Practitioners Question :

We all want to do the best for our patients,

but how do we know, what is the best ….?

 Universal Health Coverage (UHC)

Dapatkah Rumah Sakit Pendidikan

Rujukan Tersier Mempertahankan Mutu
dan Patient Safety serta Bersaing dalam
Era Global..?

Joni Wahyuhadi
FKUA.83
RSUD Dr.Soetomo-FK Unair Surabaya.
November 2018
 UHC
The ability of all people to obtain good-quality services
when they need them, without facing financial hardship.

Health Insurance

Expanding health insurance, would promote the utilization

of health services that reduce mortality and morbidity.
( WHO – WB )

The lancet , Sept 05, 2018

 Rumah Sakit Pendidikan
Rumah Sakit Pendidikan adalah rumah sakit yang
mempunyai fungsi sebagai tempat pendidikan, penelitian,
dan pelayanan kesehatan secara terpadu dalam bidang
pendidikan kedokteran dan/atau kedokteran gigi,
pendidikan berkelanjutan, dan pendidikan kesehatan
lainnya secara multiprofesi.
PP.93 th 2015
Ps 1 ayat 1

Hanya Rumah Sakit yang Aman dan Bermutu Tinggi,

yang akan menghasilkan tenaga kesehatan (dokter) yang baik,
Excellent with Morality
 Rumah Sakit
Aman - Bermutu Tinggi

Bercirikan :
1. PATIENT SAFETY  Menurunnya Angka KTD (kejadian Tidak Diinginkan) Adverse Event

2. EFFECTIVE TREATMENT  Implementasi Best Clinical Guideline

3. TIME LINE FOR ACCELERATED PATIENT FLOW  Proper Plan Of Care

4. EFFICIENT  Eliminated Of waste

5. EQUITABLE CARE
6. Value of Care
7. PATIENT CENTRE CARE

8. GROWTH AND DEVELOPMENT  Research and Technology

WHO-JCI ed 6
 Filosofi : Hubungan
Pasien – Provider ( RS-Dr )
Masa lalu Masa Kini dan Masa Depan

PATERNALISTIC COMMERCIAL
PARTNER (
JCI- KARS)
Prospective Payment

Dibutuhkan Standard
( heathcare standard )
CIRI UTAMA PELAYANAN KESEHATAN
( Evans, 1984, Thabrany , 2014 )
a. Standard Prosedur Pelayanan
b. Standard Profesi Provider 1. UNCERTAINTY
c. Standard Pembiayaan-Reward 2. ASYMETRY oF INFORMATION
3. EXTERNALITY

Pelayanan
AMAN-BERMUTU-BERKEADILAN
Abuse -Unefisiensi
Moral Hazard – FRAUD
 Abuse - Unefisiensi
Moral Hazard – FRAUD

Salah satu PEMICU lahirnya “ PROGRAM JKN”

Pembiayaan Sistim
Prospective Payment –
“Ina CBGs”
Prof. H Thabrany
 TANTANGAN PELAYANAN KESEHATAN
RUMAH SAKIT DI INDONESIA SAAT INI

Borderless
supply

Patient
INa-CGBs/BPJS
Centre Care

COST EFFECTIVENESS -> Patient VALUE OF CARE

 Patient Value of Care
VALUE OF CARE :

• Needs : The software fulfilment of their medical need, the soft

touch to their clinical care experience ( Competency )

• Feelings : The emotional expectation they want to feel as they

go through their healthcare journey ( Empathy )

• Relationship : The kind of relationship they desire from their

heatlhcare giver ( Frendly )
BAGAIMANA SISTIM KESEHATAN
DI NEGARA KITA SAAT INI…?
 KONSEP JAMINAN KESEHATAN NASIONAL
(JKN )
UU No 40/ 2004 ttg SJSN, UU N0 24/2011 ttg BPJS, PMK no 28/ 2014 ttg Pedoman Pelaksanaan JKN
Perpres 82/2018

BPJS Kesehatan Pemerintah

Kendali Biaya & kualitas Yankes

Regulasi Sistem Pelayanan
Kesehatan (rujukan, dll)
Regulasi (standarisasi)
Pemerintah Kualitas Yankes, Obat, Alkes
(Regulator) Regulasi Tarif Pelayanan
Kesehatan,

Memberi Pelayanan REGULASI SISTEM

Peserta Fasilitas REMUNERASI
Jaminan Kes Mencari Pelayanan Kesehatan
Sistem Rujukan
Berbasis Kinerja...?
Take Home Pay...?
 UHC JKN
BPJS
( Ina CBG-Kapitasi )

Rumah Sakit
Aman - Bermutu Tinggi -
Berkeadilan

DOKTER

Excellence with Mortality

 JKN UHC
MERUBAH PARADIGMA PELAYANAN

PARADIGMA LAMA ↓ PARADIGMA BARU

RETROSPECTIVE MASA PROSPECTIVE

PAYMENT TRANSISI PAYMENT
Critical Time
Turbulensi

SISTIM PEMBIAYAAN
FEE for SERVICE AGREGAT
 TURBULENSI / TEKANAN …..?

Komplikasi Implementasi INA-CBG,s

( Penelitian prof.Budi Hidayat SKM, MPPM, PhD ) th 2015

1. DUMPING ( Rujuk yg merugi ) : 33,7 % dan naik per bulan 4,3 % / bl rawat jalan
dan 3,5 % rawat inap

2. BLOODY DISCHARGE ( dipulangkan awal ) : 9,7 % rawat inap

3. READMISI / SUPPLIER INDUCED DEMAND : 43 % rawat inap / 15 % rawat jalan

4. SKIMPING ( mengurangi layanan )……….? PERLUNYA STANDAR LAYANAN

5. UP CODING ( layanan tambahan untuk naikan Kleim ) : 10,1 %

Bila hal ini dapat cegah dapat menghemat : 7,04 Trilyun rupiah / tahun
HUTANG BPJS TERATASI …?
 KASUS GUILLAIN-BARRE SYNDROME
JUNI – SEPTEMBER 2018
JUMLAH DISHARMONI NEGATIF
BILLING RS TARIF INA-CBG'S
KASUS
22 2.018.542.460 1.025.547.100 992.995.360 96,83%

KASUS KAWASAKI
JANUARI – SEPTEMBER 2018
JUMLAH DISHARMONI NEGATIF
BILLING RS TARIF INA-CBG'S
KASUS
2 43.468.272 7.884.200 35.584.072 451,33%
 Diagnosa Diagnosa Tarif Deskrip
Pasien Prosedur LOS Tarif RS
Utama Sekunder INA-CBG si

Nn. Y (23 Guillain-  Respiratory  Electromyography 146 hr Rp. Rp. VENTILASI

th)  Kls. 2 barre failure, (93.08) 383.536.055 178.007.700 MEKANIKAL
LONG TERM
syndrome unspecified  Respiratory
DENGAN
(G61.0) (J96.9) medication TRAKEOSTO
 Paraplegia, administered by MI (BERAT)
unspecified nebulizer (93.94) J-1-01-III
(G82.2)  Central venous
 Pneumonia, pressure monitoring
unspecified (89.62)
(J18.9 )  Insertion of indwelling
 Anaemia, urinary catheter
unspecified (57.94)
(D64.9)  Continuous invasive
- Hypokalemia mechanical
ventilation for 96
consecutive hours or
more (96.72)
 IVIG medication
 Transfusion of packed
cells (99.04)
 Other permanent
tracheostomy (31.29)
6. PENYAKIT KOMPLEK/BERAT BIAYA KLAIM LEBIH KECIL DARI BIAYA LAYANAN
No No Rekam Medik Diagnosa Utama Tarif RS INA CBgs Selisih

1 12630024 Z51.1 Khemoterapi Session for 35,244,567 7,833,800 27,410,767

neoplasm
2 12656095 C92.0 Acute Myeloid Leukimia 92,608,517 35,561,700 57,046,817

3 12658085 G12.9 Spinal Muscular Atrophy, 103,520,694 39,455,200 64,065,494

Unspecified
4 12658740 C18.1 Malignant Neoplasm, 144,871,076 33,413,500 111,457,576
appendix
5 12667626 G04.9 Encepalitis, myelitis and 120,094,078 50,137,500 69,956,578
encepalohyelitis, Unspecified
6 12668188 C57.4 Malignant Neoplasm, uterine 54,126,588 14,128,400 39,998,188
adnexa, Unspecified
7 12678035 C18.4 Malignan Neoplasm, 70,183,970 33,413,500 36,770,470
transverse colon
8 12678160 D32.9 Benign neoplasm, meninges, 20,118,343 6,939,700 13,178,643
Unspecified
9 12680845 P36.8 Other bacterial sepsis of 62,664,942 23,943,800 38,721,142
newborn
10 12681792 G61.0 Guilaine Barre Syndrome 113,508,658 15,929,200 97,579,458

TOTAL 816,941,433 260,756,300 556,185,133

 JUMLAH TB PARU GAGAL NAPAS
RUANG RESUSITASI RSDS TH 2018 ( MORBIDITAS )
16 15
14
12
12
10 9
8 8
8 7
Jumlah TB Paru
6 5 Linear (Jumlah TB Paru)
4
2
0
 Mortalitas
GDR NDR

Standar: ≤ 45‰ Standar: ≤ 25‰

2015 2016 2017 2015 2016 2017

RSUD Dr. Soetomo
Surabaya 89.00 94.80 93.00 38.90 40.80 21.80
RSUD Dr. Saiful Anwar
Malang 87.00 92.50 100.46 86.70 69.40 74.50
RSUD Dr. Soedono
Madiun 108.50 105.72 98.90 52.87 56.61 58.34

RSUP Dr. Sardjito 90.00 61.00

RSUP Sanglah 10.20 7.51

 GRAFIK EVALUASI AGREGAT KLAIM PASIEN JKN
JANUARI – JUNI TAHUN 2017
250,000,000,000.00

212,866,462,487.82
200,000,000,000.00
205,152,435,084.00

150,000,000,000.00

126,705,530,611.42 128,994,944,400.00
120,898,348,929.00 120,488,039,640.00 BILLING RS
100,000,000,000.00 TARIF INA-CBG
84,664,395,444.00
74,130,223,000.00

50,000,000,000.00

0.00
PX RAWAT JALAN PX RAWAT INAP PX RAWAT INAP PX RAWAT INAP
DENGAN TANPA PEMBEDAHAN
PEMBEDAHAN
 Mencegah Dorongan Untuk
MENTERI KESEHATAN
Terjadinya Fraud
REPUBLIK INDONESIA

Tekanan

Niat

Fraud
Rasionalisasi
Action

Kesempatan Kesempatan Patient Safety

Excellent with Morality

Dirjen Yanmed, Dean, Gonzales, Fricker : 2013

 KESEMPATAN

. Kasus JANTUNG : Pasien Kelas Utama IV

Resume Medis : Dx.Utama PJK
Dx. Sekunder HT, DCFC
Prosedur PTCA 2 Stent
Klaim yang diajukan : Rp. 103.652.000 (SL II)

Hasil Telusur Oleh BPJS

BRM : Dx. Utama : PJK
Dx. Sekunder : DCFC (-)
Klaim turun menjadi : Rp. 44.242.400 (SL I)
:
LOSS Rp. 59.000.000

DCFC : Decomposition Cordis Functional Class ( 1-4 )

THE LANCET SEPT 05, 2018
 UHC

Low Cost Health Care

High Morbidity and Mortality

HAL INI TIDAK BOLEH TERJADI

 WHAT SHOULD WE DO…?

BISA BERSAMA, KARENA :

KESEHATAN ADALAH BAGIAN DARI KETAHANAN NEGARA
 Sistem Kendali Mutu Kendali Biaya (KMKB)
dalam Pelayanan JKN
Health
Technology
Standar Pelayanan Assessment
(PPK, PNPK, Clinical (HTA)
Pathway)

Reviev Utilisasi

Audit Medik KMKB

Pencegahan
Fraud

Credentialing
Effisien
Pellayanan

MENKES RI 2018
 Strategic Improvement Plan
RSUD Dr.SOETOMO
Guideline Audid Edukasi dan Training
. Profesi ( PPK-CP- ETC ) ( EBM ) . Audid Medik . SDM RS
. Standard Prosedur Operasional . Audid Finansial . Anak didik
/ SPO RS ( JCI-SNARS ) . OPPE ( VALUE of CARE )

Program Visi
Integrated Practice Unit Misi
Rumah sakit
( IPU )

Finansial Sarana-Prasarana Riset-Pengembangan

. Perencanaan: . Area Fokus . Hospital Base
skala Prioritas . Integratif . Riset klinik
. Implementasi ( HOSPITAL SAFETY) ( GCP )
. Evaluasi
( GOOD SUPLAY CHAIN )

Outcome Dampak
. Pelayanan-PendidIkan-Riset : Aman - Bermutu Tinggi . Pasien : Satisfaction
Proses . Finansial : Cost-Effectiveness
.Terintegrasi-Kolaboratif R.S : Terpercaya
. Sarkes : Aman-Efektif
 TERIMA KASIH

“Everything should be made as simple as possible

but not simpler.”

Masjid Quba