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Lessons from Rapid Implementation: how the revamped system to purchase COVID services in Indonesia affected its hospitals - P4H Network

Lessons from Rapid Implementation: how the revamped system to purchase COVID services in Indonesia affected its hospitals

The authors:
Dr Anooj Pattnaik (ThinkWell Global, Deputy Director for Learning), Ryan Nugraha (ThinkWell Indonesia), Prof. Hasbullah Thabrany (ThinkWell Indonesia), and Catherine Connor (Program Director at ThinkWell). 

The spread of COVID-19 around the world has provided a litmus test on the strength and resilience of every country’s health system.  Indonesia has been no exception.  As of November 6th, there have been 421,731 positive confirmed cases with a devastating 3.38% mortality rate, putting tremendous pressure on the Indonesian health system.[1]
To ensure routine essential services are provided as usual and ballooning COVID cases are covered, the Government of Indonesia (GoI) rapidly mobilized its purchasing system to provide funding, as well as technical and operational guidance, to its health system actors. Special attention was given to hospitals, as they were hit especially hard with their highest recorded bed occupancy of 77-79% within the last 3 months.[2]  In order to meet this surge in demand, the GoI used public funds to cover all COVID-19 treatment, based on the bylaw 6/2018 of the Health Quarantine, including at hospitals.  
How hospitals now submit COVID claims
The government passed Decree 238/2020 in April 2020[3], which established that the Ministry of Health (MOH) would be the main purchaser of a COVID-related package that covers all hospitalized patients dating back to January 2020. The COVID package reimburses hospitals on a fee-for-service basis for specific services, ventilators, drugs and consumables, per diem for accommodation, as well as mortuary care.   As explained in a related blog, the GoI chose to use the MoH to disburse funds rather than use the existing but young JKN national health insurance scheme.  In turn, the MoH is assisted by BPJS-K, the agency that runs JKN, to manage and verify the COVID claims.  All hospitals, regardless of being contracted by JKN or not, submit claims for COVID through this newly established system.
The decree also clarified the process for hospitals to submit claims for COVID-19 care. The MoH decided to utilize an e-claim application that was previously established for JKN, before they moved on to a new claims system that pays a fixed amount per case. Hospitals are required to submit COVID patient claims and supporting documents through this revived application. After the claim is submitted, the MoH pays hospitals 50% of the claimed amount up front. The submitted data is then reviewed by verifiers from BPJS-K and once approved, the MOH pays the remaining balance to the hospital.  
Challenges hospitals face (so far)
While the rapidly enacted policy has been fairly accommodating of hospital costs thus far, it has presented several challenges.  First, the server of the e-claim application has been down often due to several bugs and errors, causing hospitals to often postpone submission and hindering the claim reimbursement process.[4] Many hospitals also feel that they have no feedback mechanism to the purchaser about any challenges with the application. 
Second, many hospitals perceive the claims requirements to be quite rigid, especially as the rate of claim submission is high and the process is so new.  For instance, hospitals noted instances of approval delay or denial from verifiers because they had not received the full range of completed documents from actors outside the hospital, such as a letter for proof of swab from the lab centre (outside the hospital).
Third, many of the hospitals that are now submitting COVID claims are new to the system.  Out of 2813 private hospitals, 390 were not already contracted with JKN and had no experience with the e-claim system, let alone these COVID-related claims.[5]   Even if training was provided, this took much time and had to be done over videoconferencing.  On the disbursement side, many of these hospitals note significant delays in receiving reimbursement for the many COVID claims they have submitted.
Fourth, there have been several problems that have bubbled up between the MoH as the main purchaser of COVID services and BPJS-K, who are verifying the claims.  These include:

Claims are verified by BPJS-K verifiers at the district level. Hospital administrators noted that different verifiers within the district seemed to have variable levels of competency and/or standards for verifying COVID-related claims.
The MoH is paying fee-for-service for COVID hospital care. In contrast, for all other hospital patients covered by JKN, the BPJS-K pays a fixed amount per case, similar to Medicare in the United States. BPJS-K staff verifying COVID claims must review an itemized bill for each service, lab test, drug, and hospital day, which is quite different from verifying the patient’s diagnosis and paying a fixed amount.  
There has been a lack of clarity on how to handle COVID patients who have one or more comorbidities, which drives up the cost.  Especially as a new disease, it is not always clear which parts of the claim apply to the MoH system (COVID-services) and which parts belong to JKN (all other services).  In July, the MOH revised the Decree 446/220[6] to accommodate disputes associated with patients with comorbidities and other issues.  However, there are many cases where the hospital is still unclear which purchaser to submit a claim to, and continued disagreement between MoH and BPJS-K on these more complicated claims.  These challenges have slowed down claim submission and verification.

Overcoming the Challenges
Dealing with a rapid response and in such a pressurized environment, it is rather unsurprising that the system to pay for COVID patients has experienced several implementation challenges.  At this point, it is now essential that the MOH learn from these early challenges and adapt accordingly at 3 levels:
Short term
With the inputs from hospitals, it is evident that the MOH must first improve the e-claim application itself, particularly in building its database, resolving the bugs and connectivity issues, and making its interface more user-friendly.  User feedback needs to drive these improvements and thus, the MoH needs to establish more easy-to-use feedback mechanisms that they actually take into account.
The MOH and BPJS-K need to establish better communication and coordination on comorbidities and ‘splitting the bill’.  There needs to be clear definitions and criteria for cases and simple decision rules for who pays.[7] Finally, the MoH needs to widely and transparently communicate this to not only the rest of MoH and BPJS-K, but to hospitals and verifiers, as well.  Moreover, the GoI needs to set up mechanisms for the two bodies to communicate and handle confusion and disputes.
To reduce the variability in BPJS verification of COVID claims, verifiers need to be better monitored to identify those that are having issues and then more training and supervision can be targeted to them.  The information given to verifiers, including decision rules on disease pathway and verification, needs to be communicated as simply as possible to avert confusion and ease the verification process.
Once COVID-19 is classified as an endemic infectious disease and not a pandemic emergency, the GoI will transition financing of COVID-related services from the MoH to the JKN scheme.  COVID-related services will then be purchased the same way as other services covered by JKN.  Once this happens, purchasing of COVID services will benefit from the established instruments of BPJS-K and its six years of experience in purchasing a wide range of services from both public and private hospitals. Thus, it is critical that the COVID-19 benefit package is carefully to ensure its coverage is sustained for the long term.  This process should take in the lessons learned from the last 9 months of implementation through the MoH system.
Long Term and the way forward
The purchasing decisions, and the lessons from Indonesia’s COVID-19 response, must be applied to future crises. The standard procedure for emerging disease purchasing needs to be updated and laid out should any future pandemic arise.  This should take into account the unique health system arrangements in Indonesia and the lessons of implementing the COVID response within that system. 
For instance, while the government’s rapid decision to establish the MOH, rather than BPJS-K, as the main purchaser of COVID services was understandable, it established several novel processes and systems, including a new e-claims application, purchasing from private hospitals that are not contracted with BPJS-K, and having BPJS-K staff verify newly established COVID claims.  It also relied on close coordination between two massive agencies across overlapping purchasing systems and regulations.  Thus, it is no surprise that there has been several growing pains embedded throughout this process. 
To prepare for that next crisis, the GoI needs to take a step back and review objectively the choices they made during the response and shine a light on what worked and what could be improved within its health system with all its unique quirks and ever-evolving nature.  That way, next time, their rapid response will be built on the scaffolding of the lessons learned from COVID.
[1] The Ministry of Health GoI. COVID-19 daily infographics. Retrieved from
[2] Minister of Health. COVID-19 containment and National Economic Recovery. Undisclosed presentation, October 2020.
[3] T The Ministry of Health, GoI. The Decree of the Ministry of Health HK.01.07/MENKES/238/2020 on Technical Guidance on Claim Submission to Cover Specific Emerging Infectious Disease for Hospitals Providing Care for Coronavirus Disease 2019. Jakarta, April 2020.
[4] Based on (limited) inputs by hospital administrators
[5] BPJSK. JKN Report 2019
[6] The Ministry of Health, GoI. The Decree of the Ministry of Health HK.01.07/MENKES/446/2020 on Technical Guidance on Claim Submission to Cover Specific Emerging Infectious Disease for Hospitals Providing Care for Coronavirus Disease 2019. Jakarta, July 2020.
[7]  Three examples of decision rules: 1) Active Covid infection with or without potentially related comorbidities: MOH pays 100%. 2) Active Covid infection with clearly unrelated comorbidity like injury or mental illness: MOH + JKN split cost. 3. Re-admission of previous (not currently active) Covid case: JKN pays 100% .

Published on 17 Dec 2020