Author: yuliaslovic@gmail.com

Oleh: dr. Nunang Yuliawan, RS Semen Gresik, Jawa Timur
Dipresentasikan pada Forum Mutu Pelayanan Kesehatan IHQN (Jakarta 19-20 November 2013)

Biaya pengobatan pegawai yang selalu meningkat menjadi isu yang terjadi di PT Semen Gresik (Persero) Tbk (PTSG), sekarang bernama PT Semen Indonesia (Pesero) Tbk.. Pada dasarnya PTSG menyadari bahwa peningkatan biaya ini wajar yang disebabkan faktor-faktor eksternal. Akan tetapi PTSG menghendaki ada peran aktif dari RS Semen Gresik (RSSG) atau PT Cipta Nirmala (PTCN) sebagai provider untuk ikut mengendalikan biaya pengobatan ini. Sejak 2006 wacana Managed Care sering dibahas dalam rapat-rapat pimpinan antara PTSG dan RSSG/PTCN.

Dalam tahap-tahap negosiasi belum pernah ada kesepahaman. Tahun 2012 mulai ada titik temu untuk melaksanakan Managed Care dengan konsekuensi-konsekuensinya. Secara umum akan menyulitkan pihak RSSG/PTCN, tetapi pilihan ini harus diambil atas dasar faktor-faktor efisiensi, era Jaminan Kesehatan Nasional, transparansi dan lain-lain.

Tahap awal berupa negosiasi tentang cakupan pelayanan yang diberikan oleh RSSG. Perusahaan PTSG pada dasarnya sudah memiliki regulasi tentang cakupan pelayanan kesehatan dan hak-hak pegawainya bila sakit. Akan tetapi aturan tersebut terlaksana dengan prosedur yang sangat fleksibel sehingga mengakomodir beberapa pegawai yang tidak tertib. Hal ini akan menjadi masalah bila diterapkan sistem Managed Care.

Setelah negosiasi dan mengacu pada aturan dan mekanisme yang dibuat oleh PTSG, akhirnya ada beberapa kategori penanggung biaya pengobatan, yaitu:

1. Pengobatan yang ditanggung RSSG/PTCN.
2. Pengobatan yang ditanggung PTSG,
3. Pengobatan yang ditanggung bersama PTCN dan PTSG dan
4. Pengobatan yang ditanggung pasien/ pegawai PTSG sendiri.

Pembayaran Managed Care dengan pra-upaya disepakati dibayar PTSG kepada PTCN dibayar tiap triwulan di awal dengan jumlah peserta (tertanggung) sekitar 6100-6300 orang. Nilai kontrak lebih rendah sekitar 10% dari biaya tahun sebelumnya. Cakupan pelayanan meliputi hampir semua kasus penyakit dengan perkecualian hampir sama dengan yang berlaku pada jaminan kesehatan oleh asuransi. Kasus yang mahal dibiayai dengan cost-sharing antara RSSG dan PTSG.

Tahap berikutnya sosialisasi kepada semua unit dan personal yang akan terlibat, seperti: dokter, speslalis, apoteker, perawat, front office, bendahara dan lain-lain. Sosialisasi tentang cakupan, hak dan kewajiban juga diberikan kepada semua pelanggan (peserta/ tertanggung).

Untuk menjalankan program ini dibentuk unit Verifikator Managed Care (3 orang). Untuk dokter dan spesialis ditetapkan nilai maksimal tiap lembar resep dan pilihan obat yang lebih ketat sesuai yang ditetapkan di FOSG (Formularium Obat Semen Gresik).selain Formularium RSSG. Penekanan terutaman untuk dokter umum, karena perannya sangat strategis dan menentukan besaran biaya yang akan terjadi. Kemampuan klinis ditingkatkan, sehingga jumlah rujukan ke spesialis, penunjang dan lain-lain dapat diturunkan. Standar Pelayanan Medis kasus rawat jalan dibuat khusus dan dipantau ketat.

Tahap implementasi dimonitor dengan prosedur manual seperti pemantauan oleh front office, unit terkait tentang alur dan prosedur dan melakukan verifikasi dokumen medis. Monitoring cara otomatis dengan Sistem Informasi Rumah Sakit yang memiliki fitur Decision Support System, seperti peringatan-peringatan tentang kuantum obat, interaksi obat, kunjungan yang berulang, biaya harian via SMS Gateway, dan lain-lain.

Setelah berlangsung satu tahun, indikator-indikator pelayanan kesehatan untuk pegawai PTSG dibandingkan tahun sebelumnya, didapatkan antara lain:

1. Kunjungan Poli Umum menurun 33%.
2. Kunjungan Poli gigi menurun 18%
3. Kunungan Spesialis Penyakit Dalam menurun 41%.
4. Kunjungan Spesialis Obsgyn menurun 44% .
5. Kunjungan Spesialis Anak 64%
6. Kunjungan Laboratorium menurun 26%.
7. Kunjungan X-ray menurun 22%
8. Kunjungan UGD menurun 35%
9. Kunjungan Rawat Inap menurun 19%
10. Angka kematian tetap.
11. Penanggung biaya oleh RSSG sebesar 97%.
12. Penanggung biaya oleh PTSG sebesar 1%
13. Penanggung biaya bersama RSSG dan PTCN 2%
14. Dana yang diterima dari PTSG untuk Managed Care, cukup (tidak rugi).

Dengan pencapaian ini, PTSG menghendaki kontrak baru sistem Managed Care periode 2013-2014.

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Oleh : Thomas Behrenbeck, MD (Cardiologist, Mayo Clinic, USA)
Dipresentasikan pada Forum Mutu Pelayanan Kesehatan IHQN (Jakarta 19-20 November 2013)

Both Indonesia and the United States of America are undergoing a paradigm shift in their models of health care delivery. Both countries are introducing Universal Health Care Coverage with mandated insurance for large parts of the population. Whereas the implicit goal of the American initiative is to contain the ever rising health care cost, Indonesia is in the enviable position to expand its health care expenditure from 1 – 2% of GDP (gross domestic product) to 11-12% of GDP to be more in line with health care expenditures of central European countries, whereas health care expenditure in America is one of the highest for any country, around 18% of GDP.

There are additional challenges evolving in parallel which make health care delivery ever more complex. Given the rising cost of health care, consumers, insurance companies and other payors are demanding better documentation both in regards to the practice of medicine as well as documented compliance with regulations and operations. This poses an additional burden on care givers, not just as an expense for personnel involved with the appropriate documentation, but also the integration of data to properly flow from the care provider domain into the administrative/operational domain. Knowledge accumulation, and practice differentiation have accelerated significantly over the past decades, yet the translation time from inception/innovation/invention to front-line practice is the longest for any industry. For example, the fact that beta blockers are beneficial in the treatment of coronary artery disease, particularly heart attacks has taken nearly 18 years to be embedded into best practice guidelines.

The electronic age had a profound impact on consumer behavior. The availability of data for nearly every sector has led to ever accelerating transparency, with health care providers being asked to publish performance parameters, which are universally (at least nationally) accepted and reported uniformly across a spectrum of disease and procedure outcomes.

These challenges have transformed the way medicine has been practiced in a way never seen before. Whereas the solo practice was commonplace in America as late as the 1980s, it has now been replaced by multi-specialty group practice to accommodate the rapid progress of medical practice over the past decades. Integration of care givers along various axis of knowledge, not just in their field, but across specialties are emerging with focus on disease related health care rather than specialty focused health care. Furthermore integration along the entire health care pathway (patient intake to discharge) has been shown to significantly improve patient outcomes.

Mayo Clinic early on anticipated the need for integration along its entire practice. This presentation will define the meaning of integrated practice based on the needs of the patient. It is important to understand the concept of integrated practice patterns to realize the implications for health care providers. The mechanism mentioned above tend to isolate health care providers by ever increasing demands on specialization, differentiation of tasks along the health care spectrum, and work performance which tends to diminish the exchange of information.

On the other hand, newly developed technologies also open up possibilities heretofore not available in the delivery of health care. This presentation will touch upon a number of these developments which will have a profound impact on health care delivery, yet dovetail well into the coming era of Universal Health Care and its unique challenges. Several changes cannot yet be anticipated and will evolve as the health care sector will become more familiar with UHC, but some developments are becoming evident which will have a profound impact. Among these are the vast amount of data that are being amassed and are currently only available in fractionated ways. The president of the United States signed into law a profound change how we will interact in the electronic environment in the future, the ‘Open Data’ legislation, requiring that all non-security and personal data be made available for people requesting to analyze them. Another aspect will be the telemedicine made crucial to ameliorate the gradient of medical expertise from larger tertiary health care centers like Mayo Clinic. Telemedicine in its ultimate form should make this expertise available in the farthest corners of the globe, which is particularly critical, since the number of health care providers is reducing and is anticipated to reach critical levels in the next decade. High level medical expertise can be leveraged by electronically tethering outreach sites to centers of excellence while avoiding the need for traveling which significantly reduces the efficiency of health care. High quality electronic transmission of critical data in real time through remote sensing devices will allow timely and critical decision making for patients in even the very remote areas.

Another change in medicine is the orientation of care centers around disease entities rather than practicing in specialty ‘silos’ which has been the norm for the past 40 years. Interestingly, medicine started with the individual physician consulting on every aspect of their patient’s health care needs. The explosion of medical therapeutic modalities has led to hyperspecialization and isolation among medical fields, yet the ever accelerating knowledge through research in medicine pointed to overarching physiological principles. For example, coronary artery disease has been recognized not just as a vascular phenomenon, but also as an inflammatory process, wherein experts with knowledge in immune disease, signal transmission, etc., play an ever increasing role in a field which was previously felt to be positioned in cardiology. Whereas in the past, cardiologists would try to acquire knowledge in these neighboring fields, it has been recognized that integrating experts from this field into the health care process is a more effective and successful way, resulting in formation of centers of excellence whose focus is the recruitment of experts along the disease spectrum, rather than along specialties alone.

The demand for outcomes data in the health care environment has led to the development of practice guidelines. These best practice models have been designed by boards of experts and are widely used by the medical industry to measure outcomes and determine reimbursement patterns dependent upon the compliance with these guidelines. Diffusing this best practice patterns into the everyday practice of medicine has proven to be challenging. This presentation will discuss several approaches to this problem.

The arrival of Universal Health Care Coverage has both strengthened the need for an integrated approach to the patients’ health care needs, but also created challenges to the process of integration which will need to be met if a state or country aspires to elevate its level of health care to the highest possible level.

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