Grace FK UGM TantanganSistemRujukanDalamPerspektifLayananSekunder
Tantangan Sistem Rujukan dalam
Perspektif Layanan Sekunder
Dr. Grace Frelita, MM
Siloam Hospitals Group
2
HOPE : PREVENTIVE, COMPETENCE, & COMPASSION
3/24/2016
3
Issues
3/24/2016
Issues
5
PETA JALAN ASPEK MANFAAT DAN IURAN
Manfaat bervariasi
belum komprehensif
sesuai kebutuhan
medis
- Manfaat standar
- Komprehensif
sesuai keb medis
- Berbeda non
medis
Iuran bervariasi
Iuran :
Masih berbeda PBI
dan Non PBI
2012
Konsensus
manfaat
2013
Penetapan
manfaat dlm
Perpes JK,
termasuk
koordinasi
manfaat
2014
Manfaat
sama untuk
semua
penduduk
KEGIATAN-KEGIATAN
2015
2016
Penyesuaian
Perpres
Jamkes
2017
2018
2019
Penyesuaian
Perpres
Jamkes
Kajian berkala tahunan tentang upah, iuran, efektifitas manfaat,
dan pembayaran antar wilayah
Telaah utilisasi kontinyu untuk menjamin efisiensi, menurunkan
moral hazard, dan kepuasan peserta dan tenaga / fasilitas kesehatan
3/24/2016
6
Perkembangan Healthcare di Indonesia
Source : EY_Ripe for investment_the Indonesian health care industry post
introduction of UHC_June 2015-9
3/24/2016
7
Perbandingan di ASEAN
3/24/2016
140605-GS-Goldman Sachs - ASEAN Healthcare-5
8
Populasi RS di Indonesia (Berdasarkan Kelas)
100%
90%
80%
70%
60%
Non Kelas
50%
D
C
40%
B
A
30%
20%
10%
0%
Sumber : rsonline-kemkes, 2012
3/24/2016
9
Plus VS Minus JKN – RS Rujukan
• Kenaikan biaya kesehatan dapat
ditekan.
• Biaya dan mutu pelayanan
kesehatan dapat ditingkatkan.
• Kepesertaan bersifat wajib bagi
seluruh penduduk.
• Pembayaran bersifat prospektif.
• Adanya kepastian pelayanan
kesehatan yang berkelanjutan.
• Manfaat pelayanan kesehatan
komprehensif (promotive,
preventive, curative dan
rehabilitative)
3/24/2016
• Pembiayaan di Swasta berbeda
dengan di Pemerintah.
• Sistem regionalisasi belum
berjalan baik.
• Penyebaran dokter/rumah sakit
belum merata di Indonesia.
• Terbatasnya tempat tidur di
rumah sakit rujukan tingkat
lanjut.
• Seringkali dianggap kecurangan
(fraud).
• Lamanya proses administrasi
pembayaran > verifikasi.
• Semua masyarakat memiliki
derajat yang sama
10
Sistem Rujukan Berjenjang
JENJANG
RUJUKAN
Tingkat I
Tingkat II
Tingkat III
3/24/2016
PENGERTIAN
FASILITAS PELAYANAN
KESEHATAN
MONITORING DAN
EVALUASI
Mampu memberikan
pelayanan kesehatan
dasar
•Puskesmas
•Puskesmas perawatan
•Balai pengobatan
•Praktek perorangan
•Dokter Keluarga
•Klinik pratama
•Rumah bersalin
•Klinik umum
•RS Pratama
Kadinkes Kab/Kota dan
organisasi profesi
cabang Kab/kota
Mampu memberikan
pelayanan kesehatan
spesialistik
•RS kelas C
•RS kelas D
(baik milik pemerintah,
TNI/Polri, BUMN maupun
swasta)
Kadinkes Propinsi dan
organisasi profesi
cabang Kab/kota
Mampu memberikan
pelayanan kesehatan
sub spesialistik
•RS kelas A
•RS kelas B
(baik milik pemerintah,
TNI/POLRI, BUMN maupun
swasta)
Menteri Kesehatan,
organisasi profesi, dan
institusi pendidikan
11
Panduan Praktek Klinis
SIFAT
CAKUPAN
NASIONAL
LEGALISASI
KEMENKES
PNPK
PEMBUAT
organisasi
profesi
FASYANKES
PPK/
SPO
pimpinan
fasilitas
yankes
PANDUAN
PRAKTIK KLINIS
ALUR KLINIS
= clinical pathway
Sesuai standar profesi
ALGORITME
PROTOKOL
PROSEDUR
STANDING ORDER
Akreditasi Nasional
3/24/2016
11
12
Coordination of Benefit
• Kerjasama dengan Asuransi/TPA lainnya?
• Aturan, panduan?
3/24/2016
13
SILOAM HOSPITALS GROUP
Vision
By 2017..
•
International
Quality
Reach
Godly
Compassion
Scale
Affordable and Accessible Healthcare
to all socio economic segments
3/24/2016
•
•
Beds
4,800 to 10,000
Patients per annum
2 million to 15 million
Hospitals
21 to 40 hospitals
15 to over 25 cities
14
Misi SHG
Pilihan Terpercaya Untuk Mendapatkan
Pelayanan Kesehatan Bertaraf Internasional,
Pendidikan Kesehatan,
dan Penelitian
(The trusted destination of choice for holistic world class
healthcare, health education and research)
3/24/2016
15
Values
1. Cinta Kasih
2. Belas kasihan
3. Integritas
4. Kejujuran
5. Kepedulian
6. Empati
7. Profesionalisme
3/24/2016
16
Mature and Developing Hospitals
SILOAM HOSPITALS LIPPO VILLAGE
MRCCC SILOAM SEMANGGI
TANGERANG (West of Jakarta)
SOUTH JAKARTA
308 Bed Capacity
234 GP and Specialists
455 Nurses
Centre of Excellence : Neurosience &
Heart Centre
331 Bed Capacity
172 GP and Specialists
220 Nurses
Centre of Excellence : Cancer Centre
SILOAM HOSPITALS KEBON JERUK
WEST JAKARTA
279 Bed Capacity
198 GP and Specialists
342 Nurses
Centre of Excellence : Urology &
Orthopaedic
SILOAM HOSPITALS JAMBI
SILOAM HOSPITALS SURABAYA
EAST SUMATERA
EAST JAVA
100 Bed Capacity
65 GP and Specialists
127 Nurses
Centre of Excellence : Emergency &
Trauma
162 Bed Capacity
144 GP and Specialists
265 Nurses
Centre of Excellence : Fertility Centre
83.0% Ownership
SILOAM HOSPITALS CIKARANG
SILOAM HOSPITALS BALIKPAPAN
BEKASI (East of Jakarta)
EAST KALIMANTAN
118 Bed Capacity
91 GP and Specialists
161 Nurses
Centre of Excellence : Occupational Health
228 Bed Capacity
92 GP and Specialists
180 Nurses
Centre of Excellence : Emergency & Trauma
and Orthopedics
79.45% Ownership
3/24/2016
17
New Hospitals in 2012
SILOAM GENERAL HOSPITAL (RSUS)
TANGERANG (West of Jakarta)
SILOAM HOSPITALS CINERE
DEPOK (South of Jakarta)
664 Bed Capacity
49 GP and Specialists
214 Nurses
37 Bed Capacity
19 GP and Specialists
51 Nurses
Centre of Excellence: Cardiology
SILOAM HOSPITALS MANADO
NORTH SULAWESI
3/24/2016
230 Bed Capacity
98 GP and Specialists
126 Nurses
Centre of Excellence : Emergency & Trauma
80.0% Ownership
SILOAM HOSPITALS MAKASSAR
SOUTH SULAWESI
SILOAM HOSPITALS PALEMBANG
SOUTH SUMATERA
360 Bed Capacity
97 GP and Specialists
247 Nurses
Centre of Excellence : Cardiology and
Emergency &
Trauma
347 Bed Capacity
119 GP and Specialists
161 Nurses
Centre of Excellence : Emergency &
Trauma
70.39% Ownership
18
New Hospitals in 2013
SILOAM HOSPITALS BALI
BALI
BIMC KUTA
BALI
281 Bed Capacity
97 GP and Specialists
179 Nurses
Centre of Excellence : Emergency & Trauma,
Medical Tourism,
Orthopaedics and Cardiology
19 Bed Capacity
51 GP and Specialists
65 Nurses
Centre of Excellence : Emergency & Trauma
SILOAM HOSPITALS TB SIMATUPANG
SOUTH JAKARTA
BIMC NUSA DUA
BALI
269 Bed Capacity
110 GP and Specialists
136 Nurses
Centre of Excellence : Emergency & Trauma.
Cardiology, Oncology and
Neuroscience
31 Bed Capacity
57 GP and Specialists
74 Nurses
Centre of Excellence : Emergency & Cosmetic
Surgery
80.0% Ownership
80.0% Ownership
New Hospitals in 2014
3/24/2016
SILOAM HOSPITALS PURWAKARTA
WEST JAVA
SILOAM HOSPITALS ASRI
203 Bed Capacity
34 GP and Specialists
105 Nurses
Centre of Excellence : Emergency & Trauma
42 Bed Capacity
104 GP and Specialists
76 Nurses
Centre of Excellence : Urology &
Pulmonology
19
Hospitals newly opened
SILOAM HOSPITALS KUPANG
SILOAM HOSPITALS MEDAN
NORTH SUMATERA
EAST NUSA TENGGARA
SILOAM HOSPITALS LABUAN BAJO
NUSA TENGGARA TIMUR
3/24/2016
There are currently 29 sites under
various stages of development
20
JKN – Siloam Hospitals Group
Sumatra Population :
50.6 mio
• Tidak semua RS di SHG
memiliki kemampuan yang
sama.
• Tidak semua daerah memiliki
sistem distribusi yang baik.
• Policy yang berbeda untuk
masing-masing regional.
• Lamanya proses verifikasi.
• Sosialisasi tim verifikator RS.
Maluku Population :
2.6 mio
Sulawesi Population :
17.4 mio
Kalimantan Population :
13.8 mio
Papua Population :
3.6 mio
Java Population :
136.6 mio
Nusa Tenggara Population : 9.2
mio
Bali Population :
3.9 mio
Greater Jakarta Population :
28 mio
3/24/2016
Jakarta Population :
10 mio
21
Kesimpulan
Human Resources
Facilities
expenditure
• Kurangnya Dokter
Spesialis
• Mixed Facilities:
Beds, ICU, OT, HD
• No Subsidies
• Fee for Service VS
Fixed Service
• 100 % Private
• Obat-Obat
Catastrophic
• Sistem Pendidikan
• Verifikator
• E-Catalog – tidak
ada barang
• Type B – Rujukan
kurang
Network
RS Jejaring
3/24/2016
• Cash Flow
• Operational Cost
• COB
22
JUST LIKE CATCH THE TRAIN
3/24/2016
Perspektif Layanan Sekunder
Dr. Grace Frelita, MM
Siloam Hospitals Group
2
HOPE : PREVENTIVE, COMPETENCE, & COMPASSION
3/24/2016
3
Issues
3/24/2016
Issues
5
PETA JALAN ASPEK MANFAAT DAN IURAN
Manfaat bervariasi
belum komprehensif
sesuai kebutuhan
medis
- Manfaat standar
- Komprehensif
sesuai keb medis
- Berbeda non
medis
Iuran bervariasi
Iuran :
Masih berbeda PBI
dan Non PBI
2012
Konsensus
manfaat
2013
Penetapan
manfaat dlm
Perpes JK,
termasuk
koordinasi
manfaat
2014
Manfaat
sama untuk
semua
penduduk
KEGIATAN-KEGIATAN
2015
2016
Penyesuaian
Perpres
Jamkes
2017
2018
2019
Penyesuaian
Perpres
Jamkes
Kajian berkala tahunan tentang upah, iuran, efektifitas manfaat,
dan pembayaran antar wilayah
Telaah utilisasi kontinyu untuk menjamin efisiensi, menurunkan
moral hazard, dan kepuasan peserta dan tenaga / fasilitas kesehatan
3/24/2016
6
Perkembangan Healthcare di Indonesia
Source : EY_Ripe for investment_the Indonesian health care industry post
introduction of UHC_June 2015-9
3/24/2016
7
Perbandingan di ASEAN
3/24/2016
140605-GS-Goldman Sachs - ASEAN Healthcare-5
8
Populasi RS di Indonesia (Berdasarkan Kelas)
100%
90%
80%
70%
60%
Non Kelas
50%
D
C
40%
B
A
30%
20%
10%
0%
Sumber : rsonline-kemkes, 2012
3/24/2016
9
Plus VS Minus JKN – RS Rujukan
• Kenaikan biaya kesehatan dapat
ditekan.
• Biaya dan mutu pelayanan
kesehatan dapat ditingkatkan.
• Kepesertaan bersifat wajib bagi
seluruh penduduk.
• Pembayaran bersifat prospektif.
• Adanya kepastian pelayanan
kesehatan yang berkelanjutan.
• Manfaat pelayanan kesehatan
komprehensif (promotive,
preventive, curative dan
rehabilitative)
3/24/2016
• Pembiayaan di Swasta berbeda
dengan di Pemerintah.
• Sistem regionalisasi belum
berjalan baik.
• Penyebaran dokter/rumah sakit
belum merata di Indonesia.
• Terbatasnya tempat tidur di
rumah sakit rujukan tingkat
lanjut.
• Seringkali dianggap kecurangan
(fraud).
• Lamanya proses administrasi
pembayaran > verifikasi.
• Semua masyarakat memiliki
derajat yang sama
10
Sistem Rujukan Berjenjang
JENJANG
RUJUKAN
Tingkat I
Tingkat II
Tingkat III
3/24/2016
PENGERTIAN
FASILITAS PELAYANAN
KESEHATAN
MONITORING DAN
EVALUASI
Mampu memberikan
pelayanan kesehatan
dasar
•Puskesmas
•Puskesmas perawatan
•Balai pengobatan
•Praktek perorangan
•Dokter Keluarga
•Klinik pratama
•Rumah bersalin
•Klinik umum
•RS Pratama
Kadinkes Kab/Kota dan
organisasi profesi
cabang Kab/kota
Mampu memberikan
pelayanan kesehatan
spesialistik
•RS kelas C
•RS kelas D
(baik milik pemerintah,
TNI/Polri, BUMN maupun
swasta)
Kadinkes Propinsi dan
organisasi profesi
cabang Kab/kota
Mampu memberikan
pelayanan kesehatan
sub spesialistik
•RS kelas A
•RS kelas B
(baik milik pemerintah,
TNI/POLRI, BUMN maupun
swasta)
Menteri Kesehatan,
organisasi profesi, dan
institusi pendidikan
11
Panduan Praktek Klinis
SIFAT
CAKUPAN
NASIONAL
LEGALISASI
KEMENKES
PNPK
PEMBUAT
organisasi
profesi
FASYANKES
PPK/
SPO
pimpinan
fasilitas
yankes
PANDUAN
PRAKTIK KLINIS
ALUR KLINIS
= clinical pathway
Sesuai standar profesi
ALGORITME
PROTOKOL
PROSEDUR
STANDING ORDER
Akreditasi Nasional
3/24/2016
11
12
Coordination of Benefit
• Kerjasama dengan Asuransi/TPA lainnya?
• Aturan, panduan?
3/24/2016
13
SILOAM HOSPITALS GROUP
Vision
By 2017..
•
International
Quality
Reach
Godly
Compassion
Scale
Affordable and Accessible Healthcare
to all socio economic segments
3/24/2016
•
•
Beds
4,800 to 10,000
Patients per annum
2 million to 15 million
Hospitals
21 to 40 hospitals
15 to over 25 cities
14
Misi SHG
Pilihan Terpercaya Untuk Mendapatkan
Pelayanan Kesehatan Bertaraf Internasional,
Pendidikan Kesehatan,
dan Penelitian
(The trusted destination of choice for holistic world class
healthcare, health education and research)
3/24/2016
15
Values
1. Cinta Kasih
2. Belas kasihan
3. Integritas
4. Kejujuran
5. Kepedulian
6. Empati
7. Profesionalisme
3/24/2016
16
Mature and Developing Hospitals
SILOAM HOSPITALS LIPPO VILLAGE
MRCCC SILOAM SEMANGGI
TANGERANG (West of Jakarta)
SOUTH JAKARTA
308 Bed Capacity
234 GP and Specialists
455 Nurses
Centre of Excellence : Neurosience &
Heart Centre
331 Bed Capacity
172 GP and Specialists
220 Nurses
Centre of Excellence : Cancer Centre
SILOAM HOSPITALS KEBON JERUK
WEST JAKARTA
279 Bed Capacity
198 GP and Specialists
342 Nurses
Centre of Excellence : Urology &
Orthopaedic
SILOAM HOSPITALS JAMBI
SILOAM HOSPITALS SURABAYA
EAST SUMATERA
EAST JAVA
100 Bed Capacity
65 GP and Specialists
127 Nurses
Centre of Excellence : Emergency &
Trauma
162 Bed Capacity
144 GP and Specialists
265 Nurses
Centre of Excellence : Fertility Centre
83.0% Ownership
SILOAM HOSPITALS CIKARANG
SILOAM HOSPITALS BALIKPAPAN
BEKASI (East of Jakarta)
EAST KALIMANTAN
118 Bed Capacity
91 GP and Specialists
161 Nurses
Centre of Excellence : Occupational Health
228 Bed Capacity
92 GP and Specialists
180 Nurses
Centre of Excellence : Emergency & Trauma
and Orthopedics
79.45% Ownership
3/24/2016
17
New Hospitals in 2012
SILOAM GENERAL HOSPITAL (RSUS)
TANGERANG (West of Jakarta)
SILOAM HOSPITALS CINERE
DEPOK (South of Jakarta)
664 Bed Capacity
49 GP and Specialists
214 Nurses
37 Bed Capacity
19 GP and Specialists
51 Nurses
Centre of Excellence: Cardiology
SILOAM HOSPITALS MANADO
NORTH SULAWESI
3/24/2016
230 Bed Capacity
98 GP and Specialists
126 Nurses
Centre of Excellence : Emergency & Trauma
80.0% Ownership
SILOAM HOSPITALS MAKASSAR
SOUTH SULAWESI
SILOAM HOSPITALS PALEMBANG
SOUTH SUMATERA
360 Bed Capacity
97 GP and Specialists
247 Nurses
Centre of Excellence : Cardiology and
Emergency &
Trauma
347 Bed Capacity
119 GP and Specialists
161 Nurses
Centre of Excellence : Emergency &
Trauma
70.39% Ownership
18
New Hospitals in 2013
SILOAM HOSPITALS BALI
BALI
BIMC KUTA
BALI
281 Bed Capacity
97 GP and Specialists
179 Nurses
Centre of Excellence : Emergency & Trauma,
Medical Tourism,
Orthopaedics and Cardiology
19 Bed Capacity
51 GP and Specialists
65 Nurses
Centre of Excellence : Emergency & Trauma
SILOAM HOSPITALS TB SIMATUPANG
SOUTH JAKARTA
BIMC NUSA DUA
BALI
269 Bed Capacity
110 GP and Specialists
136 Nurses
Centre of Excellence : Emergency & Trauma.
Cardiology, Oncology and
Neuroscience
31 Bed Capacity
57 GP and Specialists
74 Nurses
Centre of Excellence : Emergency & Cosmetic
Surgery
80.0% Ownership
80.0% Ownership
New Hospitals in 2014
3/24/2016
SILOAM HOSPITALS PURWAKARTA
WEST JAVA
SILOAM HOSPITALS ASRI
203 Bed Capacity
34 GP and Specialists
105 Nurses
Centre of Excellence : Emergency & Trauma
42 Bed Capacity
104 GP and Specialists
76 Nurses
Centre of Excellence : Urology &
Pulmonology
19
Hospitals newly opened
SILOAM HOSPITALS KUPANG
SILOAM HOSPITALS MEDAN
NORTH SUMATERA
EAST NUSA TENGGARA
SILOAM HOSPITALS LABUAN BAJO
NUSA TENGGARA TIMUR
3/24/2016
There are currently 29 sites under
various stages of development
20
JKN – Siloam Hospitals Group
Sumatra Population :
50.6 mio
• Tidak semua RS di SHG
memiliki kemampuan yang
sama.
• Tidak semua daerah memiliki
sistem distribusi yang baik.
• Policy yang berbeda untuk
masing-masing regional.
• Lamanya proses verifikasi.
• Sosialisasi tim verifikator RS.
Maluku Population :
2.6 mio
Sulawesi Population :
17.4 mio
Kalimantan Population :
13.8 mio
Papua Population :
3.6 mio
Java Population :
136.6 mio
Nusa Tenggara Population : 9.2
mio
Bali Population :
3.9 mio
Greater Jakarta Population :
28 mio
3/24/2016
Jakarta Population :
10 mio
21
Kesimpulan
Human Resources
Facilities
expenditure
• Kurangnya Dokter
Spesialis
• Mixed Facilities:
Beds, ICU, OT, HD
• No Subsidies
• Fee for Service VS
Fixed Service
• 100 % Private
• Obat-Obat
Catastrophic
• Sistem Pendidikan
• Verifikator
• E-Catalog – tidak
ada barang
• Type B – Rujukan
kurang
Network
RS Jejaring
3/24/2016
• Cash Flow
• Operational Cost
• COB
22
JUST LIKE CATCH THE TRAIN
3/24/2016