Using Casemix System for Hospital Reimbursement in Social Health Insurance Programme: Comparing Casemix System and Fee-For-Service as Provider Payment Method

Copyright © 2020 by Syed Aljunid, Eka Yoshida Syukri.

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Contents

Acknowledgements

List of Abbreviations

Chapter 1     Introduction

1.1   Introduction

1.2   Statement of The Problems

1.3   Justification for The Study

1.4   Significance of The Study

1.5   Research Objectives

1.6   Research Questions

1.7   Research Hypotheses

1.8   Conceptual Framework of The Study

1.9   Definition of Terms

Chapter 2     Literature Review

2.1   Health Insurance in Indonesia

2.2   Provider Payment Mechanism

2.3   Flowchart of Study Activities

Chapter 3     Methodology

3.1   Study Design

3.2   Study Site

3.3   Study Duration

3.4   Study Activities

3.5   Research Ethics

Chapter 4     Results

4.1   Review of The Hospital’s Annual Reports

4.2   Review of Medical Services

4.3   Review of Billing Process

Chapter 5     Discussion

5.1   Introduction

5.2   Review of Annual Hospital Reports

5.3   Review of Medical Services

5.4   Review of Billing Process

5.5   Compilation of Study Results

Chapter 6     Conclusion and Recommendations

6.1   Conclusion

6.2   Concluding Remarks

6.3   Limitations of The Study

6.4   Recommendations

References

Appendix 1     Distribution of gender and age of patients with ICD-10 code Z09.8 for outpatient services whose costs were reimbursed under the FFS and casemix payment methods

Appendix 2     Distribution of gender and age of patients with ICD-10 code Z08.9 for outpatient services whose costs were reimbursed under the FFS and casemix payment methods

Appendix 3     Distribution of gender and age of patients with ICD-10 code B24 for outpatient services whose costs were reimbursed under the FFS and casemix payment methods

Appendix 4     Distribution of gender and age of patients with ICD-10 code Z48.8 for outpatient services whose costs were reimbursed under the FFS and casemix payment methods

Appendix 5     Distribution of gender and age of patients with ICD-10 code Z49.1 for outpatient services whose costs were reimbursed under the FFS and casemix payment methods

Appendix 6     Distribution of age of patients with ICD-10 code O82.9 for inpatient services whose costs were reimbursed under the FFS and casemix payment methods

Appendix 7     Distribution of gender and age of patients with ICD-10 code P03.4 for inpatient services whose costs were reimbursed under the FFS and casemix payment methods

Appendix 8     Distribution of gender and age of patients with ICD-10 code Z51.1 for inpatient services whose costs were reimbursed under the FFS and casemix payment methods

Appendix 9     Distribution of age of patients with ICD-10 code O80.9 for inpatient services whose costs were reimbursed under the FFS and casemix payment methods

Appendix 10   Distribution of age of patients with ICD-10 code C53.9 for inpatient services whose costs were reimbursed under the FFS and casemix payment methods

Appendix 11   Total hospital claims and payments and percent of claims paid for inpatients whose costs were reimbursed under the FFS and casemix payment methods in 2011

Appendix 12   Total hospital claims and payments and percent of claims paid for outpatients whose costs were reimbursed under the FFS and casemix payment methods in 2011

Appendix 13   Profile of the perception survey respondents

Appendix 14   Scores for the survey on the perceptions of billing administrators under the FFS and casemix payment methods

Acknowledgements

In the name of Allah, the Most Gracious, the Most Merciful. Alhamdulillah, Praise to Allah for His Grace and His Mercy in giving me the chance, health, and barokah to complete this book.

This book has been prepared and completed with the valuable contributions of many individuals. We are very grateful for having an exceptional assistance from the support staff and academics in the International Centre for Casemix and Clinical Coding, Faculty of Medicine, National University of Malaysia (ITCC-UKM) and United Nations University-International Institute for Global Health. They have gone beyond their normal duties in helping us to manage data that became the main content of this book. We are grateful to staff of Cipto Mangunkusumo Hospital in Jakarta, Indonesia for their time and tireless efforts to support our work. Special thanks for the staff working in the section that process the hospital payment under Jaminan Kesehatan Indonesia for their support to collect and clean the data for this study.

Dr Eka Yoshida would like to thank and covey her deepest appreciation and great respect to her late parents for all their wonderful love and care over the years; those were the greatest gifts that have ever been given to her. She woud like to express special thanks with deepest love to her lovely family— her husband, Syukri, and her son, Rizqi—for their support and prayers during this study. May Allah SWT bless them with barokah and dignity.

List of Abbreviations

I

INTRODUCTION

1.1 Introduction

Health is one of the most important issues in every country in the world, including Indonesia. As a developing country, Indonesia has designated health as a priority and has introduced an excellent programme to improve its health care system. One of the health development goals outlined in the National Strategic Plan for Health through Regulation Number 40 of 2004 (The House of Representatives of the Republic of Indonesia 2004) is to provide financial protection and accessible health care for all Indonesians. This regulation is the main policy supporting the improvement of universal health coverage (UHC) initiatives to cover approximately 267.6 million people on 16,056 islands in 2016 (The Central Bureau Statistic 2017).

In 2000, the Jakarta provincial government launched the Gakin (Keluarga Maskin, or poor families) programme, known as the Jakarta Health Card (Kartu Jakarta Sehat (KJS)). The Gakin programme was a social health insurance programme only for Jakarta residents that reimbursed health care providers using the fee-for-service (FFS) payment method (PHOJP 2009).

In 2008, the Indonesian government launched a national health insurance programme for poor people, previously called Jaminan Kesehatan Masyarakat (Jamkesmas) and now known as Jaminan Kesehatan Nasional (JKN/National Health Insurance). The Jamkesmas programme adopted the casemix method for hospital reimbursement with the National Drug Formulary under the Ministry of Health (MOH) (MOH 2010). The number of participants in Jamkesmas has gradually increased from 58.2 million people in 2008 and is expected to reach more than 270 million people in 2019 through the JKN programme (MOH 2017). To complete the social health insurance system in Indonesia, the MOH launched two additional social health insurance programmes, i.e., maternity insurance (Jaminan Persalinan, Jampersal) and thalassemia insurance (Jaminan Thalasemia, Jampelthas), both of which used the casemix method to reimburse providers in 2011 (MOH 2011).

From 2008 until 2012, two types of hospital payment methods were used in Indonesia’s social health insurance programmes, i.e., the Gakin programme and the Jamkesmas programme. Gakin was operated by the Jakarta provincial government and used an FFS scheme for hospital reimbursement (PHOJP 2011), while the Jamkesmas programme, under the MOH, employed the casemix method. Both healthcare programmes covered the same benefit packages, including outpatient and inpatient services. Since 2012, the Gakin programme has changed its approach to hospital reimbursement by changing its payment method from FFS to casemix (PHOJP 2012). The benefit packages of the two programmes are similar, and patients in the Gakin programme have been incorporated into the casemix patient group. Therefore, 2011 was the last year in which the Gakin and Jamkesmas programmes had different reimbursement systems and patient group data.

In 2011, the Indonesian government launched the roadmap of achievement for the UHC programme. Presidential Regulation Number 12 of 2013 officially designated the casemix payment method as the method for hospital reimbursement under the Indonesia UHC programme, and the FFS method has been eliminated. On January 1, 2014, the Indonesian government launched the UHC programme known as JKN (MOH 2014). A study should be conducted to assess whether choosing the casemix payment method for Indonesian UHC was a good strategic decision.

Regulations regarding charge reimbursement methods are important for the sustainability of a social insurance programme. JKN has been implemented with a limited budget but must cover a very large number of people; therefore, the provider payment method used in the programme should be carefully designed. The payment method should drive efficiency in hospitals, which are generally more expensive than primary health care. Selecting an appropriate provider payment method is one strategy that can be employed to control health care costs (Mathauer and Wittenbecher 2013).

A study should be conducted to assess whether choosing the casemix payment method for Indonesian UHC was a good strategic decision. It is important to study the implementation of the FFS and casemix approaches that were used in hospitals under the social health insurance scheme before 2012. The Gakin programme changed from FFS to casemix in 2012; thus, the year 2011 represents a period when the FFS and casemix methods had separate groups of patients, reimbursement charges, billing administrators, billing processes, social health security system regulations, and payers. This period represents a rare circumstance that cannot be repeated or created regularly; it is possible that the conditions of this period will occur only once.

This study assessed the casemix and FFS methods in natural conditions—without interventions from any stakeholders, including the researcher. Thus, these conditions are unique and have not occurred since in Indonesia. Using Indonesia’s experiences, the researcher studied two familiar payment methods, i.e., FFS and casemix. This study is important because it describes the actual implementation of casemix and FFS as hospital reimbursement methods at the same time, in the same place, and using the same benefit packages for social health insurance in different groups of patients.

1.2 Statement of The Problems

UHC in Indonesia faces a large challenge to its goal of eventually covering all residents. The sustainability of this programme depends on many factors, one of which is the selection of an appropriate payment method. From 2008 until 2011, 2 payment methods were used for social health insurance, i.e., casemix and FFS

Table 1.1 Types of insurance and payments used for social health insurance in an Indonesian teaching hospital from 2008 to 2011

Source: Cipto Mangunkusumo Hospital 2011. The Annual Report

Presidential Regulation Number 12 of 2013 designated casemix as the official hospital reimbursement method under Indonesian UHC (MOH 2014). The design of the charge reimbursement method is one of the key factors for the sustainability of the UHC programme. The advantages and disadvantages of the charge reimbursement method should be considered carefully. Due to the limited source of funding, the implementation of the method will have an impact on the efficient use of available resources.

A study should be conducted to assess whether choosing the casemix payment method for Indonesian UHC was a good strategic decision. This study aims to determine why the casemix method was chosen for hospital reimbursement instead of the FFS method. This study will also attempt to determine the advantages of casemix implementation in medical care and billing systems for hospital reimbursement under the social health insurance system.

1.3 Justification for The Study

The Jakarta provincial government selected the FFS method for the Gakin programme (Keluarga Maskin or poor family), which had two groups of participants, i.e., Gakin Card