Tidak Ada Yang Salah Dengan BPJS

Salah satu kewajiban dasar negara adalah melindungi segenap warga negara dan menciptakan kesejahteraan umum sudah jelas termaktub dalam UUD 1945. Jadi negara memang bertanggung jawab terhadap pelayanan kesehatan, sehingga sektor kesehatan tidak boleh diserahkan kemekanisme pasar yang cenderung liberal. Kesehatan adalah hajat hidup orang banyak dan merupakan sektor publik yang harus “dikuasai” dan diatur oleh negara. SJSN sesungguhnya adalah program yang sangat baik, melindungi segenap tumpah darah indonesia dari sejak lahir sampai meninggal dunia.

Nah…apa yang salah kemudian dengan BPJS ?? Tidak ada yang salah, hanya persoalan faktual BPJS saat ini adalah menyangkut besaran alokasi dana untuk penganggaran dan pembiayaan jaminan kesehatan baik itu pada sistem kapitasi ataupun paket pembiayaan. Apakah salah ketika BPJS menggunakan sistem klaim pembiayan dengan package system(Sistem Paket) melalui sebuah aplikasi program yang disebut Case Mix-INA CBG ??

Tidak salah, justru memang seharusnya saat ini konsep pembiayaan kesehatan di Indonesia harus diubah paradigmanya dari sistem fee for service menjadi package system (sistem paket). Tujuannya jelas yaitu untuk melakukan kontrol (kendali) terhadap mutu dan kendali biaya.

Indonesia adalah satu dari sedikit negara dimana masyarakatnya ketika mendapatkan jasa pelayanan kesehatan sampai menit terakhir sebelum pulang, BELUM mendapatkan kejelasan BESAR BIAYA yang harus dikeluarkan. Hal ini terjadi karena tidak ada standar yang sama, contoh : pasien DHF dirawat di sebuah RS A dengan RS B pasti berbeda dalam hal lama dirawat (Length of Stay) dan tentunya juga jumlah biaya yang dikeluarkan. Itu terjadi pada daerah yang sama, konon lagi bila berbeda daerah. Ambil contoh yang paling gampang, berapa biaya operasi Sectio Cesarea (SC) di tiap rumah sakit ?? Pasti berbeda-beda. Di Jakarta ada yang biaya sekali SC (RS Swasta) mencapai 25 juta, tapi di daerah lain misal RSUD Kabupaten biaya SC paling mahal (Kelas VIP) hanya 6,5 – 7 juta. Terus apa bedanya?? Disinilah ironis-nya pelayanan kesehatan di Indonesia.

Dalam konsep manajemen rumah sakit, perbedaan biaya antar kelas ruang perawatan di rumah sakit hanyalah disebabkan karena perbedaan fasilitas saja, tapi pelayanan yang diberikan oleh dokter dan petugas kesehatan lain harus sama dan standar. Tidak ada pembedaan operasi Appendicities Acute pasien VIP dengan pasien Kelas III.

Di negara-negara yang sudah menerapkan sistem pembiayaan berdasarkan paket pelayanan, maka ketika si pasien tersebut (bahkan ketika masih di IGD / Rawat Jalan) dan diagnosa sudah ditegakkan oleh dokter, juga rencana tindakan serta pengobatan yang akan dilaksanakan, maka si pasien tersebut sudah langsung memperoleh informasi yang lengkap dan jelas meliputi : Penyakitnya, Rencana Tindakan dan Pengobatan, Lama Dirawat dan yang paling penting adalah BESAR BIAYA yang harus dibayarkan.

Nah disinilah perlunya para dokter menyusun sebuah alur pelayanan yang disebut denganClinical Pathways (CP). Karena sesungguhnya penghitungan besaran tarif per paket pelayanan dalam Case Mix-INA CBG (dulu bernama Case Mix-INA DRG) adalah berdasarkan dari Clinical Pathways (CP). CP ini bisa disusun apabila sudah ada Standar Pelayanan Medik (SPM/SOP), Protokol Terapi dan Formularium Obat (Standar Farmasi).

Yakinlah jikalau rekan-rekan TS mempermasalahkan BPJS, itu karena memang besaran kapitasi yang jauh dibawah standar (bagi PPK I) dan bagi RS yang nota bene adalah PPK II masalahnya adalah besaran tarif paket pelayanan yang ada pada sistem Case Mix-INA CBG terlalu kecil. Bisa dibayangkan ketika sebuah RS Swasta di Jakarta memasang tarif operasiSectio Cesarea (SC) sebesar 25 juta, sementara disisi lain sebuah RSUD Kabupaten Kelas C melakukan klaim dengan menggunakan Case Mix-INA CBG hanya dibayar sebesar 1,2 juta. Kenapa bisa begitu?  Kemungkinan pastinya adalah pemerintah tidak memiliki cukup dana untuk membiayai jaminan kesehatan dengan tarif yang manusiawi. Kenapa tidak cukup? Ya karena pemerintah kesulitan menentukan besaran iuran yang harus dibayarkan setiap kepala.  Faktor penyebabnya adalah sebagai berikut diantaranya (menurut versi saya ya) :

Untuk masyarakat tidak mampu sebaga PBI (Penerima Bantuan Iuran) yang premi-nya dibebankan kepada pemerintah melalu APBN dalam program Penerima Bantuan Iuran (PBI) Jaminan Kesehatan (PP Nomor 101 Tahun 2012), besaranya masih diperdebatkan. Konon Kementerian Kesehatan mengusulkan besaran iuran PBI sebesar Rp 22.000,- sementara akhirnya Kementerian Keuangan yang note bene adalah Bendahara Negara “hanya” merestui sebesar Rp 15.500,-. Padahal DKI Jakarta dengan APBD I nya siap dengan besaran Rp 55.000,-.

Untuk pekerja swasta, mereka keberatan membayar iuran sebesar 5% dari upah karena mereka sudah dipusingkan dengan banyaknya potongan-potongan pada slip gaji bulanan mereka.

Dampak pastinya adalah dana yang terhimpun tentu saja tidak optimal dan maksimal. Dana yang terhimpun tadi adalah untuk operasional BPJS yang salah satu diantaranya adalah untuk membayar dokter dan seluruh tenaga kesehatan yang telah memberikan pelayanan dalam bentuk remunerasi.

Nah…menurut hemat saya, DI TITIK INILAH KITA BERJUANG. Jangan lagi kita masih mempermasalahkan BPJS nya, apalagi menuding bahwa BPJS adalah Neo-Liberalisme. Tidak ada yang salah dengan konsep dan tujuan BPJS itu. Indonesia sekali lagi adalah satu dari sedikit negara yang BELUM melaksanakan jaring pengamanan sosial nasional padahal itu jelas sudah diamanatkan dalam UUD 1945. USA saja sudah menerapkan jaring pengaman sosial ini dan saking konsen nya sampai-sampai Presidan Obama membatalkan kunjungan pertama ke Indonesia dan lebih memilih membahas dengan Senat AS, ini mencerminkan betapa pentingnya memang program jaring pengamanan sosial nasional ini.

Mohon maaf, saya tidak antipati kepada ibu mantan Menkes ini ataupun kepada siapa saja yang kontra dengan program BPJS, tapi rekan-rekan sejawat bisa membaca pendapat tokoh nasional yang menurut saja bisa menjadi panutan yaitu Bapak Jusuf Kalla : “JK Desak BPJS Segera Dijalankan”.

Jadi menurut saya point-point utama yang harus diperjuangkan adalah :

  1. Mendesak pemerintah untuk mengalokasikan besaran Iuran Bantuan yang optimal dan mencukupi operasional BPJS ini yang secara otomatis akan berdampak langsung terhadap besaran jasa pelayanan dalam bentuk remunerasi kepada dokter.
  2. Pekerja swasta yang keberatan dipotong iuran sebesar 5% dari upahnya, harus disubsidi juga oleh negara. Tahukah rekan sejawat semua berapa subsidi pemerintah setiap hari untuk konsumsi BBM yang kita bakar sehari-hari ?? Tahun 2013 sebesarRp 272,4 TRILIUN  atau hampir Rp 800 MILIAR SEHARI. Bisa kita bayangkan apabila subsidi BBM dicabut bertahap (dikurangi) berapa besaran potensi yang bisa dianggarkan pemerintah untuk mensubsidi iuran bagi pekerja sosial, juga bisa dialokasikan untuk menambah besaran iuran bagi PBI (Masyarakat Miskin dan Tidak Mampu).
  3. Memperjuangkan besaran nilai kapitasi per-kepala untuk sarana kesehatan primer (PPK I) seperti Puskesmas, Klinik, Praktek Dokter Perorangan dan sebagainya. Memperjuangkan besaran pembiayan untuk setiap paket pelayanan yang ada dalam program Case Mix-INA CBG bagi sarana kesehatan sekunder dan tersier (PPK II dan PPK III) seperti RS Kabupaten/Kota, RS Propinsi (pusat rujukan wilayah) dan RS vertikal milik Kementerian Kesehatan.
  4. Peningkatan nilai kapitasi dan paket pelayanan ini kemudian harus segera dilanjutkan dengan sistem pengupahan (Remunerasi) berbasiskan kinerja yang berlandasakaan pada azas kelayakan dan kepatutan.

Terakhir, ada beberapa pendapat dan aspirasi dari rekan-rekan sejawat untuk memperjuangkan standar gaji dokter. Misalkan ada yang mengusulkan Take Home Paystandar untuk dokter umum adalah 25 juta/bulan. Sedangkan untuk dokter spesialis Non Bedah (Tidak memegang pisau) sebesar Rp 100 juta/bulan dan untuk dokter spesialis pemegang pisau sebesar Rp 150 Juta/bulan. Menurut saya, itu sah-sah saja kita perjuangkan. Ayo kita perjuangkan seperti negara-negara lain (Malaysia, Singapore) dimana standar gaji dokter sudah ditetapkan dan dibayar oleh pemerintah dengan syarat dokter harus full day di RS (dari jam 07.30 – 18.00). Meskipun pemerintah melalui UU 44 Tahun 2009 tentang Rumah Sakit telah secara explisit mengatur bahwa imbalan jasa pelayanan di RS adalah diberikan dalam bentuk remunerasi (UU RS 44/2009 Pasal 30 Ayat (1) huruf b). Tapi jangan lagi kita set back ke belakang dengan masih mempersolakan BPJS ini, waktu terus berputar, layar sudah tekembang. Menurut saya sudah tidak relevan lagi perdebatan tentang keberadaan program BPJS. Mengutip Pak JK : “BPJS itu harus jalan dulu. Sistem itu kan selalu akan diketahui kekurangannya setelah berjalan. Jadi yang penting sekarang ini jalan saja, baru setelah itu kita bicarakan sambil jalan”.

Secara pribadi, saya juga merasakan kegelisahan yang sama dirasakan oleh rekan-rekan sejawat lainnya. Kondisi ini kemudian melahirkan sebuah gerakan moral DOKTER INDONESIA BERSATU (DIB). Saya mendukung penuh gerakan moral rekan-rekan sejawat di DIB ini. Profesi dokter semakin “tidak dihargai” baik itu dari aspek penghargaan uang (reward) maupun rentannya diobok-obok oleh media, LSM dan kekuatan-kekuatan politik baik lokal maupun nasional. Saya adalah pengusul salah satu rekomendasi dalam Muktamar IDI ke – 28 di Makasar (20 -24 November 2012) dan alhamdulilah menjadi salah satu rekomendasi nasional yaitu “Dokter harus dilepaskan dari kepentingan-kepentingan politik praktis baik di tingkat lokal maupun nasional”.

Sebagai refleksi diri saya pribadi dan juga bagi semua rekan-rekan TS semuanya adalah marilah berupaya agar kita selalu introspeksi diri, selalu meng-upgrade kompetensi kita dengan selalu memperhatikan sisi science, skill dan attitude. Ketika kita merasa sudah benar, bekerja sesuai dengan standar profesi dan standar kompetensi kita namun masih ada pihak-pihak yang berupaya mengintervensi profesi kita, merendahkan harkat dan martabat profesi luhur kita, maka saatnyalah kita bangkit dan teriak. LAWAN !!!

Maju terus DOKTER INDONESIA BERSATU (DIB) !!! Semoga sukses dengan rencana Gerakan Damai 20 Mei 2013.

Sekian dan terimakasih.

Purwakarta, 07 Mei 2013 Pkl 02.03 WIB

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