Functional and Regulatory Review of Strategic Health Purchasing Under JKN POLICY NOTE July 15, 2018 Overview of Strategic Purchasing Functions Under JKN With over 70% of the country’s population having The dual challenges of JKN sustainability and ongoing coverage under Jaminan Kesehatan Nasional (JKN), under-investment in the health sector create an urgent Indonesia now has one of the largest national health need for action to realign revenues and expenditures insurance programs in the world, at least in terms of in the entire health system. How the government population coverage. However, at present only about addresses the current deficits will set the stage for 15% of total health expenditures come from JKN and the future ability to expand effective coverage under there remains significant co-financing from supply- JKN. Most countries face a similar challenge at this side budgetary expenditures at public facilities. The point in the journey to UHC, and they typically have government plans for everyone to have coverage 3 options: (1) increase revenues in the system; (2) under JKN, with universal health coverage (UHC) by cut costs by limiting coverage, such as reducing the 2019 as part of implementation of the Health Social benefits package or increasing cost sharing, or cutting Security Act. payments to providers; or (3) increase efficiency in the use of funds through strategic purchasing to reduce Despite recent increases, however, the level of public unproductive cost growth and shift resources to more financing for health remains low. The country faces cost-effective parts of the system. Some combination a tighter macro-fiscal environment on the one hand, of the three options is almost always necessary. But versus a growing demand for and utilization of health global experience shows that option 1 is limited by the care as coverage expands under JKN. Expenditures fiscal capacity of the government, and as international on JKN are increasing more rapidly than revenues, experience shows, voluntary contributions rarely and financial sustainability has emerged as a concern. contribute significantly to revenue. Relying only on Improving the efficiency of JKN expenditures is option 2 will erode coverage and reduce access and necessary for making progress towards UHC, and there financial protection. Therefore, there is an imperative is an imperative to make better use of existing funds to make better use of existing funds through strategic through strategic purchasing of JKN services. purchasing levers without eroding effective coverage, even if it is possible to increase revenue for JKN. OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN Overview of Strategic Purchasing Figure 1 Strategic Health Purchasing Relationships Stakeholders defined strategic purchasing for Indonesia as: Ability to purchase preventive, promotive, curative and rehabilitative services to improve the health of community members and get maximum results. Strategic health purchasing organizes relationships between individuals, health providers, and (typically) a third-party purchasing agency acting on behalf of covered individuals (Figure 1). Strategic purchasing involves three main sets of decisions (Figure 2): 2 1. Strategically decide what to buy: which interventions, services, and medicines • E.g. buying more primary health care vs. expensive tertiary services; specifying quality standards; buying generic instead of branded drugs 2. Strategically decide from whom to buy: which providers and suppliers of medicines/other providers). In Indonesia the institutional home for commodities health purchasing is Badan Penyelenggara Jaminan • For example, contracting only with accredited Sosial-Kesehatan (BPJS-K], but some purchasing providers or with both public and private providers functions continue to be carried out by the Ministry of 3. Strategically deciding how to buy: which payment Health (MOH). methods, payment rates, other contractual conditions • For example, introducing blended payment methods Next, strategic purchasing requires being clear and to get the right incentives or setting payment rates to deliberate about what is being purchased. A first step be in line with available resources some countries take is to specify a benefits or essential services package that the covered population is There are some foundational steps that are pre- entitled to receive at an affordable cost. Once the service conditions for strategic purchasing and that make more package is defined, the purchaser then pays health sophisticated strategic purchasing approaches possible providers specifically to deliver these services, which is in the future as systems mature (see Box 1). referred to as output-based payment. Output-based payment typically goes hand-in-hand with some form First, strategic purchasing requires an institutional of contracting to clarify the obligations of the provider home for the purchasing function, with roles and and also the purchaser. It also requires that providers responsibilities clearly defined to carry out the specific have some autonomy to make decisions to respond to functions (e.g. which institution decides the benefits incentives—they can decide to shift their staff around or that will be included in the benefits package, and other inputs. All of this requires new accountability which institution decides how to pay health care measures and better use of information. POLICY NOTE Figure 2 Strategic Health Purchasing Decisions • Defining the benefits package and expansion • Deciding which medicines to buy • Defining service delivery • Selecting providers to and quality standards contract with • Selecting medicines suppliers • Contracting with • Setting the terms of private providers contract • Selecting provider payment methods 3 • Setting provider payment rates • Monitoring provider performance BOX 1. FOUNDATIONS OF STRATEGIC HEALTH PURCHASING Strategic purchasing requires an institutional home where most purchasing functions will be carried out, although other institutions will likely be responsible for some purchasing functions. being clear and deliberate about what is being purchased, which starts with a well-defined benefits or essential services package. Once the service package is defined, the purchaser pays health providers specifically to deliver these services, which is referred to as output-based payment. Output-based payment typically goes hand-in- hand with some form of contracting to clarify the obligations of the provider and also the purchaser. It also requires that providers have some autonomy to make decisions to respond to incentives—they can decide to shift their staff around or other inputs. All of this requires new accountability measures and better use of information. OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN Institutional Structure for Strategic Health Purchasing Under JKN Effective strategic purchasing requires that the In partnership with USAID, the World Bank, Abt purchasing functions are distributed appropriately Associates and Results for Development (R4D), the across the institutions involved, and the roles and Social Security Council (Dewan Jaminan Sosial responsibilities are clear. The institutional structure, Nasional--DJSN) commissioned a functional and or which institutions are performing which health regulatory review of strategic purchasing under purchasing functions for JKN, is still transitioning JKN. The review examined existing legislation and urgently needs to be clarified. BPJS-K has and regulations that relate to strategic health responsibility to manage the single pool of funds in purchasing functions to identify: the health insurance system, but many purchasing functions continue to be housed within the a. which institutions are responsible for carrying MOH. There is little guidance from international out which purchasing functions according to the experience on best practices for the institutional regulations; arrangements to enable strategic purchasing, but b. whether there are any regulations that are in there are some lessons (Box 2). conflict with one another; c. how the functions are being carried out and whether a different allocation across institutions 4 would improve the implementation of the function. The set of laws and regulations that were reviewed is provided in Annex 1. BOX 2. GLOBAL LESSONS ON INSTITUTIONAL ROLES AND RESPONSIBILITIES FOR STRATEGIC PURCHASING A coherent institutional structure is needed with clear roles and responsibilities • It should be clear who does what even if some functions are shared • Supporting regulations should be clear Some functions should be separated and carried out by different institutions • E.g. definition of benefits and purchasing services (although purchasing levers should be used to drive service delivery objectives for services in the benefits package) Some functions should be carried out in coordination • Supply-side planning • Provider payment rate-setting • Quality assessment and monitoring POLICY NOTE Results of the Strategic Purchasing Functional and Regulatory Review The review examined the allocation of 17 purchasing functions covered by the laws and regulations of Indonesia related to JKN implementation (Figure 3). The purchasing functions were grouped and color- coded to facilitate analysis of how they are distributed across the responsible institutions: DJSN, BPJS-K, Ministry of Health (MOH), Ministry of Finance (MOF), Ministry of Social Affairs, Ministry of Home Affairs, and local governments. The pie charts are made up of equal-sized slices for each function the institution is responsible to carry out, so larger slices of one color indicate that there are multiple sub-functions. Figure 3 Strategic Health Purchasing Functions 5 Information management Governance Monitoring provider performance Accountability System-level Govern Benefits design monitoring g Accou ance a orin ntab nd onit ility M Be Decisions on Making payments adding new ne to providers services/ fit sa medicines Co nd n ent tr ac itlem Selective Enrollment and t in g a contracting entitlement ent n d p r o vid e r p Payment rate-setting Budget in g aym nc en na Revenue t Provider payment Fi selection and design collection Investment and Gate-keeping Ser v ic e fund management and referral system delivery Public health Supply side and prevention planning and investment Service delivery management Health workforce planning and management OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN Summary of the Findings The findings are summarized in Annex 2 where The main functions of DJSN relate to governance strategic purchasing functions covered by various and accountability and providing special studies and laws and regulations are mapped to the responsible research as part of monitoring the implementation institution(s). of JKN. DJSN also has responsibility for contributing to budget proposals and the investment plan of the National Social Security Fund. DISTRIBUTION OF FUNCTIONS DJSN BPJS-K DJSN has overall supervisory authority over the According to the original legislation, BPJS-K has implementation of JKN and the operations of BPJS-K responsibility for the main purchasing functions under [Law No. 24 of 2011 on the Implementing Agency of JKN, but more recent regulations make that unclear, Social Security Chapter IX Supervision Article 39], and the MOH has retained many functions that although the MOH has authority over the supervisory would be considered the responsibility of the health team for monitoring and evaluation of JKN [Decree purchasing agency. of Minister of Health No.046/Menkes/Sk/Ii/2014 6 regarding Monitoring and Evaluation Team of BPJS-K has the responsibility to enroll members National Health Insurance Implementation]. and initially assign them to a primary health care (PHC) provider for the gate-keeping function, after which members are free to choose their PHC provider Figure 4 Strategic Purchasing Functions of DJSN [Presidential Regulation No. 12 of 2013 article 29 Under JKN clauses 1 and 2]. BPJS-K is responsible for the function of selective contracting with providers according to technical criteria established by the MOH and taking into consideration access to services by the Governance: Propose System monitoring: population [Regulation of Minister of Health No. interim substitute Conducting studies and 71 of 2013 CHAPTER III]. The technical criteria members of the Boards of research realted to the Trustees and/or members implementation of social include human resources, infrastructure and of the Directorate of security facilities, scope of services available, and BPJS to the service commitment. BPJS-K does not have President the authority to specify certain terms of the Accountability: contract, such as reporting requirements, Investment: Receives copy of BPJS Propose investment policy which are specified by the MOH [Regulation annual management and audited financial reports for of National Social of Minister of Health Number 71 of 2013 Security Fund Chapter VII Reporting And Utilization submissions to the President Review Article 39]. Budget: Propose social Law No 40/2004 Article 24 states that BPJS-K is Accountability: Provide consultation to Security budget for responsible for implementing quality control the BPJS on the form and beneficiaries of contributions and cost control systems, the role of MOH is content of the program and the availability of management operational budget to the to support hospitals accreditation, and the role accountability report Government of local government is to contribute incentive payments for specialized physicians. Purchasing agencies often have the authority to select which POLICY NOTE service delivery and quality standards (e.g. standard Both Presidential Regulation Number 12 of 2013 on clinical practice guidelines) will be used for purchasing Health Care Benefits and Regulation of the Minister services, even if they do not develop them. The role of Health Number 71 of 2013 CHAPTER VI Quality and of BPJS to establish quality and service delivery Cost Control Article 38 state that BPJS-K is responsible standards, however, has not yet been operationalized. for monitoring provider performance, although the same regulations also give the MOH responsibility for Presidential Regulation Number 19 Article 43 A monitoring and quality control, so the institutional stipulates that the MOH should coordinate with BPJS-K responsibility for this function is unclear. Regulation on the technical operation of the health care system, of the Minister of Health Number 71 states that quality control, and provider payment. Presidential BPJS-K should monitor quality through a cost and Regulation Number 12 Article 37 states that payment quality control team (Tim Kendali Mutu dan Biaya, rates should be based on agreement between BPJS-K TKMKB) made up of representatives of professional and the association of health facilities “with reference organizations, academicians, and clinical experts. The to” the standard tariffs specified by the Ministry. The TKMKBs monitor compliance with quality standards of regulation is unclear, and in practice BPJS-K has had a health facilities, compliance with health care processes very limited role in provider payment policy and rate- and standards, and monitoring the health outcomes setting. of JKN participants [Regulation of the Minister of 7 Health Number 71 of 2013 CHAPTER VI Quality and Cost Control Article 38]. The TKMKB is authorized to use instruments such as utilization review and medical Figure 5 Strategic Purchasing Functions of BPJS-K audit to carry out the provider monitoring function. Under JKN The results from the utilization review are supposed to be reported to DJSN and MOH, but is it not clear who has the responsibility to act on the results and Enrollment: Accountability: Receive registration what those actions can be. BPJS-K is also responsible Provide information on of JKN... the implementation for establishing a formal communication forum of social security programs to between health facilities and local branch offices participants and the of BPJS-K [Implementation Manual of the community Contracting: National Health Insurance of BPJS-K]. Gatekeeping: Selective contracting Assigns participants with providers to PHC providers Finally, BPJS-K is responsible for collecting and managing information related to Revenue Collection: JKN participants and their health service Provider payment. Collect JKN contributions Paying benefits and / financing from participants, Employers utilization. BPJS-K maintains several data health services and Governments sources, including claims data for services paid using INA-CBGs and the P-Care database of PHC service utilization under Provider monitoring: Cost and quality Revenue Collection: Receive donations from capitation. BPJS-K has produced a number monitoring, including utilization review and the government of standalone analyses and reports, but a clinical audit Fund Management routine monitoring system with a standard set Information Management: Manage Social Security Funds for of indicators analyzed and reported regularly has Collecting and managing data of the benefits of participants not yet been put in place. JKN participants OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN MINISTRY OF HEALTH The MOH also continues to carry out some The MOH retains the majority of health system functions that are typically functions of the health functions, including most of those related to strategic purchasing agency, including: purchasing. The MOH has the mandate to protect the health of the population, set clinical standards, and • Specifying the technical criteria for health regulate the benefits package under JKN [Presidential facilities contracting with BPJS-K (credentialing) Regulation Number 12 of 2013 Chapter IV on Health [Regulation of Minister of Health Number 71 of Care Benefits]. The MOH is responsible for quality 2013 Chapter III Cooperation of Health Facilities and cost control together with BPJS-K [Regulation with BPJS Healthcare Section Two Article 9] of Minister of Health Number 71 of 2013 CHAPTER • Specifying the data reporting requirements in VI Quality and Cost Control] and is authorized to use BPJS-K contracts [Regulation of Minister of a number of instruments to carry out this function, Health Number 71 of 2013 Chapter VII Reporting including health technology assessment, establishing And Utilization Review Article 39] a clinical advisory board to resolve clinical disputes, • Developing provider payment systems and standard payment rate calculations, and monitoring setting payment rates [Regulation of Minister and evaluation of health services to ensure compliance of Health Number 69 on Health Services 8 with medical service standards specified by the Standard Rates at First Level Health Facilities Minister [Article 33]. and Advanced Level Health Facilities in Health Insurance Program Implementation] The MOH also has the authority to regulate how public Figure 6 Strategic Purchasing Functions of the MOH primary health care facilities (puskesmas) use the Under JKN funds they receive from BPJS-K for capitation payment [Regulations of Minister of Health Number 19 of 2014 Governance: Coordinate with the Health BPJS to develop the technical operation and 21 of 2016]. These regulations specify the role of of the health care system and quality control system the District Health Office in implementing JKN, and in Monitoring: Budget: Budget proposal of PBIJK particular guidelines on the utilization of capitation monitoring and evaluation Governance: of the performance of Impose written warning to the Ministry funds and the proportion of the capitation health insurance services sanctions on the members of Finance in coordination with DSJN of the Boards or the based on the DJSN payment to providers that can be allocated Directors of BPJS and provide advice to proposal Enrollment: Register the numbers of PBI for operational costs and staff incentives, the President Provider payment selection and design. participants in BPJS Health procurement of drugs, medical equipment, Coordinate with the Health BPJS Governance: to develop provider payment systems Regulate fraud and consumables. prevention Benefits Design: Provider payment selection and design. in JKN Manage the types of health Review provider payment systems at least every services guaranteed by JKN 2 with BPJS-K, DJSN and the Ministry of Finance Benefits Design: Regulate the JKN compensation that should be provided MINISTRY OF FINANCE Payment rate-setting: Tariff calculation to the participant of BPJS Health The Ministry of Finance has the main Payment rate-setting: Specify the cost of health services Benefits Design: Specify the list of responsibility for oversight of transfer of medicines, medical equipment, and in the event of preventable adverse events medical consumable materials contributions from the various funding Contracting: Benefits Design: sources for JKN, including the national Payment rate-setting: Define reporting Add guaranteed Organize the types and requirement of health services budget, local budgets, and employers. the platform of health health providers in based on health equipment prices contracts with BPJS technology The Ministry of Finance also provides assessment in Contracting: coordination with management and oversight for the asset and the Ministry Develop technical criteria for contracting with of Finance fund management for BPJS-K. providers in BPJS POLICY NOTE Figure 7 Strategic Purchasing Functions of the MOF Under JKN Governance: Regulate the Investment and continuation of the dues fund management: LOCAL GOVERNMENTS Specify the standard of of employer for the local government from the state The local government has full responsibility asset fund of BPJS treasurey account for health service delivery and investment to the BPJS decisions on the supply side, as well as public health and prevention activities Governance: [Law Number 23 year 2014 concerning local Investment and Govern the provision, government]. There is some lack of clarity fund management: disbursement, and Determine the percentage accountability of health on setting provider payment rates, where of operational fund insurance dues from the local government has some authority, as for BPJS the State Budget (APBN) well as the rules for how providers can use Governance: JKN funds [Regulation of Minister of Health Regulate the Number 19 of 2014 and 21 of 2016]. depositing of health Investment and insurance contribution fund management: from civil servant, and the Provide start-up capital individual all together with to the BPJS the Ministry of Home OTHER MINISTRIES Affairs based on their The Ministry of Social Affairs plays a authority governance role related to data on population 9 covered by PBI, and the Ministry of Home Affairs is responsible for governing the health insurance contributions from local Figure 8 Strategic Purchasing Functions of Local governments for civil servants and ensuring Government Under JKN that local governments are adequately implementing JKN as a strategic program. Establish Improve the quality of a community health workers through complaint Managing education and/or training unit on the the health sector accuracy include: health services of PBI human resources; pharmaceutical provision, Organize, utilize medical equipment, and recruit of food and beverage; health workers the empowerment of community in health. From the first level of health facilities, secondly and the thirdly Performing the together with the government national strategic and private sectors Providing a fund source programs for health financing a minimum of 10% of the Regional State budget (APBD), salary is excluded. Execute permissions, determine the number and types of health facilities in the regions. Implementing health management Plan the needs of medical supplies based on the national standard Guarantee and Prevention, control, eradication, provide health facilities designation, surveillance of for the sustainability of infectiouse disease; specifies health improvement and the type of diseases that prophylaxis (disease prevention) require quarantine Equalization of health Perform a guidance facilities for mental health and supervision toward the implementation of the treatment Improve the individual and/or care nutrition and its mental health OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN Key Areas of Contradiction, Mismatch or Gaps in the Regulations OVERALL RESPONSIBILITY FOR HEALTH the fund to ensure access to high-quality services for PURCHASING UNDER JKN the covered population. The main finding of the review is that there is lack of clarity in the legislation and regulations supporting the implementation of JKN related ACCOUNTABILITY to the overall responsibility for strategic Overall the review found that although accountability purchasing. Although the original 2004 social security for the implementation of JKN is mentioned law allocated most of the key purchasing functions throughout the regulations, and it is one of the core (provider payment methods, tariff-setting, and quality principles of the social security law [Law no. 40 of monitoring) to BPJS, a series of regulations brought 2004 article 4], there are few mechanisms to ensure these functions back at least partially back under the accountability. Aside from some oversight functions control of the Ministry of Health. of several ministries and other bodies, it is not clear which institutions are held accountable for which The original social security law of 2004 [Law no. 40 outcomes of JKN implementation. BPJS-K has no Article 44 the National Social Security System] states specific accountability for access to and quality of that “The Social Security Administering Body shall services it purchases, or for obtaining value for money 10 develop a health service system, a service quality with JKN funds. The regulations states that BPJS-K has control system, and health service payment system the responsibility to manage JKN funds “for the benefit to improve the effectiveness and efficiency of health of participants” but it is not clear how that is defined insurance.” A 2013 regulation [Presidential regulation or measured. And although BPJS-K is responsible no 111 of 2013], however, states that the BPJS-K for the prudent management of funds, the agency should coordinate with MOH to develop the technical does not have levers to manage claims liabilities, or operation of the health service system, quality control drive service delivery and quality improvements. A system, and health care payment system to improve further concern is that it remains unclear whether the the efficiency and effectiveness of the JKN. BPJS as a responsible institutions have adequate capacity to legal entity reports directly to the President, but its ensure accountability. position relative to the MOH (at the same level or under it) has not yet been defined. This lack of clarity In addition, according to the regulations reviewed, and contradiction has prevented BPJS-K from taking on there is no specific role for local governments in the the overall function of health purchasing under JKN. governance and accountability of JKN implementation. The Ministry of Home Affairs has the authority to The current functional roles of BPJS-K are primarily warn local governments if they are not adequately those of a financial institution rather than a implementing JKN as a national strategy, but health institution, so BPJS-K is serving as a passive adequate implementation is not clearly defined and no intermediary to transfer payments to health providers consequences for non-compliance are specified. Local and carry out some other largely administrative governments are accountable to the public for JKN only functions, rather than as a strategic purchaser. Most of so far as they are obligated to establish a community the functions that make it possible to create incentives complaint unit on the accuracy of PBI targeting. for more effective service delivery, efficient provider behavior, higher quality of care continue to be housed within the MOH. BPJS- K is responsible for managing SUPPLY SIDE READINESS the social security fund for health for the benefit of The supply-side readiness function is almost entirely its members, but it has few effective levers to manage the responsibility of local governments in Indonesia. that fund, either to manage costs effectively or to use The regulations on the role of local government POLICY NOTE create a conflicting incentives and priorities for little incentive to improve data quality. There does not ensuring the effective implementation of JKN within seem to be an organized platform for dialogue at the limited resources. There is a highly variable service local level between local governments, district/city delivery structure with uneven capacity because health offices, and local BPJS-K branches to harmonize of different priorities across local governments, and planning of health infrastructure and implementation sometimes a mismatch between investment and of JKN. the service delivery needs of the population, which has implications for both cost and effectiveness of JKN implementation. The extent of decentralization SUPPLY-SIDE READINESS IN RURAL AND in Indonesia means that local governments are REMOTE AREAS not obligated to harmonize their policies, such The geographical conditions in several Indonesian as investment decisions and health provider regions are less advantageous to implement JKN and remuneration policies, with national policies such as this impedes the JKN participants to enjoy the JKN those related to health purchasing. benefits and they should have been. Limited fiscal capacity in some regions has limited the infrastructure, Based on stakeholder interviews, there is indication of supply of health personnel, and availability of health local governments (1) redirecting local budget funds facilities adequately equipped to provide health to pay JKN premiums as they integrate Jamkesda services as needed by the local population. Regional into JKN; (2) reducing budgets for PHC in response governments in these areas are often not able to provide to JKN capitation revenue at the facility level; (3) sufficient incentives to attract the specialists to work in over-investing in hospitals; and (4) not effectively these places. As a result of difficult access/transportation pursuing private sector investment or public-private to the health facilities due to poor geographical partnerships to fill capacity gaps. Furthermore, the conditions and transportation, the populations of these investment decisions of the local governments have areas are not able to make use of JKN services, although 11 financial implications for BPJS-K, which bears a they are equally entitled to services. growing responsibility for funding recurrent costs, and curative services that are covered by JKN and paid per Geographic challenges also increase the distribution service may be crowding out public health services, costs of drugs purchased through e-catalog to the which are still the responsibility of local governments. district capital cities. Regional governments have Local governments have wide authority to make limited budget to absorb the costs of distributing drugs decisions that increase financial risk for the national to the regional puskesmas. Often the drugs needed are JKN, especially supply-side investment decisions and not available in e-catalog and the procurement outside funding for public health, which when neglected can of e-catalog is more expensive. As a result, certain drugs shift additional curative care costs to JKN. The MOH are not available at all in some of these areas. has tried to address this through the Healthy Indonesia Program as a priority program to strengthen promotive One of the funding sources that could be better and preventative activities at primary care level leveraged is the compensation funds as regulated since BPJS-K spending on non-communicable disease under Article 23 paragraph 3 of Law No. 40 of 2004 on management (NCDs) has been inadequate and referrals SJSN that reads as follows: “Compensation funds could have increased significantly. Local governments will be an alternative for source of health expenditure in be accountable for maintaining minimum service some rural and remote areas with low fiscal capability.” standards for NCD management. There are possible The policy on the use of compensation fund has financial levers through the central-level transfers to not been further regulated in the lower regulations, sub-national governments that could be used to create however, thus making it difficult to implement. some accountability for the implementation of JKN. On the other side, local governments and BPJS-K CONTRACTING AND PROVIDER district/city health offices do not have access to BPJS-K PAYMENT POLICY claims and utilization data, which are sent directly to The divisions in responsibility between the MOH and the national level. This deprives local governments of BPJS-K on contracting providers under JKN weakens useful data to make investment decisions and leaves the power of contracting as a strategic purchasing OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN mechanism. BPJS-K cannot specify the criteria for addition, some regions consider capitation income selective contracting or specify the provisions of as regional income and utilized according to local the contract, such as reporting requirements, or government policy. Puskesmas are increasingly given enforcing the contracts and imposing consequences discretion to manage their own financial affairs, and a for violations. So there is very little leverage over the number of the facilities have been converted to BLUD efficiency and quality of service delivery by providers. Puskesmas, which allows them to manage their own finances. Even in autonomous Puskesmas, however, The regulations are also unclear about how the function the complicated rules on the allocation of capitation of provider payment policy and rate-setting are shared revenue have led to low absorption in some cases, with between the MOH and BPJS-K, giving the authority the revenue taken back by the government treasury to the MOH to develop the payment systems, but if it remains unspent at the end of the year. These stipulating that it should be carried out in coordination financial rules greatly diminish the potential of the with BPJS-K. BPJS-K has the authority to negotiate capitation payment system to encourage efficient use payment rates with provider associations with reference of resources and better service delivery. to MOH standard tariffs. In practice, the MOH retains authority for the function of provider payment policy MONITORING AND QUALITY ASSURANCE and rate-setting, while BPJS-K is responsible for paying The review showed a duplication in the responsibility provider claims. BPJS-K has the responsibility to for provider monitoring and quality assurance, with selectively contract providers, with criteria for provider ultimate authority over the function residing with selection defined by the MOH. While this division the MOH but the data required for adequate provider of functional responsibility may be appropriate for monitoring under the control of BPJS-K. Article 43 of Indonesia, stakeholders suggest the need to examine Presidential Regulation Number 12 states that the and clarify responsibilities for purchasing functions MOH has the responsibility for “the monitoring and 12 across BPJS-K and the MOH. For example, the MOH evaluation of health care benefit services,” and Article PPJK, together with BPJS-K calculates the costs of 44 states ”further regulation on implementation and services in the INA-CBG and sets the hospital tariffs. enhancement of services quality control system as Since most of the public hospitals, in particular type A referred in Article 42 and guarantee of quality control and some type B, are owned by central MOH, there is and cost as referred in Article 43 shall be under Minister concern that the MOH may have conflicting interests in Regulation.” So there is some confusion over the the price-setting. International experience also suggests responsibility for the quality monitoring and control that purchasing agencies typically have a strong role in, function. It is also unclear whether BPJS-K has the or complete responsibility for, provider payment policy authority to act on the findings of the cost and quality and rated-setting. control teams, such as from the utilization reviews, and what actions they would be authorized to take. This lack of clarity and mismatch has weakened the provider PROVIDER AUTONOMY monitoring function overall. In addition, BPJS-K The level of provider autonomy over financial, maintains several data sources, including claims data personnel, service delivery and other decisions and P-Care database, but a routine monitoring system affects providers’ ability to respond to incentives by with a standard set of indicators analyzed and reported changing the mix of inputs and services they deliver. regularly has not yet been put in place. The more areas over which providers have decision rights, the more flexibility they have to respond to the incentives of purchasing and provider payment policies and the more powerful the incentives will be. Although primary health care providers puskesmas receive capitation payment from BPJS-K, the MOH has authority to determine how those funds can be used and how providers can allocate funds between staff payments and other operational costs. A provider that receives funds from multiple revenue streams must allocate and account for them separately. In POLICY NOTE Options for Improvement of the Institutional Structure for Strategic Purchasing Under JKN In order to strengthen strategic health purchasing discuss the options for strengthening, redistributing, or under the JKN, the government needs to decide how better coordinating these functions, the opportunity purchasing functions can be more effectively allocated may be explored to establish better platforms for between BPJS-K and the MOH. As it is now, BPJS-K is dialogue, analysis, and joint decision-making. There in the role of a passive intermediary. To strengthen the is also a general need to strengthen the capacity of role of strategic health purchasing, and of BPJS-K to play all institutions to carry out their functions, and clear that role, there is a need to strengthen some functions leadership to manage the shift and strengthening of the (e.g. accountability), possibly reallocate others (shifting health purchasing functions under JKN and continue responsibility for setting service delivery standards, to monitor and evaluate these changes, and overall contracting, provider payment policy and rate- program performance. While from the regulatory review setting at least partially to BPJS-K), and creating better it would appear that this leadership and oversight cooperation and shared responsibility for others (e.g. role would be the responsibility of DJSN, the power supply side planning and provider performance and capacity to carry out this role would need to be and quality monitoring). While stakeholders strengthened. KEY ISSUES TO ADDRESS IN THE INSTITUTIONAL STRUCTURE 13 FOR STRATEGIC HEALTH PURCHASING UNDER JKN Purchasing Related Regulations Options for Improvement Function Accountability Law no. 40 on the National • Strengthen accountability through improved governance system of JKN with Social Security System clear definition of which institutions are responsible for which outcomes of JKN implementation. Law No. 24 of 2011 Chapter • Clarify the mandate and accountability of BPJS-K as both a health and a VIII Accountability Article 37 finance institution, increasing accountability for access to service by JKN participants, effective and efficient service delivery, quality of care, and cost management. • Establish a routine monitoring system based on a jointly used database of BPJS-K claims data, other MOH service utilization data, and other key indicators and data sources. • Establish a link between central-level financial transfers to sub-national governments and accountability for JKN implementation. What to purchase Service delivery Law No 40/2004 President Gradually shift authority to BPJS-K to select which service delivery and quality standards Regulation number19/2016 standards (e.g. standard clinical practice guidelines set by MOH) will be used for article 43 A purchasing services, even if the agency does not develop them. From whom to purchase Supply-side readiness Law Number 23 year 2014 • Establish regional-level joint service delivery planning team including concerning local government representation of local governments, District Health Offices, professional associations (public and private), and local branches of BPJS-K to discuss Regulation of Minister of service delivery investment needs to meet service delivery standards but in Health No. 71 of 2013 consideration of the budget impact on BPJS. • Increase regional commitment to allocate funds used to build adequate health facilities, particularly in rural and remote areas. • Improve regulations to allow compensation funds as an alternative for source of health expenditure in some rural and remote areas with low fiscal capability. • Increase partnerships with the private sector, particularly for rural and remote areas, with the payer for the health care, BPJS-K, as the guarantor. OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN Purchasing Related Regulations Options for Improvement Function Selective contracting Regulation of Minister of • Increase the role of BPJS-K in the contracting function by giving greater Health Number 69 on Health authority to establish provider selection criteria, establish the terms of Services Standard Rates At contracts, negotiate contracts with providers, and monitor and enforce First Level Health Facilities contracts. and Advanced Level Health • Implement the BPJS-K credentialing process in a participatory way with Facilities in Health Insurance DHOs, local governments, professional associations (public and private), Program Implementation and other stakeholders to jointly carry out mapping in the regions, analyze population growth, and project future PHC supply needs for JKN. • Create more opportunity for private FKTPs to contract with BPJS-K: • Specify the role of private providers in JKN/BPJS-K regulations • Engage private professional associations in credentialing How to purchase Contracting and Regulation of Minister of • Increase the role of BPJS-K in the selection and development of provider provider payment Health Number 69 on Health payment systems, and provider rate-setting. policy Services Standard Rates At • Explore options to better harmonize between capitation payment for PHC First Level Health Facilities and INA-CBG payment for secondary and tertiary services. and Advanced Level Health • Provide fair contracting conditions for private providers, including tariff Facilities in Health Insurance adjustments and access to government medicines prices. Program Implementation • Consider establishing an independent provider payment policy analysis unit to gather cost information, conduct analysis to inform provider payment system design and parameter development, and budget impact analysis (possibly built from the MOH Case Mix Unit) Capitation 14 • The capitation rate-setting should be more explicitly linked to the package of services and, include adjustments for geography and other factors related to health need. • The capitation payment system should be refined to include regulations on the upper and lower limits of ratios of registered participants to physicians in a FKTP. • The pay-for-performance component should be evaluated and revised to ensure that incentives are aligned with service delivery objectives and rural and remote FKTPs are not disadvantaged. INA-CBGs • The INA-CBG payment system should be refined to improve alignment between case groups and relative costs. • The hospital costing system should be evaluated and possibly refined • Consider transitioning the INA-CBG payment system to a budget-neutral payment system (either volume caps or adjustable base rate). POLICY NOTE Purchasing Related Regulations Options for Improvement Function Provider autonomy Regulation of Minister Test a capitation waiver that allows puskesmas meeting certain criteria to of Health Number 19 of pool revenues from multiple sources (capitation, BOK, local funds, etc.) with 2014 regarding the Use increased autonomy for management and allocation of funds. of Capitation Fund of the • Set up a district-level platform for communication and monitoring among 4 National Health Security entities: DHO, BPJS, puskesmas providers, and local government For Health Care Service And • Monitor effects on service delivery Operational Cost Support on Regional Government-Owned First-Level Health Facilities MOH regulation no 21/2016 Provider performance Regulation of Minister of • Establish an integrated health information system that can be used by monitoring Health Number 71 of 2013 multiple stakeholders for multiple purposes. CHAPTER VI Quality and Cost • Improve the P-Care data system to that it can be used effectively by Control Articles 33, 37 and 38 all stakeholders, especially FKTPs, for planning, management, and performance monitoring and improvement and link it to the BPJS-K Regulation of Minister of claims database. Health Number 71 of 2013 • Establish a routine monitoring system within BPJS-K that analyzes and Chapter VII Reporting And reports on a set of standard indicators related to service delivery and other Utilization Review Article 39 key JKN outcomes. • Build on the BPJS-K cost and quality control team to build Joint provider monitoring and quality assurance commissions at the district level, including representation of the local branch of BPJS, DHO, and local government. • Establish the authority of BPJS-K to act on results of the cost and quality control teams utilization reviews, etc. and possible link to financial or other incentives. • Establish a routine reporting system for BPJS-K to report routine monitoring and evaluation results to MOH and DJSN on a regular basis 15 OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN Annex 1. Health Sector Laws and Regulations in Indonesia Related to Health Purchasing NO TOPIC LEGISLATION THE EXECUTIVE AGENCY (BPJS HEALTHCARE) 2 Selection of To determine PPK Health Care Presidential Regulation No. 12 of 2013 article 29 clause 1 Providers (PPK) by Initially BPJS-K will register each Participant to one first level Healthcare Facility which will be appointed by BPJS-K based • participants on the recommendation from Health Department at regency/city level. Presidential Regulation No. 12 of 2013 article 29 clause 2 • After the first 3 (three) months, Participant has the rights to select their own first level Healthcare Facility. 2.A Policies related to Presidential Regulation No. 12 of 2013 article 21 clause 4-7 Gender Issues 4. Family planning as referred in clause (1) letter c consists of: counseling, basic contraception, vasectomy and tubectomy working with family planning institution. 5. Vaccine for basic immunization and basic contraception materials as referred in clause (3) and clause (4) are provided by Government and/or Regional Government 6. Health screening services as referred in clause (1) letter d is provided to selective individual to detect disease risk and further impact of certain diseases. 7. Regulation on procedure of health screening, type of diseases and schedule of health screening services as referred in clause (6) shall be regulated on Minister Regulation 3 Selection of • Presidential Regulation No. 12 of 2013 article 20 – article 26 of Chapter IV Health Care Benefits of (essentially, Benefit package by comprehensive benefits unless there are some that are not excluded *) participants • And article 27 - article 28 of Chapter VI Benefit Coordination (essentially, Participants of Healthcare Benefit can enroll in additional healthcare insurance) 4 Mechanisms Law no. 40 of 2004 article 4 the National Social Security System is administered on the principles of: to ensure the • mutual assistance; 16 accountability of • not-for-profit; executive agency • transparency; to participants • prudence; • accountability; • portability; • mandatory participation; • trust fund; • return on management of the Social Security Fund to be used entirely for developing programs in the best interests of participants Elucidation of Article 4 of the Law of the Republic of Indonesia Number 40 Year 2004 on the National Social Security System and Elucidation of Article 4 Letter E of the Law of the Republic of Indonesia Number 24 Year 2011 on Implementing Agency Of Social Security, that: The principle of accountability in this provision is the principle of accurate and accountable program implementation and financial management. 5 Types of PPK • PPK qualified to work with the BPJS-K in Regulation of Minister of Health No. 71 of 2013 CHAPTER III contracted • Cooperation of Health Facilities With BPJS-K article 5 1. To be able cooperate with BPJS-K, Health Facilities referred to in Article 2 shall comply with the requirements. (This requirement is described in article 6 - article 8) 2. In addition to provisions must comply with the requirements referred to in clause (1), BPJS-K in cooperation with Health Facilities should also consider the adequacy of the number of health facilities and the number of participants to be served. 6 Mechanism for • Could you tell us about the mechanism of the selection of health care providers. selecting PPK • Regulation of Minister of Health No. 71 of 2013 CHAPTER III • Cooperation of Health Facilities With BPJS-K Article 5 1. To be able cooperate with BPJS-K, Health Facilities referred to in Article 2 shall comply with the requirements. (This requirement is described in article 6-article 8) 2. In addition to provisions must comply with the requirements referred to in clause (1), BPJS-K in cooperation with Health Facilities shall also consider the adequacy of the number of health facilities and the number of participants to be served. Article 9 1. In determining the choice of Health Facilities, BPJS-K shall perform selection and credentialing using technical criteria that include: human resources; a. infrastructure and facilities; b. scope of services; and c. service commitment. 2. Technical criteria referred to in clause (1) shall be used to determine the cooperation with BPJS-K, the type and extent of service, capitation, and the number of participants that can be served. 3. BPJS-K in establishing technical criteria referred to in clause (1) shall be based on the Regulation of the Minister. POLICY NOTE NO TOPIC LEGISLATION 7 Agreement with • Credentialing is explained in the Regulation of Minister of Health Number 71 of 2013 Chapter III Cooperation of Health the provider Facilities With BPJS-K Section Two Article 9 regarding • Payment Method is explained in the Regulation of Minister of Health Number 69 on Health Services Standard Rates At First Level Health Facilities and Advanced Level Health Facilities in Health Insurance Program Implementation a. Registration / • The benefit package provided is explained in the Presidential Regulation Number 12 of 2013 Chapter IV on Health Care credentialing Benefits article 20-24, article 25 regarding the services that are excluded. Article 26 concerns the assessment of service and specifications. accreditation • Supervision of health care quality: Regulation of Minister of Health Number 71 of 2013 CHAPTER VI QUALITY CONTROL b. Payment AND COST CONTROL method and Article 33 service leveling 1. In order to ensure quality and cost control, the Minister is authorized to: c. Benefit package a. health technology assessment; provided b. clinical advisory; d. Monitoring c. standard rate calculation; and evaluation d. monitoring and evaluation of healthcare services implementation. of health care 2. Monitoring and evaluation referred to in clause (1) letter d is in order that health professionals who provide health care quality at first-level health facilities and advanced-level referral health facilities have complied with authority and medical e. Monitoring and services standard specified by the Minister. evaluation of Article 37 health care costs Implementation of quality and cost control by Health Facilities as referred to in Article 36 shall be performed through: f. Reports / a. organization of health professionals’ authority in performing professional practice according to the competence; Information to b. utilization review and medical audit; be submitted by c. development of professional ethics and discipline to health professionals; and / or the provider d. monitoring and evaluation of the use of drugs, Medical Devices, and medical consumables in health care are carried out periodically through the utilization of health information system. Article 38 1. Implementation of quality control and cost control by BPJS-K referred to in Article 36 is performed through: a. compliance with quality standard of health facilities; b. compliance with healthcare process standard; and c. monitoring of the outcomes of participants’ health. 2. In respect of the implementation of quality control and cost control as referred to in clause (1), BPJS-K establishes a team of quality control and cost control consisting of elements of professional organizations, academician, and clinical experts. 3. The team of quality control and cost control as referred to in clause (2) can perform: a. socialization of the authority of health professionals in performing professional practice in accordance with the 17 competence; b. utilization review and medical audit; and/or c. development of professional ethics and discipline to health professionals. 4. In certain cases, a team of quality control and cost control as referred to in clause (2) may request information on the identity, diagnosis, medical history, examination history and treatment history of the Participant in the form of photocopy of the medical records to the health facilities as needed. a. Monitoring and evaluation of health services cost (Fraud): There is no regulation b. Report: Regulation of Minister of Health Number 71 of 2013 Chapter VII Reporting And Utilization Review Article 39 1. Health facilities shall make a monthly report of health care activities submitted on a regular basis to BPJS HealthcareBPJS-K. 2. BPJS HealthcareBPJS-K shall implement Utilization Review on a regular and sustainable basis and provide feedback of the Utilization Review results to Health Facilities. 3. BPJS HealthcareBPJS-K shall report the results of Utilization Review to the Minister and DJSN. 4. Provisions concerning the reporting mechanism and Utilization Review as described in clause (2) and clause (3) shall be determined by Regulations concerning BPJS HealthcareBPJS-K. 8 Financial flows of • Regulation of Minister of Health No. 69 of 2013 regarding Health Care Standard Rates On First-Level Health Facilities And Executive Agency, Advanced-Level Health Facilities in the Implementation of Health Insurance Program PPK and the • Regulation of Minister of Health Number 19 of 2014 regarding the Use of Capitation Fund of the National Health Security related parties For Health Care Service And Operational Cost Support on Regional Government-Owned First-Level Health Facilities 9 Communication Law No. 24 of 2011 Part Fourth Entitlement Article 12 the executive During implementing its authority as set forth in Article 11, the BPJS-K shall be entitled to: agency with 1. obtain operational fund for the implementation of the Social Security program of which originates from Social Security the central Fund and/ or other sources in accordance with the provision of law and regulation; and government 2. obtain the monitoring and evaluation result on the implementation of Social Security program every 6 (six) months. OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN NO TOPIC LEGISLATION 10 Regulation on • Benefit package: Presidential Regulation Number 12 of 2013 Chapter V regarding Healthcare Benefits article 20 - article 26 benefit package, • Rate of Claims: Regulation of Minister of Health Number 69 of 2013 Rate of claims and • Operational budget of the executive agency: Law No. 24 of 2011 Part Fourth Operational Cost operational budget Article 44 of the executive 1. Operational cost of the BPJS consists of personnel cost and non-personnel cost. agency 2. Personnel as set forth in section (1) above consist of Supervisory Board, Directors, and employees. 3. Personnel cost includes Salary or Wage and other additional Benefits. 4. Supervisory Board, Directors, and employees receive Salary or Wage and other additional Benefit of which is in accordance with the authority and/ or responsibility in implementing the tasks in the BPJS. 5. Salary or Wage and other additional Benefits as set forth in section (4) with due regard to the applicable level of fairness. 6. Supervisory Board, Directors, and employees could receive incentive in accordance with the performance of the BPJS of which is paid from the result of its expansion. 7. Provision regarding on the Salary or Wage and other additional Benefit as well the incentive for the employees shall be established by the Directors. 8. Provision regarding on the Salary or Wage and other additional Benefit as well the incentive for the Supervisory Board and Directors shall be established by the President. Article 45 1. Operational fund as set forth in Article 41 section (1) point d shall be determined based on percentage of the received Dues and/ or from the result of expansion fund. 2. Further provision regarding on the percentage of the expansion fund as set forth in section (1) shall be regulated in the Government Regulation. 11 Mechanism to pay Law No. 40 of 2004, Law No. 24 of 2011 attention to the priority of National Health 12 Government • Supervision towards BPJS : Law No. 24 of 2011 on the Implementing Agency of Social Security Chapter IX Supervision supervises Article 39 executive agency 1. Supervision towards BPJS shall be conducted both externally and internally. 2. The internal supervision of BPJS shall be conducted by the supervisory organ of BPJS of which consists of: a. Supervisory Board; and b. Internal supervisory unit. 3. The external supervision of BPJS shall be conducted by: a. DJSN; and 18 b. independent supervisory institution (in the explanation of law, it is mentioned that The independent supervisory institution shall be the Financial Service Authority. In certain condition in accordance with its authority, Audit Board of the Republic of Indonesia could conduct examination.) • The Corruption Eradication Commission (KPK) • Monitoring and Evaluation Team of the National Health Insurance (JKN) : Decree of Minister of Health No.046/Menkes/Sk/ Ii/2014 regarding Monitoring and Evaluation Team of National Health Insurance Implementation in 2014 GOVERNMENT 13 Government Law No. 24 of 2011 Part Fourth Entitlement Article 12 communicates During implementing its authority as set forth in Article 11, the BPJS shall be entitled to: with the executing 1. obtain operational fund for the implementation of the Social Security program of which originates from Social Security agency Fund and/ or other sources in accordance with the provision of law and regulation; and 2. obtain the monitoring and evaluation result on the implementation of Social Security program every 6 (six) months. 14 Rules regarding • Presidential Regulation No. 12 of 2013 article 20 – article 26 of Chapter IV Health Care Benefits of (essentially, benefit package comprehensive benefits unless there are some that are excluded *) Health care is not guaranteed: a. Health services are performed without going through the procedures as stipulated in the regulations; b. Health services in health facilities which do not cooperate with BPJS-K, except for emergency cases; c. Health services has been guaranteed by the program of work injury insurance against illness or injury due to accidents or employment relationship; d. Health services carried out abroad; e. Health care for aesthetic purposes; f. Services to overcome infertility; g. Leveling services of teeth (orthodontic); h. Health disorders / diseases caused by drug addiction and / or alcohol; i. Health problems caused by accidentally hurt themselves, or due hobbies endanger yourself; j. Complementary medicine, alternative and traditional, including acupuncture, shin she, chiropractic, which has not been declared effective by health technology assessment (health technology assessment); k. Treatment and medical actions categorized as an experiment (experimental); l. Contraceptives, cosmetics, baby food and milk; m. Household health supplies; n. Catastrophic health care in emergency relief, extraordinary events / outbreaks; and Cost of other services that are not related to health insurance benefits provided. • And article 27 - article 28 of Chapter VI Benefit Coordination (essentially, Participants of Healthcare Benefit can enroll in additional healthcare insurance) POLICY NOTE NO TOPIC LEGISLATION 15 Supervision and Law No. 24 of 2011 CHAPTER VIII ACCOUNTABILITY evaluation of the executive agency Article 37 1. BPJS shall be obliged to deliver accountability on the implementation of the tasks in the form of program management report and financial report of which have been audited by the public accountant to the President with carbon copy delivered to DJSN at no more than 30th June of the next year. 2. The period of program management report and financial report as set forth in section (1) above starting from 1st January up to 31st December. 3. Format and content of the program management report as set forth in section (1) above shall be proposed by the BPJS after consulting the DJSN. 4. Financial report of BPJS as set forth in section (1) above shall be prepared and presented in accordance with the applicable financial accounting standard. 5. The program management report and financial report as set forth in section (1) shall be published in the form of exclusive summary through electronic mass media and at least 2 (two) printing media of which have circulation nationally, no more than 31st July of the next year. 6. Format and content of the publication as set forth in section (5) shall be determined by the Directors upon approval of the Supervisory Board. 7. Provisions regarding on the format and content program management report as set forth in section (3) shall be regulated by the Regulation of the President. 16 Mechanisms • Law no. 40 of 2004 article 4 the National Social Security System is administered on the principles of: to ensure a. mutual assistance; accountability of b. not-for-profit; executing agency c. transparency; d. prudence; e. accountability; f. portability; g. mandatory participation; h. trust fund; and i. return on management of the Social Security Fund to be used entirely for developing programs in the best interests of participants • Elucidation of Article 4 of the Law of the Republic of Indonesia Number 40 Year 2004 on the National Social Security System and Elucidation of Article 4 Letter E of the Law of the Republic of Indonesia Number 24 Year 2011 on Implementing Agency Of Social Security, that: The principle of accountability in this provision is the principle of accurate and accountable program implementation and financial management. 19 17 Government • Yes, from conribution of PBI and the initial Fund of Rp 2 Trillion funding for • Law No. 24 of 2011 Part Fourth Entitlement Article 12 Executive Agency • During implementing its authority as set forth in Article 11, the BPJS shall be entitled to: to perform a. obtain operational fund for the implementation of the Social Security program of which originates from Social Security functions in health Fund and/ or other sources in accordance with the provision of law and regulation insurance 18 Government • Supervision towards BPJS: Law No. 24 of 2011 on the Implementing Agency of Social Security Chapter IX Supervision supervises Article 39 Executive Agency 1) Supervision towards BPJS shall be conducted both externally and internally. 2) The internal supervision of BPJS shall be conducted by the supervisory organ of BPJS of which consists of: a. Supervisory Board; and b. Internal supervisory unit. 3) The external supervision of BPJS shall be conducted by: a. DJSN; and b. independent supervisory institution (in the explanation of law, it is mentioned that The independent supervisory institution shall be the Financial Service Authority. In certain condition in accordance with its authority, Audit Board of the Republic of Indonesia could conduct examination.) • The Corruption Eradication Commission (KPK) : - • Monitoring and Evaluation Team of the National Health Insurance (JKN) : Decree of Minister of Health No.046/Menkes/Sk/ II/2014 regarding Monitoring and Evaluation Team of National Health Insurance Implementation in 2014 PROVIDER (PHC AND HOSPITAL) 19 How and how Communication Forum between Health Facilities is established by each Branch Office of BPJS-K in accordance with the often Provider working area by appointing Person in charge (PIC) from each of the Health Facilities. Task of PIC health facilities is to provide communicate information needed for referral services (in the Implementation Manual of the National Health Insurance of BPJS-K) with the Executive Agency OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN NO TOPIC LEGISLATION 20 Agreement with • Credentialing is explained in the Regulation of Minister of Health Number 71 of 2013 Chapter III Cooperation of Health the Executive Facilities With BPJS-K Section Two Article 9 Agency regarding: • Payment Method is explained in the Regulation of Minister of Health Number 69 on Health Services Standard Rates At a. Registration / First Level Health Facilities and Advanced Level Health Facilities in Health Insurance Program Implementation credentialing and • The benefit package provided is explained in the Presidential Regulation Number 12 of 2013 Chapter IV on Health Care accreditation Benefits article 20-24, article 25 regarding the services that are excluded. Article 26 concerns the assessment of service b. Payment specifications. method and • Supervision of health care quality: Regulation of Minister of Health Number 71 of 2013 CHAPTER VI QUALITY CONTROL service leveling AND COST CONTROL c. Benefit package provided Article 33 d. Monitoring 3. In order to ensure quality and cost control, the Minister is authorized to: and evaluation of a. health technology assessment; health care quality b. clinical advisory; e. Monitoring c. tandard rate calculation; and evaluation of d. monitoring and evaluation of healthcare services implementation. health care costs 4. Monitoring and evaluation referred to in clause (1) letter d is in order that health professionals who provide health care f. Reports / at first-level health facilities and advanced-level referral health facilities have complied with authority and medical Information to be services standard specified by the Minister. submitted by the provider Article 37 Implementation of quality and cost control by Health Facilities as referred to in Article 36 shall be performed through: a. organization of health professionals’ authority in performing professional practice according to the competence; b. utilization review and medical audit; c. development of professional ethics and discipline to health professionals; and / or d. monitoring and evaluation of the use of drugs, Medical Devices, and medical consumables in health care are carried out periodically through the utilization of health information system. Article 38 5. Implementation of quality control and cost control by BPJS-K referred to in Article 36 is performed through: a. compliance with quality standard of health facilities; b. compliance with healthcare process standard; and c. monitoring of the outcomes of participants’ health. 6. In respect of the implementation of quality control and cost control as referred to in clause (1), BPJS-K establishes a 20 team of quality control and cost control consisting of elements of professional organizations, academician, and clinical experts. 7. The team of quality control and cost control as referred to in clause (2) can perform: a. socialization of the authority of health professionals in performing professional practice in accordance with the competence; b. utilization review and medical audit; and/or c. development of professional ethics and discipline to health professionals. 8. In certain cases, a team of quality control and cost control as referred to in clause (2) may request information on the identity, diagnosis, medical history, examination history and treatment history of the Participant in the form of photocopy of the medical records to the health facilities as needed. • Monitoring and evaluation of health services cost (Fraud): There is no regulation • Report: Regulation of Minister of Health Number 71 of 2013 CHAPTER VII REPORTING AND UTILIZATION REVIEW Article 39 1. Health facilities shall make a monthly report of health care activities submitted on a regular basis to BPJS-K. 2. BPJS-K shall implement Utilization Review on a regular and sustainable basis and provide feedback of the Utilization Review results to Health Facilities. 3. BPJS-K shall report the results of Utilization Review to the Minister and DJSN. 4. Provisions concerning the reporting mechanism and Utilization Review as described in clause (2) and clause (3) shall be determined by Regulations concerning BPJS-K 21 Accountability Report: Regulation of Minister of Health Number 71 of 2013 CHAPTER VII REPORTING AND UTILIZATION REVIEW Article 39 mechanism of PPK 1. Health facilities shall make a monthly report of health care activities submitted on a regular basis to BPJS-K. to the Executive 2. BPJS-K shall implement Utilization Review on a regular and sustainable basis and provide feedback of the Utilization Agency Review results to Health Facilities. 3. BPJS-K shall report the results of Utilization Review to the Minister and DJSN. 4. Provisions concerning the reporting mechanism and Utilization Review as described in clause (2) and clause (3) shall be determined by Regulations concerning BPJS-K. 22 The financial • Regulation of Minister of Health No. 69 of 2013 regarding Health Care Standard Rates On First-Level Health Facilities And flow between the Advanced-Level Health Facilities in the Implementation of Health Insurance Program Executive Agency, • Regulation of Minister of Health Number 19 of 2014 regarding the Use of Capitation Fund of the National Health Security PPK and other For Health Care Service And Operational Cost Support on Regional Government-Owned First-Level Health Facilities parties involved in the National Health Insurance 23 Executive Agency In accordance with its Tasks and Functions, the Executive Agency supervise PPK in Cost Control And Quality Control. And encourage Credentialing before the Contract. innovation in the provider POLICY NOTE NO TOPIC LEGISLATION PUBLIC / PARTICIPANTS 24 Participants’ Law no. 40 of 2004 article 16: Each participant is entitled to receive benefits and information about implementation of social opinion about the security programs in which he or she is participating. performance of the Executive Agency 25 Mechanism to • Presidential Regulation No. 12 of 2013 article 29 clause 1 channel the Initially BPJS Healthcare will register each Participant to one first level Healthcare Facility which will be aspirations of the appointed by BPJS Healthcare based on the recommendation from Health Department at regency/city level people in choosing • Presidential Regulation No. 12 of 2013 article 29 clause 2 the PPK and health After the first 3 (three) months, Participant has the rights to select their own first level Healthcare Facility. care benefits • Participants cannot select secondary health care. 26 Mechanism that Presidential Regulation No. 12 of 2013 article 20 – article 26 of Chapter IV Health Care Benefits of (essentially, integrates between comprehensive benefits unless there are some that are excluded *) the needs of the participants’ Health care is not guaranteed : preference and • Health services are performed without going through the procedures as stipulated in the regulations; the PPK as • Health services in health facilities which do not cooperate with BPJS-K, except for emergency cases; well as benefit • Health services has been guaranteed by the program of work injury insurance against illness or injury due to accidents or package that will employment relationship; be received by • Health services carried out abroad; Participants • Health care for aesthetic purposes; • Services to overcome infertility; • Leveling services of teeth (orthodontic); • Health disorders / diseases caused by drug addiction and / or alcohol; • Health problems caused by accidentally hurt themselves, or due hobbies endanger yourself; • Complementary medicine, alternative and traditional, including acupuncture, shin she, chiropractic, which has not been declared effective by health technology assessment (health technology assessment); • Treatment and medical actions categorized as an experiment (experimental); • Contraceptives, cosmetics, baby food and milk; • Household health supplies; • Catastrophic health care in emergency relief, extraordinary events / outbreaks; and • Cost of other services that are not related to health insurance benefits provided. And article 27 - article 28 of Chapter VI Benefit Coordination (essentially, Participants of Healthcare Benefit can enroll 21 in additional healthcare insurance) 27 a mechanism Presidential Regulation No. 12 of 2013 to express CHAPTER 10 COMPLAINT HANDLING participants’ Article 45 displeasure/ 1. In case Participant is not satisfied with Healthcare Benefit services performed by Healthcare Facilities in partnership complaints to the with BPJS-K, complaint can be raised to Healthcare Facilities and/or BPJS-K. PPK and / or the 2. In case Participant do not received proper services from BPJS-K, complaint can be raised to Minister. Executive Agency 3. Complaint raised as referred in clause (1) and clause (2) shall be handled appropriately and in short period and shall provide feedback to complaining Participant. 4. Raising complaint as referred in clause (3) shall be in accordance of prevailing law. 28 The Executive Law no. 40 of 2004 article 4 the National Social Security System is administered on the principles of: Agency guarantees a. Mutual assistance; its accountability b. Not-for-profit; to participants c. Tansparency; d. Prudence; e. Accountability; f. Fortability; g. Mandatory participation; h. Trust fund; and i. Return on management of the Social Security Fund to be used entirely for developing programs in the best interests of participants Elucidation of Article 4 of the Law of the Republic of Indonesia Number 40 Year 2004 on the National Social Security System and Elucidation of Article 4 Letter E of the Law of the Republic of Indonesia Number 24 Year 2011 on Implementing Agency Of Social Security, that: The principle of accountability in this provision is the principle of accurate and accountable program implementation and financial management. 29 Mechanism There is no mechanism. However, the Laws have mandated for participants • Law no. 40 of 2004 article 16: Each participant is entitled to receive benefits and information about implementation of to know the social security programs in which he or she is participating. performance of the • Law No. 14 of 2008 on Public Information Disclosure. Consisting of 64 articles, this law in essence gives liability to any Executive Agency Public Agency for opening access to every public information applicant to obtain public information, except for some specific information. OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN Annex 2. Mapping of Strategic Health Purchasing Functions to Responsible Institutions INSTITUTION FUNCTION MINISTRY MINISTRY OF LOCAL DJSN BPJS-K MOH MOF OF SOCIAL HOME AFFAIRS GOVERNMENT AFFAIRS Governance Governance Propose interim Provide Coordinate Regulate the Verify and Provide written No role for local and substitute information with the Health continuation validate BPJS data, warning to governments in Accountability members of the on the BPJS to develop of the dues of establish criteria governors and/ governance and Board of Trustees implementation the technical employer for the for the poor and or vice-governors accountability and / or members of social security operation of the local government vulnerable people not implementing of the Directorate programs to health care system from the state into an integrated JKN as a national of BPJS to the participants and and quality treasury account data set strategic program. President. the Community control system to the BPJS Regulate the fraud Govern the Regulate the Regulate the prevention system provision, procedures and depositing of in JKN disbursement, and the change of health insurance accountability of requirements contribution from Fraud prevention health insurance of PBI health civil servants, is typically a dues from the insurance data government function of the State Budget employee non- purchasing (APBN). civil servant, and agency. the individual all together with the Ministry of Home Affairs based on their authority Impose written Regulate the Regulate the warning sanctions depositing of procedure of 22 on the members health insurance verification and of the Board or contribution from validation of the the Directors of civil servants, alteration of PBI BPJS and provide government JK data, set the advice to the employee non- alteration of such president civil servant, and data, and deliver it the individual all to the Minister of together with the Health and DJSN Ministry of Home Affairs based on their authority. Accountability Provide Insufficient Establish a consultation to accountability community the BPJS on the mechanisms complaint unit form and content on the accuracy of the program of PBI management accountability report. Receives copy of BPJS annual management and audited financial reports for submission to the President. POLICY NOTE INSTITUTION FUNCTION MINISTRY MINISTRY OF LOCAL DJSN BPJS-K MOH MOF OF SOCIAL HOME AFFAIRS GOVERNMENT AFFAIRS Benefits and Benefits design Manage the types entitlement of health services guaranteed by JKN Regulate the JKN compensation that should be provided to the participant of BPJS Health Specify the list of medicines, medical equipment, and medical consumable materials. Decisions Add guaranteed on adding health services new services/ based on health medicines technology assessment in coordination with the Ministry of Finance Enrollment and Receive Register the entitlement registration of JKN numbers of PBI participants participants in BPJS Health Service Supply side Plan the needs of delivery planning and medical supplies investment based on the national standards 23 Investment decisions made without dialogue on payment of recurrent costs through JKN Health Organize, utilize, workforce and recruit of planning and health workers management Improve the quality of health workers through education and/or training Service Managing the delivery health sector management included: health services; human resources; pharmaceutical provision, medical equipment, food, and beverage; the empowerment of community in health Implement national strategic programs Health Prevention, promotion and control, prevention eradication, designation, surveillance of infectious disease Improve the individual nutrition and mental health OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN INSTITUTION FUNCTION MINISTRY MINISTRY OF LOCAL DJSN BPJS-K MOH MOF OF SOCIAL HOME AFFAIRS GOVERNMENT AFFAIRS Financing Budget Propose social Budget proposal security budget of PBI JK to for beneficiaries of the Ministry of contributions and Finance based the availability on the DJSN of operational proposal. budget to the Government. Revenue Collect JKN Providing a collection contributions fund source for from Participants, health financing a Employers and minimum of 10% Governments. of the Regional State budget Receive donations (APBD), salary is from the excluded. government Investment Propose Manage Social Provide start-up and fund investment policy Security Funds capital to the BPJS management of National Social for the benefit of Determine the Security Fund. participants percentage of operational fund Responsible for for BPJS fund management but do not have Specify the levers to manage standard of asset claims liabilities. fund of BPJS. Contracting Provider Although the Coordinate with and provider payment regulation states the Health BPJS to payment selection and MOH should develop provider design coordinate payment systems with BPJS on Review provider payment system payment systems development that (capitation, INA- 24 has not happened in practice. CBGs, etc.) at least every 2 together with health The purchasing BPJS, DJSN, and agency typically the Ministry of is responsible Finance for or has a role Payment rate- in provider Tariff calculation setting payment selection Organize the and design and types and the payment rate- platform of health setting. equipment prices Specify the cost of health services in the event of preventable adverse events. Selective Selecting Setting the contracting providers for technical criteria contracting based for contracting on established with BPJS technical criteria Purchaser typically has role in determining criteria for selecting providers Making Paying benefits payments to and / financing providers health services POLICY NOTE INSTITUTION FUNCTION MINISTRY MINISTRY OF LOCAL DJSN BPJS-K MOH MOF OF SOCIAL HOME AFFAIRS GOVERNMENT AFFAIRS Monitoring Monitoring Conducting Cost and quality Monitoring and studies and monitoring at evaluation of the research the provider performance of related to the level, including health insurance implementation utilization review services in of social security and medical audit. coordination with DJSN Duplication with MOH function. Information Collecting and Disconnect management managing data of between data JKN participants collection and monitoring. Overall weak monitoring function. 25 OVERVIEW OF STRATEGIC PURCHASING FUNCTIONS UNDER JKN 26