katastropik
berdasarkan aspek
pemerataan
Mengelola dana-dana tersebut
dalam pool risiko kesehatan
yang efisien dan merata
Menjamin pembelian/
pemerolehan dan
pembayaran pelayanan
kesehatan yang efisien
Mekanisme Revenue Collection
Melalui mekanisme pemerintah/lembaga
asuransi kuasi pemerintah
• Pajak langsung atau tidak
langsung
• Pendapatan pemerintah yang
berasal dari bukan pajak
• Kontribusi asuransi wajib dan
potongan gaji
• Pembayaran premi ke
pemerintah
• Grant dan pinjaman luarnegeri
Dari masyarakat
• Dari kantong pasien
perorangan
• Yayasan-yayasan
kemanusiaan
6
Paja
k
Apa yang terjadi dalam
Pengumpulan dana
Kesehatan
Pendapatan
Negara bukan
Pajak
Non-PBi PNS,
Jamsostek dll
dll
APBN (67,5 T)
PBI
Kemenkes
Kab/K
ota 489
( 72.9
T)
Kementerian
lain
Pemda
Pendapatan
Asli Daerah
19.93T
BPJS
Non-PBI
Mandiri
18.89T
2.24T
Askes
Swasta
Pelayanan
Primer:
Pelayanan
Rujukan
NHA 2009 (dana
masyarakat
langsung) (18 T)
Dana dari Masyarakat langsung
7
Trisnantoro, 2014
Pooling
• Pooling yaitu bagaimana pengumpulan dana dibagikan
yang mempunyai risiko kesehatan diantara pengumpul
dana /atau anggota kelompok (pool member) (World
Bank, 2014).
• Dana yang dikumpulkan untuk kesehatan akan
dibayarkan ke provider kesehatan,
• tempat penampungan (pools) dana bisa berbagai
macam, seperti anggaran pemerintah pusat dan
pemerintah daerah, asuransi kesehatan publik dan
swasta, dan asuransi kesehatan berbasis masyarakat.
8
Pooling dana kesehatan
1. APBN
Dua Pool
besar:
1.APBN
2.BPJS
• 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)
9
Pajak
Apa yang terjadi
dalam Pooling
Pendapatan
Negara bukan
Pajak
Non-PBi PNS,
Jamsostek dll
dll
APBN
PBI
BPJS
Kemenkes
Kementerian
lain
Pemda
Pendapatan
Asli Daerah
Non-PBI
Mandiri
Askes
Swasta
Pelayanan
Primer:
Pelayanan
Rujukan
Dana dari Masyarakat
langsung
10
Trisnantoro, 2014
Pooling & Purchasing Functions Not Separated by Revenue
Revenue
Collection
Pooling
of Funds
Health
Purchasing
Providers
Population
National
Budget
Local
Budget
Payroll
Tax
Donor
Funds
Pooling of Funds
Health Purchaser or Purchasers
Unified or Coordinated Benefits Package
Unified or Coordinated Provider Payment Systems
Private
Funds
Pooled
or not
Pooled
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
Purchasing dalam JKN
RASIO KLAIM 2014 - PEMBEBANAN
(JUTA RUPIAH)
IURAN
PELKES
RASIO
KLAIM
40.719.862
42.658.702
104,76 %
38.242.870
42.658.702
111,55 %
LAPORAN AKUNTANSI AUDITED
RASIO KLAIM 2014 - PELAYANAN
(DIKURANGI BIAYA OPERASIONAL BPJS )
(JUTA RUPIAH)
IURAN
PELKES
RASIO
KLAIM
40.719.862
46.665.539
114,60 %
38.242.870
46.665.539
122,02 %
• 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%
LAPORAN BOA, CPR & KEUANGAN DIOLAH
14
Biaya manfaat 2014
42.658.702 *
Peserta 133.273.918
PBI –N : 86.399.836 PBI-D : 8.649.830 BP : 4.885.140 PPU : 24.288.688
Biaya Pelayanan Primer
Rp. 8.347.850
Jlh faskes primer :
17.492
Puskesmas
: 9.788
DPP
: 3.984
Klinik pratama : 2.388
Faskes TNI-POLRI : 1.324
RS Rata
pratama
: per8
rata biaya
faskes Rp.39.77
juta/bulan
Biaya Non
Kapitasi
Non CBG’s,
promprev
Rp. 3.871.280
* Cash basis
PBPU : 9.050424
Biaya Pelayanan
Rujukan
Rp. 30.439.572
Jlh Faskes Rujukan : 1. 681
RS Pemerintah
: 776
RS TNI-POLRI
: 143
RS Swasta
: 652
RS BUMN
:
42
Klinik Utama
:
68
Rata rata biaya per
faskes
Rp. 1,509 M/bulan
Biaya manfaat sd Juni 2015
27.178.466 *
Peserta 147.675.544
PBI –N :
86.426.543
PBI-D :
10.613.788
PPU swasta
18.347.445
Biaya Pelayanan Primer
Rp. 4.953.108
Jlh faskes primer : 18.347
Puskesmas
: 9.814
DPP
: 4.314
Klinik pratama : 2.923
Faskes TNI-POLRI : 1.288
RS pratama
:
8
Rata rata biaya per
faskes Rp.44,99
juta/bulan
Eks Askes :
19.534.154
PBPU :
12.753.614
Biaya Pelayanan Rujukan
Rp. 22.270.069
Biaya Non
Kapitasi
Non CBG’s,
promprev
Rp. 816.879
* Cash basis
Jlh Faskes Rujukan : 1.783
RS Pemerintah
: 692
RS TNI-POLRI
: 147
RS Swasta
: 903
RS BUMN
:
41
Rata rata biaya per faskes
Rp. 2,081 M/bulan
Fund Collection Indicators
Indicators
Purpose
•The formal sector share of GDP
• Potential resources available to finance
•Natural resources revenue as a share public health spending
of total public budget
• Total health expenditure % GDP
• 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 •A broad measure of financial protection
that are prepaid
against out-of-pocket expenses
17
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
18
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
•To measure the financial incentives
different payment mechanisms (e.g. embedded in payments to providers
salaries, fee-for-service, capitation)
19
Health Financing Schemes
Financing
mechanisms
Health
care
services
Financing sources
Tax-based
financing
1. General tax or
other revenue
Social health
insurance
2.Payroll tax
Other
prepayment
schemes
3.Contribution or
premium
Out-ofpocket
payments
Natural
resource
revenue
Household
4. Direct payment
Extern
al
resourc
e
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?