Leveraging the strengths of a mixed purchasing system for COVID-19: a perspective from Indonesia
\nAnooj Pattnaik,\u00a0Deputy Director for Learning
\nwww.ThinkWell.global
\nPrastuti Soewondo, Country Director, ThinkWell Indonesia
\nNadhila Adani,\u00a0Analyst, ThinkWell Indonesia<\/p>\n
Purchasing of health services during normal times is rarely done by a single entity.\u00a0 Rather, there are usually many different purchasers in a country\u2019s health system, from ministries of health, subnational governments to national health insurance agencies.\u00a0\u00a0 This is certainly the case in Indonesia, where their young national health insurance scheme founded in 2014, Jaminan Kesehatan Nasional (JKN), covers over 80% of the population for individual health services, while the government still plays a substantial role in delivering population health and allocating funds to public providers for expenses like wages and supplies.\u00a0 So how does a mixed purchasing system, like the one in Indonesia, adapt and respond to the advent of a crisis like COVID-19?
\nA Hybrid Approach
\nWhen the virus hit the shores of Indonesia in March 2020, the Indonesian government needed to rapidly adapt its mixed purchasing system to prepare for the potential rapid rise of COVID-19 within its borders.\u00a0 It decided to adopt a hybrid approach between its Ministry of Health (MoH) and BPJS-K, the government agency responsible for implementing JKN.\u00a0 The MoH would be responsible for defining the clinical pathways for COVID-19, developing the tariff and payment mechanism (cost-per-day), and making the payment directly to the providers.\u00a0 BPJS-K would be responsible for receiving and verifying claims around COVID-19 from health facilities and submitting to the MoH for payment.\u00a0 In this way, the Indonesian government aimed to leverage the strengths of each agency: the deep experience and technical expertise of the MoH to set the guidelines and receive\/disburse significant amounts of funds, and the strong claims management and verification systems of BPJS-K, as well as their existing contracts with both public and private providers who are delivering COVID-19 services to the population.\u00a0 Once the pandemic is over, the plan is for COVID-19 to be part of the case-based group payment (CBG) system of JKN. Therefore BPJS-K involvement has been crucial in these early stages so they can better devise how they will incorporate COVID-19 coverage in the future.
\nPurchasing Features of the Response
\nQuickly after COVID-19 permeated Indonesian shores, the MoH clarified key details of how COVID-19 services would be purchased in the emergency response.\u00a0 The first regulation was that local citizens would pay nothing out-of-pocket (OOP) if they met 3 categories: probable (if they were admitted to the hospital due to pneumonia, fever, or respiratory infections at any age), suspected (if they are 60+ and had any symptoms in the last two weeks (e.g. fever, trouble breathing), or confirmed cases.\u00a0 This regulation was updated in August 2020 to now include those under 60 who show any symptoms.
\nThis coverage extends to only public and private hospitals, not PHC facilities, as the MoH transfers funds directly to the hospital, not the patient. \u00a0However, testing for COVID-19 is only free if the person fits under these 3 categories.\u00a0 If not, Indonesians must pay OOP for the test, which is certainly not ideal and has likely led to under-testing of the population.
\nThe President has implored for COVID testing to be increased across the country. To this effect, the availability of PCR tests has increased tenfold in the last 3 months.\u00a0 However, these PCR tests have been unequally distributed, especially outside Java island. \u00a0On the contract tracing side, developing a unified strategy and then implementing it has been a tremendous challenge, resulting in targeted testing being scattered and largely ineffective. \u00a0In addition, there is a significant delay (around 10-14 days) for test results due to the limited lab capacity in the country.
\nThe services that are covered under the new COVID-19 package include administration fees, accommodation (e.g. inpatient, ICU, or isolation rooms), treatments, ventilator use, medical consumables, diagnostic support tests, drugs, referrals, and other related health services.\u00a0 The hospital then submits the claim through the existing JKN claims system and is paid by the MOH via a case-based group (CBG) rate for outpatient care or cost-per-day for inpatient care.\u00a0 There is one fixed tariff for all hospital classes (for both public and private), with a range of severity level from moderate, complex, and critical.
\nThe Indonesian government also is responsible for procuring and supplying these hospitals with PPE, necessary equipment like ventilators and oxygen, and improving the physical infrastructure of these hospitals to optimally respond to the virus.\u00a0 These funds and supplies are allocated to health facilities through separate purchasing channels than this COVID-19 claims one.\u00a0 All hospitals that are appointed to receive COVID patients should be able to receive supply assistance. However, in practice, public hospitals and government-related providers (military and police hospitals) have been prioritized with only few selected private hospitals confirming that they received assistance.
\nInitially, hospitals were only allowed to submit COVID claims once every two weeks.\u00a0 This has been updated recently to allow for a weekly submission.\u00a0 BPJS-K then is supposed to verify the claim within a week and submit the verified claim to the MoH.\u00a0 When hospitals submit claims to BPJS-K, they should also send the claim to the MOH. \u00a0While waiting for approval from BPJS-K, the MoH transfers 50% of the total claim to the provider. \u00a0The MoH then transfers the rest of the payment to the hospital within 3 days of receiving the verified claim.
\nPerhaps unsurprisingly, there have been challenges around this system, as many of the claims submitted by public and private hospitals for COVID still have not received payment, far past the stated payment schedule. \u00a0This is more of a critical issue for private hospitals who rely on these payments to stay afloat and do not receive government subsidies like their public counterparts. \u00a0Rapidly setting up this purchasing arrangement likely has also led to bottlenecks that delay payments, while JKN has had its share of existing challenges with processing payments even before COVID.
\nMoving forward
\nIt remains to be seen how effective and efficient this hybrid purchasing arrangement has been for dealing with the COVID-19 crisis in Indonesia.\u00a0 Nonetheless, the Indonesian government clearly aimed to leverage the strengths of its different purchasing agencies in its response.\u00a0 The MoH has decades of experience in this type of fund management and disbursement through programs like Jampersal and previous emergency responses.\u00a0 On the other hand, JKN still is only 6 years old and it could have been a heavy burden for BPJS-K to play this central role in such a massive crisis the way the more experienced PhilHealth has done in the Philippines.\u00a0 Instead, JKN\u2019s existing claims management infrastructure, routine data systems, and contractual arrangements with both public and private providers (which expand access) were tapped in the response, which may prove to be a more appropriate and considered approach.\u00a0 In any case, this type of joint response and collaboration between the two major purchasers of health services in Indonesia could help to usher in a more coherent approach to achieving UHC once the immediate crisis has receded.<\/p>\n","protected":false},"excerpt":{"rendered":"
Leveraging the strengths of a mixed purchasing system for COVID-19: a perspective from Indonesia Anooj Pattnaik,\u00a0Deputy Director for Learning www.ThinkWell.global Prastuti Soewondo, Country Director, ThinkWell Indonesia Nadhila Adani,\u00a0Analyst, ThinkWell Indonesia Purchasing of health services during normal times is rarely done by a single entity.\u00a0 Rather, there are usually many different purchasers in a country\u2019s health…<\/p>\n","protected":false},"author":237,"featured_media":987526183,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_et_pb_use_builder":"","_et_pb_old_content":"","_et_gb_content_width":""},"categories":[1],"tags":[118,124,132],"acf":[],"_links":{"self":[{"href":"https:\/\/p4h.world\/en\/wp-json\/wp\/v2\/posts\/987526182"}],"collection":[{"href":"https:\/\/p4h.world\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/p4h.world\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/p4h.world\/en\/wp-json\/wp\/v2\/users\/237"}],"replies":[{"embeddable":true,"href":"https:\/\/p4h.world\/en\/wp-json\/wp\/v2\/comments?post=987526182"}],"version-history":[{"count":1,"href":"https:\/\/p4h.world\/en\/wp-json\/wp\/v2\/posts\/987526182\/revisions"}],"predecessor-version":[{"id":987724876,"href":"https:\/\/p4h.world\/en\/wp-json\/wp\/v2\/posts\/987526182\/revisions\/987724876"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/p4h.world\/en\/wp-json\/wp\/v2\/media\/987526183"}],"wp:attachment":[{"href":"https:\/\/p4h.world\/en\/wp-json\/wp\/v2\/media?parent=987526182"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/p4h.world\/en\/wp-json\/wp\/v2\/categories?post=987526182"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/p4h.world\/en\/wp-json\/wp\/v2\/tags?post=987526182"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}