HEALTH FINANCING : revenue collection, pooling and purchasing

Transkripsi

1 HEALTH FINANCING : revenue collection, pooling and purchasing Yulita Hendrartini Magister Kebijakan Pembiayaan dan Manajamen Asuransi Kesehatan Universitas Gadjah Mada

2 Agents in health care financing

3 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)

4 Financing is More Than Mobilize Money Mobilize & collect Funds Pool the Risk Allocate Resources Purchaser

5 Fungsi dan Tujuan Pembiayaan Kesehatan Fungsi Tujuan Revenue Collection Pooling Purchasing & Payment Hsiao 2013 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 secara teknis dan alokatif

6 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

7 Paja k Pendapatan Negara bukan Pajak Apa yang terjadi dalam Pengumpulan dana Kesehatan APBN (67,5 T) Non-PBi PNS, Jamsostek dll dll 18.89T Kab/K ota 489 ( 72.9 T) Kemenkes Kementerian lain Pemda Pendapatan Asli Daerah 19.93T PBI Pelayanan Primer: BPJS Pelayanan Rujukan Dana dari Masyarakat langsung Non-PBI Mandiri Askes Swasta NHA 2009 (dana masyarakat langsung) (18 T) 2.24T 7 Trisnantoro, 2014

8 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

9 Pooling dana kesehatan Dua Pool besar: 1. APBN 2. BPJS 1. APBN 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

10 Pajak Pendapatan Negara bukan Pajak Apa yang terjadi dalam Pooling APBN Non-PBi PNS, Jamsostek dll dll Kemenkes Kementerian lain Pemda Pendapatan Asli Daerah PBI Pelayanan Primer: BPJS Pelayanan Rujukan Dana dari Masyarakat langsung Non-PBI Mandiri Askes Swasta Trisnantoro,

11 Pooling & Purchasing Functions Not Separated by Revenue Revenue Collection National Budget Local Budget Payroll Tax Donor Funds Private Funds Pooling of Funds Health Purchasing Pooling of Funds Health Purchaser or Purchasers Unified or Coordinated Benefits Package Unified or Coordinated Provider Payment Systems Pooled or not Pooled Providers Population

12 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

13 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

14 Purchasing dalam JKN RASIO KLAIM PEMBEBANAN (JUTA RUPIAH) IURAN RASIO KLAIM PELAYANAN (DIKURANGI BIAYA OPERASIONAL BPJS ) (JUTA RUPIAH) IURAN PELKES PELKES RASIO KLAIM ,76 % ,55 % LAPORAN AKUNTANSI AUDITED RASIO KLAIM ,60 % ,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 : dan Biaya manfaat POPB : Bila tanpa peserta PBPU, rasio klaim 84,29% LAPORAN BOA, CPR & KEUANGAN DIOLAH 14

15 Biaya manfaat * Peserta PBI N : PBI-D : BP : PPU : PBPU : Biaya Pelayanan Primer Rp Jlh faskes primer : Puskesmas : DPP : Klinik pratama : Faskes TNI-POLRI : RS Rata pratama rata biaya : per 8 faskes Rp juta/bulan Biaya Non Kapitasi Non CBG s, promprev Rp * Cash basis Biaya Pelayanan Rujukan Rp Jlh Faskes Rujukan : 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

16 PBI N : PBI-D : Biaya manfaat sd Juni * Peserta PPU swasta Eks Askes : PBPU : Biaya Pelayanan Primer Rp Jlh faskes primer : Puskesmas : DPP : Klinik pratama : Faskes TNI-POLRI : RS pratama : 8 Rata rata biaya per faskes Rp.44,99 juta/bulan Biaya Non Kapitasi Non CBG s, promprev Rp * Cash basis Biaya Pelayanan Rujukan Rp Jlh Faskes Rujukan : RS Pemerintah : 692 RS TNI-POLRI : 147 RS Swasta : 903 RS BUMN : 41 Rata rata biaya per faskes Rp. 2,081 M/bulan

17 Fund Collection Indicators Indicators The formal sector share of GDP Natural resources revenue as a share of total public budget Total health expenditure % GDP Public sector spending as % GDP External health sector aid as % of GDP The share of public health to total public expenditures Per capita total and public health expenditures The share of total health expenditures that are prepaid Purpose Potential resources available to finance public health spending To measure resources specially available to the public sector To measure public sector allocation decisions, additional resources, and potential constraints A broad measure of financial protection against out-of-pocket expenses 17

18 Pooling Indicators Indicators 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 Purpose 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

19 Purchasing Indicators Indicators Share of expenditures accounted for by strategic purchasing 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 Share of total funds spent with different payment mechanisms (e.g. salaries, fee-for-service, capitation) Purpose Characterizing the pool-purchaser relationship To characterize the structure of interaction between purchasers and providers To measure the financial incentives embedded in payments to providers 19

20 Health Financing Schemes Financing mechanisms Financing sources Tax-based financing 1. General tax or other revenue Natural resource revenue Health care services Social health insurance Other prepayment schemes 2.Payroll tax 3.Contribution or premium Household External resource Out-ofpocket payments 4. Direct payment

21 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?