14 February 2007

DR.Ronnie Rivany, Drg, MSc

Pusat Kajian Kebijakan dan Ekonomi Kesehatan
FKMUI
2007
TOPIK DISKUSI
BIAYA & ANALISIS BIAYA
UNIT COST
UTILIZATION REVIEW
PERHITUNGAN BIAYA KAPITASI
PENETAPAN PREMI



Ronnie Rivany
Pusat Kajian Kebijakan dan Ekonomi Kesehatan
FKMUI
2006
KONSEP BIAYA & ANALISIS BIAYA
DUPLIKASI dengan sesi sesi y.a.d

APLIKASI UNIT COST
Tarif
Premi
CLINICAL PATHWAY
Diagnostic Related Groups & CASEMIX
KONSEP Badan Layanan Umum

Bab IV Pasal 8 . Standar Pelayanan Minimum

Bab IV Pasal 9 . Perhitungan biaya per unit layanan
DITERMINAN TARIF per TINDAKAN
TARIF
UNIT COST
ATP/WTP PESAING
e
CRR
Total cost quantity
margin
ANALISIS
BIAYA
Distinguishing Characteristic of
Health Care Evaluation
Scope of Examination: Both Cost and Consequences
NO YES
Examine only
Consequences
Examine only
Costs


Outcome
Description


Cost
Description
1A PARTIAL EVALUATION 1B



Efficacy or
Effectiveness
Evaluation







Cost
Analysis




3A PARTIAL EVALUATION 3B


2 PARTIAL EVALUATION




4 FULL ECONOMIC
EVALUATION

Cost-Minimization Analysis
Cost-Effectiveness Analysis
Cost-Utility Analysis
Cost-Benefit Analysis



N
O



Y
E
S

2

o
r

m
o
r
e

A
l
t
e
r
n
a
t
i
v
e
s
KONSEP BIAYA & ANALISIS BIAYA
DUPLIKASI dengan sesi sesi y.a.d

Contoh Analisis Biaya di RSUD 45 Kuningan
Jawa Barat tahun 2001, untuk menghitung Unit
Cost dengan mempergunakan metode Double
Distribution
Principle Characteristics of
Provider Payments Systems
(Normand & Weber, 1999)
Payment
System
Definition of basis for payment (unit)
Fee for services Single act or product
Case payment Single case diagnosis (DRGs &
Casemix)
Daily charge Patient day
Bonus payment For specific act (e.g. immunization)
Flat rate For approved investments
Capitation fee All services for one person in one
period
Salary Period of work (one month)
Budget All services for health fund members in one
period
WHAT (1)
CAPITATION (Normand &
Weber,1999)
KEPALA = CAPUT (?)
BIAYA PER KEPALA = CAPITATION
FEE
A CAPITATION FEE COVERS SERVICES
FOR ONE HEALTH FUND MEMBER OVER
A CERTAIN PERIOD (NORMALLY ONE
YEAR)
CAPITATION FEE ARE SUITABLE AS A
PAYMENT MECHANISM FOR PRIMARY
OR AND SECONDARY CARE
THE CAPITATION FEE IS BASED ON THE
POOLING OF RISK OF THE POPULATION


WHAT (2)
CAPITATION COVERAGE
OUT PATIENT
IN PATIENT
SUPPORTING SERVICES
DRUGS & SUPPLIES
COSMETIC (?)
EXTRA ORDINARY
CANCER
HIV/AIDS
Morale hazards (?)

WHO
MEMBER OF THE
POPULATION
DEMOGRAPHIC by
SEX
AGE
MARITAL STATUS
FAMILY STATUS
EMPLOYMENT STATUS
BENEFIT PACKAGE

WHERE
LOCAL
INDUSTRY
HEALTH
EDUCATION
CAPTIVE MARKET
REGIONAL
NATIONAL
GLOBAL
WHEN
POPULATION AT RISK
EPIDEMIOLOGICAL
TRANSITION
HEALTH CARE COST
INFLATION
COST OF DRUGS & SUPPLIES
COST OF TECHNOLOGY
Including NON MEDICAL
COMPONENT
Including TERTIARY CARE



HOW (1)
KEY WORDS
POPULATION
LAW OF LARGE NUMBER
POOLING RISK
BI PARTIT vs TRI PARTIT
UTILIZATION ~ PROBABILITY
(ACTUAL vs ALLOWED RISK)
UNIT COST
LOADING FACTOR
PREMIUM

HOW (2)
THEORY

PROBABILITY RATE
= UTILIZATION
NO OF POPULATION

CAPITATION
= UNIT COST X PROB. RATE



HOW (3)
Probability Rate & Capitation
Demographic Utilization
(1)
Unit cost
(2)
Capitation
(2 X 3)
By Sex
By Age
By Marital status
By Employ status
HOW (4)
APLIKASI PT ASKES.1
Perhitungan Premi

1. Biaya Pelayanan Kesehatan
(70 80 %)
2. Biaya Loading (20 30 %)
Cadangan ( 5 %)
Biaya operasi (5 10 %)
Profit (10 15%)




HOW (5)
APLIKASI PT ASKES.2
Biaya Pelayanan Kesehatan
Dihitung berdasarkan experience
(angka utilisasi & harga layanan
kesehatan rerata 2 tahun terakhir)
Pengelompokan layanan :
RJTP
RJTL
Rawat Inap
Khusus
Suplemen
Rumus : C = F x P
C = Biaya layanan setiap kompoonen
F = Angka utilisasi setiap komponen
P = Harga komponen layanan kesehatan




HOW (6)
APLIKASI PT ASKES.3
Contoh ( per member per month)
Angka utilisasi (per 1000 peserta per
bulan)
RJTP = 250/1000
RJTL = 25/1000
RI = 5/1000
Layanan khusus = 5/1000
Layanan suplemen = 5/1000
Biaya per kasus
RJTP = Rp 20.000
RJTL = Rp 300.000
RI = Rp 2.000.000 (kls II)
Layanan Khusus = Rp 250.000
Layanan suplemen = Rp 1.000.000




HOW (7)
APLIKASI PT ASKES.4
Komponen
layanan
Prevalensi Harga per
kasus (Rp)
Biaya (Rp)
RJTP 250/1000 20.000 5.000
RJTL 25/1000 300.000 7.500
RI 5/1000 4.000.000 20.000
Khusus 5/1000 2.000.000 10.000
Suplemen 5/1000 1.000.000 5.000
Total
(80%)
47.500
Premi
(100%)
59.375
Loading
(20%)
12.500
HOW (8) APLIKASI RS.1
Unit Cost Review
Utilisation Review
Analisis utilisasi
per jenis layanan
Review CRR dan Tarif
Kecenderungan utilisasi
Average Cost
Penghitungan
Nilai Kapitasi



Unit cost / Average cost
Per Pasien

Batasan Layanan
(Ekslusi - Inklusi)

Analisis
Probabilitas
Riil / allowed risk


Internal Customer
Review
Analisis Populasi
Scr Internal
Demografi Target

Kapitasi
HOW (9) APLIKASI RS.2
COST STRUCTURE
Jenis
layanan
TC % VC % FC % OP UC
Poli homo Act/
norm
OK Hetero/
RVU
Act/
norm
Lab Hetero/
RVU
Act/
norm
Total 100
HOW (10) APLIKASI RS.3
Cost Recovery Rate
Jenis
layanan
TC
+ dep
O
P
UC Tarif CRR
(TR/TC x 100%)
Poli.1 10.000 20 500 650 (650x20) / (500x20)=
130,00

Poli.2 15.000 25 600 350 (350x25) / (15.000)=
58,33
OK
Lab
HOW (11) APLIKASI RS.4
Kapitasi + LF 40 % + Actual Prob
Jenis Layanan Unit Cost Actual Prob Kapitasi
Rajal.1 6.000 0,0002 1,2
Penunjang
Medis.1
250.000 0,02 5.000
Ranap.1 150.000 0,006 900
Sub total 5.901,2
Loading factor 0,40 2.360,4
Premi per
orang
8.261,6
Faktor
keluarga 4 org
33.046,4
35.000
HOW (12) APLIKASI RS.5
Kapitasi + LF 40 % + Allowed Risk
Jenis Layanan Unit Cost Allowed
Risk
Kapitasi
Rajal.1 6.000 0,0002 3 1,8
Penunjang
Medis.1
250.000 0,02 3 7.500
Ranap.1 150.000 0,006 7 1.050
Sub total 8.551,8
Loading factor 0,40 3.420,7
Premi per
orang
11.972,5
Faktor
keluarga 4 org
47.890
50.000
DISKUSI (1)
DITERMINAN TEKNIS
SERUPA TAPI TAK SAMA
(Konsep sama, teknis beda)
EXPERIENCE vs EVIDENCE
ACTUAL vs ALLOWED RISK
PROBABILITY
BIAYA LAYANAN / TARIF (?) vs
UNIT COST
GENERIC vs SPECIFIC
DEMOGRAPHIC / POPULATION


DISKUSI (2)
DITERMINAN
DEMAND for HEALTH INSURANCE
(Rivany,1988)
UTILITY
PROBABILITY OF LOSS
MAGNITUDE OF LOSS
INCOME
PREMIUM
SERVICES

DISKUSI (3)
DITERMINAN UNIT COST
METODE
SIMPLE DISTRIBUTION
STEP-DOWN DISTRIBUTION
DOUBLE DISTRIBUTION
MULTIPLE DISTRIBUTION
ACTIVITY BASED COSTING

ACTUAL vs NORMATIVE
HOMOGEN vs HETEROGEN
OUTPUT (RELATIVE VALUE UNIT)


DISKUSI (4)
DITERMINAN PREMIUM
UNIT COST
PRICE
COST RECOVERY RATE
(CRR)
CAPITATION
PROBABILITY RATE
(ACTUAL vs ALLOWED RISK)
POLICY LOADING FACTOR
ATP / WTP (?)

DISKUSI (5)
DRG & CASEMIX, the answer
International Classification Disease
IX X
Major Diagnostic Classification
Diagnostic Related Group
AN-DRGs, 3
rd
version, 1996
23 MDCs, 956 DRGs
4
th
version, 1999/2000
CASEMIX
CLINICAL PATHWAY
INA DRGs (?)
PPE Depkes

HEALTH vs ECONOMICS
INDONESIAN DRGs

International Classification of Disease (ICD)

Major Diagnostic Categories (MDC)

Surgical / Other / Medical

Diagnosis Related Groups (DRGs)

Casemix


Clinical
Pathway
Pengembangan Konsep Clinical Pathway
1 Diseases and disorders of the nervous system
2 Disease and disorders of the eye
3 Disease and disorders of the ear, nose, and throat
4 Disease and disorders of the respiratory system
5 Disease and disorders of the circulatory system
6 Disease and disorders of the digestive system
7 Disease and disorders of the hepatobiliiary system and pancreas
8 Disease and disorders of the musculoskeletal system and connective tissue
9 Disease and disorders of the skin, subcutaneous tissue, and breast
10 Endocrine, nutritional, and metabolic diseases and disorders
11 Disease and disorders of the kidney and the urinary tract
12 Disease and disorders of the male reproductive
13 Disease and disorders of the female reproductive system
14 Pregnancy, childbirth, and the purperium
15 Newborn and other neonates with conditions originating in the perinatal period
16 Disease and disorders of blood and blood forming organs and immunological disorders
17 Myeloproliferative disease and disorder, and poorly differentiated neoplasm
18 Infectious and parasitic disease (systemic or unspecified sites)
19 Mental diseases and disorders
20 Alcohol/drug use and alcohol/drug- induced organic mental disorders
21 Injuries, poisoning, and toxic effects of drugs
22 Burns
23 Factors influencing health status and other contact with health services
Major Diagnostic Categories
POLA PIKIR INDONESIAN DRGs (1)
INA - DRG
1.Konfirmasi DRG 2.Hitung Cost/DRG
Clinical Pathway & Casemix
Activity Based Costing
POLA PIKIR INDONESIAN DRGs (2)
ICD
MDC
DRG DRG
CASEMIX
COST
COST
DRG
TARIF
TARIF
1
2
Clinical Pathway
Clinical pathway adalah suatu
konsep perencanaan pelayanan
terpadu yang merangkum setiap
langkah yang diberikan kepada
pasien mulai masuk sampai keluar
rumah sakit berdasarkan standar
pelayanan medis, standar asuhan
keperawatan, dan standar
pelayanan tenaga kesehatan
lainnya, yang berbasis bukti dengan
hasil yang dapat diukur dan dalam
jangka tertentu selama di rumah
sakit.
Bab IV. Pasal 8
Standar Pelayanan Minimum (?????)
Definisi Operasional
SPM diusulkan denan mempertimbangkan kualitas
layanan, pemerataan dan kesetaraan layanan, biaya
serta kemudahan untuk mendapatkan layanan
Specific, Measureable, Attainable, Reliable, Timely


PAKET PELAYANAN ESENSIAL (PPE) ???


CLINICAL PATHWAY


Tahapan Clinical Pathway & Activity
Based Costing

Admission Diagnostic
Pra
Therapy
Follow Up Therapy

Activities Based Costing + Simple Distribution
Discharge
Format dasar Clinical Pathway
Aktivitas pelayanan
Pra R.I
(Poliklinik/
UGD)
Rawat Inap (R.I)
Hari I
Tgl
Hari 2
Tgl
Komplikasi
/
Co-
morbidity
1 2 3 4 5
Pendaftaran
Penetapan Diagnose
Pra-Perawatan
Perawatan
Tindak Lanjut
Bab IV. Pasal 9
Pola Tarif Layanan
Definisi Operasional
Pola Tarif Layanan adalah imbalan atas barang/jasa
layanan yang diberikan / disesuaikan dengan jenis
layanan serta ditetapkan dalam bentuk tarif yang disusun
atas dasar perhitungan biaya per unit layanan atau hasil
per investasi dana, dengan mempertimbangkan
kontinuitas dan pengembangan layanan, daya beli
masyarakat, asas keadilan dan kepatutan serta kompetisi
yang sehat


COST OF TREATMENT ( COST / DRG / CASEMIX)
DITERMINAN TARIF per TINDAKAN
TARIF
UNIT COST
ATP/WTP PESAING
e
CRR
Total cost quantity
margin
ANALISIS
BIAYA
DITERMINAN TARIF per DRGS
TARIF
UNIT COST
TINDAKAN RI
UNIT COST
TINDAKAN Obat
UNIT COST
TINDAKAN OK
UNIT COST
TINDAKAN Alkes
UNIT COST
TINDAKAN Lab
Total cost
Q
COST/DRGs
Marjin
ACTIVITY BASED COSTING + SIMPLE DISTRIBUTION
Cost of Treatment (Cost/DRG/Casemix) &
Pola Tarif PK-BLU
No Cost of Treatment / Activity Based
Costing
Pola Tarif PK-BLU
1 Admission Biaya Admission
2 Diagnostic Biaya Diagnostic
3 Pra Therapy Biaya Pra Therapy
4 Therapy Biaya Therapy
5 Follow Up Biaya Follow Up
6 Discharge Biaya Discharge
Total Biaya Total Biaya per unit
layanan
Lesson Learnt (INA-DRGs 2000-2005)
Tahun MDC Diseases DRG Casemix
2000 MDC.14 Abortion DRG.380 DRG.381
2001 MDC.01 Head Injury DRG.2
2002 MDC.18 Malaria DRG.423
2003 MDC.06 Appendicitis DRG.165
DRG.166
DRG.164
DRG.167
2004 MDC.18 Typhoid fever DRG.423
2005 MDC.14 Pregnancy DRG.O01D DRG.O01A
DRG.O01B
DRG.O01C
2005 MDC.06 Gastro Enteritis DRG.G68B DRG.G68A
Australian Refined
Diagnosis Related Group
Classification, Version 4.1
DRG ALOS COST / Public Sector CITO
kls 3
Direct Overhead Total
O01A 9,14
11
5,444
3.710.590
2,089
98.622
7,533
3.809.212
O01B 6,13
6
3,998
3.205.076
1,550
98.622
5,548
3.303.698
O01C 5,00
6
3,792
3.067259
1,373
98.622
5,166
3.165.881
O01D 4,63
5
3,327
2.721526
1,262
98.622
4,589
2.820.148
INA DRGs
Lesson Learnt (INA-DRGs 2006-2007)
Tahun MDC Diseases DRG Casemix
2006 MDC.1 Stroke DRG.B.70C DRG.B 70A
DRG.B70B
DRG.B70D
2006 MDC. HIV / AIDS DRG.
2006 MDC. DBD DRG.
2006/7 MDC. Prostat DRG.

DRG.
2006/7 MDC. Mata DRG. DRG.
Aplikasi INA-DRG dalam Cost
of Treatment Stroke ( template )
MDC 1 dan DRG B70
Terdiri dari 4 kelompok

B70A:
Stroke dengan penyerta dan penyulit
B70B:
Stroke dengan penyerta atau
penyulit
B70C:
Stroke murni
B70D:
Stroke, meninggal atau dirujuk
dibawah 4 hari

MEDICAL PARTITION
Stroke
LOS > 4 days
Or survived/
Not trasfered
Sev or
Compl
Dx or
proc
CC
B 70A
B 70B
B 70C
B 70D
No
yes
yes
yes
yes
No
No
No
patient
KK WOMEN & Children Hospital
(Spore 2006)
Adopting Australian Version
(667 codes)
Subsidy = Discount
Amount of charges (cost) to be
borne by Government
CLASS AMOUNT OF
SUBSIDY
A 0 %
B1 20 %
B2+ 50 %
B2 65 %
C 80 %

Cost of Treatment Rawat Inap dan Rawat Jalan
No AR-DRG KLS. III KLS. II KLS.I UTAMA VIP RAJAL
1 B70A 5181485 5281384 5339924 5778045 5805053 803121
2 B70B 4075179 4153671 4199667 4543904 4565126 995167
3 B70C 1905273 1976629 2018443 2331386 2350678 987047
4 B70D 1848767 1863038 1871401 1933989 1937848
Perbandingan Biaya Rawat Inap KLS.III
No AR-DRG KLS. III Tanpa Gaji Tanpa Obat Tanpa Gaji
Dan Obat
1 B70A 5181485 4250350 2972007 2040872
2 B70B 4075179 3476706 2250808 1652334
3 B70C 1905273 1489521 1438879 1023127
4 B70D 1848767 1624600 1030735 806568
APLIKASI COST/DRG/Casemix dalam PK BLU(1)


INDONESIAN DRGs


KESIMPULAN
Pengembangan perhitungan Unit Cost
per Tindakan menjadi Unit Cost per
Layanan / Kinerja ( Cost per
DRG/Casemix)

Pengembngan INA-DRG
ICD tetap
MDC untuk sementara tetap
Clinical Pathway bisa dibuat
DRG di konfirmasi + bisa dibuat
Casemix di konfirmasi + bisa dibuat
Costing dilakukan dengan pendekatan
Activity Based Costing + Simple
Distribution