Strategi Rujukan Dan Premi Pada Sistem Asuransi Kesehatan Nasional

Kurnianingtyas, Diva (2021) Strategi Rujukan Dan Premi Pada Sistem Asuransi Kesehatan Nasional. Doctoral thesis, Institut Teknologi Sepuluh Nopember.

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Abstract

Sistem Asuransi Kesehatan Nasional (SAKN) merupakan program pemerintah untuk membantu kebutuhan kesehatan penduduknya. Indonesia merupakan salah satu negara pelaksana program SAKN. Namun memiliki kendala dalam pelaksanaannya, yang ditunjukkan dari hasil evaluasi program setiap tahun bahwa terdapat masalah defisit mulai tahun 2014 sebesar Rp 3,3 triliun dan meningkat tajam pada tahun 2019 menjadi Rp 50,9 triliun, bahkan diperkirakan akan meningkat dalam beberapa tahun mendatang. Salah satu kemungkinan faktor penyebab defisit adalah ketidakefisienan pada perubahan dari perilaku pasien dan sistem rujukan yang berdampak pada besaran premi. Tujuan penelitian ini yaitu mengidentifikasi faktor-faktor utama, mengevaluasi, dan merencanakan kebijakan selanjutnya dengan data historis mulai tahun 2014 hingga 2019. Pendekatan sistem dinamik digunakan untuk membangun model dan mensimulasikan pengaruh kepesertaan, perawatan kesehatan, pendapatan premi, dan biaya layanan. Hasil simulasi kondisi eksisting menunjukkan bahwa ketika peserta tidak menunggak pembayaran premi setiap bulannya maka rata-rata pendapatan premi dari 2014 hingga 2019 yang seharusnya diperoleh Rp80,5 triliun tetapi kenyataannya hanya sebesar Rp73 triliun yang diterima. Selain itu, berdasarkan uji sensitivitas, pengembangan model akan difokuskan pada mekanisme rujukan yang memiliki pengaruh besar pada biaya layanan dan premi yang mempengaruhi pendapatan premi. Ada dua model usulan yan dikembangkan menjadi tiga model perencanaan antara lain (1) model rujukan berjenjang diubah menjadi rujukan langsung, (2) besaran premi berdasarkan tingkat layanan menjadi berdasarkan umur, dan (3) kombinasi usulan pertama dan kedua untuk menentukan kebijakan selanjutnya. Dari ketiga model perencanaan yang ditawarkan, jika diurutkan dari terendah ke tertinggi jumlah dana bantuan yang perlu pemerintah persiapkan dihasilkan dari model perencanaan ketiga, pertama, dan kedua. Namun, keberhasilan dalam mengimplementasikan strategi tersebut dapat terjadi jika ada kolaborasi yang baik antara tenaga medis, pemangku kepentingan, peserta serta perlu dilakukan pembenahan struktur pelayanan kesehatan agar tujuan program tercapai. ==================================================================================================== The National Health Insurance System (NHIS) is a government program to assist the health needs of the population. Indonesia is one of the implementing countries for the NHIS program. However, it has obstacles in its implementation, which is shown from the results of program evaluations every year that there is a deficit problem starting in 2014 of Rp 3,3 trillion and increasing sharply in 2019 to Rp 50,9 trillion, and it is even predicted to increase in the next few years. One of the possible causes of the deficit is the inefficiency of changes in patient behavior and the referral system which has an impact on the amount of premiums. The purpose of this study is to identify the main factors, evaluate, and plan further policies with historical data from 2014 to 2019. A system dynamics approach is used to build models and simulate the effects of membership, health care, premium income, and service costs. The simulation results of existing conditions show that when participants do not pay monthly premiums in arrears, the average premium income from 2014 to 2019 should have been Rp 80,5 trillion, but in reality only Rp 73 trillion was received. In addition, based on the sensitivity test, the model development will focus on the referral mechanism which has a large influence on service fees and premiums that affect premium income. There are two proposed models that have been developed into three planning models, namely (1) the tiered referral model is changed to direct referral, (2) the amount of premium based on service level is based on age, and (3) the combination of the first and second proposals to determine the next policy. Of the three planning models offered, if sorted from lowest to highest, the amount of aid funds that the x government needs to prepare is generated from the third, first, and second planning models. However, success in implementing this strategy can occur if there is good collaboration between medical personnel, stakeholders, participants and it is necessary to reform the structure of health services so that program objectives are achieved.

Item Type: Thesis (Doctoral)
Uncontrolled Keywords: sistem dinamik, simulasi, Sistem Asuransi Kesehatan Nasional (SAKN), BPJS Kesehatan, besaran premi, rujukan kesehatan, strategi keuangan, system dynamics, simulation, National Health Insurance System (NHIS), BPJS Health, premium amount, health referral, financial strategy
Subjects: H Social Sciences > H Social Sciences (General) > H61.4 Forecasting in the social sciences
H Social Sciences > HA Statistics > HA30.3 Time-series analysis
H Social Sciences > HA Statistics > HA31.7 Estimation
H Social Sciences > HF Commerce > HF1916 Tariff
H Social Sciences > HF Commerce > HF5415.335 Consumer satisfaction
H Social Sciences > HF Commerce > HF5415.5 Customer services. Customer relations
H Social Sciences > HF Commerce > HF5416.5 Pricing
H Social Sciences > HF Commerce > HF5658.5 Price fluctuations
H Social Sciences > HG Finance > HG8771 Life insurance
R Medicine > R Medicine (General) > R727.3 Patient satisfaction.
R Medicine > RA Public aspects of medicine > RA960+ Hospitals
R Medicine > RA Public aspects of medicine > RA971 Health services administration.
T Technology > T Technology (General) > T57.5 Data Processing
T Technology > T Technology (General) > T57.62 Simulation
Divisions: Faculty of Industrial Technology and Systems Engineering (INDSYS) > Industrial Engineering > 26001-(S3) PhD Thesis
Depositing User: Diva Kurnianingtyas
Date Deposited: 02 Sep 2021 02:03
Last Modified: 02 Sep 2021 02:03
URI: https://repository.its.ac.id/id/eprint/90630

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