scholarly journals DOES MORAL HAZARD OCCOUR IN THE IMPLEMENTATION OF SOCIAL HEALTH INSURANCE? EVIDENCE FROM PUBLIC HOSPITALS IN A RURAL PROVINCE OF INDONESIA

2020 ◽  
Vol 5 (1) ◽  
pp. 24
Author(s):  
Rizanda Machmud ◽  
Syafrawati Syafrawati ◽  
Prof. Syed Mohamed Aljunid ◽  
Rima Semiarty
Keyword(s):  
Health Insurance ◽  
Moral Hazard ◽  
National Health Insurance ◽  
National Health ◽  
Medical Records ◽  
Social Health Insurance ◽  
Public Hospitals ◽  
Social Health ◽  
Severity Level ◽  
Discharge Status

Indonesia is now encountering moral hazard problems in the implementation of social health insurance. BPJS, as the administrator of Indonesia’s National Health Insurance, reported that there was an increase in deficit in the 4 years of the implementation of National Health Insurance from US$ 228 million in 2014 to US$ 470 million in 2016. Despite efforts conducted to overcome the problem, no evidence-based predictor that might be significantly associated with moral hazard in a rural province hospital in Indonesia. The purpose of this research is to identify the incidence of moral hazard in the implementation of National Health Insurance in Indonesia. Data consisting of 180 medical records obtained from three public hospitals in rural province of Indonesia were selected as samples in this study. These medical records were reviewed by Independent Senior Coder (ISC) who had more than 5 years experiences as a coder. The indicators of moral hazard in this study were upcoding, readmission, and possible unnecessary admission. Logistic regression was used to explore determinant of moral hazard from patient, coder, and physician side. The results show that rate of moral hazard cases for upcoding is 10%, readmission is 2.8%, and possible unnecessary admission is 18.9%. It can be seen from multivariate analysis that discharge status, severity level and LOS have a significant relationship with moral hazard. Illness severity level, Discharge against Medical Advice, and higher Length of Stay are risk factors for moral hazard incidence.

scholarly journals SOCIAL HEALTH INSURANCE LITERACY: LESSON LEARNED FROM SOCIAL INSURANCE FOR MATERNITY CARE BY NATIONAL HEALTH INSURANCE PROGRAMME

2019 ◽  
Vol 7 (1) ◽  
pp. 25
Author(s):  
Choirun Nisa' ◽  
Intan Nina Sari
Keyword(s):  
Health Insurance ◽  
National Health Insurance ◽  
National Health ◽  
Maternity Care ◽  
Social Insurance ◽  
Post Partum ◽  
Social Health Insurance ◽  
Social Health ◽  
Health Insurance Literacy ◽  
The Government

Background: Health insurance is a right for all Indonesian citizens. To provide this, the Indonesian government must provide health services that are equitable, fair, and affordable for all levels of society. Before National Health Insurance (JKN) was established, the government launched Social Insurance for Maternity Care or Jaminan Persalinan (Jampersal) as a special health facility for pre-pregnant to post-partum mothers. The JKN program will run well if it is accompanied with good health service literacy of the community.Aims: This study aims to analyze the relationship of social health insurance literacy with the utilization of Jampersal and predict the response towards JKN utilization based on Jampersal mothers. These responses can be used as an input for JKN improvement.Methods: This research is a descriptive study that focuses on the experience of the subjects. The study does so by analyzing Jampersal users’ response and utilizing it for the improvement of JKN. The respondents of this study are Jampersal and non-Jampersal mothers consisting of 75 pregnant and post-partum mothers.Results: The results show that the number of Jampersal users (47%) were less than non Jampersal (53%) with a ratio of 2:3. In addition, literacy about Jampersal of Jampersal mothers' was higher (28 out of 30 people - 93.33%) compared to non Jampersal mothers (29 out of 45 people - 64.44%).Conclusions: This study concludes that there is a lack of promotion of government programs, especially social health insurance. What needs to be done to improve participation and use of social health insurance is to encourage primary healthcare centers to promote the programs. Intervention policy, especially by educating the communities, is necessary for the improvement of JKN literacy.                                                                                                                                                          Keywords: Literacy, Participation, Social health insurance.

scholarly journals An Audit of Knowledge and Attitude Regarding Implementation of the National Health Insurance (JKN) in BPK RI

2019 ◽  
Vol 6 (5) ◽  
pp. 50
Author(s):  
Hari Suhud
Keyword(s):  
Health Insurance ◽  
Human Resources ◽  
National Health Insurance ◽  
National Health ◽  
Social Health Insurance ◽  
Social Health ◽  
Health Card ◽  
Knowledge And Attitude ◽  
The Republic ◽  
Unfavorable Attitude

This study aims to evaluate the knowledge and attitude of Human Resource Bureau employees regarding implementation of National Health Insurance (JKN) in The Audit Board of the Republic of Indonesia (known as BPK RI). The study is carried out by quantitative method through the distribution of questionnaires. Based on the data obtained from the results of research on 155 respondents in terms of knowledge and attitude, it can be concluded as follows: 1. the level of knowledge of employees at Human Resources Bureau in BPK RI mostly have low knowledge about the National Health Insurance (JKN) (58.1%). The results are exposed to employees who have never used Social Health Insurance/BPJS Health card with a large enough score (36.1%), and the rest are employees who have used the card; 2. the attitude of employees at Human Resources Bureau in BPK RI has a favorable attitude towards the positive statement (84.5%), as for the attitude of employees to negative statements obtained the opposite result, that most respondents have unfavorable attitude (76.1%). The results were distributed to respondents who had never used Social Health/ BPJS Health card with similar percentages.

scholarly journals INCIDENCE AND ROOT CAUSE OF UPCODING IN THE IMPLEMENTATION OF SOCIAL HEALTH INSURANCE IN RURAL PROVINCE HOSPITAL IN INDONESIA

2020 ◽  
Vol 5 (1) ◽  
pp. 56
Author(s):  
Syafrawati Syafrawati ◽  
Rizanda Machmud ◽  
Prof. Syed Mohammed Aljunid ◽  
Rima Semiarty
Keyword(s):  
Health Insurance ◽  
Medical Records ◽  
Statutory Health Insurance ◽  
Group Discussion ◽  
Social Health Insurance ◽  
Social Health ◽  
Root Cause ◽  
Medical Background ◽  
Hospital Policies ◽  
Hospital Revenue

Upcoding is one of important indicators of moral hazard and fraud in Social Health Insurance scheme. However, there seems to be little evidence about incidence of upcoding and how upcoding occurs in hospital, especially in rural province hospital. The objective of this study is to determine incidence and root cause of upcoding in the implementation of Social Health Insurance in Rural Province Hospital in Indonesia. The data used in this study were both qualitative and quantitative data (mixed method). Three hundred and sixty (360) inpatient medical records from six rural province hospitals were examined in this study. Diagnosis and procedure codes recorded in these medical records were re-coded by an independent senior coder (ISC). Codes from hospitals’ coders and codes from ISC were then re-grouped using INA-CBG casemix grouper to determine the casemix groups and the hospital tariffs. If the hospital tariff obtained by hospital coder is higher than that obtained by ISC, it is considered as upcoding. This qualitative study was conducted using Focus Group Discussion (FGD) and in-depth interviews in hospitals located in a rural province of Indonesia. In depth interview was held for two hospital directors and two officers from the Social Security Administrator (Indonesia: BadanPenyelenggaraJaminanSosial/BPJS), an agent that manages the Statutory Health Insurance (SHI). Six clinicians and six coders attended the FGD. We asked open-ended questions about their perceptions on upcoding in hospitals. The interviews were recorded and transcribed verbatim. The transcripts were then thematically analyzed. Upcoding cases were found in 11.9% (43/360) medical records. Upcoding cases were dominated by Deliveries Group 2.8% (10/360) and Female reproductive system Groups 1.7% (6/360). The potential loss of income due to upcoding was IDR 154.626.000 or 9% of hospital revenue. Appointment of non-medical doctors as internal verifiers, lack of clear coding guidelines, lack of training for doctors and coders, and poor coordination between hospital and BPJS to resolve coding disagreement were root causes of upcoding in hospital. Policies to prevent and manage upcoding should be urgently developed and implemented in the Statutory Health Insurance (SHI) program in Indonesia especially to prepare upcoding guidelines, enhance medical coding trainingregularly, increase number of coders and verification staff from medical background, and strengthen coordination for coding problem solving in hospital.

Social Health Insurance Difference in Inpatient Expenditure and Service Category in China

2018 ◽  
Vol 30 (1) ◽  
pp. 56-66 ◽  
Author(s):  
Qing Wang ◽  
Jay Shen ◽  
Jennifer Rice ◽  
Kaitlyn Frakes
Keyword(s):  
Health Insurance ◽  
Social Health Insurance ◽  
Public Hospitals ◽  
Social Health ◽  
Institutional Characteristics ◽  
Inpatient Service ◽  
Care Seeking ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Service Category

China successfully achieved universal health insurance coverage in 2011. Previous work on the effects of social health insurance in China has overlooked the association between health insurance and inpatient service category as well as the mechanisms of institutional characteristics. This study seeks to estimate the social health insurance difference in inpatient expenditure and service category. The role of institutional characteristics was also studied. The logistic model was applied to estimate the association of social health insurance and service category. In addition, Heckman Selected Model and generalized linear model were used to examine the association of health insurance and inpatient expenditure. Estimations were done for 4076 individuals older than 45 years using pooled cross-sectional survey data from the China Health and Retirement Longitudinal Study conducted in 2011 and 2013. Patients with health insurance were more likely to spend more and receive more types of inpatient service. This relationship was partially explained by the institutional characteristics. Therefore, this study highlights the importance of enforcing the regulation of referral mechanisms, the tiered copayment requirement to guide people’s care-seeking behavior, and reforming the allocation of limited health resources between different levels of facilities and also between private and public hospitals.

Program design, implementation and performance: the case of social health insurance in India

2018 ◽  
Vol 14 (4) ◽  
pp. 487-508 ◽  
Author(s):  
Dayashankar Maurya ◽  
M. Ramesh
Keyword(s):  
Health Insurance ◽  
National Health Insurance ◽  
National Health ◽  
Program Design ◽  
Implementation Process ◽  
Social Health Insurance ◽  
Care Program ◽  
Comparative Case Study ◽  
Opportunistic Behavior ◽  
Governance Mechanism

AbstractPublished works on health insurance tend to focus on program design and its impact, neglecting the implementation process that links the two and affects outcomes. This paper examines the National Health Insurance [Rashtriya Swasthya Bima Yojana (RSBY)] in India with the objective of assessing the role of implementation structures and processes in shaping performance. The central question that the paper addresses is: why does the performance of RSBY vary across states despite similar program design? Using a comparative case study approach analyzing the program’s functioning in three states, it finds the answer in the differences in governance of implementation. The unavoidable gaps in design of health care program allow abundant scope for opportunistic behavior on the part of different stakeholders. The study finds that the performance of the program, as a result, depends on the extent to which the governance mechanism is able to contain and channel opportunistic behavior during implementation. By opening up the black box of implementation, the paper contributes to improving the performance of national health insurance in India and elsewhere.

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